SMART Base Clinical
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SMART Base Clinical, published by WHO. 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/WorldHealthOrganization/smart-base-clinical/ and changes regularly. See the Directory of published versions

Resource Profile: SGCarePlan - Detailed Descriptions

Draft as of 2024-12-02

Definitions for the sg-careplan resource profile.

Guidance on how to interpret the contents of this table can be found here

0. CarePlan
Must Supporttrue
2. CarePlan.identifier
NoteThis is a business identifier, not a resource identifier (see discussion)
Control1..*
Must Supporttrue
4. CarePlan.identifier.use
Control1..1
Must Supporttrue
6. CarePlan.identifier.system
Control1..1
Must Supporttrue
8. CarePlan.identifier.value
Control1..1
Must Supporttrue
10. CarePlan.status
Must Supporttrue
12. CarePlan.intent
Must Supporttrue
14. CarePlan.category
Must Supporttrue
16. CarePlan.title
Control1..1
Must Supporttrue
18. CarePlan.description
Must Supporttrue
20. CarePlan.subject
TypeReference(WHO SMART Guidelines Patient)
Must Supporttrue
22. CarePlan.encounter
TypeReference(WHO SMART Guidelines Encounter)
Must Supporttrue
24. CarePlan.period
Must Supporttrue
26. CarePlan.careTeam
Control1..1
TypeReference(WHO SMART Guidelines CareTeam)
Must Supporttrue
28. CarePlan.addresses
TypeReference(WHO SMART Guidelines Condition)
Must Supporttrue
30. CarePlan.activity
Must Supporttrue
32. CarePlan.activity.outcomeReference
TypeReference(WHO SMART Guidelines AllergyIntolerance, WHO SMART Guidelines Condition, WHO SMART Guidelines Encounter, WHO SMART Guidelines EpisodeOfCare, WHO SMART Guidelines Immunization, WHO SMART Guidelines Immunization Not Done, WHO SMART Guidelines Observation, WHO SMART Guidelines Observation Not Done, WHO SMART Guidelines Procedure, WHO SMART Guidelines Procedure Not Done)
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
34. CarePlan.activity.reference
TypeReference(WHO SMART Guidelines Medication Not Requested, WHO SMART Guidelines MedicationRequest, WHO SMART Guidelines Service Not Requested, WHO SMART Guidelines ServiceRequest)
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
36. CarePlan.activity.detail
Control0..0

Guidance on how to interpret the contents of this table can be found here

0. CarePlan
Definition

Describes the intention of how one or more practitioners intend to deliver care for a particular patient, group or community for a period of time, possibly limited to care for a specific condition or set of conditions.

ShortHealthcare plan for patient or group
Control0..*
Is Modifierfalse
Must Supporttrue
Summaryfalse
Alternate NamesCare Team
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. CarePlan.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

ShortA set of rules under which this content was created
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Control0..1
Typeuri
Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
4. CarePlan.extension:planFor
Slice NameplanFor
Definition

Specifies a case (episode of care) which this care plan is managing.

ShortCPG Plan For Extension
Comments

The enrollment may be automatic, prompted, or manual.

Control0..*
This element is affected by the following invariants: ele-1
TypeExtension(CPG Plan For Extension) (Extension Type: Reference(CPG Case))
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
6. CarePlan.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
8. CarePlan.identifier
Definition

Business identifiers assigned to this care plan by the performer or other systems which remain constant as the resource is updated and propagates from server to server.

ShortExternal Ids for this plan
Comments

This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control10..*
TypeIdentifier
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

Allows identification of the care plan as it is known by various participating systems and in a way that remains consistent across servers.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. CarePlan.identifier.use
Definition

The purpose of this identifier.

Shortusual | official | temp | secondary | old (If known)
Comments

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Control10..1
BindingThe codes SHALL be taken from IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1
(required to http://hl7.org/fhir/ValueSet/identifier-use|4.0.1)

Identifies the purpose for this identifier, if known .

Typecode
Is Modifiertrue because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. CarePlan.identifier.system
Definition

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

ShortThe namespace for the identifier value
Comments

Identifier.system is always case sensitive.

Control10..1
Typeuri
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

Example<br/><b>General</b>:http://www.acme.com/identifiers/patient
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
14. CarePlan.identifier.value
Definition

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

ShortThe value that is unique
Comments

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

Control10..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Example<br/><b>General</b>:123456
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
16. CarePlan.instantiatesCanonical
Definition

The URL pointing to a FHIR-defined protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlan.

ShortInstantiates FHIR protocol or definition
Control0..*
Typecanonical(PlanDefinition, Questionnaire, Measure, ActivityDefinition, OperationDefinition)
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
18. CarePlan.status
Definition

Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.

Shortdraft | active | on-hold | revoked | completed | entered-in-error | unknown
Comments

The unknown code is not to be used to convey other statuses. The unknown code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the care plan.

This element is labeled as a modifier because the status contains the code entered-in-error that marks the plan as not currently valid.

Control1..1
BindingThe codes SHALL be taken from RequestStatushttp://hl7.org/fhir/ValueSet/request-status|4.0.1
(required to http://hl7.org/fhir/ValueSet/request-status|4.0.1)

Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.

Typecode
Is Modifiertrue because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Allows clinicians to determine whether the plan is actionable or not.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. CarePlan.intent
Definition

Indicates the level of authority/intentionality associated with the care plan and where the care plan fits into the workflow chain.

Shortproposal | plan | order | option
Comments

This element is labeled as a modifier because the intent alters when and how the resource is actually applicable.

Control1..1
BindingThe codes SHALL be taken from CarePlanIntenthttp://hl7.org/fhir/ValueSet/care-plan-intent|4.0.1
(required to http://hl7.org/fhir/ValueSet/care-plan-intent|4.0.1)

Codes indicating the degree of authority/intentionality associated with a care plan.

Typecode
Is Modifiertrue because This element changes the interpretation of all descriptive attributes. For example "the time the request is recommended to occur" vs. "the time the request is authorized to occur" or "who is recommended to perform the request" vs. "who is authorized to perform the request"
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Proposals/recommendations, plans and orders all use the same structure and can exist in the same fulfillment chain.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. CarePlan.category
Definition

Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", "wellness plan", etc.

ShortType of plan
Comments

There may be multiple axes of categorization and one plan may serve multiple purposes. In some cases, this may be redundant with references to CarePlan.concern.

Control10..*
BindingFor example codes, see CarePlanCategoryhttp://hl7.org/fhir/ValueSet/care-plan-category
(example to http://hl7.org/fhir/ValueSet/care-plan-category)

Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc.

TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

Used for filtering what plan(s) are retrieved and displayed to different types of users.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
24. CarePlan.title
Definition

Human-friendly name for the care plan.

ShortHuman-friendly name for the care plan
Control10..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
26. CarePlan.description
Definition

A description of the scope and nature of the plan.

ShortSummary of nature of plan
Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Provides more detail than conveyed by category.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
28. CarePlan.subject
Definition

Identifies the patient or group whose intended care is described by the plan.

ShortWho the care plan is for
Control1..1
TypeReference(WHO SMART Guidelines Patient, Patient, Group)
Is Modifierfalse
Must Supporttrue
Summarytrue
Alternate Namespatient
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. CarePlan.encounter
Definition

The Encounter during which this CarePlan was created or to which the creation of this record is tightly associated.

ShortEncounter created as part of
Comments

This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. CarePlan activities conducted as a result of the care plan may well occur as part of other encounters.

Control0..1
TypeReference(WHO SMART Guidelines Encounter, Encounter)
Is Modifierfalse
Must Supporttrue
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
32. CarePlan.period
Definition

Indicates when the plan did (or is intended to) come into effect and end.

ShortTime period plan covers
Comments

Any activities scheduled as part of the plan should be constrained to the specified period regardless of whether the activities are planned within a single encounter/episode or across multiple encounters/episodes (e.g. the longitudinal management of a chronic condition).

Control0..1
TypePeriod
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

Allows tracking what plan(s) are in effect at a particular time.

Alternate Namestiming
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
34. CarePlan.created
Definition

Represents when this particular CarePlan record was created in the system, which is often a system-generated date.

ShortDate record was first recorded
Control0..1
TypedateTime
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Alternate NamesauthoredOn
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
36. CarePlan.careTeam
Definition

Identifies all people and organizations who are expected to be involved in the care envisioned by this plan.

ShortWho's involved in plan?
Control10..1*
TypeReference(WHO SMART Guidelines CareTeam, CareTeam)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Allows representation of care teams, helps scope care plan. In some cases may be a determiner of access permissions.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
38. CarePlan.addresses
Definition

Identifies the conditions/problems/concerns/diagnoses/etc. whose management and/or mitigation are handled by this plan.

ShortHealth issues this plan addresses
Comments

When the diagnosis is related to an allergy or intolerance, the Condition and AllergyIntolerance resources can both be used. However, to be actionable for decision support, using Condition alone is not sufficient as the allergy or intolerance condition needs to be represented as an AllergyIntolerance.

Control0..*
TypeReference(WHO SMART Guidelines Condition, Condition)
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

Links plan to the conditions it manages. The element can identify risks addressed by the plan as well as active conditions. (The Condition resource can include things like "at risk for hypertension" or "fall risk".) Also scopes plans - multiple plans may exist addressing different concerns.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
40. CarePlan.goal
Definition

Describes the intended objective(s) of carrying out the care plan.

ShortDesired outcome of plan
Comments

Goal can be achieving a particular change or merely maintaining a current state or even slowing a decline.

Control0..*
TypeReference(Goal)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Provides context for plan. Allows plan effectiveness to be evaluated by clinicians.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
42. CarePlan.activity
Definition

Identifies a planned action to occur as part of the plan. For example, a medication to be used, lab tests to perform, self-monitoring, education, etc.

ShortAction to occur as part of plan
Control0..*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Allows systems to prompt for performance of planned activities, and validate plans against best practice.

Invariantscpl-3: Provide a reference or detail, not both (detail.empty() or reference.empty())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
cpl-3: Provide a reference or detail, not both (detail.empty() or reference.empty())
44. CarePlan.activity.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
46. CarePlan.activity.outcomeReference
Definition

Details of the outcome or action resulting from the activity. The reference to an "event" resource, such as Procedure or Encounter or Observation, is the result/outcome of the activity itself. The activity can be conveyed using CarePlan.activity.detail OR using the CarePlan.activity.reference (a reference to a “request” resource).

ShortAppointment, Encounter, Procedure, etc.
Comments

The activity outcome is independent of the outcome of the related goal(s). For example, if the goal is to achieve a target body weight of 150 lbs and an activity is defined to diet, then the activity outcome could be calories consumed whereas the goal outcome is an observation for the actual body weight measured.

Control0..*
TypeReference(WHO SMART Guidelines AllergyIntolerance, WHO SMART Guidelines Condition, WHO SMART Guidelines Encounter, WHO SMART Guidelines EpisodeOfCare, WHO SMART Guidelines Immunization, WHO SMART Guidelines Immunization Not Done, WHO SMART Guidelines Observation, WHO SMART Guidelines Observation Not Done, WHO SMART Guidelines Procedure, WHO SMART Guidelines Procedure Not Done, Resource)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summaryfalse
Requirements

Links plan to resulting actions.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
48. CarePlan.activity.reference
Definition

The details of the proposed activity represented in a specific resource.

ShortActivity details defined in specific resource
Comments

Standard extension exists (resource-pertainsToGoal) that allows goals to be referenced from any of the referenced resources in CarePlan.activity.reference.
The goal should be visible when the resource referenced by CarePlan.activity.reference is viewed independently from the CarePlan. Requests that are pointed to by a CarePlan using this element should not point to this CarePlan using the "basedOn" element. i.e. Requests that are part of a CarePlan are not "based on" the CarePlan.

Control0..1
This element is affected by the following invariants: cpl-3
TypeReference(WHO SMART Guidelines Medication Not Requested, WHO SMART Guidelines MedicationRequest, WHO SMART Guidelines Service Not Requested, WHO SMART Guidelines ServiceRequest, Appointment, CommunicationRequest, DeviceRequest, MedicationRequest, NutritionOrder, Task, ServiceRequest, VisionPrescription, RequestGroup)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summaryfalse
Requirements

Details in a form consistent with other applications and contexts of use.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
50. CarePlan.activity.detail
Definition

A simple summary of a planned activity suitable for a general care plan system (e.g. form driven) that doesn't know about specific resources such as procedure etc.

ShortIn-line definition of activity
Control0..01
This element is affected by the following invariants: cpl-3
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Details in a simple form for generic care plan systems.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

Guidance on how to interpret the contents of this table can be found here

0. CarePlan
Definition

Describes the intention of how one or more practitioners intend to deliver care for a particular patient, group or community for a period of time, possibly limited to care for a specific condition or set of conditions.

ShortHealthcare plan for patient or group
Control0..*
Is Modifierfalse
Must Supporttrue
Summaryfalse
Alternate NamesCare Team
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. CarePlan.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

ShortLogical id of this artifact
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Control0..1
Typeid
Is Modifierfalse
Summarytrue
4. CarePlan.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

ShortMetadata about the resource
Control0..1
TypeMeta
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
6. CarePlan.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

ShortA set of rules under which this content was created
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Control0..1
Typeuri
Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. CarePlan.language
Definition

The base language in which the resource is written.

ShortLanguage of the resource content
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Control0..1
BindingThe codes SHOULD be taken from CommonLanguages
(preferred to http://hl7.org/fhir/ValueSet/languages)

A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. CarePlan.text
Definition

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

ShortText summary of the resource, for human interpretation
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

Control0..1
TypeNarrative
Is Modifierfalse
Summaryfalse
Alternate Namesnarrative, html, xhtml, display
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. CarePlan.contained
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

ShortContained, inline Resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

Control0..*
TypeResource
Is Modifierfalse
Summaryfalse
Alternate Namesinline resources, anonymous resources, contained resources
14. CarePlan.extension
Definition

An Extension

ShortExtension
Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
SlicingThis element introduces a set of slices on CarePlan.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ url
  • 16. CarePlan.extension:planFor
    Slice NameplanFor
    Definition

    Specifies a case (episode of care) which this care plan is managing.

    ShortCPG Plan For Extension
    Comments

    The enrollment may be automatic, prompted, or manual.

    Control0..*
    This element is affected by the following invariants: ele-1
    TypeExtension(CPG Plan For Extension) (Extension Type: Reference(CPG Case))
    Is Modifierfalse
    Must Supporttrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    18. CarePlan.modifierExtension
    Definition

    May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

    ShortExtensions that cannot be ignored
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
    Summaryfalse
    Requirements

    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    20. CarePlan.identifier
    Definition

    Business identifiers assigned to this care plan by the performer or other systems which remain constant as the resource is updated and propagates from server to server.

    ShortExternal Ids for this plan
    Comments

    This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.

    NoteThis is a business identifier, not a resource identifier (see discussion)
    Control1..*
    TypeIdentifier
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Requirements

    Allows identification of the care plan as it is known by various participating systems and in a way that remains consistent across servers.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    22. CarePlan.identifier.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    24. CarePlan.identifier.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    SlicingThis element introduces a set of slices on CarePlan.identifier.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • value @ url
    • 26. CarePlan.identifier.use
      Definition

      The purpose of this identifier.

      Shortusual | official | temp | secondary | old (If known)
      Comments

      Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

      Control1..1
      BindingThe codes SHALL be taken from IdentifierUse
      (required to http://hl7.org/fhir/ValueSet/identifier-use|4.0.1)

      Identifies the purpose for this identifier, if known .

      Typecode
      Is Modifiertrue because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      28. CarePlan.identifier.type
      Definition

      A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

      ShortDescription of identifier
      Comments

      This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

      Control0..1
      BindingUnless not suitable, these codes SHALL be taken from Identifier Type Codes
      (extensible to http://hl7.org/fhir/ValueSet/identifier-type)

      A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

      TypeCodeableConcept
      Is Modifierfalse
      Summarytrue
      Requirements

      Allows users to make use of identifiers when the identifier system is not known.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      30. CarePlan.identifier.system
      Definition

      Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

      ShortThe namespace for the identifier value
      Comments

      Identifier.system is always case sensitive.

      Control1..1
      Typeuri
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

      Example<br/><b>General</b>:http://www.acme.com/identifiers/patient
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      32. CarePlan.identifier.value
      Definition

      The portion of the identifier typically relevant to the user and which is unique within the context of the system.

      ShortThe value that is unique
      Comments

      If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

      Control1..1
      Typestring
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Example<br/><b>General</b>:123456
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      34. CarePlan.identifier.period
      Definition

      Time period during which identifier is/was valid for use.

      ShortTime period when id is/was valid for use
      Control0..1
      TypePeriod
      Is Modifierfalse
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      36. CarePlan.identifier.assigner
      Definition

      Organization that issued/manages the identifier.

      ShortOrganization that issued id (may be just text)
      Comments

      The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

      Control0..1
      TypeReference(Organization)
      Is Modifierfalse
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      38. CarePlan.instantiatesCanonical
      Definition

      The URL pointing to a FHIR-defined protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlan.

      ShortInstantiates FHIR protocol or definition
      Control0..*
      Typecanonical(PlanDefinition, Questionnaire, Measure, ActivityDefinition, OperationDefinition)
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Must Support TypesNo must-support rules about the choice of types/profiles
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      40. CarePlan.instantiatesUri
      Definition

      The URL pointing to an externally maintained protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlan.

      ShortInstantiates external protocol or definition
      Comments

      This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.

      Control0..*
      Typeuri
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      42. CarePlan.basedOn
      Definition

      A care plan that is fulfilled in whole or in part by this care plan.

      ShortFulfills CarePlan
      Control0..*
      TypeReference(CarePlan)
      Is Modifierfalse
      Summarytrue
      Requirements

      Allows tracing of the care plan and tracking whether proposals/recommendations were acted upon.

      Alternate Namesfulfills
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      44. CarePlan.replaces
      Definition

      Completed or terminated care plan whose function is taken by this new care plan.

      ShortCarePlan replaced by this CarePlan
      Comments

      The replacement could be because the initial care plan was immediately rejected (due to an issue) or because the previous care plan was completed, but the need for the action described by the care plan remains ongoing.

      Control0..*
      TypeReference(CarePlan)
      Is Modifierfalse
      Summarytrue
      Requirements

      Allows tracing the continuation of a therapy or administrative process instantiated through multiple care plans.

      Alternate Namessupersedes
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      46. CarePlan.partOf
      Definition

      A larger care plan of which this particular care plan is a component or step.

      ShortPart of referenced CarePlan
      Comments

      Each care plan is an independent request, such that having a care plan be part of another care plan can cause issues with cascading statuses. As such, this element is still being discussed.

      Control0..*
      TypeReference(CarePlan)
      Is Modifierfalse
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      48. CarePlan.status
      Definition

      Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.

      Shortdraft | active | on-hold | revoked | completed | entered-in-error | unknown
      Comments

      The unknown code is not to be used to convey other statuses. The unknown code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the care plan.

      This element is labeled as a modifier because the status contains the code entered-in-error that marks the plan as not currently valid.

      Control1..1
      BindingThe codes SHALL be taken from RequestStatus
      (required to http://hl7.org/fhir/ValueSet/request-status|4.0.1)

      Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.

      Typecode
      Is Modifiertrue because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      Allows clinicians to determine whether the plan is actionable or not.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      50. CarePlan.intent
      Definition

      Indicates the level of authority/intentionality associated with the care plan and where the care plan fits into the workflow chain.

      Shortproposal | plan | order | option
      Comments

      This element is labeled as a modifier because the intent alters when and how the resource is actually applicable.

      Control1..1
      BindingThe codes SHALL be taken from CarePlanIntent
      (required to http://hl7.org/fhir/ValueSet/care-plan-intent|4.0.1)

      Codes indicating the degree of authority/intentionality associated with a care plan.

      Typecode
      Is Modifiertrue because This element changes the interpretation of all descriptive attributes. For example "the time the request is recommended to occur" vs. "the time the request is authorized to occur" or "who is recommended to perform the request" vs. "who is authorized to perform the request"
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      Proposals/recommendations, plans and orders all use the same structure and can exist in the same fulfillment chain.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      52. CarePlan.category
      Definition

      Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", "wellness plan", etc.

      ShortType of plan
      Comments

      There may be multiple axes of categorization and one plan may serve multiple purposes. In some cases, this may be redundant with references to CarePlan.concern.

      Control1..*
      BindingFor example codes, see CarePlanCategory
      (example to http://hl7.org/fhir/ValueSet/care-plan-category)

      Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc.

      TypeCodeableConcept
      Is Modifierfalse
      Must Supporttrue
      Summarytrue
      Requirements

      Used for filtering what plan(s) are retrieved and displayed to different types of users.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      54. CarePlan.title
      Definition

      Human-friendly name for the care plan.

      ShortHuman-friendly name for the care plan
      Control1..1
      Typestring
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      56. CarePlan.description
      Definition

      A description of the scope and nature of the plan.

      ShortSummary of nature of plan
      Control0..1
      Typestring
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      Provides more detail than conveyed by category.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      58. CarePlan.subject
      Definition

      Identifies the patient or group whose intended care is described by the plan.

      ShortWho the care plan is for
      Control1..1
      TypeReference(WHO SMART Guidelines Patient)
      Is Modifierfalse
      Must Supporttrue
      Summarytrue
      Alternate Namespatient
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      60. CarePlan.encounter
      Definition

      The Encounter during which this CarePlan was created or to which the creation of this record is tightly associated.

      ShortEncounter created as part of
      Comments

      This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. CarePlan activities conducted as a result of the care plan may well occur as part of other encounters.

      Control0..1
      TypeReference(WHO SMART Guidelines Encounter)
      Is Modifierfalse
      Must Supporttrue
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      62. CarePlan.period
      Definition

      Indicates when the plan did (or is intended to) come into effect and end.

      ShortTime period plan covers
      Comments

      Any activities scheduled as part of the plan should be constrained to the specified period regardless of whether the activities are planned within a single encounter/episode or across multiple encounters/episodes (e.g. the longitudinal management of a chronic condition).

      Control0..1
      TypePeriod
      Is Modifierfalse
      Must Supporttrue
      Summarytrue
      Requirements

      Allows tracking what plan(s) are in effect at a particular time.

      Alternate Namestiming
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      64. CarePlan.created
      Definition

      Represents when this particular CarePlan record was created in the system, which is often a system-generated date.

      ShortDate record was first recorded
      Control0..1
      TypedateTime
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Alternate NamesauthoredOn
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      66. CarePlan.author
      Definition

      When populated, the author is responsible for the care plan. The care plan is attributed to the author.

      ShortWho is the designated responsible party
      Comments

      The author may also be a contributor. For example, an organization can be an author, but not listed as a contributor.

      Control0..1
      TypeReference(Patient, Practitioner, PractitionerRole, Device, RelatedPerson, Organization, CareTeam)
      Is Modifierfalse
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      68. CarePlan.contributor
      Definition

      Identifies the individual(s) or organization who provided the contents of the care plan.

      ShortWho provided the content of the care plan
      Comments

      Collaborative care plans may have multiple contributors.

      Control0..*
      TypeReference(Patient, Practitioner, PractitionerRole, Device, RelatedPerson, Organization, CareTeam)
      Is Modifierfalse
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      70. CarePlan.careTeam
      Definition

      Identifies all people and organizations who are expected to be involved in the care envisioned by this plan.

      ShortWho's involved in plan?
      Control1..1
      TypeReference(WHO SMART Guidelines CareTeam)
      Is Modifierfalse
      Must Supporttrue
      Summaryfalse
      Requirements

      Allows representation of care teams, helps scope care plan. In some cases may be a determiner of access permissions.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      72. CarePlan.addresses
      Definition

      Identifies the conditions/problems/concerns/diagnoses/etc. whose management and/or mitigation are handled by this plan.

      ShortHealth issues this plan addresses
      Comments

      When the diagnosis is related to an allergy or intolerance, the Condition and AllergyIntolerance resources can both be used. However, to be actionable for decision support, using Condition alone is not sufficient as the allergy or intolerance condition needs to be represented as an AllergyIntolerance.

      Control0..*
      TypeReference(WHO SMART Guidelines Condition)
      Is Modifierfalse
      Must Supporttrue
      Summarytrue
      Requirements

      Links plan to the conditions it manages. The element can identify risks addressed by the plan as well as active conditions. (The Condition resource can include things like "at risk for hypertension" or "fall risk".) Also scopes plans - multiple plans may exist addressing different concerns.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      74. CarePlan.supportingInfo
      Definition

      Identifies portions of the patient's record that specifically influenced the formation of the plan. These might include comorbidities, recent procedures, limitations, recent assessments, etc.

      ShortInformation considered as part of plan
      Comments

      Use "concern" to identify specific conditions addressed by the care plan.

      Control0..*
      TypeReference(Resource)
      Is Modifierfalse
      Summaryfalse
      Requirements

      Identifies barriers and other considerations associated with the care plan.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      76. CarePlan.goal
      Definition

      Describes the intended objective(s) of carrying out the care plan.

      ShortDesired outcome of plan
      Comments

      Goal can be achieving a particular change or merely maintaining a current state or even slowing a decline.

      Control0..*
      TypeReference(Goal)
      Is Modifierfalse
      Must Supporttrue
      Summaryfalse
      Requirements

      Provides context for plan. Allows plan effectiveness to be evaluated by clinicians.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      78. CarePlan.activity
      Definition

      Identifies a planned action to occur as part of the plan. For example, a medication to be used, lab tests to perform, self-monitoring, education, etc.

      ShortAction to occur as part of plan
      Control0..*
      TypeBackboneElement
      Is Modifierfalse
      Must Supporttrue
      Summaryfalse
      Requirements

      Allows systems to prompt for performance of planned activities, and validate plans against best practice.

      Invariantscpl-3: Provide a reference or detail, not both (detail.empty() or reference.empty())
      ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      80. CarePlan.activity.id
      Definition

      Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

      ShortUnique id for inter-element referencing
      Control0..1
      Typestring
      Is Modifierfalse
      XML FormatIn the XML format, this property is represented as an attribute.
      Summaryfalse
      82. CarePlan.activity.extension
      Definition

      May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

      ShortAdditional content defined by implementations
      Comments

      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

      Control0..*
      TypeExtension
      Is Modifierfalse
      Summaryfalse
      Alternate Namesextensions, user content
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      84. CarePlan.activity.modifierExtension
      Definition

      May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

      Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

      ShortExtensions that cannot be ignored even if unrecognized
      Comments

      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

      Control0..*
      TypeExtension
      Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
      Summarytrue
      Requirements

      Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

      Alternate Namesextensions, user content, modifiers
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      86. CarePlan.activity.outcomeCodeableConcept
      Definition

      Identifies the outcome at the point when the status of the activity is assessed. For example, the outcome of an education activity could be patient understands (or not).

      ShortResults of the activity
      Comments

      Note that this should not duplicate the activity status (e.g. completed or in progress).

      Control0..*
      BindingFor example codes, see CarePlanActivityOutcome
      (example to http://hl7.org/fhir/ValueSet/care-plan-activity-outcome)

      Identifies the results of the activity.

      TypeCodeableConcept
      Is Modifierfalse
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      88. CarePlan.activity.outcomeReference
      Definition

      Details of the outcome or action resulting from the activity. The reference to an "event" resource, such as Procedure or Encounter or Observation, is the result/outcome of the activity itself. The activity can be conveyed using CarePlan.activity.detail OR using the CarePlan.activity.reference (a reference to a “request” resource).

      ShortAppointment, Encounter, Procedure, etc.
      Comments

      The activity outcome is independent of the outcome of the related goal(s). For example, if the goal is to achieve a target body weight of 150 lbs and an activity is defined to diet, then the activity outcome could be calories consumed whereas the goal outcome is an observation for the actual body weight measured.

      Control0..*
      TypeReference(WHO SMART Guidelines AllergyIntolerance, WHO SMART Guidelines Condition, WHO SMART Guidelines Encounter, WHO SMART Guidelines EpisodeOfCare, WHO SMART Guidelines Immunization, WHO SMART Guidelines Immunization Not Done, WHO SMART Guidelines Observation, WHO SMART Guidelines Observation Not Done, WHO SMART Guidelines Procedure, WHO SMART Guidelines Procedure Not Done)
      Is Modifierfalse
      Must Supporttrue
      Must Support TypesNo must-support rules about the choice of types/profiles
      Summaryfalse
      Requirements

      Links plan to resulting actions.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      90. CarePlan.activity.progress
      Definition

      Notes about the adherence/status/progress of the activity.

      ShortComments about the activity status/progress
      Comments

      This element should NOT be used to describe the activity to be performed - that occurs either within the resource pointed to by activity.detail.reference or in activity.detail.description.

      Control0..*
      TypeAnnotation
      Is Modifierfalse
      Summaryfalse
      Requirements

      Can be used to capture information about adherence, progress, concerns, etc.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      92. CarePlan.activity.reference
      Definition

      The details of the proposed activity represented in a specific resource.

      ShortActivity details defined in specific resource
      Comments

      Standard extension exists (resource-pertainsToGoal) that allows goals to be referenced from any of the referenced resources in CarePlan.activity.reference.
      The goal should be visible when the resource referenced by CarePlan.activity.reference is viewed independently from the CarePlan. Requests that are pointed to by a CarePlan using this element should not point to this CarePlan using the "basedOn" element. i.e. Requests that are part of a CarePlan are not "based on" the CarePlan.

      Control0..1
      This element is affected by the following invariants: cpl-3
      TypeReference(WHO SMART Guidelines Medication Not Requested, WHO SMART Guidelines MedicationRequest, WHO SMART Guidelines Service Not Requested, WHO SMART Guidelines ServiceRequest)
      Is Modifierfalse
      Must Supporttrue
      Must Support TypesNo must-support rules about the choice of types/profiles
      Summaryfalse
      Requirements

      Details in a form consistent with other applications and contexts of use.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      94. CarePlan.activity.detail
      Definition

      A simple summary of a planned activity suitable for a general care plan system (e.g. form driven) that doesn't know about specific resources such as procedure etc.

      ShortIn-line definition of activity
      Control0..0
      This element is affected by the following invariants: cpl-3
      TypeBackboneElement
      Is Modifierfalse
      Must Supporttrue
      Summaryfalse
      Requirements

      Details in a simple form for generic care plan systems.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      116. CarePlan.note
      Definition

      General notes about the care plan not covered elsewhere.

      ShortComments about the plan
      Control0..*
      TypeAnnotation
      Is Modifierfalse
      Summaryfalse
      Requirements

      Used to capture information that applies to the plan as a whole that doesn't fit into discrete elements.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))