Nurse Plan of care note   64295-9

LOINC Code


LOINC code64295-9
nameNurse Plan of care note
descriptionA nursing plan of care is a document that outlines the nursing care to be provided to an individual/family/community. It is a set of actions the nurse will implement to resolve/support nursing diagnoses identified by nursing assessment. The creation of the plan is an intermediate stage of the nursing process. It guides in the ongoing provision of nursing care and assists in the evaluation of that care. It includes a) nursing diagnosis including related and risk factors, b) expected outcomes (e.g. goals), and c) nursing interventions.
statusACTIVE

Fully-Specified Name

componentPlan of care note
propertyFind  =  Finding
timePt  =  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}
scaleDoc  =  Document:  A document that could be in many formats (XML, narrative, etc.)
methodNurse

Additional Names

short nameNurse Plan of care note

Basic Attributes

classDOC.ONTOLOGY
type2  Clinical
order vs. observationBoth

Ask At Order Entry

Ask at Order Entry (AOE) observations for a clinical observation or laboratory test. A LOINC term may represent a single AOE observation or a panel containing several AOE observations.

81215-6Care plan - recommended C-CDA R2.0 and R2.1 sections

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

LG38952-4Nurse|ANYTypeOfService|ANYKindOfNote|ANYSetting
LG38745-2Plan of care note|ANYRole|ANYSetting
LG41826-5{Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain

History/Usage

first released
last updated2.67
last change typeMIN  - change to field other than name
change reasonBased on Clinical LOINC Committee approval on 8/2012, component was changed from "Care plan" to "Plan of Care" to harmonize existing document terms related to plan of care.

Related Names

Care plan
DOC.ONT
Document
Encounter
Evaluation and management
Evaluation and management note
Finding
Findings
notes
nursing
Point in time
Random
Treatment plan
Visit note

Copyright © 2024 Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright © 1995-2024, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee. See https://loinc.org/license for the full LOINC copyright and license.

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