Clinical Documentation

What is Clinical Documentation?

A detailed recording of a medical treatment, medical trial, or a clinical test is called Clinical Documentation. it may be in a digital or analogue form. These records are for the purpose of understanding the services provided to the patient. Hence it must be accurate and chronological. Clinical and laboratory tests like X-rays, EKGs, MRIs etc., are also added to these records as part of clinical documentation.

The important requirements of documentation are to be clear, legible concise, contemporaneous, progressive and accurate.

There are two main types of documentation.

  • 1) Clinical documentation.
  • 2) Non-clinical documentation.

Clinical documentation is helpful for providers to quickly understand the diagnoses and treatment provided to a patient and also serves as evidences for legal purposes in case of medical malpractices. Insurance service providers require clinical documentation to evaluate patient claims.

Clinical document improvement (CDI) specialists are employed to ensure that these documents are without errors and is comprehensible by insurance providers, medical billers, and coders. The clinical documentation improvement systems (CDIS) also help billing departments with easy transition to ICD 10 coding language.

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