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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 Office of Inspector General (OIG) for the United States Department of Health and Human Services (HHS) is responsible for oversight of the United States Department of Health and Human Service 's approximately $2.4 trillion portfolio of programs. Approximately 1,650 auditors, investigators, and evaluators, supplemented by staff with expertise ...
In the past few decades, nurses have witnessed a change toward a more independent practice with explicit knowledge of nursing care. [8] The obligation to point of care documentation not only applies to the performed interventions, medical and nursing, but also impacts the decision-making process; explaining why a specific action has been ...
Medical law. Scope of practice describes the procedures, actions, and processes that a healthcare practitioner is permitted to undertake in keeping with the terms of their professional license. The scope of practice is limited to that which the law allows for specific education and experience, and specific demonstrated competency.
The nursing process is a cyclical and ongoing process that can end at any stage if the problem is solved. The nursing process exists for every problem that the individual/family/community has. The nursing process not only focuses on ways to improve physical needs, but also on social and emotional needs as well. [11]
v. t. e. Patient rights consist of enforceable duties that healthcare professionals and healthcare business persons owe to patients to provide them with certain services or benefits. [1] When such services or benefits become rights instead of simply privileges, then a patient can expect to receive them and can expect the support of people who ...
Standard of care. In tort law, the standard of care is the only degree of prudence and caution required of an individual who is under a duty of care. The requirements of the standard are closely dependent on circumstances. [1] Whether the standard of care has been breached is determined by the trier of fact, and is usually phrased in terms of ...