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.
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Clinical documentation News
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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. ...
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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.
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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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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
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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
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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
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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
Evaluate Clinical documentation Vendors & Products
Weigh the pros and cons of technologies, products and projects you are considering.
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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
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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
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Compare EHR systems with these key features in mind
Compare EHR software options and look at the features they offer healthcare organizations for mobile access, certifications, reporting, workflow automation and document management. Continue Reading
Manage Clinical documentation
Learn to apply best practices and optimize your operations.
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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
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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
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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.
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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
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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
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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