CCC System (V-2.5) offers a new approach to documenting nursing practice in an Electronic Health Record (EHR). It consists of a standardized framework representing four unique levels that represents: a) 176 Nursing Diagnoses, b) 804 Nursing Intervention/Actions & c) 528 Nursing Outcomes, each of which are classified by 21 Care Components representing 4 Healthcare Patterns to form one system — CCC System. The Framework’s four levels make it possible to code the concepts for each level separately so that the coded data can be aggregated upward for summary information or parsed downward to view the atomic level data elements.
- 1st Level: 4 Healthcare Patterns Categorize the Care Components: 1) Physiological, 2) Psychological, 3) Functional, & 4) Health Behavioral.
- 2nd level: 21 Care Components Classify the CCC Terminologies:
- Activity, Bowel/Gastric, Cardiac, Cognitive/Neuro, Coping, Fluid Volume, Health Behavior, Medication, Metabolic, Nutritional, Physical Regulation, Respiratory, Role relationship, Safety, Self-Care, Self-Concept, Sensory, Skin Integrity, Tissue Perfusion, Urinary Elimination, Life Cycle.
- 3rd Levels 2 Nursing Terminologies that consist of Coded Concepts below:
- CCC of 176 Nursing Diagnoses/Problems
- CCC of 804 (201 Core Nursing Interventions with 4 Action Types)
- CCC of 528 Nursing Outcomes (176 Diagnoses with 3 Outcome qualifiers)
- 4th Level 2 Sets of Separate Concept Qualifiers:
- 3 Outcome Qualifiers (Improved, Stabilized, or Deteriorated). 528 Outcomes: Each Nursing Diagnosis is Combined with I of 3 Outcomes to depict the Expected and/or Actual Outcomes
- 4 Action Type Qualifiers (Monitor, Perform, Teach, or Manage). 804 Nursing Intervention /Actions: Each Nursing Intervention is Combined with 1 of 4 Action Types to expand the scope of the Intervention.
CCC System Coding Structure is similar to ICD-10 (International Statistical Classification of Diseases and Health-Related Problems, 1990). Each concept code consists of five alphanumeric characters for information exchange and interoperability:
1st: Alpha Character Represents = Care Component = A
2nd: Two or Three Digits Represent = Nursing Concepts= A02.1
- A Nursing Concept represents either: Nursing Diagnosis or Nursing Intervention
5th Last Digit Represents either:
- 1 of 3 Outcome Qualifiers (last digit), or
- 1 of 4 Intervention Action Types (last digit)