Matney Susan A, Dolin Gay, Buhl Lindy, Sheide Amy
Author Affiliations: 3M Health Information Systems (Dr Matney and Ms Sheide); University of Utah, College of Nursing (Dr Matney) University of Utah, Bioinformatics Department (Ms Sheide); Intermountain Health Care (Ms Buhl), and Intelligent Medical Objects (Ms Dolin).
Comput Inform Nurs. 2016 Mar;34(3):128-36. doi: 10.1097/CIN.0000000000000214.
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.
护理计划描绘了患者、家庭或社区的情况，并概述了将要提供的护理。当在不同系统和/或环境之间共享护理计划时，卫生级别七（HL7）联合临床文档架构（C-CDA）第2版护理计划文档用于构建护理计划数据。美国护士协会建议使用两种术语，即用于评估和结果的逻辑观察标识符名称和代码（LOINC），以及用于C-CDA中的问题、程序（干预措施）、结果和观察结果的医学临床术语系统命名法（SNOMED CT）。本文介绍了C-CDA，引入了LOINC和SNOMED CT，讨论了C-CDA护理计划如何与护理流程保持一致，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。
