Hines G L
State University of New York, Health Science Center, Brooklyn.
Nurs Clin North Am. 1988 Sep;23(3):579-86.
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.
病历中的护理记录是病历编码员的重要信息来源。编码数据对于质量保证、风险管理、研究和统计目的以及正确的诊断相关分组（DRG）付费分配是必要的。从护理记录中收集的信息，在医生记录和实验室数据的支持下，通常可以增加医院的报销金额。
