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.

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/subject whose intended care is described by the plan.

Care plans are associated with the patient the plan is for.

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.

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 most recent date on which the plan has been revised.

Indicates how current the plan is.

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 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".

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.

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 an action that is planned to happen as part of the careplan. 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.