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The gold standard for clinical documentation specifies that entries should be legible, reliable, precise, complete, consistent, clear, and Timely.
What is Documentation?
Any communicable material used to describe, clarify, or provide instructions for certain characteristics of a thing, a system, or a procedure, such as its components, assembly, installation, maintenance, and use, is considered documentation. Documentation can be distributed on papers, online, or on analog or digital media, including audio tapes or CDs, as a method of organizational learning and organizing.
User manuals, white papers, online support, and quick reference guides are a few examples. The distribution of documentation on paper or in hard copies has decreased. Nowadays, documentation is frequently supplied online through websites, software, and other online tools.
Contrary to popular belief, documentation science is not the study of recording and retrieving information; rather, it is a set of educational resources.
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