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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 ...
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 ...
Optum ICD-10 Training Curriculum Helps Hospitals Prepare for the New Coding Standard Optum ICD-10 Core Education delivers comprehensive training to prepare physicians, coders and other staff ...
Computerized physician order entry. Computerized physician order entry ( CPOE ), sometimes referred to as computerized provider order entry or computerized provider order management ( CPOM ), is a process of electronic entry of medical practitioner instructions for the treatment of patients (particularly hospitalized patients) under his or her ...
The Minimum Data Set ( MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes and non-critical access hospitals with Medicare swing bed agreements. (The term "swing bed" refers to the Social Security Act's authorizing small, rural hospitals to use their beds ...
An ICD is the umbrella document over the system interfaces; examples of what these interface specifications should describe include: The inputs and outputs of a single system, documented in individual SIRS (Software Interface Requirements Specifications) and HIRS (Hardware Interface Requirements Specifications) documents, would fall under "The Wikipedia Interface Control Document".
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 ...
3M Introduces ICD-10 Physician Education Web-based curriculum trains physicians to capture complete and accurate ICD-10 documentation SALT LAKE CITY--(BUSINESS WIRE)-- 3M Health Information ...
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