PATIENT ADMINISTRTAION (PA) Workgroup Development Draft

4.4 Resource CarePlan - Content

This resource maintained by the Patient Care Work Group

Describes the intention of how one or more practitioners intend to deliver care for a particular patient 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.

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

Comments are welcome about the appropriateness of the proposed level of granularity, whether it's too much detail for what most systems need, or not sufficient for common essential use cases.

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.

This resource is referenced by ClinicalImpression and Procedure

4.4.3 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan DomainResourceHealthcare plan for patient
... identifier Σ0..*IdentifierExternal Ids for this plan
... patient Σ0..1PatientWho care plan is for
... status ?! Σ1..1codeplanned | active | completed
CarePlanStatus (Required)
... period Σ0..1PeriodTime period plan covers
... author Σ0..*Patient | Practitioner | RelatedPerson | OrganizationWho is responsible for plan
... modified Σ0..1dateTimeWhen last updated
... category Σ0..*CodeableConceptType of plan
... concern Σ0..*ConditionHealth issues this plan addresses
... support 0..*AnyInformation considered as part of plan
... participant 0..*ElementWho's involved in plan?
.... role 0..1CodeableConceptType of involvement
.... member 1..1Practitioner | RelatedPerson | Patient | OrganizationWho is involved
... goal 0..*GoalDesired outcome of plan
... activity 0..*ElementAction to occur as part of plan
.... actionResulting 0..*AnyAppointments, orders, etc.
.... notes 0..1stringComments about the activity
.... reference I0..1Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticOrder | MedicationPrescription | NutritionOrder | Order | ProcedureRequest | ProcessRequest | ReferralRequest | Supply | VisionPrescriptionActivity details defined in specific resource
.... detail I0..1ElementIn-line definition of activity
Only provide a detail reference, or a simple detail summary
Quantity can only be specified if activity category is supply
DailyDose can only be specified if activity category is drug or food
..... category 1..1codediet | drug | encounter | observation | procedure | supply | other
CarePlanActivityCategory (Required)
..... code 0..1CodeableConceptDetail type of activity
..... reason[x] Why activity should be done
...... reasonCodeableConcept0..1CodeableConcept
...... reasonReference0..1Condition
..... goal 0..*GoalGoals this activity relates to
..... status ?!0..1codenot-started | scheduled | in-progress | on-hold | completed | cancelled
CarePlanActivityStatus (Required)
..... statusReason 0..1CodeableConceptReason for current status
..... prohibited ?!1..1booleanDo NOT do
..... scheduled[x] When activity is to occur
...... scheduledTiming0..1Timing
...... scheduledPeriod0..1Period
...... scheduledString0..1string
..... location 0..1LocationWhere it should happen
..... performer 0..*Practitioner | Organization | RelatedPerson | PatientWho will be responsible?
..... product 0..1Medication | SubstanceWhat is to be administered/supplied
..... dailyAmount I0..1QuantityHow to consume/day?
..... quantity I0..1QuantityHow much to administer/supply/consume
..... note 0..1stringExtra info on activity occurrence
... notes 0..1stringComments about the plan

UML Diagram

CarePlan (DomainResource)This records identifiers associated with this care plan that are defined by business processed 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/subject whose intended care is described by the planpatient : Reference(Patient) 0..1Indicates whether the plan is currently being acted upon, represents future intentions or is now just 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 just historical record.CarePlanStatus »Indicates when the plan did (or is intended to) come into effect and endperiod : Period 0..1Identifies the individual(s) or ogranization who is responsible for the content of the care planauthor : Reference(Patient|Practitioner| RelatedPerson|Organization) 0..*Identifies the most recent date on which the plan has been revisedmodified : dateTime 0..1Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans. E.g. "Home health", "psychiatric", "asthma", "disease management", etccategory : CodeableConcept 0..*Identifies the conditions/problems/concerns/diagnoses/etc. whose management and/or mitigation are handled by this planconcern : Reference(Condition) 0..*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(Any) 0..*Describes the intended objective(s) of carrying out the Care Plangoal : Reference(Goal) 0..*General notes about the care plan not covered elsewherenotes : string 0..1ParticipantIndicates specific responsibility of an individual within the care plan. E.g. "Primary physician", "Team coordinator", "Caregiver", etcrole : CodeableConcept 0..1The specific person or organization who is participating/expected to participate in the care planmember : Reference(Practitioner|RelatedPerson| Patient|Organization) 1..1ActivityResources that describe follow-on actions resulting from the plan, such as drug prescriptions, encounter records, appointments, etcactionResulting : Reference(Any) 0..*Notes about the execution of the activitynotes : string 0..1The details of the proposed activity represented in a specific resourcereference : Reference(Appointment| CommunicationRequest|DeviceUseRequest| DiagnosticOrder|MedicationPrescription| NutritionOrder|Order|ProcedureRequest| ProcessRequest|ReferralRequest|Supply| VisionPrescription) 0..1DetailHigh-level categorization of the type of activity in a care plancategory : code 1..1 « High-level categorization of the type of activity in a care plan.CarePlanActivityCategory »Detailed description of the type of planned activity. E.g. What lab test, what procedure, what kind of encountercode : CodeableConcept 0..1Provides the health condition(s) or other rationale that drove the inclusion of this particular activity as part of the planreason[x] : CodeableConcept|Reference(Condition) 0..1Internal reference that identifies the goals that this activity is intended to contribute towards meetinggoal : Reference(Goal) 0..*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 cycleCarePlanActivityStatus »Provides reason why the activity isn't yet started, is on hold, was cancelled, etcstatusReason : CodeableConcept 0..1If 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..1The period, timing or frequency upon which the described activity is to occurscheduled[x] : Timing|Period|string 0..1Identifies the facility where the activity will occur. E.g. home, hospital, specific clinic, etclocation : Reference(Location) 0..1Identifies who's expected to be involved in the activityperformer : Reference(Practitioner|Organization| RelatedPerson|Patient) 0..*Identifies the food, drug or other product to be consumed or supplied in the activityproduct : Reference(Medication|Substance) 0..1Identifies the quantity expected to be consumed in a given daydailyAmount : Quantity 0..1Identifies the quantity expected to be supplied, addministered or consumed by the subjectquantity : Quantity 0..1This 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, etcnote : string 0..1Identifies all people and organizations who are expected to be involved in the care envisioned by this planparticipant0..*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 etcdetail0..1Identifies a planned action to occur as part of the plan. For example, a medication to be used, lab tests to perform, self-monitoring, education, etcactivity0..*

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>
 <patient><!-- 0..1 Reference(Patient) Who care plan is for --></patient>
 <status value="[code]"/><!-- 1..1 planned | active | completed -->
 <period><!-- 0..1 Period Time period plan covers --></period>
 <author><!-- 0..* Reference(Patient|Practitioner|RelatedPerson|Organization) Who is responsible for plan --></author>
 <modified value="[dateTime]"/><!-- 0..1 When last updated -->
 <category><!-- 0..* CodeableConcept Type of plan --></category>
 <concern><!-- 0..* Reference(Condition) Health issues this plan addresses --></concern>
 <support><!-- 0..* Reference(Any) Information considered as part of plan --></support>
 <participant>  <!-- 0..* Who's involved in plan? -->
  <role><!-- 0..1 CodeableConcept Type of involvement --></role>
  <member><!-- 1..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>
  <notes value="[string]"/><!-- 0..1 Comments about the activity -->
  <reference><!-- ?? 0..1 Reference(Appointment|CommunicationRequest|
    DeviceUseRequest|DiagnosticOrder|MedicationPrescription|NutritionOrder|Order|
    ProcedureRequest|ProcessRequest|ReferralRequest|Supply|VisionPrescription) Activity details defined in specific resource --></reference>
  <detail>  <!-- ?? 0..1 In-line definition of activity -->
   <category value="[code]"/><!-- 1..1 diet | drug | encounter | observation | procedure | supply | other -->
   <code><!-- 0..1 CodeableConcept Detail type of activity --></code>
   <reason[x]><!-- 0..1 CodeableConcept|Reference(Condition) Why activity should be done --></reason[x]>
   <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><!-- 0..1 Reference(Medication|Substance) What is to be administered/supplied --></product>
   <dailyAmount><!-- ?? 0..1 Quantity How to consume/day? --></dailyAmount>
   <quantity><!-- ?? 0..1 Quantity How much to administer/supply/consume --></quantity>
   <note value="[string]"/><!-- 0..1 Extra info on activity occurrence -->
  </detail>
 </activity>
 <notes value="[string]"/><!-- 0..1 Comments about the plan -->
</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
  "patient" : { Reference(Patient) }, // Who care plan is for
  "status" : "<code>", // R!  planned | active | completed
  "period" : { Period }, // Time period plan covers
  "author" : [{ Reference(Patient|Practitioner|RelatedPerson|Organization) }], // Who is responsible for plan
  "modified" : "<dateTime>", // When last updated
  "category" : [{ CodeableConcept }], // Type of plan
  "concern" : [{ Reference(Condition) }], // Health issues this plan addresses
  "support" : [{ Reference(Any) }], // Information considered as part of plan
  "participant" : [{ // Who's involved in plan?
    "role" : { CodeableConcept }, // Type of involvement
    "member" : { Reference(Practitioner|RelatedPerson|Patient|Organization) } // R!  Who is involved
  }],
  "goal" : [{ Reference(Goal) }], // Desired outcome of plan
  "activity" : [{ // Action to occur as part of plan
    "actionResulting" : [{ Reference(Any) }], // Appointments, orders, etc.
    "notes" : "<string>", // Comments about the activity
    "reference" : { Reference(Appointment|CommunicationRequest|
    DeviceUseRequest|DiagnosticOrder|MedicationPrescription|NutritionOrder|Order|
    ProcedureRequest|ProcessRequest|ReferralRequest|Supply|VisionPrescription) }, // C? Activity details defined in specific resource
    "detail" : { // C? In-line definition of activity
      "category" : "<code>", // R!  diet | drug | encounter | observation | procedure | supply | other
      "code" : { CodeableConcept }, // Detail type of activity
      // reason[x]: Why activity should be done. One of these 2:
      "reasonCodeableConcept" : { CodeableConcept },
      "reasonReference" : { Reference(Condition) },
      "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" : { Reference(Medication|Substance) }, // What is to be administered/supplied
      "dailyAmount" : { Quantity }, // C? How to consume/day?
      "quantity" : { Quantity }, // C? How much to administer/supply/consume
      "note" : "<string>" // Extra info on activity occurrence
    }
  }],
  "notes" : "<string>" // Comments about the plan
}

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan DomainResourceHealthcare plan for patient
... identifier Σ0..*IdentifierExternal Ids for this plan
... patient Σ0..1PatientWho care plan is for
... status ?! Σ1..1codeplanned | active | completed
CarePlanStatus (Required)
... period Σ0..1PeriodTime period plan covers
... author Σ0..*Patient | Practitioner | RelatedPerson | OrganizationWho is responsible for plan
... modified Σ0..1dateTimeWhen last updated
... category Σ0..*CodeableConceptType of plan
... concern Σ0..*ConditionHealth issues this plan addresses
... support 0..*AnyInformation considered as part of plan
... participant 0..*ElementWho's involved in plan?
.... role 0..1CodeableConceptType of involvement
.... member 1..1Practitioner | RelatedPerson | Patient | OrganizationWho is involved
... goal 0..*GoalDesired outcome of plan
... activity 0..*ElementAction to occur as part of plan
.... actionResulting 0..*AnyAppointments, orders, etc.
.... notes 0..1stringComments about the activity
.... reference I0..1Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticOrder | MedicationPrescription | NutritionOrder | Order | ProcedureRequest | ProcessRequest | ReferralRequest | Supply | VisionPrescriptionActivity details defined in specific resource
.... detail I0..1ElementIn-line definition of activity
Only provide a detail reference, or a simple detail summary
Quantity can only be specified if activity category is supply
DailyDose can only be specified if activity category is drug or food
..... category 1..1codediet | drug | encounter | observation | procedure | supply | other
CarePlanActivityCategory (Required)
..... code 0..1CodeableConceptDetail type of activity
..... reason[x] Why activity should be done
...... reasonCodeableConcept0..1CodeableConcept
...... reasonReference0..1Condition
..... goal 0..*GoalGoals this activity relates to
..... status ?!0..1codenot-started | scheduled | in-progress | on-hold | completed | cancelled
CarePlanActivityStatus (Required)
..... statusReason 0..1CodeableConceptReason for current status
..... prohibited ?!1..1booleanDo NOT do
..... scheduled[x] When activity is to occur
...... scheduledTiming0..1Timing
...... scheduledPeriod0..1Period
...... scheduledString0..1string
..... location 0..1LocationWhere it should happen
..... performer 0..*Practitioner | Organization | RelatedPerson | PatientWho will be responsible?
..... product 0..1Medication | SubstanceWhat is to be administered/supplied
..... dailyAmount I0..1QuantityHow to consume/day?
..... quantity I0..1QuantityHow much to administer/supply/consume
..... note 0..1stringExtra info on activity occurrence
... notes 0..1stringComments about the plan

UML Diagram

CarePlan (DomainResource)This records identifiers associated with this care plan that are defined by business processed 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/subject whose intended care is described by the planpatient : Reference(Patient) 0..1Indicates whether the plan is currently being acted upon, represents future intentions or is now just 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 just historical record.CarePlanStatus »Indicates when the plan did (or is intended to) come into effect and endperiod : Period 0..1Identifies the individual(s) or ogranization who is responsible for the content of the care planauthor : Reference(Patient|Practitioner| RelatedPerson|Organization) 0..*Identifies the most recent date on which the plan has been revisedmodified : dateTime 0..1Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans. E.g. "Home health", "psychiatric", "asthma", "disease management", etccategory : CodeableConcept 0..*Identifies the conditions/problems/concerns/diagnoses/etc. whose management and/or mitigation are handled by this planconcern : Reference(Condition) 0..*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(Any) 0..*Describes the intended objective(s) of carrying out the Care Plangoal : Reference(Goal) 0..*General notes about the care plan not covered elsewherenotes : string 0..1ParticipantIndicates specific responsibility of an individual within the care plan. E.g. "Primary physician", "Team coordinator", "Caregiver", etcrole : CodeableConcept 0..1The specific person or organization who is participating/expected to participate in the care planmember : Reference(Practitioner|RelatedPerson| Patient|Organization) 1..1ActivityResources that describe follow-on actions resulting from the plan, such as drug prescriptions, encounter records, appointments, etcactionResulting : Reference(Any) 0..*Notes about the execution of the activitynotes : string 0..1The details of the proposed activity represented in a specific resourcereference : Reference(Appointment| CommunicationRequest|DeviceUseRequest| DiagnosticOrder|MedicationPrescription| NutritionOrder|Order|ProcedureRequest| ProcessRequest|ReferralRequest|Supply| VisionPrescription) 0..1DetailHigh-level categorization of the type of activity in a care plancategory : code 1..1 « High-level categorization of the type of activity in a care plan.CarePlanActivityCategory »Detailed description of the type of planned activity. E.g. What lab test, what procedure, what kind of encountercode : CodeableConcept 0..1Provides the health condition(s) or other rationale that drove the inclusion of this particular activity as part of the planreason[x] : CodeableConcept|Reference(Condition) 0..1Internal reference that identifies the goals that this activity is intended to contribute towards meetinggoal : Reference(Goal) 0..*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 cycleCarePlanActivityStatus »Provides reason why the activity isn't yet started, is on hold, was cancelled, etcstatusReason : CodeableConcept 0..1If 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..1The period, timing or frequency upon which the described activity is to occurscheduled[x] : Timing|Period|string 0..1Identifies the facility where the activity will occur. E.g. home, hospital, specific clinic, etclocation : Reference(Location) 0..1Identifies who's expected to be involved in the activityperformer : Reference(Practitioner|Organization| RelatedPerson|Patient) 0..*Identifies the food, drug or other product to be consumed or supplied in the activityproduct : Reference(Medication|Substance) 0..1Identifies the quantity expected to be consumed in a given daydailyAmount : Quantity 0..1Identifies the quantity expected to be supplied, addministered or consumed by the subjectquantity : Quantity 0..1This 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, etcnote : string 0..1Identifies all people and organizations who are expected to be involved in the care envisioned by this planparticipant0..*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 etcdetail0..1Identifies a planned action to occur as part of the plan. For example, a medication to be used, lab tests to perform, self-monitoring, education, etcactivity0..*

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>
 <patient><!-- 0..1 Reference(Patient) Who care plan is for --></patient>
 <status value="[code]"/><!-- 1..1 planned | active | completed -->
 <period><!-- 0..1 Period Time period plan covers --></period>
 <author><!-- 0..* Reference(Patient|Practitioner|RelatedPerson|Organization) Who is responsible for plan --></author>
 <modified value="[dateTime]"/><!-- 0..1 When last updated -->
 <category><!-- 0..* CodeableConcept Type of plan --></category>
 <concern><!-- 0..* Reference(Condition) Health issues this plan addresses --></concern>
 <support><!-- 0..* Reference(Any) Information considered as part of plan --></support>
 <participant>  <!-- 0..* Who's involved in plan? -->
  <role><!-- 0..1 CodeableConcept Type of involvement --></role>
  <member><!-- 1..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>
  <notes value="[string]"/><!-- 0..1 Comments about the activity -->
  <reference><!-- ?? 0..1 Reference(Appointment|CommunicationRequest|
    DeviceUseRequest|DiagnosticOrder|MedicationPrescription|NutritionOrder|Order|
    ProcedureRequest|ProcessRequest|ReferralRequest|Supply|VisionPrescription) Activity details defined in specific resource --></reference>
  <detail>  <!-- ?? 0..1 In-line definition of activity -->
   <category value="[code]"/><!-- 1..1 diet | drug | encounter | observation | procedure | supply | other -->
   <code><!-- 0..1 CodeableConcept Detail type of activity --></code>
   <reason[x]><!-- 0..1 CodeableConcept|Reference(Condition) Why activity should be done --></reason[x]>
   <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><!-- 0..1 Reference(Medication|Substance) What is to be administered/supplied --></product>
   <dailyAmount><!-- ?? 0..1 Quantity How to consume/day? --></dailyAmount>
   <quantity><!-- ?? 0..1 Quantity How much to administer/supply/consume --></quantity>
   <note value="[string]"/><!-- 0..1 Extra info on activity occurrence -->
  </detail>
 </activity>
 <notes value="[string]"/><!-- 0..1 Comments about the plan -->
</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
  "patient" : { Reference(Patient) }, // Who care plan is for
  "status" : "<code>", // R!  planned | active | completed
  "period" : { Period }, // Time period plan covers
  "author" : [{ Reference(Patient|Practitioner|RelatedPerson|Organization) }], // Who is responsible for plan
  "modified" : "<dateTime>", // When last updated
  "category" : [{ CodeableConcept }], // Type of plan
  "concern" : [{ Reference(Condition) }], // Health issues this plan addresses
  "support" : [{ Reference(Any) }], // Information considered as part of plan
  "participant" : [{ // Who's involved in plan?
    "role" : { CodeableConcept }, // Type of involvement
    "member" : { Reference(Practitioner|RelatedPerson|Patient|Organization) } // R!  Who is involved
  }],
  "goal" : [{ Reference(Goal) }], // Desired outcome of plan
  "activity" : [{ // Action to occur as part of plan
    "actionResulting" : [{ Reference(Any) }], // Appointments, orders, etc.
    "notes" : "<string>", // Comments about the activity
    "reference" : { Reference(Appointment|CommunicationRequest|
    DeviceUseRequest|DiagnosticOrder|MedicationPrescription|NutritionOrder|Order|
    ProcedureRequest|ProcessRequest|ReferralRequest|Supply|VisionPrescription) }, // C? Activity details defined in specific resource
    "detail" : { // C? In-line definition of activity
      "category" : "<code>", // R!  diet | drug | encounter | observation | procedure | supply | other
      "code" : { CodeableConcept }, // Detail type of activity
      // reason[x]: Why activity should be done. One of these 2:
      "reasonCodeableConcept" : { CodeableConcept },
      "reasonReference" : { Reference(Condition) },
      "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" : { Reference(Medication|Substance) }, // What is to be administered/supplied
      "dailyAmount" : { Quantity }, // C? How to consume/day?
      "quantity" : { Quantity }, // C? How much to administer/supply/consume
      "note" : "<string>" // Extra info on activity occurrence
    }
  }],
  "notes" : "<string>" // Comments about the plan
}

 

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

4.4.3.1 Terminology Bindings

PathDefinitionTypeReference
CarePlan.status Indicates whether the plan is currently being acted upon, represents future intentions or is now just historical record.Requiredhttp://hl7.org/fhir/care-plan-status
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.UnknownNo details provided yet
CarePlan.participant.role Indicates specific responsibility of an individual within the care plan. E.g. "Primary physician", "Team coordinator", "Caregiver", etc.UnknownNo details provided yet
CarePlan.activity.detail.category High-level categorization of the type of activity in a care plan.Requiredhttp://hl7.org/fhir/care-plan-activity-category
CarePlan.activity.detail.code Detailed description of the type of activity. E.g. What lab test, what procedure, what kind of encounter.UnknownNo details provided yet
CarePlan.activity.detail.reason[x] Identifies why a care plan activity is needed. Can include any health condition codes as well as such concepts as "general wellness", prohylaxis, surgical preparation, etc.UnknownNo details provided yet
CarePlan.activity.detail.status Indicates where the activity is at in its overall life cycleRequiredhttp://hl7.org/fhir/care-plan-activity-status
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 activityUnknownNo details provided yet

4.4.3.2 Constraints

  • cpl-1: On CarePlan.activity.detail: DailyDose can only be specified if activity category is drug or food (xpath on f:CarePlan/f:activity/f:detail: (f:category/@value=('drug','diet')) = exists(f:dailyAmount))
  • cpl-2: On CarePlan.activity.detail: Quantity can only be specified if activity category is supply (xpath on f:CarePlan/f:activity/f:detail: (f:category/@value=('supply')) = exists(f:quantity))
  • cpl-3: On CarePlan.activity.detail: Only provide a detail reference, or a simple detail summary (xpath on f:CarePlan/f:activity/f:detail: not(exists(f:detail)) or not(exists(f:simple)))

4.4.4 Open Issues

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

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
(Appointment, Order, ReferralRequest, MedicationPrescription, ProcessRequest, NutritionOrder, VisionPrescription, Supply, DiagnosticOrder, ProcedureRequest, DeviceUseRequest, CommunicationRequest)
conditionreferenceHealth issues this plan addressesCarePlan.concern
(Condition)
datedateTime period plan coversCarePlan.period
goalreferenceDesired outcome of planCarePlan.goal
(Goal)
participantreferenceWho is involvedCarePlan.participant.member
(Practitioner, Organization, Patient, RelatedPerson)
patientreferenceWho care plan is forCarePlan.patient
(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
(Practitioner, Organization, Patient, RelatedPerson)