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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 ...
The clinical pathway concept appeared for the first time at the New England Medical Center (Boston, United States) in 1985, inspired by Karen Zander and Kathleen Bower. [9] [non-primary source needed] Clinical pathways appeared as a result of the adaptation of the documents used in industrial quality management, the standard operating procedures (SOPs), whose goals are:
The HL7 Clinical Document Architecture (CDA) is an XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange. In November 2000, HL7 published Release 1.0.
Clinical peer review, also known as medical peer review is the process by which health care professionals, including those in nursing and pharmacy, evaluate each other's clinical performance. [1] [2] A discipline-specific process may be referenced accordingly (e.g., physician peer review, nursing peer review).
The Trauma Quality Improvement Program (TQIP) was initiated in 2008 by the American College of Surgeons Committee on Trauma. Its aim is to provide risk-adjusted data for the purpose of reducing variability in adult trauma outcomes and offering best practice guidelines to improve trauma care. TQIP makes use of national data to allows hospitals ...
A nursing care plan promotes documentation and is used for reimbursement purposes such as Medicare and Medicaid. The therapeutic nursing plan is a tool and a legal document that contains priority problems or needs specific to the patient and the nursing directives linked to the problems. It shows the evolution of the clinical profile of a patient.
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The Healthcare Effectiveness Data and Information Set (HEDIS) is a widely used set of performance measures in the managed care industry, developed and maintained by the National Committee for Quality Assurance (NCQA). HEDIS was designed to allow consumers to compare health plan performance to other plans and to national or regional benchmarks.