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9.5 Resource CarePlan - Content

Patient Care icon Work GroupMaturity Level: 2 Trial UseSecurity Category: Patient Compartments: Encounter, Patient

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.

9.5.1 Scope and Usage

CarePlan is one of the request resources in the FHIR workflow specification.

Care Plans are used in many 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, prenatal plan, postpartum plan, grief management plan, etc.)
  • Decision support generated plans following specific practice guidelines (e.g. stroke care plan, diabetes plan, falls prevention, etc.)
  • Self-maintained patient or care-giver authored plans identifying their goals and an integrated understanding of actions to be taken. This does not include the legal Advance Directives, which should be represented with either the Consent resource with Consent.category = Advance Directive or with a specific request resource with intent = directive. Informal advance directives could be represented as a Goal, such as "I want to die at home."

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.

9.5.2 Boundaries and Relationships

CarePlan activities can 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 CarePlan dealing only with immunization events. Where such information could appear in either resource, the immunization-specific resource is preferred.

CarePlans represent 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. CarePlan represents a specific intent, not a general definition. Protocols and order sets are supported through PlanDefinition.

9.5.3 References to this Resource

9.5.4 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan TU DomainResource Healthcare plan for patient or group

Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier Σ 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

... replaces Σ 0..* Reference(CarePlan) CarePlan replaced by this CarePlan

... partOf Σ 0..* Reference(CarePlan) Part of referenced CarePlan

... status ?!Σ 1..1 code draft | active | on-hold | revoked | completed | entered-in-error | unknown
Binding: RequestStatus (Required)
... intent ?!Σ 1..1 code proposal | plan | order | option | directive
Binding: Care Plan Intent (Required)
... category Σ 0..* CodeableConcept Type of plan
Binding: Care Plan Category (Example)

... title Σ 0..1 string Human-friendly name for the care plan
... description Σ 0..1 string Summary of nature of plan
... subject Σ 1..1 Reference(Patient | Group) Who the care plan is for
... encounter Σ 0..1 Reference(Encounter) The Encounter during which this CarePlan was created
... period Σ 0..1 Period Time period plan covers
... 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 0..* Reference(CareTeam) Who's involved in plan?

... addresses Σ 0..* CodeableReference(Condition | Procedure | MedicationAdministration) Health issues this plan addresses
Binding: SNOMED CT Clinical Findings (Example)

... supportingInfo 0..* Reference(Any) Information considered as part of plan

... goal 0..* Reference(Goal) Desired outcome of plan

... activity 0..* BackboneElement Action to occur or has occurred as part of plan

.... performedActivity 0..* CodeableReference(Any) Activities that are completed or in progress (concept, or Appointment, Encounter, Procedure, etc.)
Binding: Care Plan Activity Performed (Example)

.... 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 icon

See the Extensions for this resource

UML Diagram (Legend)

CarePlan (DomainResource)Business identifiers assigned to this care plan by the performer or other systems which remain constant as the resource is updated and propagates from server to serveridentifier : Identifier [0..*]The URL pointing to a FHIR-defined protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlaninstantiatesCanonical : canonical [0..*] « PlanDefinition| Questionnaire|Measure|ActivityDefinition|OperationDefinition »The URL pointing to an externally maintained protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlaninstantiatesUri : uri [0..*]A higher-level request resource (i.e. a plan, proposal or order) that is fulfilled in whole or in part by this care planbasedOn : Reference [0..*] « CarePlan|ServiceRequest| RequestOrchestration|NutritionOrder »Completed or terminated care plan whose function is taken by this new care planreplaces : Reference [0..*] « CarePlan »A larger care plan of which this particular care plan is a component or steppartOf : Reference [0..*] « CarePlan »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] « null (Strength=Required)RequestStatus! »Indicates the level of authority/intentionality associated with the care plan and where the care plan fits into the workflow chain (this element modifies the meaning of other elements)intent : code [1..1] « null (Strength=Required)CarePlanIntent! »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..*] « null (Strength=Example)CarePlanCategory?? »Human-friendly name for the care plantitle : string [0..1]A description of the scope and nature of the plandescription : string [0..1]Identifies the patient or group whose intended care is described by the plansubject : Reference [1..1] « Patient|Group »The Encounter during which this CarePlan was created or to which the creation of this record is tightly associatedencounter : Reference [0..1] « Encounter »Indicates when the plan did (or is intended to) come into effect and endperiod : Period [0..1]Represents when this particular CarePlan record was created in the system, which is often a system-generated datecreated : dateTime [0..1]When populated, the custodian is responsible for the care plan. The care plan is attributed to the custodiancustodian : Reference [0..1] « Patient|Practitioner|PractitionerRole| Device|RelatedPerson|Organization|CareTeam »Identifies the individual(s), organization or device who provided the contents of the care plancontributor : Reference [0..*] « Patient|Practitioner| PractitionerRole|Device|RelatedPerson|Organization|CareTeam »Identifies all people and organizations who are expected to be involved in the care envisioned by this plancareTeam : Reference [0..*] « CareTeam »Identifies the conditions/problems/concerns/diagnoses/etc. whose management and/or mitigation are handled by this planaddresses : CodeableReference [0..*] « Condition|Procedure| MedicationAdministration; null (Strength=Example)SNOMEDCTClinicalFindings?? »Identifies portions of the patient's record that specifically influenced the formation of the plan. These might include comorbidities, recent procedures, limitations, recent assessments, etcsupportingInfo : 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..*]ActivityIdentifies the activity that was performed. For example, an activity could be patient education, exercise, or a medication administration. The reference to an "event" resource, such as Procedure or Encounter or Observation, represents the activity that was performed. The requested activity can be conveyed using the CarePlan.activity.plannedActivityReference (a reference to a “request” resource)performedActivity : CodeableReference [0..*] « Any; null (Strength=Example) CarePlanActivityPerformed?? »Notes about the adherence/status/progress of the activityprogress : Annotation [0..*]The details of the proposed activity represented in a specific resourceplannedActivityReference : Reference [0..1] « Appointment| CommunicationRequest|DeviceRequest|MedicationRequest| NutritionOrder|Task|ServiceRequest|VisionPrescription| RequestOrchestration|ImmunizationRecommendation|SupplyRequest »Identifies an action that has occurred or is a planned action to occur as part of the plan. For example, a medication to be used, lab tests to perform, self-monitoring that has occurred, 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>
 <instantiatesCanonical><!-- 0..* canonical(ActivityDefinition|Measure|
   OperationDefinition|PlanDefinition|Questionnaire) Instantiates FHIR protocol or definition --></instantiatesCanonical>
 <instantiatesUri value="[uri]"/><!-- 0..* Instantiates external protocol or definition -->
 <basedOn><!-- 0..* Reference(CarePlan|NutritionOrder|RequestOrchestration|
   ServiceRequest) Fulfills plan, proposal or order --></basedOn>
 <replaces><!-- 0..* Reference(CarePlan) CarePlan replaced by this CarePlan --></replaces>
 <partOf><!-- 0..* Reference(CarePlan) Part of referenced CarePlan --></partOf>
 <status value="[code]"/><!-- 1..1 draft | active | on-hold | revoked | completed | entered-in-error | unknown -->
 <intent value="[code]"/><!-- 1..1 proposal | plan | order | option | directive -->
 <category><!-- 0..* CodeableConcept Type of plan --></category>
 <title value="[string]"/><!-- 0..1 Human-friendly name for the care plan -->
 <description value="[string]"/><!-- 0..1 Summary of nature of plan -->
 <subject><!-- 1..1 Reference(Group|Patient) Who the care plan is for --></subject>
 <encounter><!-- 0..1 Reference(Encounter) The Encounter during which this CarePlan was created --></encounter>
 <period><!-- 0..1 Period Time period plan covers --></period>
 <created value="[dateTime]"/><!-- 0..1 Date record was first recorded -->
 <custodian><!-- 0..1 Reference(CareTeam|Device|Organization|Patient|Practitioner|
   PractitionerRole|RelatedPerson) Who is the designated responsible party --></custodian>
 <contributor><!-- 0..* Reference(CareTeam|Device|Organization|Patient|
   Practitioner|PractitionerRole|RelatedPerson) Who provided the content of the care plan --></contributor>
 <careTeam><!-- 0..* Reference(CareTeam) Who's involved in plan? --></careTeam>
 <addresses><!-- 0..* CodeableReference(Condition|MedicationAdministration|
   Procedure) Health issues this plan addresses --></addresses>
 <supportingInfo><!-- 0..* Reference(Any) Information considered as part of plan --></supportingInfo>
 <goal><!-- 0..* Reference(Goal) Desired outcome of plan --></goal>
 <activity>  <!-- 0..* Action to occur or has occurred as part of plan -->
  <performedActivity><!-- 0..* CodeableReference(Any) Activities that are completed or in progress (concept, or Appointment, Encounter, Procedure, etc.) --></performedActivity>
  <progress><!-- 0..* Annotation Comments about the activity status/progress --></progress>
  <plannedActivityReference><!-- 0..1 Reference(Appointment|CommunicationRequest|
    DeviceRequest|ImmunizationRecommendation|MedicationRequest|NutritionOrder|
    RequestOrchestration|ServiceRequest|SupplyRequest|Task|VisionPrescription) Activity that is intended to be part of the care plan --></plannedActivityReference>
 </activity>
 <note><!-- 0..* 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
  "instantiatesCanonical" : ["<canonical(PlanDefinition|Questionnaire|Measure|ActivityDefinition|OperationDefinition)>"], // Instantiates FHIR protocol or definition
  "instantiatesUri" : ["<uri>"], // Instantiates external protocol or definition
  "basedOn" : [{ Reference(CarePlan|NutritionOrder|RequestOrchestration|
   ServiceRequest) }], // Fulfills plan, proposal or order
  "replaces" : [{ Reference(CarePlan) }], // CarePlan replaced by this CarePlan
  "partOf" : [{ Reference(CarePlan) }], // Part of referenced CarePlan
  "status" : "<code>", // R!  draft | active | on-hold | revoked | completed | entered-in-error | unknown
  "intent" : "<code>", // R!  proposal | plan | order | option | directive
  "category" : [{ CodeableConcept }], // Type of plan
  "title" : "<string>", // Human-friendly name for the care plan
  "description" : "<string>", // Summary of nature of plan
  "subject" : { Reference(Group|Patient) }, // R!  Who the care plan is for
  "encounter" : { Reference(Encounter) }, // The Encounter during which this CarePlan was created
  "period" : { Period }, // Time period plan covers
  "created" : "<dateTime>", // Date record was first recorded
  "custodian" : { Reference(CareTeam|Device|Organization|Patient|Practitioner|
   PractitionerRole|RelatedPerson) }, // Who is the designated responsible party
  "contributor" : [{ Reference(CareTeam|Device|Organization|Patient|
   Practitioner|PractitionerRole|RelatedPerson) }], // Who provided the content of the care plan
  "careTeam" : [{ Reference(CareTeam) }], // Who's involved in plan?
  "addresses" : [{ CodeableReference(Condition|MedicationAdministration|
   Procedure) }], // Health issues this plan addresses
  "supportingInfo" : [{ Reference(Any) }], // Information considered as part of plan
  "goal" : [{ Reference(Goal) }], // Desired outcome of plan
  "activity" : [{ // Action to occur or has occurred as part of plan
    "performedActivity" : [{ CodeableReference(Any) }], // Activities that are completed or in progress (concept, or Appointment, Encounter, Procedure, etc.)
    "progress" : [{ Annotation }], // Comments about the activity status/progress
    "plannedActivityReference" : { Reference(Appointment|CommunicationRequest|
    DeviceRequest|ImmunizationRecommendation|MedicationRequest|NutritionOrder|
    RequestOrchestration|ServiceRequest|SupplyRequest|Task|VisionPrescription) } // Activity that is intended to be part of the care plan
  }],
  "note" : [{ Annotation }] // Comments about the plan
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:CarePlan;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:identifier  ( [ Identifier ] ... ) ; # 0..* External Ids for this plan
  fhir:instantiatesCanonical  ( [ canonical(ActivityDefinition|Measure|OperationDefinition|PlanDefinition|Questionnaire) ] ... ) ; # 0..* Instantiates FHIR protocol or definition
  fhir:instantiatesUri  ( [ uri ] ... ) ; # 0..* Instantiates external protocol or definition
  fhir:basedOn  ( [ Reference(CarePlan|NutritionOrder|RequestOrchestration|ServiceRequest) ] ... ) ; # 0..* Fulfills plan, proposal or order
  fhir:replaces  ( [ Reference(CarePlan) ] ... ) ; # 0..* CarePlan replaced by this CarePlan
  fhir:partOf  ( [ Reference(CarePlan) ] ... ) ; # 0..* Part of referenced CarePlan
  fhir:status [ code ] ; # 1..1 draft | active | on-hold | revoked | completed | entered-in-error | unknown
  fhir:intent [ code ] ; # 1..1 proposal | plan | order | option | directive
  fhir:category  ( [ CodeableConcept ] ... ) ; # 0..* Type of plan
  fhir:title [ string ] ; # 0..1 Human-friendly name for the care plan
  fhir:description [ string ] ; # 0..1 Summary of nature of plan
  fhir:subject [ Reference(Group|Patient) ] ; # 1..1 Who the care plan is for
  fhir:encounter [ Reference(Encounter) ] ; # 0..1 The Encounter during which this CarePlan was created
  fhir:period [ Period ] ; # 0..1 Time period plan covers
  fhir:created [ dateTime ] ; # 0..1 Date record was first recorded
  fhir:custodian [ Reference(CareTeam|Device|Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Who is the designated responsible party
  fhir:contributor  ( [ Reference(CareTeam|Device|Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ... ) ; # 0..* Who provided the content of the care plan
  fhir:careTeam  ( [ Reference(CareTeam) ] ... ) ; # 0..* Who's involved in plan?
  fhir:addresses  ( [ CodeableReference(Condition|MedicationAdministration|Procedure) ] ... ) ; # 0..* Health issues this plan addresses
  fhir:supportingInfo  ( [ Reference(Any) ] ... ) ; # 0..* Information considered as part of plan
  fhir:goal  ( [ Reference(Goal) ] ... ) ; # 0..* Desired outcome of plan
  fhir:activity ( [ # 0..* Action to occur or has occurred as part of plan
    fhir:performedActivity  ( [ CodeableReference(Any) ] ... ) ; # 0..* Activities that are completed or in progress (concept, or Appointment, Encounter, Procedure, etc.)
    fhir:progress  ( [ Annotation ] ... ) ; # 0..* Comments about the activity status/progress
    fhir:plannedActivityReference [ Reference(Appointment|CommunicationRequest|DeviceRequest|ImmunizationRecommendation|
  MedicationRequest|NutritionOrder|RequestOrchestration|ServiceRequest|
  SupplyRequest|Task|VisionPrescription) ] ; # 0..1 Activity that is intended to be part of the care plan
  ] ... ) ;
  fhir:note  ( [ Annotation ] ... ) ; # 0..* Comments about the plan
]

Changes from both R4 and R4B

CarePlan
CarePlan.basedOn
  • Type Reference: Added Target Types ServiceRequest, RequestOrchestration, NutritionOrder
CarePlan.intent
  • Add code directive
CarePlan.custodian
  • Renamed from author to custodian
CarePlan.addresses
  • Type changed from Reference(Condition) to CodeableReference
CarePlan.activity.performedActivity
  • Added Element
CarePlan.activity.plannedActivityReference
  • Renamed from reference to plannedActivityReference
  • Type Reference: Added Target Types RequestOrchestration, ImmunizationRecommendation, SupplyRequest
  • Type Reference: Removed Target Type RequestGroup
CarePlan.activity.outcomeCodeableConcept
  • Deleted (-> CarePlan.activity.performedActivity)
CarePlan.activity.outcomeReference
  • Deleted (-> CarePlan.activity.performedActivity)
CarePlan.activity.detail
  • Deleted (-> CarePlan.activity.plannedActivityReference)

See the Full Difference for further information

This analysis is available for R4 as XML or JSON and for R4B as XML or JSON.

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan TU DomainResource Healthcare plan for patient or group

Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier Σ 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

... replaces Σ 0..* Reference(CarePlan) CarePlan replaced by this CarePlan

... partOf Σ 0..* Reference(CarePlan) Part of referenced CarePlan

... status ?!Σ 1..1 code draft | active | on-hold | revoked | completed | entered-in-error | unknown
Binding: RequestStatus (Required)
... intent ?!Σ 1..1 code proposal | plan | order | option | directive
Binding: Care Plan Intent (Required)
... category Σ 0..* CodeableConcept Type of plan
Binding: Care Plan Category (Example)

... title Σ 0..1 string Human-friendly name for the care plan
... description Σ 0..1 string Summary of nature of plan
... subject Σ 1..1 Reference(Patient | Group) Who the care plan is for
... encounter Σ 0..1 Reference(Encounter) The Encounter during which this CarePlan was created
... period Σ 0..1 Period Time period plan covers
... 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 0..* Reference(CareTeam) Who's involved in plan?

... addresses Σ 0..* CodeableReference(Condition | Procedure | MedicationAdministration) Health issues this plan addresses
Binding: SNOMED CT Clinical Findings (Example)

... supportingInfo 0..* Reference(Any) Information considered as part of plan

... goal 0..* Reference(Goal) Desired outcome of plan

... activity 0..* BackboneElement Action to occur or has occurred as part of plan

.... performedActivity 0..* CodeableReference(Any) Activities that are completed or in progress (concept, or Appointment, Encounter, Procedure, etc.)
Binding: Care Plan Activity Performed (Example)

.... 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 icon

See the Extensions for this resource

UML Diagram (Legend)

CarePlan (DomainResource)Business identifiers assigned to this care plan by the performer or other systems which remain constant as the resource is updated and propagates from server to serveridentifier : Identifier [0..*]The URL pointing to a FHIR-defined protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlaninstantiatesCanonical : canonical [0..*] « PlanDefinition| Questionnaire|Measure|ActivityDefinition|OperationDefinition »The URL pointing to an externally maintained protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlaninstantiatesUri : uri [0..*]A higher-level request resource (i.e. a plan, proposal or order) that is fulfilled in whole or in part by this care planbasedOn : Reference [0..*] « CarePlan|ServiceRequest| RequestOrchestration|NutritionOrder »Completed or terminated care plan whose function is taken by this new care planreplaces : Reference [0..*] « CarePlan »A larger care plan of which this particular care plan is a component or steppartOf : Reference [0..*] « CarePlan »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] « null (Strength=Required)RequestStatus! »Indicates the level of authority/intentionality associated with the care plan and where the care plan fits into the workflow chain (this element modifies the meaning of other elements)intent : code [1..1] « null (Strength=Required)CarePlanIntent! »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..*] « null (Strength=Example)CarePlanCategory?? »Human-friendly name for the care plantitle : string [0..1]A description of the scope and nature of the plandescription : string [0..1]Identifies the patient or group whose intended care is described by the plansubject : Reference [1..1] « Patient|Group »The Encounter during which this CarePlan was created or to which the creation of this record is tightly associatedencounter : Reference [0..1] « Encounter »Indicates when the plan did (or is intended to) come into effect and endperiod : Period [0..1]Represents when this particular CarePlan record was created in the system, which is often a system-generated datecreated : dateTime [0..1]When populated, the custodian is responsible for the care plan. The care plan is attributed to the custodiancustodian : Reference [0..1] « Patient|Practitioner|PractitionerRole| Device|RelatedPerson|Organization|CareTeam »Identifies the individual(s), organization or device who provided the contents of the care plancontributor : Reference [0..*] « Patient|Practitioner| PractitionerRole|Device|RelatedPerson|Organization|CareTeam »Identifies all people and organizations who are expected to be involved in the care envisioned by this plancareTeam : Reference [0..*] « CareTeam »Identifies the conditions/problems/concerns/diagnoses/etc. whose management and/or mitigation are handled by this planaddresses : CodeableReference [0..*] « Condition|Procedure| MedicationAdministration; null (Strength=Example)SNOMEDCTClinicalFindings?? »Identifies portions of the patient's record that specifically influenced the formation of the plan. These might include comorbidities, recent procedures, limitations, recent assessments, etcsupportingInfo : 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..*]ActivityIdentifies the activity that was performed. For example, an activity could be patient education, exercise, or a medication administration. The reference to an "event" resource, such as Procedure or Encounter or Observation, represents the activity that was performed. The requested activity can be conveyed using the CarePlan.activity.plannedActivityReference (a reference to a “request” resource)performedActivity : CodeableReference [0..*] « Any; null (Strength=Example) CarePlanActivityPerformed?? »Notes about the adherence/status/progress of the activityprogress : Annotation [0..*]The details of the proposed activity represented in a specific resourceplannedActivityReference : Reference [0..1] « Appointment| CommunicationRequest|DeviceRequest|MedicationRequest| NutritionOrder|Task|ServiceRequest|VisionPrescription| RequestOrchestration|ImmunizationRecommendation|SupplyRequest »Identifies an action that has occurred or is a planned action to occur as part of the plan. For example, a medication to be used, lab tests to perform, self-monitoring that has occurred, 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>
 <instantiatesCanonical><!-- 0..* canonical(ActivityDefinition|Measure|
   OperationDefinition|PlanDefinition|Questionnaire) Instantiates FHIR protocol or definition --></instantiatesCanonical>
 <instantiatesUri value="[uri]"/><!-- 0..* Instantiates external protocol or definition -->
 <basedOn><!-- 0..* Reference(CarePlan|NutritionOrder|RequestOrchestration|
   ServiceRequest) Fulfills plan, proposal or order --></basedOn>
 <replaces><!-- 0..* Reference(CarePlan) CarePlan replaced by this CarePlan --></replaces>
 <partOf><!-- 0..* Reference(CarePlan) Part of referenced CarePlan --></partOf>
 <status value="[code]"/><!-- 1..1 draft | active | on-hold | revoked | completed | entered-in-error | unknown -->
 <intent value="[code]"/><!-- 1..1 proposal | plan | order | option | directive -->
 <category><!-- 0..* CodeableConcept Type of plan --></category>
 <title value="[string]"/><!-- 0..1 Human-friendly name for the care plan -->
 <description value="[string]"/><!-- 0..1 Summary of nature of plan -->
 <subject><!-- 1..1 Reference(Group|Patient) Who the care plan is for --></subject>
 <encounter><!-- 0..1 Reference(Encounter) The Encounter during which this CarePlan was created --></encounter>
 <period><!-- 0..1 Period Time period plan covers --></period>
 <created value="[dateTime]"/><!-- 0..1 Date record was first recorded -->
 <custodian><!-- 0..1 Reference(CareTeam|Device|Organization|Patient|Practitioner|
   PractitionerRole|RelatedPerson) Who is the designated responsible party --></custodian>
 <contributor><!-- 0..* Reference(CareTeam|Device|Organization|Patient|
   Practitioner|PractitionerRole|RelatedPerson) Who provided the content of the care plan --></contributor>
 <careTeam><!-- 0..* Reference(CareTeam) Who's involved in plan? --></careTeam>
 <addresses><!-- 0..* CodeableReference(Condition|MedicationAdministration|
   Procedure) Health issues this plan addresses --></addresses>
 <supportingInfo><!-- 0..* Reference(Any) Information considered as part of plan --></supportingInfo>
 <goal><!-- 0..* Reference(Goal) Desired outcome of plan --></goal>
 <activity>  <!-- 0..* Action to occur or has occurred as part of plan -->
  <performedActivity><!-- 0..* CodeableReference(Any) Activities that are completed or in progress (concept, or Appointment, Encounter, Procedure, etc.) --></performedActivity>
  <progress><!-- 0..* Annotation Comments about the activity status/progress --></progress>
  <plannedActivityReference><!-- 0..1 Reference(Appointment|CommunicationRequest|
    DeviceRequest|ImmunizationRecommendation|MedicationRequest|NutritionOrder|
    RequestOrchestration|ServiceRequest|SupplyRequest|Task|VisionPrescription) Activity that is intended to be part of the care plan --></plannedActivityReference>
 </activity>
 <note><!-- 0..* 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
  "instantiatesCanonical" : ["<canonical(PlanDefinition|Questionnaire|Measure|ActivityDefinition|OperationDefinition)>"], // Instantiates FHIR protocol or definition
  "instantiatesUri" : ["<uri>"], // Instantiates external protocol or definition
  "basedOn" : [{ Reference(CarePlan|NutritionOrder|RequestOrchestration|
   ServiceRequest) }], // Fulfills plan, proposal or order
  "replaces" : [{ Reference(CarePlan) }], // CarePlan replaced by this CarePlan
  "partOf" : [{ Reference(CarePlan) }], // Part of referenced CarePlan
  "status" : "<code>", // R!  draft | active | on-hold | revoked | completed | entered-in-error | unknown
  "intent" : "<code>", // R!  proposal | plan | order | option | directive
  "category" : [{ CodeableConcept }], // Type of plan
  "title" : "<string>", // Human-friendly name for the care plan
  "description" : "<string>", // Summary of nature of plan
  "subject" : { Reference(Group|Patient) }, // R!  Who the care plan is for
  "encounter" : { Reference(Encounter) }, // The Encounter during which this CarePlan was created
  "period" : { Period }, // Time period plan covers
  "created" : "<dateTime>", // Date record was first recorded
  "custodian" : { Reference(CareTeam|Device|Organization|Patient|Practitioner|
   PractitionerRole|RelatedPerson) }, // Who is the designated responsible party
  "contributor" : [{ Reference(CareTeam|Device|Organization|Patient|
   Practitioner|PractitionerRole|RelatedPerson) }], // Who provided the content of the care plan
  "careTeam" : [{ Reference(CareTeam) }], // Who's involved in plan?
  "addresses" : [{ CodeableReference(Condition|MedicationAdministration|
   Procedure) }], // Health issues this plan addresses
  "supportingInfo" : [{ Reference(Any) }], // Information considered as part of plan
  "goal" : [{ Reference(Goal) }], // Desired outcome of plan
  "activity" : [{ // Action to occur or has occurred as part of plan
    "performedActivity" : [{ CodeableReference(Any) }], // Activities that are completed or in progress (concept, or Appointment, Encounter, Procedure, etc.)
    "progress" : [{ Annotation }], // Comments about the activity status/progress
    "plannedActivityReference" : { Reference(Appointment|CommunicationRequest|
    DeviceRequest|ImmunizationRecommendation|MedicationRequest|NutritionOrder|
    RequestOrchestration|ServiceRequest|SupplyRequest|Task|VisionPrescription) } // Activity that is intended to be part of the care plan
  }],
  "note" : [{ Annotation }] // Comments about the plan
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:CarePlan;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:identifier  ( [ Identifier ] ... ) ; # 0..* External Ids for this plan
  fhir:instantiatesCanonical  ( [ canonical(ActivityDefinition|Measure|OperationDefinition|PlanDefinition|Questionnaire) ] ... ) ; # 0..* Instantiates FHIR protocol or definition
  fhir:instantiatesUri  ( [ uri ] ... ) ; # 0..* Instantiates external protocol or definition
  fhir:basedOn  ( [ Reference(CarePlan|NutritionOrder|RequestOrchestration|ServiceRequest) ] ... ) ; # 0..* Fulfills plan, proposal or order
  fhir:replaces  ( [ Reference(CarePlan) ] ... ) ; # 0..* CarePlan replaced by this CarePlan
  fhir:partOf  ( [ Reference(CarePlan) ] ... ) ; # 0..* Part of referenced CarePlan
  fhir:status [ code ] ; # 1..1 draft | active | on-hold | revoked | completed | entered-in-error | unknown
  fhir:intent [ code ] ; # 1..1 proposal | plan | order | option | directive
  fhir:category  ( [ CodeableConcept ] ... ) ; # 0..* Type of plan
  fhir:title [ string ] ; # 0..1 Human-friendly name for the care plan
  fhir:description [ string ] ; # 0..1 Summary of nature of plan
  fhir:subject [ Reference(Group|Patient) ] ; # 1..1 Who the care plan is for
  fhir:encounter [ Reference(Encounter) ] ; # 0..1 The Encounter during which this CarePlan was created
  fhir:period [ Period ] ; # 0..1 Time period plan covers
  fhir:created [ dateTime ] ; # 0..1 Date record was first recorded
  fhir:custodian [ Reference(CareTeam|Device|Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Who is the designated responsible party
  fhir:contributor  ( [ Reference(CareTeam|Device|Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ... ) ; # 0..* Who provided the content of the care plan
  fhir:careTeam  ( [ Reference(CareTeam) ] ... ) ; # 0..* Who's involved in plan?
  fhir:addresses  ( [ CodeableReference(Condition|MedicationAdministration|Procedure) ] ... ) ; # 0..* Health issues this plan addresses
  fhir:supportingInfo  ( [ Reference(Any) ] ... ) ; # 0..* Information considered as part of plan
  fhir:goal  ( [ Reference(Goal) ] ... ) ; # 0..* Desired outcome of plan
  fhir:activity ( [ # 0..* Action to occur or has occurred as part of plan
    fhir:performedActivity  ( [ CodeableReference(Any) ] ... ) ; # 0..* Activities that are completed or in progress (concept, or Appointment, Encounter, Procedure, etc.)
    fhir:progress  ( [ Annotation ] ... ) ; # 0..* Comments about the activity status/progress
    fhir:plannedActivityReference [ Reference(Appointment|CommunicationRequest|DeviceRequest|ImmunizationRecommendation|
  MedicationRequest|NutritionOrder|RequestOrchestration|ServiceRequest|
  SupplyRequest|Task|VisionPrescription) ] ; # 0..1 Activity that is intended to be part of the care plan
  ] ... ) ;
  fhir:note  ( [ Annotation ] ... ) ; # 0..* Comments about the plan
]

Changes from both R4 and R4B

CarePlan
CarePlan.basedOn
  • Type Reference: Added Target Types ServiceRequest, RequestOrchestration, NutritionOrder
CarePlan.intent
  • Add code directive
CarePlan.custodian
  • Renamed from author to custodian
CarePlan.addresses
  • Type changed from Reference(Condition) to CodeableReference
CarePlan.activity.performedActivity
  • Added Element
CarePlan.activity.plannedActivityReference
  • Renamed from reference to plannedActivityReference
  • Type Reference: Added Target Types RequestOrchestration, ImmunizationRecommendation, SupplyRequest
  • Type Reference: Removed Target Type RequestGroup
CarePlan.activity.outcomeCodeableConcept
  • Deleted (-> CarePlan.activity.performedActivity)
CarePlan.activity.outcomeReference
  • Deleted (-> CarePlan.activity.performedActivity)
CarePlan.activity.detail
  • Deleted (-> CarePlan.activity.plannedActivityReference)

See the Full Difference for further information

This analysis is available for R4 as XML or JSON and for R4B as XML or JSON.

 

Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis

9.5.4.1 Terminology Bindings

Path ValueSet Type Documentation
CarePlan.status RequestStatus Required

Codes identifying the lifecycle stage of a request.
CarePlan.intent CarePlanIntent Required

Codes indicating the degree of authority/intentionality associated with a care plan.
CarePlan.category CarePlanCategory Example

Example codes indicating the category a care plan falls within. Note that these are in no way complete and might not even be appropriate for some uses.
CarePlan.addresses SNOMEDCTClinicalFindings Example

This value set includes all the "Clinical finding" SNOMED CT icon codes - concepts where concept is-a 404684003 (Clinical finding (finding)).
CarePlan.activity.performedActivity CarePlanActivityPerformed Example

Example codes indicating the care plan activity that was performed. Note that these are in no way complete and might not even be appropriate for some uses.

9.5.4.2 Notes

The Provenance resource can be used for detailed review information, such as when the care plan was last reviewed and by whom.

9.5.5 Open Issues

9.5.6 Search Parameters

Search parameters for this resource. See also the full list of search parameters for this resource, and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
activity-reference reference Activity that is intended to be part of the care plan CarePlan.activity.plannedActivityReference
(Appointment, MedicationRequest, Task, NutritionOrder, RequestOrchestration, VisionPrescription, DeviceRequest, ServiceRequest, CommunicationRequest, ImmunizationRecommendation, SupplyRequest)
based-on reference Fulfills CarePlan CarePlan.basedOn
(CarePlan, RequestOrchestration, NutritionOrder, ServiceRequest)
care-team reference Who's involved in plan? CarePlan.careTeam
(CareTeam)
category token Type of plan CarePlan.category
condition reference Reference to a resource (by instance) CarePlan.addresses.reference
custodian reference Who is the designated responsible party CarePlan.custodian
(Practitioner, Organization, CareTeam, Device, Patient, PractitionerRole, RelatedPerson)
date date Time period plan covers CarePlan.period 26 Resources
encounter reference The Encounter during which this CarePlan was created CarePlan.encounter
(Encounter)		 29 Resources
goal reference Desired outcome of plan CarePlan.goal
(Goal)
identifier token External Ids for this plan CarePlan.identifier 65 Resources
instantiates-canonical reference Instantiates FHIR protocol or definition CarePlan.instantiatesCanonical
(Questionnaire, Measure, PlanDefinition, OperationDefinition, ActivityDefinition)
instantiates-uri uri Instantiates external protocol or definition CarePlan.instantiatesUri
intent token proposal | plan | order | option | directive CarePlan.intent
part-of reference Part of referenced CarePlan CarePlan.partOf
(CarePlan)
patient reference Who the care plan is for CarePlan.subject.where(resolve() is Patient)
(Patient)		 65 Resources
replaces reference CarePlan replaced by this CarePlan CarePlan.replaces
(CarePlan)
status token draft | active | on-hold | revoked | completed | entered-in-error | unknown CarePlan.status
subject reference Who the care plan is for CarePlan.subject
(Group, Patient)