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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.
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.
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.
A written record of information.