Version 2.78

Term Description

The Oncology Treatment Plan and Summary document provides a limited summary of a patient's care during and/or after treatment and continue to serve as a form of on-going communication to augment the coordination of care between health care providers while a patient is receiving care. Providers involved in the care of the patient may include the patient's primary care provider, medical oncologist, surgical oncologist, and radiation oncologist. This term was created for, but not limited in use to, the HL7 Implementation Guide for CDA, Release 2®: Clinical Oncology Treatment Plan and Summary. This guide was derived from the American Society of Clinical Oncology (ASCO) Breast Cancer Adjuvant Treatment Plan and Summary. However, the templates in this document are not restrictive and can be applied to other types of cancer.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Plan of care+summary note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
Oncology

Additional Names

Short Name
Oncology Care plan+summary note

Associated Observations

74293-2 Oncology plan of care and summary - recommended CDA set

This panel term contains the set of LOINC codes referenced in the Oncology Treatment Plan and Summary HL7 Implementation Guide.

LOINC Name R/O/C Cardinality Example UCUM Units
74293-2 Oncology plan of care and summary - recommended CDA set
Indent10157-6 History of family member diseases Narrative O
Indent10160-0 History of Medication use Narrative O
Indent11450-4 Problem list - Reported O
Indent11323-3 General health - Reported O
Indent16112-5 Estrogen receptor [Interpretation] in Tissue
Indent16113-3 Progesterone receptor [Interpretation] in Tissue
Indent18776-5 Plan of care note
Indent59408-5 Oxygen saturation in Arterial blood by Pulse oximetry %
Indent29308-4 Diagnosis
Indent33999-4 Diagnosis status
Indent30954-2 Relevant diagnostic tests/laboratory data Narrative
Indent3140-1 Body surface area Derived from formula m2
Indent3141-9 Body weight Measured [lb_av];kg
Indent34122-2 Pathology procedure note
Indent34133-9 Summary of episode note
Indent21894-1 Regional lymph nodes examined [#] Specimen {#}
Indent46240-8 History of Hospitalizations+Outpatient visits Narrative
Indent47420-5 Functional status assessment note
Indent47519-4 History of Procedures Document
Indent48676-1 HER2 [Interpretation] in Tissue
Indent48765-2 Allergies and adverse reactions Document
Indent54614-3 Brief Interview for Mental Status - summary score [BIMS] {score}
Indent56780-0 CYP21A2 gene mutations tested for in Blood or Tissue by Molecular genetics method Nominal
Indent57251-1 Ambulation [OASIS-C]
Indent64293-4 Procedure consent Document
Indent8287-5 Head Occipital-frontal circumference by Tape measure cm
Indent8302-2 Body height [in_us];cm;m
Indent8306-3 Body height --lying [in_us];cm;m
Indent8310-5 Body temperature Cel
Indent8462-4 Diastolic blood pressure mm[Hg]
Indent8480-6 Systolic blood pressure mm[Hg]
Indent8716-3 Vital signs
Indent18043-0 Left ventricular Ejection fraction by US %
Indent18044-8 Left ventricular Ejection fraction by US.2D+Calculated by single-plane ellipse method %
Indent18045-5 Left ventricular Ejection fraction by US.2D+Calculated by biplane ellipse method %
Indent18046-3 Left ventricular Ejection fraction by US 2D modified %
Indent18047-1 Left ventricular Ejection fraction by US 2D modified biplane %
Indent18048-9 Left ventricular Ejection fraction by US 2D modified single-plane %
Indent18049-7 Left ventricular Ejection fraction by US.M-mode+Calculated by Teichholz method %
Indent8806-2 Left ventricular Ejection fraction by 2D echo %
Indent8807-0 Left ventricular Ejection fraction by 2D echo.visual estimate %
Indent8808-8 Left ventricular Ejection fraction by Cardiac angiogram %
Indent8809-6 Left ventricular Ejection fraction by Cardiac angiogram.visual estimate %
Indent8810-4 Left ventricular Ejection fraction by Spiral CT %
Indent8811-2 Left ventricular Ejection fraction by MR %
Indent8812-0 Left ventricular Ejection fraction by Nuclear blood pool %
Indent8867-4 Heart rate {beats}/min;{counts/min}
Indent9279-1 Respiratory rate {breaths}/min;{counts/min}

82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections

This panel contains the recommended sections for a care plan note based on the HL7 Implementation Guide for CDA® Release 2: Clinical Oncology Treatment Plan and Summary, Release 1 - US Realm - DSTU 2, of November 2014.

LOINC Name R/O/C Cardinality Example UCUM Units
82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
Indent48765-2 Allergies and adverse reactions Document R
Indent46240-8 History of Hospitalizations+Outpatient visits Narrative R
Indent10157-6 History of family member diseases Narrative R
Indent47420-5 Functional status assessment note R
Indent10160-0 History of Medication use Narrative R
Indent61144-2 Diet and nutrition Narrative R
Indent18776-5 Plan of care note R
Indent11450-4 Problem list - Reported R
Indent47519-4 History of Procedures Document R
Indent30954-2 Relevant diagnostic tests/laboratory data Narrative R
Indent8716-3 Vital signs R

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.46
Last Updated
Version 2.63
Change Reason
Previous Releases: Based on Clinical LOINC Committee approval on 2/2014, the Component was changed from 'Oncology treatment plan and summary' and Method was changed from '{Provider}' to harmonize with the current LOINC Document Ontology model. Based on Clinical LOINC Committee review on 2/2016, it was decided that there is little, if any, distinction between plan of treatment and plan of care notes. For consistency, all terms in the LOINC Document Ontology described as "treatment plans" would be named "plan of care" notes. The Component for this term was changed from "Treatment plan+summary note" to "Plan of care+summary note".;
Order vs. Observation
Both
HL7® Attachment Structure
Implementation guide exists

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38980-5 Oncology|ANYTypeOfService|ANYKindOfNote|ANYSetting

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Plan de cuidados + nota resumida:Tipo:Punto temporal:{Configuración}:Documento:Oncology
it-IT Italian (Italy) Piano di trattamento+nota di sintesi:Osservazione:Pt:{Setting}:Doc:Oncologia
Synonyms: Documentazione dell''ontologia Osservazione Piano di trattamento e nota di sintesi;Piano di trattamento e riassunto;Piano di trattamento+riassunto Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) behandelplan + samenvatting:bevinding:moment:{instelling}:document:oncologie
zh-CN Chinese (China) 医疗服务计划+摘要:发现:时间点:{环境}:文档型:肿瘤学
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 医疗服务（照护服务、护理服务、护理、照护、医疗照护、诊疗、诊疗服务、照顾、看护）计划（方案）+摘要（小结、概要、总结）;治疗计划（治疗方案）与摘要（小结、概要、总结）;肿瘤学治疗计划（治疗方案）与摘要（小结、概要、总结）;肿瘤学治疗计划与摘要;治疗计划+摘要记录 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 小结;概要;概括;总汇;总结 文档本体;临床文档本体;文档本体;文书本体;医疗文书本体;临床医疗文书本体 时刻;随机;随意;瞬间 笔记;按语;注释;说明;票据;单据;证明书 肿瘤学方法

LOINC Terminology Service (API) using HL7® FHIR® Get Info

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=74156-1