Category: Clinical governance

Studies have shown that facilities that utilize evidence-based protocols can significantly reduce medical errors, improve patient outcomes, and increase operational efficiency. This highlights why it is so important to understand what does protocol mean in health and social care, as these systematic guides form the foundation of safe and effective service delivery.

According to the Centers for Medicare & Medicaid Services (CMS), healthcare providers are ultimately responsible for ensuring all patient encounters are documented completely and accurately. Determining who is responsible for clinical documentation involves understanding a collaborative, multi-layered process that impacts patient care, compliance, and billing. This guide explores the different roles involved.