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The systematic review of nursing documentation audit studies in different settings [19] identified the following relevant quality characteristics of nursing documentation: Quality of documentation structure and format: relates to constructive features and physical presentation of records such as quantity, completeness, legibility, read- ability ...
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 nurse.
must hold a current, unrestricted practical/vocational nurse license in the United States or its territories and must have hospice and palliative licensed practical/vocational nursing practice of 500 hours in the most recent 12 months or 1000 hours in the most recent 24 months prior to applying for the examination.
A number have deeming power for Medicare and Medicaid.. American Association for Accreditation of Ambulatory Surgery Facilities [2] (AAAASF); Accreditation Association for Ambulatory Health Care (AAAHC)
Audits of providers of health care services full-text: 31-02: 1990: Audits of providers of health care services, second edition full-text: 31-03: 1990: Audits of providers of health care services, as of December 31, 1990 full-text: 31-04: 1992: Audits of providers of health care services, with conforming changes as of May 1, 1992 full-text: 31 ...
Re-audit: Sustaining Improvements. After an agreed period, the audit should be repeated. The same strategies for identifying the sample, methods and data analysis should be used to ensure comparability with the original audit. The re-audit should demonstrate that the changes have been implemented and that improvements have been made.
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The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.