Clinical documentation is the information a person responsible for a patient’s medical care enters in a medical record, which is a repository for an individual’s health information.

Jun 11, 2024 · What is clinical documentation? Clinical documentation (CD) is the creation of a digital or analog record detailing a medical treatment, medical trial or clinical test. Clinical documents must be …

Mar 24, 2025 · Clinical documentation is the cornerstone of effective, safe, and compliant healthcare. It refers to the process of recording, managing, and maintaining information related to a patient’s …

Jun 2, 2025 · What is clinical documentation integrity + Improvement? While many people use “clinical documentation improvement” and “clinical documentation integrity” interchangeably, there are a few …

Documentation in healthcare is used to convey essential clinical information about patients’ diagnoses, treatment, and outcomes.

However, the primary purpose of clinical documentation is to support high-quality patient care. Therefore, this study investigated the effect of increased structured and standardized documentation …

Feb 16, 2025 · What is clinical documentation in healthcare? Clinical documentation refers to the creation of medical records that pertain to patient healthcare. It is the primary method of tracking a …