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Template Plan of Treatment Section (V2) 2014‑06‑09

Id2.16.840.1.113883.10.20.22.2.10Effective Date2014‑06‑09
Statusdraft DraftVersion Label2.1
NamePlanofTreatmentSectionV2Display NamePlan of Treatment Section (V2)
Description

This section, formerly known as "Plan of Care", contains data that define pending orders, interventions, encounters, services, and procedures for the patient. It is limited to prospective, unfulfilled, or incomplete orders and requests only. These are indicated by the @moodCode of the entries within this section. All active, incomplete, or pending orders, appointments, referrals, procedures, services, or any other pending event of clinical significance to the current care of the patient should be listed.

Clinical reminders are placed here to provide prompts for disease prevention and management, patient safety, and healthcare quality improvements, including widely accepted performance measures. 

The plan may also indicate that patient education will be provided.

When used in a document that includes a Goals Section, all the goals (whether narrative only, or structured Goal Observation entries) should be recorded in the Goals Section, rather than in the Plan of Treatment Section, to avoid confusion as to “which/whose goals should be in which section?”  

When used in a document that does not include a Goals Section, the Plan of Treatment section may also contain information about care team members’ goals, including the patient’s values, beliefs, preferences, care expectations, and overarching care goals. Values may include the importance of quality of life over longevity. These values are taken into account when prioritizing all problems and their treatments. Beliefs may include comfort with dying or the refusal of blood transfusions because of the patient’s religious convictions. Preferences may include liquid medicines over tablets, or treatment via secure email instead of in person. Care expectations may range from being treated only by female clinicians, to expecting all calls to be returned within 24 hours. Overarching goals described in this section are not tied to a specific condition, problem, health concern, or intervention. Examples of overarching goals could be to minimize pain or dependence on others, or to walk a daughter down the aisle for her marriage.


ContextParent nodes of template element with id 2.16.840.1.113883.10.20.22.2.10
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 10 transactions and 15 templates, Uses 11 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.27Transactionfinal Operative Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.31Transactionfinal Transfer Summary (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.25Transactionfinal Discharge Summary (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.29Transactionfinal Progress Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.26Transactionfinal History and Physical (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.22Transactionfinal Consultation Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.28Transactionfinal Procedure Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.23Transactionfinal Continuity of Care Document (CCD) (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.30Transactionfinal Referral Note (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.21Transactionfinal Care Plan (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.61.17.10.2Containmentdraft SHN StructuredBody2015‑05‑09 11:18:02
2.16.840.1.113883.3.1937.99.61.17.10.3linkdraft SHN component2015‑05‑09 11:28:46
2.16.840.1.113883.3.1937.99.61.18.10.6Containmentdraft Выписной эпикриз2015‑06‑06 14:32:25
2.16.840.1.113883.3.1937.99.61.28.10.3Containmentdraft CDA de Consulta (1)2017‑04‑22 23:20:01
2.16.840.1.113883.10.20.22.1.2Containmentdraft Continuity of Care Document (CCD) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.3Containmentdraft History and Physical (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.4Containmentdraft Consultation Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.6Containmentdraft Procedure Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.7Containmentdraft Operative Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.8Containmentdraft Discharge Summary (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.9Containmentdraft Progress Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.13Containmentdraft Transfer Summary (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.14Containmentdraft Referral Note (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.15Containmentdraft Care Plan (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.101Containmentdraft BC CDA Referral Note (V2) (2.1)2019‑04‑06 02:03:17
Uses as NameVersion
2.16.840.1.113883.10.20.22.4.20Containmentdraft Instruction (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.39Containmentdraft Planned Act (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.40Containmentdraft Planned Encounter (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.41Containmentdraft Planned Procedure (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.42Containmentdraft Planned Medication Activity (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.43Containmentdraft Planned Supply (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.44Containmentdraft Planned Observation (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.120Containmentdraft Planned Immunization Activity (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.121Containmentdraft Goal Observation (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.130Containmentdraft Nutrition Recommendation (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.141Containmentdraft Handoff Communication Participants (2.1)2015‑08‑13
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-

Version: template 2.16.840.1.113883.10.20.22.2.10 Plan of Care Section (2013‑01‑31)
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0 … *Contains 2.16.840.1.113883.10.20.22.4.141 Handoff Communication Participants (2015‑08‑13)CONFdots9621
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0 … *Contains 2.16.840.1.113883.10.20.22.4.130 Nutrition Recommendation (2015‑08‑13)CONFdots1841
cda:entry
0 … *Contains 2.16.840.1.113883.10.20.22.4.120 Planned Immunization Activity (2015‑08‑13)CONFdots2353
cda:entry
0 … *Contains 2.16.840.1.113883.10.20.22.4.121 Goal Observation (2015‑08‑13)CONFdots2887