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clinical documentation vs medical documentation

Both 'clinical documentation' and 'medical documentation' are correct phrases, but they are used in slightly different contexts. 'Clinical documentation' refers to the documentation of a patient's medical history, treatment, and progress in a clinical setting, while 'medical documentation' is a broader term that encompasses all types of documentation related to medicine and healthcare.

Last updated: March 24, 2024 • 801 views

clinical documentation

This phrase is correct and commonly used in the medical field to refer to the documentation of a patient's medical history, treatment, and progress in a clinical setting.

Use 'clinical documentation' when referring to the specific documentation of a patient's medical information, treatment plans, and progress within a clinical setting.

Examples:

  • The nurse completed the clinical documentation after the patient's examination.
  • Accurate clinical documentation is essential for providing quality patient care.
  • Following the opinion on the quality data, the marketing authorisation holder, where requested by the Agency, shall submit the clinical documentation and data concerning stability of the medicinal product to the Agency by day 57 at the latest.
  • In accordance with Article 15(2) and (3), expert reports must be provided on the analytical documentation, the pharmacotoxicological documentation, the residues documentation and the clinical documentation.
  • All pre-clinical and clinical documentation must be sufficiently detailed to enable an objective judgement to be made.
  • The reference Member State will circulate the assessment report on the clinical documentation with its final decision to the concerned Member States within seven days from receipt of the clinical data.
  • The dossier on efficacy shall include all pre-clinical and clinical documentation and/or results of trials, whether favourable or unfavourable to the veterinary medicinal products, in order to enable an objective overall assessment of the risk/benefit balance of the product.
  • The Marketing Authorisation Holder should provide all supporting data (preclinical and clinical documentation, including the expert reports, efficacy and tolerance studies conducted), to justify a positive benefit-risk ratio for the treated animal.
  • In accordance with Article 12(2), expert reports must be provided on the chemical, pharmaceutical and biological documentation, the pharmacotoxicological documentation and the clinical documentation respectively.

Alternatives:

  • medical records
  • patient charts
  • healthcare documentation
  • clinical notes
  • medical files

medical documentation

This phrase is correct and commonly used to refer to any type of documentation related to medicine and healthcare, including clinical documentation.

Use 'medical documentation' as a more general term that encompasses all types of documentation related to medicine and healthcare, including clinical documentation.

Examples:

  • The hospital implemented a new system for organizing medical documentation.
  • Accurate medical documentation is crucial for legal and billing purposes.
  • There was nothing unusual in this, and it is backed up by the appropriate medical documentation.
  • If an applicant for an LAPL medical certificate is referred to an AME or AeMC in accordance with MED.B.001, the GMP shall transfer the relevant medical documentation to the AeMC or AME.
  • If an applicant for a Class 1 or Class 2 medical certificate is referred to the licensing authority in accordance with MED. B.001, the AeMC or AME shall transfer the relevant medical documentation to the licensing authority.
  • the medical assessor or medical staff designated by the competent authority shall evaluate the relevant medical documentation and request further medical documentation, examinations and tests where necessary; and
  • I can get you medical records, deployment documentation.
  • 'electronic health record' means a comprehensive medical record or similar documentation of the past and present physical and mental state of health of an individual in electronic form, and providing for ready availability of these data for medical treatment and other closely related purposes;
  • As you know, the FDA requires fastidious documentation of any surgically-implanted medical devices.
  • have adequate facilities, procedures, documentation and functioning equipment suitable for aero-medical examinations; and
  • falsification of medical records, certificates or documentation;
  • 3. Quotations as well as tables and other illustrative matter taken from medical journals or other scientific works for use in the documentation referred to in paragraph 1 shall be faithfully reproduced and the precise sources indicated.
  • The application for marketing authorisation shall include all the administrative information and scientific documentation necessary for demonstrating the quality, safety and efficacy of the veterinary medical product in question.
  • Quotations as well as tables and other illustrative matter taken from medical journals or other scientific works for use in the documentation referred to in paragraph 1 shall be faithfully reproduced and the precise sources indicated.
  • For medical devices of Class IIa or IIb, the notified bodies should review the technical documentation on the basis of representative samples with a frequency and depth following established best practices, taking account of the device's class, risk and novelty.
  • in addition to the documentation for the approval of an organisation required in ORA.GEN.115, provide details of clinical attachments to or liaison with designated hospitals or medical institutes for the purpose of specialist medical examinations.
  • The EESC fully agrees with the clarifications proposed for conformity assessment and the obligation to submit design documentation for the medical device, in line with the classification of the device and the novelty of the technology or treatment involved.
  • documentation and data relevant to all seafarers employed on its ships are maintained and readily accessible, and include, without being limited to, documentation and data on their experience, training, medical fitness and competence in assigned duties;

Alternatives:

  • healthcare documentation
  • medical records
  • patient charts
  • clinical documentation
  • medical files

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