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Documentation is a form of communication that provides information about the healthcare client and confirms that care was provided. Accurate, objective, and complete documentation of client care is required by both accreditation and reimbursement agencies, including federal and state governments. Purposes of documentation include:

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The importance of good documentation practice needs to be emphasized to investigator sites to ensure that the study results are built on the foundation of credible and valid data. This article focuses on the key principles of good documentation practice and offers suggestions for improvement.

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Submission of Documentation: The time period to submit documentation is 14 business days from the date that you receive a written request from your housing provider asking that you provide documentation of the occurrence of domestic violence, dating violence, sexual assault, or stalking.

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to the patient, and made at or around the time indicated in the documentation. ¾ The medical record may include records maintained in an electronic medical / record system, e.g., an electronic system framework that integrates data from multiple sources, captures data at the point of care, and supports caregiver decision making.

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important for documentation of source data to be standardized across all sites to ensure consistency of the trial data. Scope This SOP is based upon: 1) the Code of Federal Regulations (CFR), 2) guidances that apply to the involvement of human subjects in clinical research, and …

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