Coded Nursing Documentation Profile

IHE Patient Care CoordinationIHE Patient Care CoordinationVirgina K.Saba, EdD, RNVirgina K.Saba, EdD, RN

Keith BooneKeith Boone

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.

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).

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

Scope

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