ADOC documentation requirements are the details Abu Dhabi doctors record in each outpatient note so the visit can be coded, classified, and paid correctly under the Abu Dhabi Outpatient Classification (ADOC).
The Department of Health Abu Dhabi (DoH) bases code assignment on documentation by the provider responsible for the diagnosis. Every note should state why the patient came, what was done, and how certain the diagnosis is.
In outpatient care, a diagnosis written as “suspected” or “rule out” is not coded. Coders code what is known for that visit instead, such as signs, symptoms, or abnormal test results.
The timing matters. Under DoH Circular 76/2026, ADOC shadow billing became mandatory on 1 July 2026 for all outpatient providers except dental service providers and pharmacies. From 1 January 2027, ADOC becomes the main way outpatient care is paid in Abu Dhabi.
This guide sets out what ADOC clinical notes should include and the gaps to fix before go-live.
What Are ADOC Documentation Requirements and Why Do They Matter Now?
Under ADOC, the doctor’s note is the starting point for every outpatient claim. Coders turn what the note says into codes, and DoH states that coded data is used to reimburse claims between payers and providers. Meeting ADOC documentation requirements means giving coders enough clear detail to code the visit accurately.
When detail is missing, accuracy drops. The DoH Coding Manual says “unspecified” codes are used when the medical record lacks enough information for a more specific code.
ADOC is the DoH payment method for outpatient care. Shadow claims go through the Shafafiya platform and must follow the ADOC Definitions Manual and DoH’s approved calculation rules.
| Date | What DoH set out |
| May to June 2026 | Draft pricing details and orientation workshops for providers |
| 1 July 2026 | Mandatory shadow billing starts on Shafafiya |
| 1 January 2027 | ADOC becomes the primary reimbursement method for outpatient services |
DoH has told insurers and TPAs that shadow billing must not affect normal claim settlement, payments, or approvals. One of the phase’s stated aims is accuracy in classification and calculation. For ADOC Abu Dhabi providers, these months are the time to check that notes support correct classification.
What Must ADOC Clinical Notes Include for Every Outpatient Visit?
ADOC clinical notes should show who was seen, why they came, what the clinician found, and what was done. Coders use these facts to assign diagnosis and procedure codes under the DoH Coding Manual. When one is missing, the coder has to query the doctor or settle for a less specific code.
Who Was Seen, and Who Made the Diagnosis?
DoH requires providers to capture a minimum data set in their EMR and send it to Malaffi, the Abu Dhabi Health Information Exchange. This includes patient identifier details and clinical encounter information.
The note should also make clear which clinician is responsible for the diagnosis, because DoH bases code assignment on that provider’s documentation. Other clinicians can record some details, such as BMI or pressure ulcer stage. The related diagnosis must still come from the responsible provider.
Why Did the Patient Come, and How Certain Is the Diagnosis?
For outpatient visits, DoH defines the principal diagnosis as the reason the patient presented, together with the clinician’s assessment. It should match the tests or services given. If the cause is not yet known, a symptom can be the principal diagnosis.
Record these for every visit:
- The chief complaint, usually in the patient’s own words
- The clinician’s assessment
- A confirmed diagnosis, or the signs and symptoms if it is still uncertain
Terms such as “probable,” “suspected,” or “rule out” mean the condition is not coded for that outpatient visit. Coders code the signs, symptoms, or abnormal results instead.
What Was Done, and What Else Affected Care?
- Procedures: describe each one exactly. DoH tells coders not to pick a code that only roughly matches the service.
- Coexisting conditions: include chronic conditions that affected care at this visit. DoH excludes conditions with no bearing on the encounter.
- Interpreted tests: for test-only visits, state any confirmed diagnosis in the physician’s final report. Coders code that diagnosis.
- Complications: write the link between the condition and the care. DoH requires the note to show cause and effect.
How Do Coders Handle Unclear or Conflicting Notes?
When a note is unclear, DoH tells coders to ask the doctor rather than guess. The DoH Coding Manual lists querying and clarification as a standard step in the coding process. It also calls for a joint effort between the provider and the coder to reach complete and accurate documentation.
The table shows how common note problems are handled, and what doctors can do to prevent each one.
| Note problem | What DoH tells coders to do | What the doctor can do |
| Not enough detail for a specific code | Use an “unspecified” code | Record the specific details the condition requires |
| Entries conflict, from one or several clinicians | Query the attending provider | Check that all entries for the visit agree |
| A complication is not clearly linked to care | Query the provider | State the cause-and-effect link in the note |
| Diagnosis is uncertain | Code signs, symptoms, or abnormal results | Say clearly whether the diagnosis is confirmed |
| No code matches the procedure exactly | Use an unlisted code, never a close match | Describe exactly what was done |
Meeting ADOC documentation requirements comes down to this: the note must fully support the code chosen, as the DoH Coding Manual requires.
How Long Must Abu Dhabi Clinics Keep Patient Records?
Abu Dhabi clinics must keep patient records for set minimum periods under both DoH and UAE federal rules. The DoH standard sets five years from the last treatment for medical purposes. UAE Federal Law No. 2 of 2019 sets at least 25 years for health information kept through electronic systems.
What Counts as Health Information?
The DoH retention standard (issued in 2015 under DoH’s former name, HAAD) defines health information broadly. It includes:
- Medical notes and care plans
- Diagnostic tests, test results, and imaging data
- Drug and treatment prescriptions
The rules apply to paper, electronic, and film records alike.
What Are the Minimum Retention Periods?
| Rule | Minimum period |
| DoH standard, medical purposes | 5 years from the last treatment |
| DoH standard, insurance purposes (Article 23) | At least 2 years from the last insurance policy or treatment, whichever is later, with permanent disposal only 5 years after the last treatment |
| Federal Law No. 2 of 2019, Article 20 | At least 25 years from the last health procedure, for health information kept through electronic systems |
DoH also bans destroying birth and death records. No record may be destroyed while litigation, or an investigation by DoH or another competent authority, is pending.
Because these periods differ, clinics should confirm with DoH which one applies to their records.
Who Can See the Record?
Records of care given to insured patients are confidential. A third party can see them only:
- With the patient’s written consent
- On the order of a court, the police, or DoH
- Where the health insurance regulation requires it, and the recipient agrees to keep the information confidential
An insured patient who changes provider can ask for a complete copy of their file.
Which Documentation Gaps Cause ADOC Claim Problems?
Most claim problems start with a note that is missing one clear fact. Under the DoH Coding Manual, these gaps can lead to invalid, less specific, or wrongly ordered diagnosis codes. DoH uses that coded data to reimburse claims.
- Too little detail for a complete code. DoH treats a diagnosis code as invalid if it lacks a required character. Fix: record details such as the side of the body, or whether an injury visit is the first or a follow-up.
- A symptom kept as the main diagnosis after confirmation. Symptom codes should not be the principal diagnosis once a related definitive diagnosis is established. Fix: write the confirmed diagnosis clearly.
- Old problems carried into today’s note. Conditions that were treated and no longer exist are not coded. Fix: separate active problems from resolved ones.
- No reason given for a test. Testing because of a sign or symptom counts as diagnostic, not screening. Fix: state why each test was ordered.
- The treated condition is missing from therapy visits. For chemotherapy or radiation therapy visits, DoH rules list the service code first, then the condition being treated. Fix: name the condition in every therapy note.
Checking notes against these ADOC documentation requirements regularly helps ADOC Abu Dhabi clinics catch gaps early.
How Can Clinics Build ADOC-Ready Notes Before 1 January 2027?
Clinics can meet ADOC documentation requirements by fixing note habits during shadow billing, while payments still run on the current model. The work is shared between doctors, coders, and the tools that support them.
For Doctors
- Write the reason for the visit and your assessment in every note.
- State plainly whether each diagnosis is confirmed or still uncertain.
- Describe procedures exactly, and say why each test was ordered.
- Answer coder queries quickly, since DoH expects coders to ask when notes are unclear.
For Coders and Documentation Teams
- Confirm every coder meets DoH certification rules: membership of a body such as AHIMA or AAPC, or a bachelor’s degree or higher diploma in health information management or medical records, plus at least two years of coding experience.
- Work from the latest ADOC files on the DoH Shafafiya Prices page.
- Track repeat query reasons and share them with doctors.
Where Do AI Scribes Fit?
AI scribes can draft ADOC clinical notes from the consultation, which reduces manual typing. A tool such as HealthOrbit’s ambient AI scribe produces a first draft, but the doctor stays responsible for the final note. Review every draft carefully before signing.
DoH has also issued a policy on AI use in Abu Dhabi healthcare, so check any tool against it.
What Should Abu Dhabi Clinics Do Next?
Start by auditing a sample of recent outpatient notes. Check each for the visit reason, a clear diagnosis status, and an exact record of what was done, then fix gaps before 1 January 2027.
HealthOrbit AI can help. The Ambient AI Scribe drafts notes for doctor review, the Medical Coding Engine suggests codes from them, and the Claim Scrubber checks claims before submission. Book a demo to see it in your workflow.
Frequently Asked Questions About ADOC Documentation Requirements
What are the ADOC documentation requirements for an outpatient visit?
ADOC documentation requirements are the facts a doctor records so an outpatient visit can be coded and paid correctly. The note should state the reason for the visit, the clinician’s assessment, how certain the diagnosis is, and what was done. DoH bases code assignment on documentation by the provider responsible for the diagnosis.
Do ADOC clinical notes need to say whether a diagnosis is confirmed?
Yes, they should. Under the DoH Coding Manual, outpatient diagnoses written as “probable,” “suspected,” or “rule out” are not coded. Coders code signs, symptoms, or abnormal test results instead, so ADOC clinical notes should state clearly when a diagnosis is confirmed.
Does ADOC Abu Dhabi shadow billing apply to dental clinics and pharmacies?
No. DoH excluded dental service providers and pharmacies from the mandatory ADOC shadow billing phase that began on 1 July 2026. All other outpatient providers, insurers, and claims management organizations must take part.
When does ADOC become the main payment method for outpatient care?
ADOC becomes the primary reimbursement method for outpatient services in Abu Dhabi on 1 January 2027. Until then, shadow billing must not affect normal claim settlement, payments, or approvals.
