Clinical Documentation

Clinical Documentation contains data consisting of patient-centric clinical and administrative documentation and serves as the main foundation for medical and administrative processes. The data documents observations, treatments, and care provided to the patient by the healthcare provider as an outpatient or inpatient as well as upon consultation and referral. The data also contains patient education and patient consents. The data is used by clinicians, nurses and other healthcare professionals to diagnose and treat the patient. The data provides a foundation for coding and classification for billing and/ reimbursement and is used by administrative staff to document patient movement and assignment of diagnostic codes to reflect the diagnoses treated and procedures performed during the care. Healthcare documentation is utilized by accrediting and licensing agencies as well as insurance company reviewers to substantiate the quality of care provided.

Work efforts performed that contributed content to the domain:

Clinical Documentation Main
Logical Information Model Enumerations Conceptual Information Model

Diagrams

Properties:

Alias
informationDomain
Keywords
modeler
NameClinical Documentation
Name Expression
NamespaceVHA
Nesting PackageVHA
Owned Template Signature
OwnerVHA
Owning Template Parameter
projectID
Qualified NameVHA::Clinical Documentation
StereotypeModelDictionary
Template Parameter
VisibilityPublic