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There are 11 document types in the C-CDA standard [5] Care Plan - A Care Plan (including Home Health Plan of Care (HHPoC)) is a consensus-driven dynamic plan that represents a patient's and Care Team Members' prioritized concerns, goals, and planned interventions. It represents an instance of this dynamic Care Plan at a point in time. [6]
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] The Clinical Care Classification (CCC), previously the Home Health Care Classification (HHCC), was originally created to document nursing care in home health and ambulatory care settings ...
The HL7 Clinical Document Architecture (CDA) is an XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange. In November 2000, HL7 published Release 1.0.
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Documentation development may involve document drafting, formatting, submitting, reviewing, approving, distributing, reposting and tracking, etc., and are convened by associated standard operating procedure in a regulatory industry. It could also involve creating content from scratch. Documentation should be easy to read and understand.
A nursing care plan promotes documentation and is used for reimbursement purposes such as Medicare and Medicaid. The therapeutic nursing plan is a tool and a legal document that contains priority problems or needs specific to the patient and the nursing directives linked to the problems. It shows the evolution of the clinical profile of a patient.