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Assessment and Plan of Treatment

Represents a health professional’s conclusions and working assumptions that will guide treatment of the patient.

Data Element

Applicable Vocabulary Standard(s)

Assessment and Plan of Treatment

Data Element

Applicable Vocabulary Standard(s)

Assessment and Plan of Treatment

SDOH Assessment

Structured evaluation of risk (e.g., PRAPARE, Hunger Vital Sign, AHC-HRSN screening tool) for any Social Determinants of Health domain such as food, housing, or transportation security. SDOH data relate to conditions in which people live, learn, work, and play and their effects on health risks and outcomes.

  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.70
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2021 Release

Comment

Seeking clarity (or removal) of this Data Class and Data Element

As they exist today, this Data Class (Assessment and Plan of Treatment) and the redundant Data Element are ambiguous and cause confusion in the industry. No applicable standard has been named either in USCDI Version 1 or the Draft USCDI V2, and the definition is extraordinarily vague. Without an anchoring to more precise information and terminology mappings, implementers are left wondering...is this meant to be:
  • only the A&P sections of a (SOAP) clinical note?
  • diagnoses/conditions/functional impairments because the definition refers to "conclusions"?
  • a formal "assessment instrument" such as those required by CMS in post acute care (MDS, OASIS, IRF-PAI)?
  • an activity performed (e.g. assessing readiness for return to work or sport)?
  • the whole Care Plan/Plan of Care?
  • or something altogether different?
I recognize that the FHIR US Core Profile has interpreted this as a profile on the CarePlan resource, so many will use that interpretation in their implementations.  Yet, for the broader purposes of USCDI (e.g. information blocking), I recommend one of the following:
  1. Clarify the Data Class (e.g. Care Plan) and the relevant corresponding Data Elements (e.g. narrative summary, status, etc) and their relevant standards, or
  2. Remove the Data Class and Data Element until greater consensus meaning is achieved and precision is defined.

Agree with dvreeman

Agree with comment from dvreeman:  Unclear what this Data Class seeks to contain.  I see the cancer staging information -- is that the purpose of this section?  If so, perhaps the title "Assessment and Plan of Treatment" is too broadly worded for that more narrow use case.  Perhaps a 2-3 sentence description would help. Recommend either:
  1. Clarify purpose / intent of this Class and Elements; 
  2. Rename to the Class to reflect the cancer staging use; or
  3. Remove the Class until better understood

Agree with other commenters…

Agree with other commenters that the data class Assessment and Plan of Treatment requires further clarification or to be removed. Health care providers such as LTPAC settings have various types of clinicians utilizing multiple assessment approaches such as completing a SOAP note to document an assessment in a narrative note, completion of an assessment instrument/tool, synthesizing various data sources to assess status and develop or update the plan of care, etc. The definition of the Plan of Treatment is also not clear. Does this class represent the care plan/plan of care or something different altogether?   Depending on the clarification, this data class and related elements may be duplicative of other data classes (e.g., narrative notes, medications, procedures, etc.).

Clarification Needed on Data Class

Agree with other commenters that the data class Assessment and Plan of Treatment requires further clarification or to be removed. Health care providers such as LTPAC settings have various types of clinicians utilizing multiple assessment approaches such as completing a SOAP note to document an assessment in a narrative note, completion of an assessment instrument/tool, synthesizing various data sources to assess status and develop or update the plan of care, etc. The definition of the Plan of Treatment is also not clear. Does this class represent the care plan/plan of care or something different altogether?   Depending on the clarification, this data class and related elements may be duplicative of other data classes (e.g., narrative notes, medications, procedures, etc.).

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