Coded Nursing Documentation Profile

1. Coded Nursing Documentation Profile IHE Patient Care Coordination VirginaK.Saba, EdD, RN Keith Boone

2. Value Proposition • Coded Nursing Documentation (CND) - Plans of Care data is one of the largest gaps in hospital care delivery. • Plan of care data supports Federal Policy is to promote quality health care & transparency • Nursing Care is 30% of total hospital operating budgets. • Typical hospital Plan of Care will have multiple Nursing Diagnoses requiring multiple Nursing Interventions and Actions used to measure Outcomes. • Will save funds withheld by CMS “Reasonable Preventable” patient care conditions by providing Plan of Care Quality Data.

3. Profile Abstract • The Coded Nursing Documentation (CND) Profile provides a mechanism for electronic data interoperability between and among HIT systems. The CND demonstrates the exchange of ‘Plans of Care” based on atomic level diagnoses, interventions, and outcomes in a standardized framework using an information model (nursing process).

4. Plan of Care Framework • The Plan of Care Framework consists of six steps of the ANA’s Nursing Process representing a continuous process: • Diagnosis • Outcome Identification • Planning • Interventions • Evaluation • Follow-up Assessment

5. Scope

6. Key Technical Properties • Use of Standards: • IHE XDS – MS • HL7 Clinical Documentation Architecture (CDA) • HL7 Continuity of Care Documentation (CCD) • Use of Information Model • Nursing Process • Use of a HITSP Terminology • Clinical Care Classification (CCC) System – Coded Nursing Terminology