Nurse Plan of care note
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
- Plan of care note
- Short Name
- Nurse Plan of care note
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|
|Indent75310-3||Health concerns Document||R|
|Indent11383-7||Patient problem outcome Narrative||O|
- 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
- HL7® Attachment Structure
- Implementation guide exists
Member of these Groups Get Info
|LOINC Group||Group Name|
|LG38745-2||Plan of care note|
Language Variants Get Info
|es-MX||Spanish (Mexico)||Nota del plan de cuidados:
|it-IT||Italian (Italy)||Piano di cura, nota:
Synonyms: Documentazione dell''ontologia Osservazione Piano di cura Punto nel tempo (episodio)
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