Contemporaneous record
Definition
Notes made at or very close to the time of the event they describe. Courts give contemporaneous records more weight than later reconstructions because memory degrades and interest may shift.
Related terms
- Addendum
- A separate, dated, and signed entry added to an existing record to correct an error or supply omitted information. It preserves the...
- Interpretive language
- Words that assign cause, meaning, or legal category to a finding. Phrases such as 'consistent with sexual assault' or 'defensive wound' are...
- Objective documentation
- Recording only what can be directly observed, measured, or quoted, without inference about cause, intent, or legal category. The nurse's role is...
- SANE examination record
- The structured documentation completed by a Sexual Assault Nurse Examiner: triage, history in the patient's own words, systematic body map, specimen chain-of-custody...
- Verbatim quote
- The patient's exact words, enclosed in double quotation marks and attributed to the patient, rather than the nurse's paraphrase or summary of...
Explained in
- Forensic Nursing Documentation StandardsNotes made at or very close to the time of the event they describe. Courts give contemporaneous records more weight than later reconstructions because memory d...