In today’s healthcare environment complete and accurate documentation of patient care is on the forefront and is a number one priority within the healthcare delivery system. With the development and implementation of the electronic health record additional resources have become available to assist allied healthcare professionals ensure proper documentation of patient care and outcomes. Medical data code sets are required for data elements in the administrative and financial health care transaction standards adopted under HIPAA for diagnoses, procedures, and drugs. Under HIPAA, a code set is known to be any set of codes used for encoding data elements (Frequently asked questions about Code Set Standards adopted under HIPPA, …show more content…
Clinical Care Classification also known as CCC is a code set that was developed for the use of nurses to document patient care. It was designed to be computerized while some other systems may not be. It may be used to document care within several settings such as home health agencies, ambulatory care clinics, and hospitals among other healthcare settings. The documenting of this care is of upmost importance as it assists the nurse in being able to develop necessary patient care plans. This is largely due to the fact that the nursing diagnosis drives interventions and patient outcomes. In addition driving interventions and outcomes, nursing diagnosis also provides a standard nomenclature that can be integrated for use in the Electronic Health Record (Sayles N. , Health Information Management Technology: An Applied Approach, 2013). The system consists of two interrelated terminologies which are the CCC of Nursing diagnosis and outcomes and the CCC of Nursing interventions and Actions. These terminologies are classified by 21 Care Components to form one single system (Clinical Classification System). The system consists of a four level coded Standardized Framework. This framework makes it possible for the data represented in all four levels to be coded. The first level of the framework is 4 Healthcare patterns (Physiological, …show more content…
Initially the CCC system was called the Home Health Care Classification system and later took on the name Clinical Care Classification System. In 2006, under the direction of President George W. Bush an executive order was issued to ensure that every person in the country should have an electronic health record by 2014. During the 2007/2008 timeframe the HIT standards panel selected and recommended the CCC as the first national terminology interoperable for the exchange of information among HIT