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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.


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 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

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