Keywords

Clinical care classification, Nursing diagnosis, interventions and outcomes, Nursing terminology, Nursing standards

 

Authors

  1. SABA, VIRGINIA K. EdD, RN, FAAN, FACMI
  2. TAYLOR, SHERYL L. BSN, RN

Abstract

This article provides an overview of the Clinical Care Classification System Version 2.0, a standardized coded nursing terminology designed to enhance nursing visibility. The article provides a background as to why a coded language is needed to describe the "essence of care" to validate patient outcomes. The article highlights the research that produced Clinical Care Classification System and describes how the two interrelated terminologies-the Clinical Care Classification System of Nursing Diagnoses and Outcomes and the Clinical Care Classification System of Nursing Interventions/Actions-are linked and mapped to each other using its coding structure. Examples of the two terminologies are presented with detailed explanations about the coding process. The article highlights the attributes of the Clinical Care Classification System and its place in electronic health record systems.