The admission note records the reason for a patient's admission and includes the initial diagnosis and planned course of treatment.
A CDS ensures that clinical documentation accurately reflects the patient’s care, supporting proper coding and billing processes.
The main goal of healthcare documentation is to accurately and comprehensively capture all aspects of patient care to ensure quality treatment and proper billing.
Effective healthcare documentation requires detailed and accurate entries that are made promptly to reflect the patient's condition and treatment accurately.
Consistent documentation among all providers ensures that everyone involved in the patient’s care has a clear and unified understanding of the patient's condition and the care being provided.
