Studies in health technology and informatics · 2016 · 14 citations · 0 references
ComputingHealth InformaticsNursing InformaticsClinical Classification SystemsClinical Information SystemsElectronic Health RecordsClinical Document StandardsClinical DocumentationContinuity Of Care DocumentationDocumentation StandardsHospital DocumentationTerminology StandardsCare Plan DocumentationClinical Nursing Classification SystemsDocumentation ProcessElectronic Health Record DocumentationNursing DocumentationNursing Terminology StandardizationRegistered NursesStandardized Nursing Terminology
An innovative nursing documentation project conducted at Bumrungrad International Hospital in Bangkok, Thailand demonstrated patient care continuity between nursing patient assessments and nursing Plans of Care using the Clinical Care Classification System (CCC). The project developed a new generation of interactive nursing Plans of Care using the six steps of the American Nurses Association (ANA) Nursing process and the MEDCIN®clinical knowledgebase to present CCC coded concepts as a natural by-product of a nurse's documentation process. The MEDCIN®clinical knowledgebase is a standardized point-of-care terminology intended for use in electronic health record systems. The CCC is an ANA recognized nursing terminology.