Watch the assignedNational Library of Medicinevideo on Health Data Standards:
: Standardized Nursing Terminology:
1. Review Clinical Care Classification (CCC) nursing terminology, thinking about the types of patients you may see as a DNP or Specialist.
2. Review the SuperBills provided to find one similar to your specialty. If nothing fits, request one from your DNP Program Director.
3. In Assessment, document at least one specialty-related ICD 10 diagnosis & code. Include at least
of the CCC Assessment/Nursing Diagnoses that complement, not repeat, the ICD medical diagnosis. Each CCC Nursing Diagnosis will have a Goal/ Expected Outcome as the final digit in the code.
4. In the Plan, include a CPT visit code plus at least one CPT-coded procedure from your specialty SuperBill. Document also a LOINC code for the procedure or lab. Document any medications ordered with an RxNorm code. Also in the Plan, describe at least
CCC-coded Nursing Interventions; each will have one of the 4 Action Types as the final digit in the code
. See the Tips below for how to write the CCC codes properly.
View the Project NeLL data dictionary and search tool to identify data categories and specific data tables where the data would fit (if it is not buried in free text notes).