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Good documentation practice (recommended to abbreviate as GDocP to distinguish from "good distribution practice" also abbreviated GDP) is a term in the pharmaceutical and medical device industries to describe standards by which documents are created and maintained.
The systematic review of nursing documentation audit studies in different settings [19] identified the following relevant quality characteristics of nursing documentation: Quality of documentation structure and format: relates to constructive features and physical presentation of records such as quantity, completeness, legibility, read- ability ...
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 ...
CDA specifies the syntax and supplies a framework for specifying the full semantics of a clinical document, defined by six characteristics: [2] Persistence; Stewardship; Potential for authentication; Context; Wholeness; Human readability; CDA can hold any kind of clinical information that would be included in a patient's medical record ...
To enter this program, physicians must have left the medical field in good standing, and they must want to reenter in the same clinical practice for which they were trained. [ 9 ] The Patient Care Documentation Seminar teaches physicians how to identify basic documentation guidelines, understand the legal issues associated with poor ...
For prescription medications, the insert is technical, providing information for medical professionals about how to prescribe the drug. Package inserts for prescription drugs often include a separate document called a "patient package insert" with information written in plain language intended for the end-user —the person who will take the ...
The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
It allows documentation at any level of detail. It includes extension codes, a terminology system, with medicaments, chemicals, infections agents, histopathology, anatomy and mechanisms, objects and animals, and other elements that serve to describe sources of injury or harm.