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

Id2.16.840.1.113883.10.20.22.2.10
ref
ccda-
Gültigkeit ab2014‑06‑09
Statusdraft EntwurfVersions-Label2.1
NamePlanofTreatmentSectionV2BezeichnungPlan of Treatment Section (V2)
Beschreibung
en-US

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.


KontextElternknoten des Template-Element mit Id 2.16.840.1.113883.10.20.22.2.10
KlassifikationCDA Section level template
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Benutzt von / Benutzt
Benutzt von 10 Transactions und 15 Templates, Benutzt 11 Templates
Benutzt von als NameVersion
2.16.840.1.113883.3.1937.99.3.4.27Transaktionfinal en-US Operative Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.31Transaktionfinal en-US Transfer Summary (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.25Transaktionfinal en-US Discharge Summary (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.29Transaktionfinal en-US Progress Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.26Transaktionfinal en-US History and Physical (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.22Transaktionfinal en-US Consultation Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.28Transaktionfinal en-US Procedure Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.23Transaktionfinal en-US Continuity of Care Document (CCD) (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.30Transaktionfinal en-US Referral Note (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.21Transaktionfinal en-US 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
Benutzt als 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
BeziehungSpezialisierung: Template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
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ad1bbr-

Version: Template 2.16.840.1.113883.10.20.22.2.10 Plan of Care Section (2013‑01‑31)
ref
ccda-
ItemDTKardKonfBeschreibungLabel
cda:section
PlandotsonV2
cda:templateId
II1 … 1Men-US C-CDA R1.1 templateId root without an extensionCONFdots2936
@root
uid1 … 1F2.16.840.1.113883.10.20.22.2.10
cda:templateId
II1 … 1Men-US SHALL contain exactly one [1..1] templateId (CONF:1098-7723) such that itCONFdots7723
@root
uid1 … 1F2.16.840.1.113883.10.20.22.2.10CONFdots0435
 en-US SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.10" (CONF:1098-10435).
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 en-US SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32501).
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cda:text
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0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.44 Planned Observation (V2) (2014‑06‑09)CONFdots7726
cda:entry
0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.40 Planned Encounter (V2) (2014‑06‑09)CONFdots8805
cda:entry
0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.39 Planned Act (V2) (2014‑06‑09)CONFdots8807
cda:entry
0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.41 Planned Procedure (V2) (2014‑06‑09)CONFdots8809
cda:entry
0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.42 Planned Medication Activity (V2) (2014‑06‑09)CONFdots8811
cda:entry
0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.43 Planned Supply (V2) (2014‑06‑09)CONFdots8813
cda:entry
0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.20 Instruction (V2) (2014‑06‑09)CONFdots4695
cda:entry
0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.141 Handoff Communication Participants (2015‑08‑13)CONFdots9621
cda:entry
0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.130 Nutrition Recommendation (2015‑08‑13)CONFdots1841
cda:entry
0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.120 Planned Immunization Activity (2015‑08‑13)CONFdots2353
cda:entry
0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.121 Goal Observation (2015‑08‑13)CONFdots2887

Template Plan of Care Section 2013‑01‑31

Id2.16.840.1.113883.10.20.22.2.10
ref
ccda-
Gültigkeit ab2013‑01‑31
Statusdraft EntwurfVersions-Label1.1
NamePlanofCareSectionBezeichnungPlan of Care Section
Beschreibung
en-US The Plan of Care section contains data that defines pending orders, interventions, encounters, services, and procedures for the patient. It is limited to prospective, unfulfilled, or incomplete orders and requests only, which 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 unless constrained due to privacy issues. The plan may also contain information about ongoing care of the patient and information regarding goals and clinical reminders. Clinical reminders are placed here to provide prompts for disease prevention and management, patient safety, and health-care quality improvements, including widely accepted performance measures. The plan may also indicate that patient education will be provided.
KontextElternknoten des Template-Element mit Id 2.16.840.1.113883.10.20.22.2.10
KlassifikationCDA Section level template
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Benutzt von / Benutzt
Benutzt von 7 Transactions und 8 Templates, Benutzt 7 Templates
Benutzt von als NameVersion
2.16.840.1.113883.3.1937.99.3.4.4Transaktionfinal en-US Progress Note (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.3Transaktionfinal en-US Discharge Summary (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.6Transaktionfinal en-US Operative Note (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.5Transaktionfinal en-US Procedure Note (US Realm – Release 1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.2Transaktionfinal en-US Consultation Notes (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.7Transaktionfinal en-US History and Physical (H and P) (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.1Transaktionfinal en-US Continuity of Care Document (CCD) (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.61.41.10.4Containmentdraft Discharge Summary (1.1)2018‑02‑19 15:30:38
2.16.840.1.113883.10.20.22.1.2Containmentdraft Continuity of Care Document (CCD) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.3Containmentdraft History and Physical (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.4Containmentdraft Consultation Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.6Containmentdraft Procedure Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.7Containmentdraft Operative Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.8Containmentdraft Discharge Summary (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.9Containmentdraft Progress Note (1.1)2013‑01‑31
Benutzt als NameVersion
2.16.840.1.113883.10.20.22.4.20Containmentdraft Instructions (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.39Containmentdraft Plan of Care Activity Act (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.40Containmentdraft Plan of Care Activity Encounter (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.41Containmentdraft Plan of Care Activity Procedure (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.42Containmentdraft Plan of Care Activity Substance Administration (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.43Containmentdraft Plan of Care Activity Supply (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.44Containmentdraft Plan of Care Activity Observation (1.1)2013‑01‑31
ItemDTKardKonfBeschreibungLabel
cda:section
Plandotstion
cda:templateId
II1 … 1Men-US SHALL contain exactly one [1..1] templateId (CONF:7723) such that itconf‑7723
@root
uid1 … 1F2.16.840.1.113883.10.20.22.2.10confdots0435
cda:code
CE1 … 1Men-US SHALL contain exactly one [1..1] code (CONF:14749).confdots4749
@code
CONF1 … 1F18776-5
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cda:title
ST1 … 1en-US SHALL contain exactly one [1..1] title (CONF:16986).confdots6986
cda:text
SD.TEXT1 … 1en-US SHALL contain exactly one [1..1] text (CONF:7725).conf‑7725
cda:entry
0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.39 Plan of Care Activity Act (2013‑01‑31)conf‑7726
cda:entry
0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.40 Plan of Care Activity Encounter (2013‑01‑31)conf‑8805
cda:entry
0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.44 Plan of Care Activity Observation (2013‑01‑31)conf‑8807
cda:entry
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0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.42 Plan of Care Activity Substance Administration (2013‑01‑31)conf‑8811
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0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.43 Plan of Care Activity Supply (2013‑01‑31)conf‑8813
cda:entry
0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.20 Instructions (2013‑01‑31)confdots4695