Submitted by Albert Taylor 
on
test
test
Conclusions and working assumptions that will guide treatment of the patient, and recommendations for future treatment.
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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) |
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Assessment and Plan of Treatment
Health professional’s conclusions and working assumptions that will guide treatment of the patient. |
Data Element |
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Data Element |
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Comment
Submitted by LisaRNelson on
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.
Submitted by LisaRNelsonRI on
USCDI V5 Feedback
This Data Class should include a Patient Summary document which contains a summary of the patient’s relevant medical history. This is the type of collection of information carried in a Continuity of Care Document (CCD) or an International Patient Summary (IPS) document. This Data Class needs to include:
Patient Summary Document
A collection of information describing the patient’s medical history.
Care Plan Document
A collection of information describing a plan to direct the course of care for the patient.
Screenings and Screening Results
Questions and answers used to gather information from the patient to be used by a provider when assessing the patient, or measuring progress toward a goal.
Assessments
A provider’s conclusions about a patient’s situation based on gathered information and physical observations of the patient’s condition.
Health Concerns
Issues identified by the patient or practitioner as having risen to the level of a “concern” to be tracked and addressed. The issues could be a medical problem identified on the patient’s Problem List, or it could any other type of issue that rises to the level of being a concern for the patient’s overall health.
Patient Goals
Patients goals, or goals for the patient set by provider or shared goals held by both the patient and provider, established as the desired outcome to guide the course of care.
Interventions or Plan of Treatment
A set of activities to be performed to achieve progress toward a patient goal.
Evaluations
Evaluations are similar to Assessments but for the timing and purpose. Assessments are made to determine diagnoses prior to developing a Plan. Evaluations come after some or all of the interventions in a Plan have been performed and their purpose is to determine progress toward the goals which the plan is intended to meet. Because the diagnostic process is circular, Assessments and Evaluations appear to happen at the same point in the cycle. You have to look at the cycle as a linear process flattened out over time to see they are not the same thing. The work is similar in that there is a human clinician apply their professional judgement to the situation, but the purpose of the work differs.
Conclusions regarding progress toward a goal based on qualitative or observable or measurable information gathered by screening instruments, physical assessment, or other types of testing.