clinical document

A clinical document is a documentation of clinical observations and services, with the following characteristics:

1. Persistence - A clinical document continues to exist in an unaltered state, for a time period defined by local and regulatory requirements;
2. Stewardship - A clinical document is maintained by a person or organization entrusted with its care;
3. Potential for authentication - A clinical document is an assemblage of information that is intended to be legally authenticated;
4. Wholeness - Authentication of a clinical document applies to the whole and does not apply to portions of the document without the full context of the document;
5. Human readability - A clinical document is human readable.