Clinical Documentation
type: Function
concept domain: health care specific
page: 296
chapter: Thesaurus
label: Klinische Dokumentation @de
label: مستندات بالینی @fa
definition: Documentation in clinical environment. Recording all clinically relevant patient data that arise during patient care as completely, correctly, and quickly as possible. This supports the coordination of patient treatment between all involved health care professionals, and also the legal justification of the actions taken. Structured documentation of data is a precondition for data aggregation and statistics, computerized decision support, and retrieval of data. Is supported by medical documentation systems and nursing management and documentation systems. Is not considered as enterprise function but takes place every time an enterprise function is executed, new information is generated, and respective data are stored.