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The goals were adapted from the JCAHO's National Patient Safety Goals. [1] Compliance with IPSG has been monitored in JCI-accredited hospitals since January 2006. [1] The JCI recommends targeted solution tools to help hospital to meet IPSG standards. [2]
The CCC System was one of the standards in the first set of 55 national standards approved for use in the EHR, by the Department of Health and Human Services (AHIC, 2006) and the only national nursing terminology standard. In 2020, HCA Healthcare became the new custodian of Dr. Virginia Saba's Clinical Care Classification (CCC) System.
Nursing documentation mainly consists of a client's background information or nursing history referred as admission form, numerous assessment forms, nursing care plan and progress notes. These documents record the client's data captured at the relevant stages of the nursing process . [ 2 ]
The Joint Commission is a United States-based nonprofit tax-exempt 501(c) organization [1] that accredits more than 22,000 US health care organizations and programs. [2] The international branch accredits medical services from around the world.
MDS assessment forms are completed for all residents in certified nursing homes, including SNFs, regardless of source of payment for the individual resident. MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames.
The CPT code set describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.
The Patient Safety and Quality Improvement Act of 2005 ("Patient Safety Act"), Public Law 109–41, USC 299b-21-b-26 [50] amended title IX of the Public Health Service Act to create a general framework to support and protect voluntary initiatives to improve quality and patient safety in all healthcare settings through reporting to Patient ...
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care. [1]