Clinical Documentation Basics (Medi-Cal)

Clinical documentation consists of all notes clinicians make regarding a patient’s health status and treatment. This course covers key aspects of clinical documentation, including the different types, important characteristics, and best practices for monitoring performance.

  • Identify types of clinical documentation
  • Name the seven key characteristics of quality clinical documentation
  • Identify benefits and drawbacks of different electronic health record, or EHR, data entry methods
  • Associate different EHR data entry methods with their ideal usages
  • Choose key practices for monitoring documentation performance

Additional Information

Advance Preparation: None

Prerequisites: None

Program level: Basic

Delivery Method: Self-study

CPE Field of Study: Specialized Knowledge


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