臺灣核心實作指引(TW Core IG)
0.3.2 - Ci-Build Trial Use

臺灣核心實作指引(TW Core IG), published by 衛生福利部. This guide is not an authorized publication; it is the continuous build for version 0.3.2 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/cctwFHIRterm/MOHW_TWCoreIG_Build/ and changes regularly. See the Directory of published versions

Resource Profile: TWCoreCarePlan - Detailed Descriptions

Active as of 2025-02-04

Definitions for the CarePlan-twcore resource profile.

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
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.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.

ShortCarePlan Resource之內容摘要以供人閱讀Text 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
Must Supporttrue
Summaryfalse
Alternate Namesnarrative, html, xhtml, display
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
6. CarePlan.text.status
Definition

The status of the narrative - whether it's entirely generated (from just the defined data or the extensions too), or whether a human authored it and it may contain additional data.

Shortgenerated | additionalgenerated | extensions | additional | empty
Control1..1
BindingThe codes SHALL be taken from 臺灣衛福部資訊處Narrative狀態值集http://hl7.org/fhir/ValueSet/narrative-status|4.0.1
(required to https://twcore.mohw.gov.tw/ig/twcore/ValueSet/narrative-status)

Constrained value set of narrative statuses.


The status of a resource narrative.

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

The actual narrative content, a stripped down version of XHTML.

ShortLimited xhtml content
Comments

The contents of the html element are an XHTML fragment containing only the basic html formatting elements described in chapters 7-11 and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained stylesheets. The XHTML content SHALL NOT contain a head, a body, external stylesheet references, scripts, forms, base/link/xlink, frames, iframes and objects.

Control1..1
Typexhtml
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
txt-1: 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: The narrative SHALL have some non-whitespace content (htmlChecks())
txt-1: 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: The narrative SHALL have some non-whitespace content (htmlChecks())
10. 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())
12. CarePlan.basedOn
Definition

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

ShortFulfills CarePlan
Control0..*
TypeReference(TW Core CarePlan, 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()))
14. 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(TW Core CarePlan, 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()))
16. 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(TW Core CarePlan, CarePlan)
Is Modifierfalse
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)

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

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


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)

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


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

Type of plan.


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

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.


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()))
SlicingThis element introduces a set of slices on CarePlan.category. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • pattern @ $this
  • 24. CarePlan.category:AssessPlan
    Slice NameAssessPlan
    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..1*
    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.

    Pattern Value{
      "coding" : [{
        "system" : "https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/careplan-category-tw",
        "code" : "assess-plan"
      }]
    }
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    26. CarePlan.subject
    Definition

    Who care plan is for.


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

    ShortWho the care plan is for
    Control1..1
    TypeReference(TW Core Patient, Group, Patient)
    Is Modifierfalse
    Must Supporttrue
    Must Support TypesReference(TW Core Patient)
    Summarytrue
    Requirements

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

    Alternate Namespatient
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    28. 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(TW Core Encounter, Encounter)
    Is Modifierfalse
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    30. 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(TW Core Patient, TW Core Practitioner, TW Core PractitionerRole, TW Core Implantable Device, TW Core RelatedPerson, TW Core Organization, TW Core CareTeam, 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()))
    32. 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(TW Core Patient, TW Core Practitioner, TW Core PractitionerRole, TW Core Implantable Device, TW Core RelatedPerson, TW Core Organization, TW Core CareTeam, 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()))
    34. 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?
    Control0..*
    TypeReference(TW Core CareTeam, CareTeam)
    Is Modifierfalse
    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()))
    36. 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(TW Core Condition, Condition)
    Is Modifierfalse
    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()))