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A standard operating procedure (SOP) is a set of step-by-step instructions compiled by an organization to help workers carry out routine operations. [1] SOPs aim to achieve efficiency, quality output, and uniformity of performance, while reducing miscommunication and failure to comply with industry regulations .
Organizations typically document procedures in their published policy and procedures guide, or their standard operating procedure (S.O.P.) guide. A procedures manual or procedural manual typically gathers together a number of procedures used within an organisation, [3] or for a specific set of functions. [4]
The operations manual is the documentation by which an organisation provides guidance for members and employees to perform their functions correctly and reasonably efficiently. [1] It documents the approved standard procedures for performing operations safely to produce goods and provide services. [ 2 ]
The PMAG may seek additional expertise and/or input from other national health care organizations, as necessary, for the development of Category II codes. These may include national medical specialty societies, other national health care professional associations, accrediting bodies and federal regulatory agencies.
If it is too long and too wordy, it may be misunderstood or ignored. Clear, concise words should be used, and sentences should be limited to a maximum of 15 words. Documentation intended for a general audience should avoid gender-specific terms and cultural biases. In a series of procedures, steps should be clearly numbered. [6] [7] [8] [9]
A medical procedure with the intention of determining, measuring, or diagnosing a patient condition or parameter is also called a medical test. Other common kinds of procedures are therapeutic (i.e., intended to treat, cure, or restore function or structure), such as surgical and physical rehabilitation procedures.
Health information management's standards history is dated back to the introduction of the American Health Information Management Association, founded in 1928 "when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to 'elevate the standards of clinical records in hospitals and other medical institutions.'" [3]
The ICD-10 Procedure Coding System (ICD-10-PCS) is a US system of medical classification used for procedural coding.The Centers for Medicare and Medicaid Services, the agency responsible for maintaining the inpatient procedure code set in the U.S., contracted with 3M Health Information Systems in 1995 to design and then develop a procedure classification system to replace Volume 3 of ICD-9-CM.