Conclusions and working assumptions that will guide treatment of the patient, and recommendations for future treatment.

Data Element

Applicable Vocabulary Standard(s)

Assessment and Plan of Treatment

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

Health professional’s conclusions and working assumptions that will guide treatment of the patient.

Data Element

Care Plan

Comment

Clarification Needed for Patient Summary and Plan

The Patient Summary and Plan data class needs to be renamed to Patient Assessment and Plan.

The Patient Summary and Plan data class should clarify that this data class covers Patient Assessment, and  Plan of Treatment information. Using the words “Patient Summary” is confusing because a “Patient Summary” is a type of Clinical Note Document that summarizes the patient’s medical history over a span of time. The term "Patient Summary" is widely used throughout the Sequoia, Commonwell/Carequality communities and will lead to widespread confusion if used here.

See related comments on how to clarify the Clinical Notes data class.

 

Lisa Nelson Comments 20230221_0.pdf

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