Question

Historically, clinical documentation improvement activities have focused on the inpatient setting because of _________.

Answer 1

Historically, clinical documentation improvement activities have focused on the inpatient setting because of the large amount of inpatient documentation.

Clinical documentation:

The development of a digital or analog record outlining a medical treatment, medical trial, or clinical test is referred to as clinical documentation (CD). Clinical records must be accurate, timely, and unique to the services offered to a patient.

What is the purpose of clinical documentation?

Clinical documentation's primary goal should be to support patient care and improve clinical outcomes through improved communication. The basic goal of clinical documentation is to promote effective patient care.

What are the types of clinical documentation?

Treatment and observation notes, care plans, letters, test results, x-rays, clinical pictures, medication charts, checklists, operation reports, transfer forms, clinical summaries, and information from specialists, community workers, or general practitioners are all examples of these papers.

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