关键词: 临床护理分类系统；标准化护理语言；护理电子病历

Abstract: Clinical medical institutions are increasingly aware that standardized language is essential for the implementation of electronic medical record. The electronic nursing information system urgently needs to use a standardized language, and the Clinical Care Classification System provides a new method for recording patient care in electronic health record System. This paper reviewed the establishment process, the framework and coding structure and the research and application progress of Clinical Care Classification System. It is expected to provide reference for further study and practice.

Key words: Clinical Care Classification System; standardized nursing terminologies; nursing electronic record system