HL7.FHIR.US.PACIO-ADI\ADI Preference Care Plan

PACIO Advance Directive Interoperability Implementation Guide
0.1.0 - STU1

PACIO Advance Directive Interoperability Implementation Guide, published by HL7 Patient Empowerment Working Group. This is not an authorized publication; it is the continuous build for version 0.1.0). This version is based on the current content of https://github.com/HL7/pacio-adi/ and changes regularly. See the Directory of published versions

Resource Profile: ADI Preference Care Plan

Defining URL:

http://hl7.org/fhir/us/pacio-adi/StructureDefinition/PADI-PreferenceCarePlan

Version:

0.1.0

Name:

PADIPreferenceCarePlan

Title:

ADI Preference Care Plan

Status:

Active as of 2021-11-08T23:13:35+00:00

Definition:

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.

Publisher:

HL7 Patient Empowerment Working Group

Source Resource:

XML / JSON / Turtle

The official URL for this profile is:

http://hl7.org/fhir/us/pacio-adi/StructureDefinition/PADI-PreferenceCarePlan

Formal Views of Profile Content

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

This structure is derived from CarePlan

Summary

Mandatory: 4 elements
Must-Support: 4 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-goal-order-by-descending-priority-extension

Slices

This structure defines the following Slices:

The element CarePlan.category is sliced based on the value of pattern:$this

This structure is derived from CarePlan

Name	Flags	Card.	Type	Description & Constraints
CarePlan		0..*	CarePlan	Healthcare plan for patient or group
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
padi-goal-order-by-descending-priority-extension		0..1	CodeableConcept	Goal Order by Descending Priority URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-goal-order-by-descending-priority-extension Binding: hl7VS-yes-no-Indicator (extensible)
status		1..1	code	draft \| active \| on-hold \| revoked \| completed \| entered-in-error \| unknown Required Pattern: active
intent		1..1	code	proposal \| plan \| order \| option Required Pattern: proposal
Slices for category		1..*	CodeableConcept	Type of plan Slice: Unordered, Open by pattern:$this
category:advance_care_planning	S	1..1	CodeableConcept	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://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 736366004
display		1..1	string	Representation defined by the system Fixed Value: Advance care plan
subject	S	1..1	Reference(US Core Patient Profile)	Who the care plan is for
addresses	S	1..*	Reference(Condition)	Health issues this plan addresses
goal	S	1..*	Reference(Personal Intervention Preference \| ADI Personal Goal \| ADI Care Experience Preference)	Patient's preferences and goals for the scope of this care plan.
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
CarePlan		0..*	CarePlan	Healthcare plan for patient or group
id	Σ	0..1	string	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) Max Binding: AllLanguages: A human language.
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
padi-goal-order-by-descending-priority-extension		0..1	CodeableConcept	Goal Order by Descending Priority URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-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	?!Σ	1..1	code	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	?!Σ	1..1	code	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	Σ	1..*	CodeableConcept	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:advance_care_planning	SΣ	1..1	CodeableConcept	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://snomed.info/sct
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 736366004
display		1..1	string	Representation defined by the system Fixed Value: Advance care plan
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
title	Σ	0..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)	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	1..*	Reference(Condition)	Health issues this plan addresses
supportingInfo		0..*	Reference(Resource)	Information considered as part of plan
goal	S	1..*	Reference(Personal Intervention Preference \| ADI Personal Goal \| ADI Care Experience Preference)	Patient's preferences and goals for the scope of this care plan.
activity	I	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	I	0..1	Reference(Appointment \| CommunicationRequest \| DeviceRequest \| MedicationRequest \| NutritionOrder \| Task \| ServiceRequest \| VisionPrescription \| RequestGroup)	Activity details defined in specific resource
detail	I	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

Name	Flags	Card.	Type	Description & Constraints
CarePlan		0..*	CarePlan	Healthcare plan for patient or group
category:advance_care_planning	Σ	1..1	CodeableConcept	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://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 736366004
display		1..1	string	Representation defined by the system Fixed Value: Advance care plan
subject	Σ	1..1	Reference(US Core Patient Profile)	Who the care plan is for
addresses	Σ	1..*	Reference(Condition)	Health issues this plan addresses
goal		1..*	Reference(Personal Intervention Preference \| ADI Personal Goal \| ADI Care Experience Preference)	Patient's preferences and goals for the scope of this care plan.
Documentation for this format

This structure is derived from CarePlan

Summary

Mandatory: 4 elements
Must-Support: 4 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-goal-order-by-descending-priority-extension

Slices

This structure defines the following Slices:

The element CarePlan.category is sliced based on the value of pattern:$this

Differential View

This structure is derived from CarePlan

Name	Flags	Card.	Type	Description & Constraints
CarePlan		0..*	CarePlan	Healthcare plan for patient or group
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
padi-goal-order-by-descending-priority-extension		0..1	CodeableConcept	Goal Order by Descending Priority URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-goal-order-by-descending-priority-extension Binding: hl7VS-yes-no-Indicator (extensible)
status		1..1	code	draft \| active \| on-hold \| revoked \| completed \| entered-in-error \| unknown Required Pattern: active
intent		1..1	code	proposal \| plan \| order \| option Required Pattern: proposal
Slices for category		1..*	CodeableConcept	Type of plan Slice: Unordered, Open by pattern:$this
category:advance_care_planning	S	1..1	CodeableConcept	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://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 736366004
display		1..1	string	Representation defined by the system Fixed Value: Advance care plan
subject	S	1..1	Reference(US Core Patient Profile)	Who the care plan is for
addresses	S	1..*	Reference(Condition)	Health issues this plan addresses
goal	S	1..*	Reference(Personal Intervention Preference \| ADI Personal Goal \| ADI Care Experience Preference)	Patient's preferences and goals for the scope of this care plan.
Documentation for this format

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
CarePlan		0..*	CarePlan	Healthcare plan for patient or group
id	Σ	0..1	string	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) Max Binding: AllLanguages: A human language.
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
padi-goal-order-by-descending-priority-extension		0..1	CodeableConcept	Goal Order by Descending Priority URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-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	?!Σ	1..1	code	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	?!Σ	1..1	code	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	Σ	1..*	CodeableConcept	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:advance_care_planning	SΣ	1..1	CodeableConcept	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://snomed.info/sct
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 736366004
display		1..1	string	Representation defined by the system Fixed Value: Advance care plan
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
title	Σ	0..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)	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	1..*	Reference(Condition)	Health issues this plan addresses
supportingInfo		0..*	Reference(Resource)	Information considered as part of plan
goal	S	1..*	Reference(Personal Intervention Preference \| ADI Personal Goal \| ADI Care Experience Preference)	Patient's preferences and goals for the scope of this care plan.
activity	I	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	I	0..1	Reference(Appointment \| CommunicationRequest \| DeviceRequest \| MedicationRequest \| NutritionOrder \| Task \| ServiceRequest \| VisionPrescription \| RequestGroup)	Activity details defined in specific resource
detail	I	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

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

Path	Conformance	ValueSet / Code
CarePlan.language	preferred	CommonLanguages Max Binding: AllLanguages
CarePlan.status	required	Pattern: active
CarePlan.intent	required	Pattern: proposal
CarePlan.category	example	CarePlanCategory
CarePlan.category:advance_care_planning	example	Pattern: SNOMED CT code 736366004("Advance care plan")
CarePlan.activity.outcomeCodeableConcept	example	CarePlanActivityOutcome
CarePlan.activity.detail.kind	required	CarePlanActivityKind
CarePlan.activity.detail.code	example	ProcedureCodes(SNOMEDCT)
CarePlan.activity.detail.reasonCode	example	SNOMEDCTClinicalFindings
CarePlan.activity.detail.status	required	CarePlanActivityStatus
CarePlan.activity.detail.product[x]	example	SNOMEDCTMedicationCodes

Constraints

Id	Path	Details	Requirements
cpl-3	CarePlan.activity	Provide a reference or detail, not both : detail.empty() or reference.empty()