the MU Data as the assessment, plan of care (for treatment), goals, and health “Common Set” concerns for a single patient encounter or inpatient stay. These stakeholders have expressed safety concerns that the volume of data in a comprehensive care plan can be so extensive that it may be difficult for a provider to quickly determine the information of value for the patient for the given situation. In consideration of this feedback, we clarify that we plan field(s), including intend “care goals and to be a single documentation of their assessment, plan of instructions” provider’s treatment, goals, and health concerns for the patient (this clarification applies for 2014 Edition certification). We also make this clarification to better align with the terms used in the C-CDA Release 2.0, which includes the and Plan Section Section “Assessment (V2),” “Assessment of Treatment Section and Concerns In (V2),” “Plan (V2),” “Goals Section,” “Health Section.” previous iterations of the C-CDA, the of was called the of Care “Plan Treatment Section” “Plan which resulted in the same level of confusion on whether the information was intended Section,” to represent a single encounter or the synthesis of multiple encounters. For that reason, the “Plan of Care is now called the of Treatment to indicate that it is intended to Section” “Plan Section” represent a single encounter and not to be confused with the Plan document “Care template.” For certification to the 2015 Edition, we propose to include in the Common Clinical Data Set and plan of and data in accordance with “assessment treatment,” “goals,” “health concerns” the C-CDA Release 2.0 and Plan Section or both the Section “Assessment (V2)” “Assessment and of Treatment Section the and the Concerns (V2)” “Plan (V2);” “Goals Section;” “Health In practice, health care providers may document the assessment and plan of treatment Section.” together or separately, and the C-CDA Release 2.0 provides for both modes of practice. We understand that the C-CDA Release 2.0 permits both free-text and structured documentation of
the “Common MU Data Set” as the assessment, plan of care (for treatment), goals, and health concerns for a single patient encounter or inpatient stay. These stakeholders have expressed safety concerns that the volume of data in a comprehensive care plan can be so extensive that it may be difficult for a provider to quickly determine the information of value for the patient for the given situation. In consideration of this feedback, we clarify that we intend “care plan field(s), including goals and instructions” to be a single provider’s documentation of their assessment, plan of treatment, goals, and health concerns for the patient (this clarification applies for 2014 Edition certification). We also make this clarification to better align with the terms used in the C-CDA Release 2.0, which includes the “Assessment and Plan Section (V2),” “Assessment Section (V2),” “Plan of Treatment Section (V2),” “Goals Section,” and “Health Concerns Section.” In previous iterations of the C-CDA, the “Plan of Treatment Section” was called the “Plan of Care Section,” which resulted in the same level of confusion on whether the information was intended to represent a single encounter or the synthesis of multiple encounters. For that reason, the “Plan of Care Section” is now called the “Plan of Treatment Section” to indicate that it is intended to represent a single encounter and not to be confused with the “Care Plan document template.” For certification to the 2015 Edition, we propose to include in the Common Clinical Data Set “assessment and plan of treatment,” “goals,” and “health concerns” data in accordance with the C-CDA Release 2.0 “Assessment and Plan Section (V2)” or both the “Assessment Section (V2)” and “Plan of Treatment Section (V2);” the “Goals Section;” and the “Health Concerns Section.” In practice, health care providers may document the assessment and plan of treatment together or separately, and the C-CDA Release 2.0 provides for both modes of practice. We understand that the C-CDA Release 2.0 permits both free-text and structured documentation of
2015_editionnprm_ofr_disclaimer_3-20-15.docx