Clinical Care Classification System

Clinical Care Classification System

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 for documenting the plan of care following the nursing process in all health care settings.[1]

The CCC, capturing the essence of patient care, consists of two interrelated terminologies - the CCC of Nursing Diagnoses and Outcomes and the CCC of Nursing Interventions and Actions - classified by 21 Care Components that link the two together and enables mapping to other health-related classification systems.

The Clinical Care Classification (CCC) System is an American Nurses Association (ANA)-recognized comprehensive, coded, nursing terminology standard. In 2007, the CCC was accepted by the Department of Health and Human Services as the first national nursing terminology.[2] [3] The computable structure of the CCC System allows nurses, allied health professionals, and researchers, to determine care needs (resources), workload (productivity), and outcomes (quality).

The CCC System consists of discrete atomic-level data elements that encompasses nursing diagnoses, interventions, and outcomes. The CCC is a nursing terminology specifically developed for computerization: e.g. electronic healthcare information systems (EHR), computer-based patient records (CPR), and Clinical Information Systems (CIS), from research which collected live patient care data. The CCC System describes the six steps of the Nursing Process:

  1. Assessment
  2. Diagnosis
  3. Outcome Identification
  4. Planning
  5. Implementation
  6. Evaluation

The Nursing Process is the standard of professional nursing practice recognized by the ANA for clinical decision making in a coded, standardized framework. The CCC supports the exchange of nursing information and makes available for data retrieval and analysis in the electronic health record and health information record systems databases specifically linking nursing diagnoses to nursing interventions to nursing outcomes.

  • Open Architecture
  • Specifically designed for computer-based systems - EHR, CIS, and PHR
  • Tested and applicable in ALL healthcare settings. [4] [5] [6] [7] [8]
  • Atomic-Level Concepts
  • Approved as an interoperable terminology by the American National Standards Institute (ANSI) Standards Development Organization (SDO) Health Level Seven (HL7®).
  • Conforms to Cimino criteria for a standardized terminology[9]
  • Coded standardized framework for electronic documentation, retrieval & analysis[10] [11]
  • Codes based on ICD structure for information exchange promoting interoperability
  • Designed for determining care costs
  • Integrated in the Metathesaurus of the Unified Medical Language System (UMLS) of the National Library of Medicine (NLM) and SNOMED CT
  • Integrated in the Cumulative Index to Nursing and Allied Health Literature® (CINAHL)
  • Used in the Clinical LOINC System for documenting diagnoses outcomes
  • Tested as an international nursing standard based on the An Integrated Reference Terminology Model for Nursing approved by the International Organization for Standardization (ISO/TC 215:Health Informatics) in October 2003.
  • Concept terminology with online source files so public and private organizations may harmonize nursing information formats for the cross organizational sharing of information.[12]
  • One of the contributed terminologies used as the basis for the original alpha version of the International Classification of Nursing Practice (ICNP®) [13] developed by the International Council of Nurses (ICN).
  • Indexed to the MEDCIN ® terminology through a contextual hierarchy to the full array of medical terminology standards and concepts with intelligent prompting (IP). The indexing allows for the presentation and documentation of relevant clinical symptoms, history, physical findings, and diagnoses to the CCC nursing terminology from the Current Procedural Terminology (CPT)®, Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), ICD, LOINC®, RxNORM, SNOMED CT® and others for virtually any clinical condition.

    The Clinical Care Classification System was developed from a research study conducted by Dr. Virginia K. Saba, EdD, RN, FAAN, FACMI and a research team through a contract with the Health Care Financing Agency (HCFA),[14] currently known as the Centers for Medicare and Medicaid Services (CMS). The objective was to develop a computerized method for assessing and classifying patients for the prediction of nursing resources needs and for evaluating the outcomes of care. "To accomplish this goal, data on actual resource use, which could objectively be measured, were collected and used to predict resource requirements" (Saba, 1995).[15] The CCC System was developed from retrospective research data from 8,967 patient records from a sample of 800 organizations randomly stratified by staff size, type of ownership, and geographic location. [16] The methodology was applied to a national sample of home health agencies that provided all services and products (Spradley & Dorsey, 1985).[17] Dr. Saba and the research team analyzed and coded the research from 10,000 patient records from which the team obtained more than 70,000 statements focusing on nursing interventions and actions provided to patients as well as 40,000 diagnostic conditions and problems describing patient care needs.[18]

    The CCC System is a standardized framework consisting of four levels designed to allow nursing data to flow upward as well as downward. At the highest level the CCC System Framework consists of four healthcare patterns (Saba, 2007):

    • Health Behavioral
    • Functional
    • Physiological
    • Psychological

    Each represents a different set of Care Components. The second level consists of the 21 Care Components which serve to classify the two terminologies and defined as a cluster of elements that depict one of four healthcare patterns. The third level consists of:

    • 182 nursing diagnosis concepts representing concrete patient problems
    • 792 nursing interventions and actions (198 interventions each with one of 4 action types (assess, perform, teach, and manage) each depicting a unique single atomic-level concept

    The fourth level is represented by the expected and actual outcomes 182 diagnoses each with one of three outcomes for Expected Outcome (Saba, 2007, p. 154):

    • Improve or resolve patient's condition
    • Stabilize or maintain patient's condition
    • Support deterioration of patient's condition

    And one of three outcomes for Actual Outcome:

    • Improved or resolved patient's condition
    • Stabilized or maintained patient's condition
    • Deteriorated or died

    The CCC System uses a five-character structure to code the two terminologies: (1) CCC of Nursing Diagnoses and Outcomes and (2) CCC of Nursing Interventions and Actions. The CCC coding structure is paced on the format of the International Statistical Classification of Diseases and Related Health Problems: Tenth Revision: Volume 1, WHO, 1992. The coding strategy for each terminology consists of the following (Saba, 2007):[19] The graphic shows examples of the coding structure for a CCC diagnosis code and a CCC intervention code.

    Two examples of CCC codes showing the derivation of the character positions
    • First position: One alphabetic character code for Care Component (A to U);
    • Second and Third positions: Two-digit code for a Core Concept (major category) followed by a decimal point;
    • Fourth position: One-digit code for a subcategory, if available, followed by a decimal point;
    • Fifth position: One-digit code for: one of three Expected or Actual Outcomes and /or; one of four Nursing Intervention Action Types.
    • There are 4 CCC Action Types derived from the frequencies analyzed in the research study of 70,000 textual phrases described above.

    The significance of the CCC is a nursing terminology that completes the missing link needed to address nursing contribution to healthcare quality. Nursing care may be the most critical factor in a patient’s treatment and recovery.[20] The partnership of nursing and technology is vital for designing nursing practice environments. [21]

    The benefit of the CCC is the ability to represent the essence of nursing care in health information systems and applications durinng any patient care transfer or transition from one healthcare practice setting to another. The CCC supports the mandate of accrediting organizations to reconcile patient-centric information (JCA, 2011) [1] and supports the information exchange and data integrity requirements of CMS and the Office of the National Coordinator (ONC) for meaningful use when patient-centric data is exchanged across boundaries by using the Nurse Process recognized for professional nursing.

    • Standardized professional documentation)
    • Standardized data on nursing interventions for evidence-based practice and research
    • Re-usable health data for cross-organization exchange comparisons
    • Documented outcomes by nursing diagnoses
    • Standardized quality outcomes comparisons by nursing intervention and action type

    The computable structure of the Clinical Care Classification (CCC) System in the public domain (copyright permission) promotes the system upgrades of existing electronic healthcare information systems. The system architecture of the CCC offers a return on investment with discrete atomic-level data to describe the impact of nursing care on care quality, as well as productivity (workload), resources (staffing), and outcomes management.[22]


    1. ^ Saba, V. K. (2005). Clinical Care Classification (CCC) of Nursing Interventions. Retrieved December 15, 2005, from
    2. ^ American Health Information Community Meeting 31 October 2006,
    3. ^ Alliance for Nursing Informatics (ANI), News of 12 February 2007
    4. ^ Gartee, R. & Beale, S. (2011). Electronic Health Records and Nursing. Upper Saddle River, NJ: Pearson/Prentice Hall.
    5. ^ Feeg, V. D., Saba, V. K., & Feeg, A. (2008). Development and testing of a bedside personal computer (PC) Clinical Care Classification System for nursing students using Microsoft Access, Computers in Nursing, 26 (6), 339-49.
    6. ^ Parlocha, P. K. & Henry, S. B. (1998). The usefulness of the Georgetown Home Health Care Classification system for coding patient problems and nursing interventions in psychiatric home care. Computers in Nursing, 16, 45-52.
    7. ^ Holzemer, W. L, Henry, S. B., Dawson, C. Sousa, k, Bain, C. & Hsieh, S. F. (1997). An evaluation of the utility of the home health care classification for categorizing patient problems and nursing interventions from the hospital setting. Studies in Health Technology & Informatics, 46, 21-26.
    8. ^ Moss, J., Damrongsak, M., & Gallichio, K. (2005). Representing critical care data using the Clinical Care Classification. In C. P. Friedman, J. Ash, & P. Tarcy-Hornoch (Eds.), American Medical Informatics Assocation 2005 Proceedings: CD-ROM (p.545-549). Washington, Dc: OmniPress, Omipro-CD.
    9. ^ In Defense of the Desiderata, by James J. Cimino, Journal of Biomedical Informatics - JBI , vol. 39, no. 3, pp. 299-306, 2006
    10. ^ Whittenburg, L. (2009). Nursing Terminology Documentation of Quality Outcomes. Journal of Health Information Management, 23, (3):51-5.
    11. ^ Saba, V. K., & Taylor, S. L. (2007). Moving past theory: Use of a standardized coded nursing terminology to enhance nursing visibility. Computers in Nursing, 25 (6), 324-331.
    12. ^ ANSI/HISB (1998/1999) Home health care classification (HHCC) of nursing diagnosis and nursing interventions. Inventory of Clinical Information Standards. Washington, DC: ANSI.
    13. ^ Journal of the American Medical Informatics Association, J Am Med Inform Assoc. 1998 Jul–Aug; 5(4): 335–336
    14. ^ Saba, V. K. (1991). Home health care classification project. Washington, DC: Georgetown University (NTIS No. PB 92-177013/AS)
    15. ^ Saba, V. K. (1995) A new paradigm for computer-based nursing information systesm: twenty care components. In R. A. Greenes, H. E. Peterson, & D. J. Proti (eds.), Medinfo ’95 Proceedings (p. 1404-1406), Edmonton, Canada: IMIA. Saba, V. K. (2002). Nursing classifications: Home Health Care Classification System (HHCC): An Overview, Online Journal of Issues in Nursing. Retrieved March 16, 2011 from
    16. ^ Saba, V. K. (1992). The classification of home health care nursing diagnoses and interventions. Caring, 10(3), 50-57.
    17. ^ Spradley, B. W., & Dorsey, B. (1985). Home health care. In B. W. Spradley (Ed.), Community health nursing. Boston, MA: Little, Brown & Co.
    18. ^ Saba, V. K. & Zuckerman, A. E. (1992). A new home health classification method. Caring Magazine, 11, 27-34.
    19. ^ Saba, V. K. (2007). Clinical Care Classification (CCC) System manual: A guide to nursing documentation. New York: Springer Publishing.
    20. ^ Gordon, S. (2005). Nursing Against the Odds: How Health Care Cost Cutting, Media Stereotypes, and Medical Hubris Undermine Nurses and Patient Care. Ithaca, New York, Cornell University Press.
    21. ^ Improving the nurse work environment on medical surgical units through technology. RWJF Online. Retrieved April 24, 2011 from
    22. ^ Saba, V. K., & McCormick, K. A. (2011). Essentials of Nursing Informatics (5th ed.). New York, NY: McGraw-Hill.

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