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written notations in a patient's record. in the nursing interventions classification, a nursing intervention defined as recording of pertinent patient data in a clinical record.


Etymology: L, documentum, proof
written material associated with a computer or a program. Kinds of documentation include user documentation, an instruction manual that provides enough information to allow an individual to use the system; system documentation, a complete description of the hardware and software that make up a system; and program documentation, a general and specific description of what a program does and how it does it.


a nursing intervention from the Nursing Interventions Classification (NIC) defined as recording of pertinent patient data in a clinical record. See also Nursing Interventions Classification.


All records in any form—including written, electronic, magnetic and optical, scans, X-rays, EKGs, etc.—that describe or record the methods, conduct and/or results of a clinical trial, the factors affecting the study, and any actions taken during the trial’s performance.


Medical practice The creation of a formal record, especially those that record Pt-physician contacts with dates–and often times and 'document' various aspects of Pt management; in certain types of Pt care–eg, cosmetic surgery, photographs are used as documentation of such interactions. See Defensive medicine, Forensic documentation, Medical documentation, Photodocumentation.


A written record of information.
References in periodicals archive ?
There is frequent duplication of effort, since there is no means to utilize each other's documentation.
103 Differ" on page 65, and "The New Audit Documentation Requirements," JofA, Apr.
The availability of well-designed record-keeping systems that lower the cost of documentation will greatly facilitate the development of these differentiated markets.
The average LTV ratio of loans with alternative documentation, at 80.
Tracking and scheduling processes with historical tracking and appropriate documentation attachments--enhanced with alerts driven by integrated benchmarking and scorecarding--reduce the effort; increase the visibility of an operation's efficiency and effectiveness; and ultimately improve the cost/benefit factor of compliance.
Ensuring that your documentation is complete and timely is more than a one-person job.
Is the documentation confidential and, if so, how do you insure this?
PATA members have endeavored to develop a set of principles and document guidelines pursuant to which multinational taxpayers may create and maintain a single package of transfer-pricing records and documentation (hereinafter the "PATA documentation package") in order to satisfy the transfer-pricing documentation requirements of all PATA members.
Numerous tax authorities have followed the lead of the Internal Revenue Service (IRS), enforcing the "arm's length standard" for transfer pricing by means of documentation requirements with penalties for noncompliance.
GOOD DOCUMENTATION SKILLS HAVE ALWAYS BEEN IMPORTANT clinically speaking, but they take on new significance under Medicare's prospective payment system.

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