Healthcare documentation having two parts: information captures and report generation. Both have to be considered in order to have high-quality documentation.
Information captures is the process of recording representations of human thought, perception, or action in documenting patient care, as well as device-generated information that is gathered and/or computed about a patient as a part of health care. (MRI, 2004, p. 2)
Report generation consists of the formatting and/or structuring of captured information. It is the process of analyzing, organizing, and presenting recorded patient information for authentication and inclusion in the patient healthcare record. (MRI, 2004, p. 2)