Communicating Nursing Care Using the Health Level Seven Consolidated Clinical Document Architecture Release 2 Care Plan
Communicating Nursing Care Using the Health Level Seven Consolidated Clinical Document Architecture Release 2 Care Plan
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DOI：
10.1097/cin.0000000000000214
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发表时间：
2016-03-01
影响因子：
1.3
通讯作者：
Sheide, Amy
中科院分区：
文献类型：
--
作者：
Matney, Susan A.;Dolin, Gay;Sheide, Amy
护理计划提供了病人、家庭或社区的情况，并概述了要提供的护理。当在系统和/或设置之间共享护理计划时，健康级别7综合临床文档架构（C-CDA）第2版护理计划文档用于构建护理计划数据。美国护士协会推荐使用两个术语，用于评估和结果的逻辑观察标识名称和代码（LOINC）和用于C-CDA中的问题、程序（干预）、结果和观察结果的医学临床术语系统化命名法（SNOMED CT）。本文描述了C-CDA，介绍了LOINC和SNOMED CT，讨论了C-CDA护理计划如何与护理过程保持一致，并说明了如何在C-CDA护理计划中对护理数据进行结构化和编码。
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.