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Major Diagnostic Category. The Major Diagnostic Categories (MDC) are formed by dividing all possible principal diagnoses (from ICD-9-CM) into 25 mutually exclusive diagnosis areas. MDC codes, like diagnosis-related group (DRG) codes, are primarily a claims and administrative data element unique to the United States medical care reimbursement ...
The World Health Organization uses the term "alcohol dependence syndrome" rather than alcoholism. [106] The concept of "harmful use" (as opposed to "abuse") was introduced in 1992's ICD-10 to minimize underreporting of damage in the absence of dependence. [115] The term "alcoholism" was removed from ICD between ICD-8/ICDA-8 and ICD-9. [119] ICD-11
SOAP note. The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient 's chart, along with other common formats, such as the admission note. [ 1][ 2] Documenting patient encounters in the medical record is an integral part of practice ...
Appearance. Inborn errors of metabolism form a large class of genetic diseases involving congenital disorders of enzyme activities. [ 1 ] The majority are due to defects of single genes that code for enzymes that facilitate conversion of various substances ( substrates) into others ( products ). In most of the disorders, problems arise due to ...
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]
ICD-10 is the 10th revision of the International Classification of Diseases (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. [ 1] Work on ICD-10 began in 1983, [ 2 ...
Pediatrics. Small for gestational age ( SGA) newborns are those who are smaller in size than normal for the gestational age. SGA is most commonly defined as a weight below the 10th percentile for the gestational age. [ 1] SGA predicts susceptibility to hypoglycemia, hypothermia, and polycythemia. [ 2] By definition, at least 10% of all newborns ...
The ICD-10 Clinical Modification ( ICD-10-CM) is a set of diagnosis codes used in the United States of America. [ 1] It was developed by a component of the U.S. Department of Health and Human services, [ 2] as an adaption of the ICD-10 with authorization from the World Health Organization. In 2015, ICD-10-CM replaced ICD-9-CM as the federally ...