Search results
Results from the WOW.Com Content Network
A clinical coder—also known as clinical coding officer, diagnostic coder, medical coder, or nosologist—is a health information professional whose main duties are to analyse clinical statements and assign standardized codes using a classification system.
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 ...
In health care, diagnosis codes are used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnostic coding is the translation of written descriptions of diseases, illnesses and injuries into codes from a particular classification.
As the AMA decided in April 1960, the Current Medical Terminology (CMT) handbook was first published in June 1962 – 1963 to standardize terminology of the Standard Nomenclature of Diseases and Operations (SNDO) and International Classification of Diseases (ICD), and for the analysis of patient records, and was aided by an IBM computer. [22]
Upload file; Special pages; Permanent link; Page information; Get shortened URL; Download QR code; Print/export Download as PDF; Printable version; In other projects ...
Outpatient surgery, also known as ambulatory surgery, day surgery, [1] day case surgery, or same-day surgery, is surgery that does not require an overnight hospital stay. [ note 1 ] The term “ outpatient ” arises from the fact that surgery patients may enter and leave the facility on the same day.
The terms EHR, electronic patient record (EPR) and electronic medical record (EMR) have often been used interchangeably, but "subtle" differences exist. [6] The electronic health record (EHR) is a more longitudinal collection of the electronic health information of individual patients or populations.
An OpenDocument file commonly consists of a standard ZIP archive (JAR archive [13]) containing a number of files and directories; but OpenDocument file can also consist only of a single XML document. An OpenDocument file is commonly a collection of several subdocuments within a (ZIP) package. An OpenDocument file as a single XML is not widely used.