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4.3 Resource CarePlan - Content

Describes the intention of how one or more practitioners intend to deliver care for a particular patient for a period of time, possibly limited to care for a specific condition or set of conditions.

4.3.1 Scope and Usage

Care Plans are used in many of areas of healthcare with a variety of scopes. They can be as simple as a general practitioner keeping track of when their patient is next due for a tetanus immunization through to a detailed plan for an oncology patient covering diet, chemotherapy, radiation, lab work and counseling with detailed timing relationships, pre-conditions and goals.

This resource takes an intermediate approach. It captures basic details about who is involved and what actions are intended without dealing in discrete data about dependencies and timing relationships. These can be supported where necessary using the extension mechanisms.

Comments are welcome about the appropriateness of the proposed level of granularity, whether it's too much detail for what most systems need, or not sufficient for common essential use cases.

4.3.2 Resource Content

CarePlan (Resource)This records identifiers associated with this care plan that are defined by business processed and/ or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation)identifier : Identifier 0..*Identifies the patient/subject whose intended care is described by the planpatient : Resource(Patient) 0..1Indicates whether the plan is currently being acted upon, represents future intentions or is now just historical record (this element modifies the meaning of other elements)status : code 1..1 <<Indicates whether the plan is currently being acted upon, represents future intentions or is now just historical record.CarePlanStatus>>Indicates when the plan did (or is intended to) come into effect and endperiod : Period 0..1Identifies the most recent date on which the plan has been revisedmodified : dateTime 0..1Identifies the conditions/problems/concerns/diagnoses/etc. whose management and/or mitigation are handled by this planconcern : Resource(Condition) 0..*General notes about the care plan not covered elsewherenotes : string 0..1ParticipantIndicates specific responsibility of an individual within the care plan. E.g. "Primary physician", "Team coordinator", "Caregiver", etcrole : CodeableConcept 0..1The specific person or organization who is participating/expected to participate in the care planmember : Resource(Practitioner|RelatedPerson| Patient|Organization) 1..1GoalHuman-readable description of a specific desired objective of the care plandescription : string 1..1Indicates whether the goal has been reached and is still considered relevantstatus : code 0..1 <<Indicates whether the goal has been met and is still being targetedCarePlanGoalStatus>>Any comments related to the goalnotes : string 0..1The identified conditions that this goal relates to - the condition that caused it to be created, or that it is intended to addressconcern : Resource(Condition) 0..*ActivityInternal reference that identifies the goals that this activity is intended to contribute towards meetinggoal : idref 0..*Identifies what progress is being made for the specific activitystatus : code 0..1 <<Indicates where the activity is at in its overall life cycleCarePlanActivityStatus>>If true, indicates that the described activity is one that must NOT be engaged in when following the plan (this element modifies the meaning of other elements)prohibited : boolean 1..1Resources that describe follow-on actions resulting from the plan, such as drug prescriptions, encounter records, appointments, etcactionResulting : Resource(Any) 0..*Notes about the execution of the activitynotes : string 0..1The details of the proposed activity represented in a specific resourcedetail : Resource(Procedure| MedicationPrescription|DiagnosticOrder| Encounter) 0..1SimpleHigh-level categorization of the type of activity in a care plancategory : code 1..1 <<High-level categorization of the type of activity in a care plan.CarePlanActivityCategory>>Detailed description of the type of activity. E.g. What lab test, what procedure, what kind of encountercode : CodeableConcept 0..1The period, timing or frequency upon which the described activity is to occurtiming[x] : Schedule|Period|string 0..1Identifies the facility where the activity will occur. E.g. home, hospital, specific clinic, etclocation : Resource(Location) 0..1Identifies who's expected to be involved in the activityperformer : Resource(Practitioner|Organization| RelatedPerson|Patient) 0..*Identifies the food, drug or other product being consumed or supplied in the activityproduct : Resource(Medication|Substance) 0..1Identifies the quantity expected to be consumed in a given daydailyAmount : Quantity 0..1Identifies the quantity expected to be suppliedquantity : Quantity 0..1This provides a textual description of constraints on the activity occurrence, including relation to other activities. It may also include objectives, pre-conditions and end-conditions. Finally, it may convey specifics about the activity such as body site, method, route, etcdetails : string 0..1Identifies all people and organizations who are expected to be involved in the care envisioned by this planparticipant0..*Describes the intended objective(s) of carrying out the Care Plangoal0..*A simple summary of details suitable for a general care plan system (e.g. form driven) that doesn't know about specific resources such as procedure etcsimple0..1Identifies a planned action to occur as part of the plan. For example, a medication to be used, lab tests to perform, self-monitoring, education, etcactivity0..*

This resource is referenced by [Procedure]

<CarePlan xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: extension, modifierExtension, language, text, and contained -->
 <identifier><!-- 0..* Identifier External Ids for this plan --></identifier>
 <patient><!-- 0..1 Resource(Patient) Who care plan is for --></patient>
 <status value="[code]"/><!-- 1..1 planned | active | completed -->
 <period><!-- 0..1 Period Time period plan covers --></period>
 <modified value="[dateTime]"/><!-- 0..1 When last updated -->
 <concern><!-- 0..* Resource(Condition) Health issues this plan addresses --></concern>
 <participant>  <!-- 0..* Who's involved in plan? -->
  <role><!-- 0..1 CodeableConcept Type of involvement --></role>
  <member><!-- 1..1 Resource(Practitioner|RelatedPerson|Patient|Organization) Who is involved --></member>
 </participant>
 <goal>  <!-- 0..* Desired outcome of plan -->
  <description value="[string]"/><!-- 1..1 What's the desired outcome? -->
  <status value="[code]"/><!-- 0..1 in progress | achieved | sustaining | cancelled -->
  <notes value="[string]"/><!-- 0..1 Comments about the goal -->
  <concern><!-- 0..* Resource(Condition) Health issues this goal addresses --></concern>
 </goal>
 <activity>  <!-- 0..* Action to occur as part of plan -->
  <goal value="[idref]"/><!-- 0..* Goals this activity relates to -->
  <status value="[code]"/><!-- 0..1 not started | scheduled | in progress | on hold | completed | cancelled -->
  <prohibited value="[boolean]"/><!-- 1..1 Do NOT do -->
  <actionResulting><!-- 0..* Resource(Any) Appointments, orders, etc. --></actionResulting>
  <notes value="[string]"/><!-- 0..1 Comments about the activity -->
  <detail><!-- ?? 0..1 Resource(Procedure|MedicationPrescription|DiagnosticOrder|
    Encounter) Activity details defined in specific resource --></detail>
  <simple>  <!-- ?? 0..1 Activity details summarised here -->
   <category value="[code]"/><!-- 1..1 diet | drug | encounter | observation | procedure | supply | other -->
   <code><!-- 0..1 CodeableConcept Detail type of activity --></code>
   <timing[x]><!-- 0..1 Schedule|Period|string When activity is to occur --></timing[x]>
   <location><!-- 0..1 Resource(Location) Where it should happen --></location>
   <performer><!-- 0..* Resource(Practitioner|Organization|RelatedPerson|Patient) 
       Who's responsible? --></performer>
   <product><!-- 0..1 Resource(Medication|Substance) What's administered/supplied --></product>
   <dailyAmount><!-- ?? 0..1 Quantity How much consumed/day? --></dailyAmount>
   <quantity><!-- ?? 0..1 Quantity How much is administered/supplied/consumed --></quantity>
   <details value="[string]"/><!-- 0..1 Extra info on activity occurrence -->
  </simple>
 </activity>
 <notes value="[string]"/><!-- 0..1 Comments about the plan -->
</CarePlan>

Alternate definitions: Schema/Schematron, Resource Profile

4.3.2.1 Terminology Bindings

PathDefinitionTypeReference
CarePlan.status Indicates whether the plan is currently being acted upon, represents future intentions or is now just historical record.Fixedhttp://hl7.org/fhir/care-plan-status
CarePlan.participant.role Indicates specific responsibility of an individual within the care plan. E.g. "Primary physician", "Team coordinator", "Caregiver", etc.UnknownNo details provided yet
CarePlan.goal.status Indicates whether the goal has been met and is still being targetedFixedhttp://hl7.org/fhir/care-plan-goal-status
CarePlan.activity.status Indicates where the activity is at in its overall life cycleFixedhttp://hl7.org/fhir/care-plan-activity-status
CarePlan.activity.simple.category High-level categorization of the type of activity in a care plan.Fixedhttp://hl7.org/fhir/care-plan-activity-category
CarePlan.activity.simple.code Detailed description of the type of activity. E.g. What lab test, what procedure, what kind of encounter.UnknownNo details provided yet

4.3.2.2 Constraints

4.3.3 Open Issues

4.3.4 Search Parameters

Search parameters for this resource. The standard parameters also apply. See Searching for more information about searching in REST, messaging, and services.

NameTypeDescriptionPaths
_idtokenThe logical resource id associated with the resource (must be supported by all servers)
_languagetokenThe language of the resource
activitycodetokenDetail type of activityCarePlan.activity.simple.code
activitydatedateSpecified date occurs within period specified by CarePlan.activity.timingScheduleCarePlan.activity.simple.timing[x]
activitydetailreferenceActivity details defined in specific resourceCarePlan.activity.detail
(MedicationPrescription, Encounter, Procedure, DiagnosticOrder)
conditionreferenceHealth issues this plan addressesCarePlan.concern
(Condition)
datedateTime period plan coversCarePlan.period
participantreferenceWho is involvedCarePlan.participant.member
(Organization, Patient, Practitioner, RelatedPerson)
patientreferenceWho care plan is forCarePlan.patient
(Patient)
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