18776-5Plan of care noteActive
Term Description
Plan of care notes (previously defined as "Plan of treatment") contains data that defines pending orders, interventions, encounters, services, and procedures for the patient. The plan includes prospective, unfulfilled, or incomplete orders and requests only. The plan may also contain information about ongoing care of the patient and information regarding goals and clinical reminders.
Source: Regenstrief LOINC
Fully-Specified Name
- Component
- Plan of care note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Plan of care note
Associated Observations
This panel contains the recommended sections for a care plan note based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Releases 2.0 & 2.1.
LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
---|---|---|---|---|
81215-6 | Care plan - recommended C-CDA R2.0 and R2.1 sections | |||
Indent61146-7 | Goals Narrative | R | ||
Indent75310-3 | Health concerns Document | R | ||
Indent11383-7 | Patient problem outcome Narrative | O | ||
Indent62387-6 | Interventions Narrative | O |
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.67
- Change Reason
- Previous Releases: Based on Clinical LOINC Committee review (2/2016), it was decided that there is little, if any, distinction between plan of treatment and plan of care notes. This term was meant to represent a general plan of care/treatment note. In order to align with the LOINC Document Ontology model, the Component was changed from "Plan of treatment" to "Plan of Care note", System changed from "Treatment plan" to {Setting}, Scale changed from "Nar" to "Doc" and Method changed from null to {Role}.;
- Order vs. Observation
- Both
- HL7 Attachment Structure
- Implementation guide exists
Member of these Panels
LOINC | Long Common Name |
---|---|
57082-0 | Antepartum record panel |
69459-6 | Care record summary panel |
72231-4 | Consultation note - recommended C-CDA R1.1 sections |
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
72232-2 | Continuity of Care Document - recommended C-CDA R1.1 sections |
81214-9 | Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections |
48769-4 | Continuity of Care panel |
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 sections |
81242-0 | Enhanced discharge summary - recommended CDP Set 1 R1.0 sections |
81615-7 | Enhanced discharge summary - recommended CDP Set 1 R1.1 sections |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
81244-6 | Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections |
81241-2 | Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections |
72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
82811-1 | Nurse summary note - recommended sections |
82308-8 | Oncology plan of care and summary - recommended CDA R1.2 sections |
74293-2 | Oncology plan of care and summary - recommended CDA set |
59843-3 | Procedure note - recommended C-CDA R1.1 sections |
81217-2 | Procedure note - recommended C-CDA R2.0 and R2.1 sections |
72225-6 | Progress note - recommended C-CDA R1.1 sections |
81216-4 | Progress note - recommended C-CDA R2.0 and R2.1 sections |
81223-0 | Referral note - recommended C-CDA R2.0 and R2.1 sections |
72227-2 | Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Member of these Groups
LG41826-5 | {Setting}| |
LG38745-2 | Plan of care note| |
Language Variants Get Info
- zh-CNChinese (China)
- 医疗服务计划记录:
发现: 时间点: {环境}: 文档型: {角色} - de-DEGerman (Germany)
- Behandlungsplan - Notiz:
Befund: Zeitpunkt: {Setting}: Dokument: {Funktion} - it-ITItalian (Italy)
- Piano di cura, nota:
Osservazione: Pt: {Setting}: Doc: {Role} - es-ARSpanish (Argentina)
- plan de tratamiento:
hallazgo: punto en el tiempo: plan de tratamiento: Narrativo: - es-MXSpanish (Mexico)
- Nota del plan de cuidados:
Tipo: Punto temporal: {Configuración}: Documento: {Role}
LOINC FHIR® API Example - CodeSystem Request Get Info
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=18776-5
LOINC Copyright
Copyright © 2022 Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright