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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.


n the permanent recording of information properly identified as to time, place, circumstances, and attribution.
References in periodicals archive ?
Taxpayers from a wide variety of industries had previously objected to a one-size-fits-all documentation standard; it is not surprising that the Service and Treasury declined to give "detailed guidance" on how to apply the PE requirement in specific situations.
Consider some examples to understand the importance of good physician documentation.
Consider filing all documentation related to Y2K in one place and having one manager control such files.
Balanced documentation that shows how an organization discovered and addressed problems will be a great asset, and will reduce the overall need to keep records while ensuring that sufficient records are retained.
6662-5(j)(5)(ii) requires "contemporaneous" documentation of a taxpayer's transfer pricing methodology in order to come within the reasonable cause exception.
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 average LTV ratio of loans with alternative documentation, at 80.
The availability of well-designed record-keeping systems that lower the cost of documentation will greatly facilitate the development of these differentiated markets.
If the taxpayer fails to submit the required documentation six weeks after a request, the tax authority may impose late submission penalties of up to 1 million.
This approach provides a value-added aspect by tying controls and documentation requirements under SOX to process efficiency improvements that can have a direct positive impact on the bottom line.
In addition to the proposed audit documentation SAS, the exposure draft includes proposed amendments to SAS No.

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