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