3.16 Plan of Care

The template identifier for the plan of care section is 2.16.840.1.113883.10.20.1.10.

The plan of care section contains data defining pending orders, interventions, encounters, services, and procedures for the patient. It is limited to prospective, unfulfilled, or incomplete orders and requests only. All active, incomplete, or pending orders, appointments, referrals, procedures, services, or any other pending event of clinical significance to the current and ongoing care of the patient should be listed, unless constrained due to issues of privacy.

The plan of care section also contains information regarding goals and clinical reminders. Clinical reminders are placed here for purposes of providing prompts that may be used for disease prevention, disease management, patient safety, and healthcare quality improvements, including widely accepted performance measures.

CONF-480: CCDSHOULD contain exactly one and SHALL NOT contain more than one Plan of Care section (templateId 2.16.840.1.113883.10.20.1.10). The Plan of Care section SHALL contain a narrative block, and SHOULD contain clinical statements. Clinical statements SHALL include one or more plan of care activities (templateId 2.16.840.1.113883.10.20.1.25).

3.16.1 Section conformance

CONF-481: The plan of care section SHALL contain Section / code.
CONF-482: The value for “Section / code” SHALL be “18776-5” “Treatment plan” 2.16.840.1.113883.6.1 LOINC STATIC.
CONF-483: The plan of care section SHALL contain Section / title.
CONF-484: Section / titleSHOULD be valued with a case-insensitive language-insensitive text string containing “plan”.

3.16.2 Clinical statement conformance

3.16.2.1 Plan of care activities

The template identifier for a plan of care activity is 2.16.840.1.113883.10.20.1.25.

CONF-485: A plan of care activity (templateId 2.16.840.1.113883.10.20.1.25) SHALL be represented with Act, Encounter, Observation, Procedure, SubstanceAdministration, or Supply.
CONF-486: A plan of care activity SHALL contain at least one [Act | Encounter | Observation | Procedure | SubstanceAdministration | Supply] / id.
CONF-487: A plan of care activity SHALL contain exactly one [Act | Encounter | Observation | Procedure | SubstanceAdministration | Supply] / @moodCode.
CONF-488: The value for “[Act | Encounter | Procedure] / @moodCode” in a plan of care activity SHALL be [“INT” (intent) | “ARQ” (appointment request) | “PRMS” (promise) | “PRP” (proposal) | “RQO” (request)] 2.16.840.1.113883.5.1001 ActMood STATIC.
CONF-489: The value for “[SubstanceAdministration | Supply] / @moodCode” in a plan of care activity SHALL be [“INT” (intent) | “PRMS” (promise) | “PRP” (proposal) | “RQO” (request)] 2.16.840.1.113883.5.1001 ActMood STATIC.
CONF-490: The value for “Observation / @moodCode” in a plan of care activity SHALL be [“INT” (intent) | “PRMS” (promise) | “PRP” (proposal) | “RQO” (request) | “GOL” (goal)] 2.16.840.1.113883.5.1001 ActMood STATIC.
CONF-491: A plan of care activity SHALL contain one or more sources of information, as defined in section 5.2 Source.