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.

November 18, 2020 18 Nov'20
To prep for COVID-19 vaccine distribution, CIOs turn to data

CIOs should prepare a COVID-19 vaccine distribution plan now. Making sure immunization records are digitized and easy to access is a good first step.
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.

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ICD-10-CM (Clinical Modification)

The ICD-10-CM (Clinical Modification) is a system used by physicians and other healthcare providers to classify and code all diagnoses, symptoms and procedures recorded in conjunction with hospital care in the United States. Continue Reading
computerized physician order entry (CPOE)

Computerized physician order entry (CPOE), also known as computerized provider order entry or computerized practitioner order entry, refers to the process of a medical professional entering and sending medication orders and treatment instructions ... Continue Reading
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

Weigh the pros and cons of technologies, products and projects you are considering.

Healthcare NLP mines valuable insights from unstructured data

Most of the data in an EHR is unstructured and often ignored. Natural language processing enables healthcare providers to extract meaningful insights from this untapped resource. Continue Reading
Find the best EHR software to manage your patient data

EHR software is required for most health organizations but is available with a variety of features from different vendors. Learn which system offers what your business needs. Continue Reading
Population health management programs require goal alignment

In this Q&A, KLAS population health researcher Bradley Hunter says successful population health management programs hinge on goal alignment. Continue Reading

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

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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
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