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.
New & Notable
Download Complete Guide to Healthcare IoT Now
Healthcare IoT has the potential to greatly improve patient care – but it’s not without its challenges. Download this essential guide in one PDF and learn how to overcome the obstacles: security, data overload, regulations, and more.
Clinical documentation News
-
February 03, 2017
03
Feb'17
Patient-reported data often excluded from EHR documentation
A recent eye health study found that patient-reported data doesn't always get recorded in a patient's electronic health record (EHR), raising questions about the accuracy of clinical documentation. ...
-
June 30, 2016
30
Jun'16
EHR interoperability, regulations top patient record concerns
From meeting new government standards to navigating EHR interoperability woes, providers have a lot on their minds. Find out how they are accommodating EHR regulations without sacrificing security.
-
August 21, 2015
21
Aug'15
Sample high-value claims before ICD-10 implementation date
With the heat on physician practices to prepare for the impending ICD-10 implementation date, two analysts discuss how best to avoid negative outcomes.
-
August 13, 2015
13
Aug'15
Experts predict bleak results after ICD-10 implementation date
As the Oct. 1 ICD-10 implementation date looms on the horizon, three experts question whether ICD-10 will provide value to physicians or patients.
Clinical documentation Get Started
Bring yourself up to speed with our introductory content
-
clinical decision support system (CDSS)
A clinical decision support system (CDSS) is an application that analyzes data to help healthcare providers make decisions and improve patient care. Continue Reading
-
biomedical informatics
Biomedical informatics is the branch of health informatics that uses data to help clinicians, researchers and scientists improve human health and provide healthcare. Continue Reading
-
SharePoint for healthcare aids HIPAA compliance, workflow automation
Hospital IT may have a love-hate relationship with SharePoint, but features like Information Rights Management can help ensure the security of PHI and other health data. Continue Reading
Evaluate Clinical documentation Vendors & Products
Weigh the pros and cons of technologies, products and projects you are considering.
-
Patient care documentation benefits from dictation tools, AI
Physicians spend a lot of time entering clinical data and notes into EHRs. AI, natural language processing and dictation tools can alleviate the burden of care documentation. Continue Reading
-
Considerations for transgender patient documentation in EHRs
Most modern EHRs document sexual identity as a fixed, binary value, but classic designations such as male and female fail to include documentation for transgender patients. Continue Reading
-
A review of electronic prior authorization technology
Migrating to electronic prior authorization software offers a chance to improve revenue cycle operations and reduce complexity, which can be a win for all involved. Continue Reading
Manage Clinical documentation
Learn to apply best practices and optimize your operations.
-
The ICD-10 release date: Here are important facts to know
The ICD-10 implementation date is fast approaching, and providers should know what to expect. Here are some important facts from CMS' ICD-10 resources. Continue Reading
-
Implementation of ICD-10 requires precision and accuracy
An EHR vendor product manager continues her discussion on why providers need to be serious about testing and budgeting when implementing ICD-10. Continue Reading
-
Late-stage best practices for implementing ICD-10
In a two-part Q&A PointClickCare ICD-10 expert, Genice Hornberger, explains what providers should do in the last phases of implementing ICD-10. Continue Reading
Problem Solve Clinical documentation Issues
We’ve gathered up expert advice and tips from professionals like you so that the answers you need are always available.
-
Population health, revenue cycle management on CIO's agenda
Marc Probst, CIO at Intermountain Healthcare, said his organization is taking strides to make population health happen, is investing heavily in data analytics, and more. Continue Reading
-
Image sharing tested by meaningful use stage 2 criteria
Providers that don't host their own imaging systems don't waive all responsibility -- they still have meaningful use and patients to satisfy. Continue Reading
-
Missing chunk of Open Payments data raises concerns
Why up to one-third of Open Payments data won't be available in the public database is one reason supporters and detractors alike are prodding CMS. Continue Reading