Version 2.78

Term Description

A nursing plan of care is a document that outlines the nursing care to be provided to an individual/family/community. It is a set of actions the nurse will implement to resolve/support nursing diagnoses identified by nursing assessment. The creation of the plan is an intermediate stage of the nursing process. It guides in the ongoing provision of nursing care and assists in the evaluation of that care. It includes a) nursing diagnosis including related and risk factors, b) expected outcomes (e.g. goals), and c) nursing interventions.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Plan of care note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
Nurse

Additional Names

Long Common Name
Nurse Plan of care note
Short Name
Nurse Plan of care note

Associated Observations

81215-6 Care plan - recommended C-CDA R2.0 and R2.1 sections

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 2.36
Last Updated
Version 2.67
Change Reason
Based on Clinical LOINC Committee approval on 8/2012, component was changed from "Care plan" to "Plan of Care" to harmonize existing document terms related to plan of care.
Order vs. Observation
Both
HL7® Attachment Structure
Implementation guide exists

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38952-4 Nurse|ANYTypeOfService|ANYKindOfNote|ANYSetting
LG38745-2 Plan of care note|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Nota del plan de cuidados:Tipo:Punto temporal:{Configuración}:Documento:Nurse
it-IT Italian (Italy) Piano di cura, nota:Osservazione:Pt:{Setting}:Doc:Infermiere
Synonyms: Documentazione dell''ontologia Osservazione Piano di cura Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) behandelplan:bevinding:moment:{instelling}:document:verpleegkundige
Synonyms: zorgplan
zh-CN Chinese (China) 医疗服务计划记录:发现:时间点:{环境}:文档型:护士
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 保护者 医疗服务（照护服务、护理服务、护理、照护、医疗照护、诊疗、诊疗服务、照顾、看护）计划（方案）记录 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 笔记;按语;注释;说明;票据;单据;证明书

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=64295-9