PlanofTreatmentSection

Plan of Treatment Section

draftC-CDA Templates4.0.0logical19 key elements

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.

This section may also contain information about ongoing care of the patient, clinical reminders, patient's values, beliefs, preferences, care expectations, and overarching care goals.

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

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.

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

When this section.text contains extra information not contained in the discrete entries, it is helpful to wrap the text of this section in a Note Activity to support ingestion.

Metadata

hl7.org/fhir
Canonical URL
http://hl7.org/cda/us/ccda/StructureDefinition/PlanofTreatmentSection
ID
PlanofTreatmentSection
Type
Base Definition
Section
Derivation
constraint
Mandatory and Must-Support Elements

Elements with cardinality > 0 or marked as Must Support (S)

PathCard.TypeFlagsDescription
templateId
1+
:section1..1
1+
templateId.root
1+
templateId.extension
1+
code
1+
Plan of care note
code.code
1+
code.codeSystem
1+
title
1+
text
1+
entry.encounter
http://hl7.org/cda/stds/core/StructureDefinition/Encounter
1+
entry.procedure
http://hl7.org/cda/stds/core/StructureDefinition/Procedure
1+
entry.substanceAdministration
http://hl7.org/cda/stds/core/StructureDefinition/SubstanceAdministration
1+
𝗨𝗦𝗖𝗗𝗜: MedicationOrder
entry.supply
http://hl7.org/cda/stds/core/StructureDefinition/Supply
1+
entry.observation
http://hl7.org/cda/stds/core/StructureDefinition/Observation
1+
entry.act
http://hl7.org/cda/stds/core/StructureDefinition/Act
1+
entry.act
http://hl7.org/cda/stds/core/StructureDefinition/Act
1+
entry.substanceAdministration
http://hl7.org/cda/stds/core/StructureDefinition/SubstanceAdministration
1+
entry.observation
http://hl7.org/cda/stds/core/StructureDefinition/Observation
1+
entry.act
http://hl7.org/cda/stds/core/StructureDefinition/Act
1+