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.

Clinical documentation News

Clinical documentation Get Started

Bring yourself up to speed with our introductory content

Evaluate Clinical documentation Vendors & Products

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

Manage Clinical documentation

Learn to apply best practices and optimize your operations.

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.