In healthcare, what is considered as 'documentation'?

In the context of healthcare, 'documentation' encompasses any written or recorded information regarding patient care. This includes a wide array of materials such as clinical notes, progress reports, treatment plans, and assessments that are vital for maintaining comprehensive records of a patient's medical history and treatment. Proper documentation is essential for ensuring continuity of care, facilitating communication among healthcare providers, and fulfilling legal and regulatory requirements.

Written or recorded information is critical in providing evidence of the care provided and the patient's response to that care over time. It plays a significant role in monitoring a patient's progress and outcomes, making it crucial for quality assurance within healthcare settings.

While notes taken by the patient, health insurance forms, and oral patient histories contribute to the overall understanding of a patient's health, they do not fully represent the formal or structured documentation regularly required in clinical practice. Documentation needs to adhere to specific standards and formats to ensure it effectively supports patient care and meets institutional requirements.