Care Plan Goals and Instructions

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Example metadata last updated 2017-08-06 10:15:50.484000 UTC

Approval Status: Approved

  • Approval Status: Approved
  • Example Task Force: 8/20/15
  • SDWG: 9/10/2015
  • SDWG C-CDA R2.1 Upgrade: 2/2/2017

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ONC Certification

Comments:

  • This example illustrates how to structure a Goals and Instructions for the 170.314(b)(2) Transitions of care - K) Care Plan (Goals and Instructions).

Custodian: Lisa Nelson

Full sample: Empty CCD

Example: download example view on GitHub

<section>
    <templateId root="2.16.840.1.113883.10.20.22.2.10" extension="2014-06-09"/>
    <templateId root="2.16.840.1.113883.10.20.22.2.10"/>
    <!-- Plan of Care Section -->
    <code code="18776-5" codeSystem="2.16.840.1.113883.6.1" displayName="Plan of Treatment"/>
    <title>PLAN OF CARE</title>
    <text>
        <table border="1" width="100%">
            <thead>
                <tr>
                    <th>Date/time</th>
                    <th>Goal</th>
                    <th>Instructions</th>
                </tr>
            </thead>
            <tbody>
                <tr ID="Goal1">
                    <td>August 15, 2012 10:00am</td>
                    <td ID="Goal1_desc">Weight Loss</td>
                    <td ID="Action1">
                        <content ID="Action1_Type">Patient Education:</content>
                        <content ID="Action1_desc">Diet and exercise counseling provided during
                            visit.</content>
                    </td>
                </tr>
                <tr ID="Goal2">
                    <td>August 15, 2012 10:00am</td>
                    <td ID="Goal2_desc">Asthma management</td>
                    <td ID="Action2">
                        <content ID="Action2_Type">Patient Education:</content>
                        <content ID="Action2_desc">Resources and instructions provided during
                            visit.</content>
                    </td>
                </tr>
            </tbody>
        </table>
    </text>
    <entry>
        <observation classCode="OBS" moodCode="GOL">
            <!-- Goal Observation C-CDA R2.1-->
            <!-- Plan of Care Activity Observation C-CDA R1.1-->
            <templateId root="2.16.840.1.113883.10.20.22.4.121"/>
            <templateId root="2.16.840.1.113883.10.20.22.4.44"/>
            <id root="2a620155-9d11-439e-92b3-5d9815ff4dd4"/>
            <code code="289169006" displayName="weight loss" codeSystem="2.16.840.1.113883.6.96"
                codeSystemName="SNOMED CT">
                <originalText>
                    <reference value="#Goal1_desc"/>
                </originalText>
            </code>
            <text>
                <reference value="#Goal1"/>
            </text>
            <statusCode code="active"/>
            <effectiveTime value="201208151000-0800"/>
            <entryRelationship typeCode="RSON" inversionInd="true">
                <act classCode="ACT" moodCode="EVN">
                    <!-- Procedure Activity Act - selected over instructions template
									since it requries moodCode=INT. This act records education provided
									during the visit.-->
                    <templateId root="2.16.840.1.113883.10.20.22.4.12" extension="2014-06-09"/>
                    <templateId root="2.16.840.1.113883.10.20.22.4.12"/>
                    <id root="2a620155-9d11-439e-92b3-5d9815ff4df2"/>
                    <code code="311401005" displayName="patient education"
                        codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
                        <originalText>
                            <reference value="#Action1_Type"/>
                        </originalText>
                    </code>
                    <statusCode code="completed"/>
                    <!-- 
					   <text>
						  <reference value="#Action1"></reference>
					   </text>
								-->
                    <!-- In this example, the instruction was given at the same time that the goal was set.
									effectiveTime is the same in this case. -->
                    <effectiveTime value="201208151000-0800"/>
                </act>
            </entryRelationship>
        </observation>
    </entry>
    <entry>
        <observation classCode="OBS" moodCode="INT">
            <!-- Plan of Care Activity Observation -->
            <templateId root="2.16.840.1.113883.10.20.22.4.44" extension="2014-06-09"/>
            <templateId root="2.16.840.1.113883.10.20.22.4.44"/>
            <id root="2a620155-9d11-439e-92b3-5d9815ff4dd3"/>
            <code code="406162001" displayName="asthma management"
                codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
                <originalText>
                    <reference value="#Goal2_desc"/>
                </originalText>
            </code>
            <text>
                <reference value="#Goal2"/>
            </text>
            <statusCode code="active"/>
            <effectiveTime value="201208151000-0800"/>
            <entryRelationship typeCode="RSON" inversionInd="true">
                <act classCode="ACT" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.22.4.12" extension="2014-06-09"/>
                    <templateId root="2.16.840.1.113883.10.20.22.4.12"/>
                    <id root="2a620155-9d11-439e-92b3-5d9815ff4df6"/>
                    <code code="311401005" displayName="patient education"
                        codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
                        <originalText>
                            <reference value="#Action2_Type"/>
                        </originalText>
                    </code>
                    <statusCode code="completed"/>
                    <!-- 
						<text>
						  <reference value="#Action2"></reference>
						</text>
					-->
                    <!-- In this example, the instruction was given at the same time that the goal was set.
									effectiveTime is the same in this case. -->
                    <effectiveTime value="201208151000-0800"/>
                </act>
            </entryRelationship>
        </observation>
    </entry>
</section>
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