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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]
However the coded data is often used for other purposes too; including reimbursement practices such as medical billing. ICD has a hierarchical structure, and coding in this context, is the term applied when representations are assigned to the words they represent. [ 30 ]
A software development methodology is a framework that is used to structure, plan, and control the life cycle of a software product. Common methodologies include waterfall, prototyping, iterative and incremental development, spiral development, agile software development, rapid application development, and extreme programming.
One method of research for evidence-based practice in nursing is 'qualitative research': The word implies an entity and meanings that are not experimentally examined or measured in terms of quantity, amount, frequency, or intensity. With qualitative research, researchers learn about patient experiences through discussions and interviews.
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.
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