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:

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:
ContextAlias
pluralCODED CLINICAL ENTRIES

ISO 9001 CERTIFICATION EUROPE