Version 2.78

Fully-Specified Name

Component
Plan of care note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
Physical medicine and rehab

Additional Names

Short Name
PM+R 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 2.56
Last Updated
Version 2.58
Change Reason
Shortened Method from "Physical medicine and rehabilitation" to "Physical medicine and rehab" in order to allow for space in the Method field for Role attributes e.g. "Physical medicine and rehab.physician attending".
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
LG38987-0 Physical medicine and rehab|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:Physical medicine and rehab
it-IT Italian (Italy) Piano di cura, nota:Osservazione:Pt:{Setting}:Doc:Medicina fisica e riabilitazione
Synonyms: Documentazione dell''ontologia Osservazione Piano di cura Punto nel tempo (episodio)
zh-CN Chinese (China) 医疗服务计划记录:发现:时间点:{环境}:文档型:物理医学与康复学
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 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 物理医学与康复;Physical medicine and rehabilitation 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=80786-7