Clinician Documentation Hub

Your reference for documenting patient encounters with WHO classifications.

Overview

WHO classifications are designed for clinical use and for a range of further uses, including public health, epidemiology, casemix, and patient safety. Information is therefore documented once and is directly reusable for these multiple purposes. Through the integration of terminology and classification in a single framework, ICD-11 supports documentation of clinical reality at the point of care, not only statistical aggregation.  ICF extends the framework to functioning and disability; ICHI covers health interventions. Together they provide the foundation on which clinicians can document patient encounters in a way that is meaningful at the bedside, comparable across institutions and borders, and structurally suitable for secondary use including statistics, decision support, and clinical AI.

Documentation in WHO classifications is direct. The clinician finds the concept that fits the patient encounter or moment of care to be documented - by medical term, by lay term, by chapter, by anatomy, by mechanism - and records it. Each concept is selected at the granularity that reflects current clinical knowledge - diseases and disorders where confirmed, symptom-level where not, and refined as the picture becomes clearer. Where finer clinical detail matters, postcoordination captures it. Where functioning or intervention is relevant, ICF and ICHI concepts extend the record.

Why this matters for clinicians

• Documentation that is meaningful at the point of care, in content that reflects clinical practice and medical understanding.
• Records that carry the same information across institutions, borders, and health systems without mapping or transformation. The context in which a concept was selected is preserved, so that the documentation remains correctly interpretable and its clinical use is not separated from its wider public health value.
• Structured content for decision support, research, and clinical AI - built on a code system adapted for clinical use, rather than requiring clinicians to adapt to the code system.
• A single global standard, available in multiple languages and governed transparently by the World Health Organization, supporting global surveillance and preparedness.
• WHO classifications allow clinical information to remain governed by the health system in which it is created.

  Tools for clinician documentation

  The following tools are designed for direct clinician use and for integration into electronic health records, ambient documentation systems, and clinical decision support.

  ICD-11 Browser and Coding Tool

  The ICD-11 Browser presents the full classification with lay-term search, multilingual support, rich clinical descriptions, and anatomical and mechanism-based navigation. The Coding Tool helps clinicians find the right concept quickly, including support for postcoordination. Both are available without registration at icd.who.int.

  Worth knowing for clinical use:

• Medical content is maintained on an annual update cycle, with revisions drawn largely from clinician proposals, so that concepts reflect current clinical knowledge.
• Training for clinical documentation with ICD-11 is available; see the training question under frequently asked questions below.
• The polyhierarchical view shows the primary placement of a concept in one chapter and, where relevant, its clinical relationships to concepts in other chapters.
• Search by everyday terms ("chest pain," " distal fracture of right radius, dorsal tilt ") returns clinically relevant concepts.
• Concepts include inclusions, exclusions, and clinical descriptions so the clinician can confirm fit before selecting.
• Flexible level of detail through postcoordination: use it where clinical detail matters, and omit it where the stem code is sufficient.
• Available in the WHO official languages, with further national language versions produced by Member States at different levels of completion.

  ICD-11 Coding Tool API and integration

  For developers integrating ICD-11 into electronic health records, ambient scribes, and clinical decision support tools:

• The ICD-API provides programmatic access to ICD-11 content for tool development.
• CodeFusion supports mapping and content alignment for tool builders.
• FHIR-based integration is supported through the ICD-11 FHIR endpoints.
• Implementations that import simple lists, dropdowns, or other interfaces without search functionality lose the easy classification coding and postcoordination features that the ICD-API supports. Code samples for embedding ICD-11 coding tools locally are available at https://icd.who.int/docs/icd-api/
• When a value set is needed, prefer reusing a published global value set over creating a locally adapted one. Local variants accumulate small differences that compound over time and make data comparability harder to recover.

  ICF and ICHI documentation tools

  The ICF and ICHI browsers present the two classifications that extend the clinical record beyond diagnosis. Both are available without registration.

  ICF: describes functioning

  The ICF Browser presents the classification of functioning, disability and health, covering body functions, body structures, activities and participation, and environmental factors. Functioning is recorded by combining a domain code with a qualifier stating the extent of the impairment, limitation, restriction, or facilitation, complemented by the WHODAS2 for direct assessment.

  ICHI: codes interventions

  The ICHI Browser presents the classification of health interventions. Each code is constructed from three axes - target, action, and means - so that an intervention can be recorded with clinical precision and analysed by each of these components.

  Documentation in practice

  The examples below show how clinicians document common patient encounters using WHO classifications. Each example walks through the clinical reasoning, the documentation choices, and the resulting structured record. The examples are designed to be useful both for clinicians learning to document in ICD-11, ICF, and ICHI, and for developers of clinical documentation tools.

  Example 1 - Primary care visit with multi-system presentation

  Clinical scenario

  A 58-year-old patient presents to primary care with several months of fatigue, intermittent chest discomfort on exertion, increased thirst, and a recent ankle swelling. Past history includes hypertension on medication. Examination shows BMI 31, blood pressure 152/94, mild bilateral ankle oedema, otherwise unremarkable. Initial blood tests show HbA1c 8.1% and fasting glucose 9.4 mmol/L.

  Documentation

  Documented concepts	ICD-11
  Primary diagnosis	[5A11] Type 2 diabetes mellitus
  Comorbidity	[BA00.Z] Essential hypertension
  Symptom requiring further workup	[MD30.Z] Chest pain
  Risk factor	[5B81.Z] Obesity
  Examination finding	[MG29.01] Oedema of legs

  Clinical reasoning

  The clinician documents the new diagnosis of Type 2 diabetes (the HbA1c and fasting glucose are diagnostic), the established hypertension as comorbidity, and the chest pain on exertion as a symptom requiring cardiac workup rather than a diagnosis at this stage. Obesity is documented as a modifiable risk factor relevant to management. The peripheral oedema is documented as an examination finding pending further evaluation.

  Why this works

  The documentation captures the clinical reality: a new diagnosis with comorbidity and a symptom that needs investigation. Each concept is selected at the granularity that reflects current clinical knowledge - definitive where confirmed, symptom-level where not. The structured output supports subsequent care (the chest pain prompts cardiac investigation), population health reporting (diabetes incidence), and clinical decision support (medication interactions, screening reminders).

  Example 2 - Hospital discharge with comorbidities and intervention

  Clinical scenario

  A 67-year-old patient is discharged after elective laparoscopic total sigmoid colectomy for a stage 1 adenocarcinoma of the sigmoid colon (pT1 pN0 M0, moderately differentiated). Past history: type 2 diabetes mellitus on metformin, essential hypertension, BMI 29. Post-operative course was uncomplicated. At discharge, the patient is mobilizing independently with mild fatigue and reduced exercise tolerance, eating a soft diet, with the wound healing well. Histology confirms clear resection margins; the multidisciplinary team has recommended surveillance without adjuvant chemotherapy. A community nurse visit is arranged for wound check on day 5.

  Documentation

  Documented concepts	ICD-11
  Primary diagnosis	[2B90.30] Adenocarcinoma of sigmoid colon
  Stage (postcoordination)	& [XS7A] Stage 1
  Grade (postcoordination)	& [XS58] Histopathological grade 2 (moderately differentiated)
  Comorbidity	[5A11] Type 2 diabetes mellitus
  Comorbidity	[BA00.Z] Essential hypertension
  	[5B80.0Z] Overweight

   

  Documented intervention	ICHI
  Surgical intervention	[KBU.JK.AB] Laparoscopic sigmoidectomy

   

  Functioning - discharge profile	ICF
  Activities - walking	d450.qp1 (mild limitation)
  Activities - Carrying out daily routine	d230.qp1 (mild limitation)
  Body functions - Exercise tolerance	b455.qp2 (moderate impairment)
  Environmental factors - Health services and support	e580.qf3 (substantial facilitator)

   

  Clinical reasoning

  The discharge record captures three distinct clinical layers. The cancer diagnosis is documented with full staging and grading postcoordination, so the record carries the prognostic information needed for surveillance planning and cancer registry reporting in a single structured expression. The comorbidities are documented as they remain clinically active and influence post-discharge care (glycaemic monitoring, antihypertensive continuation). The intervention is captured in ICHI, whose codes are constructed from three axes - target, action, and means - so that the record preserves the clinical specificity of the procedure while remaining analysable by each of these components. The ICF discharge profile records what the patient can do on leaving hospital, which is the information the community nurse and the patient's GP need to support recovery. The diagnosis tells them what the patient has; the ICF profile tells them what to help with.

  Why this works

  This is the documentation a receiving clinician - GP, community nurse, oncology follow-up team - actually needs. Diagnosis alone (stage 1 colon cancer, status post-resection) is insufficient for continuity of care: it does not say whether the patient can climb stairs, manage their medications, or return to driving. The ICF layer answers those questions in structured form. The ICHI intervention code carries forward into long-term records as a precise statement of what surgery was performed, which becomes relevant if recurrence, anastomotic complications, or future abdominal surgery arise. The combination supports oncology registries (ICD-11 stem + staging cluster), surgical audit (ICHI), rehabilitation planning (ICF), and clinical decision support - all from one structured discharge record.

  WHO classifications and clinical AI

  Clinical artificial intelligence is moving rapidly into documentation work. Ambient scribes generate clinical notes from conversation. Dictation systems propose structured codes from free text. Decision support tools draw on structured patient records to suggest investigations, treatments, and follow-up. Large language models with clinical capabilities increasingly produce or assist in producing clinical documentation.

  All of these tools depend on the terminology substrate that encodes clinical reality into structured form. The properties of that substrate - its openness, its governance, its stability, its lawful availability across health systems - become the properties of the tools built on it.

  Why WHO classifications work for clinical AI

• WHO classifications are openly available worldwide under published licensing terms that are the same in every Member State. Licensing of the classification content is therefore not a source of variation between countries, although the deployment of any clinical AI tool remains subject to national law, including data protection and medical device regulation.
• WHO classifications are stable. The update cycle is transparent, the governance is published, and changes are coordinated through public processes.
• WHO classifications are governed for the public interest. Encoding documentation in WHO classifications places no royalty or membership restriction of its own on the downstream use of that documentation; what may be done with the data is determined by the health system that holds it and by applicable law.
• The data stays with the clinician’s health system. Encoding patient documentation in WHO classifications does not transfer ownership or governance of the data to any external owner: the data and any AI training based on it remain governed by the clinician’s health system and applicable national data protection law. The WHO licensing framework governs only the classifications themselves.
• WHO classifications cover the core clinical domain (diagnoses, functioning, interventions, and external causes), with derived and related classifications such as ICD-O extending coverage into adjacent areas. The integration of terminology and classification means a single system supports diagnosis, functioning, intervention, and external cause - the substrate a clinical AI needs to work end-to-end.

  What this means for clinicians using AI documentation tools

  When you use a clinical AI tool that produces or assists in producing documentation, the substrate matters. Ask whether the tool is built on WHO classifications or on a proprietary terminology layer. Tools built on WHO classifications use classification content that is licensed on the same published terms in all WHO Member States. That content is developed through consensus among Member States, scientific experts, and civil society organizations.

  WHO works with HL7, ISO/TC 215, and CEN on the alignment of WHO classifications with the international interoperability standards on which clinical AI tools depend. This work supports tool developers building on a substrate that is stable, openly governed, and lawfully usable worldwide.

  Working with WHO on clinical documentation

  Clinicians shape WHO classifications. The content of ICD-11, ICF, and ICHI reflects continuous input from clinical practice through the WHO-FIC Network, Collaborating Centres, professional societies, and individual clinician contributors.

  Channels for clinical input

• Proposals for content changes can be submitted through the ICD-11 Proposal Platform. The Platform supports proposals for new concepts, clarifications, and corrections.
• Collaborating Centres in each region work directly with clinical communities.
• Professional societies and other non-governmental organizations engaged with WHO classifications provide a further route for clinical input.

  WHO-FIC Network

  The WHO Family of International Classifications Network coordinates the development, implementation, and maintenance of WHO classifications. Collaborating Centres across WHO regions support clinical implementation, training, and content development. Clinicians interested in deeper engagement with WHO classifications can connect through their regional Collaborating Centre.

  Frequently asked questions

  These FAQs address questions clinicians commonly ask about documenting in WHO classifications.

  Do I have to be a trained coder to document in ICD-11?

  No. ICD-11 is designed for direct clinician use. The Coding Tool's natural language search lets clinicians find concepts using the language of clinical practice rather than coding terminology. Coding specialists remain important for complex cases and for specialized use cases, but day-to-day clinical documentation does not require coder training.

  What if my electronic health record doesn't support ICD-11 yet?

  ICD-11 adoption in EHR systems is ongoing. Where ICD-11 is not yet integrated into your EHR, the Coding Tool at icd.who.int is available as a free-standing reference. Many EHR vendors are developing ICD-11 support; clinical demand from users accelerates this work. National health authorities and Collaborating Centres provide guidance on transition planning.

  Is postcoordination required for routine documentation?

  No. Postcoordination (code combination) is available for where such a clinical detail matters. For routine documentation where the base concept captures the clinical reality, or the detail ins not required for other reasons, the base code is often sufficient. Use postcoordination for severity, anatomy, laterality, temporality, and similar dimensions where they are clinically relevant, and omit it where they are not.

  How does documenting in ICD-11 differ from documenting with other terminologies?

  ICD-11 is designed as an integrated framework that combines both a clinical terminology in the Foundation, and classification structures, such as the Mortality and Morbidity Statistics (MMS) linearization. This supports both detailed knowledge of clinical concepts and their relationships, and tools for aggregation, reporting, and statistical analysis.

  ICD-11 provides a framework that links clinical documentation and statistical reporting, while other terminologies may rely on additional analytical models, value sets, or mappings to support aggregation and reporting.

  What happens to my documentation when it is used for AI training?

  WHO licensing governs the classification content and tools (ICD-11, ICF, ICHI, and the related software); it does not govern patient data. Whether documentation may be used to train an artificial intelligence system is determined by the health system that holds the data and by applicable national law and policy. Encoding documentation in WHO classifications adds no licensing restriction of its own to that decision.

  Can I propose changes or additions to ICD-11 content?

  Yes. The ICD-11 Proposal Platform at icd.who.int/dev11 accepts proposals for new concepts, clarifications, and corrections from any clinician or researcher. Proposals are reviewed by the relevant content advisory groups. Many of the refinements in ICD-11 over the past decade have come from clinician proposals. Basic information is also available online in the format of videos at www.youtube.com/@WHOICD-11.

  How are ICD-11 updates managed and how often do they occur?

  ICD-11 is maintained on an annual update cycle. Updates are coordinated through the WHO-FIC Network, which brings together technical, medical, and statistical expertise, and are published with version identifiers so that documentation from any point in time can be interpreted unambiguously. National implementers and EHR vendors plan their transitions to incorporate updates on a predictable schedule.

  Is ICD-11 available in languages other than English?

  ICD-11 is translated into the WHO official languages and into other national languages by Member States. The Coding Tool supports multilingual search and presentation. Specific current language coverage is published at different levels of completion.

  Where do I get training in clinical documentation with WHO classifications?

  Training is available through several channels: Online modules on classifications; Collaborating Centres in your region; national health authorities implementing ICD-11; and professional societies engaged with WHO classifications. The WHO-FIC Network maintains an inventory of training resources. Basic information is also available online in the format of videos at www.youtube.com/@WHOICD-11.

  What do Foundation, MMS, and postcoordination mean?

  The Foundation is the underlying knowledge base of ICD-11 - the encyclopedia of clinical concepts and their relationships. A concept can sit under more than one parent (gastric cancer is both a cancer and a gastrointestinal disease). Coding tools draw on the Foundation - its synonyms, lay terms, and relationships - to lead the clinician to the concept that fits the case.

  The MMS (Mortality and Morbidity Statistics) is a linearization derived from the Foundation - the table of contents used for counting. Each case lands in one MMS bucket, the buckets are mutually exclusive and exhaustive, and residual categories (“other specified”, “unspecified”) ensure that nothing falls outside the count. Other linearizations exist for specific purposes such as primary care.

  Pre-coordination means one concept expressed as one term: Gastric cancer stage 2 grade 2. Postcoordination means the same idea built from parts: Gastric cancer + Cancer stage 2 + Grade 2. Either is valid; use postcoordination when the clinical detail matters and a pre-coordinated concept is not available.

  For clinical work, the practical consequence is that documentation is recorded at the granularity clinical knowledge supports, while the linearization used for reporting determines how that documentation is aggregated for statistical purposes. Implementations differ in whether clinicians record against Foundation concepts or directly against a linearization such as the MMS; national implementation guidance states which applies.

  Related pages

• WHO Family of International Classifications and Terminologies - the institutional context for WHO classifications.
• WHO-FIC Interoperability Hub - technical resources for the integration of WHO classifications into digital health systems.
• International Classification of Diseases (ICD) - the main page for ICD-11.
• International Classification of Functioning, Disability and Health (ICF).
• International Classification of Health Interventions (ICHI).
• Youtube channel for ICD-11

  References

  • ICD-11 Browser: icd.who.int
  • ICD-11 Coding Tool and API documentation: icd.who.int/docs/icd-api/
  • ICD-11 Reference Guide: icdcdn.who.int/icd11referenceguide/en/html/index.html
  • ICD-11 Proposal Platform: icd.who.int/dev11
  • WHO-FIC Network: who.int/groups/who-family-of-international-classifications-network