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Patient Care icon Work GroupMaturity Level: 2 Trial UseSecurity Category: Patient Compartments: Encounter, Patient

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.

Short DisplayHealthcare plan for patient or group
Cardinality0..*
TypeDomainResource
Alternate NamesCare Team
Summaryfalse
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.

Short DisplayExternal Ids for this plan
NoteThis is a business identifier, not a resource identifier (see discussion)
Cardinality0..*
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.instantiatesCanonical
Element IdCarePlan.instantiatesCanonical
Definition

The URL pointing to a FHIR-defined protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlan.

Short DisplayInstantiates FHIR protocol or definition
Cardinality0..*
Typecanonical(PlanDefinition | Questionnaire | Measure | ActivityDefinition | OperationDefinition)
Summarytrue
CarePlan.instantiatesUri
Element IdCarePlan.instantiatesUri
Definition

The URL pointing to an externally maintained protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlan.

Short DisplayInstantiates external protocol or definition
Cardinality0..*
Typeuri
Summarytrue
Comments

This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.

CarePlan.basedOn
Element IdCarePlan.basedOn
Definition

A higher-level request resource (i.e. a plan, proposal or order) that is fulfilled in whole or in part by this care plan.

Short DisplayFulfills plan, proposal or order
Cardinality0..*
TypeReference(CarePlan | ServiceRequest | RequestOrchestration | NutritionOrder)
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.

Short DisplayCarePlan replaced by this CarePlan
Cardinality0..*
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.

Short DisplayPart of referenced CarePlan
Cardinality0..*
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.

Short Displaydraft | active | on-hold | revoked | completed | entered-in-error | unknown
Cardinality1..1
Terminology BindingRequestStatus (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.

Short Displayproposal | plan | order | option | directive
Cardinality1..1
Terminology BindingCare Plan Intent (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. This element is expected to be immutable. E.g. A "proposal" instance should never change to be a "plan" instance or "order" instance. Instead, a new instance 'basedOn' the prior instance should be created with the new 'intent' value.

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.

Short DisplayType of plan
Cardinality0..*
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.addresses.

CarePlan.title
Element IdCarePlan.title
Definition

Human-friendly name for the care plan.

Short DisplayHuman-friendly name for the care plan
Cardinality0..1
Typestring
Summarytrue
CarePlan.description
Element IdCarePlan.description
Definition

A description of the scope and nature of the plan.

Short DisplaySummary of nature of plan
Cardinality0..1
Typestring
Requirements

Provides more detail than conveyed by category.

Summarytrue
Comments

CarePlan.description is not intended to convey the entire care plan. It is possible to convey the entire care plan narrative using CarePlan.text instead.

CarePlan.subject
Element IdCarePlan.subject
Definition

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

Short DisplayWho the care plan is for
Cardinality1..1
TypeReference(Patient | Group)
Alternate Namespatient
Summarytrue
CarePlan.encounter
Element IdCarePlan.encounter
Definition

The Encounter during which this CarePlan was created or to which the creation of this record is tightly associated.

Short DisplayThe Encounter during which this CarePlan was created
Cardinality0..1
TypeReference(Encounter)
Summarytrue
Comments

This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. CarePlan activities conducted as a result of the care plan may well occur as part of other encounters.

CarePlan.period
Element IdCarePlan.period
Definition

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

Short DisplayTime period plan covers
Cardinality0..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.created
Element IdCarePlan.created
Definition

Represents when this particular CarePlan record was created in the system, which is often a system-generated date.

Short DisplayDate record was first recorded
Cardinality0..1
TypedateTime
Alternate NamesauthoredOn
Summarytrue
CarePlan.custodian
Element IdCarePlan.custodian
Definition

When populated, the custodian is responsible for the care plan. The care plan is attributed to the custodian.

Short DisplayWho is the designated responsible party
Cardinality0..1
TypeReference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam)
Summarytrue
Comments

The custodian might or might not be a contributor.

CarePlan.contributor
Element IdCarePlan.contributor
Definition

Identifies the individual(s), organization or device who provided the contents of the care plan.

Short DisplayWho provided the content of the care plan
Cardinality0..*
TypeReference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam)
Summaryfalse
Comments

Collaborative care plans may have multiple contributors.

CarePlan.careTeam
Element IdCarePlan.careTeam
Definition

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

Short DisplayWho's involved in plan?
Cardinality0..*
TypeReference(CareTeam)
Requirements

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

Summaryfalse
CarePlan.addresses
Element IdCarePlan.addresses
Definition

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

Short DisplayHealth issues this plan addresses
Cardinality0..*
Terminology BindingSNOMED CT Clinical Findings (Example)
TypeCodeableReference(Condition | Procedure | MedicationAdministration)
Requirements

The element can identify risks addressed by the plan as well as concerns. Also scopes plans - multiple plans may exist addressing different concerns.

Summarytrue
Comments

Use CarePlan.addresses.concept when a code sufficiently describes the concern (e.g. condition, problem, diagnosis, risk). Use CarePlan.addresses.reference when referencing a resource, which allows more information to be conveyed, such as onset date. CarePlan.addresses.concept and CarePlan.addresses.reference are not meant to be duplicative. For a single concern, either CarePlan.addresses.concept or CarePlan.addresses.reference can be used. CarePlan.addresses.concept may be a summary code, or CarePlan.addresses.reference may be used to reference a very precise definition of the concern using Condition. Both CarePlan.addresses.concept and CarePlan.addresses.reference can be used if they are describing different concerns for the care plan.

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.

Short DisplayInformation considered as part of plan
Cardinality0..*
TypeReference(Any)
Requirements

Identifies barriers and other considerations associated with the care plan.

Summaryfalse
Comments

Use "concern" to identify specific conditions addressed by the care plan. supportingInfo can be used to convey one or more Advance Directives or Medical Treatment Consent Directives by referencing Consent or any other request resource with intent = directive.

CarePlan.goal
Element IdCarePlan.goal
Definition

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

Short DisplayDesired outcome of plan
Cardinality0..*
TypeReference(Goal)
Requirements

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

Summaryfalse
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 an action that has occurred or is a planned action to occur as part of the plan. For example, a medication to be used, lab tests to perform, self-monitoring that has occurred, education etc.

Short DisplayAction to occur or has occurred as part of plan
Cardinality0..*
Requirements

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

Summaryfalse
CarePlan.activity.performedActivity
Element IdCarePlan.activity.performedActivity
Definition

Identifies the activity that was performed. For example, an activity could be patient education, exercise, or a medication administration. The reference to an "event" resource, such as Procedure or Encounter or Observation, represents the activity that was performed. The requested activity can be conveyed using the CarePlan.activity.plannedActivityReference (a reference to a “request” resource).

Short DisplayResults of the activity (concept, or Appointment, Encounter, Procedure, etc.)
Cardinality0..*
Terminology BindingCare Plan Activity Performed (Example)
TypeCodeableReference(Any)
Requirements

Links plan to resulting actions.

Summaryfalse
Comments

Note that this should not duplicate the activity status (e.g. completed or in progress). The activity performed 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 exercise, then the activity performed could be amount and intensity of exercise performed 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.

Short DisplayComments about the activity status/progress
Cardinality0..*
TypeAnnotation
Requirements

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

Summaryfalse
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.plannedActivityReference
Element IdCarePlan.activity.plannedActivityReference
Definition

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

Short DisplayActivity that is intended to be part of the care plan
Cardinality0..1
TypeReference(Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestOrchestration | ImmunizationRecommendation | SupplyRequest)
Requirements

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

Summaryfalse
Comments

Standard extension exists (http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal) that allows goals to be referenced from any of the referenced resources in CarePlan.activity.plannedActivityReference.
The goal should be visible when the resource referenced by CarePlan.activity.plannedActivityReference 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.

CarePlan.note
Element IdCarePlan.note
Definition

General notes about the care plan not covered elsewhere.

Short DisplayComments about the plan
Cardinality0..*
TypeAnnotation
Requirements

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

Summaryfalse