Communicating Nursing Care Using the Health Level Seven Consolidated Clinical Document Architecture Release 2 Care...

Area of Science:

• Health Informatics
• Nursing Informatics

Background:

• Care plans are essential for outlining patient care.
• Health Level Seven Consolidated Clinical Document Architecture (C-CDA) Release 2 Care Plan Document facilitates data sharing.
• Standardized terminologies are crucial for consistent data representation.

Purpose of the Study:

• To describe the C-CDA Care Plan Document.
• To introduce Logical Observation Identifiers Names and Codes (LOINC) and Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT).
• To demonstrate the alignment of C-CDA Care Plan with the nursing process and its application in encoding nursing data.

Main Methods:

• Description of the C-CDA Care Plan Document structure.
• Introduction to LOINC and SNOMED CT terminologies.
• Discussion on the integration of nursing process steps within the C-CDA framework.

Main Results:

• The C-CDA Care Plan Document provides a structured format for care data.
• LOINC and SNOMED CT offer standardized coding for assessments, problems, interventions, and outcomes.
• Nursing data can be effectively encoded within the C-CDA Care Plan.

Conclusions:

• The C-CDA Care Plan Document, utilizing LOINC and SNOMED CT, supports standardized nursing data.
• This approach enhances interoperability and data consistency across healthcare settings.
• The framework aligns with the nursing process, facilitating comprehensive care documentation.