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DSTU2

This page is part of the FHIR Specification (v1.0.2: DSTU 2). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

4.4 Resource CarePlan - Content

Patient Care Work GroupMaturity Level: 1Compartments: Patient, Practitioner, RelatedPerson

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.

4.4.1 Scope and Usage

Care Plans are used in many of areas of healthcare with a variety of scopes. They can be as simple as a general practitioner keeping track of when their patient is next due for a tetanus immunization through to a detailed plan for an oncology patient covering diet, chemotherapy, radiation, lab work and counseling with detailed timing relationships, pre-conditions and goals. They may be used in veterinary care or clinical research to describe the care of a herd or other collection of animals. In public health, they may describe education or immunization campaigns.

This resource takes an intermediate approach to complexity. It captures basic details about who is involved and what actions are intended without dealing in discrete data about dependencies and timing relationships. These can be supported where necessary using the extension mechanism.

The scope of care plans may vary widely. Examples include:

  • Multi-disciplinary cross-organizational care plans; e.g. An oncology plan including the oncologist, home nursing staff, pharmacy and others
  • Plans to manage specific disease/condition(s) (e.g. nutritional plan for a patient post bowel resection, neurological plan post head injury, pre-natal plan, post-partum plan, grief management plan, etc.)
  • Decision support-generated plans following specific practice guidelines (e.g. stroke care plan, diabetes plan, falls prevention, etc.)
  • Definition and management of a care team, including roles associated with a particular condition or set of conditions.
  • Self-maintained patient or care-giver authored plans identifying their goals and an integrated understanding of actions to be taken

Note that this resource represents a specific plan instance for a particular patient or group. It is not intended to be used to define generic plans or protocols that are independent of a specific individual or group. I.e. It represents a specific intent, not a general definition. Protocols and order sets will be supported through future resources.

This resource can be used to represent both proposed plans (for example, recommendations from a decision support engine or returned as part of a consult report) as well as active plans. The nature of the plan is communicated by the status. Some systems may need to filter CarePlans to ensure that only appropriate plans are exposed via a given user interface.

4.4.2 Boundaries and Relationships

For simplicity sake, CarePlan allows the in-line definition of activities as part of a plan using the activity.detail element. However, activities can also be defined using references to the various "request" resources. These references could be to resources with a status of "planned" or to an active order. It is possible for planned activities to exist (e.g. appointments) without needing a CarePlan at all. CarePlans are used when there's a need to group activities, goals and/or participants together to provide some degree of context.

CarePlans can be tied to specific Conditions however they can also be condition-independent and instead focused on a particular type of care (e.g. psychological, nutritional) or the care delivered by a particular practitioner or group of practitioners.

An ImmunizationRecommendation can be interpreted as a narrow type of Care Plan dealing only with immunization events. Where such information could appear in either resource, the immunization-specific resource is preferred.

This resource is referenced by ClinicalImpression and Procedure

4.4.3 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan DomainResourceHealthcare plan for patient or group
... identifier Σ0..*IdentifierExternal Ids for this plan
... subject Σ0..1Reference(Patient | Group)Who care plan is for
... status ?! Σ1..1codeproposed | draft | active | completed | cancelled
CarePlanStatus (Required)
... context Σ0..1Reference(Encounter | EpisodeOfCare)Created in context of
... period Σ0..1PeriodTime period plan covers
... author Σ0..*Reference(Patient | Practitioner | RelatedPerson | Organization)Who is responsible for contents of the plan
... modified Σ0..1dateTimeWhen last updated
... category Σ0..*CodeableConceptType of plan
Care Plan Category (Example)
... description Σ0..1stringSummary of nature of plan
... addresses Σ0..*Reference(Condition)Health issues this plan addresses
... support 0..*Reference(Any)Information considered as part of plan
... relatedPlan 0..*BackboneElementPlans related to this one
.... code 0..1codeincludes | replaces | fulfills
CarePlanRelationship (Required)
.... plan 1..1Reference(CarePlan)Plan relationship exists with
... participant 0..*BackboneElementWho's involved in plan?
.... role 0..1CodeableConceptType of involvement
Participant Roles (Example)
.... member 0..1Reference(Practitioner | RelatedPerson | Patient | Organization)Who is involved
... goal 0..*Reference(Goal)Desired outcome of plan
... activity I0..*BackboneElementAction to occur as part of plan
Provide a reference or detail, not both
.... actionResulting 0..*Reference(Any)Appointments, orders, etc.
.... progress 0..*AnnotationComments about the activity status/progress
.... reference I0..1Reference(Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticOrder | MedicationOrder | NutritionOrder | Order | ProcedureRequest | ProcessRequest | ReferralRequest | SupplyRequest | VisionPrescription)Activity details defined in specific resource
.... detail I0..1BackboneElementIn-line definition of activity
..... category 0..1CodeableConceptdiet | drug | encounter | observation | procedure | supply | other
CarePlanActivityCategory (Example)
..... code 0..1CodeableConceptDetail type of activity
Care Plan Activity (Example)
..... reasonCode 0..*CodeableConceptWhy activity should be done
Activity Reason (Example)
..... reasonReference 0..*Reference(Condition)Condition triggering need for activity
..... goal 0..*Reference(Goal)Goals this activity relates to
..... status ?!0..1codenot-started | scheduled | in-progress | on-hold | completed | cancelled
CarePlanActivityStatus (Required)
..... statusReason 0..1CodeableConceptReason for current status
GoalStatusReason (Example)
..... prohibited ?!1..1booleanDo NOT do
..... scheduled[x] 0..1When activity is to occur
...... scheduledTimingTiming
...... scheduledPeriodPeriod
...... scheduledStringstring
..... location 0..1Reference(Location)Where it should happen
..... performer 0..*Reference(Practitioner | Organization | RelatedPerson | Patient)Who will be responsible?
..... product[x] 0..1What is to be administered/supplied
SNOMED CT Medication Codes (Example)
...... productCodeableConceptCodeableConcept
...... productReferenceReference(Medication | Substance)
..... dailyAmount 0..1SimpleQuantityHow to consume/day?
..... quantity 0..1SimpleQuantityHow much to administer/supply/consume
..... description 0..1stringExtra info describing activity to perform
... note 0..1AnnotationComments about the plan

doco Documentation for this format

UML Diagram

CarePlan (DomainResource)This records identifiers associated with this care plan that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation)identifier : Identifier [0..*]Identifies the patient or group whose intended care is described by the plansubject : Reference [0..1] « Patient|Group »Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record (this element modifies the meaning of other elements)status : code [1..1] « Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record. (Strength=Required)CarePlanStatus! »Identifies the context in which this particular CarePlan is definedcontext : Reference [0..1] « Encounter|EpisodeOfCare »Indicates when the plan did (or is intended to) come into effect and endperiod : Period [0..1]Identifies the individual(s) or ogranization who is responsible for the content of the care planauthor : Reference [0..*] « Patient|Practitioner|RelatedPerson| Organization »Identifies the most recent date on which the plan has been revisedmodified : dateTime [0..1]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", etccategory : CodeableConcept [0..*] « Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. (Strength=Example)Care Plan Category?? »A description of the scope and nature of the plandescription : string [0..1]Identifies the conditions/problems/concerns/diagnoses/etc. whose management and/or mitigation are handled by this planaddresses : Reference [0..*] « Condition »Identifies portions of the patient's record that specifically influenced the formation of the plan. These might include co-morbidities, recent procedures, limitations, recent assessments, etcsupport : Reference [0..*] « Any »Describes the intended objective(s) of carrying out the care plangoal : Reference [0..*] « Goal »General notes about the care plan not covered elsewherenote : Annotation [0..1]RelatedPlanIdentifies the type of relationship this plan has to the target plancode : code [0..1] « Codes identifying the types of relationships between two plans. (Strength=Required)CarePlanRelationship! »A reference to the plan to which a relationship is assertedplan : Reference [1..1] « CarePlan »ParticipantIndicates specific responsibility of an individual within the care plan; e.g. "Primary physician", "Team coordinator", "Caregiver", etcrole : CodeableConcept [0..1] « Indicates specific responsibility of an individual within the care plan; e.g. "Primary physician", "Team coordinator", "Caregiver", etc. (Strength=Example)Participant Roles?? »The specific person or organization who is participating/expected to participate in the care planmember : Reference [0..1] « Practitioner|RelatedPerson|Patient| Organization »ActivityResources that describe follow-on actions resulting from the plan, such as drug prescriptions, encounter records, appointments, etcactionResulting : Reference [0..*] « Any »Notes about the adherence/status/progress of the activityprogress : Annotation [0..*]The details of the proposed activity represented in a specific resourcereference : Reference [0..1] « Appointment|CommunicationRequest| DeviceUseRequest|DiagnosticOrder|MedicationOrder| NutritionOrder|Order|ProcedureRequest|ProcessRequest| ReferralRequest|SupplyRequest|VisionPrescription »DetailHigh-level categorization of the type of activity in a care plancategory : CodeableConcept [0..1] « High-level categorization of the type of activity in a care plan. (Strength=Example)CarePlanActivityCategory?? »Detailed description of the type of planned activity; e.g. What lab test, what procedure, what kind of encountercode : CodeableConcept [0..1] « Detailed description of the type of activity; e.g. What lab test, what procedure, what kind of encounter. (Strength=Example)Care Plan Activity?? »Provides the rationale that drove the inclusion of this particular activity as part of the planreasonCode : CodeableConcept [0..*] « Identifies why a care plan activity is needed. Can include any health condition codes as well as such concepts as "general wellness", prophylaxis, surgical preparation, etc. (Strength=Example)Activity Reason?? »Provides the health condition(s) that drove the inclusion of this particular activity as part of the planreasonReference : Reference [0..*] « Condition »Internal reference that identifies the goals that this activity is intended to contribute towards meetinggoal : Reference [0..*] « Goal »Identifies what progress is being made for the specific activity (this element modifies the meaning of other elements)status : code [0..1] « Indicates where the activity is at in its overall life cycle. (Strength=Required)CarePlanActivityStatus! »Provides reason why the activity isn't yet started, is on hold, was cancelled, etcstatusReason : CodeableConcept [0..1] « Describes why the current activity has the status it does; e.g. "Recovering from injury" as a reason for non-started or on-hold, "Patient does not enjoy activity" as a reason for cancelling a planned activity. (Strength=Example)GoalStatusReason?? »If true, indicates that the described activity is one that must NOT be engaged in when following the plan (this element modifies the meaning of other elements)prohibited : boolean [1..1]The period, timing or frequency upon which the described activity is to occurscheduled[x] : Type [0..1] « Timing|Period|string »Identifies the facility where the activity will occur; e.g. home, hospital, specific clinic, etclocation : Reference [0..1] « Location »Identifies who's expected to be involved in the activityperformer : Reference [0..*] « Practitioner|Organization| RelatedPerson|Patient »Identifies the food, drug or other product to be consumed or supplied in the activityproduct[x] : Type [0..1] « CodeableConcept|Reference(Medication| Substance); A product supplied or administered as part of a care plan activity. (Strength=Example)SNOMED CT Medication ?? »Identifies the quantity expected to be consumed in a given daydailyAmount : Quantity(SimpleQuantity) [0..1]Identifies the quantity expected to be supplied, administered or consumed by the subjectquantity : Quantity(SimpleQuantity) [0..1]This provides a textual description of constraints on the intended activity occurrence, including relation to other activities. It may also include objectives, pre-conditions and end-conditions. Finally, it may convey specifics about the activity such as body site, method, route, etcdescription : string [0..1]Identifies CarePlans with some sort of formal relationship to the current planrelatedPlan[0..*]Identifies all people and organizations who are expected to be involved in the care envisioned by this planparticipant[0..*]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 etcdetail[0..1]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, etcactivity[0..*]

XML Template

<CarePlan xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier External Ids for this plan --></identifier>
 <subject><!-- 0..1 Reference(Patient|Group) Who care plan is for --></subject>
 <status value="[code]"/><!-- 1..1 proposed | draft | active | completed | cancelled -->
 <context><!-- 0..1 Reference(Encounter|EpisodeOfCare) Created in context of --></context>
 <period><!-- 0..1 Period Time period plan covers --></period>
 <author><!-- 0..* Reference(Patient|Practitioner|RelatedPerson|Organization) Who is responsible for contents of the plan --></author>
 <modified value="[dateTime]"/><!-- 0..1 When last updated -->
 <category><!-- 0..* CodeableConcept Type of plan --></category>
 <description value="[string]"/><!-- 0..1 Summary of nature of plan -->
 <addresses><!-- 0..* Reference(Condition) Health issues this plan addresses --></addresses>
 <support><!-- 0..* Reference(Any) Information considered as part of plan --></support>
 <relatedPlan>  <!-- 0..* Plans related to this one -->
  <code value="[code]"/><!-- 0..1 includes | replaces | fulfills -->
  <plan><!-- 1..1 Reference(CarePlan) Plan relationship exists with --></plan>
 </relatedPlan>
 <participant>  <!-- 0..* Who's involved in plan? -->
  <role><!-- 0..1 CodeableConcept Type of involvement --></role>
  <member><!-- 0..1 Reference(Practitioner|RelatedPerson|Patient|Organization) Who is involved --></member>
 </participant>
 <goal><!-- 0..* Reference(Goal) Desired outcome of plan --></goal>
 <activity>  <!-- 0..* Action to occur as part of plan -->
  <actionResulting><!-- 0..* Reference(Any) Appointments, orders, etc. --></actionResulting>
  <progress><!-- 0..* Annotation Comments about the activity status/progress --></progress>
  <reference><!-- ?? 0..1 Reference(Appointment|CommunicationRequest|
    DeviceUseRequest|DiagnosticOrder|MedicationOrder|NutritionOrder|Order|
    ProcedureRequest|ProcessRequest|ReferralRequest|SupplyRequest|
    VisionPrescription) Activity details defined in specific resource --></reference>
  <detail>  <!-- ?? 0..1 In-line definition of activity -->
   <category><!-- 0..1 CodeableConcept diet | drug | encounter | observation | procedure | supply | other --></category>
   <code><!-- 0..1 CodeableConcept Detail type of activity --></code>
   <reasonCode><!-- 0..* CodeableConcept Why activity should be done --></reasonCode>
   <reasonReference><!-- 0..* Reference(Condition) Condition triggering need for activity --></reasonReference>
   <goal><!-- 0..* Reference(Goal) Goals this activity relates to --></goal>
   <status value="[code]"/><!-- 0..1 not-started | scheduled | in-progress | on-hold | completed | cancelled -->
   <statusReason><!-- 0..1 CodeableConcept Reason for current status --></statusReason>
   <prohibited value="[boolean]"/><!-- 1..1 Do NOT do -->
   <scheduled[x]><!-- 0..1 Timing|Period|string When activity is to occur --></scheduled[x]>
   <location><!-- 0..1 Reference(Location) Where it should happen --></location>
   <performer><!-- 0..* Reference(Practitioner|Organization|RelatedPerson|Patient) Who will be responsible? --></performer>
   <product[x]><!-- 0..1 CodeableConcept|Reference(Medication|Substance) What is to be administered/supplied --></product[x]>
   <dailyAmount><!-- 0..1 Quantity(SimpleQuantity) How to consume/day? --></dailyAmount>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) How much to administer/supply/consume --></quantity>
   <description value="[string]"/><!-- 0..1 Extra info describing activity to perform -->
  </detail>
 </activity>
 <note><!-- 0..1 Annotation Comments about the plan --></note>
</CarePlan>

JSON Template

{doco
  "resourceType" : "CarePlan",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // External Ids for this plan
  "subject" : { Reference(Patient|Group) }, // Who care plan is for
  "status" : "<code>", // R!  proposed | draft | active | completed | cancelled
  "context" : { Reference(Encounter|EpisodeOfCare) }, // Created in context of
  "period" : { Period }, // Time period plan covers
  "author" : [{ Reference(Patient|Practitioner|RelatedPerson|Organization) }], // Who is responsible for contents of the plan
  "modified" : "<dateTime>", // When last updated
  "category" : [{ CodeableConcept }], // Type of plan
  "description" : "<string>", // Summary of nature of plan
  "addresses" : [{ Reference(Condition) }], // Health issues this plan addresses
  "support" : [{ Reference(Any) }], // Information considered as part of plan
  "relatedPlan" : [{ // Plans related to this one
    "code" : "<code>", // includes | replaces | fulfills
    "plan" : { Reference(CarePlan) } // R!  Plan relationship exists with
  }],
  "participant" : [{ // Who's involved in plan?
    "role" : { CodeableConcept }, // Type of involvement
    "member" : { Reference(Practitioner|RelatedPerson|Patient|Organization) } // Who is involved
  }],
  "goal" : [{ Reference(Goal) }], // Desired outcome of plan
  "activity" : [{ // Action to occur as part of plan
    "actionResulting" : [{ Reference(Any) }], // Appointments, orders, etc.
    "progress" : [{ Annotation }], // Comments about the activity status/progress
    "reference" : { Reference(Appointment|CommunicationRequest|
    DeviceUseRequest|DiagnosticOrder|MedicationOrder|NutritionOrder|Order|
    ProcedureRequest|ProcessRequest|ReferralRequest|SupplyRequest|
    VisionPrescription) }, // C? Activity details defined in specific resource
    "detail" : { // C? In-line definition of activity
      "category" : { CodeableConcept }, // diet | drug | encounter | observation | procedure | supply | other
      "code" : { CodeableConcept }, // Detail type of activity
      "reasonCode" : [{ CodeableConcept }], // Why activity should be done
      "reasonReference" : [{ Reference(Condition) }], // Condition triggering need for activity
      "goal" : [{ Reference(Goal) }], // Goals this activity relates to
      "status" : "<code>", // not-started | scheduled | in-progress | on-hold | completed | cancelled
      "statusReason" : { CodeableConcept }, // Reason for current status
      "prohibited" : <boolean>, // R!  Do NOT do
      // scheduled[x]: When activity is to occur. One of these 3:
      "scheduledTiming" : { Timing },
      "scheduledPeriod" : { Period },
      "scheduledString" : "<string>",
      "location" : { Reference(Location) }, // Where it should happen
      "performer" : [{ Reference(Practitioner|Organization|RelatedPerson|Patient) }], // Who will be responsible?
      // product[x]: What is to be administered/supplied. One of these 2:
      "productCodeableConcept" : { CodeableConcept },
      "productReference" : { Reference(Medication|Substance) },
      "dailyAmount" : { Quantity(SimpleQuantity) }, // How to consume/day?
      "quantity" : { Quantity(SimpleQuantity) }, // How much to administer/supply/consume
      "description" : "<string>" // Extra info describing activity to perform
    }
  }],
  "note" : { Annotation } // Comments about the plan
}

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan DomainResourceHealthcare plan for patient or group
... identifier Σ0..*IdentifierExternal Ids for this plan
... subject Σ0..1Reference(Patient | Group)Who care plan is for
... status ?! Σ1..1codeproposed | draft | active | completed | cancelled
CarePlanStatus (Required)
... context Σ0..1Reference(Encounter | EpisodeOfCare)Created in context of
... period Σ0..1PeriodTime period plan covers
... author Σ0..*Reference(Patient | Practitioner | RelatedPerson | Organization)Who is responsible for contents of the plan
... modified Σ0..1dateTimeWhen last updated
... category Σ0..*CodeableConceptType of plan
Care Plan Category (Example)
... description Σ0..1stringSummary of nature of plan
... addresses Σ0..*Reference(Condition)Health issues this plan addresses
... support 0..*Reference(Any)Information considered as part of plan
... relatedPlan 0..*BackboneElementPlans related to this one
.... code 0..1codeincludes | replaces | fulfills
CarePlanRelationship (Required)
.... plan 1..1Reference(CarePlan)Plan relationship exists with
... participant 0..*BackboneElementWho's involved in plan?
.... role 0..1CodeableConceptType of involvement
Participant Roles (Example)
.... member 0..1Reference(Practitioner | RelatedPerson | Patient | Organization)Who is involved
... goal 0..*Reference(Goal)Desired outcome of plan
... activity I0..*BackboneElementAction to occur as part of plan
Provide a reference or detail, not both
.... actionResulting 0..*Reference(Any)Appointments, orders, etc.
.... progress 0..*AnnotationComments about the activity status/progress
.... reference I0..1Reference(Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticOrder | MedicationOrder | NutritionOrder | Order | ProcedureRequest | ProcessRequest | ReferralRequest | SupplyRequest | VisionPrescription)Activity details defined in specific resource
.... detail I0..1BackboneElementIn-line definition of activity
..... category 0..1CodeableConceptdiet | drug | encounter | observation | procedure | supply | other
CarePlanActivityCategory (Example)
..... code 0..1CodeableConceptDetail type of activity
Care Plan Activity (Example)
..... reasonCode 0..*CodeableConceptWhy activity should be done
Activity Reason (Example)
..... reasonReference 0..*Reference(Condition)Condition triggering need for activity
..... goal 0..*Reference(Goal)Goals this activity relates to
..... status ?!0..1codenot-started | scheduled | in-progress | on-hold | completed | cancelled
CarePlanActivityStatus (Required)
..... statusReason 0..1CodeableConceptReason for current status
GoalStatusReason (Example)
..... prohibited ?!1..1booleanDo NOT do
..... scheduled[x] 0..1When activity is to occur
...... scheduledTimingTiming
...... scheduledPeriodPeriod
...... scheduledStringstring
..... location 0..1Reference(Location)Where it should happen
..... performer 0..*Reference(Practitioner | Organization | RelatedPerson | Patient)Who will be responsible?
..... product[x] 0..1What is to be administered/supplied
SNOMED CT Medication Codes (Example)
...... productCodeableConceptCodeableConcept
...... productReferenceReference(Medication | Substance)
..... dailyAmount 0..1SimpleQuantityHow to consume/day?
..... quantity 0..1SimpleQuantityHow much to administer/supply/consume
..... description 0..1stringExtra info describing activity to perform
... note 0..1AnnotationComments about the plan

doco Documentation for this format

UML Diagram

CarePlan (DomainResource)This records identifiers associated with this care plan that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation)identifier : Identifier [0..*]Identifies the patient or group whose intended care is described by the plansubject : Reference [0..1] « Patient|Group »Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record (this element modifies the meaning of other elements)status : code [1..1] « Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record. (Strength=Required)CarePlanStatus! »Identifies the context in which this particular CarePlan is definedcontext : Reference [0..1] « Encounter|EpisodeOfCare »Indicates when the plan did (or is intended to) come into effect and endperiod : Period [0..1]Identifies the individual(s) or ogranization who is responsible for the content of the care planauthor : Reference [0..*] « Patient|Practitioner|RelatedPerson| Organization »Identifies the most recent date on which the plan has been revisedmodified : dateTime [0..1]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", etccategory : CodeableConcept [0..*] « Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. (Strength=Example)Care Plan Category?? »A description of the scope and nature of the plandescription : string [0..1]Identifies the conditions/problems/concerns/diagnoses/etc. whose management and/or mitigation are handled by this planaddresses : Reference [0..*] « Condition »Identifies portions of the patient's record that specifically influenced the formation of the plan. These might include co-morbidities, recent procedures, limitations, recent assessments, etcsupport : Reference [0..*] « Any »Describes the intended objective(s) of carrying out the care plangoal : Reference [0..*] « Goal »General notes about the care plan not covered elsewherenote : Annotation [0..1]RelatedPlanIdentifies the type of relationship this plan has to the target plancode : code [0..1] « Codes identifying the types of relationships between two plans. (Strength=Required)CarePlanRelationship! »A reference to the plan to which a relationship is assertedplan : Reference [1..1] « CarePlan »ParticipantIndicates specific responsibility of an individual within the care plan; e.g. "Primary physician", "Team coordinator", "Caregiver", etcrole : CodeableConcept [0..1] « Indicates specific responsibility of an individual within the care plan; e.g. "Primary physician", "Team coordinator", "Caregiver", etc. (Strength=Example)Participant Roles?? »The specific person or organization who is participating/expected to participate in the care planmember : Reference [0..1] « Practitioner|RelatedPerson|Patient| Organization »ActivityResources that describe follow-on actions resulting from the plan, such as drug prescriptions, encounter records, appointments, etcactionResulting : Reference [0..*] « Any »Notes about the adherence/status/progress of the activityprogress : Annotation [0..*]The details of the proposed activity represented in a specific resourcereference : Reference [0..1] « Appointment|CommunicationRequest| DeviceUseRequest|DiagnosticOrder|MedicationOrder| NutritionOrder|Order|ProcedureRequest|ProcessRequest| ReferralRequest|SupplyRequest|VisionPrescription »DetailHigh-level categorization of the type of activity in a care plancategory : CodeableConcept [0..1] « High-level categorization of the type of activity in a care plan. (Strength=Example)CarePlanActivityCategory?? »Detailed description of the type of planned activity; e.g. What lab test, what procedure, what kind of encountercode : CodeableConcept [0..1] « Detailed description of the type of activity; e.g. What lab test, what procedure, what kind of encounter. (Strength=Example)Care Plan Activity?? »Provides the rationale that drove the inclusion of this particular activity as part of the planreasonCode : CodeableConcept [0..*] « Identifies why a care plan activity is needed. Can include any health condition codes as well as such concepts as "general wellness", prophylaxis, surgical preparation, etc. (Strength=Example)Activity Reason?? »Provides the health condition(s) that drove the inclusion of this particular activity as part of the planreasonReference : Reference [0..*] « Condition »Internal reference that identifies the goals that this activity is intended to contribute towards meetinggoal : Reference [0..*] « Goal »Identifies what progress is being made for the specific activity (this element modifies the meaning of other elements)status : code [0..1] « Indicates where the activity is at in its overall life cycle. (Strength=Required)CarePlanActivityStatus! »Provides reason why the activity isn't yet started, is on hold, was cancelled, etcstatusReason : CodeableConcept [0..1] « Describes why the current activity has the status it does; e.g. "Recovering from injury" as a reason for non-started or on-hold, "Patient does not enjoy activity" as a reason for cancelling a planned activity. (Strength=Example)GoalStatusReason?? »If true, indicates that the described activity is one that must NOT be engaged in when following the plan (this element modifies the meaning of other elements)prohibited : boolean [1..1]The period, timing or frequency upon which the described activity is to occurscheduled[x] : Type [0..1] « Timing|Period|string »Identifies the facility where the activity will occur; e.g. home, hospital, specific clinic, etclocation : Reference [0..1] « Location »Identifies who's expected to be involved in the activityperformer : Reference [0..*] « Practitioner|Organization| RelatedPerson|Patient »Identifies the food, drug or other product to be consumed or supplied in the activityproduct[x] : Type [0..1] « CodeableConcept|Reference(Medication| Substance); A product supplied or administered as part of a care plan activity. (Strength=Example)SNOMED CT Medication ?? »Identifies the quantity expected to be consumed in a given daydailyAmount : Quantity(SimpleQuantity) [0..1]Identifies the quantity expected to be supplied, administered or consumed by the subjectquantity : Quantity(SimpleQuantity) [0..1]This provides a textual description of constraints on the intended activity occurrence, including relation to other activities. It may also include objectives, pre-conditions and end-conditions. Finally, it may convey specifics about the activity such as body site, method, route, etcdescription : string [0..1]Identifies CarePlans with some sort of formal relationship to the current planrelatedPlan[0..*]Identifies all people and organizations who are expected to be involved in the care envisioned by this planparticipant[0..*]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 etcdetail[0..1]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, etcactivity[0..*]

XML Template

<CarePlan xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier External Ids for this plan --></identifier>
 <subject><!-- 0..1 Reference(Patient|Group) Who care plan is for --></subject>
 <status value="[code]"/><!-- 1..1 proposed | draft | active | completed | cancelled -->
 <context><!-- 0..1 Reference(Encounter|EpisodeOfCare) Created in context of --></context>
 <period><!-- 0..1 Period Time period plan covers --></period>
 <author><!-- 0..* Reference(Patient|Practitioner|RelatedPerson|Organization) Who is responsible for contents of the plan --></author>
 <modified value="[dateTime]"/><!-- 0..1 When last updated -->
 <category><!-- 0..* CodeableConcept Type of plan --></category>
 <description value="[string]"/><!-- 0..1 Summary of nature of plan -->
 <addresses><!-- 0..* Reference(Condition) Health issues this plan addresses --></addresses>
 <support><!-- 0..* Reference(Any) Information considered as part of plan --></support>
 <relatedPlan>  <!-- 0..* Plans related to this one -->
  <code value="[code]"/><!-- 0..1 includes | replaces | fulfills -->
  <plan><!-- 1..1 Reference(CarePlan) Plan relationship exists with --></plan>
 </relatedPlan>
 <participant>  <!-- 0..* Who's involved in plan? -->
  <role><!-- 0..1 CodeableConcept Type of involvement --></role>
  <member><!-- 0..1 Reference(Practitioner|RelatedPerson|Patient|Organization) Who is involved --></member>
 </participant>
 <goal><!-- 0..* Reference(Goal) Desired outcome of plan --></goal>
 <activity>  <!-- 0..* Action to occur as part of plan -->
  <actionResulting><!-- 0..* Reference(Any) Appointments, orders, etc. --></actionResulting>
  <progress><!-- 0..* Annotation Comments about the activity status/progress --></progress>
  <reference><!-- ?? 0..1 Reference(Appointment|CommunicationRequest|
    DeviceUseRequest|DiagnosticOrder|MedicationOrder|NutritionOrder|Order|
    ProcedureRequest|ProcessRequest|ReferralRequest|SupplyRequest|
    VisionPrescription) Activity details defined in specific resource --></reference>
  <detail>  <!-- ?? 0..1 In-line definition of activity -->
   <category><!-- 0..1 CodeableConcept diet | drug | encounter | observation | procedure | supply | other --></category>
   <code><!-- 0..1 CodeableConcept Detail type of activity --></code>
   <reasonCode><!-- 0..* CodeableConcept Why activity should be done --></reasonCode>
   <reasonReference><!-- 0..* Reference(Condition) Condition triggering need for activity --></reasonReference>
   <goal><!-- 0..* Reference(Goal) Goals this activity relates to --></goal>
   <status value="[code]"/><!-- 0..1 not-started | scheduled | in-progress | on-hold | completed | cancelled -->
   <statusReason><!-- 0..1 CodeableConcept Reason for current status --></statusReason>
   <prohibited value="[boolean]"/><!-- 1..1 Do NOT do -->
   <scheduled[x]><!-- 0..1 Timing|Period|string When activity is to occur --></scheduled[x]>
   <location><!-- 0..1 Reference(Location) Where it should happen --></location>
   <performer><!-- 0..* Reference(Practitioner|Organization|RelatedPerson|Patient) Who will be responsible? --></performer>
   <product[x]><!-- 0..1 CodeableConcept|Reference(Medication|Substance) What is to be administered/supplied --></product[x]>
   <dailyAmount><!-- 0..1 Quantity(SimpleQuantity) How to consume/day? --></dailyAmount>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) How much to administer/supply/consume --></quantity>
   <description value="[string]"/><!-- 0..1 Extra info describing activity to perform -->
  </detail>
 </activity>
 <note><!-- 0..1 Annotation Comments about the plan --></note>
</CarePlan>

JSON Template

{doco
  "resourceType" : "CarePlan",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // External Ids for this plan
  "subject" : { Reference(Patient|Group) }, // Who care plan is for
  "status" : "<code>", // R!  proposed | draft | active | completed | cancelled
  "context" : { Reference(Encounter|EpisodeOfCare) }, // Created in context of
  "period" : { Period }, // Time period plan covers
  "author" : [{ Reference(Patient|Practitioner|RelatedPerson|Organization) }], // Who is responsible for contents of the plan
  "modified" : "<dateTime>", // When last updated
  "category" : [{ CodeableConcept }], // Type of plan
  "description" : "<string>", // Summary of nature of plan
  "addresses" : [{ Reference(Condition) }], // Health issues this plan addresses
  "support" : [{ Reference(Any) }], // Information considered as part of plan
  "relatedPlan" : [{ // Plans related to this one
    "code" : "<code>", // includes | replaces | fulfills
    "plan" : { Reference(CarePlan) } // R!  Plan relationship exists with
  }],
  "participant" : [{ // Who's involved in plan?
    "role" : { CodeableConcept }, // Type of involvement
    "member" : { Reference(Practitioner|RelatedPerson|Patient|Organization) } // Who is involved
  }],
  "goal" : [{ Reference(Goal) }], // Desired outcome of plan
  "activity" : [{ // Action to occur as part of plan
    "actionResulting" : [{ Reference(Any) }], // Appointments, orders, etc.
    "progress" : [{ Annotation }], // Comments about the activity status/progress
    "reference" : { Reference(Appointment|CommunicationRequest|
    DeviceUseRequest|DiagnosticOrder|MedicationOrder|NutritionOrder|Order|
    ProcedureRequest|ProcessRequest|ReferralRequest|SupplyRequest|
    VisionPrescription) }, // C? Activity details defined in specific resource
    "detail" : { // C? In-line definition of activity
      "category" : { CodeableConcept }, // diet | drug | encounter | observation | procedure | supply | other
      "code" : { CodeableConcept }, // Detail type of activity
      "reasonCode" : [{ CodeableConcept }], // Why activity should be done
      "reasonReference" : [{ Reference(Condition) }], // Condition triggering need for activity
      "goal" : [{ Reference(Goal) }], // Goals this activity relates to
      "status" : "<code>", // not-started | scheduled | in-progress | on-hold | completed | cancelled
      "statusReason" : { CodeableConcept }, // Reason for current status
      "prohibited" : <boolean>, // R!  Do NOT do
      // scheduled[x]: When activity is to occur. One of these 3:
      "scheduledTiming" : { Timing },
      "scheduledPeriod" : { Period },
      "scheduledString" : "<string>",
      "location" : { Reference(Location) }, // Where it should happen
      "performer" : [{ Reference(Practitioner|Organization|RelatedPerson|Patient) }], // Who will be responsible?
      // product[x]: What is to be administered/supplied. One of these 2:
      "productCodeableConcept" : { CodeableConcept },
      "productReference" : { Reference(Medication|Substance) },
      "dailyAmount" : { Quantity(SimpleQuantity) }, // How to consume/day?
      "quantity" : { Quantity(SimpleQuantity) }, // How much to administer/supply/consume
      "description" : "<string>" // Extra info describing activity to perform
    }
  }],
  "note" : { Annotation } // Comments about the plan
}

 

Alternate definitions: Schema/Schematron, Resource Profile (XML, JSON), Questionnaire

4.4.3.1 Terminology Bindings

PathDefinitionTypeReference
CarePlan.status Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.RequiredCarePlanStatus
CarePlan.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.ExampleCare Plan Category
CarePlan.relatedPlan.code Codes identifying the types of relationships between two plans.RequiredCarePlanRelationship
CarePlan.participant.role Indicates specific responsibility of an individual within the care plan; e.g. "Primary physician", "Team coordinator", "Caregiver", etc.ExampleParticipant Roles
CarePlan.activity.detail.category High-level categorization of the type of activity in a care plan.ExampleCarePlanActivityCategory
CarePlan.activity.detail.code Detailed description of the type of activity; e.g. What lab test, what procedure, what kind of encounter.ExampleCare Plan Activity
CarePlan.activity.detail.reasonCode Identifies why a care plan activity is needed. Can include any health condition codes as well as such concepts as "general wellness", prophylaxis, surgical preparation, etc.ExampleActivity Reason
CarePlan.activity.detail.status Indicates where the activity is at in its overall life cycle.RequiredCarePlanActivityStatus
CarePlan.activity.detail.statusReason Describes why the current activity has the status it does; e.g. "Recovering from injury" as a reason for non-started or on-hold, "Patient does not enjoy activity" as a reason for cancelling a planned activity.ExampleGoalStatusReason
CarePlan.activity.detail.product[x] A product supplied or administered as part of a care plan activity.ExampleSNOMED CT Medication Codes

4.4.3.2 Constraints

  • cpl-3: On CarePlan.activity: Provide a reference or detail, not both (xpath on f:CarePlan/f:activity: not(exists(f:detail)) or not(exists(f:reference)))

4.4.4 Open Issues

DSTU Note: During the Trial use period, feedback is welcome on two issues:

  • This resource combines the concepts of "Care Plan" and "Care Team" into a single resource. Is this appropriate?
  • At present, the patient element is optional to allow experimentation with care plan templates, though the resource was not designed for this use

Feedback here .

4.4.5 Search Parameters

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

NameTypeDescriptionPaths
activitycodetokenDetail type of activityCarePlan.activity.detail.code
activitydatedateSpecified date occurs within period specified by CarePlan.activity.timingScheduleCarePlan.activity.detail.scheduled[x]
activityreferencereferenceActivity details defined in specific resourceCarePlan.activity.reference
(ReferralRequest, ProcedureRequest, Appointment, CommunicationRequest, Order, SupplyRequest, VisionPrescription, MedicationOrder, ProcessRequest, DeviceUseRequest, NutritionOrder, DiagnosticOrder)
conditionreferenceHealth issues this plan addressesCarePlan.addresses
(Condition)
datedateTime period plan coversCarePlan.period
goalreferenceDesired outcome of planCarePlan.goal
(Goal)
participantreferenceWho is involvedCarePlan.participant.member
(Organization, Patient, Practitioner, RelatedPerson)
patientreferenceWho care plan is forCarePlan.subject
(Patient)
performerreferenceMatches if the practitioner is listed as a performer in any of the "simple" activities. (For performers of the detailed activities, chain through the activitydetail search parameter.)CarePlan.activity.detail.performer
(Patient, Organization, Practitioner, RelatedPerson)
relatedcompositeA combination of the type of relationship and the related plan
relatedcodetokenincludes | replaces | fulfillsCarePlan.relatedPlan.code
relatedplanreferencePlan relationship exists withCarePlan.relatedPlan.plan
(CarePlan)
subjectreferenceWho care plan is forCarePlan.subject
(Patient, Group)