What type of documentation is made by healthcare clinicians related to a patient's medical condition or treatment?

Clinical documentation encompasses all written records created by healthcare clinicians that include patient information related to diagnoses, treatment plans, and the course of patient care. This documentation plays a crucial role in ensuring accurate communication among healthcare providers, supporting clinical decision-making, and facilitating continuity of care. It includes a wide range of documents such as notes from patient encounters, assessments, plans, and treatment updates, which are essential for maintaining a comprehensive record of a patient's health status and interventions over time.

While other options like patient history records and electronic health records are part of the broader spectrum of clinical documentation, they refer to specific elements or structures within that documentation. Progress notes, on the other hand, are specific types of clinical documentation that detail a patient's ongoing treatment and response to care but do not encompass the entirety of what clinical documentation represents.