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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 ...
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.
To be eligible for RHIA certification, an individual must complete a bachelor's degree in a health information management program accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) or graduate from a foreign association that has a reciprocity agreement with AHIMA. [3]
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 ...
DCBA, Inc. DCBA, Inc. provides clinical audit and clinical documentation improvement programs. Healthcare Quality Improvement Partnership (HQIP) Promoting quality for better health services, HQIP is funded by the Department of Health to increase the impact that clinical audit has on healthcare quality in England and Wales. Clinical Audit Tool ...
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]
Before applying to any medical school, a candidate must earn a bachelor's degree with credits in certain required subjects. A candidate must be at least 18 years of age. The most common pre-medical degrees include biology, psychology, pharmacy, medical technology, biochemistry, microbiology, nursing, radiologic technology and physical ther
Nursing documentation is the principal clinical information source to meet legal and professional requirements, care nurses' knowledge of nursing documentation, and is one of the most significant components in nursing care.