title: Communicating Nursing Care Using the Health Level Seven Consolidated Clinical Document Architecture Release 2 Care Plan.
abstract: A care plan provides a patient, family, or community picture and outlines the care to be provided. The Health Level Seven Consolidated Clinical Document Architecture (C-CDA) Release 2 Care Plan Document is used to structure care plan data when sharing the care plan between systems and/or settings. The American Nurses Association has recommended the use of two terminologies, Logical Observation Identifiers Names and Codes (LOINC) for assessments and outcomes and Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) for problems, procedures (interventions), outcomes, and observation findings within the C-CDA. This article describes C-CDA, introduces LOINC and SNOMED CT, discusses how the C-CDA Care Plan aligns with the nursing process, and illustrates how nursing care data can be structured and encoded within a C-CDA Care Plan.
authors.affiliation: Author Affiliations: 3M Health Information Systems (Dr Matney and Ms Sheide); University of Utah, College of Nursing (Dr Matney) University of Utah, Bioinformatics Department (Ms Sheide); Intermountain Health Care (Ms Buhl), and Intelligent Medical Objects (Ms Dolin).
authors.forename: Susan A
authors.initials: SA
authors.lastname: Matney
authors.forename: Gay
authors.initials: G
authors.lastname: Dolin
authors.forename: Lindy
authors.initials: L
authors.lastname: Buhl
authors.forename: Amy
authors.initials: A
authors.lastname: Sheide
mesh_terms: D004282:Documentation / Q000379:methods*; D057208:Health Level Seven; D006801:Humans; D039703:Logical Observation Identifiers Names and Codes; D009732:Nursing Care; D048108:Nursing Informatics; D015404:Nursing Methodology Research; D009736:Nursing Process; D010347:Patient Care Planning; D039061:Systematized Nomenclature of Medicine