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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 ...
MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames. Participants in the assessment process are health care professionals and direct care staff such as registered nurses , licensed practical or vocational nurses (LPN/LVN), Therapists, Social Services ...
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 ...
The CCD specification is a constraint on the HL7 Clinical Document Architecture (CDA) standard. The CDA specifies that the content of the document consists of a mandatory textual part (which ensures human interpretation of the document contents) and optional structured parts (for software processing).
HCFA was renamed the Centers for Medicare and Medicaid Services on July 1, 2001. [9] [11] In 2013, a report by the inspector general found that CMS had paid $23 million in benefits to deceased beneficiaries in 2011. [12] In April 2014, CMS released raw claims data from 2012 that gave a look into what types of doctors billed Medicare the most. [13]
Good documentation practice (recommended to abbreviate as GDocP to distinguish from "good distribution practice" also abbreviated GDP) is a term in the pharmaceutical and medical device industries to describe standards by which documents are created and maintained.
The Accreditation Council for Continuing Medical Education (ACCME) sets and enforces standards in physician continuing education (or "lifelong learning") within the United States.
Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides.
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