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The ICD-10 Procedure Coding System (ICD-10-PCS) is a US system of medical classification used for procedural coding.The Centers for Medicare and Medicaid Services, the agency responsible for maintaining the inpatient procedure code set in the U.S., contracted with 3M Health Information Systems in 1995 to design and then develop a procedure classification system to replace Volume 3 of ICD-9-CM.
The Portable Document Format (PDF) is a file format used to present documents in a manner independent of application software, hardware, and operating systems. Each PDF file encapsulates a complete description of the presentation of the document, including the text, fonts, graphics, and other information needed to display it.
The ICD-10 Clinical Modification (ICD-10-CM) is a set of diagnosis codes used in the United States of America. [1] It was developed by a component of the U.S. Department of Health and Human services, [2] as an adaption of the ICD-10 with authorization from the World Health Organization.
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care. [1]
Enable evidence-based practice protocols to process and analyze patient care data and to evaluate the effects of nursing care on patient outcomes. Nursing Education Applications: Teach students how to electronically document and code POCs based on the nursing process. Track student assignments: procedures and protocols.
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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.
A PDF file is organized using ASCII characters, except for certain elements that may have binary content. The file starts with a header containing a magic number (as a readable string) and the version of the format, for example %PDF-1.7. The format is a subset of a COS ("Carousel" Object Structure) format. [23]