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2. Nursing documentation - Wikipedia

   en.wikipedia.org/wiki/Nursing_documentation

   Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process. Nursing documentation is the principal clinical information source to meet legal ...

3. Pacific Open Learning Health Net - Wikipedia

   en.wikipedia.org/wiki/Pacific_Open_Learning...

   Pacific Open Learning Health Net (POLHN / ˈ p ɒ l h ən /) is a non-profit established in 2003, focused on distance education for health professionals working in the Pacific. . Since 2004, it has provided free online courses for continuing professional development in a wide range of health and science related discip

4. Clinical Care Classification System - Wikipedia

   en.wikipedia.org/wiki/Clinical_Care...

   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]

5. Clinical documentation improvement - Wikipedia

   en.wikipedia.org/wiki/Clinical_documentation...

   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 ...

6. Progress note - Wikipedia

   en.wikipedia.org/wiki/Progress_note

   Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Progress ...

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