A clinical document (CD) is a written, printed or electronic record that provides evidence of medical care.
Clinical documents use an XML markup standard developed by Health Level 7 International (HL7), an organization dedicated to developing standards for the exchange of electronic health information. The standard, which is known as the Clinical Document Architecture (CDA), defines the structure of many common clinical documents such as admission or discharge records.
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According to HL7, a clinical document has the following characteristics:
Persistence – the clinical document continues to exist in an unaltered state for a period of time defined by local and regulatory requirements.
Stewardship – the clinical document is maintained by a person or organization entrusted with its care.
Potential for authentication - the clinical document can be legally authenticated.
Wholeness – legal authentication applies to the entire clinical document; it does not apply to parts of the document taken out of context.
Human readability - the clinical document can be easily read and understood.
Many hospitals employ specialists who understand the clinical needs of patients to review clinical documents, identify gaps in documentation and solicit missing information from physicians. This process is known as clinical document improvement (CDI).