Document Clinical Note

Type: Process
Status: Planned
Industry Sector: Healthcare

Description:

Documentation of clinical observations, assessments, decisions and care actions in the patient record.

Parent Process: Manage Health Information

Subprocesses:

None

Served by Application(s):

Electronic Health Record System

Realizes Capabilities:

Medical Records Management
Patient Care Management

Uses Information Object(s):

Patient
Clinical Note
Diagnosis

Performed by Role(s):

Physician
Nurse

Triggers Process(es):

None

Planned Manage Health Information Healthcare Medical Records ManagementPatient Care Management PhysicianNurse

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