Care Coordination Management
0.0.1 - ci-build Estonia (EST)

Care Coordination Management, published by Helex OÜ. This guide is not an authorized publication; it is the continuous build for version 0.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/helexlab/ig-ccm/ and changes regularly. See the Directory of published versions

Resource Profile: CarePlanCcm

Official URL: http://helex.org/ig/ccm/StructureDefinition/care-plan-ccm Version: 0.0.1
Draft as of 2025-12-05 Computable Name: CarePlanCcm

CCM CarePlan profile linking a patient with a ResearchStudy and tracking lifecycle via progress entries.

Usages:

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.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. CarePlan 0..* CarePlan Healthcare plan for patient or group
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... contained 0..* Resource Contained, inline Resources
... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 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 ?!Σ 1..1 code proposal | plan | order | option | directive
Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan.
... subject SΣ 1..1 Reference(PatientCcm) Who the care plan is for
... period SΣ 1..1 Period Time period plan covers
.... start SΣC 1..1 dateTime Starting time with inclusive boundary
.... end SΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... careTeam S 0..* Reference(CareTeamCcm) Who's involved in plan?
... supportingInfo S 0..* Reference(ResearchSubjectCcm) Information considered as part of plan
... goal S 0..* Reference(GoalCcm) Desired outcome of plan

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
CarePlan.status Base required RequestStatus 📍5.0.0 FHIR Std.
CarePlan.intent Base required Care Plan Intent 📍5.0.0 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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()

This structure is derived from CarePlan

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. CarePlan 0..* CarePlan Healthcare plan for patient or group
... identifier S 0..* Identifier External Ids for this plan
... status S 1..1 code draft | active | on-hold | revoked | completed | entered-in-error | unknown
... subject S 1..1 Reference(PatientCcm) Who the care plan is for
.... start S 1..1 dateTime Starting time with inclusive boundary
.... end S 0..1 dateTime End time with inclusive boundary, if not ongoing
... careTeam S 0..* Reference(CareTeamCcm) Who's involved in plan?
... supportingInfo S 0..* Reference(ResearchSubjectCcm) Information considered as part of plan
... goal S 0..* Reference(GoalCcm) Desired outcome of plan

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. CarePlan 0..* CarePlan 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: AllLanguages (required): IETF language tag for a human language
Additional BindingsPurpose
CommonLanguages Starter
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
... identifier SΣ 0..* Identifier External Ids for this plan
... instantiatesCanonical Σ 0..* canonical(PlanDefinition | Questionnaire | Measure | ActivityDefinition | OperationDefinition) Instantiates FHIR protocol or definition
... instantiatesUri Σ 0..* uri Instantiates external protocol or definition
... basedOn Σ 0..* Reference(CarePlan | ServiceRequest | RequestOrchestration | NutritionOrder) Fulfills plan, proposal or order
... replaces Σ 0..* Reference(CarePlan) CarePlan replaced by this CarePlan
... partOf Σ 0..* Reference(CarePlan) Part of referenced CarePlan
... status ?!SΣ 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 ?!Σ 1..1 code proposal | plan | order | option | directive
Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan.
... category Σ 0..* 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.
... title Σ 0..1 string Human-friendly name for the care plan
... description Σ 0..1 string Summary of nature of plan
... subject SΣ 1..1 Reference(PatientCcm) Who the care plan is for
... encounter Σ 0..1 Reference(Encounter) The Encounter during which this CarePlan was created
... period SΣ 1..1 Period Time period plan covers
.... id 0..1 id Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... start SΣC 1..1 dateTime Starting time with inclusive boundary
.... end SΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... created Σ 0..1 dateTime Date record was first recorded
... custodian Σ 0..1 Reference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam) Who is the designated responsible party
... contributor 0..* Reference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam) Who provided the content of the care plan
... careTeam S 0..* Reference(CareTeamCcm) Who's involved in plan?
... addresses Σ 0..* CodeableReference(Condition) Health issues this plan addresses
Binding: SNOMEDCTClinicalFindings (example): Codes that describe the health issues this plan addresses.
... supportingInfo S 0..* Reference(ResearchSubjectCcm) Information considered as part of plan
... goal S 0..* Reference(GoalCcm) Desired outcome of plan
... activity 0..* BackboneElement Action to occur or has occurred as part of plan
.... 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
.... performedActivity 0..* CodeableReference(Resource) Results of the activity (concept, or Appointment, Encounter, Procedure, etc.)
Binding: CarePlanActivityPerformed (example): Identifies the results of the activity.
.... progress 0..* Annotation Comments about the activity status/progress
.... plannedActivityReference 0..1 Reference(Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestOrchestration | ImmunizationRecommendation | SupplyRequest) Activity that is intended to be part of the care plan
... note 0..* Annotation Comments about the plan

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
CarePlan.language Base required All Languages 📍5.0.0 FHIR Std.
CarePlan.status Base required RequestStatus 📍5.0.0 FHIR Std.
CarePlan.intent Base required Care Plan Intent 📍5.0.0 FHIR Std.
CarePlan.category Base example Care Plan Category 📍5.0.0 FHIR Std.
CarePlan.addresses Base example SNOMED CT Clinical Findings 📍5.0.0 FHIR Std.
CarePlan.activity.performedActivity Base example Care Plan Activity Performed 📍5.0.0 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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()

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. CarePlan 0..* CarePlan Healthcare plan for patient or group
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... contained 0..* Resource Contained, inline Resources
... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 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 ?!Σ 1..1 code proposal | plan | order | option | directive
Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan.
... subject SΣ 1..1 Reference(PatientCcm) Who the care plan is for
... period SΣ 1..1 Period Time period plan covers
.... start SΣC 1..1 dateTime Starting time with inclusive boundary
.... end SΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... careTeam S 0..* Reference(CareTeamCcm) Who's involved in plan?
... supportingInfo S 0..* Reference(ResearchSubjectCcm) Information considered as part of plan
... goal S 0..* Reference(GoalCcm) Desired outcome of plan

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
CarePlan.status Base required RequestStatus 📍5.0.0 FHIR Std.
CarePlan.intent Base required Care Plan Intent 📍5.0.0 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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()

Differential View

This structure is derived from CarePlan

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. CarePlan 0..* CarePlan Healthcare plan for patient or group
... identifier S 0..* Identifier External Ids for this plan
... status S 1..1 code draft | active | on-hold | revoked | completed | entered-in-error | unknown
... subject S 1..1 Reference(PatientCcm) Who the care plan is for
.... start S 1..1 dateTime Starting time with inclusive boundary
.... end S 0..1 dateTime End time with inclusive boundary, if not ongoing
... careTeam S 0..* Reference(CareTeamCcm) Who's involved in plan?
... supportingInfo S 0..* Reference(ResearchSubjectCcm) Information considered as part of plan
... goal S 0..* Reference(GoalCcm) Desired outcome of plan

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. CarePlan 0..* CarePlan 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: AllLanguages (required): IETF language tag for a human language
Additional BindingsPurpose
CommonLanguages Starter
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
... identifier SΣ 0..* Identifier External Ids for this plan
... instantiatesCanonical Σ 0..* canonical(PlanDefinition | Questionnaire | Measure | ActivityDefinition | OperationDefinition) Instantiates FHIR protocol or definition
... instantiatesUri Σ 0..* uri Instantiates external protocol or definition
... basedOn Σ 0..* Reference(CarePlan | ServiceRequest | RequestOrchestration | NutritionOrder) Fulfills plan, proposal or order
... replaces Σ 0..* Reference(CarePlan) CarePlan replaced by this CarePlan
... partOf Σ 0..* Reference(CarePlan) Part of referenced CarePlan
... status ?!SΣ 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 ?!Σ 1..1 code proposal | plan | order | option | directive
Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan.
... category Σ 0..* 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.
... title Σ 0..1 string Human-friendly name for the care plan
... description Σ 0..1 string Summary of nature of plan
... subject SΣ 1..1 Reference(PatientCcm) Who the care plan is for
... encounter Σ 0..1 Reference(Encounter) The Encounter during which this CarePlan was created
... period SΣ 1..1 Period Time period plan covers
.... id 0..1 id Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... start SΣC 1..1 dateTime Starting time with inclusive boundary
.... end SΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... created Σ 0..1 dateTime Date record was first recorded
... custodian Σ 0..1 Reference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam) Who is the designated responsible party
... contributor 0..* Reference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam) Who provided the content of the care plan
... careTeam S 0..* Reference(CareTeamCcm) Who's involved in plan?
... addresses Σ 0..* CodeableReference(Condition) Health issues this plan addresses
Binding: SNOMEDCTClinicalFindings (example): Codes that describe the health issues this plan addresses.
... supportingInfo S 0..* Reference(ResearchSubjectCcm) Information considered as part of plan
... goal S 0..* Reference(GoalCcm) Desired outcome of plan
... activity 0..* BackboneElement Action to occur or has occurred as part of plan
.... 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
.... performedActivity 0..* CodeableReference(Resource) Results of the activity (concept, or Appointment, Encounter, Procedure, etc.)
Binding: CarePlanActivityPerformed (example): Identifies the results of the activity.
.... progress 0..* Annotation Comments about the activity status/progress
.... plannedActivityReference 0..1 Reference(Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestOrchestration | ImmunizationRecommendation | SupplyRequest) Activity that is intended to be part of the care plan
... note 0..* Annotation Comments about the plan

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
CarePlan.language Base required All Languages 📍5.0.0 FHIR Std.
CarePlan.status Base required RequestStatus 📍5.0.0 FHIR Std.
CarePlan.intent Base required Care Plan Intent 📍5.0.0 FHIR Std.
CarePlan.category Base example Care Plan Category 📍5.0.0 FHIR Std.
CarePlan.addresses Base example SNOMED CT Clinical Findings 📍5.0.0 FHIR Std.
CarePlan.activity.performedActivity Base example Care Plan Activity Performed 📍5.0.0 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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()

 

Other representations of profile: CSV, Excel, Schematron