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Healthcare systems are complex in that they are diverse in both structure (e.g. nursing units, pharmacies, emergency departments, operating rooms) and professional mix (e.g. nurses, physicians, pharmacists, administrators, therapists) and made up of multiple interconnected elements with adaptive tendencies in that they have the capacity to change and learn from experience.
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]
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]
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.
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.
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 Iowa Model is used to promote quality of care. It is a guideline for nurses in their decision-making process. The decision making can include clinical and administration practices. These practices affect patient outcomes. The model is based on problem-solving steps that are a part of the scientific process.
The Nursing Interventions Classification (NIC) is a care classification system which describes the activities that nurses perform as a part of the planning phase of the nursing process associated with the creation of a nursing care plan.