MCC eCare Plan Implementation Guide
1.0.0-ballot2 - ballot United States of America flag

This page is part of the MCC eCare Plan Implementation Guide (v1.0.0-ballot2: STU 1 Ballot 2) based on FHIR R4. . For a full list of available versions, see the Directory of published versions

Resource Profile: Multiple Chronic Care Condition Care Plan

Official URL: http://hl7.org/fhir/us/mcc/StructureDefinition/mccCarePlan Version: 1.0.0-ballot2
Active as of 2022-04-13 Computable Name: MCCCarePlan

This profile constrains the FHIR Care Plan Resource to represent the requirements of a care plan for patients with multiple chronic conditions.

In the R5 Care Plan Resource, author has been replaced by custodian, as in R4 the CarePlan author was incorrectly defined as the “responsible party”. The CarePlan.contributor is intended to record who or what added data to the care plan. The custodian extension has been added to the MCC Care Plan to represent the designated responsible party for the care and maintenance of the care plan. It is available for use but is nor required or must support. We are seeking comments with respect to who or what is the responsible party of a care plan that is dynamically generated with data from different health systems.

A Care Plan is a consensus-driven dynamic plan that represents a patient’s and Care Team Members’ prioritized concerns, goals, and planned interventions. It serves as a blueprint shared by all Care Team Members (including the patient, their caregivers, and providers), to guide the patient’s care. A Care Plan integrates multiple interventions proposed by multiple providers and disciplines for multiple conditions. A Care Plan may represent one or more Care Plans and serves to reconcile and resolve conflicts between the various plans developed for a specific patient by different providers. It supports the following use cases:

  • Query for patient data across providers and compile into a consolidated care plan representation.
  • Encourage capture of and communication of a patient’s health concerns and related goals, interventions, and outcomes.
  • Gather and aggregate patient data for uses beyond the point of care (e.g. public health, population health, quality measurement, risk adjustment, quality improvement, and research.)

Standards Supported Care Planning and Coordination Process

The vision of this implementation guide (IG), with the FHIR Care Plan profile as its framework, is to define a profile on the FHIR Care Plan resource that describes how it can be implemented and leveraged to support machine assisted care coordination between systems. It is assumed that clinician and patient facing SMART on FHIR Apps can be designed off of this guide to achieve that goal. The IG will also inform EHR systems on how to implement a structured encoded Care Plan.

The dynamic care plan process diagram shows Care Plan Cornerstones as they exist within the clinical world and elements and attributes from the FHIR Care Plan resource structure that support the process. In order to encourage reuse and dynamic, machine assisted care coordination, the Care Plan profile design leverages referrencing profiles wherever possible, especially within CarePlan.Activity.

High Level Dynamic Care Plan Process Diagram

This profile on the FHIR Care Plan Resource describes rules and contraints to record, search, and fetch care plan data associated with a patient with multiple chronic conditions. It identifies which profiles, core elements, extensions, vocabularies and value sets SHALL be present in the resource when using this profile. Care plan data may or may not be tagged in an EHR as part of a care plan, but is also useful to retrieve data such as goals, problems, medications etc. and their time stamps from EHRs and other health system records to bring into an aggegated plan. This includes care plans that may be authored by a patient.

Multiple Chronic Condition FHIR Care Plan Profile Relationship Diagram

Supporting Machine Assisted Dynamic Care Coordination/Planning with the FHIR Care Plan Resource and FHIR Goal Resource

The machine assisted dynamic care planning/coordination is supported in FHIR by leveraging together the Care Plan resource, the Goal resource, resource referencing and available extensions within those resources to “link together the health concern or problem, and it’s associated goals, interventions and outcomes. The intention is to re-use data entered in the EHR, whether it is in a Care Plan Application, or elsewhere in the EHR or other information system, rather than having a care plan be a double documentation burden. For example, if a procedure is ordered and performed and the health concern or problem reason for that procedure is asserted in the ordering workflow or documentation workflow - this information can be pulled into the Care Plan. If a goal is asserted for a patient outside of a care plan, along with the reason for that goal, this also can be pulled into a care plan. The Care Plan profile relies on referencing of profiles rather than “in-line” representation or documentation to enable a dynamic workflow and to be able to pull in and aggregate care coordination activities from disparate systems to provide a comprehensive care coordination view for patients

CarePlan.activity is a Backbone element. It identifies an action that has occurred or is a planned action to occur as part of the plan. For example, a medication to be used, lab tests to perform, self-monitoring that has occurred, education etc., within which in R4 can be activity.reference, activity.outcomeCodeableConcept, activity.outcomeReference or activity.progress (annotated note).

OUTCOME REFERENCE - activity.outcomeReference (aka PERFORMED ACTIVITY reference): has been renamed in R5 to “CarePlan.performedActivity”. To be in line with R5 do not use activity.detail. Also, outcomeReference is not only an outcome but rather an action such as Procedure or an Encounter that was made or occurred or an Observation. Within the target of the CarePlan.activity.outcomeReference, the extension, “resource-pertainsToGoal” SHALL be used to reference this activity’s related goal. Within the resource referenced within CarePlan.activity.outcomeReference, “xxx.reason” SHALL be used to reference the health concern or problem for which the activity is done. CarePlan.outcomeCodeableConcept can also be used to indicate the outcome of an activity, such as patient understanding or lack thereof. It should not duplicate the activity status (e.g., completed or in progress). Simple free text can be used in the OutcomeCodeableConcept if no specific code is available.

ACTIVITY REFERENCE - activity.reference (aka PLANNED ACTIVITY reference): has been renamed in R5 to “CarePlan.plannedActivityReference”. To be in line with R5 do not use activity.detail. Within the target of the CarePlan.activity.reference, the extension, “resource-pertainsToGoal” SHALL be used to reference this activity’s request’s related goal. “xxx.reason” SHALL be used to reference the health concern or problem for which the activity is done. Within the referenced Goal resource, goal.address SHALL be used to reference the goal’s related Condition, Observation, MedicationStatement, NutritionOrder, ServiceRequest or RiskAssessment. Within the referenced Goal resource, Goal.outcomeReference, references the outcome (e.g observations related to the specific goal). Consider using activity.progress, which is an annotation data type, to satisfy the desire in the comment to provide plain free text on progress (in addition to the text, it contains the author and a date-time).

Health Concerns represented with:

  • CarePlan.addresses
  • CarePlan.suppportingInfo
  • Goal.addresses
  • xxx.reason.reference

Goals represented with:

  • CarePlan.goal (for entire plan)
  • resource-pertainsToGoal (specific planned or performed activity)

Interventions represented with:

  • CarePlan.activity.reference (aka plannedActivityReference)
  • CarePlan.activity.outcomeReference (aka performedActivityReference)

Outcomes represented with:

  • CarePlan.activity.outcomeReference
  • CarePlan.activity.outcomeCodeableConcept
  • Goal.outcome.reference

Instanciated FHIR Supported Dynamic Care Planning and Coordination

Usage:

Formal Views of Profile Content

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

This structure is derived from USCoreCarePlanProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan 0..*USCoreCarePlanProfileHealthcare plan for patient or group
... custodian 0..1Reference(US Core Patient Profile | US Core Practitioner Profile | US Core PractitionerRole Profile | US Core CareTeam Profile | US Core Organization Profile | RelatedPerson | Device | Multiple Chronic Condition Care Plan Care Team)When populated, the custodian is responsible for the care and maintenance of the care plan. The care plan is attributed to the custodian. The custodian might or might not be a contributor. This CarePlan.custodian extension should be used instead of CarePlan.author which in R4 is currently identified as the designated responsible party and in R5 has been removed.
URL: http://hl7.org/fhir/us/mcc/StructureDefinition/custodian
... status S1..1code(USCDI) draft | active | on-hold | revoked | completed | entered-in-error | unknown
... intent S1..1code(USCDI) proposal | plan | order | option
... subject 1..1Reference(US Core Patient Profile)(USCDI) Who the care plan is for
... author 0..1Reference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam)Use the CarePlan custodian extension instead. Use of CarePlan.author is discouraged, it is removed in R5.
... contributor S0..*Reference(US Core Patient Profile | US Core Practitioner Profile | US Core PractitionerRole Profile | US Core CareTeam Profile | US Core Organization Profile | RelatedPerson | Device | Multiple Chronic Condition Care Plan Care Team)Who provided the content of the care plan
... careTeam S0..*Reference(Multiple Chronic Condition Care Plan Care Team | US Core CareTeam Profile)Who's involved in plan?
... addresses
.... reference 0..1stringLiteral reference, Relative, internal or absolute URL
... supportingInfo S0..*Reference(US Core Blood Pressure Profile | US Core BMI Profile | US Core Body Weight Profile | Multiple Chronic Condition Care Plan Chronic Disease Conditions | Multiple Chronic Condition Care Plan Laboratory Result Observation | Multiple Chronic Condition Care Plan Diagnostic Report and Note | Multiple Chronic Condition Care Plan Procedure | US Core Immunization Profile | Multiple Chronic Condition Care Plan Family History | Document Reference to Patient's Personal Advance Care Plan (Advance Directive) | SDC Questionnaire Response | Multiple Chronic Condition Care Plan Symptom Observation | Multiple Chronic Condition Care Plan Service Request | Multiple Chronic Condition Care Plan Observation SDOH Assessment | Multiple Chronic Condition Care Plan Immunization | Multiple Chronic Condition Care Plan Nutrition Order | Multiple Chronic Condition Care Plan Clinical Impression | Multiple Chronic Condition Care Plan Patient/Caregiver Condition Status Observation | Multiple Chronic Condition Care Plan Questionnaire Response | Multiple Chronic Condition Care Plan Caregiver Considerations Observation | Multiple Chronic Condition Care Plan Clinical Test Observation | US Core RelatedPerson Profile | US Core Observation Occupation Profile)Please see the libraries of available value sets pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.supportingInfo
... goal 0..*Reference(Multiple Chronic Condition Care Plan Goal)This Goal represents one or more overarching goal applicable to the entire care plan
... activity S0..*BackboneElementAction to occur as part of plan. This is the backbone element of the care plan that is the root of care coordination activities. While there can be many activities in a care plan, each activity has only one planned.activityRefence
.... outcomeReference S0..*Reference(Multiple Chronic Condition Care Plan Procedure | Multiple Chronic Condition Care Plan Laboratory Result Observation | US Core Immunization Profile | Multiple Chronic Condition Care Plan Diagnostic Report and Note | US Core Immunization Profile | Multiple Chronic Condition Care Plan Medication Request | Multiple Chronic Condition Care Plan Chronic Disease Conditions | US Core Body Weight Profile | US Core Blood Pressure Profile | Multiple Chronic Condition Care Plan Goal | US Core BMI Profile | Multiple Chronic Condition Care Plan Symptom Observation)This CarePlan element represents a PERFORMED ACTIVITY. Please see the libraries of available value sets pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.activity.outcomeReference
.... reference S0..1Reference(NutritionOrder | Multiple Chronic Condition Care Plan Medication Request | CommunicationRequest | DeviceRequest | Task | ServiceRequest | VisionPrescription | RequestGroup | Appointment)This CarePlan element represents a PLANNED ACTIVITY. Please see the libraries of available value sets pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.activity.reference
.... detail 0..0

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan 0..*USCoreCarePlanProfileHealthcare plan for patient or group
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text S0..1Narrative(USCDI) Text summary of the resource, for human interpretation
.... status S1..1code(USCDI) generated | extensions | additional | empty
Binding: US Core Narrative Status (required): Constrained value set of narrative statuses.

.... div SC1..1xhtml(USCDI) Limited xhtml content
... custodian 0..1Reference(US Core Patient Profile | US Core Practitioner Profile | US Core PractitionerRole Profile | US Core CareTeam Profile | US Core Organization Profile | RelatedPerson | Device | Multiple Chronic Condition Care Plan Care Team)When populated, the custodian is responsible for the care and maintenance of the care plan. The care plan is attributed to the custodian. The custodian might or might not be a contributor. This CarePlan.custodian extension should be used instead of CarePlan.author which in R4 is currently identified as the designated responsible party and in R5 has been removed.
URL: http://hl7.org/fhir/us/mcc/StructureDefinition/custodian
... status ?!SΣ1..1code(USCDI) draft | active | on-hold | revoked | completed | entered-in-error | unknown
Binding: RequestStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.

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

... Slices for category SΣ1..*CodeableConceptCare Plan category code describes the type of care plan. Please see CarePlan.category detail for guidance.
Slice: Unordered, Open by pattern:$this
Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc.


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



Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/careplan-category
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: assess-plan
... subject SΣ1..1Reference(US Core Patient Profile)(USCDI) Who the care plan is for
... author Σ0..1Reference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam)Use the CarePlan custodian extension instead. Use of CarePlan.author is discouraged, it is removed in R5.
... contributor S0..*Reference(US Core Patient Profile | US Core Practitioner Profile | US Core PractitionerRole Profile | US Core CareTeam Profile | US Core Organization Profile | RelatedPerson | Device | Multiple Chronic Condition Care Plan Care Team)Who provided the content of the care plan
... careTeam S0..*Reference(Multiple Chronic Condition Care Plan Care Team | US Core CareTeam Profile)Who's involved in plan?
... supportingInfo S0..*Reference(US Core Blood Pressure Profile | US Core BMI Profile | US Core Body Weight Profile | Multiple Chronic Condition Care Plan Chronic Disease Conditions | Multiple Chronic Condition Care Plan Laboratory Result Observation | Multiple Chronic Condition Care Plan Diagnostic Report and Note | Multiple Chronic Condition Care Plan Procedure | US Core Immunization Profile | Multiple Chronic Condition Care Plan Family History | Document Reference to Patient's Personal Advance Care Plan (Advance Directive) | SDC Questionnaire Response | Multiple Chronic Condition Care Plan Symptom Observation | Multiple Chronic Condition Care Plan Service Request | Multiple Chronic Condition Care Plan Observation SDOH Assessment | Multiple Chronic Condition Care Plan Immunization | Multiple Chronic Condition Care Plan Nutrition Order | Multiple Chronic Condition Care Plan Clinical Impression | Multiple Chronic Condition Care Plan Patient/Caregiver Condition Status Observation | Multiple Chronic Condition Care Plan Questionnaire Response | Multiple Chronic Condition Care Plan Caregiver Considerations Observation | Multiple Chronic Condition Care Plan Clinical Test Observation | US Core RelatedPerson Profile | US Core Observation Occupation Profile)Please see the libraries of available value sets pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.supportingInfo
... goal 0..*Reference(Multiple Chronic Condition Care Plan Goal)This Goal represents one or more overarching goal applicable to the entire care plan
... activity SC0..*BackboneElementAction to occur as part of plan. This is the backbone element of the care plan that is the root of care coordination activities. While there can be many activities in a care plan, each activity has only one planned.activityRefence
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... outcomeReference S0..*Reference(Multiple Chronic Condition Care Plan Procedure | Multiple Chronic Condition Care Plan Laboratory Result Observation | US Core Immunization Profile | Multiple Chronic Condition Care Plan Diagnostic Report and Note | US Core Immunization Profile | Multiple Chronic Condition Care Plan Medication Request | Multiple Chronic Condition Care Plan Chronic Disease Conditions | US Core Body Weight Profile | US Core Blood Pressure Profile | Multiple Chronic Condition Care Plan Goal | US Core BMI Profile | Multiple Chronic Condition Care Plan Symptom Observation)This CarePlan element represents a PERFORMED ACTIVITY. Please see the libraries of available value sets pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.activity.outcomeReference
.... reference SC0..1Reference(NutritionOrder | Multiple Chronic Condition Care Plan Medication Request | CommunicationRequest | DeviceRequest | Task | ServiceRequest | VisionPrescription | RequestGroup | Appointment)This CarePlan element represents a PLANNED ACTIVITY. Please see the libraries of available value sets pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.activity.reference

doco Documentation for this format

Terminology Bindings

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

Constraints

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

Additional BindingsPurpose
AllLanguagesMax Binding
... text S0..1Narrative(USCDI) Text summary of the resource, for human interpretation
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... status S1..1code(USCDI) generated | extensions | additional | empty
Binding: US Core Narrative Status (required): Constrained value set of narrative statuses.

.... div SC1..1xhtml(USCDI) Limited xhtml content
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... custodian 0..1Reference(US Core Patient Profile | US Core Practitioner Profile | US Core PractitionerRole Profile | US Core CareTeam Profile | US Core Organization Profile | RelatedPerson | Device | Multiple Chronic Condition Care Plan Care Team)When populated, the custodian is responsible for the care and maintenance of the care plan. The care plan is attributed to the custodian. The custodian might or might not be a contributor. This CarePlan.custodian extension should be used instead of CarePlan.author which in R4 is currently identified as the designated responsible party and in R5 has been removed.
URL: http://hl7.org/fhir/us/mcc/StructureDefinition/custodian
... 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 ?!SΣ1..1code(USCDI) draft | active | on-hold | revoked | completed | entered-in-error | unknown
Binding: RequestStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.

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

... Slices for category SΣ1..*CodeableConceptCare Plan category code describes the type of care plan. Please see CarePlan.category detail for guidance.
Slice: Unordered, Open by pattern:$this
Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc.


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



Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/careplan-category
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: assess-plan
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
... title Σ0..1stringHuman-friendly name for the care plan
... description Σ0..1stringSummary of nature of plan
... subject SΣ1..1Reference(US Core Patient Profile)(USCDI) 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)Use the CarePlan custodian extension instead. Use of CarePlan.author is discouraged, it is removed in R5.
... contributor S0..*Reference(US Core Patient Profile | US Core Practitioner Profile | US Core PractitionerRole Profile | US Core CareTeam Profile | US Core Organization Profile | RelatedPerson | Device | Multiple Chronic Condition Care Plan Care Team)Who provided the content of the care plan
... careTeam S0..*Reference(Multiple Chronic Condition Care Plan Care Team | US Core CareTeam Profile)Who's involved in plan?
... addresses Σ0..*Reference(Condition)Health issues this plan addresses
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC0..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... supportingInfo S0..*Reference(US Core Blood Pressure Profile | US Core BMI Profile | US Core Body Weight Profile | Multiple Chronic Condition Care Plan Chronic Disease Conditions | Multiple Chronic Condition Care Plan Laboratory Result Observation | Multiple Chronic Condition Care Plan Diagnostic Report and Note | Multiple Chronic Condition Care Plan Procedure | US Core Immunization Profile | Multiple Chronic Condition Care Plan Family History | Document Reference to Patient's Personal Advance Care Plan (Advance Directive) | SDC Questionnaire Response | Multiple Chronic Condition Care Plan Symptom Observation | Multiple Chronic Condition Care Plan Service Request | Multiple Chronic Condition Care Plan Observation SDOH Assessment | Multiple Chronic Condition Care Plan Immunization | Multiple Chronic Condition Care Plan Nutrition Order | Multiple Chronic Condition Care Plan Clinical Impression | Multiple Chronic Condition Care Plan Patient/Caregiver Condition Status Observation | Multiple Chronic Condition Care Plan Questionnaire Response | Multiple Chronic Condition Care Plan Caregiver Considerations Observation | Multiple Chronic Condition Care Plan Clinical Test Observation | US Core RelatedPerson Profile | US Core Observation Occupation Profile)Please see the libraries of available value sets pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.supportingInfo
... goal 0..*Reference(Multiple Chronic Condition Care Plan Goal)This Goal represents one or more overarching goal applicable to the entire care plan
... activity SC0..*BackboneElementAction to occur as part of plan. This is the backbone element of the care plan that is the root of care coordination activities. While there can be many activities in a care plan, each activity has only one planned.activityRefence
.... 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 S0..*Reference(Multiple Chronic Condition Care Plan Procedure | Multiple Chronic Condition Care Plan Laboratory Result Observation | US Core Immunization Profile | Multiple Chronic Condition Care Plan Diagnostic Report and Note | US Core Immunization Profile | Multiple Chronic Condition Care Plan Medication Request | Multiple Chronic Condition Care Plan Chronic Disease Conditions | US Core Body Weight Profile | US Core Blood Pressure Profile | Multiple Chronic Condition Care Plan Goal | US Core BMI Profile | Multiple Chronic Condition Care Plan Symptom Observation)This CarePlan element represents a PERFORMED ACTIVITY. Please see the libraries of available value sets pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.activity.outcomeReference
.... progress 0..*AnnotationComments about the activity status/progress
.... reference SC0..1Reference(NutritionOrder | Multiple Chronic Condition Care Plan Medication Request | CommunicationRequest | DeviceRequest | Task | ServiceRequest | VisionPrescription | RequestGroup | Appointment)This CarePlan element represents a PLANNED ACTIVITY. Please see the libraries of available value sets pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.activity.reference
... note 0..*AnnotationComments about the plan

doco Documentation for this format

Terminology Bindings

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

Constraints

IdGradePath(s)DetailsRequirements
cpl-3errorCarePlan.activityProvide a reference or detail, not both
: detail.empty() or reference.empty()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
txt-1errorCarePlan.text.divThe narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes
: htmlChecks()
txt-2errorCarePlan.text.divThe narrative SHALL have some non-whitespace content
: htmlChecks()

This structure is derived from USCoreCarePlanProfile

Summary

Must-Support: 9 elements
Prohibited: 1 element

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Differential View

This structure is derived from USCoreCarePlanProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan 0..*USCoreCarePlanProfileHealthcare plan for patient or group
... custodian 0..1Reference(US Core Patient Profile | US Core Practitioner Profile | US Core PractitionerRole Profile | US Core CareTeam Profile | US Core Organization Profile | RelatedPerson | Device | Multiple Chronic Condition Care Plan Care Team)When populated, the custodian is responsible for the care and maintenance of the care plan. The care plan is attributed to the custodian. The custodian might or might not be a contributor. This CarePlan.custodian extension should be used instead of CarePlan.author which in R4 is currently identified as the designated responsible party and in R5 has been removed.
URL: http://hl7.org/fhir/us/mcc/StructureDefinition/custodian
... status S1..1code(USCDI) draft | active | on-hold | revoked | completed | entered-in-error | unknown
... intent S1..1code(USCDI) proposal | plan | order | option
... subject 1..1Reference(US Core Patient Profile)(USCDI) Who the care plan is for
... author 0..1Reference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam)Use the CarePlan custodian extension instead. Use of CarePlan.author is discouraged, it is removed in R5.
... contributor S0..*Reference(US Core Patient Profile | US Core Practitioner Profile | US Core PractitionerRole Profile | US Core CareTeam Profile | US Core Organization Profile | RelatedPerson | Device | Multiple Chronic Condition Care Plan Care Team)Who provided the content of the care plan
... careTeam S0..*Reference(Multiple Chronic Condition Care Plan Care Team | US Core CareTeam Profile)Who's involved in plan?
... addresses
.... reference 0..1stringLiteral reference, Relative, internal or absolute URL
... supportingInfo S0..*Reference(US Core Blood Pressure Profile | US Core BMI Profile | US Core Body Weight Profile | Multiple Chronic Condition Care Plan Chronic Disease Conditions | Multiple Chronic Condition Care Plan Laboratory Result Observation | Multiple Chronic Condition Care Plan Diagnostic Report and Note | Multiple Chronic Condition Care Plan Procedure | US Core Immunization Profile | Multiple Chronic Condition Care Plan Family History | Document Reference to Patient's Personal Advance Care Plan (Advance Directive) | SDC Questionnaire Response | Multiple Chronic Condition Care Plan Symptom Observation | Multiple Chronic Condition Care Plan Service Request | Multiple Chronic Condition Care Plan Observation SDOH Assessment | Multiple Chronic Condition Care Plan Immunization | Multiple Chronic Condition Care Plan Nutrition Order | Multiple Chronic Condition Care Plan Clinical Impression | Multiple Chronic Condition Care Plan Patient/Caregiver Condition Status Observation | Multiple Chronic Condition Care Plan Questionnaire Response | Multiple Chronic Condition Care Plan Caregiver Considerations Observation | Multiple Chronic Condition Care Plan Clinical Test Observation | US Core RelatedPerson Profile | US Core Observation Occupation Profile)Please see the libraries of available value sets pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.supportingInfo
... goal 0..*Reference(Multiple Chronic Condition Care Plan Goal)This Goal represents one or more overarching goal applicable to the entire care plan
... activity S0..*BackboneElementAction to occur as part of plan. This is the backbone element of the care plan that is the root of care coordination activities. While there can be many activities in a care plan, each activity has only one planned.activityRefence
.... outcomeReference S0..*Reference(Multiple Chronic Condition Care Plan Procedure | Multiple Chronic Condition Care Plan Laboratory Result Observation | US Core Immunization Profile | Multiple Chronic Condition Care Plan Diagnostic Report and Note | US Core Immunization Profile | Multiple Chronic Condition Care Plan Medication Request | Multiple Chronic Condition Care Plan Chronic Disease Conditions | US Core Body Weight Profile | US Core Blood Pressure Profile | Multiple Chronic Condition Care Plan Goal | US Core BMI Profile | Multiple Chronic Condition Care Plan Symptom Observation)This CarePlan element represents a PERFORMED ACTIVITY. Please see the libraries of available value sets pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.activity.outcomeReference
.... reference S0..1Reference(NutritionOrder | Multiple Chronic Condition Care Plan Medication Request | CommunicationRequest | DeviceRequest | Task | ServiceRequest | VisionPrescription | RequestGroup | Appointment)This CarePlan element represents a PLANNED ACTIVITY. Please see the libraries of available value sets pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.activity.reference
.... detail 0..0

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan 0..*USCoreCarePlanProfileHealthcare plan for patient or group
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text S0..1Narrative(USCDI) Text summary of the resource, for human interpretation
.... status S1..1code(USCDI) generated | extensions | additional | empty
Binding: US Core Narrative Status (required): Constrained value set of narrative statuses.

.... div SC1..1xhtml(USCDI) Limited xhtml content
... custodian 0..1Reference(US Core Patient Profile | US Core Practitioner Profile | US Core PractitionerRole Profile | US Core CareTeam Profile | US Core Organization Profile | RelatedPerson | Device | Multiple Chronic Condition Care Plan Care Team)When populated, the custodian is responsible for the care and maintenance of the care plan. The care plan is attributed to the custodian. The custodian might or might not be a contributor. This CarePlan.custodian extension should be used instead of CarePlan.author which in R4 is currently identified as the designated responsible party and in R5 has been removed.
URL: http://hl7.org/fhir/us/mcc/StructureDefinition/custodian
... status ?!SΣ1..1code(USCDI) draft | active | on-hold | revoked | completed | entered-in-error | unknown
Binding: RequestStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.

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

... Slices for category SΣ1..*CodeableConceptCare Plan category code describes the type of care plan. Please see CarePlan.category detail for guidance.
Slice: Unordered, Open by pattern:$this
Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc.


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



Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/careplan-category
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: assess-plan
... subject SΣ1..1Reference(US Core Patient Profile)(USCDI) Who the care plan is for
... author Σ0..1Reference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam)Use the CarePlan custodian extension instead. Use of CarePlan.author is discouraged, it is removed in R5.
... contributor S0..*Reference(US Core Patient Profile | US Core Practitioner Profile | US Core PractitionerRole Profile | US Core CareTeam Profile | US Core Organization Profile | RelatedPerson | Device | Multiple Chronic Condition Care Plan Care Team)Who provided the content of the care plan
... careTeam S0..*Reference(Multiple Chronic Condition Care Plan Care Team | US Core CareTeam Profile)Who's involved in plan?
... supportingInfo S0..*Reference(US Core Blood Pressure Profile | US Core BMI Profile | US Core Body Weight Profile | Multiple Chronic Condition Care Plan Chronic Disease Conditions | Multiple Chronic Condition Care Plan Laboratory Result Observation | Multiple Chronic Condition Care Plan Diagnostic Report and Note | Multiple Chronic Condition Care Plan Procedure | US Core Immunization Profile | Multiple Chronic Condition Care Plan Family History | Document Reference to Patient's Personal Advance Care Plan (Advance Directive) | SDC Questionnaire Response | Multiple Chronic Condition Care Plan Symptom Observation | Multiple Chronic Condition Care Plan Service Request | Multiple Chronic Condition Care Plan Observation SDOH Assessment | Multiple Chronic Condition Care Plan Immunization | Multiple Chronic Condition Care Plan Nutrition Order | Multiple Chronic Condition Care Plan Clinical Impression | Multiple Chronic Condition Care Plan Patient/Caregiver Condition Status Observation | Multiple Chronic Condition Care Plan Questionnaire Response | Multiple Chronic Condition Care Plan Caregiver Considerations Observation | Multiple Chronic Condition Care Plan Clinical Test Observation | US Core RelatedPerson Profile | US Core Observation Occupation Profile)Please see the libraries of available value sets pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.supportingInfo
... goal 0..*Reference(Multiple Chronic Condition Care Plan Goal)This Goal represents one or more overarching goal applicable to the entire care plan
... activity SC0..*BackboneElementAction to occur as part of plan. This is the backbone element of the care plan that is the root of care coordination activities. While there can be many activities in a care plan, each activity has only one planned.activityRefence
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... outcomeReference S0..*Reference(Multiple Chronic Condition Care Plan Procedure | Multiple Chronic Condition Care Plan Laboratory Result Observation | US Core Immunization Profile | Multiple Chronic Condition Care Plan Diagnostic Report and Note | US Core Immunization Profile | Multiple Chronic Condition Care Plan Medication Request | Multiple Chronic Condition Care Plan Chronic Disease Conditions | US Core Body Weight Profile | US Core Blood Pressure Profile | Multiple Chronic Condition Care Plan Goal | US Core BMI Profile | Multiple Chronic Condition Care Plan Symptom Observation)This CarePlan element represents a PERFORMED ACTIVITY. Please see the libraries of available value sets pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.activity.outcomeReference
.... reference SC0..1Reference(NutritionOrder | Multiple Chronic Condition Care Plan Medication Request | CommunicationRequest | DeviceRequest | Task | ServiceRequest | VisionPrescription | RequestGroup | Appointment)This CarePlan element represents a PLANNED ACTIVITY. Please see the libraries of available value sets pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.activity.reference

doco Documentation for this format

Terminology Bindings

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

Constraints

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

Snapshot View

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

Additional BindingsPurpose
AllLanguagesMax Binding
... text S0..1Narrative(USCDI) Text summary of the resource, for human interpretation
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... status S1..1code(USCDI) generated | extensions | additional | empty
Binding: US Core Narrative Status (required): Constrained value set of narrative statuses.

.... div SC1..1xhtml(USCDI) Limited xhtml content
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... custodian 0..1Reference(US Core Patient Profile | US Core Practitioner Profile | US Core PractitionerRole Profile | US Core CareTeam Profile | US Core Organization Profile | RelatedPerson | Device | Multiple Chronic Condition Care Plan Care Team)When populated, the custodian is responsible for the care and maintenance of the care plan. The care plan is attributed to the custodian. The custodian might or might not be a contributor. This CarePlan.custodian extension should be used instead of CarePlan.author which in R4 is currently identified as the designated responsible party and in R5 has been removed.
URL: http://hl7.org/fhir/us/mcc/StructureDefinition/custodian
... 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 ?!SΣ1..1code(USCDI) draft | active | on-hold | revoked | completed | entered-in-error | unknown
Binding: RequestStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.

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

... Slices for category SΣ1..*CodeableConceptCare Plan category code describes the type of care plan. Please see CarePlan.category detail for guidance.
Slice: Unordered, Open by pattern:$this
Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc.


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



Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/careplan-category
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: assess-plan
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
... title Σ0..1stringHuman-friendly name for the care plan
... description Σ0..1stringSummary of nature of plan
... subject SΣ1..1Reference(US Core Patient Profile)(USCDI) 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)Use the CarePlan custodian extension instead. Use of CarePlan.author is discouraged, it is removed in R5.
... contributor S0..*Reference(US Core Patient Profile | US Core Practitioner Profile | US Core PractitionerRole Profile | US Core CareTeam Profile | US Core Organization Profile | RelatedPerson | Device | Multiple Chronic Condition Care Plan Care Team)Who provided the content of the care plan
... careTeam S0..*Reference(Multiple Chronic Condition Care Plan Care Team | US Core CareTeam Profile)Who's involved in plan?
... addresses Σ0..*Reference(Condition)Health issues this plan addresses
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC0..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... supportingInfo S0..*Reference(US Core Blood Pressure Profile | US Core BMI Profile | US Core Body Weight Profile | Multiple Chronic Condition Care Plan Chronic Disease Conditions | Multiple Chronic Condition Care Plan Laboratory Result Observation | Multiple Chronic Condition Care Plan Diagnostic Report and Note | Multiple Chronic Condition Care Plan Procedure | US Core Immunization Profile | Multiple Chronic Condition Care Plan Family History | Document Reference to Patient's Personal Advance Care Plan (Advance Directive) | SDC Questionnaire Response | Multiple Chronic Condition Care Plan Symptom Observation | Multiple Chronic Condition Care Plan Service Request | Multiple Chronic Condition Care Plan Observation SDOH Assessment | Multiple Chronic Condition Care Plan Immunization | Multiple Chronic Condition Care Plan Nutrition Order | Multiple Chronic Condition Care Plan Clinical Impression | Multiple Chronic Condition Care Plan Patient/Caregiver Condition Status Observation | Multiple Chronic Condition Care Plan Questionnaire Response | Multiple Chronic Condition Care Plan Caregiver Considerations Observation | Multiple Chronic Condition Care Plan Clinical Test Observation | US Core RelatedPerson Profile | US Core Observation Occupation Profile)Please see the libraries of available value sets pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.supportingInfo
... goal 0..*Reference(Multiple Chronic Condition Care Plan Goal)This Goal represents one or more overarching goal applicable to the entire care plan
... activity SC0..*BackboneElementAction to occur as part of plan. This is the backbone element of the care plan that is the root of care coordination activities. While there can be many activities in a care plan, each activity has only one planned.activityRefence
.... 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 S0..*Reference(Multiple Chronic Condition Care Plan Procedure | Multiple Chronic Condition Care Plan Laboratory Result Observation | US Core Immunization Profile | Multiple Chronic Condition Care Plan Diagnostic Report and Note | US Core Immunization Profile | Multiple Chronic Condition Care Plan Medication Request | Multiple Chronic Condition Care Plan Chronic Disease Conditions | US Core Body Weight Profile | US Core Blood Pressure Profile | Multiple Chronic Condition Care Plan Goal | US Core BMI Profile | Multiple Chronic Condition Care Plan Symptom Observation)This CarePlan element represents a PERFORMED ACTIVITY. Please see the libraries of available value sets pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.activity.outcomeReference
.... progress 0..*AnnotationComments about the activity status/progress
.... reference SC0..1Reference(NutritionOrder | Multiple Chronic Condition Care Plan Medication Request | CommunicationRequest | DeviceRequest | Task | ServiceRequest | VisionPrescription | RequestGroup | Appointment)This CarePlan element represents a PLANNED ACTIVITY. Please see the libraries of available value sets pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.activity.reference
... note 0..*AnnotationComments about the plan

doco Documentation for this format

Terminology Bindings

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

Constraints

IdGradePath(s)DetailsRequirements
cpl-3errorCarePlan.activityProvide a reference or detail, not both
: detail.empty() or reference.empty()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
txt-1errorCarePlan.text.divThe narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes
: htmlChecks()
txt-2errorCarePlan.text.divThe narrative SHALL have some non-whitespace content
: htmlChecks()

This structure is derived from USCoreCarePlanProfile

Summary

Must-Support: 9 elements
Prohibited: 1 element

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

 

Other representations of profile: CSV, Excel, Schematron