Nurse Plan of care note 64295-9
LOINC Code
| LOINC code | 64295-9 | ||||||
|---|---|---|---|---|---|---|---|
| name | Nurse Plan of care note | ||||||
| description | A 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. | ||||||
| status | ACTIVE | ||||||
Fully-Specified Name | |||||||
| component | Plan of care 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 | Nurse | ||||||
Additional Names | |||||||
| short name | Nurse Plan of care note | ||||||
Basic Attributes | |||||||
| class | DOC.ONTOLOGY | ||||||
| type | 2 Clinical | ||||||
| order vs. observation | Both | ||||||
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.
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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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History/Usage | |||||||
| first released | |||||||
| last updated | 2.67 | ||||||
| last change type | MIN - change to field other than name | ||||||
| change reason | Based 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 | |||||||
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