Assessment and Plan of Treatment

Assessment and Plan of Treatment

In USCDI V3 the Assessment and Plan of Treatment Data Class represents a health professional’s conclusions and working assumptions that will guide treatment of the patient. This definition works well for describing the Plan of Treatment part of this Data Class. However, it does not describe the assessment part well.  Assessment information is different than Plan information. That’s why Larry Weed’s seminal work on defining the structure of a SOAP note separated the Assessment information from the Plan. Assessment information is much more closely related to Health Status information. The organization of the Data Classes and Data Elements would make more sense if the Assessment and Health Status Data Classes were grouped together and the SDOH Assessment and Assessment Data Elements were moved under this adjusted Assessment and Health Status Data Class.

USCDI V3 Comment 20220429_4.pdf

Agree with others...need to distinguish from other data classes

This data class seems like it will be duplicative of other data classes - procedures, clinical notes, etc. Need to distinguish this against other data classes if we want to keep it.

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.).

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.).

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.