Clinical documentation is about how we build health records. It is also a requirement of all who serve patients. Whether in electronic or written format, proper documentation is mandated by professional, regulatory, legal, accreditation and Alberta Health Services (AHS) expectations. More importantly, it enables inter-professional communication, care coordination, service continuity and outcome monitoring.
The Clinical Knowledge & Content Management (CKCM) team coordinates program-specific multi-disciplinary clinical documentation working groups. Work is underway to promote best practices, build consensus about documentation norms, expose clinically essential documentation elements, and reduce unhelpful program-to-program variation.
Bringing consistency and efficiency to clinical documentation can reduce health practitioners’ total information burden, streamline complex medical records, speed recovery of clinically important data, and focus caregivers on the communication needs of patients and families. Follow the links to learn more about harmonizing clinical documentation in AHS and how you can get involved.