Consolidated CDA Release 2.2
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Consolidated CDA Release 2.2, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.2). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.2/ and changes regularly. See the Directory of published versions

Resource Profile: Plan of Treatment Section

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.10 Version: 2.2
Active as of 2022-05-13 Computable Name: PlanofTreatmentSection
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.2.10:2014-06-09

This section, formerly known as “Plan of Care”, contains data that define pending orders, interventions, encounters, services, and procedures for the patient. It is limited to prospective, unfulfilled, or incomplete orders and requests only. These are indicated by the @moodCode of the entries within this section. All active, incomplete, or pending orders, appointments, referrals, procedures, services, or any other pending event of clinical significance to the current care of the patient should be listed. Clinical reminders are placed here to provide prompts for disease prevention and management, patient safety, and healthcare quality improvements, including widely accepted performance measures. The plan may also indicate that patient education will be provided. When used in a document that includes a Goals Section, all the goals (whether narrative only, or structured Goal Observation entries) should be recorded in the Goals Section, rather than in the Plan of Treatment Section, to avoid confusion as to which/whose goals should be in which section? When used in a document that does not include a Goals Section, the Plan of Treatment section may also contain information about care team members goals, including the patients values, beliefs, preferences, care expectations, and overarching care goals. Values may include the importance of quality of life over longevity. These values are taken into account when prioritizing all problems and their treatments. Beliefs may include comfort with dying or the refusal of blood transfusions because of the patients religious convictions. Preferences may include liquid medicines over tablets, or treatment via secure email instead of in person. Care expectations may range from being treated only by female clinicians, to expecting all calls to be returned within 24 hours. Overarching goals described in this section are not tied to a specific condition, problem, health concern, or intervention. Examples of overarching goals could be to minimize pain or dependence on others, or to walk a daughter down the aisle for her marriage.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from CDAR2.Section

Summary

Mandatory: 8 elements (11 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Section.templateId is sliced based on the values of value:root, value:extension
  • The element Section.entry is sliced based on the values of profile:observation, profile:encounter, profile:act, profile:procedure, profile:substanceAdministration, profile:supply

This structure is derived from CDAR2.Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.Section
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.10
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CE
.... code 1..1stringRequired Pattern: 18776-5
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ED
... Slices for entry 0..*ElementSlice: Unordered, Open by profile:observation, profile:encounter, profile:act, profile:procedure, profile:substanceAdministration, profile:supply
.... entry:plannedObs 0..*Element
..... observation 1..1PlannedObservation
.... entry:plannedEnc 0..*Element
..... encounter 1..1PlannedEncounter
.... entry:plannedAct 0..*Element
..... act 1..1PlannedAct
.... entry:plannedProc 0..*Element
..... procedure 1..1PlannedProcedure
.... entry:plannedMed 0..*Element
..... substanceAdministration 1..1PlannedMedicationActivity
.... entry:plannedSupply 0..*Element
..... supply 1..1PlannedSupply
.... entry:instruction 0..*Element
..... act 1..1Instruction
.... entry:handoffCommParticipants 0..*Element
..... act 1..1HandoffCommunicationParticipants
.... entry:nutrition 0..*Element
..... act 1..1NutritionRecommendation
.... entry:plannedImmunization 0..*Element
..... substanceAdministration 1..1PlannedImmunizationActivity
.... entry:goal 0..*Element
..... observation 1..1GoalObservation

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.Section
... ID 0..1string
... nullFlavor 0..1codeBinding: NullFlavor (required)
... classCode 1..1code​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.10
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 18776-5
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ED
... text S1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... Slices for entry I0..*ElementSlice: Unordered, Open by profile:observation, profile:encounter, profile:act, profile:procedure, profile:substanceAdministration, profile:supply
.... entry:All Slices Content/Rules for all slices
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
.... entry:plannedObs I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... observation 1..1PlannedObservation
.... entry:plannedEnc I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... encounter 1..1PlannedEncounter
.... entry:plannedAct I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... act 1..1PlannedAct
.... entry:plannedProc I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... procedure 1..1PlannedProcedure
.... entry:plannedMed I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... substanceAdministration 1..1PlannedMedicationActivity
.... entry:plannedSupply I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... supply 1..1PlannedSupply
.... entry:instruction I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... act 1..1Instruction
.... entry:handoffCommParticipants I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... act 1..1HandoffCommunicationParticipants
.... entry:nutrition I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... act 1..1NutritionRecommendation
.... entry:plannedImmunization I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... substanceAdministration 1..1PlannedImmunizationActivity
.... entry:goal I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... observation 1..1GoalObservation
... component 0..*Element
.... typeCode 1..1codeFixed Value: COMP
.... contextConductionInd 1..1boolean
.... section 1..1Section

doco Documentation for this format

This structure is derived from CDAR2.Section

Summary

Mandatory: 8 elements (11 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Section.templateId is sliced based on the values of value:root, value:extension
  • The element Section.entry is sliced based on the values of profile:observation, profile:encounter, profile:act, profile:procedure, profile:substanceAdministration, profile:supply

Differential View

This structure is derived from CDAR2.Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.Section
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.10
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CE
.... code 1..1stringRequired Pattern: 18776-5
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ED
... Slices for entry 0..*ElementSlice: Unordered, Open by profile:observation, profile:encounter, profile:act, profile:procedure, profile:substanceAdministration, profile:supply
.... entry:plannedObs 0..*Element
..... observation 1..1PlannedObservation
.... entry:plannedEnc 0..*Element
..... encounter 1..1PlannedEncounter
.... entry:plannedAct 0..*Element
..... act 1..1PlannedAct
.... entry:plannedProc 0..*Element
..... procedure 1..1PlannedProcedure
.... entry:plannedMed 0..*Element
..... substanceAdministration 1..1PlannedMedicationActivity
.... entry:plannedSupply 0..*Element
..... supply 1..1PlannedSupply
.... entry:instruction 0..*Element
..... act 1..1Instruction
.... entry:handoffCommParticipants 0..*Element
..... act 1..1HandoffCommunicationParticipants
.... entry:nutrition 0..*Element
..... act 1..1NutritionRecommendation
.... entry:plannedImmunization 0..*Element
..... substanceAdministration 1..1PlannedImmunizationActivity
.... entry:goal 0..*Element
..... observation 1..1GoalObservation

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.Section
... ID 0..1string
... nullFlavor 0..1codeBinding: NullFlavor (required)
... classCode 1..1code​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.10
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 18776-5
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ED
... text S1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... Slices for entry I0..*ElementSlice: Unordered, Open by profile:observation, profile:encounter, profile:act, profile:procedure, profile:substanceAdministration, profile:supply
.... entry:All Slices Content/Rules for all slices
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
.... entry:plannedObs I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... observation 1..1PlannedObservation
.... entry:plannedEnc I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... encounter 1..1PlannedEncounter
.... entry:plannedAct I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... act 1..1PlannedAct
.... entry:plannedProc I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... procedure 1..1PlannedProcedure
.... entry:plannedMed I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... substanceAdministration 1..1PlannedMedicationActivity
.... entry:plannedSupply I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... supply 1..1PlannedSupply
.... entry:instruction I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... act 1..1Instruction
.... entry:handoffCommParticipants I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... act 1..1HandoffCommunicationParticipants
.... entry:nutrition I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... act 1..1NutritionRecommendation
.... entry:plannedImmunization I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... substanceAdministration 1..1PlannedImmunizationActivity
.... entry:goal I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... observation 1..1GoalObservation
... component 0..*Element
.... typeCode 1..1codeFixed Value: COMP
.... contextConductionInd 1..1boolean
.... section 1..1Section

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredNullFlavor
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.templateId:primary.nullFlavorrequiredNullFlavor
Section.codeextensibleDocumentSectionType
Section.code.nullFlavorrequiredNullFlavor
Section.languageCoderequiredHumanLanguage
Section.subject.typeCoderequiredFixed Value: SBJ
Section.subject.contextControlCoderequiredFixed Value: OP
Section.subject.awarenessCodeextensibleTargetAwareness
Section.informant.typeCoderequiredFixed Value: INF
Section.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePathDetailsRequirements
only-one-statementerrorSection.entrySHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
only-one-statementerrorSection.entry:plannedObsSHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
only-one-statementerrorSection.entry:plannedEncSHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
only-one-statementerrorSection.entry:plannedActSHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
only-one-statementerrorSection.entry:plannedProcSHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
only-one-statementerrorSection.entry:plannedMedSHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
only-one-statementerrorSection.entry:plannedSupplySHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
only-one-statementerrorSection.entry:instructionSHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
only-one-statementerrorSection.entry:handoffCommParticipantsSHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
only-one-statementerrorSection.entry:nutritionSHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
only-one-statementerrorSection.entry:plannedImmunizationSHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
only-one-statementerrorSection.entry:goalSHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1