This dissertation describes the utility of using the Clinical Care Classification System (CCC) as a data integrator for the exchange of nursing documentation among electronic health information record systems (HIRS). The goal of nursing is to improve the health of communities, families, and individuals (Berg & Woods, 2009). Medical diagnoses cannot be expected to explain the nursing care of patients, and do not serve as an effective framework for documenting patient care and nursing data.
The author conducted a literature search and reviewed HIRS templates. The dissertation results found a HIRS is unable to describe the complexity of nursing care. This may serve as a reference and resource for graduate students on the use of structured nursing data and the use of the CCC nursing standard as an integrator to achieve the exchange of nursing outcomes, resources, and workload between and among health systems. Key words: CCC, HIRS, nursing, documentation, intervention, and exchange.