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.

SNOMED-CT as a standardized language system model for nursing: an integrative review

“…Communicating nursing care using the health level seven consolidated clinical document architecture release 2 care plan. Matney, Dolin, Buhl, Sheide (25) USA, 2016 CIN: Computers, Informatics, Nursing To describe the Consolidated Clinical Document Architecture (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.…”

“…In addition, studies have been developed associating the use of this clinical nomenclature with other standardized languages used by nursing, such as Logical Observation Identifiers, Names, and Codes (LOINC), ICNP ® , NANDA-I, and Omaha System, as well as other health information platforms like Unified Medical Language System (UMLS) (18,(20)(21)25,(27)(28)(29)(30) . This demonstrates an effort that the discipline, in different countries, has made in an attempt to find a system that better contemplates its practice.…”

“…LOINC is a standards set terminology designed for use in the USA federal government systems for the electronic exchange of clinical health information, as it refers to laboratory tests on transactions between health facilities. LOINC and SNOMED-CT are contained in the 10 terminologies or classifications recognized by the American Nurses Association (ANA) as standards that apply to the nursing practice (25) . The use of standard terminologies facilitates semantic interoperability and models based on standards and incorporated into hospital electronic records.…”

Impacto de tecnologias na implementação da sistematização da assistência de enfermagem hospitalar: uma revisão integrativa

“…Atualmente considera-se que a formação dos profissionais de enfermagem comtemplam às diversas áreas de gestão da instituição hospitalar, englobando principalmente os recursos humanos e financeiros considerando o uso das tecnologias. 31,32 O artigo VII relatou que a informatização do sistema possibilitou o gerenciamento das ações da equipe de enfermagem e visualização dos acontecimentos. Além disso, a confiabilidade dos registros devido à rigorosidade dos dados registrados no sistema, à vigilância e monitoramento de ações em saúde e a segurança dos dados armazenados oferecem suporte para tomada de decisões, favorecendo a gestão da equipe de saúde quanto à qualidade da assistência prestada.…”

A Shovel‐Ready Solution to Fill the Nursing Data Gap in the Interdisciplinary Clinical Picture

“…Overview of SNOMED‐CT and LOINC Related to Nursing Terminologies According to the International Health Terminology Standards Development Organization (2016) (Matney, Dolin, Buhl, & Sheide, ; Regenstrief Institute, 2016; International Health Terminology Standards Development Organization, n.d.)…”