Electronic Long-Term Services and Supports (eLTSS) Release 1 - US Realm
2.0.0-ballot - ballot United States of America flag

This page is part of the electronic Long-Term Services and Supports Implementation Guide (v2.0.0-ballot: STU2 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions

Resource Profile: eLTSS CarePlan Profile

Official URL: http://hl7.org/fhir/us/eltss/StructureDefinition/CarePlan-eltss Version: 2.0.0-ballot
Standards status: Trial-use Maturity Level: 2 Computable Name: CarePlan_eltss

CarePlan for eLTSS

Implementer mapping guidance

The following aids in finding the location of eLTSS data elements. See R4 FHIR Mapping page for complete guidance, here we are providing a subset of fields for convenience. The CarePlan Resource links to all eLTSS data elements, while specific elements are provided below the implementer should review all the guidance on R4 FHIR Mapping page. This is especially imporant for ServiceRequest related items, Person Centered Planning concepts such as “Person Setting Choice Options,” risk assessments, signatures and financial data.

eLTSS Grouping eLTSS Data Element Name Data Element Definition (includes examples, expected list of values and usage note where applicable) FHIR R4 Resource Element(s) FHIR R4 Resource Element Cardinality (with US Core Constraints) Additional Mapping Details Important change
Goals & Strengths Step or Action A planned measurable step or action that needs to be taken to accomplish a goal identified by the person. CarePlan → activity
→ reference(Resource) → note
→ text → extension(pertainsToGoal)		 CarePlan
...activity 0..*
......reference(Resource) 0..1
.........note 0..*
............text 1
.........extension(pertainsToGoal)		 1) CarePlan includes activity → reference, which can be a reference to ServiceRequest, Task or other Resource.
2) ServiceRequest would be used when the Step or Action is a task under a service. If the Step or Action is an informal support or an activity being undertaken by the beneficiary the Task Resource, similar to a Patient Task used in the Gravity SDOH IG, can be used.
3) activity → reference(Resource) is linked to the Goal the step or action addresses through the pertainsToGoal Extension in the referenced activity.
4) activity → reference(Resource) includes a performer, author, participant with type or other data element that can be used to reference who is responsible for performing the step or action, such as to indicate that the person or a related person is responsible.
5) text is where the Step or Action text would be provided.
6) text is required by FHIR if note is provided.
7) Note that a stated goal may lead directly to a service, and not necessarily to an explicit Step or Action. For example, a person's goal could be to attend church regularly, and this would be achieved through a transportation service.		 Replaced use of CarePlan.activity.detail, and emphasized the extension pertainsToGoal
Goals & Strengths Strength A favorable attribute of oneself, his/her support network, environment and/or elements of his/her life. CarePlan → supportingInfo(Observation)

Observation → valueString
Observation → code → coding → code Observation → code → coding → system		 CarePlan
...supportingInfo(Observation) 0..*
......valueString 0..1
......code 1
........coding 0..*
..........code 0..1
............system 0..1
 1) Will use CarePlan → supportingInfo to reference the Observation containing the Strength.
2) code is required by FHIR, and is a CodeableConcept where coding → code can be set to "Strength" with the corresponding NEW code → system "http://hl7.org/us/eLTSS/CodeSystem/eltss-observation-code".
3) valueString is where the Strength text would be provided.
Person Centered Planning Assessed Need The clinical and/or community-based necessity or desire as identified through an assessment that should be addressed by a service. CarePlan → addresses(Condition)

Condition → code → text
Condition → category		 CarePlan
...addresses(Condition) 0..*
......code 1
.........text 0..1
......category 1..*		 1) Will use CarePlan → addresses to reference the Condition(s) for the care plan being developed.
2) code is required by US Core and is a CodeableConcept which per US Core is bound to the extensible Problem Value Set. That value set is based on SNOMED-CT and includes very specific values that do not line up with assessed needs. Per US Core's documentation on extensible CodeableConcepts, the CodeableConcept's text element can be used "if no suitable codes exist", so we can use the text element for the assessed need.
3) Each assessed need should go into a separate Condition element so each can potentially be linked to a service(s) that addresses it.
4) category is required by US Core and is a CodeableConcept which per US Core is bound to the extensible US Core Condition Category Codes value set (http://hl7.org/fhir/ValueSet/condition-category) which has values: problem-list-item, encounter-diagnosis. Could use the value "problem-list-item" to indicate the underlying condition, and extend the value set to add the value "assessed-need".
5) An "assessed need" condition can refer to another condition via the condition-dueTo extension.
Person Centered Planning Plan Monitor Name The name of the person responsible for monitoring the plan. CarePlan → encounter (Encounter)

Encounter → episodeOfCare(EpisodeOfCare)

EpisodeOfCare → careManager(Practitioner)

Practitioner → name → family
Practitioner → name → given
Practitioner → name → text		 CarePlan
...encounter(Encounter) 0..1
...... episodeOfCare(EpisodeOfCare)0..1
.........careManager(Practitioner) 0..1
............name 0..*
...............family 0-1
................given 0-*
................text 0-1		 1) Will use CarePlan → encounter to reference the EpisodeOfCare that defines the plan monitor (care manager) for the plan.
2) EpisodeOfCare → careManager references the Practitioner who is monitoring the plan.
3) given is used for both first name & MI, so need more than one.
4) family is a string with the person's surname.
5) text is a string that contains the full name of the person.
6) The values for Plan Monitor Name and Plan Monitor Printed Name would include the same information.
Person Centered Planning Plan Monitor Phone Number The primary phone number (and extension when applicable) of the plan monitor. CarePlan → encounter (Encounter)

Encounter → episodeOfCare(EpisodeOfCare)

EpisodeOfCare → careManager(Practitioner)

Practitioner → telecom → system
Practitioner → telecom → value		 CarePlan
...encounter(Encounter) 0..1
...... episodeOfCare(EpisodeOfCare)0..1
.........careManager(Practitioner) 0..1
............telecom 0..*
...............system 0..1
................value 0..1		 1) Will use CarePlan → encounter to reference the EpisodeOfCare that defines the plan monitor (care manager) for the plan.
2) EpisodeOfCare → careManager references the Practitioner who is monitoring the plan.
3) telecom is of type ContactPoint (https://www.hl7.org/fhir/datatypes.html#contactpoint) which contains elements to populate for the phone number.
4) system is required if value is provided, and can be: phone, fax, email, pager, url, sms, other.
5) Per FHIR, phone # should be formatted according to ITU-T E.123, so "(555) 675 5745" or "+22 555 675 5745".
Person Centered Planning Preference Presents the person's personal thoughts about something he or she feels is relevant to his or her life experience and may be pertinent when planning. CarePlan → supportingInfo(Observation)

Observation → valueString
Observation → code → coding → code
Observation → code → coding → system
 CarePlan
...supportingInfo(Observation) 0..*
......valueString 0..1
......code 1
.........coding 0..*
............code 0..1
............system 0..1		 1) Will use CarePlan → supportingInfo to reference the Observation containing the Preference.
2) code is required by FHIR and is a CodeableConcept where coding → code can be set to "Preference" with the corresponding NEW code -> system "http://hl7.org/us/eLTSS/CodeSystem/eltss-observation-code".
3) valueString is where the Preference text would be provided.
Plan Information Plan Effective Date The date upon which the plan goes into effect.

Start date is required, end date is optional.		 CarePlan → period → start
CarePlan → period → end		 CarePlan 0..*
...period 0..1
......start 1
......end 0..1		 1) period includes a start and an end element, which are both dateTime formats which can be date, date-time or partial date (e.g. just year or year + month).
2) start is required by eLTSS.
Service Provider Information Support Planner Name The name of the person (e.g., Case Manager, Care Coordinator, Plan Coordinator) who helped develop the plan. CarePlan → author(Patient | Practitioner | PractitionerRole | RelatedPerson | Organization | CareTeam)

Practitioner | Patient | RelatedPerson
→ name → family
Practitioner | Patient | RelatedPerson
→ name → given
Practitioner | Patient | RelatedPerson
→ name → text
Organization | CareTeam → name 		CarePlan
...author(Patient | Practitioner | RelatedPerson ) 0..1
......name 0..*
.........family 0..1
.........given 0..*
.........text 0..1
CarePlan
…author(Organization | CareTeam ) 0..1
......name 0..1		 1) Will use CarePlan → author to reference a Practitioner, PractitionerRole, RelatedPerson, Organization, CareTeam or Patient (in self-directed plans) who is the primary author of the care plan being developed.
2) Practitioner, Organization, CareTeam, RelatedPerson and Patient all include name.
3) PractitionerRole should be used when the Organization for whom the Practitioner works for is also needed.
4) given is used for both first name & MI, so need more than one.
5) family is a string with the person's surname.
6) text is a string that contains the full name of the person.
7) The values for Support Planner Name and Support Planner Printed Name would include the same information.
Service Provider Information Support Planner Phone Number The primary phone number (and extension when applicable) of the support planner. CarePlan → author(Patient | Practitioner | PractitionerRole | RelatedPerson | Organization | CareTeam )

Patient | Practitioner | PractitionerRole | RelatedPerson | Organization | CareTeam
→ telecom → system
Patient | Practitioner | PractitionerRole | RelatedPerson | Organization | CareTeam
→ telecom → value		 CarePlan
...author(Patient | Practitioner | PractitionerRole | RelatedPerson | Organization | CareTeam ) 0..1
......telecom 0..*
.........system 0..1
.........value 0..1		 1) Will use CarePlan → author to reference a Practitioner, PractitionerRole, RelatedPerson, Organization, CareTeam or Patient (in self-directed plan) who is the primary author of the care plan being developed.
2) Practitioner, PractitionerRole, RelatedPerson, Organization, CareTeam and Patient all include telecom.
3) PractitionerRole should be used when the Organization for whom the Practitioner works for is also needed.
4) telecom is of type ContactPoint which contains elements to populate for the phone number.
5) system is required if value is provided, and can be: phone, fax, email, pager, url, sms, other.
6) Per FHIR, phone # should be formatted according to ITU-T E.123, so "(555) 675 5745" or "+22 555 675 5745".
Data Requirements Not Specific to eLTSS Dataset Data Elements
This section documents data elements that are mandatory per FHIR XML schemas or US Core requirements, but that do not align with individual eLTSS Dataset data elements.
FHIR Data Element Name
Requirement Source		 Data Element Definition FHIR R4 Resource Element(s) FHIR R4 Resource Element Cardinality (with US Core Constraints) Additional Mapping Details
CarePlan Status
FHIR
US Core		 Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record. CarePlan → status CarePlan
...status 1		 1) status is required by both FHIR and US Core, and must use the RequestStatus value set (http://hl7.org/fhir/valueset-request-status.html). Possible values are: draft, active, suspended, completed, entered-in-error, cancelled, and unknown.
CarePlan Intent
FHIR
US Core 		Indicates the level of authority/intentionality associated with the care plan and where the care plan fits into the workflow chain. CarePlan → intent CarePlan
...intent 1		 1) intent is required by both FHIR and US Core, and must use the CarePlanIntent value set (http://hl7.org/fhir/valueset-care-plan-intent.html). Possible values are: proposal, plan, order, and option.
CarePlan Narrative Summary
US Core		 Text summary of the resource, for human interpretation. The narrative is an XHTML fragment with a flag to indicate its relationship to the data. CarePlan → text → status
CarePlan → text → div		 CarePlan
...text 1
......status 1
......div 1		 1) text is required by US Core.
2) status is required by FHIR and must use the NarrativeStatus value set (http://hl7.org/fhir/us/core/2019Jan/ValueSet-us-core-narrative-status.html). Possible values are: generated, additional.
3) div is required by FHIR and contains limited xhtml content that contains only the basic html formatting elements and attributes.
CarePlan Category
US Core		 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. CarePlan → category → coding → system
CarePlan → category → coding → code		 CarePlan
...category 1..*
......coding 1..*
.........system 1
.........code 1		 1) Per US Core, one category must appear, and must include system with the value "http://hl7.org/fhir/us/core/CodeSystem/careplan-category" and code with the value "assess-plan".
2) US Core does not restrict the number of additional category elements that may appear.
CarePlan Activity Status
FHIR		 Identifies what progress is being made for the specific activity. CarePlan → activity → reference(Resource) → status
and
CarePlan→ activity → progress		 CarePlan
...activity
......reference(Resource)
.........status 1
and CarePlan
...activity
......progress
 1) status is required by FHIR in Resources Reference by CarePlan.activity.reference. Possible values are: not-started, scheduled, in-progress, on-hold, completed, cancelled, stopped, unknown, and entered-in-error.
2) There is also CarePlan.activity.progress to add a free-text description of the progress, or note. CarePlan.activity.progress is an Annotation data type in FHIR, this means it can be dated and contain the identification of the person who uttered the text. This might be used, for example, when the status stays in the same state, i.e. 'in-progress,' but where there is a evolution of that progress.		 Replaced use of CarePlan.activity.detail, and emphasized the use of the status element in the referenced activity and CarePlan.activity.progress free-text annotation

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from USCoreCarePlanProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan 0..*USCoreCarePlanProfileeLTSS Healthcare plan for patient or group
... basedOn 0..*Reference(CarePlan_eltss)Fulfills CarePlan
... replaces 0..*Reference(CarePlan_eltss)CarePlan replaced by this CarePlan
... partOf S0..*Reference(CarePlan_eltss)Emergency Backup Plan
... encounter S0..1Reference(Encounter)Encounter created as part of
... period S0..1PeriodPlan Effective Date
.... start S1..1dateTimeStarting time with inclusive boundary
.... end S0..1dateTimeEnd time with inclusive boundary, if not ongoing
... author S0..1Reference(Patient_eltss | Practitioner_eltss S | eLTSS PractitionerRole Profile S | eLTSS RelatedPerson Profile | US Core Organization Profile | US Core CareTeam Profile)Support Planner
... contributor 0..*Reference(Patient_eltss | Practitioner_eltss | eLTSS PractitionerRole Profile | eLTSS RelatedPerson Profile | US Core Organization Profile | US Core CareTeam Profile)Who provided the content of the care plan
... addresses S0..*Reference(Condition_eltss)Assessed Need
... supportingInfo S0..*Reference(Resource)Information considered as part of plan
... goal S0..*Reference(Goal_eltss)Desired outcome of plan
... activity S0..*BackboneElementAction to occur as part of a plan
.... reference S0..1Reference(Appointment S | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task S | ServiceRequest_eltss S | VisionPrescription | RequestGroup)Activity details defined in specific resource
.... detail 0..0
... note S0..*AnnotationComments about the plan

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan 0..*USCoreCarePlanProfileeLTSS Healthcare plan for patient or group
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text S1..1NarrativeText summary of the resource, for human interpretation
.... status S1..1codegenerated | extensions | additional | empty
Binding: US Core Narrative Status (required): Constrained value set of narrative statuses.

.... div C1..1xhtmlLimited xhtml content
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... replaces Σ0..*Reference(CarePlan_eltss)CarePlan replaced by this CarePlan
... partOf SΣ0..*Reference(CarePlan_eltss)Emergency Backup Plan
... status ?!SΣ1..1codedraft | active | on-hold | revoked | completed | entered-in-error | unknown
Binding: RequestStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.

... intent ?!SΣ1..1codeproposal | plan | order | option
Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan

... Slices for category SΣ1..*CodeableConceptType of plan
Slice: Unordered, Open by pattern:$this
Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc.


.... category:AssessPlan SΣ1..1CodeableConceptType of plan
Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc.



Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/careplan-category
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: assess-plan
... subject SΣ1..1Reference(Patient_eltss)CarePlan Subject
... encounter SΣ0..1Reference(Encounter)Encounter created as part of
... period SΣ0..1PeriodPlan Effective Date
.... start SΣC1..1dateTimeStarting time with inclusive boundary
.... end SΣC0..1dateTimeEnd time with inclusive boundary, if not ongoing
... author SΣ0..1Reference(Practitioner_eltss | eLTSS PractitionerRole Profile)Support Planner
... contributor 0..*Reference(Patient_eltss | Practitioner_eltss | eLTSS PractitionerRole Profile | eLTSS RelatedPerson Profile | US Core Organization Profile | US Core CareTeam Profile)Who provided the content of the care plan
... addresses SΣ0..*Reference(Condition_eltss)Assessed Need
... supportingInfo S0..*Reference(Resource)Information considered as part of plan
... goal S0..*Reference(Goal_eltss)Desired outcome of plan
... activity SC0..*BackboneElementAction to occur as part of a plan
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... reference SC0..1Reference(Appointment | Task | ServiceRequest_eltss)Activity details defined in specific resource
... note S0..*AnnotationComments about the plan

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
CarePlan.text.statusrequiredNarrativeStatus
CarePlan.statusrequiredRequestStatus
CarePlan.intentrequiredCarePlanIntent
CarePlan.categoryexampleCarePlanCategory
CarePlan.category:AssessPlanexamplePattern: assess-plan
CarePlan.activity.detail.statusrequiredCarePlanActivityStatus

Constraints

IdGradePath(s)DetailsRequirements
cpl-3errorCarePlan.activityProvide a reference or detail, not both
: detail.empty() or reference.empty()
dom-2errorCarePlanIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCarePlanIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorCarePlanIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorCarePlanIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCarePlanA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
txt-1errorCarePlan.text.divThe narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes
: htmlChecks()
txt-2errorCarePlan.text.divThe narrative SHALL have some non-whitespace content
: htmlChecks()
NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan 0..*USCoreCarePlanProfileeLTSS Healthcare plan for patient or group
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text S1..1NarrativeText summary of the resource, for human interpretation
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... status S1..1codegenerated | extensions | additional | empty
Binding: US Core Narrative Status (required): Constrained value set of narrative statuses.

.... div C1..1xhtmlLimited xhtml content
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Ids for this plan
... instantiatesCanonical Σ0..*canonical(PlanDefinition | Questionnaire | Measure | ActivityDefinition | OperationDefinition)Instantiates FHIR protocol or definition
... instantiatesUri Σ0..*uriInstantiates external protocol or definition
... basedOn Σ0..*Reference(CarePlan_eltss)Fulfills CarePlan
... replaces Σ0..*Reference(CarePlan_eltss)CarePlan replaced by this CarePlan
... partOf SΣ0..*Reference(CarePlan_eltss)Emergency Backup Plan
... status ?!SΣ1..1codedraft | active | on-hold | revoked | completed | entered-in-error | unknown
Binding: RequestStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.

... intent ?!SΣ1..1codeproposal | plan | order | option
Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan

... Slices for category SΣ1..*CodeableConceptType of plan
Slice: Unordered, Open by pattern:$this
Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc.


.... category:AssessPlan SΣ1..1CodeableConceptType of plan
Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc.



Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/careplan-category
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: assess-plan
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
... title Σ0..1stringHuman-friendly name for the care plan
... description Σ0..1stringSummary of nature of plan
... subject SΣ1..1Reference(Patient_eltss)CarePlan Subject
... encounter SΣ0..1Reference(Encounter)Encounter created as part of
... period SΣ0..1PeriodPlan Effective Date
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... start SΣC1..1dateTimeStarting time with inclusive boundary
.... end SΣC0..1dateTimeEnd time with inclusive boundary, if not ongoing
... created Σ0..1dateTimeDate record was first recorded
... author SΣ0..1Reference(Patient_eltss | Practitioner_eltss S | eLTSS PractitionerRole Profile S | eLTSS RelatedPerson Profile | US Core Organization Profile | US Core CareTeam Profile)Support Planner
... contributor 0..*Reference(Patient_eltss | Practitioner_eltss | eLTSS PractitionerRole Profile | eLTSS RelatedPerson Profile | US Core Organization Profile | US Core CareTeam Profile)Who provided the content of the care plan
... careTeam 0..*Reference(CareTeam)Who's involved in plan?
... addresses SΣ0..*Reference(Condition_eltss)Assessed Need
... supportingInfo S0..*Reference(Resource)Information considered as part of plan
... goal S0..*Reference(Goal_eltss)Desired outcome of plan
... activity SC0..*BackboneElementAction to occur as part of a plan
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... outcomeCodeableConcept 0..*CodeableConceptResults of the activity
Binding: CarePlanActivityOutcome (example): Identifies the results of the activity.


.... outcomeReference 0..*Reference(Resource)Appointment, Encounter, Procedure, etc.
.... progress 0..*AnnotationComments about the activity status/progress
.... reference SC0..1Reference(Appointment S | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task S | ServiceRequest_eltss S | VisionPrescription | RequestGroup)Activity details defined in specific resource
... note S0..*AnnotationComments about the plan

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
CarePlan.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
CarePlan.text.statusrequiredNarrativeStatus
CarePlan.statusrequiredRequestStatus
CarePlan.intentrequiredCarePlanIntent
CarePlan.categoryexampleCarePlanCategory
CarePlan.category:AssessPlanexamplePattern: assess-plan
CarePlan.activity.outcomeCodeableConceptexampleCarePlanActivityOutcome
CarePlan.activity.detail.kindrequiredCarePlanActivityKind
CarePlan.activity.detail.codeexampleProcedureCodes(SNOMEDCT)
CarePlan.activity.detail.reasonCodeexampleSNOMEDCTClinicalFindings
CarePlan.activity.detail.statusrequiredCarePlanActivityStatus
CarePlan.activity.detail.product[x]exampleSNOMEDCTMedicationCodes

Constraints

IdGradePath(s)DetailsRequirements
cpl-3errorCarePlan.activityProvide a reference or detail, not both
: detail.empty() or reference.empty()
dom-2errorCarePlanIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCarePlanIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorCarePlanIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorCarePlanIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCarePlanA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
txt-1errorCarePlan.text.divThe narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes
: htmlChecks()
txt-2errorCarePlan.text.divThe narrative SHALL have some non-whitespace content
: htmlChecks()

Differential View

This structure is derived from USCoreCarePlanProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan 0..*USCoreCarePlanProfileeLTSS Healthcare plan for patient or group
... basedOn 0..*Reference(CarePlan_eltss)Fulfills CarePlan
... replaces 0..*Reference(CarePlan_eltss)CarePlan replaced by this CarePlan
... partOf S0..*Reference(CarePlan_eltss)Emergency Backup Plan
... encounter S0..1Reference(Encounter)Encounter created as part of
... period S0..1PeriodPlan Effective Date
.... start S1..1dateTimeStarting time with inclusive boundary
.... end S0..1dateTimeEnd time with inclusive boundary, if not ongoing
... author S0..1Reference(Patient_eltss | Practitioner_eltss S | eLTSS PractitionerRole Profile S | eLTSS RelatedPerson Profile | US Core Organization Profile | US Core CareTeam Profile)Support Planner
... contributor 0..*Reference(Patient_eltss | Practitioner_eltss | eLTSS PractitionerRole Profile | eLTSS RelatedPerson Profile | US Core Organization Profile | US Core CareTeam Profile)Who provided the content of the care plan
... addresses S0..*Reference(Condition_eltss)Assessed Need
... supportingInfo S0..*Reference(Resource)Information considered as part of plan
... goal S0..*Reference(Goal_eltss)Desired outcome of plan
... activity S0..*BackboneElementAction to occur as part of a plan
.... reference S0..1Reference(Appointment S | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task S | ServiceRequest_eltss S | VisionPrescription | RequestGroup)Activity details defined in specific resource
.... detail 0..0
... note S0..*AnnotationComments about the plan

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan 0..*USCoreCarePlanProfileeLTSS Healthcare plan for patient or group
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text S1..1NarrativeText summary of the resource, for human interpretation
.... status S1..1codegenerated | extensions | additional | empty
Binding: US Core Narrative Status (required): Constrained value set of narrative statuses.

.... div C1..1xhtmlLimited xhtml content
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... replaces Σ0..*Reference(CarePlan_eltss)CarePlan replaced by this CarePlan
... partOf SΣ0..*Reference(CarePlan_eltss)Emergency Backup Plan
... status ?!SΣ1..1codedraft | active | on-hold | revoked | completed | entered-in-error | unknown
Binding: RequestStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.

... intent ?!SΣ1..1codeproposal | plan | order | option
Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan

... Slices for category SΣ1..*CodeableConceptType of plan
Slice: Unordered, Open by pattern:$this
Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc.


.... category:AssessPlan SΣ1..1CodeableConceptType of plan
Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc.



Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/careplan-category
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: assess-plan
... subject SΣ1..1Reference(Patient_eltss)CarePlan Subject
... encounter SΣ0..1Reference(Encounter)Encounter created as part of
... period SΣ0..1PeriodPlan Effective Date
.... start SΣC1..1dateTimeStarting time with inclusive boundary
.... end SΣC0..1dateTimeEnd time with inclusive boundary, if not ongoing
... author SΣ0..1Reference(Practitioner_eltss | eLTSS PractitionerRole Profile)Support Planner
... contributor 0..*Reference(Patient_eltss | Practitioner_eltss | eLTSS PractitionerRole Profile | eLTSS RelatedPerson Profile | US Core Organization Profile | US Core CareTeam Profile)Who provided the content of the care plan
... addresses SΣ0..*Reference(Condition_eltss)Assessed Need
... supportingInfo S0..*Reference(Resource)Information considered as part of plan
... goal S0..*Reference(Goal_eltss)Desired outcome of plan
... activity SC0..*BackboneElementAction to occur as part of a plan
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... reference SC0..1Reference(Appointment | Task | ServiceRequest_eltss)Activity details defined in specific resource
... note S0..*AnnotationComments about the plan

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
CarePlan.text.statusrequiredNarrativeStatus
CarePlan.statusrequiredRequestStatus
CarePlan.intentrequiredCarePlanIntent
CarePlan.categoryexampleCarePlanCategory
CarePlan.category:AssessPlanexamplePattern: assess-plan
CarePlan.activity.detail.statusrequiredCarePlanActivityStatus

Constraints

IdGradePath(s)DetailsRequirements
cpl-3errorCarePlan.activityProvide a reference or detail, not both
: detail.empty() or reference.empty()
dom-2errorCarePlanIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCarePlanIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorCarePlanIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorCarePlanIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCarePlanA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
txt-1errorCarePlan.text.divThe narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes
: htmlChecks()
txt-2errorCarePlan.text.divThe narrative SHALL have some non-whitespace content
: htmlChecks()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan 0..*USCoreCarePlanProfileeLTSS Healthcare plan for patient or group
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text S1..1NarrativeText summary of the resource, for human interpretation
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... status S1..1codegenerated | extensions | additional | empty
Binding: US Core Narrative Status (required): Constrained value set of narrative statuses.

.... div C1..1xhtmlLimited xhtml content
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Ids for this plan
... instantiatesCanonical Σ0..*canonical(PlanDefinition | Questionnaire | Measure | ActivityDefinition | OperationDefinition)Instantiates FHIR protocol or definition
... instantiatesUri Σ0..*uriInstantiates external protocol or definition
... basedOn Σ0..*Reference(CarePlan_eltss)Fulfills CarePlan
... replaces Σ0..*Reference(CarePlan_eltss)CarePlan replaced by this CarePlan
... partOf SΣ0..*Reference(CarePlan_eltss)Emergency Backup Plan
... status ?!SΣ1..1codedraft | active | on-hold | revoked | completed | entered-in-error | unknown
Binding: RequestStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.

... intent ?!SΣ1..1codeproposal | plan | order | option
Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan

... Slices for category SΣ1..*CodeableConceptType of plan
Slice: Unordered, Open by pattern:$this
Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc.


.... category:AssessPlan SΣ1..1CodeableConceptType of plan
Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc.



Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/careplan-category
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: assess-plan
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
... title Σ0..1stringHuman-friendly name for the care plan
... description Σ0..1stringSummary of nature of plan
... subject SΣ1..1Reference(Patient_eltss)CarePlan Subject
... encounter SΣ0..1Reference(Encounter)Encounter created as part of
... period SΣ0..1PeriodPlan Effective Date
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... start SΣC1..1dateTimeStarting time with inclusive boundary
.... end SΣC0..1dateTimeEnd time with inclusive boundary, if not ongoing
... created Σ0..1dateTimeDate record was first recorded
... author SΣ0..1Reference(Patient_eltss | Practitioner_eltss S | eLTSS PractitionerRole Profile S | eLTSS RelatedPerson Profile | US Core Organization Profile | US Core CareTeam Profile)Support Planner
... contributor 0..*Reference(Patient_eltss | Practitioner_eltss | eLTSS PractitionerRole Profile | eLTSS RelatedPerson Profile | US Core Organization Profile | US Core CareTeam Profile)Who provided the content of the care plan
... careTeam 0..*Reference(CareTeam)Who's involved in plan?
... addresses SΣ0..*Reference(Condition_eltss)Assessed Need
... supportingInfo S0..*Reference(Resource)Information considered as part of plan
... goal S0..*Reference(Goal_eltss)Desired outcome of plan
... activity SC0..*BackboneElementAction to occur as part of a plan
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... outcomeCodeableConcept 0..*CodeableConceptResults of the activity
Binding: CarePlanActivityOutcome (example): Identifies the results of the activity.


.... outcomeReference 0..*Reference(Resource)Appointment, Encounter, Procedure, etc.
.... progress 0..*AnnotationComments about the activity status/progress
.... reference SC0..1Reference(Appointment S | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task S | ServiceRequest_eltss S | VisionPrescription | RequestGroup)Activity details defined in specific resource
... note S0..*AnnotationComments about the plan

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
CarePlan.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
CarePlan.text.statusrequiredNarrativeStatus
CarePlan.statusrequiredRequestStatus
CarePlan.intentrequiredCarePlanIntent
CarePlan.categoryexampleCarePlanCategory
CarePlan.category:AssessPlanexamplePattern: assess-plan
CarePlan.activity.outcomeCodeableConceptexampleCarePlanActivityOutcome
CarePlan.activity.detail.kindrequiredCarePlanActivityKind
CarePlan.activity.detail.codeexampleProcedureCodes(SNOMEDCT)
CarePlan.activity.detail.reasonCodeexampleSNOMEDCTClinicalFindings
CarePlan.activity.detail.statusrequiredCarePlanActivityStatus
CarePlan.activity.detail.product[x]exampleSNOMEDCTMedicationCodes

Constraints

IdGradePath(s)DetailsRequirements
cpl-3errorCarePlan.activityProvide a reference or detail, not both
: detail.empty() or reference.empty()
dom-2errorCarePlanIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorCarePlanIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorCarePlanIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorCarePlanIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceCarePlanA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
txt-1errorCarePlan.text.divThe narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes
: htmlChecks()
txt-2errorCarePlan.text.divThe narrative SHALL have some non-whitespace content
: htmlChecks()

 

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