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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 Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings. [1]
MRHITs usually work in hospitals. However they also work in a variety of other healthcare settings, including office based physician practices, nursing homes, home health agencies, mental health facilities, and public health agencies. Technicians who specialize in coding are called medical coders or coding specialists.
ICD has a hierarchical structure, and coding in this context, is the term applied when representations are assigned to the words they represent. [30] Coding diagnoses and procedures is the assignment of codes from a code set that follows the rules of the underlying classification or other coding guidelines.
The Nursing Minimum Data Set (NMDS) is a classification system which allows for the standardized collection of essential nursing data. The collected data are meant to provide an accurate description of the nursing process used when providing nursing care. The NMDS allow for the analysis and comparison of nursing data across populations ...
The American Nurses Association recognized the Omaha System as a standardized terminology to support nursing practice in 1992. In 2014, Minnesota became the first state to recommend that point-of-care terminologies recognized by the American Nurses Association be used in all electronic health records. The evidence underlying this decision was a ...
The nursing care plan (NCP) is a clinical document recording the nursing process, which is a systematic method of planning and providing care to clients. [6] It was originally developed in hospitals to guide nursing students or junior nurses in providing care to client; however, the format was task-oriened rather than nursing-process-based. [8]
An example of an application of informatics in medicine is bioimage informatics.. Jan van Bemmel has described medical informatics as the theoretical and practical aspects of information processing and communication based on knowledge and experience derived from processes in medicine and health care.