Legal Implications of Clinical Documentation A clinical record is a set of documents and other records that embodies statements of fact and opinion by health professionals regarding their observations of a patient’s clinical status and course of care. At a minimum, the clinical record uses standardized forms imprinted with the institution’s name; contains the ... Article
Article  |   March 01, 2004
Legal Implications of Clinical Documentation
Author Affiliations & Notes
  • Jennifer Horner
    Medical University of South Carolina, Charleston, SC
Article Information
Swallowing, Dysphagia & Feeding Disorders / Professional Issues & Training / Regulatory, Legislative & Advocacy / Articles
Article   |   March 01, 2004
Legal Implications of Clinical Documentation
SIG 13 Perspectives on Swallowing and Swallowing Disorders (Dysphagia), March 2004, Vol. 13, 10-16. doi:10.1044/sasd13.1.10
SIG 13 Perspectives on Swallowing and Swallowing Disorders (Dysphagia), March 2004, Vol. 13, 10-16. doi:10.1044/sasd13.1.10
A clinical record is a set of documents and other records that embodies statements of fact and opinion by health professionals regarding their observations of a patient’s clinical status and course of care. At a minimum, the clinical record uses standardized forms imprinted with the institution’s name; contains the patient’s name, hospital number, and other relevant identifying information; identifies the date of the tests, examinations, or procedures; and closes with the signature and title of the responsible practitioner. Any medium may be used (e.g., paper, electronic, photographic, radiographic). The form of the clinical record is dictated by the purpose of the task (e.g., history, consultation, diagnostic report, progress note) and may be centralized in a medical records department and/or decentralized in a variety of ancillary clinics.
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