Name Flags Card. Type Description & Constraints CarePlan 0..* US Core CarePlan Profile text S 1..1 Narrative status S 1..1 code Binding: Narrative Status (required) status S 1..1 code Binding: CarePlanStatus (required) intent S 1..1 code Binding: CarePlanIntent (required) category SI 1..* CodeableConcept us-core-1: Must have a category of 'assess-plan' and a code system 'http://hl7.org/fhir/us/core/CodeSystem/careplan-category' subject S 1..1 Reference(US Core Patient Profile) Documentation for this format
United States Minor Outlying Islands (the)
The US Core CarePlan Profile is based upon the core FHIR CarePlan Resource and created to meet the 2015 Edition Common Clinical Data Set 'Assessment and Plan of Treatment requirements.
If the resource is contained in another resource, it SHALL NOT contain nested Resources
not(parent::f:contained and f:contained)
If the resource is contained in another resource, it SHALL NOT contain any narrative
If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
contained.where(('#'+id in %resource.descendants().reference).not()).empty()
not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))]))
The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.
A set of rules under which this content was created
A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.
Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.
The base language in which the resource is written.
Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Text summary of the resource, for human interpretation
A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded in formation is added later.
unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
Additional Content defined by implementations
May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
generated | extensions | additional | empty
Constrained value set of narrative statuses.
The actual narrative content, a stripped down version of XHTML.
The contents of the html element are an XHTML fragment containing only the basic html formatting elements described in chapters 7-11 and 15 of the HTML 4.0 standard, elements (either name or href), images and internally contained stylesheets. The XHTML content may not contain a head, a body, external stylesheet references, scripts, forms, base/link/xlink, frames, iframes and objects.
The narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, elements (either name or href), images and internally contained style attributes
not(descendant-or-self::*[not(local-name(.)=('a', 'abbr', 'acronym', 'b', 'big', 'blockquote', 'br', 'caption', 'cite', 'code', 'col', 'colgroup', 'dd', 'dfn', 'div', 'dl', 'dt', 'em', 'h1', 'h2', 'h3', 'h4', 'h5', 'h6', 'hr', 'i', 'img', 'li', 'ol', 'p', 'pre', 'q', 'samp', 'small', 'span', 'strong', 'sub', 'sup', 'table', 'tbody', 'td', 'tfoot', 'th', 'thead', 'tr', 'tt', 'ul', 'var'))]) and not(descendant-or-self::*/@*[not(name(.)=('abbr', 'accesskey', 'align', 'alt', 'axis', 'bgcolor', 'border', 'cellhalign', 'cellpadding', 'cellspacing', 'cellvalign', 'char', 'charoff', 'charset', 'cite', 'class', 'colspan', 'compact', 'coords', 'dir', 'frame', 'headers', 'height', 'href', 'hreflang', 'hspace', 'id', 'lang', 'longdesc', 'name', 'nowrap', 'rel', 'rev', 'rowspan', 'rules', 'scope', 'shape', 'span', 'src', 'start', 'style', 'summary', 'tabindex', 'title', 'type', 'valign', 'value', 'vspace', 'width'))])
The narrative SHALL have some non-whitespace content
descendant::text()[normalize-space(.)!=''] or descendant::h:img[@src]
These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.
May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
This records identifiers associated with this care plan that are defined by business processes 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).
Need to allow connection to a wider workflow.
Identifies the protocol, questionnaire, guideline or other specification the care plan should be conducted in accordance with.
A care plan that is fulfilled in whole or in part by this care plan.
Allows tracing of the care plan and tracking whether proposals/recommendations were acted upon.
Completed or terminated care plan whose function is taken by this new care plan.
The replacement could be because the initial care plan was immediately rejected (due to an issue) or because the previous care plan was completed, but the need for the action described by the care plan remains ongoing.
Allows tracing the continuation of a therapy or administrative process instantiated through multiple care plans.
A larger care plan of which this particular care plan is a component or step.
Each care plan is an independent request, such that having a care plan be part of another care plan can cause issues with cascading statuses. As such, this element is still being discussed.
draft | active | suspended | completed | entered-in-error | cancelled | unknown
Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.
The unknown code is not to be used to convey other statuses. The unknown code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the care plan. This element is labeled as a modifier because the status contains the code entered-in-error] that marks the plan as not currently valid.
Request.status (uses different ValueSet)
.statusCode planned = new active = active completed = completed
Indicates the level of authority/intentionality associated with the care plan and where the care plan fits into the workflow chain.
This element is labeled as a modifier because the intent alters when and how the resource is actually applicable.
Proposals/recommendations, plans and orders all use the same structure and can exist in the same fulfillment chain.
Codes indicating the degree of authority/intentionality associated with a care plan
There may be multiple axis of categorization and one plan may serve multiple purposes. In some cases, this may be redundant with references to CarePlan.concern.
Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", "wellness plan", etc.
Must have a category of 'assess-plan' and a code system 'http://hl7.org/fhir/us/core/CodeSystem/careplan-category'
where(coding.system='http://hl7.org/fhir/us/core/CodeSystem/careplan-category' and coding.code='assess-plan').exists()
exists(f:coding/code[@value='assess-plan']) and exists(f:coding/system[@value='http://hl7.org/fhir/us/core/CodeSystem/careplan-category'])
Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc.
A description of the scope and nature of the plan.
Provides more detail than conveyed by category.
Identifies the patient or group whose intended care is described by the plan.
Identifies the original context in which this particular CarePlan was created.
Activities conducted as a result of the care plan may well occur as part of other encounters/episodes.
Indicates when the plan did (or is intended to) come into effect and end.
Any activities scheduled as part of the plan should be constrained to the specified period regardless of whether the activities are planned within a single encounter/episode or across multiple encounters/episodes (e.g. the longitudinal management of a chronic condition).
Allows tracking what plan(s) are in effect at a particular time.
Who is responsible for contents of the plan
Identifies the individual(s) or ogranization who is responsible for the content of the care plan.
Collaborative care plans may have multiple authors.
Request.requester.agent (if only one author)
Identifies all people and organizations who are expected to be involved in the care envisioned by this plan.
Allows representation of care teams, helps scope care plan. In some cases may be a determiner of access permissions.
Request.performer (similar but does not entail CareTeam)
Identifies the conditions/problems/concerns/diagnoses/etc. whose management and/or mitigation are handled by this plan.
Links plan to the conditions it manages. The element can identify risks addressed by the plan as well as active conditions. (The Condition resource can include things like "at risk for hypertension" or "fall risk".) Also scopes plans - multiple plans may exist addressing different concerns.
.actRelationship[typeCode=SUBJ].target[classCode=CONC, moodCode=EVN]
Identifies portions of the patient's record that specifically influenced the formation of the plan. These might include co-morbidities, recent procedures, limitations, recent assessments, etc.
Use "concern" to identify specific conditions addressed by the care plan.
Identifies barriers and other considerations associated with the care plan.
Describes the intended objective(s) of carrying out the care plan.
Goal can be achieving a particular change or merely maintaining a current state or even slowing a decline.
Provides context for plan. Allows plan effectiveness to be evaluated by clinicians.
Identifies a planned action to occur as part of the plan. For example, a medication to be used, lab tests to perform, self-monitoring, education, etc.
Allows systems to prompt for performance of planned activities, and validate plans against best practice.
All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
not(exists(f:detail)) or not(exists(f:reference))
no mapping NOTE: This is a list of contained Request-Event tuples!
May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Identifies the outcome at the point when the status of the activity is assessed. For example, the outcome of an education activity could be patient understands (or not).
Note that this should not duplicate the activity status (e.g. completed or in progress).
Details of the outcome or action resulting from the activity. The reference to an "event" resource, such as Procedure or Encounter or Observation, is the result/outcome of the activity itself. The activity can be conveyed using CarePlan.activity.detail OR using the CarePlan.activity.reference (a reference to a “request” resource).
The activity outcome is independent of the outcome of the related goal(s). For example, if the goal is to achieve a target body weight of 150 lb and an activity is defined to diet, then the activity outcome could be calories consumed whereas the goal outcome is an observation for the actual body weight measured.
Event that is outcome of Request in activity.reference
Comments about the activity status/progress
Notes about the adherence/status/progress of the activity.
This element should NOT be used to describe the activity to be performed - that occurs either within the resource pointed to by activity.detail.reference or in activity.detail.description.
Can be used to capture information about adherence, progress, concerns, etc.
Event.status (Annotation instead of CodableConcept)
.inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="annotation"].value
Activity details defined in specific resource
The details of the proposed activity represented in a specific resource.
Standard extension exists ([goal-pertainstogoal](extension-goal-pertainstogoal.html)) that allows goals to be referenced from any of the referenced resources in CarePlan.activity.reference. The goal should be visible when the resource referenced by CarePlan.activity.reference is viewed indepedently from the CarePlan. Requests that are pointed to by a CarePlan using this element should *not* point to this CarePlan using the "basedOn" element. i.e. Requests that are part of a CarePlan are not "based on" the CarePlan.
Details in a form consistent with other applications and contexts of use.
Request that resulted in Event in activity.actionResulting
A simple summary of a planned activity suitable for a general care plan system (e.g. form driven) that doesn't know about specific resources such as procedure etc.
Details in a simple form for generic care plan systems.
.outboundRelationship[typeCode=COMP, subsetCode=SUMM].target
diet | drug | encounter | observation | procedure | supply | other
High-level categorization of the type of activity in a care plan.
May determine what types of extensions are permitted.
Identifies the protocol, questionnaire, guideline or other specification the planned activity should be conducted in accordance with.
Allows Questionnaires that the patient (or practitioner) should fill in to fulfill the care plan activity.
Detailed description of the type of planned activity; e.g. What lab test, what procedure, what kind of encounter.
Tends to be less relevant for activities involving particular products. Codes should not convey negation - use "prohibited" instead.
Allows matching performed to planned as well as validation against protocols.
Detailed description of the type of activity; e.g. What lab test, what procedure, what kind of encounter.
Why activity should be done or why activity was prohibited
Provides the rationale that drove the inclusion of this particular activity as part of the plan or the reason why the activity was prohibited.
This could be a diagnosis code. If a full condition record exists or additional detail is needed, use reasonCondition instead.
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.
Provides the health condition(s) that drove the inclusion of this particular activity as part of the plan.
Conditions can be identified at the activity level that are not identified as reasons for the overall plan.
Internal reference that identifies the goals that this activity is intended to contribute towards meeting.
So that participants know the link explicitly.
not-started | scheduled | in-progress | on-hold | completed | cancelled | unknown
Identifies what progress is being made for the specific activity.
Some aspects of status can be inferred based on the resources linked in actionTaken. Note that "status" is only as current as the plan was most recently updated. The unknown code is not to be used to convey other statuses. The unknown code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the activity.
Indicates progress against the plan, whether the activity is still relevant for the plan.
Indicates where the activity is at in its overall life cycle.
.statusCode not-started = new scheduled = not-started (and fulfillment relationship to appointent) in-progress = active on-hold = suspended completed = completed cancelled = aborted
Provides reason why the activity isn't yet started, is on hold, was cancelled, etc.
Will generally not be present if status is "complete". Be sure to prompt to update this (or at least remove the existing value) if the status is changed.
If true, indicates that the described activity is one that must NOT be engaged in when following the plan. If false, indicates that the described activity is one that should be engaged in when following the plan.
This element is labeled as a modifier because it marks an activity as an activity that is not to be performed.
Captures intention to not do something that may have been previously typical.
The period, timing or frequency upon which the described activity is to occur.
Allows prompting for activities and detection of missed planned activities.
Identifies the facility where the activity will occur; e.g. home, hospital, specific clinic, etc.
May reference a specific clinical location or may identify a type of location.
Identifies who's expected to be involved in the activity.
A performer MAY also be a participant in the care plan.
PRT-5 : ( PRV-4 e {provider participations} ) / PRT-5 : ( PRV-4 e {non-provider person participations} ) / PRT-5 : ( PRV-4 = (patient non-subject of care) ) / PRT-8
Identifies the food, drug or other product to be consumed or supplied in the activity.
A product supplied or administered as part of a care plan activity.
Identifies the quantity expected to be consumed in a given day.
Identifies the quantity expected to be supplied, administered or consumed by the subject.
Extra info describing activity to perform
This provides a textual description of constraints on the intended 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, etc.
General notes about the care plan not covered elsewhere.
Used to capture information that applies to the plan as a whole that doesn't fit into discrete elements.