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ICD-10 Procedure Coding System (ICD-10-PCS) (for inpatient use; used in United States) ICD-9-CM Volume 3 (subset of ICD-9-CM) (formerly used in United States prior to the introduction of the ICD-10-PCS) Nursing Interventions Classification (NIC) (used in United States) [3] Nursing Minimum Data Set (NMDS) Nursing Outcomes Classification (NOC)
Nursing Interventions: A nursing intervention is defined as a single nursing action – treatment, procedure or activity – designed to achieve an outcome to a diagnosis, nursing or medical, for which the nurse is accountable. [12] Patient services are usually initiated as medical orders by a referring physician and reviewed by the admitting ...
Types of coding systems specific to health care include: Diagnostic codes. Are used to determine diseases, disorders, and symptoms; Can be used to measure morbidity and mortality; Examples: ICD-9-CM, ICD-10, ICD-11 [1] Procedural codes. They are numbers or alphanumeric codes used to identify specific health interventions taken by medical ...
The second two levels form a taxonomy in which each intervention is grouped into 27 classes, and each class is grouped into six domains. An intent of this structure is to make it easier for a nurse to select an intervention for the situation, and to use a computer to describe the intervention in terms of standardized labels for classes and domains.
Adoption of ICD-10-CM was slow in the United States. Since 1979, the US had required ICD-9-CM codes [11] for Medicare and Medicaid claims, and most of the rest of the American medical industry followed suit. On 1 January 1999 the ICD-10 (without clinical extensions) was adopted for reporting mortality, but ICD-9-CM was still used for morbidity ...
These nursing actions can take place at any point in the patient's recovery. For example, the ICU nurse may put in a long-term disability referral for a patient who is likely to survive ICU with new physical deficits. Furthermore, a home care nurse could suggest a peer-support group for a PICS patient with new social dysfunctions.
The National Institutes of Health Stroke Scale, or NIH Stroke Scale (NIHSS), is a tool used by healthcare providers to objectively quantify the impairment caused by a stroke and aid planning post-acute care disposition, though was intended to assess differences in interventions in clinical trials. The NIHSS was designed for the National ...
The NOC is a system to evaluate the effects of nursing care as a part of the nursing process. The NOC contains 330 outcomes, and each with a label, a definition, and a set of indicators and measures to determine achievement of the nursing outcome and are included The terminology is an American Nurses' Association -recognized terminology, is ...