Clinical Care Classification (CCC) System Manual: A Guide to Nursing Documentation

by Virginia Saba EdD, DSN, DScN, RN, FAAN, FACMI, LL

Overview

Designated a Doody's Core Title!

The Preeminent Nursing Terminology Classification System

"The Clinical Care Classification (CCC) System described in this manual is the only standard coded nursing terminology that is based on sound research using the nursing process model framework and that meets the Patient Medical Record Information (PMRI) comparability requirement. The CCC System allows patient care data generated by nurses to be incorporated into the PMRI database, and enables nurses' contributions to patient outcomes to be studied and acknowledged."
-- From the Foreword by Sheryl L. Taylor, BSN, RN, Senior Consultant, Farrell Associates

TESTIMONIES:

"ABC Coding Solutions-Alternative Link developed ABC codes for nursing in collaboration with Dr. Virginia Saba, developer of the CCC system. Approximately two hundred ABC codes were developed from the CCC System of Nursing Interventions to accurately document nursing and integrative health care processes, classify and track clinical care, and develop evidence-based practice models, thus filling significant gaps in older medical code sets."
--Connie Koshewa, Practitioner Relations Director, ABC Coding Solutions-Alternative Link

"The International Classification for Nursing Practice (ICNPÆ) is a program of the International Council of Nurses (ICN). One of the first steps in the development of the ICNPÆ was to collect and compare all the nursing concepts in existing nursing terminologies, including the CCC. To facilitate the goal of ICNPÆ as a unified nursing language system, a project is under way to map the CCC to the ICNPÆ Version 1.0. This work will facilitate evaluation and ongoing development of both terminologies and allow ICN to compare data using CCC codes with data from other standard nursing terminologies."
--Amy Coenen, PhD, RN, FAAN, Director, ICNPÆ Program, International Council of Nurses

Product Details

ISBN-13:	9780826103543
Publisher:	Springer Publishing Company
Publication date:	10/09/2006
Sold by:	Barnes & Noble
Format:	eBook
Pages:	280
File size:	14 MB
Note:	This product may take a few minutes to download.

About the Author

Virginia K. Saba, EdD, RN, FAAN, FACMI, is President and CEO of SabaCare, Inc., an AAN "Living Legend," and pioneer in digital technology for nursing.

Table of Contents

"ContributorsForeword Sheryl L. Taylor
Preface
Acknowledgments

PART I: OVERVIEW
Chapter 1. Why Clinical Care Classification (CCC)?, Kathleen A. McCormick
Chapter 2.Background and Development of the Clinical Care Classification System
Chapter 3.Features, Uses, and Policies

PART II: RESEARCH, INTEGRATION, AND EVALUATION
Chapter 4. Research and Evaluation Studies
Chapter 5.Mappings and Testimonies
Chapter 6. Messaging the Clinical Care Classification System (CCC) using Logical Observation Identifiers, Names, and Codes (LOINC) and Health Level 7 (HL7),Susan Matney, Suzanne Bakken, and Stanley M. Huff
Chapter 7.Why SNOMED CT?, Debra J. Konicek
Chapter 8.Use of the Clinical Care Classification (CCC) in Nursing Research Protocols: A Case Study of the Client Adherence Profiling-Intervention Tailoring (CAP-IT) Intervention Protocol, Suzanne Bakken and William L. Holzemer
Chapter 9.Approaches to Implementing the CCC: Educating Nurses in Electronic Documentation, Veronica D. Feeg
Chapter 10. Integration of the Clinical Care Classification into an Electronic Student Clinical Log, Suzanne Bakken and Nam-Ju Lee
Chapter 11. Bibliography of Major Clinical Care Classification (CCC) System Articles: 1991-2006

PART III: TERMINOLOGY USES
Chapter 12. AClinical Care Classification (CCC) Cost Method, Jean M. Arnold and Virginia K. Saba
Chapter 13. Documentation Strategies

Table 13.1. CCC Working Table--Nursing Diagnoses, and Nursing Interventions, With Definitions by Care Components
Chapter 14. Clinical Care Classification (CCC) Framework and Terminology Tables
Care Component Tables
Table 14.1. Clinical Care Classification 21 Care Components (Version 2.0): Coded by Four Health Care Patterns
Table 14.2. Clinical Care Classification 21 Care Components (Version 2.0): Coded by Alphabetic Classes
Table 14.3. Clinical Care Classification System 21 Care Components (Version 2.0): Coded by Alphabetic Classes with Definitions
Nursing Diagnoses Tables:
Table 14.4: Clinical Care Classification of 182 Nursing Diagnoses (Version 2.0): Coded&Classified by 21 Care Components
Table 14.5. Clinical Care Classification of 182 Nursing Diagnoses (Version 2.0): Coded with Definitions&Classified by 21 Care Components.
Table 14.6. Clinical Care Classification of 182 Nursing Diagnoses (Version 2.0): Coded Alphabetically with Definitions
Table 14.7. Clinical Care Classification of 182 Nursing Diagnoses (Version 2.0): Listed Alphabetically by Code Numbers
Nursing Diagnoses Outcomes Tables
Table 14.8. Clinical Care Classification of 182 Nursing Diagnoses (Version 2.0): Coded with Definitions, Three Expected Outcomes,&Classified by 21 Care Components
Table 14.9. Clinical Care Classification of 182 Nursing Diagnoses (Version 2.0): Coded with Definitions, Three Actual Outcomes,&Classified by 21 Care Components
Nursing Interventions Tables:
Table 14.10. Clinical Care Classification of 198 Nursing Interventions (Version 2.0): Coded&Classified by 21 Care Components
Table 14.11. Clinical Care Classification of 198 Nursing Interventions (Version 2.0): Coded with Definitions&Classified by 21 Care Components.
Table 14.12. Clinical Care Classification of 198 Nursing Interventions (Version 2.0): Coded Alphabetically with Definitions
Table 14.13. Clinical Care Classification of 198 Nursing Interventions (Version 2.0): Listed Alphabetically by Code Numbers
Table 14.14. Clinical Care Classification of 198 Nursing Interventions (Version 2.0): Coded with Definitions, Four Action Types,&Classified by 21 Care Components
APPENDICES:
Appendix A.Clinical Care Classification Care Components, Nursing Diagnoses, and Nursing Interventions (Version 2.0) Revisions from Home Health Care Classification (Version 1.0)
Table A.1. Clinical Care Classification Care Components (Version 2.0) Revisions from Home Health Care Classification (Version 1.0)
Table A.2. Clinical Care Classification of Nursing Diagnoses (Version 2.0) Revisions from Home Health Care Classification (Version 1.0)
Table A.3. Clinical Care Classification of Nursing Interventions (Version 2.0) Revisions from Home Health Care Classification (Version 1.0)

Appendix B. Permission Form
Appendix C. NTIS Order Form
Index"

Editorial Reviews

Reviewer: Carole A. Kenner, PhD, RN, FAAN, FNAP, ANEF (The College of New Jersey)
Description: This book is the first to present a unified coded classification system or Clinical Care Classification that can be used to implement and document patient care or to code care according to an electronic medical record. The previous edition was published in 1994 as Home Health Care Classification.
Purpose: The purpose is to present a unified classification system that quantifies and codes nursing care and patient care actions. These worthy objectives are met.
Audience: The audience is anyone who is charged with implementing, documenting, and coding patient care and using a standard terminology for an electronic medical record. The author is a pioneer in the area of nursing informatics and an internationally recognized authority.
Features: The book describes a clinical care classification system and why it was developed. The next section addresses the system's use in research and education. Content includes information about how to teach nurses about use of standardized language, for example, in clinical logs as well as the need for such classification in electronic records. The last section focuses on terminology and its use to cost out services and care and the interface with nursing diagnoses and interventions. A strength is the system's use in standardized care plans to guide nurses in how to apply the information.
Assessment: This book is unique. There are no others that pull together the nursing process, coding of actions, and documentation of those actions under one unified language. It is the first time that nursing actions can be quantitatively measured to determine the impact on patient outcomes, thus leading the way for a better understanding of the value-consumer and cost of nursing care. The previous edition focused only on home care but after a decade of application, this edition demonstrates that use of the system is not setting-specific.

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