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Clinical Care Classification System. 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.
It contains information in accordance with the steps of the nursing process. Nursing documentation is the principal clinical information source to meet legal and professional requirements, care nurses' knowledge of nursing documentation, and is one of the most significant components in nursing care. Quality nursing documentation plays a vital ...
Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]
Certificate of medical necessity. In the US a certificate of medical necessity is a document required by Centers for Medicare and Medicaid Services to substantiate in detail the medical necessity of an item of durable medical equipment or a service to a Medicare beneficiary. [1] There are different types of CMN for different requirements, e.g ...
The Five Wishes. Wishes 1 and 2 are both legal documents. Once signed, they meet the legal requirements for an advance directive in the states listed below. Wishes 3, 4, and 5 are unique to Five Wishes, in that they address matters of comfort care, spirituality, forgiveness, and final wishes. Wish 1: "The Person I Want to Make Care Decisions ...
Home health care is medical in nature and is provided by licensed, skilled healthcare professionals. Home health care providers deliver services in the client's own home. Professional home health services may include medical or psychological assessment, wound care, pain management, disease education and management, physical therapy, speech ...
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