LOINC
Version 2.71

64295-9Nurse Plan of care noteActive

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

Short Name
Nurse 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 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

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

zh-CNChinese (China)
医疗服务计划记录:发现:时间点:{环境}:文档型:护士
nl-NLDutch (Netherlands)
behandelplan:bevinding:moment:{instelling}:document:verpleegkundige
it-ITItalian (Italy)
Piano di cura, nota:Osservazione:Pt:{Setting}:Doc:Infermiere

LOINC FHIR® API Example - CodeSystem Request Get Info

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