Section Templates
The article What is a CDA Template?, introduces the template concept in CDA. In particular, C-CDA section templates define the rules for sections of the structured body in C-CDA documents. Each section template begins at the XML XPath: /ClinicalDocument/component/structuredBody/component/section.

Section templates are particularly important in the context of MU2. As explained in the article Does MU2 define C-CDA document templates?, the MU2 document types provide CDA Header requirements and guide to which C-CDA section templates are optional or required in the CDA body.

In this article we’ll look at the Plan of Care section template in C-CDA.

The Plan of Care Section Template
The Plan of Care section template is described in the C-CDA specification (more formally, the C-CDA implementation guide, as follows:

The Plan of Care section contains data that defines pending orders, interventions, encounters, services, and procedures for the patient. It is limited to prospective, unfulfilled, or incomplete orders and requests only… 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 unless constrained due to privacy issues. The plan may also contain information about ongoing care of the patient and information regarding goals and clinical reminders. Clinical reminders are placed here to provide prompts for disease prevention and management, patient safety, and health-care quality improvements, including widely accepted performance measures. The plan may also indicate that patient education will be provided.

Entry Templates Within the Plan of Care Section Template
Within the Plan of Care section template, all of the entry templates are optional (and there can be more than one of each). These optional entry templates include:

  • Instructions: A template for patient instructions that contains unstructured text with the instructions.
  • Plan of Care Activity Act: An entry template that defines a generic act clinical act statement (refer to The act element, for additional information).
  • Plan of Care Activity Encounter: An entry template that defines a generic encounter clinical act statement (refer to The encounter element, for additional information).
  • Plan of Care Activity Observation: An entry template that defines a generic observation clinical act statement (refer to The observation element, for additional information).
  • Plan of Care Activity Procedure: An entry template that defines a generic procedure clinical act statement (refer to The procedure element, for additional information).
  • Plan of Care Activity Substance Administration: An entry template that defines a generic substanceAdministration clinical act statement (refer to The substanceAdministration element, for additional information).
  • Plan of Care Activity Supply: An entry template that defines a generic supply clinical act statement.

Essentially, then, the Plan of Care section template may optionally contain patient instructions and/or any clinical act statements to represent planned clinical acts.

The moodCode attribute of the clinical act statements contained with the Plan of Care section template, generally have the value “INT” (intended for the future) or one of its variants such as “RQO” (a request or order). Refer to The moodCode attribute, for additional information.

Standard Sub-Elements and Attributes
Like all sections in CDA documents, the mandatory classCode and moodCode attributes of the section element take on default values of “DOCSECT” and “EVN”, respectively, and are thus not explicitly included.

The templateId element has its root attribute set to 2.16.840.1.113883.10.20.22.2.10 – the OID for this template.

The code element has its attributes set to correspond to the LOINC code 18776-5 which encodes “Plan of Care”. Refer to the article Codes in CDA, for additional information about the attributes of the code element.

The only other sub-elements required by the Reason for Referral template are the section title in the title element (which is usually set to “Plan of Care”) and the section narrative text in the text element.

Entry Templates Are Optional
As noted above, the use of structured entry templates within the Plan of Care section template, is optional. So, it is fairly common to see this section template used with only an unstructured narrative text (aka “the narrative block”), where the plan of care is described. This is a valid use of the Plan of Care section template.

Plan of Care in C-CDA Document Templates
In terms of C-CDA document templates, only the Discharge Summary requires the use of the Plan of Care section template.

The Plan of Care section template is called out as optional in the Progress Note, Consultation Note, History and Physical, Procedure Note, Operative Note, and CCD document templates in C-CDA.

Plan of Care in MU2
As explained in Does MU2 define C-CDA document templates?, MU2 does not require the use of any particular C-CDA document template (or even the use of any C-CDA document template). Rather, it guides to the use of specific C-CDA section templates for various MU2 document types.

The plan of care is required in all MU2 document types.

For purposed of communicating the plan of care, MU2 allows for either the use of the Plan of Care section template or the Assessment and Plan section template. C-CDA includes separate section templates for Assessment and for Plan of Care. In addition, it offers a combined Assessment and Plan section template for those settings where local policy prefers that they be combined.

Other CDA PRO Know Articles Referenced In This Article