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The nursing care plan (NCP) is a clinical document recording the nursing process, which is a systematic method of planning and providing care to clients. [6] It was originally developed in hospitals to guide nursing students or junior nurses in providing care to client; however, the format was task-oriened rather than nursing-process-based. [8]
A nursing care plan promotes documentation and is used for reimbursement purposes such as Medicare and Medicaid. The therapeutic nursing plan is a tool and a legal document that contains priority problems or needs specific to the patient and the nursing directives linked to the problems. It shows the evolution of the clinical profile of a patient.
Clinical quality management systems (CQMS) are systems used in the life sciences sector (primarily in the pharmaceutical, biologics and medical device industries) designed to manage quality management best practices throughout clinical research and clinical study management. A CQMS system is designed to manage all of the documents, activities ...
Medical billing practices vary across states and healthcare settings, influenced by federal regulations, state laws, and payor-specific requirements. Despite these variations, the fundamental goal remains consistent: to streamline the financial transactions between physicians and payors, ensuring access to care and financial sustainability for ...
Health information management professionals plan information systems, develop health policy, and identify current and future information needs. In addition, they may apply the science of informatics to the collection, storage, analysis, use, and transmission of information to meet legal, professional, ethical and administrative records-keeping ...
A clinical judgment about the healthcare consumer's response to actual or potential health conditions or needs. The diagnosis provides the basis for determination of a plan to achieve expected outcomes. Registered nurses utilize nursing and medical diagnoses depending upon education and clinical preparation and legal authority" [11]
A clinical pathway is a multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course, in which the different tasks (interventions) by the professionals involved in the patient care are defined, optimized and sequenced either by hour (ED), day (acute care) or visit (homecare).
A similar guideline for clinical trials of medical devices is the international standard ISO 14155, which is valid in the European Union as a harmonized standard. These standards for clinical trials are sometimes referred to as ICH-GCP or ISO-GCP to differentiate between the two and the lowest grade of recommendation in clinical guidelines.