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9.5 Resource CarePlan - Content

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

Describes the intention of how one or more practitioners intend to deliver care for a particular patient, group or community for a period of time, possibly limited to care for a specific condition or set of conditions.

9.5.1 Scope and Usage

CarePlan is one of the request resources in the FHIR workflow specification.

Care Plans are used in many areas of healthcare with a variety of scopes. They can be as simple as a general practitioner keeping track of when their patient is next due for a tetanus immunization through to a detailed plan for an oncology patient covering diet, chemotherapy, radiation, lab work and counseling with detailed timing relationships, pre-conditions and goals. They may be used in veterinary care or clinical research to describe the care of a herd or other collection of animals. In public health, they may describe education or immunization campaigns.

This resource takes an intermediate approach to complexity. It captures basic details about who is involved and what actions are intended without dealing in discrete data about dependencies and timing relationships. These can be supported where necessary using the extension mechanism.

The scope of care plans may vary widely. Examples include:

  • Multi-disciplinary cross-organizational care plans; e.g. An oncology plan including the oncologist, home nursing staff, pharmacy and others
  • Plans to manage specific disease/condition(s) (e.g. nutritional plan for a patient post bowel resection, neurological plan post head injury, prenatal plan, postpartum plan, grief management plan, etc.)
  • Decision support generated plans following specific practice guidelines (e.g. stroke care plan, diabetes plan, falls prevention, etc.)
  • Self-maintained patient or care-giver authored plans identifying their goals and an integrated understanding of actions to be taken. This does not include the legal Advance Directives, which should be represented with either the Consent resource with Consent.category = Advance Directive or with a specific request resource with intent = directive. Informal advance directives could be represented as a Goal, such as "I want to die at home."

This resource can be used to represent both proposed plans (for example, recommendations from a decision support engine or returned as part of a consult report) as well as active plans. The nature of the plan is communicated by the status. Some systems may need to filter CarePlans to ensure that only appropriate plans are exposed via a given user interface.

9.5.2 Boundaries and Relationships

CarePlan activities can be defined using references to the various "request" resources. These references could be to resources with a status of "planned" or to an active order. It is possible for planned activities to exist (e.g. appointments) without needing a CarePlan at all. CarePlans are used when there's a need to group activities, goals and/or participants together to provide some degree of context.

The CarePlan resource represents an authorization as well as fulfillment on the service provided, while not necessarily providing all the details of such fulfillment. Further details about the fulfillment are handled by the Task resource. For further information about this separation of responsibilities, refer to the Fulfillment/Execution section of the Request pattern.

CarePlans can be tied to specific Conditions, however they can also be condition-independent and instead focused on a particular type of care (e.g. psychological, nutritional) or the care delivered by a particular practitioner or group of practitioners.

An ImmunizationRecommendation can be interpreted as a narrow type of CarePlan dealing only with immunization events. Where such information could appear in either resource, the immunization-specific resource is preferred.

CarePlans represent a specific plan instance for a particular patient or group. It is not intended to be used to define generic plans or protocols that are independent of a specific individual or group. CarePlan represents a specific intent, not a general definition. Protocols and order sets are supported through PlanDefinition.

9.5.3 References to this Resource

9.5.4 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan TU DomainResource Healthcare plan for patient or group

Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier Σ 0..* Identifier External Ids for this plan

... basedOn Σ 0..* Reference(CarePlan | ServiceRequest | RequestOrchestration | NutritionOrder) Fulfills plan, proposal or order

... replaces Σ 0..* Reference(CarePlan) CarePlan replaced by this CarePlan

... status ?!Σ 1..1 code draft | active | on-hold | entered-in-error | ended | completed | revoked | unknown
Binding: RequestStatus (Required)
... intent ?!Σ 1..1 code proposal | plan | order | option | directive
Binding: Care Plan Intent (Required)
... category Σ 0..* CodeableConcept Type of plan
Binding: Care Plan Category (Example)

... title Σ 0..1 string Human-friendly name for the care plan
... description Σ 0..1 string Summary of nature of plan
... subject Σ 1..1 Reference(Patient | Group) Who the care plan is for
... encounter Σ 0..1 Reference(Encounter) The Encounter during which this CarePlan was created
... period Σ 0..1 Period Time period plan covers
... created Σ 0..1 dateTime Date record was first recorded
... custodian 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 Σ 0..* CodeableReference(Condition | Procedure | MedicationAdministration) Health issues this plan addresses
Binding: SNOMED CT Clinical Findings (Example)

... supportingInfo 0..* Reference(Any) Information considered as part of plan

... goal 0..* Reference(Goal) Desired outcome of plan

... activity 0..* BackboneElement Action to occur or has occurred as part of plan

.... performedActivity 0..* CodeableReference(Any) Activities that are completed or in progress (concept, or Appointment, Encounter, Procedure, etc.)
Binding: Care Plan Activity Performed (Example)

.... progress 0..* Annotation Comments about the activity status/progress

.... plannedActivityReference 0..1 Reference(Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestOrchestration | ImmunizationRecommendation | SupplyRequest) Activity that is intended to be part of the care plan
... note 0..* Annotation Comments about the plan


doco Documentation for this format icon

See the Extensions for this resource

 

Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis

9.5.4.1 Terminology Bindings

Path ValueSet Type Documentation
CarePlan.status RequestStatus Required

Codes identifying the lifecycle stage of a request.
CarePlan.intent CarePlanIntent Required

Codes indicating the degree of authority/intentionality associated with a care plan.
CarePlan.category CarePlanCategory Example

Example codes indicating the category a care plan falls within. Note that these are in no way complete and might not even be appropriate for some uses.
CarePlan.addresses SNOMEDCTClinicalFindings Example

This value set includes all the "Clinical finding" SNOMED CT icon codes - concepts where concept is-a 404684003 (Clinical finding (finding)).
CarePlan.activity.performedActivity CarePlanActivityPerformed Example

Example codes indicating the care plan activity that was performed. Note that these are in no way complete and might not even be appropriate for some uses.

9.5.4.2 Notes

The Provenance resource can be used for detailed review information, such as when the care plan was last reviewed and by whom.

9.5.5 Open Issues

9.5.6 Search Parameters

Search parameters for this resource. See also the full list of search parameters for this resource, and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
activity-reference reference Activity that is intended to be part of the care plan CarePlan.activity.plannedActivityReference
(Appointment, MedicationRequest, Task, NutritionOrder, RequestOrchestration, VisionPrescription, DeviceRequest, ServiceRequest, CommunicationRequest, ImmunizationRecommendation, SupplyRequest)
based-on reference Fulfills CarePlan CarePlan.basedOn
(CarePlan, RequestOrchestration, NutritionOrder, ServiceRequest)
care-team reference Who's involved in plan? CarePlan.careTeam
(CareTeam)
category token Type of plan CarePlan.category
condition reference Reference to a resource (by instance) CarePlan.addresses.reference
custodian reference Who is the designated responsible party CarePlan.custodian
(Practitioner, Organization, CareTeam, Device, Patient, PractitionerRole, RelatedPerson)
date date Time period plan covers CarePlan.period 26 Resources
encounter reference The Encounter during which this CarePlan was created CarePlan.encounter
(Encounter)		 29 Resources
goal reference Desired outcome of plan CarePlan.goal
(Goal)
identifier token External Ids for this plan CarePlan.identifier 65 Resources
intent token proposal | plan | order | option | directive CarePlan.intent
part-of reference Part of referenced CarePlan CarePlan.partOf
(CarePlan)
patient reference Who the care plan is for CarePlan.subject.where(resolve() is Patient)
(Patient)		 65 Resources
replaces reference CarePlan replaced by this CarePlan CarePlan.replaces
(CarePlan)
status token draft | active | on-hold | revoked | completed | entered-in-error | unknown CarePlan.status
subject reference Who the care plan is for CarePlan.subject
(Group, Patient)