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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 ...
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 ...
The Clinical Care Classification System was developed from a research study conducted by Dr. Virginia K. Saba and a research team through a contract with the Health Care Financing Agency (HCFA), [24] currently known as the Centers for Medicare and Medicaid Services (CMS). The objective was to develop a computerized method for assessing and ...
HCFA was renamed the Centers for Medicare and Medicaid Services on July 1, 2001. [9] [11] In 2013, a report by the inspector general found that CMS had paid $23 million in benefits to deceased beneficiaries in 2011. [12] In April 2014, CMS released raw claims data from 2012 that gave a look into what types of doctors billed Medicare the most. [13]
The Council's seven founding member organizations are the American Board of Medical Specialties (ABMS), the American Hospital Association (AHA), the American Medical Association (AMA), the Association of American Medical Colleges (AAMC), the Association for Hospital Medical Education (AHME), the Council of Medical Specialty Societies (CMSS ...
The NLN was founded in 1893 as the American Society of Superintendents of Training Schools for Nurses and was the first organization for nursing in the U.S. [2]. In 1912, it was renamed the National League for Nursing Education (NLNE) [2] and released the first Standard Curriculum for Schools of Nursing in 1917.
The National Council Licensure Examination (NCLEX) is a nationwide examination for the licensing of nurses in the United States, Canada, and Australia since 1982, 2015, and 2020, respectively. [2] [3] There are two types: the NCLEX-RN and the NCLEX-PN. After graduating from a school of nursing, one takes the NCLEX exam to receive a nursing license.
This exam, upon completion of the nursing program, measures a student's readiness for the NCLEX-RN licensure exam [23] administered through the National Council of State Nursing Boards. Successful completion of NCLEX-RN is required for state licensure as an RN. Nurses may complete licensing requirements in more than one state.