clinical documentation

Clinical documentation refers to the process of recording patient-related information within healthcare settings. This includes details about medical history, treatments, diagnoses, test results, and care plans. Proper documentation is crucial for ensuring continuity of care, facilitating communication among healthcare providers, and meeting legal and regulatory requirements. It helps to ensure that patients receive safe and effective treatment while also enabling accurate billing and health data analysis. Overall, clinical documentation serves as a vital record that supports patient care and healthcare operations.