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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 ...
Medcin, is a system of standardized medical terminology, a proprietary medical vocabulary and was developed by Medicomp Systems, Inc. MEDCIN is a point-of-care terminology, intended for use in Electronic Health Record (EHR) systems, [1] and it includes over 280,000 clinical data elements encompassing symptoms, history, physical examination, tests, diagnoses and therapy. [2]
Oracle Health, formerly Cerner Corporation then Oracle Cerner, is a US-based, multinational provider of health information technology (HIT) platforms and services. As of February 2018 [update] , it had 27,000 customers globally [ 3 ] and 29,000 employees, with over 13,000 at its headquarters in North Kansas City, Missouri .
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All Cerner Millennium health information technology software uses CCL/Discern Explorer to select from, insert into, update into and delete from a Cerner Millennium database and allows a programmer to fetch data from an Oracle database and display it as the user wants to see. With features like Record Structure and subroutines it allows a user ...
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 ...
For large hospitals with over 500 beds, Epic and Cerner had over 85% market share in 2019. [96] In ambulatory care, Practice Fusion had the highest satisfaction, while in acute hospital care Epic scored relatively well. [97] Interoperability is a focus for systems; in 2018, Epic and athenahealth were rated highly for interoperability. [98]
Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be required anywhere from several times an hour to several times a day.
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