CODED CLINICAL ENTRY
An entry in an ELECTRONIC HEALTH RECORD, recorded by a CARE PROFESSIONAL, PATIENT or Patient Proxy, or other authorised PERSON, relating to ACTIVITIES for the care and treatment of a PATIENT.
CODED CLINICAL ENTRIES may describe:
- ACTIVITY GROUPS
- CARE ACTIVITIES
- any other aspect of PATIENT care and management.
A CODED CLINICAL ENTRY in an ELECTRONIC HEALTH RECORD should include the recording of relevant CLINICAL TERMINOLOGY CODES and/or CLINICAL CLASSIFICATION CODES. Where information to complete the CODED CLINICAL ENTRY is missing, a DATA ABSENT REASON should be recorded.
This class is also known by these names:
|plural||CODED CLINICAL ENTRIES|