Abstract
Clinical documentation is used throughout healthcare to describe care provided to a patient, communicate essential information between healthcare providers and to maintain a patient medical record. What is a clinical document? The simple and easy answer is that a clinical document is anything that you might find in a patient’s medical record or anywhere else that documents the care given to that patient.
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© 2011 Springer-Verlag London Limited
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Boone, K.W. (2011). Clinical Documentation. In: The CDA TM book. Springer, London. https://doi.org/10.1007/978-0-85729-336-7_2
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DOI: https://doi.org/10.1007/978-0-85729-336-7_2
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