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Progress Note - This template represents a patient's clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter. [ 14 ] Transfer Summary - The Transfer Summary standardizes critical information for exchange of information between providers of care when a patient moves between ...
Clinical peer review, also known as medical peer review is the process by which health care professionals, including those in nursing and pharmacy, evaluate each other's clinical performance. [ 1 ] [ 2 ] A discipline-specific process may be referenced accordingly (e.g., physician peer review , nursing peer review ).
The HL7 Clinical Document Architecture (CDA) is an XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange. In November 2000, HL7 published Release 1.0.
The Common Technical Document (CTD) is a set of specifications for an application dossier for the registration of medicine, designed for use across Europe, Japan, the United States, and beyond. [ 1 ] Major Synopsis
Clinical governance is a systematic approach to maintaining and improving the quality of patient care within the National Health Service (NHS) and private sector health care. Clinical governance became important in health care after the Bristol heart scandal in 1995, during which an anaesthetist, Dr Stephen Bolsin , exposed the high mortality ...
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 National Institute for Health and Care Excellence (NICE) is an executive non-departmental public body of the Department of Health and Social Care. [ 1 ] As the national health technology assessment body of England, it is responsible for judging the cost-effectiveness of medicines and making them available on the NHS through reimbursement ...
Often there is a gap between what an organization wants to do and what the employees actually do, so many times many institutions set up infrastructure to focus on service excellence. [9] In an effort to provide patients with the highest possible quality of clinical care, the National institute of clinical excellence (NICE) was created. [10]