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Keywords

Care plan, C-CDA, data exchange, interoperability, LOINC, meaningful use, nursing process, SNOMED CT

 

Authors

  1. Matney, Susan A. PhD, RNC-OB, FAAN
  2. Dolin, Gay RN, MSN
  3. Buhl, Lindy MS, BSN, RN
  4. Sheide, Amy MPH, BSN, RN

Abstract

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.