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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 ...
series) is a product line of how-to and other reference books published by Dorling Kindersley (DK). The books in this series provide a basic understanding of a complex and popular topics. The term "idiot" is used as hyperbole, to reassure readers that the guides will be basic and comprehensible, even if the topics seem intimidating.
Facilitates the electronic documentation of patient care at the point of care. Uses a framework of care components to classify the two CCC System terminologies and represent 4 healthcare patterns focusing on a holistic approach to patient care. Consists of flexible, adaptable, and expandable concepts/data elements.
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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.
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.
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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 ...
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