臺灣長期照顧實作指引(TW LTC IG)
1.0.0 - STU 1.0.0

臺灣長期照顧實作指引(TW LTC IG), published by 經濟部產業發展署. 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/Lorex/TWLongTermCare_IG_Build/ and changes regularly. See the Directory of published versions

## Resource Profile: 長照 SDK－照顧計畫（不含輔具）

Official URL: http://ltc-ig.fhir.tw/StructureDefinition/LTC-CarePlan-Payload | Version: 1.0.0
Draft as of 2026-03-01 | Computable Name: LTCCarePlanPayload

此 Profile 說明本 IG 如何進一步定義 FHIR 的 CarePlan Resource，以呈現長照 SDK 回傳之照顧計畫，包含服務項目代碼、金額、數量及頻率等資料。

Usages:

- Derived from this Profile: 長照 SDK－照顧計畫（CS100）
- Use this Profile: 長照 SDK－回傳包（4合1）
- Refer to this Profile: 個案總查詢（CS100 對應版）Case Summary
- Examples for this Profile: CarePlan/ltc-careplan-cs100-example and CarePlan/ltc-careplan-sdk-example

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

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

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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
CarePlan |  | 0..* | TWCoreCarePlan | 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 | CarePlan Resource之內容摘要以供人閱讀 This profile does not constrain the narrative in regard to content, language, or traceability to data elements
status | S | 1..1 | code | generated | additional Binding: 臺灣衛福部資訊處Narrative狀態值集 (required): Constrained value set of narrative statuses.
div | S C | 1..1 | xhtml | Limited xhtml content Constraints: txt-1, txt-2
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!S Σ | 1..1 | code | 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 | ?!S Σ | 1..1 | code | proposal | plan | order | option Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan Required Pattern: plan
Slices for category | S Σ | 1..* | CodeableConcept | 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 | S Σ | 1..1 | CodeableConcept | 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: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/careplan-category-tw
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
subject | S Σ | 1..1 | Reference(長期照顧－住民基本資料) | Who the care plan is for
period | S Σ | 0..1 | Period | Time period plan covers
activity | S 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
detail | S C | 1..1 | BackboneElement | In-line definition of activity
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:unitPrice |  | 0..1 | Money | 單價 URL: http://ltc-ig.fhir.tw/StructureDefinition/Ext-TW-LTC-UnitPrice
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code | S | 1..1 | CodeableConcept | Detail type of activity Binding: ProcedureCodes(SNOMEDCT) (example): Detailed description of the type of activity; e.g. What lab test, what procedure, what kind of encounter.
status | ?! | 1..1 | code | not-started | scheduled | in-progress | on-hold | completed | cancelled | stopped | unknown | entered-in-error Binding: CarePlanActivityStatus (required): Codes that reflect the current state of a care plan activity within its overall life cycle.
doNotPerform | ?! | 0..1 | boolean | If true, activity is prohibiting action
Slices for scheduled[x] |  | 0..1 |  | When activity is to occur Slice: Unordered, Open by type:$this
scheduledTiming |  |  | Timing |
scheduledString |  |  | string |
scheduled[x]:scheduledTiming |  | 0..1 | Timing | When activity is to occur
Slices for product[x] |  | 0..1 |  | What is to be administered/supplied Slice: Unordered, Open by type:$this Binding: SNOMEDCTMedicationCodes (example): A product supplied or administered as part of a care plan activity.
productCodeableConcept |  |  | CodeableConcept |
productReference |  |  | Reference(Medication | Substance) |
product[x]:productReference |  | 0..1 | Reference(TW Core Medication | Substance) | What is to be administered/supplied
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
CarePlan.text.status | Base | required | 臺灣衛福部資訊處Narrative狀態值集 | 📦0.3.0 | 臺灣核心實作指引 v0.3
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.activity.detail.​code | Base | example | Procedure Codes (SNOMED CT) | 📦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()`

This structure is derived from TWCoreCarePlan

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
CarePlan |  |  | TWCoreCarePlan |
intent |  | 1..1 | code | proposal | plan | order | option Required Pattern: plan
subject |  | 1..1 | Reference(長期照顧－住民基本資料) | Who the care plan is for
period | S | 0..1 | Period | Time period plan covers
activity | S | 1..* | BackboneElement | Action to occur as part of plan
detail | S | 1..1 | BackboneElement | In-line definition of activity
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:unitPrice |  | 0..1 | Money | 單價 URL: http://ltc-ig.fhir.tw/StructureDefinition/Ext-TW-LTC-UnitPrice
code | S | 1..1 | CodeableConcept | Detail type of activity
Slices for scheduled[x] |  | 0..1 |  | When activity is to occur Slice: Unordered, Open by type:$this
scheduledTiming |  |  | Timing |
scheduledString |  |  | string |
scheduled[x]:scheduledTiming |  | 0..1 | Timing | When activity is to occur
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
CarePlan |  | 0..* | TWCoreCarePlan | 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 | CarePlan Resource之內容摘要以供人閱讀 This profile does not constrain the narrative in regard to content, language, or 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 | generated | additional Binding: 臺灣衛福部資訊處Narrative狀態值集 (required): Constrained value set of narrative statuses.
div | S C | 1..1 | xhtml | 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(TW Core CarePlan) | Fulfills CarePlan
replaces | Σ | 0..* | Reference(TW Core CarePlan) | CarePlan replaced by this CarePlan
partOf | Σ | 0..* | Reference(TW Core CarePlan) | Part of referenced CarePlan
status | ?!S Σ | 1..1 | code | 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 | ?!S Σ | 1..1 | code | proposal | plan | order | option Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan Required Pattern: plan
Slices for category | S Σ | 1..* | CodeableConcept | 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 | S Σ | 1..1 | CodeableConcept | 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: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/careplan-category-tw
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
title | Σ | 0..1 | string | Human-friendly name for the care plan
description | Σ | 0..1 | string | Summary of nature of plan
subject | S Σ | 1..1 | Reference(長期照顧－住民基本資料) | Who the care plan is for
encounter | Σ | 0..1 | Reference(TW Core Encounter) | Encounter created as part of
period | S Σ | 0..1 | Period | Time period plan covers
created | Σ | 0..1 | dateTime | Date record was first recorded
author | Σ | 0..1 | Reference(TW Core Patient | TW Core Practitioner | TW Core PractitionerRole | TW Core Implantable Device | TW Core RelatedPerson | TW Core Organization | TW Core CareTeam) | Who is the designated responsible party
contributor |  | 0..* | Reference(TW Core Patient | TW Core Practitioner | TW Core PractitionerRole | TW Core Implantable Device | TW Core RelatedPerson | TW Core Organization | TW Core CareTeam) | Who provided the content of the care plan
careTeam |  | 0..* | Reference(TW Core CareTeam) | Who's involved in plan?
addresses | Σ | 0..* | Reference(TW Core Condition) | Health issues this plan addresses
supportingInfo |  | 0..* | Reference(Resource) | Information considered as part of plan
goal |  | 0..* | Reference(Goal) | Desired outcome of plan
activity | S 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 | C | 0..1 | Reference(Appointment | CommunicationRequest | DeviceRequest | TW Core MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) | Activity details defined in specific resource
detail | S C | 1..1 | BackboneElement | In-line definition of activity
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:unitPrice |  | 0..1 | Money | 單價 URL: http://ltc-ig.fhir.tw/StructureDefinition/Ext-TW-LTC-UnitPrice
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
kind |  | 0..1 | code | Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription Binding: CarePlanActivityKind (required): Resource types defined as part of FHIR that can be represented as in-line definitions of a care plan activity.
instantiatesCanonical |  | 0..* | canonical(PlanDefinition | ActivityDefinition | Questionnaire | Measure | OperationDefinition) | Instantiates FHIR protocol or definition
instantiatesUri |  | 0..* | uri | Instantiates external protocol or definition
code | S | 1..1 | CodeableConcept | Detail type of activity Binding: ProcedureCodes(SNOMEDCT) (example): Detailed description of the type of activity; e.g. What lab test, what procedure, what kind of encounter.
reasonCode |  | 0..* | CodeableConcept | Why activity should be done or why activity was prohibited Binding: SNOMEDCTClinicalFindings (example): Identifies why a care plan activity is needed. Can include any health condition codes as well as such concepts as "general wellness", prophylaxis, surgical preparation, etc.
reasonReference |  | 0..* | Reference(TW Core Condition | TW Core Observation Clinical Result | TW Core DiagnosticReport | TW Core DocumentReference) | Why activity is needed
goal |  | 0..* | Reference(Goal) | Goals this activity relates to
status | ?! | 1..1 | code | not-started | scheduled | in-progress | on-hold | completed | cancelled | stopped | unknown | entered-in-error Binding: CarePlanActivityStatus (required): Codes that reflect the current state of a care plan activity within its overall life cycle.
statusReason |  | 0..1 | CodeableConcept | Reason for current status
doNotPerform | ?! | 0..1 | boolean | If true, activity is prohibiting action
Slices for scheduled[x] |  | 0..1 |  | When activity is to occur Slice: Unordered, Open by type:$this
scheduledTiming |  |  | Timing |
scheduledString |  |  | string |
scheduled[x]:scheduledTiming |  | 0..1 | Timing | When activity is to occur
location |  | 0..1 | Reference(TW Core Location) | Where it should happen
performer |  | 0..* | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Organization | TW Core RelatedPerson | TW Core Patient | TW Core CareTeam | HealthcareService | TW Core Implantable Device) | Who will be responsible?
Slices for product[x] |  | 0..1 |  | What is to be administered/supplied Slice: Unordered, Open by type:$this Binding: SNOMEDCTMedicationCodes (example): A product supplied or administered as part of a care plan activity.
productCodeableConcept |  |  | CodeableConcept |
productReference |  |  | Reference(Medication | Substance) |
product[x]:productReference |  | 0..1 | Reference(TW Core Medication | Substance) | What is to be administered/supplied
dailyAmount |  | 0..1 | SimpleQuantity | How to consume/day?
quantity |  | 0..1 | SimpleQuantity | How much to administer/supply/consume
description |  | 0..1 | string | Extra info describing activity to perform
note |  | 0..* | Annotation | Comments about the plan
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
CarePlan.language | Base | preferred | Common Languages | 📦4.0.1 | FHIR Std.
CarePlan.text.status | Base | required | 臺灣衛福部資訊處Narrative狀態值集 | 📦0.3.0 | 臺灣核心實作指引 v0.3
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.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()`

This structure is derived from TWCoreCarePlan

Summary

Mandatory: 3 elements
Must-Support: 4 elements

Structures

This structure refers to these other structures:

- 長期照顧－住民基本資料 (http://ltc-ig.fhir.tw/StructureDefinition/LTCPatient)

Extensions

This structure refers to these extensions:

- http://ltc-ig.fhir.tw/StructureDefinition/Ext-TW-LTC-UnitPrice

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the value of CarePlan.activity.detail.scheduled[x]

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
CarePlan |  | 0..* | TWCoreCarePlan | 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 | CarePlan Resource之內容摘要以供人閱讀 This profile does not constrain the narrative in regard to content, language, or traceability to data elements
status | S | 1..1 | code | generated | additional Binding: 臺灣衛福部資訊處Narrative狀態值集 (required): Constrained value set of narrative statuses.
div | S C | 1..1 | xhtml | Limited xhtml content Constraints: txt-1, txt-2
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!S Σ | 1..1 | code | 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 | ?!S Σ | 1..1 | code | proposal | plan | order | option Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan Required Pattern: plan
Slices for category | S Σ | 1..* | CodeableConcept | 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 | S Σ | 1..1 | CodeableConcept | 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: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/careplan-category-tw
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
subject | S Σ | 1..1 | Reference(長期照顧－住民基本資料) | Who the care plan is for
period | S Σ | 0..1 | Period | Time period plan covers
activity | S 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
detail | S C | 1..1 | BackboneElement | In-line definition of activity
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:unitPrice |  | 0..1 | Money | 單價 URL: http://ltc-ig.fhir.tw/StructureDefinition/Ext-TW-LTC-UnitPrice
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code | S | 1..1 | CodeableConcept | Detail type of activity Binding: ProcedureCodes(SNOMEDCT) (example): Detailed description of the type of activity; e.g. What lab test, what procedure, what kind of encounter.
status | ?! | 1..1 | code | not-started | scheduled | in-progress | on-hold | completed | cancelled | stopped | unknown | entered-in-error Binding: CarePlanActivityStatus (required): Codes that reflect the current state of a care plan activity within its overall life cycle.
doNotPerform | ?! | 0..1 | boolean | If true, activity is prohibiting action
Slices for scheduled[x] |  | 0..1 |  | When activity is to occur Slice: Unordered, Open by type:$this
scheduledTiming |  |  | Timing |
scheduledString |  |  | string |
scheduled[x]:scheduledTiming |  | 0..1 | Timing | When activity is to occur
Slices for product[x] |  | 0..1 |  | What is to be administered/supplied Slice: Unordered, Open by type:$this Binding: SNOMEDCTMedicationCodes (example): A product supplied or administered as part of a care plan activity.
productCodeableConcept |  |  | CodeableConcept |
productReference |  |  | Reference(Medication | Substance) |
product[x]:productReference |  | 0..1 | Reference(TW Core Medication | Substance) | What is to be administered/supplied
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
CarePlan.text.status | Base | required | 臺灣衛福部資訊處Narrative狀態值集 | 📦0.3.0 | 臺灣核心實作指引 v0.3
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.activity.detail.​code | Base | example | Procedure Codes (SNOMED CT) | 📦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()`

Differential View

This structure is derived from TWCoreCarePlan

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
CarePlan |  |  | TWCoreCarePlan |
intent |  | 1..1 | code | proposal | plan | order | option Required Pattern: plan
subject |  | 1..1 | Reference(長期照顧－住民基本資料) | Who the care plan is for
period | S | 0..1 | Period | Time period plan covers
activity | S | 1..* | BackboneElement | Action to occur as part of plan
detail | S | 1..1 | BackboneElement | In-line definition of activity
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:unitPrice |  | 0..1 | Money | 單價 URL: http://ltc-ig.fhir.tw/StructureDefinition/Ext-TW-LTC-UnitPrice
code | S | 1..1 | CodeableConcept | Detail type of activity
Slices for scheduled[x] |  | 0..1 |  | When activity is to occur Slice: Unordered, Open by type:$this
scheduledTiming |  |  | Timing |
scheduledString |  |  | string |
scheduled[x]:scheduledTiming |  | 0..1 | Timing | When activity is to occur
Documentation for this format

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
CarePlan |  | 0..* | TWCoreCarePlan | 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 | CarePlan Resource之內容摘要以供人閱讀 This profile does not constrain the narrative in regard to content, language, or 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 | generated | additional Binding: 臺灣衛福部資訊處Narrative狀態值集 (required): Constrained value set of narrative statuses.
div | S C | 1..1 | xhtml | 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(TW Core CarePlan) | Fulfills CarePlan
replaces | Σ | 0..* | Reference(TW Core CarePlan) | CarePlan replaced by this CarePlan
partOf | Σ | 0..* | Reference(TW Core CarePlan) | Part of referenced CarePlan
status | ?!S Σ | 1..1 | code | 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 | ?!S Σ | 1..1 | code | proposal | plan | order | option Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan Required Pattern: plan
Slices for category | S Σ | 1..* | CodeableConcept | 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 | S Σ | 1..1 | CodeableConcept | 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: https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/careplan-category-tw
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
title | Σ | 0..1 | string | Human-friendly name for the care plan
description | Σ | 0..1 | string | Summary of nature of plan
subject | S Σ | 1..1 | Reference(長期照顧－住民基本資料) | Who the care plan is for
encounter | Σ | 0..1 | Reference(TW Core Encounter) | Encounter created as part of
period | S Σ | 0..1 | Period | Time period plan covers
created | Σ | 0..1 | dateTime | Date record was first recorded
author | Σ | 0..1 | Reference(TW Core Patient | TW Core Practitioner | TW Core PractitionerRole | TW Core Implantable Device | TW Core RelatedPerson | TW Core Organization | TW Core CareTeam) | Who is the designated responsible party
contributor |  | 0..* | Reference(TW Core Patient | TW Core Practitioner | TW Core PractitionerRole | TW Core Implantable Device | TW Core RelatedPerson | TW Core Organization | TW Core CareTeam) | Who provided the content of the care plan
careTeam |  | 0..* | Reference(TW Core CareTeam) | Who's involved in plan?
addresses | Σ | 0..* | Reference(TW Core Condition) | Health issues this plan addresses
supportingInfo |  | 0..* | Reference(Resource) | Information considered as part of plan
goal |  | 0..* | Reference(Goal) | Desired outcome of plan
activity | S 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 | C | 0..1 | Reference(Appointment | CommunicationRequest | DeviceRequest | TW Core MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) | Activity details defined in specific resource
detail | S C | 1..1 | BackboneElement | In-line definition of activity
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:unitPrice |  | 0..1 | Money | 單價 URL: http://ltc-ig.fhir.tw/StructureDefinition/Ext-TW-LTC-UnitPrice
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
kind |  | 0..1 | code | Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription Binding: CarePlanActivityKind (required): Resource types defined as part of FHIR that can be represented as in-line definitions of a care plan activity.
instantiatesCanonical |  | 0..* | canonical(PlanDefinition | ActivityDefinition | Questionnaire | Measure | OperationDefinition) | Instantiates FHIR protocol or definition
instantiatesUri |  | 0..* | uri | Instantiates external protocol or definition
code | S | 1..1 | CodeableConcept | Detail type of activity Binding: ProcedureCodes(SNOMEDCT) (example): Detailed description of the type of activity; e.g. What lab test, what procedure, what kind of encounter.
reasonCode |  | 0..* | CodeableConcept | Why activity should be done or why activity was prohibited Binding: SNOMEDCTClinicalFindings (example): Identifies why a care plan activity is needed. Can include any health condition codes as well as such concepts as "general wellness", prophylaxis, surgical preparation, etc.
reasonReference |  | 0..* | Reference(TW Core Condition | TW Core Observation Clinical Result | TW Core DiagnosticReport | TW Core DocumentReference) | Why activity is needed
goal |  | 0..* | Reference(Goal) | Goals this activity relates to
status | ?! | 1..1 | code | not-started | scheduled | in-progress | on-hold | completed | cancelled | stopped | unknown | entered-in-error Binding: CarePlanActivityStatus (required): Codes that reflect the current state of a care plan activity within its overall life cycle.
statusReason |  | 0..1 | CodeableConcept | Reason for current status
doNotPerform | ?! | 0..1 | boolean | If true, activity is prohibiting action
Slices for scheduled[x] |  | 0..1 |  | When activity is to occur Slice: Unordered, Open by type:$this
scheduledTiming |  |  | Timing |
scheduledString |  |  | string |
scheduled[x]:scheduledTiming |  | 0..1 | Timing | When activity is to occur
location |  | 0..1 | Reference(TW Core Location) | Where it should happen
performer |  | 0..* | Reference(TW Core Practitioner | TW Core PractitionerRole | TW Core Organization | TW Core RelatedPerson | TW Core Patient | TW Core CareTeam | HealthcareService | TW Core Implantable Device) | Who will be responsible?
Slices for product[x] |  | 0..1 |  | What is to be administered/supplied Slice: Unordered, Open by type:$this Binding: SNOMEDCTMedicationCodes (example): A product supplied or administered as part of a care plan activity.
productCodeableConcept |  |  | CodeableConcept |
productReference |  |  | Reference(Medication | Substance) |
product[x]:productReference |  | 0..1 | Reference(TW Core Medication | Substance) | What is to be administered/supplied
dailyAmount |  | 0..1 | SimpleQuantity | How to consume/day?
quantity |  | 0..1 | SimpleQuantity | How much to administer/supply/consume
description |  | 0..1 | string | Extra info describing activity to perform
note |  | 0..* | Annotation | Comments about the plan
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
CarePlan.language | Base | preferred | Common Languages | 📦4.0.1 | FHIR Std.
CarePlan.text.status | Base | required | 臺灣衛福部資訊處Narrative狀態值集 | 📦0.3.0 | 臺灣核心實作指引 v0.3
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.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()`

This structure is derived from TWCoreCarePlan

Summary

Mandatory: 3 elements
Must-Support: 4 elements

Structures

This structure refers to these other structures:

- 長期照顧－住民基本資料 (http://ltc-ig.fhir.tw/StructureDefinition/LTCPatient)

Extensions

This structure refers to these extensions:

- http://ltc-ig.fhir.tw/StructureDefinition/Ext-TW-LTC-UnitPrice

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the value of CarePlan.activity.detail.scheduled[x]

Other representations of profile: CSV, Excel, Schematron