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  2. Clinical Care Classification System - Wikipedia

    en.wikipedia.org/wiki/Clinical_Care...

    The CCC System uses a five-character structure to code the two terminologies: (1) CCC of Nursing Diagnoses and Outcomes and (2) CCC of Nursing Interventions and Actions. The CCC coding structure is paced on the format of the International Statistical Classification of Diseases and Related Health Problems: Tenth Revision: Volume 1, WHO , 1992 .

  3. Title 5 of the Code of Federal Regulations - Wikipedia

    en.wikipedia.org/wiki/Title_5_of_the_Code_of...

    The CFR was authorized by President Franklin D. Roosevelt on October 11, 1938, as a means to organize and maintain the growing material published by federal agencies in the newly mandated Federal Register. The first volume of the CFR was published in 1939 with general applicability and legal effect in force June 1, 1938.

  4. Diagnosis code - Wikipedia

    en.wikipedia.org/wiki/Diagnosis_code

    Classification System Detail ICD-9-CM: Volumes 1 and 2 only. Volume 3 contains Procedure codes: ICD-10: The international standard since about 1998 ICPC-2: Also includes reasons for encounter (RFE), procedure codes and process of care

  5. Code of Federal Regulations - Wikipedia

    en.wikipedia.org/wiki/Code_of_Federal_Regulations

    The CFR annual edition is published as a special issue of the Federal Register by the Office of the Federal Register (part of the National Archives and Records Administration) and the Government Publishing Office. [1] In addition to this annual edition, the CFR is published online on the Electronic CFR (eCFR) website, which is updated daily.

  6. Nursing diagnosis - Wikipedia

    en.wikipedia.org/wiki/Nursing_diagnosis

    A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions driven by physician ...

  7. Medical classification - Wikipedia

    en.wikipedia.org/wiki/Medical_classification

    Coding diagnoses and procedures is the assignment of codes from a code set that follows the rules of the underlying classification or other coding guidelines. The current version of the ICD, ICD-10, was endorsed by WHO in 1990. WHO Member states began using the ICD-10 classification system from 1994 for both morbidity and mortality reporting.

  8. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    During nursing assessment, a nurse systematically collects, verifies, analyses and communicates a health care client's information to derive a nursing diagnosis and plan individualized nursing care for the client. [5] Complete and accurate nursing assessment determines the accuracy of the other stages of the nursing process. [6] The nursing ...

  9. Nursing care plan - Wikipedia

    en.wikipedia.org/wiki/Nursing_care_plan

    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.