DSTU2

This page is part of the FHIR Specification (v0.0.82: (v1.0.2: DSTU 1). 2). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

4.3 4.4 Resource CarePlan - Content

Patient Care Work Group Maturity Level : 1 Compartments : Patient , Practitioner , RelatedPerson

Describes the intention of how one or more practitioners intend to deliver care for a particular patient patient, group or community for a period of time, possibly limited to care for a specific condition or set of conditions.

4.3.1 4.4.1 Scope and Usage

Care Plans are used in many of areas of healthcare with a variety of scopes. They can be as simple as a general practitioner keeping track of when their patient is next due for a tetanus immunization through to a detailed plan for an oncology patient covering diet, chemotherapy, radiation, lab work and counseling with detailed timing relationships, pre-conditions and goals. They may be used in veterinary care or clinical research to describe the care of a herd or other collection of animals. In public health, they may describe education or immunization campaigns.

This resource takes an intermediate approach. approach to complexity. It captures basic details about who is involved and what actions are intended without dealing in discrete data about dependencies and timing relationships. These can be supported where necessary using the extension mechanisms. mechanism.

Comments are welcome about the appropriateness The scope of care plans may vary widely. Examples include:

  • Multi-disciplinary cross-organizational care plans; e.g. An oncology plan including the proposed level oncologist, home nursing staff, pharmacy and others
  • Plans to manage specific disease/condition(s) (e.g. nutritional plan for a patient post bowel resection, neurological plan post head injury, pre-natal plan, post-partum plan, grief management plan, etc.)
  • Decision support-generated plans following specific practice guidelines (e.g. stroke care plan, diabetes plan, falls prevention, etc.)
  • Definition and management of granularity, whether it's too much detail a care team, including roles associated with a particular condition or set of conditions.
  • Self-maintained patient or care-giver authored plans identifying their goals and an integrated understanding of actions to be taken

Note that this resource represents a specific plan instance for what most systems need, a particular patient or group. It is not sufficient for common essential use cases. intended to be used to define generic plans or protocols that are independent of a specific individual or group. I.e. It represents a specific intent, not a general definition. Protocols and order sets will be supported through future resources.

This resource can be used to represent both proposed plans (for example, recommendations from a decision support engine or returned as part of a consult report) as well as active plans. The nature of the plan is communicated by the status. Some systems may need to filter CarePlans to ensure that only appropriate plans are exposed via a given user interface.

4.3.2 4.4.2 Boundaries and Relationships

For simplicity sake, CarePlan allows the in-line definition of activities as part of a plan using the activity.detail element. However, activities can also be defined using references to the various "request" resources. These references could be to resources with a status of "planned" or to an active order. It is possible for planned activities to exist (e.g. appointments) without needing a CarePlan at all. CarePlans are used when there's a need to group activities, goals and/or participants together to provide some degree of context.

CarePlans can be tied to specific Conditions however they can also be condition-independent and instead focused on a particular type of care (e.g. psychological, nutritional) or the care delivered by a particular practitioner or group of practitioners.

An ImmunizationRecommendation can be interpreted as a narrow type of Care Plan dealing only with immunization events. Where such information could appear in either resource, the immunization-specific resource is preferred.

This resource is referenced by ClinicalImpression and Procedure

4.4.3 Resource Content

Structure

Name Flags Card. Type Description & Constraints doco
.. CarePlan DomainResource Healthcare plan for patient or group
... identifier Σ 0..* Identifier External Ids for this plan
... subject Σ 0..1 Reference ( Patient | Group ) Who care plan is for
... status ?! Σ 1..1 code proposed | draft | active | completed | cancelled
CarePlanStatus ( Required )
... context Σ 0..1 Reference ( Encounter | EpisodeOfCare ) Created in context of
... period Σ 0..1 Period Time period plan covers
... author Σ 0..* Reference ( Patient | Practitioner | RelatedPerson | Organization ) Who is responsible for contents of the plan
... modified Σ 0..1 dateTime When last updated
... category Σ 0..* CodeableConcept Type of plan
Care Plan Category ( Example )
... description Σ 0..1 string Summary of nature of plan
... addresses Σ 0..* Reference ( Condition ) Health issues this plan addresses
... support 0..* Reference ( Any ) Information considered as part of plan
... relatedPlan 0..* BackboneElement Plans related to this one
.... code 0..1 code includes | replaces | fulfills
CarePlanRelationship ( Required )
.... plan 1..1 Reference ( CarePlan ) Plan relationship exists with
... participant 0..* BackboneElement Who's involved in plan?
.... role 0..1 CodeableConcept Type of involvement
Participant Roles ( Example )
.... member 0..1 Reference ( Practitioner | RelatedPerson | Patient | Organization ) Who is involved
... goal 0..* Reference ( Goal ) Desired outcome of plan
... activity I 0..* BackboneElement Action to occur as part of plan
Provide a reference or detail, not both
.... actionResulting 0..* Reference ( Any ) Appointments, orders, etc.
.... progress 0..* Annotation Comments about the activity status/progress
.... reference I 0..1 Reference ( Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticOrder | MedicationOrder | NutritionOrder | Order | ProcedureRequest | ProcessRequest | ReferralRequest | SupplyRequest | VisionPrescription ) Activity details defined in specific resource
.... detail I 0..1 BackboneElement In-line definition of activity
..... category 0..1 CodeableConcept diet | drug | encounter | observation | procedure | supply | other
CarePlanActivityCategory ( Example )
..... code 0..1 CodeableConcept Detail type of activity
Care Plan Activity ( Example )
..... reasonCode 0..* CodeableConcept Why activity should be done
Activity Reason ( Example )
..... reasonReference 0..* Reference ( Condition ) Condition triggering need for activity
..... goal 0..* Reference ( Goal ) Goals this activity relates to
..... status ?! 0..1 code not-started | scheduled | in-progress | on-hold | completed | cancelled
CarePlanActivityStatus ( Required )
..... statusReason 0..1 CodeableConcept Reason for current status
GoalStatusReason ( Example )
..... prohibited ?! 1..1 boolean Do NOT do
..... scheduled[x] 0..1 When activity is to occur
...... scheduledTiming Timing
...... scheduledPeriod Period
...... scheduledString string
..... location 0..1 Reference ( Location ) Where it should happen
..... performer 0..* Reference ( Practitioner | Organization | RelatedPerson | Patient ) Who will be responsible?
..... product[x] 0..1 What is to be administered/supplied
SNOMED CT Medication Codes ( Example )
...... productCodeableConcept CodeableConcept
...... productReference Reference ( Medication | Substance )
..... dailyAmount 0..1 SimpleQuantity How to consume/day?
..... quantity 0..1 SimpleQuantity How much to administer/supply/consume
..... description 0..1 string Extra info describing activity to perform
... note 0..1 Annotation Comments about the plan

doco Documentation for this format

UML Diagram

CarePlan ( Resource DomainResource ) This records identifiers associated with this care plan that are defined by business processed and/ or processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation) identifier : Identifier 0..* [0..*] Identifies the patient/subject patient or group whose intended care is described by the plan patient subject : Resource Reference ( [0..1] « Patient ) 0..1 | Group » Indicates whether the plan is currently being acted upon, represents future intentions or is now just a historical record (this element modifies the meaning of other elements) status : code 1..1 << [1..1] « Indicates whether the plan is currently being acted upon, represents future intentions or is now just a historical record. (Strength=Required) CarePlanStatus ! » Identifies the context in which this particular CarePlan is defined context >> : Reference [0..1] « Encounter | EpisodeOfCare » Indicates when the plan did (or is intended to) come into effect and end period : Period 0..1 [0..1] Identifies the individual(s) or ogranization who is responsible for the content of the care plan author : Reference [0..*] « Patient | Practitioner | RelatedPerson | Organization » Identifies the most recent date on which the plan has been revised modified : dateTime 0..1 [0..1] Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", "wellness plan", etc category : CodeableConcept [0..*] « Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. (Strength=Example) Care Plan Category ?? » A description of the scope and nature of the plan description : string [0..1] Identifies the conditions/problems/concerns/diagnoses/etc. whose management and/or mitigation are handled by this plan concern addresses : Resource Reference ( [0..*] « Condition ) 0..* » Identifies portions of the patient's record that specifically influenced the formation of the plan. These might include co-morbidities, recent procedures, limitations, recent assessments, etc support : Reference [0..*] « Any » Describes the intended objective(s) of carrying out the care plan goal : Reference [0..*] « Goal » General notes about the care plan not covered elsewhere notes note : string Annotation 0..1 [0..1] RelatedPlan Identifies the type of relationship this plan has to the target plan code : code [0..1] « Codes identifying the types of relationships between two plans. (Strength=Required) CarePlanRelationship ! » A reference to the plan to which a relationship is asserted plan : Reference [1..1] « CarePlan » Participant Indicates specific responsibility of an individual within the care plan. E.g. plan; e.g. "Primary physician", "Team coordinator", "Caregiver", etc role : CodeableConcept 0..1 [0..1] « Indicates specific responsibility of an individual within the care plan; e.g. "Primary physician", "Team coordinator", "Caregiver", etc. (Strength=Example) Participant Roles ?? » The specific person or organization who is participating/expected to participate in the care plan member : Resource Reference ( [0..1] « Practitioner | RelatedPerson | Patient | Organization ) 1..1 » Goal Activity Human-readable description Resources that describe follow-on actions resulting from the plan, such as drug prescriptions, encounter records, appointments, etc actionResulting : Reference [0..*] « Any » Notes about the adherence/status/progress of the activity progress : Annotation [0..*] The details of the proposed activity represented in a specific desired objective resource reference : Reference [0..1] « Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticOrder | MedicationOrder | NutritionOrder | Order | ProcedureRequest | ProcessRequest | ReferralRequest | SupplyRequest | VisionPrescription » Detail High-level categorization of the type of activity in a care plan description category : string CodeableConcept 1..1 [0..1] « High-level categorization of the type of activity in a care plan. (Strength=Example) CarePlanActivityCategory ?? » Indicates whether Detailed description of the goal has been reached and is still considered relevant type of planned activity; e.g. What lab test, what procedure, what kind of encounter status code : code CodeableConcept 0..1 << [0..1] « Indicates whether Detailed description of the goal has been met and is still being targeted type of activity; e.g. What lab test, what procedure, what kind of encounter. (Strength=Example) CarePlanGoalStatus Care Plan Activity >> ?? » Any comments related to Provides the goal rationale that drove the inclusion of this particular activity as part of the plan notes reasonCode : string CodeableConcept 0..1 [0..*] « Identifies why a care plan activity is needed. Can include any health condition codes as well as such concepts as "general wellness", prophylaxis, surgical preparation, etc. (Strength=Example) Activity Reason ?? » The identified conditions Provides the health condition(s) that drove the inclusion of this goal relates to - particular activity as part of the condition that caused it to be created, or that it is intended to address plan concern reasonReference : Resource Reference ( [0..*] « Condition ) 0..* Activity » Internal reference that identifies the goals that this activity is intended to contribute towards meeting goal : idref Reference 0..* [0..*] « Goal » Identifies what progress is being made for the specific activity (this element modifies the meaning of other elements) status : code 0..1 << [0..1] « Indicates where the activity is at in its overall life cycle cycle. (Strength=Required) CarePlanActivityStatus ! » Provides reason why the activity isn't yet started, is on hold, was cancelled, etc statusReason >> : CodeableConcept [0..1] « Describes why the current activity has the status it does; e.g. "Recovering from injury" as a reason for non-started or on-hold, "Patient does not enjoy activity" as a reason for cancelling a planned activity. (Strength=Example) GoalStatusReason ?? » If true, indicates that the described activity is one that must NOT be engaged in when following the plan (this element modifies the meaning of other elements) prohibited : boolean [1..1] The period, timing or frequency upon which the described activity is to occur scheduled[x] : Type [0..1] « Timing | Period | string » Identifies the facility where the activity will occur; e.g. home, hospital, specific clinic, etc location : Reference [0..1] « Location » Identifies who's expected to be involved in the activity performer : Reference [0..*] « Practitioner | Organization | RelatedPerson | Patient » Identifies the food, drug or other product to be consumed or supplied in the activity product[x] : Type [0..1] « CodeableConcept | Reference ( Medication | Substance ); A product supplied or administered as part of a care plan activity. (Strength=Example) SNOMED CT Medication ?? » Identifies the quantity expected to be consumed in a given day dailyAmount : Quantity ( SimpleQuantity ) [0..1] Identifies the quantity expected to be supplied, administered or consumed by the subject quantity : Quantity ( SimpleQuantity ) [0..1] This provides a textual description of constraints on the intended activity occurrence, including relation to other activities. It may also include objectives, pre-conditions and end-conditions. Finally, it may convey specifics about the activity such as body site, method, route, etc description : string [0..1] Identifies CarePlans with some sort of formal relationship to the current plan relatedPlan [0..*] Identifies all people and organizations who are expected to be involved in the care envisioned by this plan participant [0..*] A simple summary of a planned activity suitable for a general care plan system (e.g. form driven) that doesn't know about specific resources such as procedure etc detail [0..1] Identifies a planned action to occur as part of the plan. For example, a medication to be used, lab tests to perform, self-monitoring, education, etc activity [0..*]

XML Template 


<CarePlan xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier External Ids for this plan --></identifier>
 <subject><!-- 0..1 Reference(Patient|Group) Who care plan is for --></subject>
 <status value="[code]"/><!-- 1..1 proposed | draft | active | completed | cancelled -->
 <context><!-- 0..1 Reference(Encounter|EpisodeOfCare) Created in context of --></context>
 <period><!-- 0..1 Period Time period plan covers --></period>
 <author><!-- 0..* Reference(Patient|Practitioner|RelatedPerson|Organization) Who is responsible for contents of the plan --></author>
 <modified value="[dateTime]"/><!-- 0..1 When last updated -->
 <category><!-- 0..* CodeableConcept Type of plan --></category>
 <description value="[string]"/><!-- 0..1 Summary of nature of plan -->
 <addresses><!-- 0..* Reference(Condition) Health issues this plan addresses --></addresses>
 <support><!-- 0..* Reference(Any) Information considered as part of plan --></support>
 <relatedPlan>  <!-- 0..* Plans related to this one -->
  <code value="[code]"/><!-- 0..1 includes | replaces | fulfills -->
  <plan><!-- 1..1 Reference(CarePlan) Plan relationship exists with --></plan>
 </relatedPlan>
 <participant>  <!-- 0..* Who's involved in plan? -->
  <role><!-- 0..1 CodeableConcept Type of involvement --></role>
  <member><!-- 0..1 Reference(Practitioner|RelatedPerson|Patient|Organization) Who is involved --></member>
 </participant>
 <goal><!-- 0..* Reference(Goal) Desired outcome of plan --></goal>
 <activity>  <!-- 0..* Action to occur as part of plan -->
  <actionResulting><!-- 0..* Reference(Any) Appointments, orders, etc. --></actionResulting>
  <progress><!-- 0..* Annotation Comments about the activity status/progress --></progress>
  <reference><!-- ?? 0..1 Reference(Appointment|CommunicationRequest|
    DeviceUseRequest|DiagnosticOrder|MedicationOrder|NutritionOrder|Order|
    ProcedureRequest|ProcessRequest|ReferralRequest|SupplyRequest|
    VisionPrescription) Activity details defined in specific resource --></reference>

  <detail>  <!-- ?? 0..1 In-line definition of activity -->
   <category><!-- 0..1 CodeableConcept diet | drug | encounter | observation | procedure | supply | other --></category>
   <code><!-- 0..1 CodeableConcept Detail type of activity --></code>
   <reasonCode><!-- 0..* CodeableConcept Why activity should be done --></reasonCode>
   <reasonReference><!-- 0..* Reference(Condition) Condition triggering need for activity --></reasonReference>
   <goal><!-- 0..* Reference(Goal) Goals this activity relates to --></goal>
   <status value="[code]"/><!-- 0..1 not-started | scheduled | in-progress | on-hold | completed | cancelled -->
   <statusReason><!-- 0..1 CodeableConcept Reason for current status --></statusReason>
   <prohibited value="[boolean]"/><!-- 1..1 Do NOT do -->
   <scheduled[x]><!-- 0..1 Timing|Period|string When activity is to occur --></scheduled[x]>
   <location><!-- 0..1 Reference(Location) Where it should happen --></location>
   <performer><!-- 0..* Reference(Practitioner|Organization|RelatedPerson|Patient) Who will be responsible? --></performer>
   <product[x]><!-- 0..1 CodeableConcept|Reference(Medication|Substance) What is to be administered/supplied --></product[x]>
   <dailyAmount><!-- 0..1 Quantity(SimpleQuantity) How to consume/day? --></dailyAmount>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) How much to administer/supply/consume --></quantity>
   <description value="[string]"/><!-- 0..1 Extra info describing activity to perform -->
  </detail>
 </activity>
 <note><!-- 0..1 Annotation Comments about the plan --></note>
</CarePlan>

JSON Template 


{doco
  "resourceType" : "CarePlan",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // External Ids for this plan
  "subject" : { Reference(Patient|Group) }, // Who care plan is for
  "status" : "<code>", // R!  proposed | draft | active | completed | cancelled
  "context" : { Reference(Encounter|EpisodeOfCare) }, // Created in context of
  "period" : { Period }, // Time period plan covers
  "author" : [{ Reference(Patient|Practitioner|RelatedPerson|Organization) }], // Who is responsible for contents of the plan
  "modified" : "<dateTime>", // When last updated
  "category" : [{ CodeableConcept }], // Type of plan
  "description" : "<string>", // Summary of nature of plan
  "addresses" : [{ Reference(Condition) }], // Health issues this plan addresses
  "support" : [{ Reference(Any) }], // Information considered as part of plan
  "relatedPlan" : [{ // Plans related to this one
    "code" : "<code>", // includes | replaces | fulfills
    "plan" : { Reference(CarePlan) } // R!  Plan relationship exists with
  }],
  "participant" : [{ // Who's involved in plan?
    "role" : { CodeableConcept }, // Type of involvement
    "member" : { Reference(Practitioner|RelatedPerson|Patient|Organization) } // Who is involved
  }],
  "goal" : [{ Reference(Goal) }], // Desired outcome of plan
  "activity" : [{ // Action to occur as part of plan
    "actionResulting" : [{ Reference(Any) }], // Appointments, orders, etc.
    "progress" : [{ Annotation }], // Comments about the activity status/progress
    "reference" : { Reference(Appointment|CommunicationRequest|
    DeviceUseRequest|DiagnosticOrder|MedicationOrder|NutritionOrder|Order|
    ProcedureRequest|ProcessRequest|ReferralRequest|SupplyRequest|
    VisionPrescription) }, // C? Activity details defined in specific resource

    "detail" : { // C? In-line definition of activity
      "category" : { CodeableConcept }, // diet | drug | encounter | observation | procedure | supply | other
      "code" : { CodeableConcept }, // Detail type of activity
      "reasonCode" : [{ CodeableConcept }], // Why activity should be done
      "reasonReference" : [{ Reference(Condition) }], // Condition triggering need for activity
      "goal" : [{ Reference(Goal) }], // Goals this activity relates to
      "status" : "<code>", // not-started | scheduled | in-progress | on-hold | completed | cancelled
      "statusReason" : { CodeableConcept }, // Reason for current status
      "prohibited" : <boolean>, // R!  Do NOT do
      // scheduled[x]: When activity is to occur. One of these 3:

      "scheduledTiming" : { Timing },
      "scheduledPeriod" : { Period },
      "scheduledString" : "<string>",
      "location" : { Reference(Location) }, // Where it should happen
      "performer" : [{ Reference(Practitioner|Organization|RelatedPerson|Patient) }], // Who will be responsible?
      // product[x]: What is to be administered/supplied. One of these 2:

      "productCodeableConcept" : { CodeableConcept },
      "productReference" : { Reference(Medication|Substance) },
      "dailyAmount" : { Quantity(SimpleQuantity) }, // How to consume/day?
      "quantity" : { Quantity(SimpleQuantity) }, // How much to administer/supply/consume
      "description" : "<string>" // Extra info describing activity to perform
    }
  }],
  "note" : { Annotation } // Comments about the plan
}

Structure

Name Flags Card. Type Description & Constraints doco
.. CarePlan DomainResource Healthcare plan for patient or group
... identifier Σ 0..* Identifier External Ids for this plan
... subject Σ 0..1 Reference ( Patient | Group ) Who care plan is for
... status ?! Σ 1..1 code proposed | draft | active | completed | cancelled
CarePlanStatus ( Required )
... context Σ 0..1 Reference ( Encounter | EpisodeOfCare ) Created in context of
... period Σ 0..1 Period Time period plan covers
... author Σ 0..* Reference ( Patient | Practitioner | RelatedPerson | Organization ) Who is responsible for contents of the plan
... modified Σ 0..1 dateTime When last updated
... category Σ 0..* CodeableConcept Type of plan
Care Plan Category ( Example )
... description Σ 0..1 string Summary of nature of plan
... addresses Σ 0..* Reference ( Condition ) Health issues this plan addresses
... support 0..* Reference ( Any ) Information considered as part of plan
... relatedPlan 0..* BackboneElement Plans related to this one
.... code 0..1 code includes | replaces | fulfills
CarePlanRelationship ( Required )
.... plan 1..1 Reference ( CarePlan ) Plan relationship exists with
... participant 0..* BackboneElement Who's involved in plan?
.... role 0..1 CodeableConcept Type of involvement
Participant Roles ( Example )
.... member 0..1 Reference ( Practitioner | RelatedPerson | Patient | Organization ) Who is involved
... goal 0..* Reference ( Goal ) Desired outcome of plan
... activity I 0..* BackboneElement Action to occur as part of plan
Provide a reference or detail, not both
.... actionResulting 0..* Reference ( Any ) Appointments, orders, etc.
.... progress 0..* Annotation Comments about the activity status/progress
.... reference I 0..1 Reference ( Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticOrder | MedicationOrder | NutritionOrder | Order | ProcedureRequest | ProcessRequest | ReferralRequest | SupplyRequest | VisionPrescription ) Activity details defined in specific resource
.... detail I 0..1 BackboneElement In-line definition of activity
..... category 0..1 CodeableConcept diet | drug | encounter | observation | procedure | supply | other
CarePlanActivityCategory ( Example )
..... code 0..1 CodeableConcept Detail type of activity
Care Plan Activity ( Example )
..... reasonCode 0..* CodeableConcept Why activity should be done
Activity Reason ( Example )
..... reasonReference 0..* Reference ( Condition ) Condition triggering need for activity
..... goal 0..* Reference ( Goal ) Goals this activity relates to
..... status ?! 0..1 code not-started | scheduled | in-progress | on-hold | completed | cancelled
CarePlanActivityStatus ( Required )
..... statusReason 0..1 CodeableConcept Reason for current status
GoalStatusReason ( Example )
..... prohibited ?! 1..1 boolean Do NOT do
..... scheduled[x] 0..1 When activity is to occur
...... scheduledTiming Timing
...... scheduledPeriod Period
...... scheduledString string
..... location 0..1 Reference ( Location ) Where it should happen
..... performer 0..* Reference ( Practitioner | Organization | RelatedPerson | Patient ) Who will be responsible?
..... product[x] 0..1 What is to be administered/supplied
SNOMED CT Medication Codes ( Example )
...... productCodeableConcept CodeableConcept
...... productReference Reference ( Medication | Substance )
..... dailyAmount 0..1 SimpleQuantity How to consume/day?
..... quantity 0..1 SimpleQuantity How much to administer/supply/consume
..... description 0..1 string Extra info describing activity to perform
... note 0..1 Annotation Comments about the plan

doco Documentation for this format

UML Diagram

CarePlan ( DomainResource ) This records identifiers associated with this care plan that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation) identifier : Identifier [0..*] Identifies the patient or group whose intended care is described by the plan subject : Reference [0..1] « Patient | Group » Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record (this element modifies the meaning of other elements) status : code [1..1] « Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record. (Strength=Required) CarePlanStatus ! » Identifies the context in which this particular CarePlan is defined context : Reference [0..1] « Encounter | EpisodeOfCare » Indicates when the plan did (or is intended to) come into effect and end period : Period [0..1] Identifies the individual(s) or ogranization who is responsible for the content of the care plan author : Reference [0..*] « Patient | Practitioner | RelatedPerson | Organization » Identifies the most recent date on which the plan has been revised modified : dateTime [0..1] Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", "wellness plan", etc category : CodeableConcept [0..*] « Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. (Strength=Example) Care Plan Category ?? » A description of the scope and nature of the plan description : string [0..1] Identifies the conditions/problems/concerns/diagnoses/etc. whose management and/or mitigation are handled by this plan addresses : Reference [0..*] « Condition » Identifies portions of the patient's record that specifically influenced the formation of the plan. These might include co-morbidities, recent procedures, limitations, recent assessments, etc support : Reference [0..*] « Any » Describes the intended objective(s) of carrying out the care plan goal : Reference [0..*] « Goal » General notes about the care plan not covered elsewhere note : Annotation [0..1] RelatedPlan Identifies the type of relationship this plan has to the target plan code : code [0..1] « Codes identifying the types of relationships between two plans. (Strength=Required) CarePlanRelationship ! » A reference to the plan to which a relationship is asserted plan : Reference [1..1] « CarePlan » Participant Indicates specific responsibility of an individual within the care plan; e.g. "Primary physician", "Team coordinator", "Caregiver", etc role : CodeableConcept [0..1] « Indicates specific responsibility of an individual within the care plan; e.g. "Primary physician", "Team coordinator", "Caregiver", etc. (Strength=Example) Participant Roles ?? » The specific person or organization who is participating/expected to participate in the care plan member : Reference [0..1] « Practitioner | RelatedPerson | Patient | Organization » Activity Resources that describe follow-on actions resulting from the plan, such as drug prescriptions, encounter records, appointments, etc actionResulting : Resource Reference ( [0..*] « Any ) 0..* » Notes about the execution adherence/status/progress of the activity notes progress : string Annotation 0..1 [0..*] The details of the proposed activity represented in a specific resource detail reference : Resource Reference ( Procedure [0..1] « Appointment | CommunicationRequest | MedicationPrescription DeviceUseRequest | DiagnosticOrder | MedicationOrder | Encounter NutritionOrder ) 0..1 | Order | ProcedureRequest | ProcessRequest | ReferralRequest | SupplyRequest | VisionPrescription » Simple Detail High-level categorization of the type of activity in a care plan category : code CodeableConcept 1..1 << [0..1] « High-level categorization of the type of activity in a care plan. (Strength=Example) CarePlanActivityCategory >> ?? » Detailed description of the type of activity. E.g. planned activity; e.g. What lab test, what procedure, what kind of encounter code : CodeableConcept 0..1 [0..1] « Detailed description of the type of activity; e.g. What lab test, what procedure, what kind of encounter. (Strength=Example) Care Plan Activity ?? » Provides the rationale that drove the inclusion of this particular activity as part of the plan reasonCode : CodeableConcept [0..*] « Identifies why a care plan activity is needed. Can include any health condition codes as well as such concepts as "general wellness", prophylaxis, surgical preparation, etc. (Strength=Example) Activity Reason ?? » Provides the health condition(s) that drove the inclusion of this particular activity as part of the plan reasonReference : Reference [0..*] « Condition » Internal reference that identifies the goals that this activity is intended to contribute towards meeting goal : Reference [0..*] « Goal » Identifies what progress is being made for the specific activity (this element modifies the meaning of other elements) status : code [0..1] « Indicates where the activity is at in its overall life cycle. (Strength=Required) CarePlanActivityStatus ! » Provides reason why the activity isn't yet started, is on hold, was cancelled, etc statusReason : CodeableConcept [0..1] « Describes why the current activity has the status it does; e.g. "Recovering from injury" as a reason for non-started or on-hold, "Patient does not enjoy activity" as a reason for cancelling a planned activity. (Strength=Example) GoalStatusReason ?? » If true, indicates that the described activity is one that must NOT be engaged in when following the plan (this element modifies the meaning of other elements) prohibited : boolean [1..1] The period, timing or frequency upon which the described activity is to occur timing[x] scheduled[x] : Schedule Type [0..1] « Timing | Period | string 0..1 » Identifies the facility where the activity will occur. E.g. occur; e.g. home, hospital, specific clinic, etc location : Resource Reference ( [0..1] « Location ) 0..1 » Identifies who's expected to be involved in the activity performer : Resource Reference ( [0..*] « Practitioner | Organization | RelatedPerson | Patient ) 0..* » Identifies the food, drug or other product being to be consumed or supplied in the activity product product[x] : Resource Type [0..1] « CodeableConcept | Reference ( Medication | Substance ) 0..1 ); A product supplied or administered as part of a care plan activity. (Strength=Example) SNOMED CT Medication ?? » Identifies the quantity expected to be consumed in a given day dailyAmount : Quantity 0..1 ( SimpleQuantity ) [0..1] Identifies the quantity expected to be supplied supplied, administered or consumed by the subject quantity : Quantity 0..1 ( SimpleQuantity ) [0..1] This provides a textual description of constraints on the intended activity occurrence, including relation to other activities. It may also include objectives, pre-conditions and end-conditions. Finally, it may convey specifics about the activity such as body site, method, route, etc details description : string 0..1 [0..1] Identifies CarePlans with some sort of formal relationship to the current plan relatedPlan [0..*] Identifies all people and organizations who are expected to be involved in the care envisioned by this plan participant 0..* Describes the intended objective(s) of carrying out the Care Plan goal 0..* [0..*] A simple summary of details a planned activity suitable for a general care plan system (e.g. form driven) that doesn't know about specific resources such as procedure etc simple detail 0..1 [0..1] Identifies a planned action to occur as part of the plan. For example, a medication to be used, lab tests to perform, self-monitoring, education, etc activity 0..* [0..*] This resource is referenced by [Procedure]

XML Template

< <!-- from --> <</identifier> <</patient> < <</period> < <</concern> 
<CarePlan xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier External Ids for this plan --></identifier>
 <subject><!-- 0..1 Reference(Patient|Group) Who care plan is for --></subject>
 <status value="[code]"/><!-- 1..1 proposed | draft | active | completed | cancelled -->
 <context><!-- 0..1 Reference(Encounter|EpisodeOfCare) Created in context of --></context>
 <period><!-- 0..1 Period Time period plan covers --></period>
 <author><!-- 0..* Reference(Patient|Practitioner|RelatedPerson|Organization) Who is responsible for contents of the plan --></author>
 <modified value="[dateTime]"/><!-- 0..1 When last updated -->
 <category><!-- 0..* CodeableConcept Type of plan --></category>
 <description value="[string]"/><!-- 0..1 Summary of nature of plan -->
 <addresses><!-- 0..* Reference(Condition) Health issues this plan addresses --></addresses>
 <support><!-- 0..* Reference(Any) Information considered as part of plan --></support>
 <relatedPlan>  <!-- 0..* Plans related to this one -->
  <code value="[code]"/><!-- 0..1 includes | replaces | fulfills -->
  <plan><!-- 1..1 Reference(CarePlan) Plan relationship exists with --></plan>
 </relatedPlan>

 <participant>  <!-- 0..* Who's involved in plan? -->
  <</role>
  <</member>

  <role><!-- 0..1 CodeableConcept Type of involvement --></role>
  <member><!-- 0..1 Reference(Practitioner|RelatedPerson|Patient|Organization) Who is involved --></member>

 </participant>
 <
  <
  <
  <
  <</concern>
 </goal>

 <goal><!-- 0..* Reference(Goal) Desired outcome of plan --></goal>

 <activity>  <!-- 0..* Action to occur as part of plan -->
  <
  <
  <
  <</actionResulting>
  <
  <|
    </detail>
  <
   <
   <</code>
   <</timing[x]>
   <</location>
   <
       Who's responsible?</performer>
   <</product>
   <</dailyAmount>
   <</quantity>
   <
  </simple>

  <actionResulting><!-- 0..* Reference(Any) Appointments, orders, etc. --></actionResulting>
  <progress><!-- 0..* Annotation Comments about the activity status/progress --></progress>
  <reference><!-- ?? 0..1 Reference(Appointment|CommunicationRequest|
    DeviceUseRequest|DiagnosticOrder|MedicationOrder|NutritionOrder|Order|
    ProcedureRequest|ProcessRequest|ReferralRequest|SupplyRequest|
    VisionPrescription) Activity details defined in specific resource --></reference>

  <detail>  <!-- ?? 0..1 In-line definition of activity -->
   <category><!-- 0..1 CodeableConcept diet | drug | encounter | observation | procedure | supply | other --></category>
   <code><!-- 0..1 CodeableConcept Detail type of activity --></code>
   <reasonCode><!-- 0..* CodeableConcept Why activity should be done --></reasonCode>
   <reasonReference><!-- 0..* Reference(Condition) Condition triggering need for activity --></reasonReference>
   <goal><!-- 0..* Reference(Goal) Goals this activity relates to --></goal>
   <status value="[code]"/><!-- 0..1 not-started | scheduled | in-progress | on-hold | completed | cancelled -->
   <statusReason><!-- 0..1 CodeableConcept Reason for current status --></statusReason>
   <prohibited value="[boolean]"/><!-- 1..1 Do NOT do -->
   <scheduled[x]><!-- 0..1 Timing|Period|string When activity is to occur --></scheduled[x]>
   <location><!-- 0..1 Reference(Location) Where it should happen --></location>
   <performer><!-- 0..* Reference(Practitioner|Organization|RelatedPerson|Patient) Who will be responsible? --></performer>
   <product[x]><!-- 0..1 CodeableConcept|Reference(Medication|Substance) What is to be administered/supplied --></product[x]>
   <dailyAmount><!-- 0..1 Quantity(SimpleQuantity) How to consume/day? --></dailyAmount>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) How much to administer/supply/consume --></quantity>
   <description value="[string]"/><!-- 0..1 Extra info describing activity to perform -->
  </detail>

 </activity>
 <

 <note><!-- 0..1 Annotation Comments about the plan --></note>

</CarePlan>

JSON Template 


{doco
  "resourceType" : "CarePlan",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // External Ids for this plan
  "subject" : { Reference(Patient|Group) }, // Who care plan is for
  "status" : "<code>", // R!  proposed | draft | active | completed | cancelled
  "context" : { Reference(Encounter|EpisodeOfCare) }, // Created in context of
  "period" : { Period }, // Time period plan covers
  "author" : [{ Reference(Patient|Practitioner|RelatedPerson|Organization) }], // Who is responsible for contents of the plan
  "modified" : "<dateTime>", // When last updated
  "category" : [{ CodeableConcept }], // Type of plan
  "description" : "<string>", // Summary of nature of plan
  "addresses" : [{ Reference(Condition) }], // Health issues this plan addresses
  "support" : [{ Reference(Any) }], // Information considered as part of plan
  "relatedPlan" : [{ // Plans related to this one
    "code" : "<code>", // includes | replaces | fulfills
    "plan" : { Reference(CarePlan) } // R!  Plan relationship exists with
  }],
  "participant" : [{ // Who's involved in plan?
    "role" : { CodeableConcept }, // Type of involvement
    "member" : { Reference(Practitioner|RelatedPerson|Patient|Organization) } // Who is involved
  }],
  "goal" : [{ Reference(Goal) }], // Desired outcome of plan
  "activity" : [{ // Action to occur as part of plan
    "actionResulting" : [{ Reference(Any) }], // Appointments, orders, etc.
    "progress" : [{ Annotation }], // Comments about the activity status/progress
    "reference" : { Reference(Appointment|CommunicationRequest|
    DeviceUseRequest|DiagnosticOrder|MedicationOrder|NutritionOrder|Order|
    ProcedureRequest|ProcessRequest|ReferralRequest|SupplyRequest|
    VisionPrescription) }, // C? Activity details defined in specific resource

    "detail" : { // C? In-line definition of activity
      "category" : { CodeableConcept }, // diet | drug | encounter | observation | procedure | supply | other
      "code" : { CodeableConcept }, // Detail type of activity
      "reasonCode" : [{ CodeableConcept }], // Why activity should be done
      "reasonReference" : [{ Reference(Condition) }], // Condition triggering need for activity
      "goal" : [{ Reference(Goal) }], // Goals this activity relates to
      "status" : "<code>", // not-started | scheduled | in-progress | on-hold | completed | cancelled
      "statusReason" : { CodeableConcept }, // Reason for current status
      "prohibited" : <boolean>, // R!  Do NOT do
      // scheduled[x]: When activity is to occur. One of these 3:

      "scheduledTiming" : { Timing },
      "scheduledPeriod" : { Period },
      "scheduledString" : "<string>",
      "location" : { Reference(Location) }, // Where it should happen
      "performer" : [{ Reference(Practitioner|Organization|RelatedPerson|Patient) }], // Who will be responsible?
      // product[x]: What is to be administered/supplied. One of these 2:

      "productCodeableConcept" : { CodeableConcept },
      "productReference" : { Reference(Medication|Substance) },
      "dailyAmount" : { Quantity(SimpleQuantity) }, // How to consume/day?
      "quantity" : { Quantity(SimpleQuantity) }, // How much to administer/supply/consume
      "description" : "<string>" // Extra info describing activity to perform
    }
  }],
  "note" : { Annotation } // Comments about the plan
}

 

Alternate definitions: Schema / Schematron , Resource Profile ( XML , JSON ), Questionnaire

4.3.2.1 4.4.3.1 Terminology Bindings

CarePlan.goal.status CarePlan.activity.simple.category CarePlan.activity.simple.code
Path Definition Type Reference
CarePlan.status Indicates whether the plan is currently being acted upon, represents future intentions or is now just a historical record. Fixed Required http://hl7.org/fhir/care-plan-status CarePlanStatus
CarePlan.category Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. Example Care Plan Category
CarePlan.relatedPlan.code Codes identifying the types of relationships between two plans. Required CarePlanRelationship
CarePlan.participant.role Indicates specific responsibility of an individual within the care plan. E.g. plan; e.g. "Primary physician", "Team coordinator", "Caregiver", etc. Unknown Example No details provided yet Participant Roles
CarePlan.activity.detail.category Indicates whether High-level categorization of the goal has been met and is still being targeted type of activity in a care plan. Fixed Example http://hl7.org/fhir/care-plan-goal-status CarePlanActivityCategory
CarePlan.activity.detail.code Detailed description of the type of activity; e.g. What lab test, what procedure, what kind of encounter. Example Care Plan Activity
CarePlan.activity.detail.reasonCode Identifies why a care plan activity is needed. Can include any health condition codes as well as such concepts as "general wellness", prophylaxis, surgical preparation, etc. Example Activity Reason
CarePlan.activity.status CarePlan.activity.detail.status Indicates where the activity is at in its overall life cycle cycle. Fixed Required http://hl7.org/fhir/care-plan-activity-status CarePlanActivityStatus
CarePlan.activity.detail.statusReason High-level categorization of Describes why the type of current activity in has the status it does; e.g. "Recovering from injury" as a care plan. reason for non-started or on-hold, "Patient does not enjoy activity" as a reason for cancelling a planned activity. Fixed Example http://hl7.org/fhir/care-plan-activity-category GoalStatusReason
CarePlan.activity.detail.product[x] Detailed description of the type A product supplied or administered as part of a care plan activity. E.g. What lab test, what procedure, what kind of encounter. Unknown Example No details provided yet SNOMED CT Medication Codes

4.3.2.2 4.4.3.2 Constraints Inv-1 : On CarePlan.activity.simple: DailyDose can only be specified if activity category is drug or food (xpath on f:CarePlan/f:activity/f:simple: (f:category/@value=('drug','diet')) = exists(f:dailyAmount) )

Inv-2 : On CarePlan.activity.simple: Quantity can only be specified if activity category is supply (xpath on f:CarePlan/f:activity/f:simple: (f:category/@value=('supply')) = exists(f:quantity) )
  • Inv-3 cpl-3 : On CarePlan.activity.simple: Only provide CarePlan.activity: Provide a detail reference, reference or a simple detail summary detail, not both (xpath on f:CarePlan/f:activity/f:simple: f:CarePlan/f:activity: not(exists(f:detail)) or not(exists(f:simple)) not(exists(f:reference)) )

4.3.3 4.4.4 Open Issues

DSTU Note: During the Trial use period, feedback is welcome on two issues:

  • This resource combines the concepts of "Care Plan" and "Care Team" into a single resource. Is this appropriate?
  • DSTU: At present, the patient element is optional to allow experimentation with care plan templates, though the resource was not designed for this use. Feedback on this subject is requested during the trial use period.

Feedback here .

4.3.4 4.4.5 Search Parameters

Search parameters for this resource. The standard common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Paths
_id token The logical resource id associated with the resource (must be supported by all servers) _language token The language of the resource activitycode token Detail type of activity CarePlan.activity.simple.code CarePlan.activity.detail.code
activitydate date Specified date occurs within period specified by CarePlan.activity.timingSchedule CarePlan.activity.simple.timing[x] CarePlan.activity.detail.scheduled[x]
activitydetail activityreference reference Activity details defined in specific resource CarePlan.activity.detail CarePlan.activity.reference
( MedicationPrescription ReferralRequest , Encounter ProcedureRequest , Procedure Appointment , CommunicationRequest , Order , SupplyRequest , VisionPrescription , MedicationOrder , ProcessRequest , DeviceUseRequest , NutritionOrder , DiagnosticOrder )
condition reference Health issues this plan addresses CarePlan.concern CarePlan.addresses
( Condition )
date date Time period plan covers CarePlan.period
goal reference Desired outcome of plan CarePlan.goal
( Goal )
participant reference Who is involved CarePlan.participant.member
( Organization , Patient , Practitioner , RelatedPerson )
patient reference Who care plan is for CarePlan.patient CarePlan.subject
( Patient )
performer reference Matches if the practitioner is listed as a performer in any of the "simple" activities. (For performers of the detailed activities, chain through the activitydetail search parameter.) CarePlan.activity.detail.performer
( Patient , Organization , Practitioner , RelatedPerson )
related composite A combination of the type of relationship and the related plan
relatedcode token includes | replaces | fulfills CarePlan.relatedPlan.code
relatedplan reference Plan relationship exists with CarePlan.relatedPlan.plan
( CarePlan )
subject reference Who care plan is for CarePlan.subject
( Patient , Group )
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