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Electronic nursing documentation systems have been implemented in health care organizations to bring in the benefits of increasing access to more complete, accurate and up-to-date data and reducing redundancy, improving communication and care service delivery. [14]
Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance ...
The normalization process model is a sociological model, developed by Carl R. May, that describes the adoption of new technologies in health care.The model provides framework for process evaluation using three components – actors, objects, and contexts – that are compared across four constructs: Interactional workability, relational integration, skill-set workability, and contextual ...
Her methodical approach, as well as the emphasis on uniformity and comparability of the results of health care, is recognised as one of the earliest programs of outcomes management. Another notable figure who advocated clinical audit was Ernest Codman (1869–1940). Codman became known as the first true medical auditor following his work in ...
The patient health record is the primary legal record documenting the health care services provided to a person in any aspect of the health care system. The term includes routine clinical or office records, records of care in any health related setting, preventive care, lifestyle evaluation, research protocols and various clinical databases.
The ultimate objective is to improve the safety, quality, and efficiency of healthcare as well as access to healthcare through the efficient application of health information technology. RHIOs are also intended to support secondary use of clinical data for research as well as institution/provider quality assessment and improvement. [1]
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Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]