DSTU2 FHIR Release 3 (STU)

This page is part of the FHIR Specification (v1.0.2: DSTU (v3.0.2: STU 2). 3). 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 R3 R2

4.4 9.5 Resource CarePlan - Content

Patient Care Work Group Maturity Level : 1 2   Trial Use Compartments : Patient , Practitioner , RelatedPerson

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

4.4.1 9.5.1 Scope and Usage

CarePlan is one of the request resources in the FHIR workflow specification.

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 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 mechanism.

The scope of care plans may vary widely. Examples include:

  • Multi-disciplinary cross-organizational care plans; e.g. An oncology plan including the 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 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 a particular patient or group. It is not 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.

4.4.2 9.5.2 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.

CarePlans represent a specific plan instance for a particular patient or group. It is not intended to be used to define generic plans or protocols that are independent of a specific individual or group. CarePlan represents a specific intent, not a general definition. Protocols and order sets are supported through PlanDefinition .

This resource is referenced by ClinicalImpression and DiagnosticReport , GuidanceResponse , ImagingStudy , MedicationRequest , MedicationStatement , Observation , Procedure , QuestionnaireResponse and ReferralRequest

4.4.3 9.5.3 Resource Content

Structure

0..1 Who care plan is for ?! 1..1 proposed | draft | active | completed | cancelled 0..1 Created in context of 0..1 Time period plan covers 0..* Who is responsible for contents of the plan 0..1 When last updated Summary of nature of plan 0..* Health issues this Information considered as part of BackboneElement Plans related to this one includes | replaces | fulfills CarePlanRelationship ( Required ) Plan relationship exists with 0..1 Type of involvement Who is involved Appointments, orders, 0..1 1..1
Name Flags Card. Type Description & Constraints doco
. . CarePlan DomainResource Healthcare plan for patient or group
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier Σ 0..* Identifier External Ids for this plan
. . subject . definition Σ 0..* Reference ( Patient PlanDefinition | Group Questionnaire ) Protocol or definition
. . status . basedOn Σ 0..* code Reference ( CarePlan ) Fulfills care plan
CarePlanStatus ( Required )
. . context . replaces Σ 0..* Reference ( Encounter | EpisodeOfCare CarePlan ) CarePlan replaced by this CarePlan
. . period . partOf Σ 0..* Period Reference ( CarePlan ) Part of referenced CarePlan
. . author . status ?! Σ 1..1 Reference ( Patient code draft | Practitioner active | RelatedPerson suspended | Organization completed | entered-in-error | cancelled | unknown
CarePlanStatus ( Required )
. . modified . intent ?! Σ 1..1 dateTime code proposal | plan | order | option
CarePlanIntent ( Required )
. . . category Σ 0..* CodeableConcept Type of plan
Care Plan Category ( Example )
. . description . title Σ 0..1 string Human-friendly name for the CarePlan
. . addresses . description Σ 0..1 Reference ( Condition string ) Summary of nature of plan addresses
. . support . subject Σ 0..* 1..1 Reference ( Any Patient | Group ) Who care plan is for
. . relatedPlan . context Σ 0..* 0..1 Reference ( Encounter | EpisodeOfCare ) Created in context of
. . code . period Σ 0..1 code Period Time period plan covers
. . plan . author Σ 1..1 0..* Reference ( CarePlan Patient | Practitioner | RelatedPerson | Organization | CareTeam ) Who is responsible for contents of the plan
. . participant . careTeam 0..* BackboneElement Reference ( CareTeam ) Who's involved in plan?
. . role . addresses Σ CodeableConcept 0..* Participant Roles Reference ( Example Condition ) Health issues this plan addresses
. member . . supportingInfo 0..1 0..* Reference ( Practitioner | RelatedPerson | Patient | Organization Any ) Information considered as part of plan
. . . 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 . outcomeCodeableConcept 0..* CodeableConcept Results of the activity
Care Plan Activity Outcome ( Example )
.... outcomeReference 0..* Reference ( Any ) Appointment, Encounter, Procedure, etc.
. . . . progress 0..* Annotation Comments about the activity status/progress
. . . . reference I 0..1 Reference ( Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticOrder DeviceRequest | MedicationOrder MedicationRequest | NutritionOrder | Order Task | ProcedureRequest | ProcessRequest | ReferralRequest | SupplyRequest | VisionPrescription | RequestGroup ) 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 )
. . . . . definition 0..1 Reference ( PlanDefinition | ActivityDefinition | Questionnaire ) Protocol or definition
..... code 0..1 CodeableConcept Detail type of activity
Care Plan Activity ( Example )
. . . . . reasonCode 0..* CodeableConcept Why activity should be done or why activity was prohibited
Activity Reason ( Example )
. . . . . reasonReference 0..* Reference ( Condition ) Condition triggering need for activity
. . . . . goal 0..* Reference ( Goal ) Goals this activity relates to
. . . . . status ?! 1..1 code not-started | scheduled | in-progress | on-hold | completed | cancelled | unknown
CarePlanActivityStatus ( Required )
. . . . . statusReason 0..1 CodeableConcept string Reason for current status GoalStatusReason ( Example )
. . . . . prohibited ?! 0..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 | CareTeam ) 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 0..* Annotation Comments about the plan

doco Documentation for this format

UML Diagram ( Legend )

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 protocol, questionnaire, guideline or group whose intended other specification the care plan should be conducted in accordance with definition : Reference [0..*] PlanDefinition | Questionnaire A care plan that is described fulfilled in whole or in part by the this care plan subject basedOn : Reference [0..1] « Patient [0..*] CarePlan | Group Completed or terminated care plan whose function is taken by this new care plan replaces : Reference [0..*] CarePlan » A larger care plan of which this particular care plan is a component or step partOf : Reference [0..*] CarePlan 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 ! » Indicates the level of authority/intentionality associated with the care plan and where the care plan fits into the workflow chain (this element modifies the meaning of other elements) intent : code [1..1] Codes indicating the degree of authority/intentionality associated with a care plan (Strength=Required) CarePlanIntent ! 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 ?? Human-friendly name for the CarePlan title : string [0..1] A description of the scope and nature of the plan description : string [0..1] Identifies the patient or group whose intended care is described by the plan subject : Reference [1..1] Patient | Group Identifies the original context in which this particular CarePlan is defined was created 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 | CareTeam [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 all people and nature of organizations who are expected to be involved in the care envisioned by this plan description careTeam : string Reference [0..*] CareTeam [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 supportingInfo : 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] [0..*] RelatedPlan Activity Identifies the type of relationship this plan has to outcome at the target plan code : code [0..1] « Codes identifying point when the types status of relationships between two plans. (Strength=Required) CarePlanRelationship ! » A reference to the plan to which a relationship activity is asserted plan : Reference [1..1] « CarePlan » Participant Indicates specific responsibility assessed. For example, the outcome of an individual within the care plan; e.g. "Primary physician", "Team coordinator", "Caregiver", etc education activity could be patient understands (or not) role outcomeCodeableConcept : CodeableConcept [0..1] « [0..*] Indicates specific responsibility Identifies the results of an individual within the care plan; e.g. "Primary physician", "Team coordinator", "Caregiver", etc. activity (Strength=Example) Participant Roles Care Plan Activity ?? » The specific person or organization who is participating/expected to participate in the care plan member : Reference [0..1] « Practitioner | RelatedPerson | Patient | Organization Outcome » Activity ?? Resources that describe follow-on actions Details of the outcome or action resulting from the plan, activity. The reference to an "event" resource, such as drug prescriptions, encounter records, appointments, etc Procedure or Encounter or Observation, is the result/outcome of the activity itself. The activity can be conveyed using CarePlan.activity.detail OR using the CarePlan.activity.reference (a reference to a request resource) actionResulting outcomeReference : 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 resource reference : Reference [0..1] « Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticOrder DeviceRequest | MedicationOrder MedicationRequest | NutritionOrder | Order Task | ProcedureRequest | ProcessRequest | ReferralRequest | SupplyRequest | VisionPrescription » | RequestGroup Detail High-level categorization of the type of activity in a care plan category : CodeableConcept [0..1] « High-level categorization of the type of activity in a care plan. (Strength=Example) CarePlanActivityCategory ?? » Identifies the protocol, questionnaire, guideline or other specification the planned activity should be conducted in accordance with definition : Reference [0..1] PlanDefinition | ActivityDefinition | Questionnaire Detailed description of the type of planned activity; e.g. What lab test, what procedure, what kind of encounter code : CodeableConcept [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 or the reason why the activity was prohibited 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] « [1..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 string [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. If false, indicates that the described activity is one that should be engaged in when following the plan (this element modifies the meaning of other elements) prohibited : boolean [1..1] [0..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 » | CareTeam 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>
 <</subject>
 <
 <</context>
 <</period>
 <</author>
 <
 <</category>
 <
 <</addresses>
 <</support>
 <
  <
  <</plan>
 </relatedPlan>
 <
  <</role>
  <</member>
 </participant>
 <</goal>
 <
  <</actionResulting>
  <</progress>
  <|
    |
    |
    </reference>
  <
   <</category>
   <</code>
   <</reasonCode>
   <</reasonReference>
   <</goal>
   <
   <</statusReason>
   <
   <</scheduled[x]>
   <</location>
   <</performer>
   <</product[x]>
   <</dailyAmount>
   <</quantity>
   <

 <identifier><!-- 0..* Identifier External Ids for this plan --></identifier>
 <definition><!-- 0..* Reference(PlanDefinition|Questionnaire) Protocol or definition --></definition>
 <basedOn><!-- 0..* Reference(CarePlan) Fulfills care plan --></basedOn>
 <replaces><!-- 0..* Reference(CarePlan) CarePlan replaced by this CarePlan --></replaces>
 <partOf><!-- 0..* Reference(CarePlan) Part of referenced CarePlan --></partOf>
 <status value="[code]"/><!-- 1..1 draft | active | suspended | completed | entered-in-error | cancelled | unknown -->
 <intent value="[code]"/><!-- 1..1 proposal | plan | order | option -->
 <category><!-- 0..* CodeableConcept Type of plan --></category>
 <title value="[string]"/><!-- 0..1 Human-friendly name for the CarePlan -->
 <description value="[string]"/><!-- 0..1 Summary of nature of plan -->
 <subject><!-- 1..1 Reference(Patient|Group) Who care plan is for --></subject>
 <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|
   CareTeam) Who is responsible for contents of the plan --></author>

 <careTeam><!-- 0..* Reference(CareTeam) Who's involved in plan? --></careTeam>
 <addresses><!-- 0..* Reference(Condition) Health issues this plan addresses --></addresses>
 <supportingInfo><!-- 0..* Reference(Any) Information considered as part of plan --></supportingInfo>
 <goal><!-- 0..* Reference(Goal) Desired outcome of plan --></goal>
 <activity>  <!-- 0..* Action to occur as part of plan -->
  <outcomeCodeableConcept><!-- 0..* CodeableConcept Results of the activity --></outcomeCodeableConcept>
  <outcomeReference><!-- 0..* Reference(Any) Appointment, Encounter, Procedure, etc. --></outcomeReference>
  <progress><!-- 0..* Annotation Comments about the activity status/progress --></progress>
  <reference><!-- ?? 0..1 Reference(Appointment|CommunicationRequest|DeviceRequest|
    MedicationRequest|NutritionOrder|Task|ProcedureRequest|ReferralRequest|
    VisionPrescription|RequestGroup) 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>
   <definition><!-- 0..1 Reference(PlanDefinition|ActivityDefinition|
     Questionnaire) Protocol or definition --></definition>

   <code><!-- 0..1 CodeableConcept Detail type of activity --></code>
   <reasonCode><!-- 0..* CodeableConcept Why activity should be done or why activity was prohibited --></reasonCode>
   <reasonReference><!-- 0..* Reference(Condition) Condition triggering need for activity --></reasonReference>
   <goal><!-- 0..* Reference(Goal) Goals this activity relates to --></goal>
   <status value="[code]"/><!-- 1..1 not-started | scheduled | in-progress | on-hold | completed | cancelled | unknown -->
   <statusReason value="[string]"/><!-- 0..1 Reason for current status -->
   <prohibited value="[boolean]"/><!-- 0..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|
     CareTeam) 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>

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

</CarePlan>

JSON Template 

{
  "resourceType" : "",

{doco
  "resourceType" : "CarePlan",

  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "
  "
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    "
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  }],
  "
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  }],
  "
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  "identifier" : [{ Identifier }], // External Ids for this plan
  "definition" : [{ Reference(PlanDefinition|Questionnaire) }], // Protocol or definition
  "basedOn" : [{ Reference(CarePlan) }], // Fulfills care plan
  "replaces" : [{ Reference(CarePlan) }], // CarePlan replaced by this CarePlan
  "partOf" : [{ Reference(CarePlan) }], // Part of referenced CarePlan
  "status" : "<code>", // R!  draft | active | suspended | completed | entered-in-error | cancelled | unknown
  "intent" : "<code>", // R!  proposal | plan | order | option
  "category" : [{ CodeableConcept }], // Type of plan
  "title" : "<string>", // Human-friendly name for the CarePlan
  "description" : "<string>", // Summary of nature of plan
  "subject" : { Reference(Patient|Group) }, // R!  Who care plan is for
  "context" : { Reference(Encounter|EpisodeOfCare) }, // Created in context of
  "period" : { Period }, // Time period plan covers
  "author" : [{ Reference(Patient|Practitioner|RelatedPerson|Organization|
   CareTeam) }], // Who is responsible for contents of the plan

  "careTeam" : [{ Reference(CareTeam) }], // Who's involved in plan?
  "addresses" : [{ Reference(Condition) }], // Health issues this plan addresses
  "supportingInfo" : [{ Reference(Any) }], // Information considered as part of plan
  "goal" : [{ Reference(Goal) }], // Desired outcome of plan
  "activity" : [{ // Action to occur as part of plan
    "outcomeCodeableConcept" : [{ CodeableConcept }], // Results of the activity
    "outcomeReference" : [{ Reference(Any) }], // Appointment, Encounter, Procedure, etc.
    "progress" : [{ Annotation }], // Comments about the activity status/progress
    "reference" : { Reference(Appointment|CommunicationRequest|DeviceRequest|
    MedicationRequest|NutritionOrder|Task|ProcedureRequest|ReferralRequest|
    VisionPrescription|RequestGroup) }, // C? Activity details defined in specific resource

    "detail" : { // C? In-line definition of activity
      "category" : { CodeableConcept }, // diet | drug | encounter | observation | procedure | supply | other
      "definition" : { Reference(PlanDefinition|ActivityDefinition|
     Questionnaire) }, // Protocol or definition

      "code" : { CodeableConcept }, // Detail type of activity
      "reasonCode" : [{ CodeableConcept }], // Why activity should be done or why activity was prohibited
      "reasonReference" : [{ Reference(Condition) }], // Condition triggering need for activity
      "goal" : [{ Reference(Goal) }], // Goals this activity relates to
      "status" : "<code>", // R!  not-started | scheduled | in-progress | on-hold | completed | cancelled | unknown
      "statusReason" : "<string>", // Reason for current status
      "prohibited" : <boolean>, // 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|
     CareTeam) }], // 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

}

Turtle Template 


@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:CarePlan;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:CarePlan.identifier [ Identifier ], ... ; # 0..* External Ids for this plan
  fhir:CarePlan.definition [ Reference(PlanDefinition|Questionnaire) ], ... ; # 0..* Protocol or definition
  fhir:CarePlan.basedOn [ Reference(CarePlan) ], ... ; # 0..* Fulfills care plan
  fhir:CarePlan.replaces [ Reference(CarePlan) ], ... ; # 0..* CarePlan replaced by this CarePlan
  fhir:CarePlan.partOf [ Reference(CarePlan) ], ... ; # 0..* Part of referenced CarePlan
  fhir:CarePlan.status [ code ]; # 1..1 draft | active | suspended | completed | entered-in-error | cancelled | unknown
  fhir:CarePlan.intent [ code ]; # 1..1 proposal | plan | order | option
  fhir:CarePlan.category [ CodeableConcept ], ... ; # 0..* Type of plan
  fhir:CarePlan.title [ string ]; # 0..1 Human-friendly name for the CarePlan
  fhir:CarePlan.description [ string ]; # 0..1 Summary of nature of plan
  fhir:CarePlan.subject [ Reference(Patient|Group) ]; # 1..1 Who care plan is for
  fhir:CarePlan.context [ Reference(Encounter|EpisodeOfCare) ]; # 0..1 Created in context of
  fhir:CarePlan.period [ Period ]; # 0..1 Time period plan covers
  fhir:CarePlan.author [ Reference(Patient|Practitioner|RelatedPerson|Organization|CareTeam) ], ... ; # 0..* Who is responsible for contents of the plan
  fhir:CarePlan.careTeam [ Reference(CareTeam) ], ... ; # 0..* Who's involved in plan?
  fhir:CarePlan.addresses [ Reference(Condition) ], ... ; # 0..* Health issues this plan addresses
  fhir:CarePlan.supportingInfo [ Reference(Any) ], ... ; # 0..* Information considered as part of plan
  fhir:CarePlan.goal [ Reference(Goal) ], ... ; # 0..* Desired outcome of plan
  fhir:CarePlan.activity [ # 0..* Action to occur as part of plan
    fhir:CarePlan.activity.outcomeCodeableConcept [ CodeableConcept ], ... ; # 0..* Results of the activity
    fhir:CarePlan.activity.outcomeReference [ Reference(Any) ], ... ; # 0..* Appointment, Encounter, Procedure, etc.
    fhir:CarePlan.activity.progress [ Annotation ], ... ; # 0..* Comments about the activity status/progress
    fhir:CarePlan.activity.reference [ Reference(Appointment|CommunicationRequest|DeviceRequest|MedicationRequest|NutritionOrder|
  Task|ProcedureRequest|ReferralRequest|VisionPrescription|RequestGroup) ]; # 0..1 Activity details defined in specific resource

    fhir:CarePlan.activity.detail [ # 0..1 In-line definition of activity
      fhir:CarePlan.activity.detail.category [ CodeableConcept ]; # 0..1 diet | drug | encounter | observation | procedure | supply | other
      fhir:CarePlan.activity.detail.definition [ Reference(PlanDefinition|ActivityDefinition|Questionnaire) ]; # 0..1 Protocol or definition
      fhir:CarePlan.activity.detail.code [ CodeableConcept ]; # 0..1 Detail type of activity
      fhir:CarePlan.activity.detail.reasonCode [ CodeableConcept ], ... ; # 0..* Why activity should be done or why activity was prohibited
      fhir:CarePlan.activity.detail.reasonReference [ Reference(Condition) ], ... ; # 0..* Condition triggering need for activity
      fhir:CarePlan.activity.detail.goal [ Reference(Goal) ], ... ; # 0..* Goals this activity relates to
      fhir:CarePlan.activity.detail.status [ code ]; # 1..1 not-started | scheduled | in-progress | on-hold | completed | cancelled | unknown
      fhir:CarePlan.activity.detail.statusReason [ string ]; # 0..1 Reason for current status
      fhir:CarePlan.activity.detail.prohibited [ boolean ]; # 0..1 Do NOT do
      # CarePlan.activity.detail.scheduled[x] : 0..1 When activity is to occur. One of these 3
        fhir:CarePlan.activity.detail.scheduledTiming [ Timing ]
        fhir:CarePlan.activity.detail.scheduledPeriod [ Period ]
        fhir:CarePlan.activity.detail.scheduledString [ string ]
      fhir:CarePlan.activity.detail.location [ Reference(Location) ]; # 0..1 Where it should happen
      fhir:CarePlan.activity.detail.performer [ Reference(Practitioner|Organization|RelatedPerson|Patient|CareTeam) ], ... ; # 0..* Who will be responsible?
      # CarePlan.activity.detail.product[x] : 0..1 What is to be administered/supplied. One of these 2
        fhir:CarePlan.activity.detail.productCodeableConcept [ CodeableConcept ]
        fhir:CarePlan.activity.detail.productReference [ Reference(Medication|Substance) ]
      fhir:CarePlan.activity.detail.dailyAmount [ Quantity(SimpleQuantity) ]; # 0..1 How to consume/day?
      fhir:CarePlan.activity.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 How much to administer/supply/consume
      fhir:CarePlan.activity.detail.description [ string ]; # 0..1 Extra info describing activity to perform
    ];
  ], ...;
  fhir:CarePlan.note [ Annotation ], ... ; # 0..* Comments about the plan
]

Changes since DSTU2

CarePlan
CarePlan.definition
  • Added Element
CarePlan.basedOn
  • Added Element
CarePlan.replaces
  • Added Element
CarePlan.partOf
  • Added Element
CarePlan.intent
  • Added Element
CarePlan.title
  • Added Element
CarePlan.subject
  • Min Cardinality changed from 0 to 1
CarePlan.author
  • Add Reference(CareTeam)
CarePlan.careTeam
  • Added Element
CarePlan.supportingInfo
  • Renamed from support to supportingInfo
CarePlan.activity.outcomeCodeableConcept
  • Added Element
CarePlan.activity.outcomeReference
  • Renamed from actionResulting to outcomeReference
CarePlan.activity.reference
  • Remove Reference(DiagnosticOrder), Remove Reference(MedicationOrder), Remove Reference(Order), Remove Reference(ProcessRequest), Remove Reference(SupplyRequest), Add Reference(MedicationRequest), Add Reference(Task), Add Reference(RequestGroup)
CarePlan.activity.detail.definition
  • Added Element
CarePlan.activity.detail.status
  • Min Cardinality changed from 0 to 1
CarePlan.activity.detail.statusReason
  • Type changed from CodeableConcept to string
CarePlan.activity.detail.prohibited
  • Min Cardinality changed from 1 to 0
  • Default Value "false" added
CarePlan.activity.detail.performer
  • Add Reference(CareTeam)
CarePlan.note
  • Max Cardinality changed from 1 to *
CarePlan.modified
  • deleted
CarePlan.relatedPlan
  • deleted
CarePlan.participant
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON .

See R2 <--> R3 Conversion Maps (status = 10 tests that all execute ok. 8 fail round-trip testing and 10 r3 resources are invalid (33 errors). ).

Structure

0..1 Who care plan is for ?! 1..1 proposed | draft | active | completed | cancelled 0..1 Created in context of 0..1 Time period plan covers 0..* Who is responsible for contents of the plan 0..1 When last updated Summary of nature of plan 0..* Health issues this Information considered as part of BackboneElement Plans related to this one includes | replaces | fulfills CarePlanRelationship ( Required ) Plan relationship exists with 0..1 Type of involvement Who is involved Appointments, orders, 0..1 1..1
Name Flags Card. Type Description & Constraints doco
. . CarePlan DomainResource Healthcare plan for patient or group
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier Σ 0..* Identifier External Ids for this plan
. . subject . definition Σ 0..* Reference ( Patient PlanDefinition | Group Questionnaire ) Protocol or definition
. . status . basedOn Σ 0..* code Reference ( CarePlan ) Fulfills care plan
CarePlanStatus ( Required )
. . context . replaces Σ 0..* Reference ( Encounter | EpisodeOfCare CarePlan ) CarePlan replaced by this CarePlan
. . period . partOf Σ 0..* Period Reference ( CarePlan ) Part of referenced CarePlan
. . author . status ?! Σ 1..1 Reference ( Patient code draft | Practitioner active | RelatedPerson suspended | Organization completed | entered-in-error | cancelled | unknown
CarePlanStatus ( Required )
. . modified . intent ?! Σ 1..1 dateTime code proposal | plan | order | option
CarePlanIntent ( Required )
. . . category Σ 0..* CodeableConcept Type of plan
Care Plan Category ( Example )
. . description . title Σ 0..1 string Human-friendly name for the CarePlan
. . addresses . description Σ 0..1 Reference ( Condition string ) Summary of nature of plan addresses
. . support . subject Σ 0..* 1..1 Reference ( Any Patient | Group ) Who care plan is for
. . relatedPlan . context Σ 0..* 0..1 Reference ( Encounter | EpisodeOfCare ) Created in context of
. . code . period Σ 0..1 code Period Time period plan covers
. . plan . author Σ 1..1 0..* Reference ( CarePlan Patient | Practitioner | RelatedPerson | Organization | CareTeam ) Who is responsible for contents of the plan
. . participant . careTeam 0..* BackboneElement Reference ( CareTeam ) Who's involved in plan?
. . role . addresses Σ CodeableConcept 0..* Participant Roles Reference ( Example Condition ) Health issues this plan addresses
. member . . supportingInfo 0..1 0..* Reference ( Practitioner | RelatedPerson | Patient | Organization Any ) Information considered as part of plan
. . . 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 . outcomeCodeableConcept 0..* CodeableConcept Results of the activity
Care Plan Activity Outcome ( Example )
.... outcomeReference 0..* Reference ( Any ) Appointment, Encounter, Procedure, etc.
. . . . progress 0..* Annotation Comments about the activity status/progress
. . . . reference I 0..1 Reference ( Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticOrder DeviceRequest | MedicationOrder MedicationRequest | NutritionOrder | Order Task | ProcedureRequest | ProcessRequest | ReferralRequest | SupplyRequest | VisionPrescription | RequestGroup ) 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 )
. . . . . definition 0..1 Reference ( PlanDefinition | ActivityDefinition | Questionnaire ) Protocol or definition
..... code 0..1 CodeableConcept Detail type of activity
Care Plan Activity ( Example )
. . . . . reasonCode 0..* CodeableConcept Why activity should be done or why activity was prohibited
Activity Reason ( Example )
. . . . . reasonReference 0..* Reference ( Condition ) Condition triggering need for activity
. . . . . goal 0..* Reference ( Goal ) Goals this activity relates to
. . . . . status ?! 1..1 code not-started | scheduled | in-progress | on-hold | completed | cancelled | unknown
CarePlanActivityStatus ( Required )
. . . . . statusReason 0..1 CodeableConcept string Reason for current status GoalStatusReason ( Example )
. . . . . prohibited ?! 0..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 | CareTeam ) 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 0..* Annotation Comments about the plan

doco Documentation for this format

UML Diagram ( Legend )

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 protocol, questionnaire, guideline or group whose intended other specification the care plan should be conducted in accordance with definition : Reference [0..*] PlanDefinition | Questionnaire A care plan that is described fulfilled in whole or in part by the this care plan subject basedOn : Reference [0..1] « Patient [0..*] CarePlan | Group Completed or terminated care plan whose function is taken by this new care plan replaces : Reference [0..*] CarePlan » A larger care plan of which this particular care plan is a component or step partOf : Reference [0..*] CarePlan 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 ! » Indicates the level of authority/intentionality associated with the care plan and where the care plan fits into the workflow chain (this element modifies the meaning of other elements) intent : code [1..1] Codes indicating the degree of authority/intentionality associated with a care plan (Strength=Required) CarePlanIntent ! 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 ?? Human-friendly name for the CarePlan title : string [0..1] A description of the scope and nature of the plan description : string [0..1] Identifies the patient or group whose intended care is described by the plan subject : Reference [1..1] Patient | Group Identifies the original context in which this particular CarePlan is defined was created 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 | CareTeam [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 all people and nature of organizations who are expected to be involved in the care envisioned by this plan description careTeam : string Reference [0..*] CareTeam [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 supportingInfo : 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] [0..*] RelatedPlan Activity Identifies the type of relationship this plan has to outcome at the target plan code : code [0..1] « Codes identifying point when the types status of relationships between two plans. (Strength=Required) CarePlanRelationship ! » A reference to the plan to which a relationship activity is asserted plan : Reference [1..1] « CarePlan » Participant Indicates specific responsibility assessed. For example, the outcome of an individual within the care plan; e.g. "Primary physician", "Team coordinator", "Caregiver", etc education activity could be patient understands (or not) role outcomeCodeableConcept : CodeableConcept [0..1] « [0..*] Indicates specific responsibility Identifies the results of an individual within the care plan; e.g. "Primary physician", "Team coordinator", "Caregiver", etc. activity (Strength=Example) Participant Roles Care Plan Activity ?? » The specific person or organization who is participating/expected to participate in the care plan member : Reference [0..1] « Practitioner | RelatedPerson | Patient | Organization Outcome » Activity ?? Resources that describe follow-on actions Details of the outcome or action resulting from the plan, activity. The reference to an "event" resource, such as drug prescriptions, encounter records, appointments, etc Procedure or Encounter or Observation, is the result/outcome of the activity itself. The activity can be conveyed using CarePlan.activity.detail OR using the CarePlan.activity.reference (a reference to a request resource) actionResulting outcomeReference : 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 resource reference : Reference [0..1] « Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticOrder DeviceRequest | MedicationOrder MedicationRequest | NutritionOrder | Order Task | ProcedureRequest | ProcessRequest | ReferralRequest | SupplyRequest | VisionPrescription » | RequestGroup Detail High-level categorization of the type of activity in a care plan category : CodeableConcept [0..1] « High-level categorization of the type of activity in a care plan. (Strength=Example) CarePlanActivityCategory ?? » Identifies the protocol, questionnaire, guideline or other specification the planned activity should be conducted in accordance with definition : Reference [0..1] PlanDefinition | ActivityDefinition | Questionnaire Detailed description of the type of planned activity; e.g. What lab test, what procedure, what kind of encounter code : CodeableConcept [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 or the reason why the activity was prohibited 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] « [1..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 string [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. If false, indicates that the described activity is one that should be engaged in when following the plan (this element modifies the meaning of other elements) prohibited : boolean [1..1] [0..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 » | CareTeam 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>
 <</subject>
 <
 <</context>
 <</period>
 <</author>
 <
 <</category>
 <
 <</addresses>
 <</support>
 <
  <
  <</plan>
 </relatedPlan>
 <
  <</role>
  <</member>
 </participant>
 <</goal>
 <
  <</actionResulting>
  <</progress>
  <|
    |
    |
    </reference>
  <
   <</category>
   <</code>
   <</reasonCode>
   <</reasonReference>
   <</goal>
   <
   <</statusReason>
   <
   <</scheduled[x]>
   <</location>
   <</performer>
   <</product[x]>
   <</dailyAmount>
   <</quantity>
   <

 <identifier><!-- 0..* Identifier External Ids for this plan --></identifier>
 <definition><!-- 0..* Reference(PlanDefinition|Questionnaire) Protocol or definition --></definition>
 <basedOn><!-- 0..* Reference(CarePlan) Fulfills care plan --></basedOn>
 <replaces><!-- 0..* Reference(CarePlan) CarePlan replaced by this CarePlan --></replaces>
 <partOf><!-- 0..* Reference(CarePlan) Part of referenced CarePlan --></partOf>
 <status value="[code]"/><!-- 1..1 draft | active | suspended | completed | entered-in-error | cancelled | unknown -->
 <intent value="[code]"/><!-- 1..1 proposal | plan | order | option -->
 <category><!-- 0..* CodeableConcept Type of plan --></category>
 <title value="[string]"/><!-- 0..1 Human-friendly name for the CarePlan -->
 <description value="[string]"/><!-- 0..1 Summary of nature of plan -->
 <subject><!-- 1..1 Reference(Patient|Group) Who care plan is for --></subject>
 <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|
   CareTeam) Who is responsible for contents of the plan --></author>

 <careTeam><!-- 0..* Reference(CareTeam) Who's involved in plan? --></careTeam>
 <addresses><!-- 0..* Reference(Condition) Health issues this plan addresses --></addresses>
 <supportingInfo><!-- 0..* Reference(Any) Information considered as part of plan --></supportingInfo>
 <goal><!-- 0..* Reference(Goal) Desired outcome of plan --></goal>
 <activity>  <!-- 0..* Action to occur as part of plan -->
  <outcomeCodeableConcept><!-- 0..* CodeableConcept Results of the activity --></outcomeCodeableConcept>
  <outcomeReference><!-- 0..* Reference(Any) Appointment, Encounter, Procedure, etc. --></outcomeReference>
  <progress><!-- 0..* Annotation Comments about the activity status/progress --></progress>
  <reference><!-- ?? 0..1 Reference(Appointment|CommunicationRequest|DeviceRequest|
    MedicationRequest|NutritionOrder|Task|ProcedureRequest|ReferralRequest|
    VisionPrescription|RequestGroup) 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>
   <definition><!-- 0..1 Reference(PlanDefinition|ActivityDefinition|
     Questionnaire) Protocol or definition --></definition>

   <code><!-- 0..1 CodeableConcept Detail type of activity --></code>
   <reasonCode><!-- 0..* CodeableConcept Why activity should be done or why activity was prohibited --></reasonCode>
   <reasonReference><!-- 0..* Reference(Condition) Condition triggering need for activity --></reasonReference>
   <goal><!-- 0..* Reference(Goal) Goals this activity relates to --></goal>
   <status value="[code]"/><!-- 1..1 not-started | scheduled | in-progress | on-hold | completed | cancelled | unknown -->
   <statusReason value="[string]"/><!-- 0..1 Reason for current status -->
   <prohibited value="[boolean]"/><!-- 0..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|
     CareTeam) 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>

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

</CarePlan>

JSON Template 

{
  "resourceType" : "",

{doco
  "resourceType" : "CarePlan",

  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
  "
    "
    "
  }],
  "
    "
    "
  }],
  "
  "
    "
    "
    "|
    |
    |
    
    "
      "
      "
      "
      "
      "
      "
      "
      "

  "identifier" : [{ Identifier }], // External Ids for this plan
  "definition" : [{ Reference(PlanDefinition|Questionnaire) }], // Protocol or definition
  "basedOn" : [{ Reference(CarePlan) }], // Fulfills care plan
  "replaces" : [{ Reference(CarePlan) }], // CarePlan replaced by this CarePlan
  "partOf" : [{ Reference(CarePlan) }], // Part of referenced CarePlan
  "status" : "<code>", // R!  draft | active | suspended | completed | entered-in-error | cancelled | unknown
  "intent" : "<code>", // R!  proposal | plan | order | option
  "category" : [{ CodeableConcept }], // Type of plan
  "title" : "<string>", // Human-friendly name for the CarePlan
  "description" : "<string>", // Summary of nature of plan
  "subject" : { Reference(Patient|Group) }, // R!  Who care plan is for
  "context" : { Reference(Encounter|EpisodeOfCare) }, // Created in context of
  "period" : { Period }, // Time period plan covers
  "author" : [{ Reference(Patient|Practitioner|RelatedPerson|Organization|
   CareTeam) }], // Who is responsible for contents of the plan

  "careTeam" : [{ Reference(CareTeam) }], // Who's involved in plan?
  "addresses" : [{ Reference(Condition) }], // Health issues this plan addresses
  "supportingInfo" : [{ Reference(Any) }], // Information considered as part of plan
  "goal" : [{ Reference(Goal) }], // Desired outcome of plan
  "activity" : [{ // Action to occur as part of plan
    "outcomeCodeableConcept" : [{ CodeableConcept }], // Results of the activity
    "outcomeReference" : [{ Reference(Any) }], // Appointment, Encounter, Procedure, etc.
    "progress" : [{ Annotation }], // Comments about the activity status/progress
    "reference" : { Reference(Appointment|CommunicationRequest|DeviceRequest|
    MedicationRequest|NutritionOrder|Task|ProcedureRequest|ReferralRequest|
    VisionPrescription|RequestGroup) }, // C? Activity details defined in specific resource

    "detail" : { // C? In-line definition of activity
      "category" : { CodeableConcept }, // diet | drug | encounter | observation | procedure | supply | other
      "definition" : { Reference(PlanDefinition|ActivityDefinition|
     Questionnaire) }, // Protocol or definition

      "code" : { CodeableConcept }, // Detail type of activity
      "reasonCode" : [{ CodeableConcept }], // Why activity should be done or why activity was prohibited
      "reasonReference" : [{ Reference(Condition) }], // Condition triggering need for activity
      "goal" : [{ Reference(Goal) }], // Goals this activity relates to
      "status" : "<code>", // R!  not-started | scheduled | in-progress | on-hold | completed | cancelled | unknown
      "statusReason" : "<string>", // Reason for current status
      "prohibited" : <boolean>, // 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|
     CareTeam) }], // 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

}

Turtle Template 


@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:CarePlan;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:CarePlan.identifier [ Identifier ], ... ; # 0..* External Ids for this plan
  fhir:CarePlan.definition [ Reference(PlanDefinition|Questionnaire) ], ... ; # 0..* Protocol or definition
  fhir:CarePlan.basedOn [ Reference(CarePlan) ], ... ; # 0..* Fulfills care plan
  fhir:CarePlan.replaces [ Reference(CarePlan) ], ... ; # 0..* CarePlan replaced by this CarePlan
  fhir:CarePlan.partOf [ Reference(CarePlan) ], ... ; # 0..* Part of referenced CarePlan
  fhir:CarePlan.status [ code ]; # 1..1 draft | active | suspended | completed | entered-in-error | cancelled | unknown
  fhir:CarePlan.intent [ code ]; # 1..1 proposal | plan | order | option
  fhir:CarePlan.category [ CodeableConcept ], ... ; # 0..* Type of plan
  fhir:CarePlan.title [ string ]; # 0..1 Human-friendly name for the CarePlan
  fhir:CarePlan.description [ string ]; # 0..1 Summary of nature of plan
  fhir:CarePlan.subject [ Reference(Patient|Group) ]; # 1..1 Who care plan is for
  fhir:CarePlan.context [ Reference(Encounter|EpisodeOfCare) ]; # 0..1 Created in context of
  fhir:CarePlan.period [ Period ]; # 0..1 Time period plan covers
  fhir:CarePlan.author [ Reference(Patient|Practitioner|RelatedPerson|Organization|CareTeam) ], ... ; # 0..* Who is responsible for contents of the plan
  fhir:CarePlan.careTeam [ Reference(CareTeam) ], ... ; # 0..* Who's involved in plan?
  fhir:CarePlan.addresses [ Reference(Condition) ], ... ; # 0..* Health issues this plan addresses
  fhir:CarePlan.supportingInfo [ Reference(Any) ], ... ; # 0..* Information considered as part of plan
  fhir:CarePlan.goal [ Reference(Goal) ], ... ; # 0..* Desired outcome of plan
  fhir:CarePlan.activity [ # 0..* Action to occur as part of plan
    fhir:CarePlan.activity.outcomeCodeableConcept [ CodeableConcept ], ... ; # 0..* Results of the activity
    fhir:CarePlan.activity.outcomeReference [ Reference(Any) ], ... ; # 0..* Appointment, Encounter, Procedure, etc.
    fhir:CarePlan.activity.progress [ Annotation ], ... ; # 0..* Comments about the activity status/progress
    fhir:CarePlan.activity.reference [ Reference(Appointment|CommunicationRequest|DeviceRequest|MedicationRequest|NutritionOrder|
  Task|ProcedureRequest|ReferralRequest|VisionPrescription|RequestGroup) ]; # 0..1 Activity details defined in specific resource

    fhir:CarePlan.activity.detail [ # 0..1 In-line definition of activity
      fhir:CarePlan.activity.detail.category [ CodeableConcept ]; # 0..1 diet | drug | encounter | observation | procedure | supply | other
      fhir:CarePlan.activity.detail.definition [ Reference(PlanDefinition|ActivityDefinition|Questionnaire) ]; # 0..1 Protocol or definition
      fhir:CarePlan.activity.detail.code [ CodeableConcept ]; # 0..1 Detail type of activity
      fhir:CarePlan.activity.detail.reasonCode [ CodeableConcept ], ... ; # 0..* Why activity should be done or why activity was prohibited
      fhir:CarePlan.activity.detail.reasonReference [ Reference(Condition) ], ... ; # 0..* Condition triggering need for activity
      fhir:CarePlan.activity.detail.goal [ Reference(Goal) ], ... ; # 0..* Goals this activity relates to
      fhir:CarePlan.activity.detail.status [ code ]; # 1..1 not-started | scheduled | in-progress | on-hold | completed | cancelled | unknown
      fhir:CarePlan.activity.detail.statusReason [ string ]; # 0..1 Reason for current status
      fhir:CarePlan.activity.detail.prohibited [ boolean ]; # 0..1 Do NOT do
      # CarePlan.activity.detail.scheduled[x] : 0..1 When activity is to occur. One of these 3
        fhir:CarePlan.activity.detail.scheduledTiming [ Timing ]
        fhir:CarePlan.activity.detail.scheduledPeriod [ Period ]
        fhir:CarePlan.activity.detail.scheduledString [ string ]
      fhir:CarePlan.activity.detail.location [ Reference(Location) ]; # 0..1 Where it should happen
      fhir:CarePlan.activity.detail.performer [ Reference(Practitioner|Organization|RelatedPerson|Patient|CareTeam) ], ... ; # 0..* Who will be responsible?
      # CarePlan.activity.detail.product[x] : 0..1 What is to be administered/supplied. One of these 2
        fhir:CarePlan.activity.detail.productCodeableConcept [ CodeableConcept ]
        fhir:CarePlan.activity.detail.productReference [ Reference(Medication|Substance) ]
      fhir:CarePlan.activity.detail.dailyAmount [ Quantity(SimpleQuantity) ]; # 0..1 How to consume/day?
      fhir:CarePlan.activity.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 How much to administer/supply/consume
      fhir:CarePlan.activity.detail.description [ string ]; # 0..1 Extra info describing activity to perform
    ];
  ], ...;
  fhir:CarePlan.note [ Annotation ], ... ; # 0..* Comments about the plan
]

  Changes since DSTU2

CarePlan
CarePlan.definition
  • Added Element
CarePlan.basedOn
  • Added Element
CarePlan.replaces
  • Added Element
CarePlan.partOf
  • Added Element
CarePlan.intent
  • Added Element
CarePlan.title
  • Added Element
CarePlan.subject
  • Min Cardinality changed from 0 to 1
CarePlan.author
  • Add Reference(CareTeam)
CarePlan.careTeam
  • Added Element
CarePlan.supportingInfo
  • Renamed from support to supportingInfo
CarePlan.activity.outcomeCodeableConcept
  • Added Element
CarePlan.activity.outcomeReference
  • Renamed from actionResulting to outcomeReference
CarePlan.activity.reference
  • Remove Reference(DiagnosticOrder), Remove Reference(MedicationOrder), Remove Reference(Order), Remove Reference(ProcessRequest), Remove Reference(SupplyRequest), Add Reference(MedicationRequest), Add Reference(Task), Add Reference(RequestGroup)
CarePlan.activity.detail.definition
  • Added Element
CarePlan.activity.detail.status
  • Min Cardinality changed from 0 to 1
CarePlan.activity.detail.statusReason
  • Type changed from CodeableConcept to string
CarePlan.activity.detail.prohibited
  • Min Cardinality changed from 1 to 0
  • Default Value "false" added
CarePlan.activity.detail.performer
  • Add Reference(CareTeam)
CarePlan.note
  • Max Cardinality changed from 1 to *
CarePlan.modified
  • deleted
CarePlan.relatedPlan
  • deleted
CarePlan.participant
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON .

See R2 <--> R3 Conversion Maps (status = 10 tests that all execute ok. 8 fail round-trip testing and 10 r3 resources are invalid (33 errors). ).

 

Alternate definitions: Schema / Schematron , Resource Profile Master Definition ( XML , JSON ), Questionnaire XML Schema / Schematron (for ) + JSON Schema , ShEx (for Turtle )

4.4.3.1 9.5.3.1 Terminology Bindings

CarePlan.relatedPlan.code CarePlan.activity.detail.statusReason 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. Example GoalStatusReason
Path Definition Type Reference
CarePlan.status Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record. Required CarePlanStatus
CarePlan.intent Codes indicating the degree of authority/intentionality associated with a care plan Required CarePlanIntent
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.activity.outcomeCodeableConcept Codes identifying Identifies the types of relationships between two plans. Required CarePlanRelationship CarePlan.participant.role Indicates specific responsibility results of an individual within the care plan; e.g. "Primary physician", "Team coordinator", "Caregiver", etc. activity Example Participant Roles Care Plan Activity Outcome
CarePlan.activity.detail.category High-level categorization of the type of activity in a care plan. Example 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.detail.status Indicates where the activity is at in its overall life cycle. Required CarePlanActivityStatus
CarePlan.activity.detail.product[x] A product supplied or administered as part of a care plan activity. Example SNOMED CT Medication Codes

4.4.3.2 9.5.3.2 Constraints

  • cpl-3 : On CarePlan.activity: Provide a reference or detail, not both (xpath ( expression on f:CarePlan/f:activity: CarePlan.activity: not(exists(f:detail)) detail.empty() or not(exists(f:reference)) reference.empty() )

4.4.4 9.5.3.3 Open Issues Notes

DSTU Note: During the Trial use period, feedback is welcome on two issues: This The Provenance resource combines the concepts of "Care Plan" and "Care Team" into a single resource. Is this appropriate? At present, can be used for detailed review information, such as when the patient element is optional to allow experimentation with care plan templates, though the resource was not designed for this use Feedback here . last reviewed and by whom.

9.5.4 Open Issues

4.4.5 9.5.5 Search Parameters

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

Name Type Description Paths Expression In Common
activitycode activity-code token Detail type of activity CarePlan.activity.detail.code
activitydate activity-date date Specified date occurs within period specified by CarePlan.activity.timingSchedule CarePlan.activity.detail.scheduled[x] CarePlan.activity.detail.scheduled
activityreference activity-reference reference Activity details defined in specific resource CarePlan.activity.reference
( Appointment , ReferralRequest , ProcedureRequest , Appointment MedicationRequest , CommunicationRequest Task , Order NutritionOrder , SupplyRequest RequestGroup , VisionPrescription , MedicationOrder , ProcessRequest , DeviceUseRequest ProcedureRequest , NutritionOrder DeviceRequest , DiagnosticOrder CommunicationRequest )
based-on reference Fulfills care plan CarePlan.basedOn
( CarePlan )
care-team reference Who's involved in plan? CarePlan.careTeam
( CareTeam )
category token Type of plan CarePlan.category
condition reference Health issues this plan addresses CarePlan.addresses
( Condition )
context reference Created in context of CarePlan.context
( EpisodeOfCare , Encounter )
date date Time period plan covers CarePlan.period 18 Resources
definition reference Protocol or definition CarePlan.definition
( Questionnaire , PlanDefinition )
encounter reference Created in context of CarePlan.context
( Encounter )
goal reference Desired outcome of plan CarePlan.goal
( Goal )
participant identifier token External Ids for this plan CarePlan.identifier 26 Resources
intent token proposal | plan | order | option CarePlan.intent
part-of reference Who is involved Part of referenced CarePlan CarePlan.participant.member CarePlan.partOf
( Organization , Patient , Practitioner , RelatedPerson CarePlan )
patient reference Who care plan is for CarePlan.subject
( Patient ) 		31 Resources
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 Practitioner , Organization , Practitioner CareTeam , Patient , RelatedPerson )
related replaces composite reference A combination of the type of relationship and the related plan CarePlan replaced by this CarePlan CarePlan.replaces
( CarePlan )
relatedcode status token includes draft | replaces active | fulfills suspended | completed | entered-in-error | cancelled | unknown CarePlan.relatedPlan.code CarePlan.status
relatedplan reference Plan relationship exists with CarePlan.relatedPlan.plan ( CarePlan ) subject reference Who care plan is for CarePlan.subject
( Patient , Group , Patient )