United States Health Information Knowledgebase


Assessment and Plan Section

Definition:The Assessment and Plan Section contains information about the assessment of the patient's condition and expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient. An assessment and plan section varies from the plan of care section defined later in that it includes a physician assessment of the patient condition. Note: Please note that the assessments described in this section are physician assessments of the patient's current condition, and do not include assessments of functional status, or other assessments typically used in nursing. In Implementation Guides currently selected, when both the assessment and plan are documented, they are included together in a single section documenting both. When the physician assessment is not present, only the Plan of Care Section appears. There are no cases where a physician assessment is provided without a plan.
Constraint ID Definition
C83-[CT-123-1] This section SHALL conform to the IHE Assessment and Plans Section, and SHALL contain a templateId element whose root attribute is
C83-[CT-123-2] This section SHALL conform to the HL7 History and Physical Note and HL7 Consultation Note requirements for this section, and SHALL contain a templateId element whose root attribute is 2.16.840.1.113883.
C83-[CT-123-3] The Assessments and Plan Section MAY include entries conforming to the Medication, Immunization, Encounter, and Procedure modules to provide information about the intended care plan
Scroll To Top