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

• Content
• Detailed Descriptions
• Mappings
• XML
• JSON
• TTL

Resource Profile: ADI PMO Care Plan

The Portable Medical Order Care Plan.

Usage:

• This Resource Profile is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

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

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints
CarePlan		0..*	USCoreCarePlanProfile	Healthcare plan for patient or group dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
text	S	0..1	Narrative	(USCDI) Text summary of the resource, for human interpretation ele-1: All FHIR elements must have a @value or children
status	S	1..1	code	(USCDI) generated | extensions | additional | empty Binding: US Core Narrative Status (required): Constrained value set of narrative statuses. ele-1: All FHIR elements must have a @value or children
div	SC	1..1	xhtml	(USCDI) Limited xhtml content ele-1: All FHIR elements must have a @value or children 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
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
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. ele-1: All FHIR elements must have a @value or children 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 ele-1: All FHIR elements must have a @value or children Required Pattern: order
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. ele-1: All FHIR elements must have a @value or children
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. ele-1: All FHIR elements must have a @value or children 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:portable_medical_order	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. ele-1: All FHIR elements must have a @value or children 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: 93037-0
display		1..1	string	Representation defined by the system Fixed Value: Portable medical order form
subject	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who the care plan is for ele-1: All FHIR elements must have a @value or children
addresses	SΣ	0..*	Reference(Condition)	Health issues this plan addresses ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
CarePlan.text.status	required	NarrativeStatus http://hl7.org/fhir/us/core/ValueSet/us-core-narrative-status
CarePlan.status	required	Pattern: active http://hl7.org/fhir/ValueSet/request-status from the FHIR Standard
CarePlan.intent	required	Pattern: order http://hl7.org/fhir/ValueSet/care-plan-intent from the FHIR Standard
CarePlan.category	example	CarePlanCategory http://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard
CarePlan.category:AssessPlan	example	Pattern: assess-plan http://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard
CarePlan.category:portable_medical_order	example	Pattern: LOINC Code 93037-0("Portable medical order form") http://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard

This structure is derived from USCoreCarePlanProfile

Name	Flags	Card.	Type	Description & Constraints
CarePlan		0..*	USCoreCarePlanProfile	Healthcare plan for patient or group
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: order
Slices for category		2..*	CodeableConcept	(USCDI) Type of plan Slice: Unordered, Open by pattern:$this
category:portable_medical_order	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: 93037-0
display		1..1	string	Representation defined by the system Fixed Value: Portable medical order form
addresses	S	0..*	Reference(Condition)	Health issues this plan addresses
activity
reference		0..1	Reference(ADI PMO ServiceRequest)	Activity details defined in specific resource
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
CarePlan		0..*	USCoreCarePlanProfile	Healthcare plan for patient or group
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 Bindings Purpose 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
extension		0..*	Extension	Additional content defined by implementations
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: order
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:portable_medical_order	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: 93037-0
display		1..1	string	Representation defined by the system Fixed Value: Portable medical order form
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)	(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
supportingInfo		0..*	Reference(Resource)	Information considered as part of plan
goal		0..*	Reference(Goal)	Desired outcome of 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(ADI PMO ServiceRequest)	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

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
CarePlan.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
CarePlan.text.status	required	NarrativeStatus http://hl7.org/fhir/us/core/ValueSet/us-core-narrative-status
CarePlan.status	required	Pattern: active http://hl7.org/fhir/ValueSet/request-status from the FHIR Standard
CarePlan.intent	required	Pattern: order http://hl7.org/fhir/ValueSet/care-plan-intent from the FHIR Standard
CarePlan.category	example	CarePlanCategory http://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard
CarePlan.category:AssessPlan	example	Pattern: assess-plan http://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard
CarePlan.category:portable_medical_order	example	Pattern: LOINC Code 93037-0("Portable medical order form") http://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard
CarePlan.activity.outcomeCodeableConcept	example	CarePlanActivityOutcome http://hl7.org/fhir/ValueSet/care-plan-activity-outcome from the FHIR Standard
CarePlan.activity.detail.kind	required	CarePlanActivityKind http://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	SNOMEDCTClinicalFindings http://hl7.org/fhir/ValueSet/clinical-findings from the FHIR Standard
CarePlan.activity.detail.status	required	CarePlanActivityStatus http://hl7.org/fhir/ValueSet/care-plan-activity-status|4.0.1 from the FHIR Standard
CarePlan.activity.detail.product[x]	example	SNOMEDCTMedicationCodes http://hl7.org/fhir/ValueSet/medication-codes from the FHIR Standard

This structure is derived from USCoreCarePlanProfile

Summary

Mandatory: 1 element
Must-Support: 2 elements

Structures

This structure refers to these other structures:

• ADI PMO ServiceRequest (http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PMOServiceRequest)

Slices

This structure defines the following Slices:

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

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
CarePlan		0..*	USCoreCarePlanProfile	Healthcare plan for patient or group dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
text	S	0..1	Narrative	(USCDI) Text summary of the resource, for human interpretation ele-1: All FHIR elements must have a @value or children
status	S	1..1	code	(USCDI) generated | extensions | additional | empty Binding: US Core Narrative Status (required): Constrained value set of narrative statuses. ele-1: All FHIR elements must have a @value or children
div	SC	1..1	xhtml	(USCDI) Limited xhtml content ele-1: All FHIR elements must have a @value or children 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
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
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. ele-1: All FHIR elements must have a @value or children 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 ele-1: All FHIR elements must have a @value or children Required Pattern: order
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. ele-1: All FHIR elements must have a @value or children
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. ele-1: All FHIR elements must have a @value or children 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:portable_medical_order	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. ele-1: All FHIR elements must have a @value or children 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: 93037-0
display		1..1	string	Representation defined by the system Fixed Value: Portable medical order form
subject	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who the care plan is for ele-1: All FHIR elements must have a @value or children
addresses	SΣ	0..*	Reference(Condition)	Health issues this plan addresses ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
CarePlan.text.status	required	NarrativeStatus http://hl7.org/fhir/us/core/ValueSet/us-core-narrative-status
CarePlan.status	required	Pattern: active http://hl7.org/fhir/ValueSet/request-status from the FHIR Standard
CarePlan.intent	required	Pattern: order http://hl7.org/fhir/ValueSet/care-plan-intent from the FHIR Standard
CarePlan.category	example	CarePlanCategory http://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard
CarePlan.category:AssessPlan	example	Pattern: assess-plan http://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard
CarePlan.category:portable_medical_order	example	Pattern: LOINC Code 93037-0("Portable medical order form") http://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard

Differential View

This structure is derived from USCoreCarePlanProfile

Name	Flags	Card.	Type	Description & Constraints
CarePlan		0..*	USCoreCarePlanProfile	Healthcare plan for patient or group
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: order
Slices for category		2..*	CodeableConcept	(USCDI) Type of plan Slice: Unordered, Open by pattern:$this
category:portable_medical_order	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: 93037-0
display		1..1	string	Representation defined by the system Fixed Value: Portable medical order form
addresses	S	0..*	Reference(Condition)	Health issues this plan addresses
activity
reference		0..1	Reference(ADI PMO ServiceRequest)	Activity details defined in specific resource
Documentation for this format

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
CarePlan		0..*	USCoreCarePlanProfile	Healthcare plan for patient or group
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 Bindings Purpose 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
extension		0..*	Extension	Additional content defined by implementations
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: order
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:portable_medical_order	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: 93037-0
display		1..1	string	Representation defined by the system Fixed Value: Portable medical order form
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)	(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
supportingInfo		0..*	Reference(Resource)	Information considered as part of plan
goal		0..*	Reference(Goal)	Desired outcome of 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(ADI PMO ServiceRequest)	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

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
CarePlan.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
CarePlan.text.status	required	NarrativeStatus http://hl7.org/fhir/us/core/ValueSet/us-core-narrative-status
CarePlan.status	required	Pattern: active http://hl7.org/fhir/ValueSet/request-status from the FHIR Standard
CarePlan.intent	required	Pattern: order http://hl7.org/fhir/ValueSet/care-plan-intent from the FHIR Standard
CarePlan.category	example	CarePlanCategory http://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard
CarePlan.category:AssessPlan	example	Pattern: assess-plan http://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard
CarePlan.category:portable_medical_order	example	Pattern: LOINC Code 93037-0("Portable medical order form") http://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard
CarePlan.activity.outcomeCodeableConcept	example	CarePlanActivityOutcome http://hl7.org/fhir/ValueSet/care-plan-activity-outcome from the FHIR Standard
CarePlan.activity.detail.kind	required	CarePlanActivityKind http://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	SNOMEDCTClinicalFindings http://hl7.org/fhir/ValueSet/clinical-findings from the FHIR Standard
CarePlan.activity.detail.status	required	CarePlanActivityStatus http://hl7.org/fhir/ValueSet/care-plan-activity-status|4.0.1 from the FHIR Standard
CarePlan.activity.detail.product[x]	example	SNOMEDCTMedicationCodes http://hl7.org/fhir/ValueSet/medication-codes from the FHIR Standard

This structure is derived from USCoreCarePlanProfile

Summary

Mandatory: 1 element
Must-Support: 2 elements

Structures

This structure refers to these other structures:

• ADI PMO ServiceRequest (http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PMOServiceRequest)

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