02 — Capability · BC-1820.10
Clinical Documentation
Let every clinician record what was observed, decided and done for a patient, quickly and in a form others can find and trust, so the record supports care, coding and defense of the claim. Coding the record and managing it as a legal record are owned elsewhere.
- Clinical Charting
- EHR Documentation
- EMR Documentation
In scope
- Physician, nursing and allied health notes and assessments
- Problem, allergy and history lists
- Documentation templates and structured forms
- Dictation, transcription and ambient documentation
Out of scope
- Clinical documentation improvement queries for coding (see BC-1840.20)
- Record completion, amendment and retention (see BC-1880.10)
- Clinical terminology and code set content (see BC-1880.40)
Realized by · 6
- Epic · Clinical Recordcore via BC-1820.10.10
- Epic · Inpatient Nursingcore via BC-1820.10.20
- Oracle Health · Oracle Health EHRcore via BC-1820.10.10
- Oracle Health · Clinical AI Agentstrong via BC-1820.10.50
- MEDITECH Expanse · Expanse for Physicianscore via BC-1820.10.10
- MEDITECH Expanse · Expanse Patient Carecore via BC-1820.10.20
Used in · 2
Build it · 1
Decomposes into · 5
- BC-1820.10.10Clinical Note AuthoringLet physicians and other providers write history, assessment, progress and procedure notes efficiently and sign them on time.
- BC-1820.10.20Nursing DocumentationLet nurses record assessments, vital signs, intake and output and care given through each shift in flowsheets that the whole team can read.
- BC-1820.10.30Problem & Allergy ListsKeep each patient's problems, allergies and relevant history current and reconciled, so every clinician starts from the same summary.
- BC-1820.10.40Documentation Template ContentBuild and govern the note templates, structured forms and reusable text that clinicians use, so documentation is complete without being bloated.
- BC-1820.10.50Ambient & Dictated DocumentationTurn dictation and recorded conversations into draft notes for the clinician to review and sign, through transcription services, speech recognition or ambient listening tools.