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Term Description

The Assessment and Plan note (also called impression or diagnoses) represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The assessment formulates a specific plan or set of recommendations. The assessment may be a list of specific disease entities or a narrative block. The Plan 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. 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 was given or will be provided.

LOINC Names Get Info

Fully-Specified Name
Evaluation+Plan note:Find:Pt:{Setting}:Doc:{Role}
Long Common Name
Evaluation + Plan Note
Short Name
Eval+Plan Note

Part Model Get Info

  • Component
    Evaluation+Plan note
    LP74505-6
    • Analyte
      Evaluation+Plan note
      LP74505-6
      • Component Numerator
        Evaluation+Plan note
        LP74505-6
        • Component Numerator Core
          Evaluation+Plan note
          LP74505-6
        • Component Numerator Core Suffix
          NULL
           
      • Component Denominator
        NULL
         
        • Component Denominator Core
          NULL
           
        • Component Denominator Core Suffix
          NULL
           
    • Challenge
      NULL
       
    • Adjustment
      NULL
       
    • Count
      NULL
       
  • Property
    Find
    LP6813-2
  • Time
    Pt
    LP6960-1
  • System
    {Setting}
    LP32887-9
    • System Core
      {Setting}
      LP32887-9
    • Super System
      NULL
       
  • Scale
    Doc
    LP32888-7
  • Method
    {Role}
    LP187178-1

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.24
Last Updated
Version 2.81 (MIN)
Change Reason
Release 2.81: ValidHL7AttachmentRequest: Updated to add to HIPAA Attachments, per user request.; Previous Releases: Changed 'Assesment' to 'Evaluation' to harmonize existing terms with similar meaning. The term 'Evaluation' will be used in the LOINC Document Ontoloy based on Clinical LOINC Committee decision (Sept 2014).; Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.;
Order vs. Observation
Both
HL7® Attachment Structure
No implementation guide exists

Member of these Panels

LOINCLong Common Name
72231-4Consultation note - recommended C-CDA R1.1 sections
81222-2Consultation note - recommended C-CDA R2.0 and R2.1 sections
81242-0Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81243-8Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
81245-3Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
57083-8Labor and Delivery record panel
92574-3Labor and delivery summary - recommended IHE set
59843-3Procedure note - recommended C-CDA R1.1 sections
81217-2Procedure note - recommended C-CDA R2.0 and R2.1 sections
72225-6Progress note - recommended C-CDA R1.1 sections
81216-4Progress note - recommended C-CDA R2.0 and R2.1 sections
81223-0Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4Transfer summary note - recommended C-CDA R2.0 sections
81614-0Transfer summary note - recommended C-CDA R2.1 sections

Member of these Groups Get Info

LOINC GroupGroup Name
LG41826-5{Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain

Language Variants Get Info

TagLanguageTranslation
el-GRGreek (Greece)Σημείωμα Αξιολόγησης+Σχεδίου:Εύρεση:Pt:{Ρυθμίσεις}:Doc:{Ρόλος}
Synonyms: {Ρόλος} {Ρυθμίσεις} Doc DOC.ONTOLOGY Pt Εύρεση Σημείωμα Αξιολόγησης+Σχεδίου Σημείωση
es-MXSpanish (Mexico)Evaluación + nota del plan:Tipo:Punto temporal:{Configuración}:Documento:{Role}
fr-CAFrench (Canada)Note d'évaluation+plan:Observation:Temps ponctuel:{Situation}:Document:{Rôle}
it-ITItalian (Italy)Valutazione+Nota di piano:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Ruolo non specificato Valutazione + Nota di piano
nl-NLDutch (Netherlands)beoordelingsverslag en behandelplan
zh-CNChinese (China)评价+计划记录:发现:时间点:{环境}:文档型:{角色}
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 文档本体;临床文档本体;文档本体;文书本体;医疗文书本体;临床医疗文书本体 时刻;随机;随意;瞬间 未加明确说明的角色 笔记;按语;注释;说明;票据;单据;证明书 评价（评估、测评、评测、评判、评定、判定、评量、核定）+计划记录;评估+计划记录;评估与计划记录 评估 评定 鉴定

LOINC Terminology Service (API) using HL7® FHIR® Get Info

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=51847-2