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Workflow

Clinical Documentation Workflow

Clinical documentation is the workflow by which clinicians record the details of a patient encounter — history, examination, assessment, and plan — into the medical record so that care is accurate, complete, and shareable across the team. It typically spans capturing the encounter, structuring the note, coding and review, and finalizing the record. Intelligent healthcare systems can support documentation by helping draft and structure notes from the conversation and by reducing repetitive data entry, with the clinician reviewing and signing off.

How the workflow runs

  1. 01

    Capture

    The encounter — history, examination findings, and discussion — is captured during or immediately after the visit.

  2. 02

    Structure

    Information is organized into the note format the record uses, such as history, assessment, and plan.

  3. 03

    Review and code

    The clinician reviews the note for accuracy and completeness, and relevant clinical codes are associated for downstream use.

  4. 04

    Finalize

    The note is signed and committed to the medical record so it is available to the rest of the care team.

FAQ

Frequently asked questions

What is clinical documentation?
It is the process of recording the details of a patient encounter into the medical record so the information is accurate, complete, and available to the care team.
Does AI replace the clinician in documentation?
No. AI can help draft and structure a note, but the clinician reviews, edits, and signs the record, which remains their responsibility.

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