For over 30 years, I have focused on promoting and integrating computer technology in the nursing profession. Now, with the new healthcare legislation, is the time to make nursing visible in our electronic health record systems (EHRs). My call to action is for professional nurses and nursing organizations to require that the electronic healthcare industry integrate the unified, coded, national nurse-friendly language – Clinical Care Classification (CCC) System – for the nursing profession’s language of choice to document nursing practice.
The CCC System is a national nursing terminology standard recognized by the Department of the Health and Human Services and the American Nurses Association. It was developed empirically (1988-1991) from real live patient care data recorded by nurses, designed specifically for electronic documentation of nursing care, and requires no licensing fee. The CCC System identifies the discrete elements of nursing practice that follows the six steps of the nursing process—assessment, diagnoses, outcome identification, planning, implementation, and evaluation.
The CCC System is a nursing language consisting of two interrelated terminologies that are unified into one system. It uses a four level information framework: 4 Healthcare Patterns, 21 Care Component classes, 176 Nursing Diagnoses, 804 Nursing Interventions/Actions (201 Core Interventions with 4 Action Types [Assess, Perform, Teach, & Manage]), and 546 Nursing Outcomes (176 Nursing Diagnoses with 3 qualifiers [Improved, Stabilized, or Deteriorated]) to code Expected and Actual Outcomes.
Clinical Care Classification (CCC) System Version 2.5, 2nd Edition will assist nurses in implementing the CCC System into their healthcare facility. The CCC System Users Guide not only shows how to develop standardized care plans, but demonstrates how to link diagnoses/problems (goals), interventions with actions, and outcomes, as well as including information on the mapping of the CCC System to SNOMED-CT.
I feel that nursing deserves one unifying nurse-friendly language to recognize the role of nursing on patient care outcomes, resources, and workload. I urge nurses to implement the CCC System into their healthcare facility to ensure that nursing becomes a visible partner in today’s healthcare team.