The ADI PtAuthored Care Plan represents the patient’s goals for treatment based on circumstances or situations that provide context for the goals documented. A patient could document their goal of care in a situation such as a terminal condition that will result in their death in a relatively short period of time as being to extend their life for as long as possible, or allow their natural death to occur, or allow limited treatments to occur for a certain period of time before they are stopped. In a different situation, such as permanent and severe brain damage from which they are not expected to recover, that their goal of care options may be the same but their documented selection is different. Various forms and jurisdictions include circumstances or situations that are relatively consistent but still vary somewhat, so this Resource allows the basic structure of a context or circumstance or situation to be defined, against which the identification of a goal is documented, and against which in some existing forms further identification of the patient’s preference for interventions is captured. To enable the patient’s own preferred plan of care to merge with the care team’s clinical plan of care results in a jointly-authored and patient-centered plan of care that is informed by the person receiving care and the care team responsible for delivering that care.

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

This structure is derived from USCoreCarePlanProfile

Name	Flags	Card.	Type	Description & Constraints
CarePlan	C	0..*	USCoreCarePlanProfile	Healthcare plan for patient or group goal-or-supportingInfo-required: Either goal or supportingInfo must exist, ie. goal and supportingInfo cannot both be blank, ie. if goal does not exist then supportingInfo must exist.
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
GoalOrderByDescendingPriority		0..1	CodeableConcept	Goal Order by Descending Priority URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-goal-order-by-descending-priority-extension Binding: hl7VS-yes-no-Indicator (extensible)
status		1..1	code	(USCDI) draft | active | on-hold | revoked | completed | entered-in-error | unknown Required Pattern: active
intent		1..1	code	(USCDI) proposal | plan | order | option Required Pattern: proposal
Slices for category		2..*	CodeableConcept	(USCDI) Type of plan Slice: Unordered, Open by pattern:$this
category:advance_care_planning	S	1..1	CodeableConcept	(USCDI) Type of plan Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 81378-2
display		1..1	string	Representation defined by the system Fixed Value: Goals, preferences, and priorities under certain health conditions [Reported]
title	S	1..1	string	Human-friendly name for the care plan
addresses	S	0..*	Reference(Condition)	Health issues this plan addresses (use display only for potential conditions the patient does not currently have)
supportingInfo	S	0..*	Reference(ADI PtAuthored Care Experience Preference)	Observations of a patient's preferences for the scope of this care plan.
goal	S	0..*	Reference(ADI PtAuthored Personal Goal)	Patient's goals for the scope of this care plan.
activity
reference		0..1	Reference(US Core ServiceRequest Profile)	Activity details defined in specific resource
Documentation for this format

Constraints

Id	Grade	Path(s)	Details	Requirements
goal-or-supportingInfo-required	error	CarePlan	Either goal or supportingInfo must exist, ie. goal and supportingInfo cannot both be blank, ie. if goal does not exist then supportingInfo must exist. : goal.empty() implies supportingInfo.exists()

Name	Flags	Card.	Type	Description & Constraints
CarePlan	C	0..*	USCoreCarePlanProfile	Healthcare plan for patient or group goal-or-supportingInfo-required: Either goal or supportingInfo must exist, ie. goal and supportingInfo cannot both be blank, ie. if goal does not exist then supportingInfo must exist.
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
text	S	0..1	Narrative	(USCDI) Text summary of the resource, for human interpretation
status	S	1..1	code	(USCDI) generated | extensions | additional | empty Binding: US Core Narrative Status (required): Constrained value set of narrative statuses.
div	SC	1..1	xhtml	(USCDI) Limited xhtml content txt-1: The narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes txt-2: The narrative SHALL have some non-whitespace content
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
GoalOrderByDescendingPriority		0..1	CodeableConcept	Goal Order by Descending Priority URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-goal-order-by-descending-priority-extension Binding: hl7VS-yes-no-Indicator (extensible)
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!SΣ	1..1	code	(USCDI) draft | active | on-hold | revoked | completed | entered-in-error | unknown Binding: RequestStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record. Required Pattern: active
intent	?!SΣ	1..1	code	(USCDI) proposal | plan | order | option Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan Required Pattern: proposal
Slices for category	SΣ	2..*	CodeableConcept	(USCDI) Type of plan Slice: Unordered, Open by pattern:$this Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc.
category:AssessPlan	SΣ	1..1	CodeableConcept	(USCDI) Type of plan Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/careplan-category
code		1..1	code	Symbol in syntax defined by the system Fixed Value: assess-plan
category:advance_care_planning	SΣ	1..1	CodeableConcept	(USCDI) Type of plan Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 81378-2
display		1..1	string	Representation defined by the system Fixed Value: Goals, preferences, and priorities under certain health conditions [Reported]
title	SΣ	1..1	string	Human-friendly name for the care plan
subject	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who the care plan is for
addresses	SΣ	0..*	Reference(Condition)	Health issues this plan addresses (use display only for potential conditions the patient does not currently have)
supportingInfo	S	0..*	Reference(ADI PtAuthored Care Experience Preference)	Observations of a patient's preferences for the scope of this care plan.
goal	S	0..*	Reference(ADI PtAuthored Personal Goal)	Patient's goals for the scope of this care plan.
Documentation for this format

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: proposal 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:advance_care_planning	example	Pattern: LOINC Code 81378-2("Goals, preferences, and priorities under certain health conditions [Reported]") http://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
goal-or-supportingInfo-required	error	CarePlan	Either goal or supportingInfo must exist, ie. goal and supportingInfo cannot both be blank, ie. if goal does not exist then supportingInfo must exist. : goal.empty() implies supportingInfo.exists()

Name	Flags	Card.	Type	Description & Constraints
CarePlan	C	0..*	USCoreCarePlanProfile	Healthcare plan for patient or group goal-or-supportingInfo-required: Either goal or supportingInfo must exist, ie. goal and supportingInfo cannot both be blank, ie. if goal does not exist then supportingInfo must exist.
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. 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
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
GoalOrderByDescendingPriority		0..1	CodeableConcept	Goal Order by Descending Priority URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-goal-order-by-descending-priority-extension Binding: hl7VS-yes-no-Indicator (extensible)
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Ids for this plan
instantiatesCanonical	Σ	0..*	canonical(PlanDefinition | Questionnaire | Measure | ActivityDefinition | OperationDefinition)	Instantiates FHIR protocol or definition
instantiatesUri	Σ	0..*	uri	Instantiates external protocol or definition
basedOn	Σ	0..*	Reference(CarePlan)	Fulfills CarePlan
replaces	Σ	0..*	Reference(CarePlan)	CarePlan replaced by this CarePlan
partOf	Σ	0..*	Reference(CarePlan)	Part of referenced CarePlan
status	?!SΣ	1..1	code	(USCDI) draft | active | on-hold | revoked | completed | entered-in-error | unknown Binding: RequestStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record. Required Pattern: active
intent	?!SΣ	1..1	code	(USCDI) proposal | plan | order | option Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan Required Pattern: proposal
Slices for category	SΣ	2..*	CodeableConcept	(USCDI) Type of plan Slice: Unordered, Open by pattern:$this Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc.
category:AssessPlan	SΣ	1..1	CodeableConcept	(USCDI) Type of plan Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/careplan-category
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: assess-plan
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
category:advance_care_planning	SΣ	1..1	CodeableConcept	(USCDI) Type of plan Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 81378-2
display		1..1	string	Representation defined by the system Fixed Value: Goals, preferences, and priorities under certain health conditions [Reported]
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
title	SΣ	1..1	string	Human-friendly name for the care plan
description	Σ	0..1	string	Summary of nature of plan
subject	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who the care plan is for
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
period	Σ	0..1	Period	Time period plan covers
created	Σ	0..1	dateTime	Date record was first recorded
author	Σ	0..1	Reference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam)	Who is the designated responsible party
contributor		0..*	Reference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam)	Who provided the content of the care plan
careTeam		0..*	Reference(CareTeam)	Who's involved in plan?
addresses	SΣ	0..*	Reference(Condition)	Health issues this plan addresses (use display only for potential conditions the patient does not currently have)
supportingInfo	S	0..*	Reference(ADI PtAuthored Care Experience Preference)	Observations of a patient's preferences for the scope of this care plan.
goal	S	0..*	Reference(ADI PtAuthored Personal Goal)	Patient's goals for the scope of this care plan.
activity	C	0..*	BackboneElement	Action to occur as part of plan cpl-3: Provide a reference or detail, not both
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
outcomeCodeableConcept		0..*	CodeableConcept	Results of the activity Binding: CarePlanActivityOutcome (example): Identifies the results of the activity.
outcomeReference		0..*	Reference(Resource)	Appointment, Encounter, Procedure, etc.
progress		0..*	Annotation	Comments about the activity status/progress
reference	C	0..1	Reference(US Core ServiceRequest Profile)	Activity details defined in specific resource
detail	C	0..1	BackboneElement	In-line definition of activity
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
kind		0..1	code	Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription Binding: CarePlanActivityKind (required): Resource types defined as part of FHIR that can be represented as in-line definitions of a care plan activity.
instantiatesCanonical		0..*	canonical(PlanDefinition | ActivityDefinition | Questionnaire | Measure | OperationDefinition)	Instantiates FHIR protocol or definition
instantiatesUri		0..*	uri	Instantiates external protocol or definition
code		0..1	CodeableConcept	Detail type of activity Binding: ProcedureCodes(SNOMEDCT) (example): Detailed description of the type of activity; e.g. What lab test, what procedure, what kind of encounter.
reasonCode		0..*	CodeableConcept	Why activity should be done or why activity was prohibited Binding: SNOMEDCTClinicalFindings (example): Identifies why a care plan activity is needed. Can include any health condition codes as well as such concepts as "general wellness", prophylaxis, surgical preparation, etc.
reasonReference		0..*	Reference(Condition | Observation | DiagnosticReport | DocumentReference)	Why activity is needed
goal		0..*	Reference(Goal)	Goals this activity relates to
status	?!	1..1	code	not-started | scheduled | in-progress | on-hold | completed | cancelled | stopped | unknown | entered-in-error Binding: CarePlanActivityStatus (required): Codes that reflect the current state of a care plan activity within its overall life cycle.
statusReason		0..1	CodeableConcept	Reason for current status
doNotPerform	?!	0..1	boolean	If true, activity is prohibiting action
scheduled[x]		0..1		When activity is to occur
scheduledTiming			Timing
scheduledPeriod			Period
scheduledString			string
location		0..1	Reference(Location)	Where it should happen
performer		0..*	Reference(Practitioner | PractitionerRole | Organization | RelatedPerson | Patient | CareTeam | HealthcareService | Device)	Who will be responsible?
product[x]		0..1		What is to be administered/supplied Binding: SNOMEDCTMedicationCodes (example): A product supplied or administered as part of a care plan activity.
productCodeableConcept			CodeableConcept
productReference			Reference(Medication | Substance)
dailyAmount		0..1	SimpleQuantity	How to consume/day?
quantity		0..1	SimpleQuantity	How much to administer/supply/consume
description		0..1	string	Extra info describing activity to perform
note		0..*	Annotation	Comments about the plan
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
CarePlan.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
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: proposal 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:advance_care_planning	example	Pattern: LOINC Code 81378-2("Goals, preferences, and priorities under certain health conditions [Reported]") http://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard
CarePlan.activity.outcomeCodeableConcept	example	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

Constraints

Id	Grade	Path(s)	Details	Requirements
goal-or-supportingInfo-required	error	CarePlan	Either goal or supportingInfo must exist, ie. goal and supportingInfo cannot both be blank, ie. if goal does not exist then supportingInfo must exist. : goal.empty() implies supportingInfo.exists()

Differential View

This structure is derived from USCoreCarePlanProfile

Name	Flags	Card.	Type	Description & Constraints
CarePlan	C	0..*	USCoreCarePlanProfile	Healthcare plan for patient or group goal-or-supportingInfo-required: Either goal or supportingInfo must exist, ie. goal and supportingInfo cannot both be blank, ie. if goal does not exist then supportingInfo must exist.
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
GoalOrderByDescendingPriority		0..1	CodeableConcept	Goal Order by Descending Priority URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-goal-order-by-descending-priority-extension Binding: hl7VS-yes-no-Indicator (extensible)
status		1..1	code	(USCDI) draft | active | on-hold | revoked | completed | entered-in-error | unknown Required Pattern: active
intent		1..1	code	(USCDI) proposal | plan | order | option Required Pattern: proposal
Slices for category		2..*	CodeableConcept	(USCDI) Type of plan Slice: Unordered, Open by pattern:$this
category:advance_care_planning	S	1..1	CodeableConcept	(USCDI) Type of plan Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 81378-2
display		1..1	string	Representation defined by the system Fixed Value: Goals, preferences, and priorities under certain health conditions [Reported]
title	S	1..1	string	Human-friendly name for the care plan
addresses	S	0..*	Reference(Condition)	Health issues this plan addresses (use display only for potential conditions the patient does not currently have)
supportingInfo	S	0..*	Reference(ADI PtAuthored Care Experience Preference)	Observations of a patient's preferences for the scope of this care plan.
goal	S	0..*	Reference(ADI PtAuthored Personal Goal)	Patient's goals for the scope of this care plan.
activity
reference		0..1	Reference(US Core ServiceRequest Profile)	Activity details defined in specific resource
Documentation for this format

Constraints

Id	Grade	Path(s)	Details	Requirements
goal-or-supportingInfo-required	error	CarePlan	Either goal or supportingInfo must exist, ie. goal and supportingInfo cannot both be blank, ie. if goal does not exist then supportingInfo must exist. : goal.empty() implies supportingInfo.exists()

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
CarePlan	C	0..*	USCoreCarePlanProfile	Healthcare plan for patient or group goal-or-supportingInfo-required: Either goal or supportingInfo must exist, ie. goal and supportingInfo cannot both be blank, ie. if goal does not exist then supportingInfo must exist.
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
text	S	0..1	Narrative	(USCDI) Text summary of the resource, for human interpretation
status	S	1..1	code	(USCDI) generated | extensions | additional | empty Binding: US Core Narrative Status (required): Constrained value set of narrative statuses.
div	SC	1..1	xhtml	(USCDI) Limited xhtml content txt-1: The narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes txt-2: The narrative SHALL have some non-whitespace content
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
GoalOrderByDescendingPriority		0..1	CodeableConcept	Goal Order by Descending Priority URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-goal-order-by-descending-priority-extension Binding: hl7VS-yes-no-Indicator (extensible)
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!SΣ	1..1	code	(USCDI) draft | active | on-hold | revoked | completed | entered-in-error | unknown Binding: RequestStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record. Required Pattern: active
intent	?!SΣ	1..1	code	(USCDI) proposal | plan | order | option Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan Required Pattern: proposal
Slices for category	SΣ	2..*	CodeableConcept	(USCDI) Type of plan Slice: Unordered, Open by pattern:$this Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc.
category:AssessPlan	SΣ	1..1	CodeableConcept	(USCDI) Type of plan Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/careplan-category
code		1..1	code	Symbol in syntax defined by the system Fixed Value: assess-plan
category:advance_care_planning	SΣ	1..1	CodeableConcept	(USCDI) Type of plan Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 81378-2
display		1..1	string	Representation defined by the system Fixed Value: Goals, preferences, and priorities under certain health conditions [Reported]
title	SΣ	1..1	string	Human-friendly name for the care plan
subject	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who the care plan is for
addresses	SΣ	0..*	Reference(Condition)	Health issues this plan addresses (use display only for potential conditions the patient does not currently have)
supportingInfo	S	0..*	Reference(ADI PtAuthored Care Experience Preference)	Observations of a patient's preferences for the scope of this care plan.
goal	S	0..*	Reference(ADI PtAuthored Personal Goal)	Patient's goals for the scope of this care plan.
Documentation for this format

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: proposal 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:advance_care_planning	example	Pattern: LOINC Code 81378-2("Goals, preferences, and priorities under certain health conditions [Reported]") http://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
goal-or-supportingInfo-required	error	CarePlan	Either goal or supportingInfo must exist, ie. goal and supportingInfo cannot both be blank, ie. if goal does not exist then supportingInfo must exist. : goal.empty() implies supportingInfo.exists()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
CarePlan	C	0..*	USCoreCarePlanProfile	Healthcare plan for patient or group goal-or-supportingInfo-required: Either goal or supportingInfo must exist, ie. goal and supportingInfo cannot both be blank, ie. if goal does not exist then supportingInfo must exist.
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. 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
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
GoalOrderByDescendingPriority		0..1	CodeableConcept	Goal Order by Descending Priority URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-goal-order-by-descending-priority-extension Binding: hl7VS-yes-no-Indicator (extensible)
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Ids for this plan
instantiatesCanonical	Σ	0..*	canonical(PlanDefinition | Questionnaire | Measure | ActivityDefinition | OperationDefinition)	Instantiates FHIR protocol or definition
instantiatesUri	Σ	0..*	uri	Instantiates external protocol or definition
basedOn	Σ	0..*	Reference(CarePlan)	Fulfills CarePlan
replaces	Σ	0..*	Reference(CarePlan)	CarePlan replaced by this CarePlan
partOf	Σ	0..*	Reference(CarePlan)	Part of referenced CarePlan
status	?!SΣ	1..1	code	(USCDI) draft | active | on-hold | revoked | completed | entered-in-error | unknown Binding: RequestStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record. Required Pattern: active
intent	?!SΣ	1..1	code	(USCDI) proposal | plan | order | option Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan Required Pattern: proposal
Slices for category	SΣ	2..*	CodeableConcept	(USCDI) Type of plan Slice: Unordered, Open by pattern:$this Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc.
category:AssessPlan	SΣ	1..1	CodeableConcept	(USCDI) Type of plan Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/careplan-category
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: assess-plan
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
category:advance_care_planning	SΣ	1..1	CodeableConcept	(USCDI) Type of plan Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 81378-2
display		1..1	string	Representation defined by the system Fixed Value: Goals, preferences, and priorities under certain health conditions [Reported]
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
title	SΣ	1..1	string	Human-friendly name for the care plan
description	Σ	0..1	string	Summary of nature of plan
subject	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who the care plan is for
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
period	Σ	0..1	Period	Time period plan covers
created	Σ	0..1	dateTime	Date record was first recorded
author	Σ	0..1	Reference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam)	Who is the designated responsible party
contributor		0..*	Reference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam)	Who provided the content of the care plan
careTeam		0..*	Reference(CareTeam)	Who's involved in plan?
addresses	SΣ	0..*	Reference(Condition)	Health issues this plan addresses (use display only for potential conditions the patient does not currently have)
supportingInfo	S	0..*	Reference(ADI PtAuthored Care Experience Preference)	Observations of a patient's preferences for the scope of this care plan.
goal	S	0..*	Reference(ADI PtAuthored Personal Goal)	Patient's goals for the scope of this care plan.
activity	C	0..*	BackboneElement	Action to occur as part of plan cpl-3: Provide a reference or detail, not both
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
outcomeCodeableConcept		0..*	CodeableConcept	Results of the activity Binding: CarePlanActivityOutcome (example): Identifies the results of the activity.
outcomeReference		0..*	Reference(Resource)	Appointment, Encounter, Procedure, etc.
progress		0..*	Annotation	Comments about the activity status/progress
reference	C	0..1	Reference(US Core ServiceRequest Profile)	Activity details defined in specific resource
detail	C	0..1	BackboneElement	In-line definition of activity
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
kind		0..1	code	Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription Binding: CarePlanActivityKind (required): Resource types defined as part of FHIR that can be represented as in-line definitions of a care plan activity.
instantiatesCanonical		0..*	canonical(PlanDefinition | ActivityDefinition | Questionnaire | Measure | OperationDefinition)	Instantiates FHIR protocol or definition
instantiatesUri		0..*	uri	Instantiates external protocol or definition
code		0..1	CodeableConcept	Detail type of activity Binding: ProcedureCodes(SNOMEDCT) (example): Detailed description of the type of activity; e.g. What lab test, what procedure, what kind of encounter.
reasonCode		0..*	CodeableConcept	Why activity should be done or why activity was prohibited Binding: SNOMEDCTClinicalFindings (example): Identifies why a care plan activity is needed. Can include any health condition codes as well as such concepts as "general wellness", prophylaxis, surgical preparation, etc.
reasonReference		0..*	Reference(Condition | Observation | DiagnosticReport | DocumentReference)	Why activity is needed
goal		0..*	Reference(Goal)	Goals this activity relates to
status	?!	1..1	code	not-started | scheduled | in-progress | on-hold | completed | cancelled | stopped | unknown | entered-in-error Binding: CarePlanActivityStatus (required): Codes that reflect the current state of a care plan activity within its overall life cycle.
statusReason		0..1	CodeableConcept	Reason for current status
doNotPerform	?!	0..1	boolean	If true, activity is prohibiting action
scheduled[x]		0..1		When activity is to occur
scheduledTiming			Timing
scheduledPeriod			Period
scheduledString			string
location		0..1	Reference(Location)	Where it should happen
performer		0..*	Reference(Practitioner | PractitionerRole | Organization | RelatedPerson | Patient | CareTeam | HealthcareService | Device)	Who will be responsible?
product[x]		0..1		What is to be administered/supplied Binding: SNOMEDCTMedicationCodes (example): A product supplied or administered as part of a care plan activity.
productCodeableConcept			CodeableConcept
productReference			Reference(Medication | Substance)
dailyAmount		0..1	SimpleQuantity	How to consume/day?
quantity		0..1	SimpleQuantity	How much to administer/supply/consume
description		0..1	string	Extra info describing activity to perform
note		0..*	Annotation	Comments about the plan
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
CarePlan.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
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: proposal 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:advance_care_planning	example	Pattern: LOINC Code 81378-2("Goals, preferences, and priorities under certain health conditions [Reported]") http://hl7.org/fhir/ValueSet/care-plan-category from the FHIR Standard
CarePlan.activity.outcomeCodeableConcept	example	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

Constraints

Id	Grade	Path(s)	Details	Requirements
goal-or-supportingInfo-required	error	CarePlan	Either goal or supportingInfo must exist, ie. goal and supportingInfo cannot both be blank, ie. if goal does not exist then supportingInfo must exist. : goal.empty() implies supportingInfo.exists()

This structure is derived from USCoreCarePlanProfile

Summary

Mandatory: 2 elements
Must-Support: 5 elements

Structures

This structure refers to these other structures:

• ADI PtAuthored Care Experience Preference (http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-CareExperiencePreference)
• ADI PtAuthored Personal Goal (http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PersonalGoal)
• US Core ServiceRequest Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-servicerequest)

Extensions

This structure refers to these extensions:

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

Slices

This structure defines the following Slices:

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