Clinical document

Source:http://linkedlifedata.com/resource/umls/id/C1828480

HL7V3.0: <p>A clinical document is a documentation of clinical observations and services, with the following characteristics:</p><ol><li><p>Persistence - A clinical document continues to exist in an unaltered state, for a time period defined by local and regulatory requirements;</p></li><li><p>Stewardship - A clinical document is maintained by a person or organization entrusted with its care;</p></li><li><p>Potential for authentication - A clinical document is an assemblage of information that is intended to be legally authenticated;</p></li><li><p>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;</p></li><li><p>Human readability - A clinical document is human readable.</p></li></ol>

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