Person-Centered Care Plan - Person-Centered Outcomes (PCO) Implementation Guide v1.1.0

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 1.1.0 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: 1.1.0	Highlight text changes?
Standards status: Trial-use	Maturity Level: 2	Computable Name: PCOCarePlan
Other Identifiers: OID:2.16.840.1.113883.4.642.40.103.42.1

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:

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

Usages:

Examples for this Profile: CarePlan/pcoSocialConnectionsCarePlanExample

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description Differentials, Snapshots, and other representations.

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
CarePlan.implicitRules	This element is a modifier element. This element is included in summaries.	0..1	uri	A set of rules under which this content was created
CarePlan.text	This element must be supported.	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
CarePlan.text.status	This element must be supported.	1..1	code	(USCDI) generated \| extensions \| additional \| empty Binding: US Core Narrative Status (required): Constrained value set of narrative statuses.
CarePlan.text.div	This element must be supported. C	1..1	xhtml	(USCDI) Limited xhtml content Constraints: txt-1, txt-2
CarePlan.modifierExtension	This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
CarePlan.status	This element is a modifier element. This element must be supported. This element is included in summaries.	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.
CarePlan.intent	This element is a modifier element. This element must be supported. This element is included in summaries.	1..1	code	(USCDI) proposal \| plan \| order \| option Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan
CarePlan.Slices for category	This element must be supported. This element is included in summaries.	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. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
CarePlan.Slices for category.category:AssessPlan	This element must be supported. This element is included in summaries.	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: `{ "coding" : [ { "system" : "http://hl7.org/fhir/us/core/CodeSystem/careplan-category", "code" : "assess-plan" } ] }`
CarePlan.Slices for category.category:pco	This element must be supported. This element is included in summaries.	0..1	CodeableConcept	Person-Centered resource category Binding: Person-Centered Categories (required)
CarePlan.subject	This element must be supported. This element is included in summaries.	1..1	Reference(US Core Patient Profile)	(USCDI) Who the care plan is for
CarePlan.Slices for goal	This element must be supported.	1..*	Reference(Goal)	Desired outcome of plan Slice: Unordered, Open by profile:resolve() Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
CarePlan.Slices for goal.goal:SupportedGoals	This element must be supported.	1..*	Reference(Person-Centered Goal)	Person-centered goals supported by this plan
CarePlan.activity	C	1..*	BackboneElement	Action to occur as part of plan Constraints: cpl-3
CarePlan.activity.modifierExtension	This element is a modifier element. This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
CarePlan.activity.reference	This element must be supported. C	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	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	📦1.1.0	This IG
CarePlan.activity.detail.status	Base	required	CarePlanActivityStatus	📍4.0.1	FHIR Std.

Constraints

Grade

Path(s)

Description

Expression

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
CarePlan.Slices for category				Content/Rules for all slices
CarePlan.Slices for category.category:pco	This element must be supported.	0..1	CodeableConcept	Person-Centered resource category Binding: Person-Centered Categories (required)
CarePlan.Slices for goal	This element must be supported.	1..*	Reference(Goal)	Desired outcome of plan Slice: Unordered, Open by profile:resolve() Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
CarePlan.Slices for goal.goal:SupportedGoals	This element must be supported.	1..*	Reference(Person-Centered Goal)	Person-centered goals supported by this plan
CarePlan.activity		1..*	BackboneElement	Action to occur as part of plan
CarePlan.activity.reference	This element must be supported.	1..1	Reference(Appointment \| CommunicationRequest \| DeviceRequest \| MedicationRequest \| NutritionOrder \| Task \| ServiceRequest \| VisionPrescription \| RequestGroup)	Action steps for person-centered goals
CarePlan.activity.detail		0..0		Removed in FHIR R5
Documentation for this format

Terminology Bindings (Differential)

Path	Status	Usage	ValueSet	Version	Source
CarePlan.category:pco	Base	required	Person-Centered Categories	📦1.1.0	This IG

Description & Constraints Filter:

CarePlan 0..* USCoreCarePlanProfile Healthcare plan for patient or group

CarePlan.id This element is included in summaries. 0..1 id Logical id of this artifact

CarePlan.meta This element is included in summaries. 0..1 Meta Metadata about the resource

CarePlan.implicitRules This element is a modifier element. This element is included in summaries. 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

CarePlan.text This element must be supported. 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

CarePlan.text.id 0..1 string Unique id for inter-element referencing

CarePlan.text.extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url

CarePlan.text.status This element must be supported. 1..1 code (USCDI) generated | extensions | additional | empty
Binding: US Core Narrative Status (required): Constrained value set of narrative statuses.

CarePlan.text.div This element must be supported. C 1..1 xhtml (USCDI) Limited xhtml content
Constraints: txt-1, txt-2

CarePlan.contained 0..* Resource Contained, inline Resources

CarePlan.extension 0..* Extension Additional content defined by implementations

CarePlan.modifierExtension This element is a modifier element. 0..* Extension Extensions that cannot be ignored

CarePlan.identifier This element is included in summaries. 0..* Identifier External Ids for this plan

CarePlan.instantiatesCanonical This element is included in summaries. 0..* canonical(PlanDefinition | Questionnaire | Measure | ActivityDefinition | OperationDefinition) Instantiates FHIR protocol or definition

CarePlan.instantiatesUri This element is included in summaries. 0..* uri Instantiates external protocol or definition

CarePlan.basedOn This element is included in summaries. 0..* Reference(CarePlan) Fulfills CarePlan

CarePlan.replaces This element is included in summaries. 0..* Reference(CarePlan) CarePlan replaced by this CarePlan

CarePlan.partOf This element is included in summaries. 0..* Reference(CarePlan) Part of referenced CarePlan

CarePlan.status This element is a modifier element. This element must be supported. This element is included in summaries. 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.

CarePlan.intent This element is a modifier element. This element must be supported. This element is included in summaries. 1..1 code (USCDI) proposal | plan | order | option
Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan

CarePlan.Slices for category This element must be supported. This element is included in summaries. 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.

Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them

category:AssessPlan

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:

{
  "coding" : [
    {
      "system" : "http://hl7.org/fhir/us/core/CodeSystem/careplan-category",
      "code" : "assess-plan"
    }
  ]
}

CarePlan.Slices for category.category:pco This element must be supported. This element is included in summaries. 0..1 CodeableConcept Person-Centered resource category
Binding: Person-Centered Categories (required)

CarePlan.title This element is included in summaries. 0..1 string Human-friendly name for the care plan

CarePlan.description This element is included in summaries. 0..1 string Summary of nature of plan

CarePlan.subject This element must be supported. This element is included in summaries. 1..1 Reference(US Core Patient Profile) (USCDI) Who the care plan is for

CarePlan.encounter This element is included in summaries. 0..1 Reference(Encounter) Encounter created as part of

CarePlan.period This element is included in summaries. 0..1 Period Time period plan covers

CarePlan.created This element is included in summaries. 0..1 dateTime Date record was first recorded

CarePlan.careTeam 0..* Reference(CareTeam) Who's involved in plan?

CarePlan.addresses This element is included in summaries. 0..* Reference(Condition) Health issues this plan addresses

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

CarePlan.Slices for goal This element must be supported. 1..* Reference(Goal) Desired outcome of plan
Slice: Unordered, Open by profile:resolve()

Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them

CarePlan.Slices for goal.goal:SupportedGoals This element must be supported. 1..* Reference(Person-Centered Goal) Person-centered goals supported by this plan

CarePlan.activity C 1..* BackboneElement Action to occur as part of plan
Constraints: cpl-3

CarePlan.activity.id 0..1 string Unique id for inter-element referencing

CarePlan.activity.extension 0..* Extension Additional content defined by implementations

CarePlan.activity.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized

CarePlan.activity.outcomeCodeableConcept 0..* CodeableConcept Results of the activity
Binding: CarePlanActivityOutcome (example): Identifies the results of the activity.

CarePlan.activity.outcomeReference 0..* Reference(Resource) Appointment, Encounter, Procedure, etc.

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

CarePlan.note 0..* Annotation Comments about the plan

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	📦1.1.0	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

Grade

Path(s)

Description

Expression

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

Key Elements View

Name	Flags	Card.	Type	Description & Constraints Filter: Bindings Constraints Obligations
CarePlan		0..*	USCoreCarePlanProfile	Healthcare plan for patient or group
CarePlan.implicitRules	This element is a modifier element. This element is included in summaries.	0..1	uri	A set of rules under which this content was created
CarePlan.text	This element must be supported.	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
CarePlan.text.status	This element must be supported.	1..1	code	(USCDI) generated \| extensions \| additional \| empty Binding: US Core Narrative Status (required): Constrained value set of narrative statuses.
CarePlan.text.div	This element must be supported. C	1..1	xhtml	(USCDI) Limited xhtml content Constraints: txt-1, txt-2
CarePlan.modifierExtension	This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
CarePlan.status	This element is a modifier element. This element must be supported. This element is included in summaries.	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.
CarePlan.intent	This element is a modifier element. This element must be supported. This element is included in summaries.	1..1	code	(USCDI) proposal \| plan \| order \| option Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan
CarePlan.Slices for category	This element must be supported. This element is included in summaries.	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. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
CarePlan.Slices for category.category:AssessPlan	This element must be supported. This element is included in summaries.	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: `{ "coding" : [ { "system" : "http://hl7.org/fhir/us/core/CodeSystem/careplan-category", "code" : "assess-plan" } ] }`
CarePlan.Slices for category.category:pco	This element must be supported. This element is included in summaries.	0..1	CodeableConcept	Person-Centered resource category Binding: Person-Centered Categories (required)
CarePlan.subject	This element must be supported. This element is included in summaries.	1..1	Reference(US Core Patient Profile)	(USCDI) Who the care plan is for
CarePlan.Slices for goal	This element must be supported.	1..*	Reference(Goal)	Desired outcome of plan Slice: Unordered, Open by profile:resolve() Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
CarePlan.Slices for goal.goal:SupportedGoals	This element must be supported.	1..*	Reference(Person-Centered Goal)	Person-centered goals supported by this plan
CarePlan.activity	C	1..*	BackboneElement	Action to occur as part of plan Constraints: cpl-3
CarePlan.activity.modifierExtension	This element is a modifier element. This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
CarePlan.activity.reference	This element must be supported. C	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	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	📦1.1.0	This IG
CarePlan.activity.detail.status	Base	required	CarePlanActivityStatus	📍4.0.1	FHIR Std.

Constraints

Grade

Path(s)

Description

Expression

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
CarePlan.Slices for category				Content/Rules for all slices
CarePlan.Slices for category.category:pco	This element must be supported.	0..1	CodeableConcept	Person-Centered resource category Binding: Person-Centered Categories (required)
CarePlan.Slices for goal	This element must be supported.	1..*	Reference(Goal)	Desired outcome of plan Slice: Unordered, Open by profile:resolve() Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
CarePlan.Slices for goal.goal:SupportedGoals	This element must be supported.	1..*	Reference(Person-Centered Goal)	Person-centered goals supported by this plan
CarePlan.activity		1..*	BackboneElement	Action to occur as part of plan
CarePlan.activity.reference	This element must be supported.	1..1	Reference(Appointment \| CommunicationRequest \| DeviceRequest \| MedicationRequest \| NutritionOrder \| Task \| ServiceRequest \| VisionPrescription \| RequestGroup)	Action steps for person-centered goals
CarePlan.activity.detail		0..0		Removed in FHIR R5
Documentation for this format

Terminology Bindings (Differential)

Path	Status	Usage	ValueSet	Version	Source
CarePlan.category:pco	Base	required	Person-Centered Categories	📦1.1.0	This IG

Snapshot ViewView