PACIO Advance Directive Interoperability Implementation Guide
2.1.0 - STU 2 United States of America flag

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

Resource Profile: ADI Preference Care Plan

Official URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PreferenceCarePlan Version: 2.1.0
Active as of 2024-05-09 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 Preference 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:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from USCoreCarePlanProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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 Care Experience Preference) Observations of a patient's preferences for the scope of this care plan.
... goal S 0..* Reference(ADI 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

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
goal-or-supportingInfo-requirederrorCarePlanEither 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()
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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 Care Experience Preference) Observations of a patient's preferences for the scope of this care plan.
... goal S 0..* Reference(ADI Personal Goal) Patient's goals for the scope of this care plan.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
CarePlan.text.statusrequiredNarrativeStatus
http://hl7.org/fhir/us/core/ValueSet/us-core-narrative-status
CarePlan.statusrequiredPattern: active
http://hl7.org/fhir/ValueSet/request-status
from the FHIR Standard
CarePlan.intentrequiredPattern: proposal
http://hl7.org/fhir/ValueSet/care-plan-intent
from the FHIR Standard
CarePlan.categoryexampleCarePlanCategory
http://hl7.org/fhir/ValueSet/care-plan-category
from the FHIR Standard
CarePlan.category:AssessPlanexamplePattern: assess-plan
http://hl7.org/fhir/ValueSet/care-plan-category
from the FHIR Standard
CarePlan.category:advance_care_planningexamplePattern: 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

Constraints

IdGradePath(s)DetailsRequirements
goal-or-supportingInfo-requirederrorCarePlanEither 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()
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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.

Additional BindingsPurpose
AllLanguages Max Binding
... 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 Care Experience Preference) Observations of a patient's preferences for the scope of this care plan.
... goal S 0..* Reference(ADI 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
CarePlan.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
CarePlan.text.statusrequiredNarrativeStatus
http://hl7.org/fhir/us/core/ValueSet/us-core-narrative-status
CarePlan.statusrequiredPattern: active
http://hl7.org/fhir/ValueSet/request-status
from the FHIR Standard
CarePlan.intentrequiredPattern: proposal
http://hl7.org/fhir/ValueSet/care-plan-intent
from the FHIR Standard
CarePlan.categoryexampleCarePlanCategory
http://hl7.org/fhir/ValueSet/care-plan-category
from the FHIR Standard
CarePlan.category:AssessPlanexamplePattern: assess-plan
http://hl7.org/fhir/ValueSet/care-plan-category
from the FHIR Standard
CarePlan.category:advance_care_planningexamplePattern: 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.outcomeCodeableConceptexampleCarePlanActivityOutcome
http://hl7.org/fhir/ValueSet/care-plan-activity-outcome
from the FHIR Standard
CarePlan.activity.detail.kindrequiredCarePlanActivityKind
http://hl7.org/fhir/ValueSet/care-plan-activity-kind|4.0.1
from the FHIR Standard
CarePlan.activity.detail.codeexampleProcedureCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-code
from the FHIR Standard
CarePlan.activity.detail.reasonCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard
CarePlan.activity.detail.statusrequiredCarePlanActivityStatus
http://hl7.org/fhir/ValueSet/care-plan-activity-status|4.0.1
from the FHIR Standard
CarePlan.activity.detail.product[x]exampleSNOMEDCTMedicationCodes
http://hl7.org/fhir/ValueSet/medication-codes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
goal-or-supportingInfo-requirederrorCarePlanEither 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:

  • The element 1 is sliced based on the value of CarePlan.category

Differential View

This structure is derived from USCoreCarePlanProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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 Care Experience Preference) Observations of a patient's preferences for the scope of this care plan.
... goal S 0..* Reference(ADI 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

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
goal-or-supportingInfo-requirederrorCarePlanEither 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

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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 Care Experience Preference) Observations of a patient's preferences for the scope of this care plan.
... goal S 0..* Reference(ADI Personal Goal) Patient's goals for the scope of this care plan.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
CarePlan.text.statusrequiredNarrativeStatus
http://hl7.org/fhir/us/core/ValueSet/us-core-narrative-status
CarePlan.statusrequiredPattern: active
http://hl7.org/fhir/ValueSet/request-status
from the FHIR Standard
CarePlan.intentrequiredPattern: proposal
http://hl7.org/fhir/ValueSet/care-plan-intent
from the FHIR Standard
CarePlan.categoryexampleCarePlanCategory
http://hl7.org/fhir/ValueSet/care-plan-category
from the FHIR Standard
CarePlan.category:AssessPlanexamplePattern: assess-plan
http://hl7.org/fhir/ValueSet/care-plan-category
from the FHIR Standard
CarePlan.category:advance_care_planningexamplePattern: 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

Constraints

IdGradePath(s)DetailsRequirements
goal-or-supportingInfo-requirederrorCarePlanEither 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

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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.

Additional BindingsPurpose
AllLanguages Max Binding
... 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 Care Experience Preference) Observations of a patient's preferences for the scope of this care plan.
... goal S 0..* Reference(ADI 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
CarePlan.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
CarePlan.text.statusrequiredNarrativeStatus
http://hl7.org/fhir/us/core/ValueSet/us-core-narrative-status
CarePlan.statusrequiredPattern: active
http://hl7.org/fhir/ValueSet/request-status
from the FHIR Standard
CarePlan.intentrequiredPattern: proposal
http://hl7.org/fhir/ValueSet/care-plan-intent
from the FHIR Standard
CarePlan.categoryexampleCarePlanCategory
http://hl7.org/fhir/ValueSet/care-plan-category
from the FHIR Standard
CarePlan.category:AssessPlanexamplePattern: assess-plan
http://hl7.org/fhir/ValueSet/care-plan-category
from the FHIR Standard
CarePlan.category:advance_care_planningexamplePattern: 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.outcomeCodeableConceptexampleCarePlanActivityOutcome
http://hl7.org/fhir/ValueSet/care-plan-activity-outcome
from the FHIR Standard
CarePlan.activity.detail.kindrequiredCarePlanActivityKind
http://hl7.org/fhir/ValueSet/care-plan-activity-kind|4.0.1
from the FHIR Standard
CarePlan.activity.detail.codeexampleProcedureCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-code
from the FHIR Standard
CarePlan.activity.detail.reasonCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard
CarePlan.activity.detail.statusrequiredCarePlanActivityStatus
http://hl7.org/fhir/ValueSet/care-plan-activity-status|4.0.1
from the FHIR Standard
CarePlan.activity.detail.product[x]exampleSNOMEDCTMedicationCodes
http://hl7.org/fhir/ValueSet/medication-codes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
goal-or-supportingInfo-requirederrorCarePlanEither 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:

  • The element 1 is sliced based on the value of CarePlan.category

 

Other representations of profile: CSV, Excel, Schematron