Clinical Documentation
/ˈklɪnɪkəl ˌdɒkjʊmɛnˈteɪʃən/
Definitions
- (n.) The systematic recording of medical information for use in legal, regulatory, and healthcare contexts.
Accurate clinical documentation is essential for defending against malpractice claims.
Forms
- clinical documentation
Related terms
See also
Commentary
In legal contexts, clinical documentation serves both evidentiary and regulatory compliance roles, requiring accuracy and completeness to withstand legal scrutiny.
This glossary is for general informational and educational purposes only. Definitions are jurisdiction-agnostic but reflect terminology and concepts primarily drawn from English and American legal traditions. Nothing herein constitutes legal advice or creates a lawyer-client relationship. Users should consult qualified counsel for advice on specific matters or jurisdictions.