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Related Concept Videos

Guidelines for Nursing Documentation II01:26

Guidelines for Nursing Documentation II

Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Guidelines for Nursing Documentation I01:30

Guidelines for Nursing Documentation I

Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
Factual:  
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Data Reporting and Recording01:24

Data Reporting and Recording

Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...
Methods of Documentation IV: Focus Charting01:26

Methods of Documentation IV: Focus Charting

Focus Charting, also known as the focus charting system or "focus documentation," is a systematic documentation approach used in healthcare to organize patient information in medical records.
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Standards of Care II01:19

Standards of Care II

Nurses bear specific legal responsibilities under several federal statutes, including:
Introduction to Documentation and Reporting01:20

Introduction to Documentation and Reporting

Documentation is the systematic process of formally recording, maintaining, and communicating information.
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive and precise...

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Related Experiment Video

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Inverse Probability of Treatment Weighting (Propensity Score) using the Military Health System Data Repository and National Death Index
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Describing Congruence Between ICD-10 Coding and Medical Record Text in Veterans Health Administration Chiropractic

Nikhil Sharma1, Sarah E Graham2, Anna R Sites3

  • 1VA Puget Sound Healthcare System, Tacoma, Washington.

Journal of Chiropractic Medicine
|May 19, 2026
PubMed
Summary
This summary is machine-generated.

Chiropractic diagnoses in Veterans Health Administration (VHA) notes show moderate agreement between International Classification of Diseases, 10th Ed (ICD-10) codes and text. This study highlights variability in diagnostic detail, informing future data quality improvements.

Keywords:
ChiropracticDocumentationElectronic health recordVeterans health

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Area of Science:

  • Health Informatics
  • Chiropractic Research
  • Medical Coding

Background:

  • Accurate diagnostic coding is crucial for healthcare data integrity.
  • The Veterans Health Administration (VHA) utilizes International Classification of Diseases, 10th Edition (ICD-10) codes and text documentation for patient diagnoses.
  • Understanding the congruence between these two data sources in chiropractic care is essential for quality assessment.

Purpose of the Study:

  • To assess the level of agreement between ICD-10 codes and documented text diagnoses in VHA chiropractic notes.
  • To identify discrepancies in diagnostic detail between coded and text data.

Main Methods:

  • A cross-sectional analysis of 1000 VHA chiropractic visits from October 2017 to September 2018.
  • Random sampling of patients with no prior chiropractic visits within 12 months.
  • Extraction and mapping of ICD-10 codes and text diagnoses to 10 defined categories, followed by a congruence evaluation.

Main Results:

  • Perfect congruence between ICD-10 codes and text diagnoses was observed in 45.1% of cases.
  • Partial congruence was noted, with ICD-10 codes having less detail in 19.8% and more detail in 18.2% of cases.
  • No congruence was found in 6.5% of the reviewed chiropractic notes.

Conclusions:

  • VHA chiropractic diagnostic coding and text documentation exhibit considerable congruence, albeit with notable variability in diagnostic specificity.
  • These findings establish a baseline for further research aimed at enhancing the quality of VHA clinical, research, and administrative data.