Documented
Documented
Documented (/dɒkjʊˈmɛntɪd/), from the Latin documentum meaning "example, proof, lesson", is a term used in various fields, including medicine, to refer to something that has been recorded, catalogued, or verified in some way.
In the medical field, a documented condition or treatment refers to one that has been officially recorded in a patient's medical records. This can include diagnoses, test results, treatment plans, and patient histories. Documented information is crucial for ensuring continuity of care, tracking patient progress, and conducting medical research.
Related Terms
- Medical record: A detailed account of a patient's medical history and care.
- Diagnosis: The identification of the nature of an illness or other problem by examination of the symptoms.
- Treatment plan: A detailed plan with information about a patient's disease, the goal of treatment, the treatment options for the disease and possible side effects, and the expected length of treatment.
- Patient history: Information obtained from the patient to aid in establishing a medical diagnosis and developing a treatment plan.
- Medical research: The study of health and disease in people. It is the way we learn how to prevent, diagnose and treat illness.
See Also
- Electronic Health Record: An electronic version of a patient's medical history that is maintained by the provider over time.
- Clinical documentation: Includes all clinical data, test results, and other clinically relevant information.
References
- Medical Terminology: A Living Language (6th Edition) by Bonnie F. Fremgen and Suzanne S. Frucht
- Taber's Cyclopedic Medical Dictionary (23rd Edition) by Donald Venes
External links
- Medical encyclopedia article on Documented
- Wikipedia's article - Documented
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