This page is part of the electronic Long-Term Services and Supports Implementation Guide (v2.0.0: STU2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
Page standards status: Trial-use | Maturity Level: 2 |
Definitions for the CarePlan-eltss resource profile.
Guidance on how to interpret the contents of this table can be found here
0. CarePlan | |
Short | eLTSS Healthcare plan for patient or group |
2. CarePlan.basedOn | |
Type | Reference(CarePlan_eltss) |
4. CarePlan.replaces | |
Type | Reference(CarePlan_eltss) |
6. CarePlan.partOf | |
Definition | Description of how to address unforeseen events, emergency health events, emergency events, problems with medical equipment and supplies, and unavailable staffing situations for critical services that put the person’s health and safety at risk. This can be included as free text or attachment. |
Short | Emergency Backup Plan |
Comments | The CarePlan resource containing the emergency backup plan refers to the "main" CarePlan resource, rather than the other way around, by using the emergency backup plan CarePlan -> partOf data element to reference the "main" CarePlan data element. |
Type | Reference(CarePlan_eltss) |
Must Support | true |
8. CarePlan.subject | |
Definition | Referencing the Person from CarePlan. |
Short | CarePlan Subject |
Comments | Reference the Patient for the care plan being developed. |
Type | Reference(Patient_eltss) |
10. CarePlan.encounter | |
Must Support | true |
12. CarePlan.period | |
Definition | The date upon which the plan goes into effect. Start date is required, end date is optional. |
Short | Plan Effective Date |
Must Support | true |
14. CarePlan.period.start | |
Control | 1..? |
Must Support | true |
16. CarePlan.period.end | |
Must Support | true |
18. CarePlan.author | |
Definition | The person (e.g., Case Manager, Care Coordinator, Plan Coordinator) who helped develop the plan. |
Short | Support Planner |
Comments | Support Planner Name + Phone. |
Type | Reference(Patient_eltss, Practitioner_eltss, eLTSS PractitionerRole Profile, eLTSS RelatedPerson Profile, US Core Organization Profile, US Core CareTeam Profile) |
Must Support | true |
Must Support Types | Reference(Practitioner_eltss, eLTSS PractitionerRole Profile) |
20. CarePlan.contributor | |
Type | Reference(Patient_eltss, Practitioner_eltss, eLTSS PractitionerRole Profile, eLTSS RelatedPerson Profile, US Core Organization Profile, US Core CareTeam Profile) |
22. CarePlan.addresses | |
Definition | The clinical and/or community-based necessity or desire as identified through an assessment that should be addressed by a service. |
Short | Assessed Need |
Comments | Each assessed need should go into a separate Condition element so each can potentially be linked to a service(s) that addresses it. |
Type | Reference(Condition_eltss) |
Must Support | true |
24. CarePlan.supportingInfo | |
Definition | Identifies portions of the patient's record that specifically influenced the formation of the plan. These might include comorbidities, recent procedures, limitations, recent assessments, etc. This includes the RiskAssessment/Risk Management Plan |
Must Support | true |
26. CarePlan.goal | |
Type | Reference(Goal_eltss) |
Must Support | true |
28. CarePlan.activity | |
Definition | A planned measurable step or action that needs to be taken to accomplish a goal identified by the person. |
Short | Action to occur as part of a plan |
Comments | 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. |
Must Support | true |
30. CarePlan.activity.reference | |
Type | Reference(Appointment, CommunicationRequest, DeviceRequest, MedicationRequest, NutritionOrder, Task, ServiceRequest_eltss, VisionPrescription, RequestGroup) |
Must Support | true |
Must Support Types | Reference(Appointment, Task, ServiceRequest_eltss) |
32. CarePlan.activity.detail | |
Control | 0..0 |
34. CarePlan.note | |
Must Support | true |
Guidance on how to interpret the contents of this table can be found here
0. CarePlan | |
Definition | - 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. |
Short | eLTSS Healthcare plan for patient or groupHealthcare plan for patient or group |
Comments | - |
Control | 0..* |
Is Modifier | false |
Must Support | false |
Summary | false |
Alternate Names | Care Team |
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty()) dom-3: If 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-4: If 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-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (text.`div`.exists()) |
2. CarePlan.implicitRules | |
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. |
Short | A set of rules under which this content was created |
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. |
Control | 0..1 |
Type | uri |
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
4. CarePlan.text | |
Definition | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. |
Short | (USCDI) Text summary of the resource, for human interpretationText summary of the resource, for human interpretation |
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. |
Control | 0..1 |
Type | Narrative |
Is Modifier | false |
Must Support | true |
Summary | false |
Alternate Names | narrative, html, xhtml, display |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
6. CarePlan.text.status | |
Definition | The status of the narrative - whether it's entirely generated (from just the defined data or the extensions too), or whether a human authored it and it may contain additional data. |
Short | (USCDI) generated | extensions | additional | emptygenerated | extensions | additional | empty |
Control | 1..1 |
Binding | The codes SHALL be taken from US Core Narrative Statushttp://hl7.org/fhir/ValueSet/narrative-status|4.0.1 (required to http://hl7.org/fhir/us/core/ValueSet/us-core-narrative-status )Constrained value set of narrative statuses. The status of a resource narrative. |
Type | code |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
8. CarePlan.text.div | |
Definition | The actual narrative content, a stripped down version of XHTML. |
Short | (USCDI) Limited xhtml contentLimited xhtml content |
Comments | The contents of the html element are an XHTML fragment containing only the basic html formatting elements described in chapters 7-11 and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained stylesheets. The XHTML content SHALL NOT contain a head, a body, external stylesheet references, scripts, forms, base/link/xlink, frames, iframes and objects. |
Control | 1..1 |
Type | xhtml |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) txt-1: The 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-2: The narrative SHALL have some non-whitespace content ( htmlChecks() )txt-1: The 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-2: The narrative SHALL have some non-whitespace content (htmlChecks()) |
10. CarePlan.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them |
Summary | false |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
12. CarePlan.basedOn | |
Definition | A care plan that is fulfilled in whole or in part by this care plan. |
Short | Fulfills CarePlan |
Control | 0..* |
Type | Reference(CarePlan_eltss, CarePlan) |
Is Modifier | false |
Summary | true |
Requirements | Allows tracing of the care plan and tracking whether proposals/recommendations were acted upon. |
Alternate Names | fulfills |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
14. CarePlan.replaces | |
Definition | Completed or terminated care plan whose function is taken by this new care plan. |
Short | CarePlan replaced by this CarePlan |
Comments | The replacement could be because the initial care plan was immediately rejected (due to an issue) or because the previous care plan was completed, but the need for the action described by the care plan remains ongoing. |
Control | 0..* |
Type | Reference(CarePlan_eltss, CarePlan) |
Is Modifier | false |
Summary | true |
Requirements | Allows tracing the continuation of a therapy or administrative process instantiated through multiple care plans. |
Alternate Names | supersedes |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
16. CarePlan.partOf | |
Definition | Description of how to address unforeseen events, emergency health events, emergency events, problems with medical equipment and supplies, and unavailable staffing situations for critical services that put the person’s health and safety at risk. This can be included as free text or attachment. A larger care plan of which this particular care plan is a component or step. |
Short | Emergency Backup PlanPart of referenced CarePlan |
Comments | The CarePlan resource containing the emergency backup plan refers to the "main" CarePlan resource, rather than the other way around, by using the emergency backup plan CarePlan -> partOf data element to reference the "main" CarePlan data element. Each care plan is an independent request, such that having a care plan be part of another care plan can cause issues with cascading statuses. As such, this element is still being discussed. |
Control | 0..* |
Type | Reference(CarePlan_eltss, CarePlan) |
Is Modifier | false |
Must Support | true |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
18. CarePlan.status | |
Definition | Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record. |
Short | (USCDI) draft | active | on-hold | revoked | completed | entered-in-error | unknowndraft | active | on-hold | revoked | completed | entered-in-error | unknown |
Comments | The unknown code is not to be used to convey other statuses. The unknown code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the care plan. This element is labeled as a modifier because the status contains the code entered-in-error that marks the plan as not currently valid. |
Control | 1..1 |
Binding | The codes SHALL be taken from RequestStatushttp://hl7.org/fhir/ValueSet/request-status|4.0.1 (required to http://hl7.org/fhir/ValueSet/request-status )Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record. |
Type | code |
Is Modifier | true because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | true |
Requirements | Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record. Allows clinicians to determine whether the plan is actionable or not. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
20. CarePlan.intent | |
Definition | Indicates the level of authority/intentionality associated with the care plan and where the care plan fits into the workflow chain. |
Short | (USCDI) proposal | plan | order | optionproposal | plan | order | option |
Comments | This element is labeled as a modifier because the intent alters when and how the resource is actually applicable. |
Control | 1..1 |
Binding | The codes SHALL be taken from CarePlanIntenthttp://hl7.org/fhir/ValueSet/care-plan-intent|4.0.1 (required to http://hl7.org/fhir/ValueSet/care-plan-intent )Codes indicating the degree of authority/intentionality associated with a care plan Codes indicating the degree of authority/intentionality associated with a care plan. |
Type | code |
Is Modifier | true because This element changes the interpretation of all descriptive attributes. For example "the time the request is recommended to occur" vs. "the time the request is authorized to occur" or "who is recommended to perform the request" vs. "who is authorized to perform the request" |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | true |
Requirements | Proposals/recommendations, plans and orders all use the same structure and can exist in the same fulfillment chain. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
22. CarePlan.category | |
Definition | Type of plan. 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. |
Short | (USCDI) Type of planType of plan |
Comments | There may be multiple axes of categorization and one plan may serve multiple purposes. In some cases, this may be redundant with references to CarePlan.concern. |
Control | 10..* |
Binding | For example codes, see CarePlanCategoryhttp://hl7.org/fhir/ValueSet/care-plan-category (example to http://hl7.org/fhir/ValueSet/care-plan-category )Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", "wellness plan", etc. Used for filtering what plan(s) are retrieved and displayed to different types of users. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Slicing | This element introduces a set of slices on CarePlan.category . The slices areUnordered and Open, and can be differentiated using the following discriminators: |
24. CarePlan.category:AssessPlan | |
Slice Name | AssessPlan |
Definition | Type of plan. 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. |
Short | (USCDI) Type of planType of plan |
Comments | There may be multiple axes of categorization and one plan may serve multiple purposes. In some cases, this may be redundant with references to CarePlan.concern. |
Control | 10..1* |
Binding | For example codes, see CarePlanCategoryhttp://hl7.org/fhir/ValueSet/care-plan-category (example to http://hl7.org/fhir/ValueSet/care-plan-category )Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. |
Type | CodeableConcept |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", "wellness plan", etc. Used for filtering what plan(s) are retrieved and displayed to different types of users. |
Pattern Value | { |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
26. CarePlan.subject | |
Definition | Referencing the Person from CarePlan. Identifies the patient or group whose intended care is described by the plan. |
Short | CarePlan SubjectWho the care plan is for |
Comments | Reference the Patient for the care plan being developed. |
Control | 1..1 |
Type | Reference(Patient_eltss, Patient, Group) |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | Identifies the patient or group whose intended care is described by the plan. |
Alternate Names | patient |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
28. CarePlan.encounter | |
Definition | The Encounter during which this CarePlan was created or to which the creation of this record is tightly associated. |
Short | Encounter created as part of |
Comments | This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. CarePlan activities conducted as a result of the care plan may well occur as part of other encounters. |
Control | 0..1 |
Type | Reference(Encounter) |
Is Modifier | false |
Must Support | true |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
30. CarePlan.period | |
Definition | The date upon which the plan goes into effect. Start date is required, end date is optional. Indicates when the plan did (or is intended to) come into effect and end. |
Short | Plan Effective DateTime period plan covers |
Comments | Any activities scheduled as part of the plan should be constrained to the specified period regardless of whether the activities are planned within a single encounter/episode or across multiple encounters/episodes (e.g. the longitudinal management of a chronic condition). |
Control | 0..1 |
Type | Period |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | Allows tracking what plan(s) are in effect at a particular time. |
Alternate Names | timing |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
32. CarePlan.period.start | |
Definition | The start of the period. The boundary is inclusive. |
Short | Starting time with inclusive boundary |
Comments | If the low element is missing, the meaning is that the low boundary is not known. |
Control | 10..1 This element is affected by the following invariants: per-1 |
Type | dateTime |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
34. CarePlan.period.end | |
Definition | The end of the period. If the end of the period is missing, it means no end was known or planned at the time the instance was created. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time. |
Short | End time with inclusive boundary, if not ongoing |
Comments | The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03. |
Control | 0..1 This element is affected by the following invariants: per-1 |
Type | dateTime |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | true |
Meaning if Missing | If the end of the period is missing, it means that the period is ongoing |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
36. CarePlan.author | |
Definition | The person (e.g., Case Manager, Care Coordinator, Plan Coordinator) who helped develop the plan. When populated, the author is responsible for the care plan. The care plan is attributed to the author. |
Short | Support PlannerWho is the designated responsible party |
Comments | Support Planner Name + Phone. The author may also be a contributor. For example, an organization can be an author, but not listed as a contributor. |
Control | 0..1 |
Type | Reference(Patient_eltss, Practitioner_eltss, eLTSS PractitionerRole Profile, eLTSS RelatedPerson Profile, US Core Organization Profile, US Core CareTeam Profile, Patient, Practitioner, PractitionerRole, Device, RelatedPerson, Organization, CareTeam) |
Is Modifier | false |
Must Support | true |
Must Support Types | Reference(Practitioner_eltss, eLTSS PractitionerRole Profile) |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
38. CarePlan.contributor | |
Definition | Identifies the individual(s) or organization who provided the contents of the care plan. |
Short | Who provided the content of the care plan |
Comments | Collaborative care plans may have multiple contributors. |
Control | 0..* |
Type | Reference(Patient_eltss, Practitioner_eltss, eLTSS PractitionerRole Profile, eLTSS RelatedPerson Profile, US Core Organization Profile, US Core CareTeam Profile, Patient, Practitioner, PractitionerRole, Device, RelatedPerson, Organization, CareTeam) |
Is Modifier | false |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
40. CarePlan.addresses | |
Definition | The clinical and/or community-based necessity or desire as identified through an assessment that should be addressed by a service. Identifies the conditions/problems/concerns/diagnoses/etc. whose management and/or mitigation are handled by this plan. |
Short | Assessed NeedHealth issues this plan addresses |
Comments | Each assessed need should go into a separate Condition element so each can potentially be linked to a service(s) that addresses it. When the diagnosis is related to an allergy or intolerance, the Condition and AllergyIntolerance resources can both be used. However, to be actionable for decision support, using Condition alone is not sufficient as the allergy or intolerance condition needs to be represented as an AllergyIntolerance. |
Control | 0..* |
Type | Reference(Condition_eltss, Condition) |
Is Modifier | false |
Must Support | true |
Summary | true |
Requirements | Links plan to the conditions it manages. The element can identify risks addressed by the plan as well as active conditions. (The Condition resource can include things like "at risk for hypertension" or "fall risk".) Also scopes plans - multiple plans may exist addressing different concerns. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
42. CarePlan.supportingInfo | |
Definition | Identifies portions of the patient's record that specifically influenced the formation of the plan. These might include comorbidities, recent procedures, limitations, recent assessments, etc. This includes the RiskAssessment/Risk Management Plan Identifies portions of the patient's record that specifically influenced the formation of the plan. These might include comorbidities, recent procedures, limitations, recent assessments, etc. |
Short | Information considered as part of plan |
Comments | Use "concern" to identify specific conditions addressed by the care plan. |
Control | 0..* |
Type | Reference(Resource) |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Identifies barriers and other considerations associated with the care plan. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
44. CarePlan.goal | |
Definition | Describes the intended objective(s) of carrying out the care plan. |
Short | Desired outcome of plan |
Comments | Goal can be achieving a particular change or merely maintaining a current state or even slowing a decline. |
Control | 0..* |
Type | Reference(Goal_eltss, Goal) |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Provides context for plan. Allows plan effectiveness to be evaluated by clinicians. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
46. CarePlan.activity | |
Definition | A planned measurable step or action that needs to be taken to accomplish a goal identified by the person. Identifies a planned action to occur as part of the plan. For example, a medication to be used, lab tests to perform, self-monitoring, education, etc. |
Short | Action to occur as part of a planAction to occur as part of plan |
Comments | 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. |
Control | 0..* |
Type | BackboneElement |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Allows systems to prompt for performance of planned activities, and validate plans against best practice. |
Invariants | cpl-3: Provide a reference or detail, not both (detail.empty() or reference.empty() )ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) cpl-3: Provide a reference or detail, not both (detail.empty() or reference.empty()) |
48. CarePlan.activity.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
50. CarePlan.activity.reference | |
Definition | The details of the proposed activity represented in a specific resource. |
Short | Activity details defined in specific resource |
Comments | Standard extension exists (resource-pertainsToGoal) that allows goals to be referenced from any of the referenced resources in CarePlan.activity.reference. |
Control | 0..1 This element is affected by the following invariants: cpl-3 |
Type | Reference(Appointment, CommunicationRequest, DeviceRequest, MedicationRequest, NutritionOrder, Task, ServiceRequest_eltss, VisionPrescription, RequestGroup, ServiceRequest) |
Is Modifier | false |
Must Support | true |
Must Support Types | Reference(Appointment, Task, ServiceRequest_eltss) |
Summary | false |
Requirements | Details in a form consistent with other applications and contexts of use. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
52. CarePlan.activity.detail | |
Definition | A simple summary of a planned activity suitable for a general care plan system (e.g. form driven) that doesn't know about specific resources such as procedure etc. |
Short | In-line definition of activity |
Control | 0..01 This element is affected by the following invariants: cpl-3 |
Type | BackboneElement |
Is Modifier | false |
Summary | false |
Requirements | Details in a simple form for generic care plan systems. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
57. CarePlan.note | |
Definition | General notes about the care plan not covered elsewhere. |
Short | Comments about the plan |
Control | 0..* |
Type | Annotation |
Is Modifier | false |
Must Support | true |
Summary | false |
Requirements | Used to capture information that applies to the plan as a whole that doesn't fit into discrete elements. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Guidance on how to interpret the contents of this table can be found here
0. CarePlan | |||||
Definition | - | ||||
Short | eLTSS Healthcare plan for patient or group | ||||
Comments | - | ||||
Control | 0..* | ||||
Is Modifier | false | ||||
Must Support | false | ||||
Summary | false | ||||
Alternate Names | Care Team | ||||
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty() )dom-3: If 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-4: If 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-5: If a resource is contained in another resource, it SHALL NOT have a security label ( contained.meta.security.empty() )dom-6: A resource should have narrative for robust management ( text.`div`.exists() ) | ||||
2. CarePlan.id | |||||
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | ||||
Short | Logical id of this artifact | ||||
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||||
Control | 0..1 | ||||
Type | id | ||||
Is Modifier | false | ||||
Summary | true | ||||
4. CarePlan.meta | |||||
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | ||||
Short | Metadata about the resource | ||||
Control | 0..1 | ||||
Type | Meta | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
6. CarePlan.implicitRules | |||||
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | ||||
Short | A set of rules under which this content was created | ||||
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
8. CarePlan.language | |||||
Definition | The base language in which the resource is written. | ||||
Short | Language of the resource content | ||||
Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from CommonLanguages (preferred to http://hl7.org/fhir/ValueSet/languages )A human language.
| ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
10. CarePlan.text | |||||
Definition | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | ||||
Short | (USCDI) Text summary of the resource, for human interpretation | ||||
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. | ||||
Control | 0..1 | ||||
Type | Narrative | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Alternate Names | narrative, html, xhtml, display | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
12. CarePlan.text.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
14. CarePlan.text.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on CarePlan.text.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
16. CarePlan.text.status | |||||
Definition | The status of the narrative - whether it's entirely generated (from just the defined data or the extensions too), or whether a human authored it and it may contain additional data. | ||||
Short | (USCDI) generated | extensions | additional | empty | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from US Core Narrative Status (required to http://hl7.org/fhir/us/core/ValueSet/us-core-narrative-status )Constrained value set of narrative statuses. | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
18. CarePlan.text.div | |||||
Definition | The actual narrative content, a stripped down version of XHTML. | ||||
Short | (USCDI) Limited xhtml content | ||||
Comments | The contents of the html element are an XHTML fragment containing only the basic html formatting elements described in chapters 7-11 and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained stylesheets. The XHTML content SHALL NOT contain a head, a body, external stylesheet references, scripts, forms, base/link/xlink, frames, iframes and objects. | ||||
Control | 1..1 | ||||
Type | xhtml | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )txt-1: The 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-2: The narrative SHALL have some non-whitespace content ( htmlChecks() ) | ||||
20. CarePlan.contained | |||||
Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | ||||
Short | Contained, inline Resources | ||||
Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. | ||||
Control | 0..* | ||||
Type | Resource | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | inline resources, anonymous resources, contained resources | ||||
22. CarePlan.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
24. CarePlan.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them | ||||
Summary | false | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
26. CarePlan.identifier | |||||
Definition | 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 server. | ||||
Short | External Ids for this plan | ||||
Comments | This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number. | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Control | 0..* | ||||
Type | Identifier | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Allows identification of the care plan as it is known by various participating systems and in a way that remains consistent across servers. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
28. CarePlan.instantiatesCanonical | |||||
Definition | The URL pointing to a FHIR-defined protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlan. | ||||
Short | Instantiates FHIR protocol or definition | ||||
Control | 0..* | ||||
Type | canonical(PlanDefinition, Questionnaire, Measure, ActivityDefinition, OperationDefinition) | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
30. CarePlan.instantiatesUri | |||||
Definition | The URL pointing to an externally maintained protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlan. | ||||
Short | Instantiates external protocol or definition | ||||
Comments | This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier. | ||||
Control | 0..* | ||||
Type | uri | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
32. CarePlan.basedOn | |||||
Definition | A care plan that is fulfilled in whole or in part by this care plan. | ||||
Short | Fulfills CarePlan | ||||
Control | 0..* | ||||
Type | Reference(CarePlan_eltss) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Allows tracing of the care plan and tracking whether proposals/recommendations were acted upon. | ||||
Alternate Names | fulfills | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
34. CarePlan.replaces | |||||
Definition | Completed or terminated care plan whose function is taken by this new care plan. | ||||
Short | CarePlan replaced by this CarePlan | ||||
Comments | The replacement could be because the initial care plan was immediately rejected (due to an issue) or because the previous care plan was completed, but the need for the action described by the care plan remains ongoing. | ||||
Control | 0..* | ||||
Type | Reference(CarePlan_eltss) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Allows tracing the continuation of a therapy or administrative process instantiated through multiple care plans. | ||||
Alternate Names | supersedes | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
36. CarePlan.partOf | |||||
Definition | Description of how to address unforeseen events, emergency health events, emergency events, problems with medical equipment and supplies, and unavailable staffing situations for critical services that put the person’s health and safety at risk. This can be included as free text or attachment. | ||||
Short | Emergency Backup Plan | ||||
Comments | The CarePlan resource containing the emergency backup plan refers to the "main" CarePlan resource, rather than the other way around, by using the emergency backup plan CarePlan -> partOf data element to reference the "main" CarePlan data element. | ||||
Control | 0..* | ||||
Type | Reference(CarePlan_eltss) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
38. CarePlan.status | |||||
Definition | Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record. | ||||
Short | (USCDI) draft | active | on-hold | revoked | completed | entered-in-error | unknown | ||||
Comments | The unknown code is not to be used to convey other statuses. The unknown code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the care plan. This element is labeled as a modifier because the status contains the code entered-in-error that marks the plan as not currently valid. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from RequestStatus (required to http://hl7.org/fhir/ValueSet/request-status )Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record. | ||||
Type | code | ||||
Is Modifier | true because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
40. CarePlan.intent | |||||
Definition | Indicates the level of authority/intentionality associated with the care plan and where the care plan fits into the workflow chain. | ||||
Short | (USCDI) proposal | plan | order | option | ||||
Comments | This element is labeled as a modifier because the intent alters when and how the resource is actually applicable. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from CarePlanIntent (required to http://hl7.org/fhir/ValueSet/care-plan-intent )Codes indicating the degree of authority/intentionality associated with a care plan | ||||
Type | code | ||||
Is Modifier | true because This element changes the interpretation of all descriptive attributes. For example "the time the request is recommended to occur" vs. "the time the request is authorized to occur" or "who is recommended to perform the request" vs. "who is authorized to perform the request" | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | Proposals/recommendations, plans and orders all use the same structure and can exist in the same fulfillment chain. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
42. CarePlan.category | |||||
Definition | Type of plan. | ||||
Short | (USCDI) Type of plan | ||||
Comments | There may be multiple axes of categorization and one plan may serve multiple purposes. In some cases, this may be redundant with references to CarePlan.concern. | ||||
Control | 1..* | ||||
Binding | For example codes, see CarePlanCategory (example to http://hl7.org/fhir/ValueSet/care-plan-category )Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | 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. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
Slicing | This element introduces a set of slices on CarePlan.category . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
44. CarePlan.category:AssessPlan | |||||
Slice Name | AssessPlan | ||||
Definition | Type of plan. | ||||
Short | (USCDI) Type of plan | ||||
Comments | There may be multiple axes of categorization and one plan may serve multiple purposes. In some cases, this may be redundant with references to CarePlan.concern. | ||||
Control | 1..1 | ||||
Binding | For example codes, see CarePlanCategory (example to http://hl7.org/fhir/ValueSet/care-plan-category )Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | 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. | ||||
Pattern Value | { | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
46. CarePlan.title | |||||
Definition | Human-friendly name for the care plan. | ||||
Short | Human-friendly name for the care plan | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
48. CarePlan.description | |||||
Definition | A description of the scope and nature of the plan. | ||||
Short | Summary of nature of plan | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Requirements | Provides more detail than conveyed by category. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
50. CarePlan.subject | |||||
Definition | Referencing the Person from CarePlan. | ||||
Short | CarePlan Subject | ||||
Comments | Reference the Patient for the care plan being developed. | ||||
Control | 1..1 | ||||
Type | Reference(Patient_eltss) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | Identifies the patient or group whose intended care is described by the plan. | ||||
Alternate Names | patient | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
52. CarePlan.encounter | |||||
Definition | The Encounter during which this CarePlan was created or to which the creation of this record is tightly associated. | ||||
Short | Encounter created as part of | ||||
Comments | This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. CarePlan activities conducted as a result of the care plan may well occur as part of other encounters. | ||||
Control | 0..1 | ||||
Type | Reference(Encounter) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
54. CarePlan.period | |||||
Definition | The date upon which the plan goes into effect. Start date is required, end date is optional. | ||||
Short | Plan Effective Date | ||||
Comments | Any activities scheduled as part of the plan should be constrained to the specified period regardless of whether the activities are planned within a single encounter/episode or across multiple encounters/episodes (e.g. the longitudinal management of a chronic condition). | ||||
Control | 0..1 | ||||
Type | Period | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | Allows tracking what plan(s) are in effect at a particular time. | ||||
Alternate Names | timing | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
56. CarePlan.period.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
58. CarePlan.period.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on CarePlan.period.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
60. CarePlan.period.start | |||||
Definition | The start of the period. The boundary is inclusive. | ||||
Short | Starting time with inclusive boundary | ||||
Comments | If the low element is missing, the meaning is that the low boundary is not known. | ||||
Control | 1..1 This element is affected by the following invariants: per-1 | ||||
Type | dateTime | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
62. CarePlan.period.end | |||||
Definition | The end of the period. If the end of the period is missing, it means no end was known or planned at the time the instance was created. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time. | ||||
Short | End time with inclusive boundary, if not ongoing | ||||
Comments | The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03. | ||||
Control | 0..1 This element is affected by the following invariants: per-1 | ||||
Type | dateTime | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Meaning if Missing | If the end of the period is missing, it means that the period is ongoing | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
64. CarePlan.created | |||||
Definition | Represents when this particular CarePlan record was created in the system, which is often a system-generated date. | ||||
Short | Date record was first recorded | ||||
Control | 0..1 | ||||
Type | dateTime | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Alternate Names | authoredOn | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
66. CarePlan.author | |||||
Definition | The person (e.g., Case Manager, Care Coordinator, Plan Coordinator) who helped develop the plan. | ||||
Short | Support Planner | ||||
Comments | Support Planner Name + Phone. | ||||
Control | 0..1 | ||||
Type | Reference(Patient_eltss, Practitioner_eltss, eLTSS PractitionerRole Profile, eLTSS RelatedPerson Profile, US Core Organization Profile, US Core CareTeam Profile) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Must Support Types | Reference(Practitioner_eltss, eLTSS PractitionerRole Profile) | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
68. CarePlan.contributor | |||||
Definition | Identifies the individual(s) or organization who provided the contents of the care plan. | ||||
Short | Who provided the content of the care plan | ||||
Comments | Collaborative care plans may have multiple contributors. | ||||
Control | 0..* | ||||
Type | Reference(Patient_eltss, Practitioner_eltss, eLTSS PractitionerRole Profile, eLTSS RelatedPerson Profile, US Core Organization Profile, US Core CareTeam Profile) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
70. CarePlan.careTeam | |||||
Definition | Identifies all people and organizations who are expected to be involved in the care envisioned by this plan. | ||||
Short | Who's involved in plan? | ||||
Control | 0..* | ||||
Type | Reference(CareTeam) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Allows representation of care teams, helps scope care plan. In some cases may be a determiner of access permissions. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
72. CarePlan.addresses | |||||
Definition | The clinical and/or community-based necessity or desire as identified through an assessment that should be addressed by a service. | ||||
Short | Assessed Need | ||||
Comments | Each assessed need should go into a separate Condition element so each can potentially be linked to a service(s) that addresses it. | ||||
Control | 0..* | ||||
Type | Reference(Condition_eltss) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | Links plan to the conditions it manages. The element can identify risks addressed by the plan as well as active conditions. (The Condition resource can include things like "at risk for hypertension" or "fall risk".) Also scopes plans - multiple plans may exist addressing different concerns. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
74. CarePlan.supportingInfo | |||||
Definition | Identifies portions of the patient's record that specifically influenced the formation of the plan. These might include comorbidities, recent procedures, limitations, recent assessments, etc. This includes the RiskAssessment/Risk Management Plan | ||||
Short | Information considered as part of plan | ||||
Comments | Use "concern" to identify specific conditions addressed by the care plan. | ||||
Control | 0..* | ||||
Type | Reference(Resource) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Identifies barriers and other considerations associated with the care plan. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
76. CarePlan.goal | |||||
Definition | Describes the intended objective(s) of carrying out the care plan. | ||||
Short | Desired outcome of plan | ||||
Comments | Goal can be achieving a particular change or merely maintaining a current state or even slowing a decline. | ||||
Control | 0..* | ||||
Type | Reference(Goal_eltss) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Provides context for plan. Allows plan effectiveness to be evaluated by clinicians. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
78. CarePlan.activity | |||||
Definition | A planned measurable step or action that needs to be taken to accomplish a goal identified by the person. | ||||
Short | Action to occur as part of a plan | ||||
Comments | 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. | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Allows systems to prompt for performance of planned activities, and validate plans against best practice. | ||||
Invariants | cpl-3: Provide a reference or detail, not both (detail.empty() or reference.empty() )ele-1: All FHIR elements must have a @value or children ( hasValue() or (children().count() > id.count()) ) | ||||
80. CarePlan.activity.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
82. CarePlan.activity.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
84. CarePlan.activity.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
86. CarePlan.activity.outcomeCodeableConcept | |||||
Definition | Identifies the outcome at the point when the status of the activity is assessed. For example, the outcome of an education activity could be patient understands (or not). | ||||
Short | Results of the activity | ||||
Comments | Note that this should not duplicate the activity status (e.g. completed or in progress). | ||||
Control | 0..* | ||||
Binding | For example codes, see CarePlanActivityOutcome (example to http://hl7.org/fhir/ValueSet/care-plan-activity-outcome )Identifies the results of the activity. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
88. CarePlan.activity.outcomeReference | |||||
Definition | Details of the outcome or action resulting from the activity. The reference to an "event" resource, such as Procedure or Encounter or Observation, is the result/outcome of the activity itself. The activity can be conveyed using CarePlan.activity.detail OR using the CarePlan.activity.reference (a reference to a “request” resource). | ||||
Short | Appointment, Encounter, Procedure, etc. | ||||
Comments | The activity outcome is independent of the outcome of the related goal(s). For example, if the goal is to achieve a target body weight of 150 lbs and an activity is defined to diet, then the activity outcome could be calories consumed whereas the goal outcome is an observation for the actual body weight measured. | ||||
Control | 0..* | ||||
Type | Reference(Resource) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Links plan to resulting actions. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
90. CarePlan.activity.progress | |||||
Definition | Notes about the adherence/status/progress of the activity. | ||||
Short | Comments about the activity status/progress | ||||
Comments | This element should NOT be used to describe the activity to be performed - that occurs either within the resource pointed to by activity.detail.reference or in activity.detail.description. | ||||
Control | 0..* | ||||
Type | Annotation | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Can be used to capture information about adherence, progress, concerns, etc. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
92. CarePlan.activity.reference | |||||
Definition | The details of the proposed activity represented in a specific resource. | ||||
Short | Activity details defined in specific resource | ||||
Comments | Standard extension exists (resource-pertainsToGoal) that allows goals to be referenced from any of the referenced resources in CarePlan.activity.reference. | ||||
Control | 0..1 This element is affected by the following invariants: cpl-3 | ||||
Type | Reference(Appointment, CommunicationRequest, DeviceRequest, MedicationRequest, NutritionOrder, Task, ServiceRequest_eltss, VisionPrescription, RequestGroup) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Must Support Types | Reference(Appointment, Task, ServiceRequest_eltss) | ||||
Summary | false | ||||
Requirements | Details in a form consistent with other applications and contexts of use. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
94. CarePlan.activity.detail | |||||
Definition | A simple summary of a planned activity suitable for a general care plan system (e.g. form driven) that doesn't know about specific resources such as procedure etc. | ||||
Short | In-line definition of activity | ||||
Control | 0..0 This element is affected by the following invariants: cpl-3 | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Details in a simple form for generic care plan systems. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
116. CarePlan.note | |||||
Definition | General notes about the care plan not covered elsewhere. | ||||
Short | Comments about the plan | ||||
Control | 0..* | ||||
Type | Annotation | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | Used to capture information that applies to the plan as a whole that doesn't fit into discrete elements. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) |