Ad
related to: long term care documentation guides for nurses
Search results
Results from the WOW.Com Content Network
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 ...
The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings. [1]
A director of nursing (DON) is a registered nurse who supervises the care of all the patients at a health care facility. [1] The director of nursing has special training beyond the training of a staff nurse for the position that pertains to health care management, and in some places, a director of nursing must hold a special license in order to be employed in that capacity.
Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]
Nursing care plans provide continuity of care, safety, quality care and compliance. 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 ...
The American Nurses Association recognized the Omaha System as a standardized terminology to support nursing practice in 1992. In 2014, Minnesota became the first state to recommend that point-of-care terminologies recognized by the American Nurses Association be used in all electronic health records. The evidence underlying this decision was a ...
Get AOL Mail for FREE! Manage your email like never before with travel, photo & document views. Personalize your inbox with themes & tabs. You've Got Mail!
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 ...
Ad
related to: long term care documentation guides for nurses