Electronic Nursing Documentation: Patient Care Continuity Using the Clinical Care Classification System (CCC).

Area of Science:

• Nursing Informatics
• Health Information Management

Background:

• Continuity of patient care is crucial for effective healthcare delivery.
• Standardized nursing terminologies are essential for consistent documentation and data analysis.
• Existing documentation systems may not fully integrate patient assessments with care plans.

Purpose of the Study:

• To demonstrate patient care continuity between nursing assessments and nursing Plans of Care.
• To develop an innovative, interactive nursing Plan of Care system.
• To integrate the Clinical Care Classification System (CCC) into the nursing documentation process.

Main Methods:

• A nursing documentation project was conducted at Bumrungrad International Hospital.
• The Clinical Care Classification System (CCC) was utilized.
• A new generation of interactive nursing Plans of Care was developed using the American Nurses Association (ANA) nursing process.
• The MEDCIN® clinical knowledgebase was employed to present CCC coded concepts.

Main Results:

• Patient care continuity was successfully demonstrated between nursing patient assessments and nursing Plans of Care.
• Interactive nursing Plans of Care were developed, integrating standardized terminology.
• CCC coded concepts became a natural by-product of the nursing documentation process.

Conclusions:

• The project successfully enhanced patient care continuity through integrated nursing documentation.
• The developed system effectively utilizes standardized terminologies like CCC and MEDCIN®.
• This innovative approach supports efficient and consistent nursing documentation within electronic health record systems.