Paper
Sunday, November 4, 2007
154
Clinical Care Classification (CCC) System: Documentation Model & Method
Virginia Saba, EdD, PhD, RN, FAAN, FACMI, LL, School of Nursing, Georgetown University, Washington, DC, USA and S. L. Taylor, BSN, RN, Quadramed Corp, Reston, VA, USA.
| Learning Objective #1: describe the Clinical Care Classification (CCC) System and how it can be used to electronically document the essence of patient care. |
| Learning Objective #2: describe the CCC System Model and how it relates to the six steps of the Nursing Process. |
The Clinical Care Classification (CCC) System serves as a standardized coded terminology for nursing and other allied health providers. CCC provides a unique framework and coding structure for capturing the essence of patient care at the point-of-service in all health care settings. The CCC Systems consists of two interrelated terminologies: the CCC of Nursing Diagnoses and Outcomes and CCC of Nursing Interventions and Actions -- classified by 21 Care Components. The Care Components provide the stanfardized framework that links electronically the CCC terminologies to each other and enables them to be mapped to other health-related classification systems. The CCC terminologies consist of flexible, expandible, discrete atomic level concepts/data elements. The data elements have been coded and designed for computer processing in the health information technology (HIT) systems and data collected only once can be used many times for a variety of care delivery and data mining purposes. The CCC System is designed to be used: (a) with electronic health record (E.H.R.) systems that include applications to support clinical documentation and planning of care; (b) with nursing management systems used to determine workload, resources allocation, and cost; (c) in nursing education software to teach cliniciains how to document and code nursing practice in the E.H.R.; and (d) in nursing research for analysis of patiient care with specific disease conditions. The CCC System can help improve quality, safety,and outcomes measurement, and can help determine the cost of patient care provided by nurses and allied health providers. It can enable tracking and measuring patient care holistically over time across settings, population groups, and geographic ;locations. It can be used to help design decision support. evidence-based and expert systems to advance nursing knowledge.