This profile defines only a few constraints for required elements that are needed to support digital quality measures for person-centered outcomes. This PCO FHIR IG does not specify the kinds of care plan activities that may be included for treatment, nor patient preferences regarding those treatments. Care plan activities and interventions may be extensive for patients with complex care needs. For person-centered outcome quality measures, it is only required that a care plan exists for a person-centered goal to support its achievement.

This Person-Centered Care Plan profile may be applied in combination with more extensive care plan profiles from other FHIR IGs, e.g. for chronic disease management or advance care plans. A FHIR CarePlan resource may satisfy profile requirements from more than one FHIR IG.

Mandatory and Must Support Data Elements

This Person-Centered Care Plan Profile inherits from the US Core Care Plan Profile; refer to it for scope and usage guidance. It sets minimum expectations for all person-centered CarePlan resources.

Each Person-Centered Care Plan must have:

1. required elements from US Core Care Plan Profile
2. a Person-Centered Goal, either GAS or PROM goal
3. at least one activity

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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
CarePlan		0..*	USCoreCarePlanProfile	Healthcare plan for patient or group
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 This profile constrains the narrative content by fixing the status codes to generated and additional This profile does not constrain the narrative in regard to language specific sections This profile does not constrain the narrative in regard to traceability to data elements
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 Constraints: txt-1, txt-2
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.
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
Slices for category	SΣ	1..*	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:pco	SΣ	0..1	CodeableConcept	Person-Centered resource category Binding: Person-Centered Categories (required)
subject	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who the care plan is for
Slices for goal	S	1..*	Reference(Goal)	Desired outcome of plan Slice: Unordered, Open by profile:resolve()
goal:SupportedGoals	S	1..*	Reference(Person-Centered Goal)	Person-centered goals supported by this plan
activity	C	1..*	BackboneElement	Action to occur as part of plan Constraints: cpl-3
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
reference	SC	1..1	Reference(Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup)	Action steps for person-centered goals
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	RequestStatus http://hl7.org/fhir/ValueSet/request-status From the FHIR Standard
CarePlan.intent	required	CarePlanIntent 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 Value: assess-plan http://hl7.org/fhir/ValueSet/care-plan-category From the FHIR Standard
CarePlan.category:pco	required	PCOCategories http://hl7.org/fhir/us/pco/ValueSet/pco-categories From this IG
CarePlan.activity.detail.status	required	CarePlanActivityStatus http://hl7.org/fhir/ValueSet/care-plan-activity-status|4.0.1 From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
cpl-3	error	CarePlan.activity	Provide a reference or detail, not both : detail.empty() or reference.empty()
dom-2	error	CarePlan	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	CarePlan	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 : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	CarePlan	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	CarePlan	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	CarePlan	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
txt-1	error	CarePlan.text.div	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 : htmlChecks()
txt-2	error	CarePlan.text.div	The narrative SHALL have some non-whitespace content : htmlChecks()

This structure is derived from USCoreCarePlanProfile

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
CarePlan		0..*	USCoreCarePlanProfile	Healthcare plan for patient or group
Slices for category				Content/Rules for all slices
category:pco	S	0..1	CodeableConcept	Person-Centered resource category Binding: Person-Centered Categories (required)
Slices for goal	S	1..*	Reference(Goal)	Desired outcome of plan Slice: Unordered, Open by profile:resolve()
goal:SupportedGoals	S	1..*	Reference(Person-Centered Goal)	Person-centered goals supported by this plan
activity		1..*	BackboneElement	Action to occur as part of plan
reference	S	1..1	Reference(Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup)	Action steps for person-centered goals
detail		0..0
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
CarePlan.category:pco	required	PCOCategories http://hl7.org/fhir/us/pco/ValueSet/pco-categories From this IG

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
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 This profile constrains the narrative content by fixing the status codes to generated and additional This profile does not constrain the narrative in regard to language specific sections This profile does not constrain the narrative in regard to traceability to data elements
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 Constraints: txt-1, txt-2
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.
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
Slices for category	SΣ	1..*	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:pco	SΣ	0..1	CodeableConcept	Person-Centered resource category Binding: Person-Centered Categories (required)
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	Σ	0..*	Reference(Condition)	Health issues this plan addresses
supportingInfo		0..*	Reference(Resource)	Information considered as part of plan
Slices for goal	S	1..*	Reference(Goal)	Desired outcome of plan Slice: Unordered, Open by profile:resolve()
goal:SupportedGoals	S	1..*	Reference(Person-Centered Goal)	Person-centered goals supported by this plan
activity	C	1..*	BackboneElement	Action to occur as part of plan Constraints: cpl-3
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	SC	1..1	Reference(Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup)	Action steps for person-centered goals
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	RequestStatus http://hl7.org/fhir/ValueSet/request-status From the FHIR Standard
CarePlan.intent	required	CarePlanIntent 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 Value: assess-plan http://hl7.org/fhir/ValueSet/care-plan-category From the FHIR Standard
CarePlan.category:pco	required	PCOCategories http://hl7.org/fhir/us/pco/ValueSet/pco-categories From this IG
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
cpl-3	error	CarePlan.activity	Provide a reference or detail, not both : detail.empty() or reference.empty()
dom-2	error	CarePlan	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	CarePlan	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 : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	CarePlan	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	CarePlan	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	CarePlan	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
txt-1	error	CarePlan.text.div	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 : htmlChecks()
txt-2	error	CarePlan.text.div	The narrative SHALL have some non-whitespace content : htmlChecks()

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
CarePlan		0..*	USCoreCarePlanProfile	Healthcare plan for patient or group
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 This profile constrains the narrative content by fixing the status codes to generated and additional This profile does not constrain the narrative in regard to language specific sections This profile does not constrain the narrative in regard to traceability to data elements
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 Constraints: txt-1, txt-2
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.
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
Slices for category	SΣ	1..*	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:pco	SΣ	0..1	CodeableConcept	Person-Centered resource category Binding: Person-Centered Categories (required)
subject	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who the care plan is for
Slices for goal	S	1..*	Reference(Goal)	Desired outcome of plan Slice: Unordered, Open by profile:resolve()
goal:SupportedGoals	S	1..*	Reference(Person-Centered Goal)	Person-centered goals supported by this plan
activity	C	1..*	BackboneElement	Action to occur as part of plan Constraints: cpl-3
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
reference	SC	1..1	Reference(Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup)	Action steps for person-centered goals
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	RequestStatus http://hl7.org/fhir/ValueSet/request-status From the FHIR Standard
CarePlan.intent	required	CarePlanIntent 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 Value: assess-plan http://hl7.org/fhir/ValueSet/care-plan-category From the FHIR Standard
CarePlan.category:pco	required	PCOCategories http://hl7.org/fhir/us/pco/ValueSet/pco-categories From this IG
CarePlan.activity.detail.status	required	CarePlanActivityStatus http://hl7.org/fhir/ValueSet/care-plan-activity-status|4.0.1 From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
cpl-3	error	CarePlan.activity	Provide a reference or detail, not both : detail.empty() or reference.empty()
dom-2	error	CarePlan	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	CarePlan	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 : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	CarePlan	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	CarePlan	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	CarePlan	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
txt-1	error	CarePlan.text.div	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 : htmlChecks()
txt-2	error	CarePlan.text.div	The narrative SHALL have some non-whitespace content : htmlChecks()

Differential View

This structure is derived from USCoreCarePlanProfile

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
CarePlan		0..*	USCoreCarePlanProfile	Healthcare plan for patient or group
Slices for category				Content/Rules for all slices
category:pco	S	0..1	CodeableConcept	Person-Centered resource category Binding: Person-Centered Categories (required)
Slices for goal	S	1..*	Reference(Goal)	Desired outcome of plan Slice: Unordered, Open by profile:resolve()
goal:SupportedGoals	S	1..*	Reference(Person-Centered Goal)	Person-centered goals supported by this plan
activity		1..*	BackboneElement	Action to occur as part of plan
reference	S	1..1	Reference(Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup)	Action steps for person-centered goals
detail		0..0
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
CarePlan.category:pco	required	PCOCategories http://hl7.org/fhir/us/pco/ValueSet/pco-categories From this IG

Snapshot View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
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 This profile constrains the narrative content by fixing the status codes to generated and additional This profile does not constrain the narrative in regard to language specific sections This profile does not constrain the narrative in regard to traceability to data elements
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 Constraints: txt-1, txt-2
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.
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
Slices for category	SΣ	1..*	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:pco	SΣ	0..1	CodeableConcept	Person-Centered resource category Binding: Person-Centered Categories (required)
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	Σ	0..*	Reference(Condition)	Health issues this plan addresses
supportingInfo		0..*	Reference(Resource)	Information considered as part of plan
Slices for goal	S	1..*	Reference(Goal)	Desired outcome of plan Slice: Unordered, Open by profile:resolve()
goal:SupportedGoals	S	1..*	Reference(Person-Centered Goal)	Person-centered goals supported by this plan
activity	C	1..*	BackboneElement	Action to occur as part of plan Constraints: cpl-3
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	SC	1..1	Reference(Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup)	Action steps for person-centered goals
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	RequestStatus http://hl7.org/fhir/ValueSet/request-status From the FHIR Standard
CarePlan.intent	required	CarePlanIntent 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 Value: assess-plan http://hl7.org/fhir/ValueSet/care-plan-category From the FHIR Standard
CarePlan.category:pco	required	PCOCategories http://hl7.org/fhir/us/pco/ValueSet/pco-categories From this IG
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
cpl-3	error	CarePlan.activity	Provide a reference or detail, not both : detail.empty() or reference.empty()
dom-2	error	CarePlan	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	CarePlan	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 : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	CarePlan	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	CarePlan	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	CarePlan	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
txt-1	error	CarePlan.text.div	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 : htmlChecks()
txt-2	error	CarePlan.text.div	The narrative SHALL have some non-whitespace content : htmlChecks()

This structure is derived from USCoreCarePlanProfile

Summary

Mandatory: 4 elements
Must-Support: 4 elements
Prohibited: 1 element

Structures

This structure refers to these other structures:

• Person-Centered Goal (http://hl7.org/fhir/us/pco/StructureDefinition/pco-goal-profile)

Slices

This structure defines the following Slices:

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

Maturity: 2