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)
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 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.40 Planned Encounter (V2) (2014‑06‑09)CONFdots8805
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0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.42 Planned Medication Activity (V2) (2014‑06‑09)CONFdots8811
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0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.43 Planned Supply (V2) (2014‑06‑09)CONFdots8813
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0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.20 Instruction (V2) (2014‑06‑09)CONFdots4695
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0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.141 Handoff Communication Participants (2015‑08‑13)CONFdots9621
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0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.130 Nutrition Recommendation (2015‑08‑13)CONFdots1841
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0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.121 Goal Observation (2015‑08‑13)CONFdots2887