documentation


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documentation

 [dok″u-men-ta´shun]
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.

documentation

EBM
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.

documentation

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.

doc·u·men·ta·tion

(dokyū-mĕn-tāshŭn)
A written record of information.
References in periodicals archive ?
Observe a documentation test by another writer and participate in the debriefing.
Acceptance of documentation for conducting state examination of land management documentation, as well as issuing of prepared conclusions is carried out through the center of administrative services.
Baseline audit results suggested a need for standardization of documentation.
Regardless of how documentation is created, Nuance Velocity delivers structured documentation and high quality narrative to the EHR.
As such, leaders need to hurry up and zero in on implementing the clinical documentation improvement initiatives that can lead to success under ICD-9 today--and more importantly under ICD10 down the line.
Medical informaticists Velasco, Saxena, and Reddy, and their colleagues at THR, Ad ventist, and UPMC, are all finding their way towards strategies that engage physicians in their organizations and achieve successful adoption of both documentation and CPOE.
Meanwhile, BluePrint is a full 2-D drafting tool designed specifically to create PCB documentation and capable of creating anything that the CAD, fabrication and assembly departments might need.
As a result, corporate financial managers should consider engaging competent legal and tax advisors to assist in the development and issuance of transfer pricing policies and documentation, as well as consider appropriate transfer pricing planning techniques--with the proper support and documentation--to minimize corporate tax rates effectively.
Company B made the presumption that individualized, customized documentation templates are highly valued by all anesthesia groups, including those of the hospital in our example.
Other activities may fall solely under CM, such as validating the integrity of the configuration documentation and the consistency between a product and its documentation.
96, Audit Documentation, made the most significant changes to audit workpaper guidance in more than three decades.
Sebald, who appeared here in a video produced by the CCCB, carried to an extreme the pseudo-authentic effect created by conventions of image documentation, in that he combined it with fiction.

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