A new mobile-friendly Web tool of the Clinical Care Classification (CCC) System is here for use by the nursing community. The CCC System tool is available as a mobile-friendly Web site, viewable with any mobile device or smart phone. This useful CCC System lookup tool is designed for documenting an electronic Nursing Plan of Care (PoC) for any patient diagnosed with any disease condition, presenting signs or symptoms in any setting, or on any vendor system.
CCC SYSTEM STRUCTURE
The CCC System mobile Web tool is a simple standardized lookup tool designed to view the CCC System's concepts and codes. The CCC System was empirically developed from actual, live patient care data and designed to measure the relationships of nursing care to patient outcomes by documenting the "essence of care." It was designed for electronic processing, for data interoperability of nursing and allied health information, and with many critical features (Table 1). The CCC System is structured as two interrelated terminologies, each with a four-level framework, designed hierarchically and linked together to make the documentation of nursing practice feasible in the electronic health record (EHR) system. The CCC's two terminologies consist of the CCC of 176 Nursing Diagnoses and 528 Outcomes (176 Diagnoses with three Goals) and the CCC of 804 Nursing Interventions & Actions (201 Core Interventions with four Action Types), each of which is classified by 21 Care Components. The CCC System uses a five-character alpha-numeric structure to code the nursing concepts of the two CCC terminologies, making them standardized and making the coded nursing documentation able to link and track that care process.1
KEY POINTS:
* New nursing mobile-friendly Web tool for Clinical Care Classification (CCC) System.
* The CCC mobile-friendly Web tool is a lookup tool for documenting a nursing plan of care (PoC).
* The CCC mobile-friendly Web tool PoC follows the nursing process.
CARE COMPONENT
A Care Component represents a cluster of data elements designed to depict a holistic approach for documenting nursing practice. The Care Components form the basis for documenting the coded PoC for an EHR or a healthcare information technology system. These 21 Care Components provide the organizing structure for the American Nurses Association (ANA) professional practice model-nursing process-which links the six steps of the Nursing Process together: assessment, diagnoses, goals/expected outcomes, nursing interventions & action types, and actual outcomes.2
MOBILE APP SCREENS
The CCC Nursing PoC mobile-friendly tool consists of several sequential screens, representing the six steps of the nursing process. Each screen has a menu listing the options for the nurse/clinician to select one coded concept and, once selected, moves automatically to the next screen and the next step in the nursing process until the PoC screens for the nursing process are completed and one Care Pathway developed. Each screen's unique menu is designed to assist the nurse/clinician select the appropriate concept for each of the six steps of the CCC System's nursing process to form the PoC for the patient's disease condition.
CARE COMPONENT AND DIAGNOSIS SCREENS
The initial screen consists of a menu that lists the CCC System 21 Care Components, from which the nurse selects the most appropriate Care Component for one assessed sign and symptom of the patient's disease condition. This is followed by a screen listing the CCC Diagnoses/Problems for the selected Care Component and from which the nurse/clinician selects one chief Nursing Diagnosis/Problem (each diagnosis/problem is treated separately and processed one at a time regardless of the number of diagnoses/problems that the patient presents for the disease condition). A CCC Nursing Diagnosis is considered to be a granular atomic-level diagnostic condition based on the analysis of the patient's disease condition or assessed signs and symptoms that require therapeutic nursing care to alter the health status of the patient.
GOALS/EXPECTED OUTCOME SCREEN
The next screen lists the three possible Goals/Expected Outcomes for the selected Nursing Diagnosis/Problem of the patient disease condition: (1) Improve, (2) Stabilize, or (3) Deteriorate. Each Nursing Diagnosis requires a Goal/Expected Outcome to achieve a measurable Outcome resulting from the therapeutic nursing care that alters the health status of the patient. The selected Goal should depict the focus of the patient's planned care (Nursing Interventions/Action Type) for the patient's specific diagnosis/problem.
NURSING INTERVENTION & ACTION TYPE SCREENS
The next two screens are designed to select a Nursing Intervention and its Action Type (one at a time) appropriate for the nursing care of the patient's Diagnosis/Problem. All CCC Nursing Interventions are granular atomic-level services or concepts used to determine and describe the proposed nursing PoC specific for the patient. The Nursing Intervention screen lists the Nursing Interventions for the initial Care Component based on one assessed sign and symptom of the patient's disease condition. This is followed by a screen with the four possible Action Types: (1) Assess or Monitor, (2) Perform or Provide Care, (3) Teach or Instruct, or (4) Manage or Refer. One of the four Action Types must be selected to depict the exact Implementation of the Nursing Intervention. These four Action Types provide the measures used to determine the status of the care process at any given point in time as well as to measure workload, resource needs, and care outcomes.
ACTUAL OUTCOME SCREEN
The final nursing process screen contains the Actual Outcome menu that lists the same three Goals/Expected Outcome options, (1) Improved, (2) Stabilized, or (3) Deteriorated, for the completed evaluation of the Actual Outcome of the selected Diagnosis/Problem. The Actual Outcome can be completed any time during the care episode or on discharge completing a single Care Pathway. The Actual Outcome not only determines whether the Goals were "Met" or "Not Met" but also can be compared to the initial Goal/Expected Outcome to evaluate and measure the quality outcomes of the nursing care.
SUMMARY PLAN SCREEN
The last screen is a Summary Plan screen itemizing the selected single Care Pathway designed to document the PoC following the CCC System's six steps of the Nursing Process for one Nursing Diagnosis/Problem and Nursing Intervention/Action Type. This Summary Plan can be copied to the patient's EHR (recommended). This Care Pathway and/or PoC can be combined with other Care Pathways to build a comprehensive electronic Nursing PoC for a patient's disease condition. The Summary Plan Care Pathway can also provide the evidence of the care processes and its decision-support measures (see Supplemental Digital Content 1, http://links.lww.com/CIN/A23, Nursing Plan of Care Pathway Example, which provides more detail).
CONCLUSION
This CCC System mobile-friendly Web tool was developed to support the education of nurses and others working with the CCC System terminologies using any mobile device or smartphone. The application assists any nurse/clinician, in any setting, with the electronic documentation of a patient's PoC for a patient's specific disease condition regardless of vendor application. The Actual Outcomes can be evaluated and measured by summarizing the frequency and the values of Interventions/Action Types. The generated patient care data can also be used for research, for determination of quality indicators, for measurement of outcomes, and for calculation of numerous other quantitative analytics. This lookup tool will provide users with one of the first nursing mobile-friendly tools designed to standardize the documentation of nursing plans of care using today's mobile clinical technology.
To access the tool, navigate to http://www.sabacare.com or http://www.clinicalcareclassification.com.
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