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.

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).

Need to allow connection to a wider workflow.

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

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

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

Identifiers the context in which this particular CarePlan is defined.

Activities conducted as a result of the care plan may well occur as part of other encounters/episodes.

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

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

Any activities scheduled as part of the plan should be constrained to the specified period.

Identifies the individual(s) or ogranization who is responsible for the content of the care plan.

Collaborative care plans may have multiple authors.

Identifies the most recent date on which the plan has been revised.

Indicates how current the plan is.

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

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

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

A description of the scope and nature of the plan.

Provides more detail than conveyed by category.

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

Links plan to the conditions it manages. Also scopes plans - multiple plans may exist addressing different concerns.

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, etc.

Identifies barriers and other considerations associated with the care plan.

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

Identifies CarePlans with some sort of formal relationship to the current plan.

Relationships are uni-directional with the "newer" plan pointing to the older one.

Identifies the type of relationship this plan has to the target plan.

Read the relationship as "this plan" [relatedPlan.code] "relatedPlan.plan". E.g. This plan includes Plan B

Additional relationship types can be proposed for future releases or handled as extensions.

A reference to the plan to which a relationship is asserted.

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

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

Indicates specific responsibility of an individual within the care plan. E.g. "Primary physician", "Team coordinator", "Caregiver", etc.

Roles may sometimes be inferred by type of Practitioner. These are relationships that hold only within the context of the care plan. General relationships should be handled as properties of the Patient resource directly.

The specific person or organization who is participating/expected to participate in the care plan.

Patient only needs to be listed if they have a role other than "subject of care".

Member is optional because some participants may be known only by their role, particularly in draft plans.

Describes the intended objective(s) of carrying out the Care Plan.

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

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

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

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

Resources that describe follow-on actions resulting from the plan, such as drug prescriptions, encounter records, appointments, etc.

Links plan to resulting actions.

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

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

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

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

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

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

Details in a simple form for generic care plan systems.

High-level categorization of the type of activity in a care plan.

May determine what types of extensions are permitted.

Detailed description of the type of planned activity. E.g. What lab test, what procedure, what kind of encounter.

Allows matching performed to planned as well as validation against protocols.

Tends to be less relevant for activities involving particular products. Codes should not convey negation - use "prohibited" instead.

Provides the rationale that drove the inclusion of this particular activity as part of the plan.

This could be a diagnosis code. If a full condition record exists or additional detail is needed, use reasonCondition instead.

Provides the health condition(s) that drove the inclusion of this particular activity as part of the plan.

Conditions can be identified at the activity level that are not identified as reasons for the overall plan.

Internal reference that identifies the goals that this activity is intended to contribute towards meeting.

So that participants know the link explicitly.

Identifies what progress is being made for the specific activity.

Indicates progress against the plan, whether the activity is still relevant for the plan.

Some aspects of Status can be inferred based on the resources linked in actionTaken. Note that "status" is only as current as the plan was most recently updated.

Provides reason why the activity isn't yet started, is on hold, was cancelled, etc.

Will generally not be present it status is "complete". Be sure to prompt to update this (or at least remove the existing value) if the status is changed.

If true, indicates that the described activity is one that must NOT be engaged in when following the plan.

Captures intention to not do something that may have been previously typical.

The period, timing or frequency upon which the described activity is to occur.

Allows prompting for activities and detection of missed planned activities.

Identifies the facility where the activity will occur. E.g. home, hospital, specific clinic, etc.

Helps in planning of activity.

May reference a specific clinical location or may just identify a type of location.

Identifies who's expected to be involved in the activity.

Helps in planning of activity.

A performer MAY also be a participant in the care plan.

Identifies the food, drug or other product to be consumed or supplied in the activity.

Identifies the quantity expected to be consumed in a given day.

Allows rough dose checking.

Identifies the quantity expected to be supplied, addministered or consumed by the subject.

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, etc.

General notes about the care plan not covered elsewhere.

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