Clinical documentation

Clinical documentation is information such as ICD-10 codes and other standards such as HL7 and SNOMED that healthcare professionals record in a patient's record. Documentation is often turned into coded data for inclusion in a public health database as a way to inform care decisions and be considered for reimbursement payments. This data can include vital signs, or other notes on a patient's condition. The change to ICD-10 codes will alter the level of clinical documentation required for many procedures and conditions.