Information that guides 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.
Care Plan

Shared plan informed by members of a coordinated care team that details conditions, needs, and goals along with strategies for addressing them.

Usage notes: Includes problems, health concerns, assessments, goals, and interventions from across care settings.

Examples include but are not limited to clinical care plans, condition-specific care plans, coordinated care plan.

Comment

Submitted by jay.lyle@jpsys.com on

"Care Plan" is a broad term that covers a variety of uses

The description ("Information that guides treatment of the patient and recommendations for future treatment") could be taken to describe virtually any content in a patient's record. Supportive comments that use words like "magical" in describing its capabilities indicate just how broadly stakeholders may interpret the intent of this term.

In practice, HL7 Care Plan Domain Analysis Model work has shown this term used to refer to at least four manifestations: 1) an inpatient function of an EHR designed to coordinate care & treatment across shifts, 2) the plan section of a static SOAP note, 3) a query-based report of planned activities scoped by the assumptions of the query author (e.g., a CCD section or CDA Care Plan document), and 4) a function supporting a curated set of planned interventions, with associated goals and other supporting information, usually scoped by some specific concern, context of care, or role. In addition, there seems to be appetite for 5) a "dynamic" care plan that combines #4 with some capability for maintaining currency across organizational boundaries.

An implementation might assert support for such a requirement with any level of sophistication, from, at the low end, the claim that existing 'document' capabilities already support transfer of such information to, at the high end, a complex software design coordinating independent business objects with distinct provenance and state. The Element definitions may suggest that support for both of these is intended, (#2 for "Assessment and Plan of Treatment", #4 for "Care Plan"), but the alignment, if intended, could be more explicit.

Operational definitions, providing objective capabilities to distinguish the elements, might help clarify what is being requested. E.g.,
 
A #2 plan should provide not only the plan text, but the context in which this plan is asserted (viz., date, provider, and system of record)
A #3 plan should provide have not only planned interventions, but also the context in which this plan is retrieved (viz., date, query definition, and system of record)
A #4 plan capability should allow a participant to query across organizational boundaries for current state of the plan or its components
A #5 plan capability should allow a participant to execute and modify the current state of the plan's components across organizational boundaries

 

Naming these artifacts (and even their requirements) meaningfully will also be a challenge.

Finally, using the same term ("Care Plan") for both class and element can exacerbate confusion. 

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