PACIO Advance Directive Interoperability Implementation Guide
0.1.0 - STU 1 Ballot

This page is part of the PACIO Advance Directive Information Implementation Guide (v0.1.0: STU 1 Ballot 1) based on FHIR R4. . For a full list of available versions, see the Directory of published versions

Resource Profile: ADI Preference Care Plan

Defining URL:http://hl7.org/fhir/us/pacio-adi/StructureDefinition/PADI-PreferenceCarePlan
Version:0.1.0
Name:PADIPreferenceCarePlan
Title:ADI Preference Care Plan
Status:Active as of 12/6/21 8:50 PM
Definition:

The Preference Care Plan is a means for an individual to express their goals and preferences under certain circumstances that may be pertinent when planning his or her care.

Publisher:HL7 Patient Empowerment Working Group
Source Resource:XML / JSON / Turtle

The official URL for this profile is: 

http://hl7.org/fhir/us/pacio-adi/StructureDefinition/PADI-PreferenceCarePlan

The ADI Preference care plan represents the patient’s goals for treatment based on circumstances or situations that provide context for the goals documented. A patient could document their goal of care in a situation such as a terminal condition that will result in their death in a relatively short period of time as being to extend their life for as long as possible, or allow their natural death to occur, or allow limited treatments to occur for a certain period of time before they are stopped. In a different situation, such as permanent and severe brain damage from which they are not expected to recover, that their goal of care options may be the same but their documented selection is different. Various forms and jurisdictions include circumstances or situations that are relatively consistent but still vary somewhat, so this Resource allows the basic structure of a context or circumstance or situation to be defined, against which the identification of a goal is documented, and against which in some existing forms further identification of the patient’s preference for interventions is captured. To enable the patient’s own preferred plan of care to merge with the care team’s clinical plan of care results in a jointly-authored and patient-centered plan of care that is informed by the person receiving care and the care team responsible for delivering that care.

Formal Views of Profile Content

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

This structure is derived from CarePlan

NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan 0..*CarePlanHealthcare plan for patient or group
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... padi-goal-order-by-descending-priority-extension 0..1CodeableConceptGoal Order by Descending Priority
URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-goal-order-by-descending-priority-extension
Binding: hl7VS-yes-no-Indicator (extensible)
... status 1..1codedraft | active | on-hold | revoked | completed | entered-in-error | unknown
Required Pattern: active
... Slices for category 1..*CodeableConceptType of plan
Slice: Unordered, Open by pattern:$this
.... category:advance_care_planning S1..1CodeableConceptType of plan
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://snomed.info/sct
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: 736366004
...... display1..1stringRepresentation defined by the system
Fixed Value: Advance care plan
... subject S1..1Reference(US Core Patient Profile)Who the care plan is for
... addresses S1..*Reference(Condition)Health issues this plan addresses
... goal S1..*Reference(Personal Intervention Preference | ADI Personal Goal | ADI Care Experience Preference)Patient's preferences and goals for the scope of this care plan.

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan 0..*CarePlanHealthcare plan for patient or group
... id Σ0..1stringLogical 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)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... padi-goal-order-by-descending-priority-extension 0..1CodeableConceptGoal Order by Descending Priority
URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-goal-order-by-descending-priority-extension
Binding: hl7VS-yes-no-Indicator (extensible)
... 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)Fulfills CarePlan
... replaces Σ0..*Reference(CarePlan)CarePlan replaced by this CarePlan
... partOf Σ0..*Reference(CarePlan)Part of referenced CarePlan
... status ?!Σ1..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.


Required Pattern: active
... intent ?!Σ1..1codeproposal | plan | order | option
Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan.


Required Pattern: proposal
... Slices for category Σ1..*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:advance_care_planning 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://snomed.info/sct
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: 736366004
...... display1..1stringRepresentation defined by the system
Fixed Value: Advance care plan
...... 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(US Core Patient Profile)Who the care plan is for
... encounter Σ0..1Reference(Encounter)Encounter created as part of
... period Σ0..1PeriodTime period plan covers
... created Σ0..1dateTimeDate record was first recorded
... author Σ0..1Reference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam)Who is the designated responsible party
... contributor 0..*Reference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam)Who provided the content of the care plan
... careTeam 0..*Reference(CareTeam)Who's involved in plan?
... addresses SΣ1..*Reference(Condition)Health issues this plan addresses
... supportingInfo 0..*Reference(Resource)Information considered as part of plan
... goal S1..*Reference(Personal Intervention Preference | ADI Personal Goal | ADI Care Experience Preference)Patient's preferences and goals for the scope of this care plan.
... activity I0..*BackboneElementAction to occur as part of plan
cpl-3: Provide a reference or detail, not both
.... 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 I0..1Reference(Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup)Activity details defined in specific resource
.... detail I0..1BackboneElementIn-line definition of activity
..... 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
..... kind 0..1codeAppointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription
Binding: CarePlanActivityKind (required): Resource types defined as part of FHIR that can be represented as in-line definitions of a care plan activity.

..... instantiatesCanonical 0..*canonical(PlanDefinition | ActivityDefinition | Questionnaire | Measure | OperationDefinition)Instantiates FHIR protocol or definition
..... instantiatesUri 0..*uriInstantiates external protocol or definition
..... code 0..1CodeableConceptDetail type of activity
Binding: ProcedureCodes(SNOMEDCT) (example): Detailed description of the type of activity; e.g. What lab test, what procedure, what kind of encounter.

..... reasonCode 0..*CodeableConceptWhy activity should be done or why activity was prohibited
Binding: SNOMEDCTClinicalFindings (example): Identifies why a care plan activity is needed. Can include any health condition codes as well as such concepts as "general wellness", prophylaxis, surgical preparation, etc.


..... reasonReference 0..*Reference(Condition | Observation | DiagnosticReport | DocumentReference)Why activity is needed
..... goal 0..*Reference(Goal)Goals this activity relates to
..... status ?!1..1codenot-started | scheduled | in-progress | on-hold | completed | cancelled | stopped | unknown | entered-in-error
Binding: CarePlanActivityStatus (required): Codes that reflect the current state of a care plan activity within its overall life cycle.

..... statusReason 0..1CodeableConceptReason for current status
..... doNotPerform ?!0..1booleanIf true, activity is prohibiting action
..... scheduled[x] 0..1When activity is to occur
...... scheduledTimingTiming
...... scheduledPeriodPeriod
...... scheduledStringstring
..... location 0..1Reference(Location)Where it should happen
..... performer 0..*Reference(Practitioner | PractitionerRole | Organization | RelatedPerson | Patient | CareTeam | HealthcareService | Device)Who will be responsible?
..... product[x] 0..1What is to be administered/supplied
Binding: SNOMEDCTMedicationCodes (example): A product supplied or administered as part of a care plan activity.

...... productCodeableConceptCodeableConcept
...... productReferenceReference(Medication | Substance)
..... dailyAmount 0..1SimpleQuantityHow to consume/day?
..... quantity 0..1SimpleQuantityHow much to administer/supply/consume
..... description 0..1stringExtra info describing activity to perform
... note 0..*AnnotationComments about the plan

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan 0..*CarePlanHealthcare plan for patient or group
... category:advance_care_planning Σ1..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://snomed.info/sct
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 736366004
..... display1..1stringRepresentation defined by the system
Fixed Value: Advance care plan
... subject Σ1..1Reference(US Core Patient Profile)Who the care plan is for
... addresses Σ1..*Reference(Condition)Health issues this plan addresses

doco Documentation for this format

Differential View

This structure is derived from CarePlan

NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan 0..*CarePlanHealthcare plan for patient or group
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... padi-goal-order-by-descending-priority-extension 0..1CodeableConceptGoal Order by Descending Priority
URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-goal-order-by-descending-priority-extension
Binding: hl7VS-yes-no-Indicator (extensible)
... status 1..1codedraft | active | on-hold | revoked | completed | entered-in-error | unknown
Required Pattern: active
... Slices for category 1..*CodeableConceptType of plan
Slice: Unordered, Open by pattern:$this
.... category:advance_care_planning S1..1CodeableConceptType of plan
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://snomed.info/sct
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: 736366004
...... display1..1stringRepresentation defined by the system
Fixed Value: Advance care plan
... subject S1..1Reference(US Core Patient Profile)Who the care plan is for
... addresses S1..*Reference(Condition)Health issues this plan addresses
... goal S1..*Reference(Personal Intervention Preference | ADI Personal Goal | ADI Care Experience Preference)Patient's preferences and goals for the scope of this care plan.

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan 0..*CarePlanHealthcare plan for patient or group
... id Σ0..1stringLogical 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)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... padi-goal-order-by-descending-priority-extension 0..1CodeableConceptGoal Order by Descending Priority
URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/padi-goal-order-by-descending-priority-extension
Binding: hl7VS-yes-no-Indicator (extensible)
... 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)Fulfills CarePlan
... replaces Σ0..*Reference(CarePlan)CarePlan replaced by this CarePlan
... partOf Σ0..*Reference(CarePlan)Part of referenced CarePlan
... status ?!Σ1..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.


Required Pattern: active
... intent ?!Σ1..1codeproposal | plan | order | option
Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan.


Required Pattern: proposal
... Slices for category Σ1..*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:advance_care_planning 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://snomed.info/sct
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: 736366004
...... display1..1stringRepresentation defined by the system
Fixed Value: Advance care plan
...... 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(US Core Patient Profile)Who the care plan is for
... encounter Σ0..1Reference(Encounter)Encounter created as part of
... period Σ0..1PeriodTime period plan covers
... created Σ0..1dateTimeDate record was first recorded
... author Σ0..1Reference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam)Who is the designated responsible party
... contributor 0..*Reference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam)Who provided the content of the care plan
... careTeam 0..*Reference(CareTeam)Who's involved in plan?
... addresses SΣ1..*Reference(Condition)Health issues this plan addresses
... supportingInfo 0..*Reference(Resource)Information considered as part of plan
... goal S1..*Reference(Personal Intervention Preference | ADI Personal Goal | ADI Care Experience Preference)Patient's preferences and goals for the scope of this care plan.
... activity I0..*BackboneElementAction to occur as part of plan
cpl-3: Provide a reference or detail, not both
.... 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 I0..1Reference(Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup)Activity details defined in specific resource
.... detail I0..1BackboneElementIn-line definition of activity
..... 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
..... kind 0..1codeAppointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription
Binding: CarePlanActivityKind (required): Resource types defined as part of FHIR that can be represented as in-line definitions of a care plan activity.

..... instantiatesCanonical 0..*canonical(PlanDefinition | ActivityDefinition | Questionnaire | Measure | OperationDefinition)Instantiates FHIR protocol or definition
..... instantiatesUri 0..*uriInstantiates external protocol or definition
..... code 0..1CodeableConceptDetail type of activity
Binding: ProcedureCodes(SNOMEDCT) (example): Detailed description of the type of activity; e.g. What lab test, what procedure, what kind of encounter.

..... reasonCode 0..*CodeableConceptWhy activity should be done or why activity was prohibited
Binding: SNOMEDCTClinicalFindings (example): Identifies why a care plan activity is needed. Can include any health condition codes as well as such concepts as "general wellness", prophylaxis, surgical preparation, etc.


..... reasonReference 0..*Reference(Condition | Observation | DiagnosticReport | DocumentReference)Why activity is needed
..... goal 0..*Reference(Goal)Goals this activity relates to
..... status ?!1..1codenot-started | scheduled | in-progress | on-hold | completed | cancelled | stopped | unknown | entered-in-error
Binding: CarePlanActivityStatus (required): Codes that reflect the current state of a care plan activity within its overall life cycle.

..... statusReason 0..1CodeableConceptReason for current status
..... doNotPerform ?!0..1booleanIf true, activity is prohibiting action
..... scheduled[x] 0..1When activity is to occur
...... scheduledTimingTiming
...... scheduledPeriodPeriod
...... scheduledStringstring
..... location 0..1Reference(Location)Where it should happen
..... performer 0..*Reference(Practitioner | PractitionerRole | Organization | RelatedPerson | Patient | CareTeam | HealthcareService | Device)Who will be responsible?
..... product[x] 0..1What is to be administered/supplied
Binding: SNOMEDCTMedicationCodes (example): A product supplied or administered as part of a care plan activity.

...... productCodeableConceptCodeableConcept
...... productReferenceReference(Medication | Substance)
..... dailyAmount 0..1SimpleQuantityHow to consume/day?
..... quantity 0..1SimpleQuantityHow much to administer/supply/consume
..... description 0..1stringExtra info describing activity to perform
... note 0..*AnnotationComments about the plan

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / Code
CarePlan.languagepreferredCommonLanguages
Max Binding: AllLanguages
CarePlan.statusrequiredPattern: active
CarePlan.intentrequiredPattern: proposal
CarePlan.categoryexampleCarePlanCategory
CarePlan.category:advance_care_planningexamplePattern: SNOMED CT code 736366004("Advance care 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

IdPathDetailsRequirements
cpl-3CarePlan.activityProvide a reference or detail, not both
: detail.empty() or reference.empty()