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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 ...
Healthcare quality and safety require that the right information be available at the right time to support patient care and health system management decisions. Gaining consensus on essential data content and documentation standards is a necessary prerequisite for high-quality data in the interconnected healthcare system of the future.
The RHIA certification focuses on preparing members for careers in health information and medical records management, including management of the processes and systems that capture and report on health care-related data so that it can be used to evaluate care performance. [3]
A clinical coder therefore requires a good knowledge of medical terminology, anatomy and physiology, a basic knowledge of clinical procedures and diseases and injuries and other conditions, medical illustrations, clinical documentation (such as medical or surgical reports and patient charts), legal and ethical aspects of health information ...
DCBA, Inc. DCBA, Inc. provides clinical audit and clinical documentation improvement programs. Healthcare Quality Improvement Partnership (HQIP) Promoting quality for better health services, HQIP is funded by the Department of Health to increase the impact that clinical audit has on healthcare quality in England and Wales. Clinical Audit Tool ...
Nursing documentation is the principal clinical information source to meet legal and professional requirements, care nurses' knowledge of nursing documentation, and is one of the most significant components in nursing care.
Traditionally focused mainly on hospitals and paper medical records, the field presently covers all health information technology systems, including electronic health records, clinical decision support systems, and so on, for all segments of health care. As of 2013, the association has more than 71,000 members in four membership classifications.
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]
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