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Further developments in medical documentation standards, in particular HL7 clinical document architecture (CDA) [ 8] with its clinical document code, will facilitate methods for HIS benchmarking.
The Clinical Document Architecture [ 19] is such a format.
Clinical documentation can be an underappreciated.
New clinical functionality will include the electronic requesting and reporting of diagnostic tests and improved clinical documentation and communication.
Group B - Queen Victoria, East Sussex and Western Sussex – are seeking e-prescribing, clinical documentation, order communications and an integrated clinical portal.
Identifying healthcare providers' perceptions of clinical documentation methods can inform the design of computer-based documentation tools.
The promise and the reality of clinical documentation.
Clinical documentation is needed to determine whether these advantages can be realized.
Accurate clinical documentation (CD) is necessary for many aspects of modern health care, including excellent communication, quality metrics reporting, and legal documentation.
For electronic patient records to work as intended, hospitals must make a large investment now to automate clinical documentation processes, train staff and develop electronic data repositories.
The failure to view the hospital as a system has contributed to the practice of inefficient and ineffective clinical documentation.
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