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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 ...
The CCC is a nursing terminology specifically developed for computerization: e.g. electronic healthcare information systems (EHR), computer-based patient records (CPR), and Clinical Information Systems (CIS), from research which collected live patient care data. The CCC System describes the six steps of the nursing process: Assessment; Diagnosis
A type of research study that tests how well new medical approaches work in people. These studies test new methods of screening, prevention, diagnosis, or treatment of a disease. Also called a clinical trial. (NCI) A clinical trial is a research study to answer specific questions about vaccines or new therapies or new ways of using known ...
APA style (also known as APA format) is a writing style and format for academic documents such as scholarly journal articles and books. It is commonly used for citing sources within the field of behavioral and social sciences, including sociology, education, nursing, criminal justice, anthropology, and psychology.
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).
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 ...
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The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.