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)] Constraints say: This structuredBody SHOULD contain zero or one [0..1] component (CONF:1198-28763) such that it 1. SHALL contain exactly one [1..1] Interventions Section (V3) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.21.2.3:2015-08-01) (CONF:1198-28764).

Proposed Wording

The value added by a care plan is to know and communication about the planned and completed interventions that need to be or have been done to move a person toward a goal that is associated with a health concern. The inclusion of the interventions section can be optional. The SHOULD is not adequate for the standard. It needs to be a SHALL. This structuredBody SHALL contain exactly one [1..1] component (CONF:1198-28763) such that it 1. SHALL contain exactly one [1..1] Interventions Section (V3) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.21.2.3:2015-08-01) (CONF:1198-28764). This issue should be considered a technical errata because the basic intent/requirements of the Care Plan document cannot be met if this information is not included. The use of SHOULD should be considered an initial error against information exchange requirements. Here is the first sentence in the purpose definition of the Care Plan document template, "A Care Plan (including Home Health Plan of Care (HHPoC)) is a consensus-driven dynamic plan that represents a patient’s and Care Team Members’ prioritized concerns, goals, and planned interventions." While the Health Status Evaluation and Outcomes section may be optional, the Interventions section should not be optional. It is mentioned at the same level of necessity as the concerns and goals. A Care Plan document would not be complete or useful without intervention information.