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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 ...
In the past few decades, nurses have witnessed a change toward a more independent practice with explicit knowledge of nursing care. [8] The obligation to point of care documentation not only applies to the performed interventions, medical and nursing, but also impacts the decision-making process; explaining why a specific action has been ...
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 medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
Nurse licensure is the process by which various regulatory bodies, usually a Board of Nursing, regulate the practice of nursing within its jurisdiction. The primary purpose of nurse licensure is to grant permission to practice as a nurse after verifying the applicant has met minimal competencies to safely perform nursing activities within nursing's scope of practice.
Tort law. In tort law, a duty of care is a legal obligation that is imposed on an individual, requiring adherence to a standard of reasonable care to avoid careless acts that could foreseeably harm others, and lead to claim in negligence. It is the first element that must be established to proceed with an action in negligence.
Nursing is a health care profession that "integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence". [1] Nurses practice in many specialties with ...
In health care, person-centered care is a practice in which patients actively participate in their own medical treatment in close cooperation with their health professionals. Sometimes, relatives may be involved in the creation of the patient’s health plan. [1] The person-centered model of health care is used both for in and outpatient ...