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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. This section may
also contain information about ongoing care of the patient, clinical reminders, patient’s
values, beliefs, preferences, care expectations, and overarching care goals. Clinical
reminders are placed here to provide
prompts for disease prevention and management, patient safety, and healthcare quality
improvements, including widely accepted performance measures. 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 patient’s 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. The
plan may also indicate that patient education will be provided.
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Template Plan of Treatment Section (V2)
Planned Observation (V2) (2.1)
nV2)
