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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 ...
In 1991, the Database Steering Committee submitted to the Congress on Nursing Practice a resolution that NI be adopted as a new nursing specialty. This submission which was accepted, leading to the development of the Nursing Informatics: Scope and Standards of Practice [9] and the certification of NI specialists. In 1992, the Database Steering ...
The evidence underlying this decision was a survey that showed that the Omaha System was used in 96.5% of Minnesota counties. The Omaha System became a member of the Alliance for Nursing Informatics in 2009. It is a reliable nursing documentation tool for outcome and quality of care measurement for clients with mental illness. [11]
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 ...
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]
Healthcare quality and safety require that the right information be available at the right time to support patient care and health system management decisions. Gaining consensus on essential data content and documentation standards is a necessary prerequisite for high-quality data in the interconnected healthcare system of the future.
In 1984, Lippincott published the first nursing-specific journal, titled Journal Computers in Nursing, which is now known as Computers Informatics Nursing (CIN). [110] As of September 7, 2016, there are roughly 235 informatics journals listed in the National Library of Medicine (NLM) catalog of journals. [111]
Pages in category "Nursing informatics" The following 14 pages are in this category, out of 14 total. ... Nursing documentation; Nursing Interventions Classification;
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