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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. [ABSTRACT FROM AUTHOR]

The panel focuses on Point-of-Care (POC) solutions for the documentation of nursing practice in electronic health record (EHR) and/or healthcare information technology (HIT) systems using the Clinical Care Classification (CCC) System. The CCC System was developed by Dr. Saba and Colleagues for the electronic documentation of patient care by nurses and allied health professionals and has been approved by American Nurses Association and U.S. Department of Health and Human Services as an interoperable, standardized nursing terminology The unique POC solutions will be described by different nursing informaticians, designers, and implementers who will describe how they document patient care using the CCC System and their impact on care outcomes. Also the Nursing Informatics (NI) Experts will discuss the effects of POC solutions on care quality and safety, as well as highlight how the data analytics are used to measure and predict workload, staffing, and cost. They will also describe how the information is used to support evidence-based practice and advance nursing knowledge. [ABSTRACT FROM AUTHOR]

Medicomp Point of Care Clinical Knowledgebase, MEDCIN® is designed to support integrated care documentation and the care planning functions of nurses and allied health professional. In electronic medical records (EMRs) starting with one or more clinical diagnoses and/or patient signs and symptoms, the capabilities of the MEDCIN® knowledgebase are used to prompt nursing terminology concepts following the American Nurses Association (ANA) nursing process [1]. The MEDCIN® diagnostic index dynamically constructs Interactive Plans of Care (PoC) using the six standards of the nursing process and allows aggregated data analysis. MEDCIN ® is widely used in the US by EMR clients and health information technology systems around the world. [ABSTRACT FROM AUTHOR]

The Workload Action Measures Method (WAMM) is a predictive model of care workload for individual patients. Design: The Clinical Care Classification Information Model quantifies nursing workload combining two aspects of nursing practice by measuring a patient's specific nursing service time using relative value units and a patient's disease condition using the intensity of four Healthcare Patterns/Care Components. Results: WAMM provides reliable workload calculations for disease conditions combined with Nursing Interventions Actions. [ABSTRACT FROM AUTHOR]

Nurses must have a point of care documentation method to share health information and transmit nursing data. Health information exchange using an online metadata registry allows nurses, health professionals, hospital administrators, and diverse information systems to make significant strides towards improving health outcomes and human quality of care. Health information exchange using point of care documentation supports research methods to determine the cost of nursing service as well as supports the professional assessment of our significant contribution to human quality and care outcomes in electronic health record systems. [ABSTRACT FROM AUTHOR]

An online metadata registry promotes cross-system and cross-organization descriptions of common units of health data. Nurses must have a method to share health information and transmit nursing data. Health information sharing through an online metadata registry allows nurses, health administrators, and hospital systems to make significant strides towards improving customer-centered electronic health records, patient safety, reducing errors, lowering healthcare costs, and strengthening public health and disaster preparedness initiatives. [ABSTRACT FROM AUTHOR]

Knowledge models inform organizational behavior through the logical association of documentation processes, definitions, data elements, and value sets. The development of a well-designed knowledge model allows for the reuse of electronic health record data to promote efficiency in practice, data interoperability, and the extensibility of data to new capabilities or functionality such as clinical decision support, quality improvement, and research. The purpose of this article is to describe the development and validation of a knowledge model for healthcare-associated venous thromboembolism prevention. The team used FloMap, an Internet-based survey resource, to compare metadata from six healthcare organizations to an initial draft model. The team used consensus decision-making over time to compare survey results. The resulting model included seven panels, 41 questions, and 231 values. A second validation step included completion of an Internet-based survey with 26 staff nurse respondents representing 15 healthcare organizations, two electronic health record vendors, and one academic institution. The final knowledge model contained nine Logical Observation Identifiers Names and Codes panels, 32 concepts, and 195 values representing an additional six panels (groupings), 15 concepts (questions), and the specification of 195 values (answers). The final model is useful for consistent documentation to demonstrate the contribution of nursing practice to the prevention of venous thromboembolism., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

While nursing activities represent a significant proportion of inpatient care, there are no reliable methods for determining nursing costs based on the actual services provided by the nursing staff. Capture of data to support accurate measurement and reporting on the cost of nursing services is fundamental to effective resource utilization. Adopting standard terminologies that support tracking both the quality and the cost of care could reduce the data entry burden on direct care providers. This pilot study evaluated the feasibility of using a standardized nursing terminology, the Clinical Care Classification System (CCC), for developing a reliable costing method for nursing services. Two different approaches are explored; the Relative Value Unit RVU and the simple cost-to-time methods. We found that the simple cost-to-time method was more accurate and more transparent in its derivation than the RVU method and may support a more consistent and reliable approach for costing nursing services.

This article amplifies the emphasis on organizational workflow reignited by the Institute of Medicine reports on healthcare quality. The analysis of nursing workflow is central to understanding the power of technology to modify the fundamental constructs of nursing practice. The aim is to understand the evolution of nursing workflow and the concept of workflow from the management and computer science perspectives used in electronic health records and computerized provider order entry. The understanding of the workflow models within health information disciplines may improve the model of nursing workflow underlying the implementation of electronic health record systems. The article follows the Walker and Avant evolutionary method of concept analysis.

Recently, government and healthcare providers have recognized the tremendous value and importance of advancing the use of electronic healthcare information systems. Without question, the issue of quality has become a focus of concern for consumers, politicians and healthcare providers and a priority for healthcare organizations in the 21st century. The nursing profession through the American Nurses Association has long recognized the need for quantitative evidence to measure the relationship of documentation to the impact on patient care. The following article discusses the ability of electronic healthcare information systems to collect nursing data using nursing terminology for care quality and outcome management. The purpose is to inform informatics professionals of an immediate need to connect electronic healthcare information systems with a standard, concept-based, atomic-level, coded nursing terminology readily available in the public domain for the longitudinal analyses of the continuity of care and of the nurses' contribution to healthcare quality.

Nurses must have a point of care documentation method to share health information and transmit nursing data. Health information exchange using an online metadata registry allows nurses, health professionals, hospital administrators, and diverse information systems to make significant strides towards improving health outcomes and human quality of care. Health information exchange using point of care documentation supports research methods to determine the cost of nursing service as well as supports the professional assessment of our significant contribution to human quality and care outcomes in electronic health record systems.

An online metadata registry promotes cross-system and cross-organization descriptions of common units of health data. Nurses must have a method to share health information and transmit nursing data. Health information sharing through an online metadata registry allows nurses, health administrators, and hospital systems to make significant strides towards improving customer-centered electronic health records, patient safety, reducing errors, lowering healthcare costs, and strengthening public health and disaster preparedness initiatives.