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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 ...
Electronic nursing documentation systems have been implemented in health care organizations to bring in the benefits of increasing access to more complete, accurate and up-to-date data and reducing redundancy, improving communication and care service delivery. [14]
Her methodical approach, as well as the emphasis on uniformity and comparability of the results of health care, is recognised as one of the earliest programs of outcomes management. Another notable figure who advocated clinical audit was Ernest Codman (1869–1940). Codman became known as the first true medical auditor following his work in ...
The patient health record is the primary legal record documenting the health care services provided to a person in any aspect of the health care system. The term includes routine clinical or office records, records of care in any health related setting, preventive care, lifestyle evaluation, research protocols and various clinical databases.
The National Safety and Quality Health Service Standards (NSQHS Standards) are Australia's principal health care standards, and apply to all health services including inpatient, outpatient, and community care. [5] There are 8 standards: Clinical governance; Partnering with consumers; Preventing and controlling infections; Medication safety
The ultimate objective is to improve the safety, quality, and efficiency of healthcare as well as access to healthcare through the efficient application of health information technology. RHIOs are also intended to support secondary use of clinical data for research as well as institution/provider quality assessment and improvement. [1]
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Specifically designed for clinical information systems, the CCC facilitates nursing documentation at the point-of-care. The CCC was developed empirically through the examination of approximately 40,000 textual phrases representing nursing diagnoses/patient problems, and 72,000 phrases depicting patient care services and/or actions.