Evaluation + Plan note 51847-2
LOINC Code
| LOINC code | 51847-2 | ||
|---|---|---|---|
| name | Evaluation + Plan note | ||
| description | The Assessment and Plan note (also called impression or diagnoses) represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The assessment formulates a specific plan or set of recommendations. The assessment may be a list of specific disease entities or a narrative block. The Plan 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 was given or will be provided. | ||
| status | ACTIVE | ||
Fully-Specified Name | |||
| component | Evaluation+Plan note | ||
| property | Find = Finding | ||
| time | Pt = Point in time: To identify measures at a point in time. This is a synonym for “spot” or “random” as applied to urine measurements. | ||
| system | {Setting} | ||
| scale | Doc = Document: A document that could be in many formats (XML, narrative, etc.) | ||
| method | {Role} | ||
Additional Names | |||
| short name | Eval+Plan note | ||
Basic Attributes | |||
| class | DOC.ONTOLOGY | ||
| type | 2 Clinical | ||
| order vs. observation | Both | ||
Associated Observations | |||
LOINC codes that represent optional associated observation(s) for a clinical observation or laboratory test. A LOINC term may represent a single associated observation or panel containing several associated observations. | |||
Member of these Groups | |||
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Member of these Panels | |||
History/Usage | |||
| first released | |||
| last updated | 2.63 | ||
| last change type | MIN - change to field other than name | ||
| change reason | Previous Releases: Changed 'Assesment' to 'Evaluation' to harmonize existing terms with similar meaning. The term 'Evaluation' will be used in the LOINC Document Ontoloy based on Clinical LOINC Committee decision (Sept 2014).; Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.; | ||
Related Names | |||
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| hierarchy paths | LOINC Home {component} LP432695-7 Clinical LP7787-7 Document ontology LP32519-8 LOINC Document Ontology - Type of Service and Kind of Document LP261247-3 Evaluation and management LP64606-4 Plan LP175754-3 Evaluation + Plan note LP74505-6 Evaluation + Plan note | {Setting} | Document ontology LP416610-6 LOINC Home {component} LP432695-7 Clinical LP7787-7 Document ontology LP32519-8 LOINC Document Ontology - Type of Service and Kind of Document LP261247-3 Evaluation and management LP64606-4 Evaluation note LP74507-2 Evaluation + Plan note LP74505-6 Evaluation + Plan note | {Setting} | Document ontology LP416610-6 | ||
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