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  2. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    It documents a client's status, reasons why the client is being admitted, and the initial instructions for that client's care. [3] The form is completed by a nurse when a client is admitted to a health care facility. The admission form provides the basic information to establish foundations for further nursing assessment.

  3. 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 ...

  4. Point of care - Wikipedia

    en.wikipedia.org/wiki/Point_of_care

    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]

  5. Health information management - Wikipedia

    en.wikipedia.org/wiki/Health_information_management

    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.

  6. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite. The terms are used for the written (paper notes), physical (image films) and digital records that exist for each individual patient and for the body of information found therein.

  7. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    Physicians are generally required to generate at least one progress note for each patient encounter. Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be ...

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  9. Medical transcription - Wikipedia

    en.wikipedia.org/wiki/Medical_transcription

    If a medical transcriptionist accidentally typed a wrong medication or the wrong diagnosis, the patient could be at risk if the doctor (or their designee) did not review the document for accuracy. Both the doctor and the medical transcriptionist play an important role to make sure the transcribed dictation is correct and accurate.