DRGs: nursing documentation contributes to the bottom line.
Nursing documentation in the medical record is an important source of information for the medical record coder. Coded data are necessary for quality assurance, risk management, research and statistical purposes, as well as for proper DRG assignment for reimbursement. Facts gleaned from nursing documentation, supported by physician documentation and laboratory data, can often result in increased reimbursement for the hospital.
D036861:Delivery, Obstetric; D003953:Diagnosis-Related Groups; D004282:Documentation; D064420:Drug-Related Side Effects and Adverse Reactions; D005260:Female; D006801:Humans; D007262:Infusions, Intravenous / Q000009:adverse effects; D007743:Labor, Obstetric; D008508:Medication Errors; D009737:Nursing Records / Q000592:standards*; D010689:Phlebitis / Q000191:economics / Q000209:etiology; D011247:Pregnancy; D011445:Prospective Payment System; D012720:Severity of Illness Index; D014481:United States