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The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings. [1]
CC cc: cubic centimeter (use ml instead—see the list of abbreviations used in prescriptions) chief complaint cardiac catheter carbon copy closing capacity: CCA: clear cell adenocarcinoma: CCB: calcium channel blocker: CCCU: critical coronary care unit: CCE C/C/E: clubbing, cyanosis, and edema (general signs of cardiovascular disease) CCG ...
[citation needed] [1] The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other reason for a medical encounter. [2] In some instances, the nature of a patient's chief complaint may determine if services are covered by health insurance .
Health assessment has been separated by authors from physical assessment to include the focus on health occurring on a continuum as a fundamental teaching. [8] In the healthcare industry it is understood health occurs on a continuum, so the term used is assessment but may be preference by the speciality's focus such as nursing, physical therapy, etc.
Pronunciation follows convention outside the medical field, in which acronyms are generally pronounced as if they were a word (JAMA, SIDS), initialisms are generally pronounced as individual letters (DNA, SSRI), and abbreviations generally use the expansion (soln. = "solution", sup. = "superior").
Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides.
AMA style avoids use of this abbreviation (spell out "3 times a day") tinct. tinctura: tincture t.i.w. 3 times a week mistaken for "twice a week" top. topical TPN total parenteral nutrition tr, tinc., tinct. tinctura: tincture trit. triturate: grind to a powder troch. trochiscus: lozenge tsp teaspoon U unit mistaken for a "4", "0" or "cc ...
A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of ...