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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 ...
[10] [11] An in-depth study conducted by The Vancouver Clinic in Vancouver, WA from 2011-2012 found that medical scribes improved the quality of clinical documentation and allowed doctors to see extra patients, while noting the risks associated with scribe turnover and doctors' unfamiliarity with the scribe concept. [12]
Nursing credentials and certifications are the various credentials and certifications that a person must have to practice nursing legally. Nurses' postnominal letters (abbreviations listed after the name) reflect their credentials—that is, their achievements in nursing education, licensure, certification, and fellowship.
Several templates and tools are available to assist in formatting, such as reFill (documentation) and Citation bot (documentation). ( August 2022 ) ( Learn how and when to remove this message ) The examples and perspective in this article deal primarily with the United States and do not represent a worldwide view of the subject .
A clinical coder therefore requires a good knowledge of medical terminology, anatomy and physiology, a basic knowledge of clinical procedures and diseases and injuries and other conditions, medical illustrations, clinical documentation (such as medical or surgical reports and patient charts), legal and ethical aspects of health information ...
Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]
Nursing documentation is the principal clinical information source to meet legal and professional requirements, care nurses' knowledge of nursing documentation, and ...
AHDI also offers the credential of Registered Healthcare Documentation Specialist (RHDS). According to AHDI, RHDS is an entry-level credential while the CHDS is an advanced level. AHDI maintains a list of approved medical transcription schools. [9] Generally, certified medical transcriptionists earn more than their non-certified counterparts.
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