Person-Centered Outcomes (PCO) Implementation Guide
1.0.0 - STU 1 United States of America flag

Person-Centered Outcomes (PCO) Implementation Guide, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/pco-ig/ and changes regularly. See the Directory of published versions

Resource Profile: Person-Centered Care Plan

Official URL: http://hl7.org/fhir/us/pco/StructureDefinition/pco-care-plan Version: 1.0.0
Standards status: Draft Draft as of 2026-03-02 Maturity Level: 2 Computable Name: PCOCarePlan

A person-centered care plan SHALL reference a person-centered goal and SHALL include action steps that support progress toward achievement of the plan's goals and desired outcomes. A plan SHOULD address the person's stated priorities for what matters most to them. Action steps may include both treatment procedures and self-care steps identified by the person.

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

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description Differentials, Snapshots, and other representations.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
CarePlan.text.status Base required US Core Narrative Status 📦6.1.0 US Core v6.1
CarePlan.status Base required RequestStatus 📦4.0.1 FHIR Std.
CarePlan.intent Base required Care Plan Intent 📦4.0.1 FHIR Std.
CarePlan.category Base example Care Plan Category 📦4.0.1 FHIR Std.
CarePlan.category:AssessPlan Base example Care Plan Category 📦4.0.1 FHIR Std.
CarePlan.category:pco Base required Person-Centered Categories 📦1.0.0 This IG
CarePlan.activity.detail.​status Base required CarePlanActivityStatus 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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()

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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 Removed in FHIR R5

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
CarePlan.category:pco Base required Person-Centered Categories 📦1.0.0 This IG
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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 BindingsPurpose
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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
CarePlan.language Base preferred Common Languages 📦4.0.1 FHIR Std.
CarePlan.text.status Base required US Core Narrative Status 📦6.1.0 US Core v6.1
CarePlan.status Base required RequestStatus 📦4.0.1 FHIR Std.
CarePlan.intent Base required Care Plan Intent 📦4.0.1 FHIR Std.
CarePlan.category Base example Care Plan Category 📦4.0.1 FHIR Std.
CarePlan.category:AssessPlan Base example Care Plan Category 📦4.0.1 FHIR Std.
CarePlan.category:pco Base required Person-Centered Categories 📦1.0.0 This IG
CarePlan.activity.outcomeCodeableConcept Base example Care Plan Activity Outcome 📦4.0.1 FHIR Std.
CarePlan.activity.detail.​kind Base required Care Plan Activity Kind 📍4.0.1 FHIR Std.
CarePlan.activity.detail.​code Base example Procedure Codes (SNOMED CT) 📦4.0.1 FHIR Std.
CarePlan.activity.detail.​reasonCode Base example SNOMED CT Clinical Findings 📦4.0.1 FHIR Std.
CarePlan.activity.detail.​status Base required CarePlanActivityStatus 📍4.0.1 FHIR Std.
CarePlan.activity.detail.​product[x] Base example SNOMED CT Medication Codes 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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()

Summary

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

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

Maturity: 2

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
CarePlan.text.status Base required US Core Narrative Status 📦6.1.0 US Core v6.1
CarePlan.status Base required RequestStatus 📦4.0.1 FHIR Std.
CarePlan.intent Base required Care Plan Intent 📦4.0.1 FHIR Std.
CarePlan.category Base example Care Plan Category 📦4.0.1 FHIR Std.
CarePlan.category:AssessPlan Base example Care Plan Category 📦4.0.1 FHIR Std.
CarePlan.category:pco Base required Person-Centered Categories 📦1.0.0 This IG
CarePlan.activity.detail.​status Base required CarePlanActivityStatus 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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 Removed in FHIR R5

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
CarePlan.category:pco Base required Person-Centered Categories 📦1.0.0 This IG

Snapshot ViewView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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 BindingsPurpose
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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
CarePlan.language Base preferred Common Languages 📦4.0.1 FHIR Std.
CarePlan.text.status Base required US Core Narrative Status 📦6.1.0 US Core v6.1
CarePlan.status Base required RequestStatus 📦4.0.1 FHIR Std.
CarePlan.intent Base required Care Plan Intent 📦4.0.1 FHIR Std.
CarePlan.category Base example Care Plan Category 📦4.0.1 FHIR Std.
CarePlan.category:AssessPlan Base example Care Plan Category 📦4.0.1 FHIR Std.
CarePlan.category:pco Base required Person-Centered Categories 📦1.0.0 This IG
CarePlan.activity.outcomeCodeableConcept Base example Care Plan Activity Outcome 📦4.0.1 FHIR Std.
CarePlan.activity.detail.​kind Base required Care Plan Activity Kind 📍4.0.1 FHIR Std.
CarePlan.activity.detail.​code Base example Procedure Codes (SNOMED CT) 📦4.0.1 FHIR Std.
CarePlan.activity.detail.​reasonCode Base example SNOMED CT Clinical Findings 📦4.0.1 FHIR Std.
CarePlan.activity.detail.​status Base required CarePlanActivityStatus 📍4.0.1 FHIR Std.
CarePlan.activity.detail.​product[x] Base example SNOMED CT Medication Codes 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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()

Summary

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

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

Maturity: 2

 

Other representations of profile: CSV, Excel, Schematron