Current Build
Patient Care Work GroupMaturity Level: 2 Trial Use Compartments: Patient, Practitioner, RelatedPerson

Detailed Descriptions for the elements in the CarePlan resource.

CarePlan
Element IdCarePlan
Definition

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.

Control1..1
Alternate NamesCare Team
CarePlan.identifier
Element IdCarePlan.identifier
Definition

Business identifiers assigned to this care plan by the performer or other systems which remain constant as the resource is updated and propagates from server to server.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Requirements

Allows identification of the care plan as it is known by various participating systems and in a way that remains consistent across servers.

Summarytrue
Comments

This is a business identifier, not a resource identifier (see discussion).  It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types.  For example, multiple Patient and a Person resource instance might share the same social insurance number.

CarePlan.instantiates
Element IdCarePlan.instantiates
Definition

Identifies the protocol, questionnaire, guideline or other specification the care plan should be conducted in accordance with.

Control0..*
Typeuri
Summarytrue
CarePlan.basedOn
Element IdCarePlan.basedOn
Definition

A care plan that is fulfilled in whole or in part by this care plan.

Control0..*
TypeReference(CarePlan)
HierarchyThis reference is part of a strict Hierarchy
Requirements

Allows tracing of the care plan and tracking whether proposals/recommendations were acted upon.

Alternate Namesfulfills
Summarytrue
CarePlan.replaces
Element IdCarePlan.replaces
Definition

Completed or terminated care plan whose function is taken by this new care plan.

Control0..*
TypeReference(CarePlan)
HierarchyThis reference is part of a strict Hierarchy
Requirements

Allows tracing the continuation of a therapy or administrative process instantiated through multiple care plans.

Alternate Namessupersedes
Summarytrue
Comments

The replacement could be because the initial care plan was immediately rejected (due to an issue) or because the previous care plan was completed, but the need for the action described by the care plan remains ongoing.

CarePlan.partOf
Element IdCarePlan.partOf
Definition

A larger care plan of which this particular care plan is a component or step.

Control0..*
TypeReference(CarePlan)
HierarchyThis reference is part of a strict Hierarchy
Summarytrue
Comments

Each care plan is an independent request, such that having a care plan be part of another care plan can cause issues with cascading statuses. As such, this element is still being discussed.

CarePlan.status
Element IdCarePlan.status
Definition

Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.

Control1..1
Terminology BindingCarePlanStatus (Required)
Typecode
Is Modifiertrue (Reason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
Requirements

Allows clinicians to determine whether the plan is actionable or not.

Summarytrue
Comments

The unknown code is not to be used to convey other statuses. The unknown code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the care plan.

This element is labeled as a modifier because the status contains the code entered-in-error that marks the plan as not currently valid.

CarePlan.intent
Element IdCarePlan.intent
Definition

Indicates the level of authority/intentionality associated with the care plan and where the care plan fits into the workflow chain.

Control1..1
Terminology BindingCarePlanIntent (Required)
Typecode
Is Modifiertrue (Reason: This element changes the interpretation of all descriptive attributes. For example "the time the request is recommended to occur" vs. "the time the request is authorized to occur" or "who is recommended to perform the request" vs. "who is authorized to perform the request)
Requirements

Proposals/recommendations, plans and orders all use the same structure and can exist in the same fulfillment chain.

Summarytrue
Comments

This element is labeled as a modifier because the intent alters when and how the resource is actually applicable.

CarePlan.category
Element IdCarePlan.category
Definition

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.

Control0..*
Terminology BindingCare Plan Category (Example)
TypeCodeableConcept
Requirements

Used for filtering what plan(s) are retrieved and displayed to different types of users.

Summarytrue
Comments

There may be multiple axes of categorization and one plan may serve multiple purposes. In some cases, this may be redundant with references to CarePlan.concern.

CarePlan.title
Element IdCarePlan.title
Definition

Human-friendly name for the care plan.

Control0..1
Typestring
Summarytrue
CarePlan.description
Element IdCarePlan.description
Definition

A description of the scope and nature of the plan.

Control0..1
Typestring
Requirements

Provides more detail than conveyed by category.

Summarytrue
CarePlan.subject
Element IdCarePlan.subject
Definition

Identifies the patient or group whose intended care is described by the plan.

Control1..1
TypeReference(Patient | Group)
Alternate Namespatient
Summarytrue
CarePlan.context
Element IdCarePlan.context
Definition

Identifies the original context in which this particular care plan was created.

Control0..1
TypeReference(Encounter | EpisodeOfCare)
Alternate Namesencounter
Summarytrue
Comments

Activities conducted as a result of the care plan may well occur as part of other encounters/episodes.

CarePlan.period
Element IdCarePlan.period
Definition

Indicates when the plan did (or is intended to) come into effect and end.

Control0..1
TypePeriod
Requirements

Allows tracking what plan(s) are in effect at a particular time.

Alternate Namestiming
Summarytrue
Comments

Any activities scheduled as part of the plan should be constrained to the specified period regardless of whether the activities are planned within a single encounter/episode or across multiple encounters/episodes (e.g. the longitudinal management of a chronic condition).

CarePlan.author
Element IdCarePlan.author
Definition

Identifies the individual(s) or organization who is responsible for the content of the care plan.

Control0..*
TypeReference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam)
Summarytrue
Comments

Collaborative care plans may have multiple authors.

CarePlan.careTeam
Element IdCarePlan.careTeam
Definition

Identifies all people and organizations who are expected to be involved in the care envisioned by this plan.

Control0..*
TypeReference(CareTeam)
Requirements

Allows representation of care teams, helps scope care plan. In some cases may be a determiner of access permissions.

CarePlan.addresses
Element IdCarePlan.addresses
Definition

Identifies the conditions/problems/concerns/diagnoses/etc. whose management and/or mitigation are handled by this plan.

Control0..*
TypeReference(Condition)
Requirements

Links plan to the conditions it manages. The element can identify risks addressed by the plan as well as active conditions. (The Condition resource can include things like "at risk for hypertension" or "fall risk".) Also scopes plans - multiple plans may exist addressing different concerns.

Summarytrue
Comments

When the diagnosis is related to an allergy or intolerance, the Condition and AllergyIntolerance resources can both be used. However, to be actionable for decision support, using Condition alone is not sufficient as the allergy or intolerance condition needs to be represented as an AllergyIntolerance.

CarePlan.supportingInfo
Element IdCarePlan.supportingInfo
Definition

Identifies portions of the patient's record that specifically influenced the formation of the plan. These might include comorbidities, recent procedures, limitations, recent assessments, etc.

Control0..*
TypeReference(Any)
Requirements

Identifies barriers and other considerations associated with the care plan.

Comments

Use "concern" to identify specific conditions addressed by the care plan.

CarePlan.goal
Element IdCarePlan.goal
Definition

Describes the intended objective(s) of carrying out the care plan.

Control0..*
TypeReference(Goal)
Requirements

Provides context for plan. Allows plan effectiveness to be evaluated by clinicians.

Comments

Goal can be achieving a particular change or merely maintaining a current state or even slowing a decline.

CarePlan.activity
Element IdCarePlan.activity
Definition

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.

Control0..*
Requirements

Allows systems to prompt for performance of planned activities, and validate plans against best practice.

InvariantsDefined on this element
cpl-3: Provide a reference or detail, not both (expression : detail.empty() or reference.empty(), xpath: not(exists(f:detail)) or not(exists(f:reference)))
CarePlan.activity.outcomeCodeableConcept
Element IdCarePlan.activity.outcomeCodeableConcept
Definition

Identifies the outcome at the point when the status of the activity is assessed. For example, the outcome of an education activity could be patient understands (or not).

Control0..*
Terminology BindingCare Plan Activity Outcome (Example)
TypeCodeableConcept
Comments

Note that this should not duplicate the activity status (e.g. completed or in progress).

CarePlan.activity.outcomeReference
Element IdCarePlan.activity.outcomeReference
Definition

Details of the outcome or action resulting from the activity. The reference to an "event" resource, such as 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).

Control0..*
TypeReference(Any)
Requirements

Links plan to resulting actions.

Comments

The activity outcome is independent of the outcome of the related goal(s). For example, if the goal is to achieve a target body weight of 150 lbs and an activity is defined to diet, then the activity outcome could be calories consumed whereas the goal outcome is an observation for the actual body weight measured.

CarePlan.activity.progress
Element IdCarePlan.activity.progress
Definition

Notes about the adherence/status/progress of the activity.

Control0..*
TypeAnnotation
Requirements

Can be used to capture information about adherence, progress, concerns, etc.

Comments

This element should NOT be used to describe the activity to be performed - that occurs either within the resource pointed to by activity.detail.reference or in activity.detail.description.

CarePlan.activity.reference
Element IdCarePlan.activity.reference
Definition

The details of the proposed activity represented in a specific resource.

Control0..1
TypeReference(Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup)
Requirements

Details in a form consistent with other applications and contexts of use.

Comments

Standard extension exists (resource-pertainsToGoal) that allows goals to be referenced from any of the referenced resources in CarePlan.activity.reference.
The goal should be visible when the resource referenced by CarePlan.activity.reference is viewed independently from the CarePlan. Requests that are pointed to by a CarePlan using this element should not point to this CarePlan using the "basedOn" element. i.e. Requests that are part of a CarePlan are not "based on" the CarePlan.

InvariantsAffect this element
cpl-3: Provide a reference or detail, not both (expression : detail.empty() or reference.empty(), xpath: not(exists(f:detail)) or not(exists(f:reference)))
CarePlan.activity.detail
Element IdCarePlan.activity.detail
Definition

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.

Control0..1
Requirements

Details in a simple form for generic care plan systems.

InvariantsAffect this element
cpl-3: Provide a reference or detail, not both (expression : detail.empty() or reference.empty(), xpath: not(exists(f:detail)) or not(exists(f:reference)))
CarePlan.activity.detail.kind
Element IdCarePlan.activity.detail.kind
Definition

A description of the kind of resource the in-line definition of a care plan activity is representing. The CarePlan.activity.detail is an in-line definition when a resource is not referenced using CarePlan.activity.reference. For example, a MedicationRequest, a ServiceRequest, or a CommunicationRequest.

Control0..1
Terminology BindingCare Plan Activity Kind (Required)
Typecode
Requirements

May determine what types of extensions are permitted.

CarePlan.activity.detail.instantiates
Element IdCarePlan.activity.detail.instantiates
Definition

Identifies the protocol, questionnaire, guideline or other specification the planned activity should be conducted in accordance with.

Control0..1
Typeuri
Requirements

Allows Questionnaires that the patient (or practitioner) should fill in to fulfill the care plan activity.

CarePlan.activity.detail.code
Element IdCarePlan.activity.detail.code
Definition

Detailed description of the type of planned activity; e.g. what lab test, what procedure, what kind of encounter.

Control0..1
Terminology BindingProcedure Codes (SNOMED CT) (Example)
TypeCodeableConcept
Requirements

Allows matching performed to planned as well as validation against protocols.

Comments

Tends to be less relevant for activities involving particular products. Codes should not convey negation - use "prohibited" instead.

CarePlan.activity.detail.reasonCode
Element IdCarePlan.activity.detail.reasonCode
Definition

Provides the rationale that drove the inclusion of this particular activity as part of the plan or the reason why the activity was prohibited.

Control0..*
Terminology BindingSNOMED CT Clinical Findings (Example)
TypeCodeableConcept
Comments

This could be a diagnosis code. If a full condition record exists or additional detail is needed, use reasonCondition instead.

CarePlan.activity.detail.reasonReference
Element IdCarePlan.activity.detail.reasonReference
Definition

Indicates another resource, such as the health condition(s), whose existence justifies this request and drove the inclusion of this particular activity as part of the plan.

Control0..*
TypeReference(Condition | Observation | DiagnosticReport | DocumentReference)
Comments

Conditions can be identified at the activity level that are not identified as reasons for the overall plan.

CarePlan.activity.detail.goal
Element IdCarePlan.activity.detail.goal
Definition

Internal reference that identifies the goals that this activity is intended to contribute towards meeting.

Control0..*
TypeReference(Goal)
Requirements

So that participants know the link explicitly.

CarePlan.activity.detail.status
Element IdCarePlan.activity.detail.status
Definition

Identifies what progress is being made for the specific activity.

Control1..1
Terminology BindingCarePlanActivityStatus (Required)
Typecode
Is Modifiertrue (Reason: Not known why this is labelled a modifier)
Requirements

Indicates progress against the plan, whether the activity is still relevant for the plan.

Comments

Some aspects of status can be inferred based on the resources linked in actionTaken. Note that "status" is only as current as the plan was most recently updated.
The unknown code is not to be used to convey other statuses. The unknown code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the activity.

CarePlan.activity.detail.statusReason
Element IdCarePlan.activity.detail.statusReason
Definition

Provides reason why the activity isn't yet started, is on hold, was cancelled, etc.

Control0..1
Typestring
Comments

Will generally not be present if status is "complete". Be sure to prompt to update this (or at least remove the existing value) if the status is changed.

CarePlan.activity.detail.doNotPerform
Element IdCarePlan.activity.detail.doNotPerform
Definition

If true, indicates that the described activity is one that must NOT be engaged in when following the plan. If false, or missing, indicates that the described activity is one that should be engaged in when following the plan.

Control0..1
Typeboolean
Is Modifiertrue (Reason: If true this element negates the specified action. For example, instead of a request for a procedure, it is a request for the procedure to not occur.)
Meaning if MissingIf missing indicates that the described activity is one that should be engaged in when following the plan.
Requirements

Captures intention to not do something that may have been previously typical.

Comments

This element is labeled as a modifier because it marks an activity as an activity that is not to be performed.

CarePlan.activity.detail.scheduled[x]
Element IdCarePlan.activity.detail.scheduled[x]
Definition

The period, timing or frequency upon which the described activity is to occur.

Control0..1
TypeTiming|Period|string
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Allows prompting for activities and detection of missed planned activities.

CarePlan.activity.detail.location
Element IdCarePlan.activity.detail.location
Definition

Identifies the facility where the activity will occur; e.g. home, hospital, specific clinic, etc.

Control0..1
TypeReference(Location)
Requirements

Helps in planning of activity.

Comments

May reference a specific clinical location or may identify a type of location.

CarePlan.activity.detail.performer
Element IdCarePlan.activity.detail.performer
Definition

Identifies who's expected to be involved in the activity.

Control0..*
TypeReference(Practitioner | PractitionerRole | Organization | RelatedPerson | Patient | CareTeam | HealthcareService | Device)
Requirements

Helps in planning of activity.

Comments

A performer MAY also be a participant in the care plan.

CarePlan.activity.detail.product[x]
Element IdCarePlan.activity.detail.product[x]
Definition

Identifies the food, drug or other product to be consumed or supplied in the activity.

Control0..1
Terminology BindingSNOMED CT Medication Codes (Example)
TypeCodeableConcept|Reference(Medication | Substance)
[x] NoteSee Choice of Data Types for further information about how to use [x]
CarePlan.activity.detail.dailyAmount
Element IdCarePlan.activity.detail.dailyAmount
Definition

Identifies the quantity expected to be consumed in a given day.

Control0..1
TypeSimpleQuantity
Requirements

Allows rough dose checking.

Alternate Namesdaily dose
CarePlan.activity.detail.quantity
Element IdCarePlan.activity.detail.quantity
Definition

Identifies the quantity expected to be supplied, administered or consumed by the subject.

Control0..1
TypeSimpleQuantity
CarePlan.activity.detail.description
Element IdCarePlan.activity.detail.description
Definition

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.

Control0..1
Typestring
CarePlan.note
Element IdCarePlan.note
Definition

General notes about the care plan not covered elsewhere.

Control0..*
TypeAnnotation
Requirements

Used to capture information that applies to the plan as a whole that doesn't fit into discrete elements.