I. Health Behavioral Components Medication (H) Safety (N) Health Behavior (G) II. Functional Components

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Clinical Care Classification (CCC) System

Version 2.0

Terminologies:

CCC of Nursing Diagnoses & Outcomes

&

CCC of Nursing Interventions & Actions

Prepared By
Virginia K. Saba. EdD, RN, FAAN. FACMI and

Veronica D. Feeg, PhD, RN, FAAN
2006

Previously Home Health Care Classification (HHCC), All rights are reserved No part of this document may be reproduced, transmitted. Stored, and retrieved in any way, in any form, or by any means except as allowed by law without express written permission of author. Clinical Care Classification (CCC) System Version 2.0 Copyright 10/20/2004 – Virginia K. Saba

VKS 10/05

Clinical Care Classification System ©

The 21 Care Components provide the standardized framework for classifying each of the two interrelated nursing language taxonomies based on the HHCC of Nursing Diagnoses and HHCC of Nursing Interventions and available in SNOMED. They are used to code and classify the six steps of the Nursing Process: Assessment, Diagnosis, Outcome Identification (Expected Outcome/Goal), Planning (Nursing Intervention), Implementation (Type Intervention Action), and Evaluation (Actual Outcome). The Care Components are used to link, map, and track the care process for an episode of illness, facilitate computer processing, and statistical analyses. They are also used to track and measure patient/client care holistically over time, across settings, population groups, and geographic locations.

The 21 Care Components were found to be the most clinically relevant assessment classes, best predictors of nursing resources, and the most appropriate standardized framework for coding and classifying nursing diagnoses and nursing interventions regardless of setting (Holzemer et al., 1997). They were found to be 99 percent compliant for coding disease conditions in a variety of health care settings. Clinical Care Classification System (CCCS) © Virginia Saba. All Rights Reserved

I. Health Behavioral Components

Medication (H)
Safety (N)
Health Behavior (G)

II. Functional Components

Activity (A)
Fluid Volume (F)
Nutritional (J)
Self-Care (O)
Sensory (Q)

III. Physiological Components

Cardiac (C)
Respiratory (L)
Metabolic (I)
Physical Regulation (K)
Skin Integrity (R)
Tissue Perfusion (S)
Bowel Elimination (B)
Urinary Elimination (T)
Life Cycle (U)

IV. Psychological Components

Cognitive (D)
Coping (E)
Role Relationship (M)
Self Concept (P)

*A Care Components is a cluster of elements that represent a health behavioral, functional, physiological or psychological care pattern. The 21 Care Components are organized by four Care Patterns empirically developed and based on Gordon’s 11 Functional Health Patterns.

Nursing Care Process Steps – Documentation System

The steps of the nursing process include the following:

Assessment

Diagnosis

Outcome Identification (Expected Outcome)

Intervention (Planning)

Type of Action – Implementation (Monitor/Perform/Teach/Refer)

Evaluation (Actual Outcome)

Care Components: Assessment

Care Components provide the standardized framework to document and track the care with each patient contact/encounter. Care Components link and map the six steps of the care process; and provide the analysis and measures for evidence-based practice.

Nursing Diagnoses: Diagnosis

Nursing Diagnoses are used to identify the specific atomic-level diagnostic conditions based on the signs and symptoms, assessed care components and/or patient problems that require care.

Expected Outcome: Outcome Identification

Each Nursing Diagnosis requires an Expected Outcome as the goal of the care. The three qualifiers used for the Outcome Identification are: to improve patient’s condition; to stabilize the patient condition; or to support the patient’s deteriorating condition.

Nursing Interventions: Planning

The Nursing Interventions are atomic-level services identified to plan and implement patient care. They are needed to satisfy each care component, diagnostic condition, or patient problem assessed as requiring nursing care.

Type Intervention Action: Implementation

Each Nursing Intervention requires a Type of Action as the major focus of the core nursing intervention. It provides the evidence used to measure care and determine the resources The 4 qualifiers used to provide the Type Action are:
1. Assess/Monitor/Evaluate/Observe = Action evaluating the patient condition.
2. Care/Perform//Provide/Assist = Action performing actual patient care.
3. Teach/Educate/Instruct/Supervise = Action educating patient or caregiver.
4. Manage/Refer/Contact/Notify = Action managing care on-behalf of the patient or caregiver.

Actual Outcome: Evaluation

Each Nursing Diagnosis requires an Actual Outcome as an evaluation of the outcome of the care process – interventions and type actions. The same three qualifiers are used to predict the care goals and to evaluate whether they were met or not met.
Patient’s condition Improved; Stabilized; or Deteriorated

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Clinical Care Classification (CCC) (Version 2.0) of

Nursing Diagnoses

with

Expected and/or Actual Outcomes

Coding Structure

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The CCC of Nursing Diagnoses are listed below for documenting patient problems.

The CCC of Nursing Diagnoses can also be used to code Expected and/or Actual Outcomes by using one of three modifiers: (1) Improved, (2) Stabilized, or (3) Deteriorated.

The coding structure for the CCC of Nursing Diagnoses with Outcome Modifiers consist of five alphaneumeric alphaneumeric characters:

Care Component: 1^st Alpha Code: A - U
Nursing Diagnosis Major Category: 2nd/3rd Digit: 01 - 61
Nursing Diagnosis Subcategory: 4^th Decimal Digit: 1 - 9
Expected/Actual Outcome Modifier: 5^th Digit: 1 - 3

(1 = Improved, 2 = Stabilized, 3 = Deteriorated)

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Classification of Nursing Diagnoses (Version 2.0) and Coding Scheme for 59 Major Categories and 123 Subcategories^{1, 2}

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A ACTIVITY COMPONENT

01 Activity Alteration

Activity Intolerance
Activity Intolerance Risk
Diversional Activity Deficit
Fatigue
Physical Mobility Impairment
Sleep Pattern Disturbance
Sleep Deprivation

02 Musculoskeletal Alteration

1. Adapted from NANDA: Taxonomy I: Revised 1990

2. Adapted with Permission from NANDA Nursing Diagnoses & Classification 2003-2004