Clinical Care Costing Method for the Clinical Care Classification System™

Saba, Virginia K.; Arnold, Jean M.

doi:10.1111/j.1744-618x.2004.tb00002.x

Cited by 3 publications

(2 citation statements)

References 5 publications

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“…Standardized nursing terminologies have been used to calculate staffing ratios (Lundberg et al, 2008) and to capture nursing care costs (Saba and Arnold, 2004). However, economic studies using standardized nursing terminologies are rare, due to the complexity of analysis and the paucity of nursing data collected and properly coded with standardized nursing terminologies and stored in electronic health records (Stone et al, 2004).…”

Section: Introductionmentioning

confidence: 99%

Evidence for the existing American Nurses Association-recognized standardized nursing terminologies: A systematic review

Taştan

Linch²,

Keenan

et al. 2014

International Journal of Nursing Studies

143

141

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Objective To determine the state of the science for the five standardized nursing terminology sets in terms of level of evidence and study focus. Design Systematic Review. Data sources Keyword search of PubMed, CINAHL, and EMBASE databases from 1960s to March 19, 2012 revealed 1,257 publications. Review Methods From abstract review we removed duplicate articles, those not in English or with no identifiable standardized nursing terminology, and those with a low-level of evidence. From full text review of the remaining 312 articles, eight trained raters used a coding system to record standardized nursing terminology names, publication year, country, and study focus. Inter-rater reliability confirmed the level of evidence. We analyzed coded results. Results On average there were 4 studies per year between 1985 and 1995. The yearly number increased to 14 for the decade between 1996–2005, 21 between 2006–2010, and 25 in 2011. Investigators conducted the research in 27 countries. By evidence level for the 312 studies 72.4% were descriptive, 18.9% were observational, and 8.7% were intervention studies. Of the 312 reports, 72.1% focused on North American Nursing Diagnosis-International, Nursing Interventions Classification, Nursing Outcome Classification, or some combination of those three standardized nursing terminologies; 9.6% on Omaha System; 7.1% on International Classification for Nursing Practice; 1.6% on Clinical Care Classification/Home Health Care Classification; 1.6% on Perioperative Nursing Data Set; and 8.0% on two or more standardized nursing terminology sets. There were studies in all 10 foci categories including those focused on concept analysis/classification infrastructure (n = 43), the identification of the standardized nursing terminology concepts applicable to a health setting from registered nurses’ documentation (n = 54), mapping one terminology to another (n = 58), implementation of standardized nursing terminologies into electronic health records (n = 12), and secondary use of electronic health record data (n = 19). Conclusions Findings reveal that the number of standardized nursing terminology publications increased primarily since 2000 with most focusing on North American Nursing Diagnosis-International, Nursing Interventions Classification, and Nursing Outcome Classification. The majority of the studies were descriptive, qualitative, or correlational designs that provide a strong base for understanding the validity and reliability of the concepts underlying the standardized nursing terminologies. There is evidence supporting the successful integration and use in electronic health records for two standardized nursing terminology sets: (1) the North American Nursing Diagnosis-International, Nursing Interventions Classification, and Nursing Outcome Classification set; and (2) the Omaha System set. Researchers, however, should continue to strengthen standardized nursing terminology study designs to promote continuous improvement of the standardized nursing terminologies and use in clin...

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Section: Introductionmentioning

confidence: 99%

Evidence for the existing American Nurses Association-recognized standardized nursing terminologies: A systematic review

Taştan

Linch²,

Keenan

et al. 2014

International Journal of Nursing Studies

143

141

View full text Add to dashboard Cite

show abstract

“…9 Several studies have validated use of cost questionnaires for collection of the wide range of these patient expenses. 10,11,12,13 Table 3 is a list of definitions of non-reimbursed and out-of-pocket costs collected in this study. 14 …”

Section: Methodsmentioning

confidence: 99%

Patients' annual income adequacy, insurance premiums and out-of-pocket expenses related to heart failure care

et al. 2014

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Safety risks and workflow implications associated with nursing-related free-text communication orders

Staes

Yusuf

Hambly

et al. 2023

Journal of the American Medical Informatics Association

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Objective We evaluated nursing-related free-text communication orders to identify potential safety hazards and describe patterns and scope of care domains addressed that may reveal preventable workarounds and potential gaps in electronic health record (EHR) functionality. Materials and Methods A retrospective analysis of free-text EHR-based communication orders sent to or by nurses providing inpatient care at a major academic health system. Using built-in EHR tools and selection criteria, 13 193 orders were extracted, including 1373 unique orders. Using the Clinical Care Classification system standardized framework, we classified content by care domain and identified unique requests within each order. We reviewed each order for error-prone textual features based on standard patient safety guidance. We describe the distribution of domains, co-occurrence when 2 domains were present, and common patterns. Results The 1373 unique orders included a single request (65.3%), 2 requests related to 1 or 2 domains (19%), or 3 or more requests (15.7%). No orders included terms on the Joint Commission’s “Do Not Use” list. However, 13.6% of unique orders, and 16.7% of those related to medications, included error-prone symbols or abbreviations according to Institute for Safe Medication Practices guidance. Order content spanned 20 different care components but physical regulation, fluid volume, nutritional, safety, and medication were most frequently identified as single or co-occurring topics. Patterns were heterogenous. Discussion Free-text communication orders reveal workarounds, responses to upstream workarounds, and design constraints that should be further investigated. Remediation strategies are needed to reduce safety hazards and workflow impediments. Conclusions Analysis of free-text communication orders revealed opportunities for improvement.

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Clinical Care Costing Method for the Clinical Care Classification System™

Cited by 3 publications

References 5 publications

Evidence for the existing American Nurses Association-recognized standardized nursing terminologies: A systematic review

Evidence for the existing American Nurses Association-recognized standardized nursing terminologies: A systematic review

Patients' annual income adequacy, insurance premiums and out-of-pocket expenses related to heart failure care

Safety risks and workflow implications associated with nursing-related free-text communication orders

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