The preparation and updating of a hospital patient’s chart by nurses and doctors.
The process of creating a medical record for a patient. It includes the writing of nurses’ and doctors notes, and addition of test results and other documentation relevant to the patient’s stay and progress in the hospital.
The process of making a tabulated record of a patient’s progress and treatment during an illness, outpatient procedure, office visit, or hospitalization. The physician and other health care providers need detailed information about the patient that the nurse or other members of the health care team may contribute through observation and contact. These notes and flow sheet entries contain details used in planning, implementing, and evaluating patient care.