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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 ...
A nursing intervention is defined as a single nursing action – treatment, procedure or activity – designed to achieve an outcome to a diagnosis, nursing or medical, for which the nurse is accountable. [12] Patient services are usually initiated as medical orders by a referring physician and reviewed by the admitting nurse.
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 Accreditation Council for Continuing Medical Education (ACCME) sets and enforces standards in physician continuing education (or "lifelong learning") within the United States. It acts as the overseeing body for institutions and organizations providing continuing medical education (CME) activities.
Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]
The foundation of ICD-11 together with the WHO Classification of Health Interventions (ICHI) and the WHO Classification for Functioning, Disability and Health (ICF), comprising also the WHO lists of anatomy, substances and more, are a complete ecosystem for lossless documentation in digital records and at the same time they address specific ...
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