Specification - Extended

HL7 CDA® R2 IG: C-CDA Templates for Clinical Notes DSTU Release 2.1 - US Realm

Document Description

extended per extended per TSC tracker 12437, again with 14128 and jira.hl7.org/browse/TSC-38

Existing Wording

Care Plan (V2) [ClinicalDocument: identifier urn:hl7ii:2.16.840.1.113883.10.20.22.1.15:2015-08-01 (open)] The CDA Care Plan represents an instance of this dynamic Care Plan at a point in time. The CDA document itself is NOT dynamic. Key differentiators between a Care Plan CDA and CCD (another “snapshot in time” document): There are 2 required sections: o Health Concerns o Interventions There are 2 optional sections: o Goals o Outcomes • Provides the ability to identify patient and provider priorities with each act • Provides a header participant to indicate occurrences of Care Plan review A care plan document can include entry references from the information in these sections to the information (entries) in other sections. Please see Volume 1 of this guide to view a Care Plan Relationship diagram and story board.

Proposed Wording

There are 2 required sections: o Health Concerns o Goals There are 2 optional sections: o Interventions o Health Status Evaluations and Outcomes