J P Systems HIT Blog
Coded Nursing Documentation can provide a valid and reliable framework to calculate nursing resources, workload, and produce evidence-based, patient care outcomes not possible in traditional EMR free-text solutions. The CND using the Clinical Care Classification (CCC) System, a recognized national nursing terminology, can provide an algorithm for disease condition care and also represent protocols for management. The CND ensures EMR data is linked to patient care. See this White Paper by Luann Whittenburg.
Coded Nursing Documentation improves the continuity of care across encounters and bridges providers. Patient care delivery is improved though the use of standard nursing concepts with the nursing process information model to document evidence-based outcomes. Evidence of the nursing care delivered helps ensure EMR data links to improved patient care. A nurse is the patient’s key liaison during a hospital stay and much of the patient’s care coordination is accomplished through the nurse who fills in gaps between physician visits and coordinates the care of the patient with various professionals. The use of coded nursing documentation (CND) and a nursing information model is an important benefit of applied informatics. The CND White Paper proposes a coordinated framework to synchronize the nursing interventions and the actions of nurses to realize optimum patient care outcomes and support evidence-based nursing education, policy, research, and practice. The specification offers organizational awareness of nursing activities. Nurses provide continuous care to patients during inpatient stays and to healthcare consumers within community and primary care settings. The structured coding of nursing care data with the Clinical Care Classification (CCC) System, a national nursing terminology, generates analytics to calculate nursing workload (time), resource (nurse staffing), and nursing services data. And the advanced analytics of coded nursing concepts can provide an algorithm for a disease condition such as ‘pneumonia care’ and combined with nursing interventions/actions can represent a protocol for ‘pulmonary care management’. These concepts can advance patient care outcomes, nursing science as well as nursing practice. The Coded Nursing Documentation (CND) White Paper describes the Clinical Care Classification (CCC) System as a data integrator for the exchange of coded nursing documentation among electronic health information record systems. The goal of nursing is to improve the health of communities, families, and individuals. This White Paper discusses the specifications and content structures for exchanging nursing data informed by the Nursing Process Framework of the American Nurses Association and uses the Information Model of the CCC System national nursing terminology standard. Within nursing practice, this specification advocates for the instrumental role of nurses in digitally transforming healthcare and makes the call to optimize the use of information and technology to enable better patient care.
Use Case: A 70 year old is admitted to a hospital after presenting to the Emergency Department with productive cough, acute rib pain, increased work of breathing, pulse oximetry saturation of 88%, temperature of 102.2 degrees, heart rate of 108, and blood pressure of 156/88. Chest x-ray in ED showed bilateral lower lobe and right middle lobe infiltrates. Medical diagnosis is Pneumonia. *Coded in the Clinical Care Classification (CCC) System Nursing Assessment (Signs and Symptoms): Respiratory (Care Component: L) Nursing Diagnosis: Respiratory Alteration (L26.0) Expected Outcome: Improve Respiratory Alteration (L26.0.1) Nursing Intervention/Action Type: - Perform Pulmonary Care (L36.0.2) Splint ribs for deep breathing every 2 hours on Day 1 - Perform Positioning Therapy (A61.1.2) Change position every 4 hours on Day 1 - Teach Breathing Exercises (L36.1.3) Teach use of incentive spirometry for lung expansion Actual Outcome: Stabilized Respiratory Alteration (L26.0.2) The frequency and percentage of nursing interventions/actions to stabilize the patient’s condition can be linked and tracked by nursing diagnosis to optimize nursing care processes for an episode of illness and collectively create an algorithm for nursing pulmonary management.
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