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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.
Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. © 2003 by Saunders, an imprint of Elsevier, Inc. All rights reserved.
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.
Segen's Medical Dictionary. © 2012 Farlex, Inc. All rights reserved.
documentationMedical 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.
McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc.
A written record of information.
Medical Dictionary for the Dental Professions © Farlex 2012