PACIO Advance Directive Interoperability Implementation Guide, published by HL7 International / Patient Empowerment. This guide is not an authorized publication; it is the continuous build for version 2.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-pacio-adi/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PreferenceCarePlan | Version: 2.1.0 | |||
Active as of 2024-10-07 | Computable Name: ADIPreferenceCarePlan |
The Preference Care Plan is a means for an individual to express their goals and preferences under certain circumstances that may be pertinent when planning his or her care.
The ADI PtAuthored Care Plan represents the patient’s goals for treatment based on circumstances or situations that provide context for the goals documented. A patient could document their goal of care in a situation such as a terminal condition that will result in their death in a relatively short period of time as being to extend their life for as long as possible, or allow their natural death to occur, or allow limited treatments to occur for a certain period of time before they are stopped. In a different situation, such as permanent and severe brain damage from which they are not expected to recover, that their goal of care options may be the same but their documented selection is different. Various forms and jurisdictions include circumstances or situations that are relatively consistent but still vary somewhat, so this Resource allows the basic structure of a context or circumstance or situation to be defined, against which the identification of a goal is documented, and against which in some existing forms further identification of the patient’s preference for interventions is captured. To enable the patient’s own preferred plan of care to merge with the care team’s clinical plan of care results in a jointly-authored and patient-centered plan of care that is informed by the person receiving care and the care team responsible for delivering that care.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreCarePlanProfile
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
CarePlan | C | 0..* | USCoreCarePlanProfile | Healthcare plan for patient or group goal-or-supportingInfo-required: Either goal or supportingInfo must exist, ie. goal and supportingInfo cannot both be blank, ie. if goal does not exist then supportingInfo must exist. |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
GoalOrderByDescendingPriority | 0..1 | CodeableConcept | Goal Order by Descending Priority URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-goal-order-by-descending-priority-extension Binding: hl7VS-yes-no-Indicator (extensible) | |
status | 1..1 | code | (USCDI) draft | active | on-hold | revoked | completed | entered-in-error | unknown Required Pattern: active | |
intent | 1..1 | code | (USCDI) proposal | plan | order | option Required Pattern: proposal | |
Slices for category | 2..* | CodeableConcept | (USCDI) Type of plan Slice: Unordered, Open by pattern:$this | |
category:advance_care_planning | S | 1..1 | CodeableConcept | (USCDI) Type of plan Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 81378-2 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Goals, preferences, and priorities under certain health conditions [Reported] | |
title | S | 1..1 | string | Human-friendly name for the care plan |
addresses | S | 0..* | Reference(Condition) | Health issues this plan addresses (use display only for potential conditions the patient does not currently have) |
supportingInfo | S | 0..* | Reference(ADI PtAuthored Care Experience Preference) | Observations of a patient's preferences for the scope of this care plan. |
goal | S | 0..* | Reference(ADI PtAuthored Personal Goal) | Patient's goals for the scope of this care plan. |
activity | ||||
reference | 0..1 | Reference(US Core ServiceRequest Profile) | Activity details defined in specific resource | |
Documentation for this format |
Id | Grade | Path(s) | Details | Requirements |
goal-or-supportingInfo-required | error | CarePlan | Either goal or supportingInfo must exist, ie. goal and supportingInfo cannot both be blank, ie. if goal does not exist then supportingInfo must exist. : goal.empty() implies supportingInfo.exists() |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
CarePlan | C | 0..* | USCoreCarePlanProfile | Healthcare plan for patient or group goal-or-supportingInfo-required: Either goal or supportingInfo must exist, ie. goal and supportingInfo cannot both be blank, ie. if goal does not exist then supportingInfo must exist. |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
text | S | 0..1 | Narrative | (USCDI) Text summary of the resource, for human interpretation |
status | S | 1..1 | code | (USCDI) generated | extensions | additional | empty Binding: US Core Narrative Status (required): Constrained value set of narrative statuses. |
div | SC | 1..1 | xhtml | (USCDI) Limited xhtml content txt-1: The narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes txt-2: The narrative SHALL have some non-whitespace content |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
GoalOrderByDescendingPriority | 0..1 | CodeableConcept | Goal Order by Descending Priority URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-goal-order-by-descending-priority-extension Binding: hl7VS-yes-no-Indicator (extensible) | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!SΣ | 1..1 | code | (USCDI) draft | active | on-hold | revoked | completed | entered-in-error | unknown Binding: RequestStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record. Required Pattern: active |
intent | ?!SΣ | 1..1 | code | (USCDI) proposal | plan | order | option Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan Required Pattern: proposal |
Slices for category | SΣ | 2..* | CodeableConcept | (USCDI) Type of plan Slice: Unordered, Open by pattern:$this Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. |
category:AssessPlan | SΣ | 1..1 | CodeableConcept | (USCDI) Type of plan Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/careplan-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: assess-plan | |
category:advance_care_planning | SΣ | 1..1 | CodeableConcept | (USCDI) Type of plan Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 81378-2 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Goals, preferences, and priorities under certain health conditions [Reported] | |
title | SΣ | 1..1 | string | Human-friendly name for the care plan |
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | (USCDI) Who the care plan is for |
addresses | SΣ | 0..* | Reference(Condition) | Health issues this plan addresses (use display only for potential conditions the patient does not currently have) |
supportingInfo | S | 0..* | Reference(ADI PtAuthored Care Experience Preference) | Observations of a patient's preferences for the scope of this care plan. |
goal | S | 0..* | Reference(ADI PtAuthored Personal Goal) | Patient's goals for the scope of this care plan. |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
CarePlan.text.status | required | NarrativeStatushttp://hl7.org/fhir/us/core/ValueSet/us-core-narrative-status | |
CarePlan.status | required | Pattern: activehttp://hl7.org/fhir/ValueSet/request-status from the FHIR Standard | |
CarePlan.intent | required | Pattern: proposalhttp://hl7.org/fhir/ValueSet/care-plan-intent from the FHIR Standard | |
CarePlan.category | example | CarePlanCategoryhttp://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard | |
CarePlan.category:AssessPlan | example | Pattern: assess-planhttp://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard | |
CarePlan.category:advance_care_planning | example | Pattern: LOINC Code 81378-2("Goals, preferences, and priorities under certain health conditions [Reported]")http://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
goal-or-supportingInfo-required | error | CarePlan | Either goal or supportingInfo must exist, ie. goal and supportingInfo cannot both be blank, ie. if goal does not exist then supportingInfo must exist. : goal.empty() implies supportingInfo.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
CarePlan | C | 0..* | USCoreCarePlanProfile | Healthcare plan for patient or group goal-or-supportingInfo-required: Either goal or supportingInfo must exist, ie. goal and supportingInfo cannot both be blank, ie. if goal does not exist then supportingInfo must exist. | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | S | 0..1 | Narrative | (USCDI) Text summary of the resource, for human interpretation | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
status | S | 1..1 | code | (USCDI) generated | extensions | additional | empty Binding: US Core Narrative Status (required): Constrained value set of narrative statuses. | ||||
div | SC | 1..1 | xhtml | (USCDI) Limited xhtml content txt-1: The narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes txt-2: The narrative SHALL have some non-whitespace content | ||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
GoalOrderByDescendingPriority | 0..1 | CodeableConcept | Goal Order by Descending Priority URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-goal-order-by-descending-priority-extension Binding: hl7VS-yes-no-Indicator (extensible) | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | External Ids for this plan | ||||
instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | Questionnaire | Measure | ActivityDefinition | OperationDefinition) | Instantiates FHIR protocol or definition | ||||
instantiatesUri | Σ | 0..* | uri | Instantiates external protocol or definition | ||||
basedOn | Σ | 0..* | Reference(CarePlan) | Fulfills CarePlan | ||||
replaces | Σ | 0..* | Reference(CarePlan) | CarePlan replaced by this CarePlan | ||||
partOf | Σ | 0..* | Reference(CarePlan) | Part of referenced CarePlan | ||||
status | ?!SΣ | 1..1 | code | (USCDI) draft | active | on-hold | revoked | completed | entered-in-error | unknown Binding: RequestStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record. Required Pattern: active | ||||
intent | ?!SΣ | 1..1 | code | (USCDI) proposal | plan | order | option Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan Required Pattern: proposal | ||||
Slices for category | SΣ | 2..* | CodeableConcept | (USCDI) Type of plan Slice: Unordered, Open by pattern:$this Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. | ||||
category:AssessPlan | SΣ | 1..1 | CodeableConcept | (USCDI) Type of plan Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/careplan-category | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: assess-plan | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
category:advance_care_planning | SΣ | 1..1 | CodeableConcept | (USCDI) Type of plan Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 81378-2 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Goals, preferences, and priorities under certain health conditions [Reported] | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
title | SΣ | 1..1 | string | Human-friendly name for the care plan | ||||
description | Σ | 0..1 | string | Summary of nature of plan | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | (USCDI) Who the care plan is for | ||||
encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
period | Σ | 0..1 | Period | Time period plan covers | ||||
created | Σ | 0..1 | dateTime | Date record was first recorded | ||||
author | Σ | 0..1 | Reference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam) | Who is the designated responsible party | ||||
contributor | 0..* | Reference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam) | Who provided the content of the care plan | |||||
careTeam | 0..* | Reference(CareTeam) | Who's involved in plan? | |||||
addresses | SΣ | 0..* | Reference(Condition) | Health issues this plan addresses (use display only for potential conditions the patient does not currently have) | ||||
supportingInfo | S | 0..* | Reference(ADI PtAuthored Care Experience Preference) | Observations of a patient's preferences for the scope of this care plan. | ||||
goal | S | 0..* | Reference(ADI PtAuthored Personal Goal) | Patient's goals for the scope of this care plan. | ||||
activity | C | 0..* | BackboneElement | Action to occur as part of plan cpl-3: Provide a reference or detail, not both | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
outcomeCodeableConcept | 0..* | CodeableConcept | Results of the activity Binding: CarePlanActivityOutcome (example): Identifies the results of the activity. | |||||
outcomeReference | 0..* | Reference(Resource) | Appointment, Encounter, Procedure, etc. | |||||
progress | 0..* | Annotation | Comments about the activity status/progress | |||||
reference | C | 0..1 | Reference(US Core ServiceRequest Profile) | Activity details defined in specific resource | ||||
detail | C | 0..1 | BackboneElement | In-line definition of activity | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
kind | 0..1 | code | Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription Binding: CarePlanActivityKind (required): Resource types defined as part of FHIR that can be represented as in-line definitions of a care plan activity. | |||||
instantiatesCanonical | 0..* | canonical(PlanDefinition | ActivityDefinition | Questionnaire | Measure | OperationDefinition) | Instantiates FHIR protocol or definition | |||||
instantiatesUri | 0..* | uri | Instantiates external protocol or definition | |||||
code | 0..1 | CodeableConcept | Detail type of activity Binding: ProcedureCodes(SNOMEDCT) (example): Detailed description of the type of activity; e.g. What lab test, what procedure, what kind of encounter. | |||||
reasonCode | 0..* | CodeableConcept | Why activity should be done or why activity was prohibited Binding: SNOMEDCTClinicalFindings (example): 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. | |||||
reasonReference | 0..* | Reference(Condition | Observation | DiagnosticReport | DocumentReference) | Why activity is needed | |||||
goal | 0..* | Reference(Goal) | Goals this activity relates to | |||||
status | ?! | 1..1 | code | not-started | scheduled | in-progress | on-hold | completed | cancelled | stopped | unknown | entered-in-error Binding: CarePlanActivityStatus (required): Codes that reflect the current state of a care plan activity within its overall life cycle. | ||||
statusReason | 0..1 | CodeableConcept | Reason for current status | |||||
doNotPerform | ?! | 0..1 | boolean | If true, activity is prohibiting action | ||||
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 | PractitionerRole | Organization | RelatedPerson | Patient | CareTeam | HealthcareService | Device) | Who will be responsible? | |||||
product[x] | 0..1 | What is to be administered/supplied Binding: SNOMEDCTMedicationCodes (example): A product supplied or administered as part of a care plan activity. | ||||||
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..* | Annotation | Comments about the plan | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
CarePlan.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
CarePlan.text.status | required | NarrativeStatushttp://hl7.org/fhir/us/core/ValueSet/us-core-narrative-status | ||||
CarePlan.status | required | Pattern: activehttp://hl7.org/fhir/ValueSet/request-status from the FHIR Standard | ||||
CarePlan.intent | required | Pattern: proposalhttp://hl7.org/fhir/ValueSet/care-plan-intent from the FHIR Standard | ||||
CarePlan.category | example | CarePlanCategoryhttp://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard | ||||
CarePlan.category:AssessPlan | example | Pattern: assess-planhttp://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard | ||||
CarePlan.category:advance_care_planning | example | Pattern: LOINC Code 81378-2("Goals, preferences, and priorities under certain health conditions [Reported]")http://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard | ||||
CarePlan.activity.outcomeCodeableConcept | example | CarePlanActivityOutcomehttp://hl7.org/fhir/ValueSet/care-plan-activity-outcome from the FHIR Standard | ||||
CarePlan.activity.detail.kind | required | CarePlanActivityKindhttp://hl7.org/fhir/ValueSet/care-plan-activity-kind|4.0.1 from the FHIR Standard | ||||
CarePlan.activity.detail.code | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | ||||
CarePlan.activity.detail.reasonCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findings from the FHIR Standard | ||||
CarePlan.activity.detail.status | required | CarePlanActivityStatushttp://hl7.org/fhir/ValueSet/care-plan-activity-status|4.0.1 from the FHIR Standard | ||||
CarePlan.activity.detail.product[x] | example | SNOMEDCTMedicationCodeshttp://hl7.org/fhir/ValueSet/medication-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
goal-or-supportingInfo-required | error | CarePlan | Either goal or supportingInfo must exist, ie. goal and supportingInfo cannot both be blank, ie. if goal does not exist then supportingInfo must exist. : goal.empty() implies supportingInfo.exists() |
This structure is derived from USCoreCarePlanProfile
Summary
Mandatory: 2 elements
Must-Support: 5 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from USCoreCarePlanProfile
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
CarePlan | C | 0..* | USCoreCarePlanProfile | Healthcare plan for patient or group goal-or-supportingInfo-required: Either goal or supportingInfo must exist, ie. goal and supportingInfo cannot both be blank, ie. if goal does not exist then supportingInfo must exist. |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
GoalOrderByDescendingPriority | 0..1 | CodeableConcept | Goal Order by Descending Priority URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-goal-order-by-descending-priority-extension Binding: hl7VS-yes-no-Indicator (extensible) | |
status | 1..1 | code | (USCDI) draft | active | on-hold | revoked | completed | entered-in-error | unknown Required Pattern: active | |
intent | 1..1 | code | (USCDI) proposal | plan | order | option Required Pattern: proposal | |
Slices for category | 2..* | CodeableConcept | (USCDI) Type of plan Slice: Unordered, Open by pattern:$this | |
category:advance_care_planning | S | 1..1 | CodeableConcept | (USCDI) Type of plan Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 81378-2 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Goals, preferences, and priorities under certain health conditions [Reported] | |
title | S | 1..1 | string | Human-friendly name for the care plan |
addresses | S | 0..* | Reference(Condition) | Health issues this plan addresses (use display only for potential conditions the patient does not currently have) |
supportingInfo | S | 0..* | Reference(ADI PtAuthored Care Experience Preference) | Observations of a patient's preferences for the scope of this care plan. |
goal | S | 0..* | Reference(ADI PtAuthored Personal Goal) | Patient's goals for the scope of this care plan. |
activity | ||||
reference | 0..1 | Reference(US Core ServiceRequest Profile) | Activity details defined in specific resource | |
Documentation for this format |
Id | Grade | Path(s) | Details | Requirements |
goal-or-supportingInfo-required | error | CarePlan | Either goal or supportingInfo must exist, ie. goal and supportingInfo cannot both be blank, ie. if goal does not exist then supportingInfo must exist. : goal.empty() implies supportingInfo.exists() |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
CarePlan | C | 0..* | USCoreCarePlanProfile | Healthcare plan for patient or group goal-or-supportingInfo-required: Either goal or supportingInfo must exist, ie. goal and supportingInfo cannot both be blank, ie. if goal does not exist then supportingInfo must exist. |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
text | S | 0..1 | Narrative | (USCDI) Text summary of the resource, for human interpretation |
status | S | 1..1 | code | (USCDI) generated | extensions | additional | empty Binding: US Core Narrative Status (required): Constrained value set of narrative statuses. |
div | SC | 1..1 | xhtml | (USCDI) Limited xhtml content txt-1: The narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes txt-2: The narrative SHALL have some non-whitespace content |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
GoalOrderByDescendingPriority | 0..1 | CodeableConcept | Goal Order by Descending Priority URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-goal-order-by-descending-priority-extension Binding: hl7VS-yes-no-Indicator (extensible) | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!SΣ | 1..1 | code | (USCDI) draft | active | on-hold | revoked | completed | entered-in-error | unknown Binding: RequestStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record. Required Pattern: active |
intent | ?!SΣ | 1..1 | code | (USCDI) proposal | plan | order | option Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan Required Pattern: proposal |
Slices for category | SΣ | 2..* | CodeableConcept | (USCDI) Type of plan Slice: Unordered, Open by pattern:$this Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. |
category:AssessPlan | SΣ | 1..1 | CodeableConcept | (USCDI) Type of plan Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/careplan-category | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: assess-plan | |
category:advance_care_planning | SΣ | 1..1 | CodeableConcept | (USCDI) Type of plan Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 81378-2 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Goals, preferences, and priorities under certain health conditions [Reported] | |
title | SΣ | 1..1 | string | Human-friendly name for the care plan |
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | (USCDI) Who the care plan is for |
addresses | SΣ | 0..* | Reference(Condition) | Health issues this plan addresses (use display only for potential conditions the patient does not currently have) |
supportingInfo | S | 0..* | Reference(ADI PtAuthored Care Experience Preference) | Observations of a patient's preferences for the scope of this care plan. |
goal | S | 0..* | Reference(ADI PtAuthored Personal Goal) | Patient's goals for the scope of this care plan. |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
CarePlan.text.status | required | NarrativeStatushttp://hl7.org/fhir/us/core/ValueSet/us-core-narrative-status | |
CarePlan.status | required | Pattern: activehttp://hl7.org/fhir/ValueSet/request-status from the FHIR Standard | |
CarePlan.intent | required | Pattern: proposalhttp://hl7.org/fhir/ValueSet/care-plan-intent from the FHIR Standard | |
CarePlan.category | example | CarePlanCategoryhttp://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard | |
CarePlan.category:AssessPlan | example | Pattern: assess-planhttp://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard | |
CarePlan.category:advance_care_planning | example | Pattern: LOINC Code 81378-2("Goals, preferences, and priorities under certain health conditions [Reported]")http://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
goal-or-supportingInfo-required | error | CarePlan | Either goal or supportingInfo must exist, ie. goal and supportingInfo cannot both be blank, ie. if goal does not exist then supportingInfo must exist. : goal.empty() implies supportingInfo.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
CarePlan | C | 0..* | USCoreCarePlanProfile | Healthcare plan for patient or group goal-or-supportingInfo-required: Either goal or supportingInfo must exist, ie. goal and supportingInfo cannot both be blank, ie. if goal does not exist then supportingInfo must exist. | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | S | 0..1 | Narrative | (USCDI) Text summary of the resource, for human interpretation | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
status | S | 1..1 | code | (USCDI) generated | extensions | additional | empty Binding: US Core Narrative Status (required): Constrained value set of narrative statuses. | ||||
div | SC | 1..1 | xhtml | (USCDI) Limited xhtml content txt-1: The narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes txt-2: The narrative SHALL have some non-whitespace content | ||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
GoalOrderByDescendingPriority | 0..1 | CodeableConcept | Goal Order by Descending Priority URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-goal-order-by-descending-priority-extension Binding: hl7VS-yes-no-Indicator (extensible) | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | External Ids for this plan | ||||
instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | Questionnaire | Measure | ActivityDefinition | OperationDefinition) | Instantiates FHIR protocol or definition | ||||
instantiatesUri | Σ | 0..* | uri | Instantiates external protocol or definition | ||||
basedOn | Σ | 0..* | Reference(CarePlan) | Fulfills CarePlan | ||||
replaces | Σ | 0..* | Reference(CarePlan) | CarePlan replaced by this CarePlan | ||||
partOf | Σ | 0..* | Reference(CarePlan) | Part of referenced CarePlan | ||||
status | ?!SΣ | 1..1 | code | (USCDI) draft | active | on-hold | revoked | completed | entered-in-error | unknown Binding: RequestStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record. Required Pattern: active | ||||
intent | ?!SΣ | 1..1 | code | (USCDI) proposal | plan | order | option Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan Required Pattern: proposal | ||||
Slices for category | SΣ | 2..* | CodeableConcept | (USCDI) Type of plan Slice: Unordered, Open by pattern:$this Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. | ||||
category:AssessPlan | SΣ | 1..1 | CodeableConcept | (USCDI) Type of plan Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/careplan-category | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: assess-plan | |||||
display | 0..1 | string | Representation defined by the system | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
category:advance_care_planning | SΣ | 1..1 | CodeableConcept | (USCDI) Type of plan Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. Required Pattern: At least the following | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 81378-2 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Goals, preferences, and priorities under certain health conditions [Reported] | |||||
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
text | 0..1 | string | Plain text representation of the concept | |||||
title | SΣ | 1..1 | string | Human-friendly name for the care plan | ||||
description | Σ | 0..1 | string | Summary of nature of plan | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | (USCDI) Who the care plan is for | ||||
encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
period | Σ | 0..1 | Period | Time period plan covers | ||||
created | Σ | 0..1 | dateTime | Date record was first recorded | ||||
author | Σ | 0..1 | Reference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam) | Who is the designated responsible party | ||||
contributor | 0..* | Reference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam) | Who provided the content of the care plan | |||||
careTeam | 0..* | Reference(CareTeam) | Who's involved in plan? | |||||
addresses | SΣ | 0..* | Reference(Condition) | Health issues this plan addresses (use display only for potential conditions the patient does not currently have) | ||||
supportingInfo | S | 0..* | Reference(ADI PtAuthored Care Experience Preference) | Observations of a patient's preferences for the scope of this care plan. | ||||
goal | S | 0..* | Reference(ADI PtAuthored Personal Goal) | Patient's goals for the scope of this care plan. | ||||
activity | C | 0..* | BackboneElement | Action to occur as part of plan cpl-3: Provide a reference or detail, not both | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
outcomeCodeableConcept | 0..* | CodeableConcept | Results of the activity Binding: CarePlanActivityOutcome (example): Identifies the results of the activity. | |||||
outcomeReference | 0..* | Reference(Resource) | Appointment, Encounter, Procedure, etc. | |||||
progress | 0..* | Annotation | Comments about the activity status/progress | |||||
reference | C | 0..1 | Reference(US Core ServiceRequest Profile) | Activity details defined in specific resource | ||||
detail | C | 0..1 | BackboneElement | In-line definition of activity | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
kind | 0..1 | code | Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription Binding: CarePlanActivityKind (required): Resource types defined as part of FHIR that can be represented as in-line definitions of a care plan activity. | |||||
instantiatesCanonical | 0..* | canonical(PlanDefinition | ActivityDefinition | Questionnaire | Measure | OperationDefinition) | Instantiates FHIR protocol or definition | |||||
instantiatesUri | 0..* | uri | Instantiates external protocol or definition | |||||
code | 0..1 | CodeableConcept | Detail type of activity Binding: ProcedureCodes(SNOMEDCT) (example): Detailed description of the type of activity; e.g. What lab test, what procedure, what kind of encounter. | |||||
reasonCode | 0..* | CodeableConcept | Why activity should be done or why activity was prohibited Binding: SNOMEDCTClinicalFindings (example): 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. | |||||
reasonReference | 0..* | Reference(Condition | Observation | DiagnosticReport | DocumentReference) | Why activity is needed | |||||
goal | 0..* | Reference(Goal) | Goals this activity relates to | |||||
status | ?! | 1..1 | code | not-started | scheduled | in-progress | on-hold | completed | cancelled | stopped | unknown | entered-in-error Binding: CarePlanActivityStatus (required): Codes that reflect the current state of a care plan activity within its overall life cycle. | ||||
statusReason | 0..1 | CodeableConcept | Reason for current status | |||||
doNotPerform | ?! | 0..1 | boolean | If true, activity is prohibiting action | ||||
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 | PractitionerRole | Organization | RelatedPerson | Patient | CareTeam | HealthcareService | Device) | Who will be responsible? | |||||
product[x] | 0..1 | What is to be administered/supplied Binding: SNOMEDCTMedicationCodes (example): A product supplied or administered as part of a care plan activity. | ||||||
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..* | Annotation | Comments about the plan | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
CarePlan.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
CarePlan.text.status | required | NarrativeStatushttp://hl7.org/fhir/us/core/ValueSet/us-core-narrative-status | ||||
CarePlan.status | required | Pattern: activehttp://hl7.org/fhir/ValueSet/request-status from the FHIR Standard | ||||
CarePlan.intent | required | Pattern: proposalhttp://hl7.org/fhir/ValueSet/care-plan-intent from the FHIR Standard | ||||
CarePlan.category | example | CarePlanCategoryhttp://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard | ||||
CarePlan.category:AssessPlan | example | Pattern: assess-planhttp://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard | ||||
CarePlan.category:advance_care_planning | example | Pattern: LOINC Code 81378-2("Goals, preferences, and priorities under certain health conditions [Reported]")http://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard | ||||
CarePlan.activity.outcomeCodeableConcept | example | CarePlanActivityOutcomehttp://hl7.org/fhir/ValueSet/care-plan-activity-outcome from the FHIR Standard | ||||
CarePlan.activity.detail.kind | required | CarePlanActivityKindhttp://hl7.org/fhir/ValueSet/care-plan-activity-kind|4.0.1 from the FHIR Standard | ||||
CarePlan.activity.detail.code | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | ||||
CarePlan.activity.detail.reasonCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findings from the FHIR Standard | ||||
CarePlan.activity.detail.status | required | CarePlanActivityStatushttp://hl7.org/fhir/ValueSet/care-plan-activity-status|4.0.1 from the FHIR Standard | ||||
CarePlan.activity.detail.product[x] | example | SNOMEDCTMedicationCodeshttp://hl7.org/fhir/ValueSet/medication-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
goal-or-supportingInfo-required | error | CarePlan | Either goal or supportingInfo must exist, ie. goal and supportingInfo cannot both be blank, ie. if goal does not exist then supportingInfo must exist. : goal.empty() implies supportingInfo.exists() |
This structure is derived from USCoreCarePlanProfile
Summary
Mandatory: 2 elements
Must-Support: 5 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron