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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.