Patient medical records are used by clinicians to document a patient’s care. Their primary purpose is to routinely record and communicate patient and clinical information – for example, pre-existing conditions/risk factors, patient characteristics, diagnoses, treatments and procedures.
The quality of the health data used in the model are dependent on clear clinical documentation in the medical record. As such, IHPA and the Commission have consulted with clinical stakeholders to produce a short animation to support data improvement by raising awareness among clinicians of what clinical coding is and how the medical record is used in this context.
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