A preliminary study on the use of clinical care classification in nursing documentation data sets.
This study analyzed and organized the content coverage of the clinical care classification (CCC) system to represent nursing record data in a medical center in Taiwan. The nursing care plan was analyzed using the process of knowledge discovery in the data set. The nursing documentation was mapped based on the full list of nursing diagnoses and interventions available using the CCC system. The result showed that 75.45% of the documented diagnosis terms can be mapped using the CCC system. A total of 21 established nursing diagnoses were recommended for inclusion in the CCC system. The results also showed that 30.72% of assessment/monitor tasks and 31.16% of care/perform tasks were provided by nursing professionals, whereas manage/refer actions accounted for 15.36% of the tasks involved in nursing care. The results showed that the CCC system is a suitable clinical information system for the majority of nursing care documentation, and is useful for determining the patterns in nursing practices.
Department of Nursing, Taipei Veterans General Hospital, R.O.C., Taiwan; School of Nursing, National Defense Medical Center, R.O.C., Taiwan; Institute of Biomedical Informatics, National Yang-Ming University, R.O.C., Taiwan.
Rung-Chuang
RC
Feng
Kuan-Jui
KJ
Tseng
Hsiu-Fang
HF
Yan
Hsiu-Ya
HY
Huang
Polun
P
Chang
D004282:Documentation; D009733:Nursing Diagnosis; D009736:Nursing Process; D009737:Nursing Records; D015203:Reproducibility of Results; D013624:Taiwan
Clinical care classification; Nursing documentation; Nursing terminology