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INTRODUCTION

Objectives

  1. Describe the characteristics of the Clinical Care Classification (CCC) System.

  2. List the benefits of the Clinical Care Classification (CCC) System coding structure and Information Model to aggregate and parse Plan of Care data.

  3. Highlight the HHS-recognized, national nursing terminology standard for the electronic capture of discrete coded data to advance evidence-based practice.

  4. Define the benefits of a coded Nursing Plan of Care to measure and predict clinical care workload and care cost in electronic health records.

  5. Identify the two core WAMM© processes used to calculate Relative Value Units (RVUs) and Workload Value Units for nursing and allied health services.

Key Words

Analyses

Applications

Clinical Care Classification (CCC) System

Nursing Plan of Care (POC)

Workload Actions Measures Method (WAMM©)

An introduction to the Clinical Care Classification (CCC) System is presented in this Appendix which consists of several sections. The Appendix begins with a description of the CCC System which includes two CCC interrelated terminologies: (a) the CCC of Nursing Diagnoses and Outcomes and (b) the CCC of Nursing Interventions and Actions. Each is classified by a Care Component to form a single system. This is followed by a review of the CCC System Information Model which serves as the framework for the documentation of a Nursing Plan of Care using the six steps of the Nursing Process (ANA, 2010). The next section presents a sample case study for a three-day inpatient episode of illness. The case study is a coded Nursing Plan of Care using the CCC System terminologies with examples of data frequencies to provide evidence-based care and other new information about nursing services. The Appendix also provides an analytics section to illustrate how basic nursing care data frequencies, when combined with new formulas, can generate new information such as patient Workload and Care Requirements data, called the Workload Action Measures Method (WAMM©).

The Appendix concludes with a CCC System “Ready-to-Use Guide” (Fig. A.6). The Guide is a resource for the use of standardized data and the use of the CCC System to achieve the exchange of nursing data. The CCC System provides the evidence to improve patient care and health outcomes. The Guide provides a listing of the CCC System terminologies as a foundation for conducting research, guiding the documentation of Nursing Practice and/or the development of a Nursing Plan of Care for electronic health record (EHR) systems. Also see Chapter 27, Nursing Plan of Care Framework for HIT.

STATUS

The urgent need for coded, structured, and standardized nursing concepts in an EHR system is more critical than ever. Nursing can no longer rely on the empirical evidence-based trial and error methodologies and/or narrative nursing notes based on the intuition of senior nurses. As a profession, nursing must harness the current healthcare information technology (HIT) systems to investigate nursing practice, generate new nursing knowledge, ...

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