Frequently asked coding questions

Leslie Narramore1, Maurits J Wiersema, Klaus Mergener

  • 1MARC Associates, 1101 17th Street, NW, Suite 1102, Washington, DC 20036, USA.

Related Concept Videos

Guidelines and Strategies for Safe Computer Charting01:18

Guidelines and Strategies for Safe Computer Charting

The guidelines and strategies provided by the American Nurses Association (ANA) and the Canadian Nurses Association (CNA) offer essential principles for ensuring safe and secure computer charting systems in healthcare settings. Let's break down each recommendation:
Maintain Confidentiality and Security:
Nursing Code of Ethics01:29

Nursing Code of Ethics

The Nursing Code of Ethics sets the ethical benchmark for the profession, and guides nurses in ethical analysis and decision making at the societal, organizational, and clinical levels. The code encompasses showing compassion and respect for the patient, their families, and communities in all circumstances while committing to providing patient-centered care. In addition, the code states that nurses must advocate for the patient by defending a cause or recommendation to protect their rights,...
Nursing Clinical Information System01:27

Nursing Clinical Information System

Nursing Clinical Information System (NCIS)
A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
Critical attributes of NCIS include:
Standards of Care I01:22

Standards of Care I

Federal statutes profoundly impact nursing practice, providing critical guidelines to ensure patient care is equitable, accessible, and of the highest quality. The following laws address distinct aspects of healthcare provision and patient rights:
Standards of Care II01:19

Standards of Care II

Nurses bear specific legal responsibilities under several federal statutes, including:
Formats for Nursing Documentation01:28

Formats for Nursing Documentation

Nursing documentation encompasses various formats designed to capture precise patient data, facilitate communication among healthcare team members, and ensure comprehensive and accurate patient records. Let's explore each of these formats in detail:
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history, current medications, vital...