RESUMO
Nursing terminology development efforts in the United States and globally provide concept coverage across many domains of nursing practice. Efforts to integrate concepts from across terminology systems into a single reference terminology support broad concept coverage but do not provide a means to leverage the full benefits of the individual terminology systems. The purpose of this paper is to explore the feasibility of harmonizing the 198 Clinical Care Classification (CCC) System core intervention concepts with intervention concepts in the International Classification for Nursing Practice (ICNP®) as a means to leverage both the information model components of the CCC system and the broad concept coverage of the ICNP®. Findings suggest that the CCC system and ICNP® are largely interoperable and a common framework underlying the two terminology systems provides a foundation for harmonization.
RESUMO
As health care systems and providers move towards meaningful use of electronic health records, the once distant vision of collaborative patient-centric, interdisciplinary plans of care, generated and updated across organizations and levels of care, may soon become a reality. Effective care planning is included in the proposed Stages 2-3 Meaningful Use quality measures. To facilitate interoperability, standardization of plan of care messaging, content, information and terminology models are needed. This degree of standardization requires local and national coordination. The purpose of this paper is to review some existing standards that may be leveraged to support development of interdisciplinary patient-centric plans of care. Standards are then applied to a use case to demonstrate one method for achieving patient-centric and interoperable interdisciplinary plan of care documentation. Our pilot work suggests that existing standards provide a foundation for adoption and implementation of patient-centric plans of care that are consistent with federal requirements.