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A clinical coder—also known as clinical coding officer, diagnostic coder, medical coder, or nosologist—is a health information professional whose main duties are to analyse clinical statements and assign standardized codes using a classification system.
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 ...
In health care, diagnosis codes are used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnostic coding is the translation of written descriptions of diseases, illnesses and injuries into codes from a particular classification.
For each patient seen in the ED, a scribe may: Accompany the physician into the exam room; Document the history of the patient's present illness; Document the Review-of-Systems (ROS) and physical examination; Enter vital signs and keep track of lab values; Look up pertinent past medical records; Keep track of and enter the results of imaging ...
Ambulatory care or outpatient care is medical care provided on an outpatient basis, including diagnosis, observation, consultation, treatment, intervention, and rehabilitation services. This care can include advanced medical technology and procedures even when provided outside of hospitals.
Nurse/patient encounters can occur once or as a series of occurrences, are usually less than 24 hours in length at any one time, and occur singly or in-group settings. Ambulatory care registered nurses, acting as partners and advisers, assist and support patients and families to optimally manage their health care, respecting their culture and ...
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Download as PDF; Printable version; In other projects Wikidata item; ... Pages in category "User template coder-2" The following 152 pages are in this category, out ...