Advances, Implementation, and Outcomes Greetings from the Clinical Care Classification (CCC) System 3rd User Meeting, Nashville, December 7 and 8, 2017

The third user meeting of the Clinical Care Classification (CCC) was held in Nashville, Tennessee in December. The linkage between Dr Virginia K. Saba, the developer and the leader of the CCC, and Finland, and the University of Eastern Finland (UEF) with the Finnish Care Classification (FinCC) terminology is long and productive. Therefore, FinCC reps have had invitations to the CCC User meeting, and now, for the second time December 6-7, the meeting took place in Nashville.

During the User meeting, keynotes and several other presentations regarding the CCC implementation, use, development, and data re-use were put forth. We heard examples of several hospitals, which use Epic or Meditech together with the CCC. Experiences were bracing and encouraging. It was great to hear also, how the Chinese colleagues have begun to link CCC to their own electronic patient record system. In their presentation, we heard of their development and translation work of the CCC terminology, and the implementation of the rating aggregation into the electronic patient record system. The translation work showed cultural differences in patient care. They were very interested and enthusiastic about translating and introducing their system to us in Finland.

From Finland, we had two presentations:

Ulla-Mari Kinnunen: Standardized Nursing Documentation for the EHR Using the FinCC

Minna Mykkänen: Nursing Audit as a Method for Developing Nursing Documentation and Nursing Care

In Finland, the strategic objectives of the eHealth and eSocial Strategy by 2020 are e.g. that citizens use online services and produce data for their own use and for the professionals, reliable information on well-being and services supporting its utilization are available, and information on the quality and availability of services is available in all parts of Finland. The objectives of the eHealth strategy of the Finnish Nurses Association 2015–2020 has the connection to the national strategy. Kanta-services has been developed for citizens to get access to their health and social care data, and ePrescription. eNursing Summaries has been transferred to this National Patient Data Repository since 2011.  EPR covers the whole Finland.

In Finland, a standardized nursing documentation model has been developed for several years. The national Finnish nursing documentation model is based on a defined nursing core data, a standardized nursing terminology: FinCC, and a nursing process model in decision making. Nationally agreed core data includes nursing diagnoses, nursing interventions, nursing outcomes, patient care intensity, and nursing summary. The FinCC consists of the Finnish classification of nursing diagnoses (FiCND), the Finnish classification of nursing interventions (FiCNI) and the Finnish classification of nursing outcomes (FiCNO). The latest version, 3.0, was launched at the beginning of 2012. FinCC is based on the CCCd eveloped in the USA by Virginia Saba (

At the UEF, we have had several research projects of the FinCC. In the latest project, we tried to find connection to the FinCC-based nursing documentation and triggers developed for epilepsy patient. According to the results, nurses daily patient care documentation is good. However, discussions with the nurses and re-training of the documentation of FinCC components and categories is important. FinCC is under development, and the expert group works closely with the National Institute of Health and Welfare multiprofessional expert group developing both the FinCC and the national data structures. The aim to launch FinCC version 4.0 is 2018.

Nursing documentation is a written proof of implemented nursing interventions and should show what information nursing decisions are based on and what outcomes were achieved. Evaluating the quality of nursing documentation makes it possible to demonstrate the quality level. In Finland, an audit instrument was developed in the national development project in 2005 -2009. The audit model is based on the national Finnish nursing documentation model. The aim of the audit of the nursing documentation model was set as maintaining documentation according to the model. It contains 13 sections assessing achievement, patient orientation and recognition of the coherence of nursing process steps. Consequently, the levels of recording quality are grouped into five categories, from unacceptable to commendable. An audit of nursing records at the Kuopio University Hospital was carried out in 2010-2017. The results are encouraging. The quality and level of nursing documentation have improved during the assessment period. The statistical significance of changes in the nursing documentation has been calculated. The changes in documentation are statistically significant. In light of the audit method for nursing documentation it appears that the standardized nursing documentation model is appropriate in various operating environments regardless of the field of specialization.  When the audit is made according to the audit form, the qualitative evaluation of the content of documentation is possible.

Use, monitoring and evaluation of the documentation model make it possible to develop the process of patient care, the quality of nursing and patient safety.  Quality assessment of nursing documentation serves to identify development areas in nursing documentation and so through improved information transfer to improve the information flow between professional groups participating in the care of the patient, in the patient’s best interests. Utilizing the knowledge generated in the development of evidence-based nursing for improved information flow and knowledge management is possible. Such information can be used to support decision-making in nursing practice, education, management and research. In addition, it is very important to provide feedback to the nurses about the quality and level of the nursing documentation. It is important for every nurse to know and recognize the significance of enrollment in the patient’s care process.

During the User meeting, we faced the fact that wherever we are, we have the same challenges in nursing documentation, in its education and training, use and data re-use. We have to use nursing process to get the patient process visible. We have the technology, we have nursing terminologies, now we just have to say, when and how are we going to implement standardized nursing documentation systems. Everyone has a common need and the goal to provide the information generated in the patient’s care to develop patient care processes, leadership, education and research. The challenge is to implement a consistent record and develop reporting systems to produce accurate and uniform information.


Ulla-Mari Kinnunen

PhD, RN, Senior Lecturer

Health and Human Services Informatics

Department of Health and Social Management

The Faculty of Social Sciences and Business Studies

University of Eastern Finland

Mailing address: P.O.Box 1627, FI-70211 KUOPIO, FINLAND

Visiting address: Yliopistonranta 1 E, Snellmania

+358 403553953


Minna Mykkänen

MHSc, RN, PfD candidate, Director of Nursing

Kuopio University Hospital

Heart and Neuro Center

Puijo`s Hospital

Puijonlaaksontie 2

70210 KUOPIO, Finland



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