What's the Problem??? Implementation of Priority Problems Using the Clinical Classification Model
John E. Rice, RN, BSN                                                             john.rice@vanderbilt.edu
Staff Nurse IV - Vanderbilt University Hospital

Project goal was to standardize how nurses document and communicate the patient's top priorities, identify plans and goals, and assess actual outcomes. Benefits include improvement in patient care, clearly defined nursing's contributions to patient care, and increase interdisciplinary collaboration and teamwork. Assessment of the current Plan of Care Documentation revealed deficiencies. Nurses using other nurse's documentation during the handover process found it hard to identify care priorities. Paper pathways were difficult to find in the patient's chart, and were not part of the electronic record. Managers and Regulators reviewing nursing documentation found it difficult to determine the most important patient problems. A recent JCAHO survey prompted us to review our process. A new Plan of Care documentation system called Priority Problems using the evidenced based Clinical Care Classification (CCC) model was implemented. A pilot on two nursing inpatient units was conducted.


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