FHIR Release 3 (STU)

This page is part of the FHIR Specification (v3.0.2: STU 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

Patient Care Work GroupMaturity Level: 2 Trial UseCompartments: Patient, Practitioner, RelatedPerson

Detailed Descriptions for the elements in the CarePlan resource.

CarePlan
Definition

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

Control1..1
Alternate NamesCare Team
CarePlan.identifier
Definition

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).

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Requirements

Need to allow connection to a wider workflow.

Summarytrue
CarePlan.definition
Definition

Identifies the protocol, questionnaire, guideline or other specification the care plan should be conducted in accordance with.

Control0..*
TypeReference(PlanDefinition | Questionnaire)
Summarytrue
CarePlan.basedOn
Definition

A care plan that is fulfilled in whole or in part by this care plan.

Control0..*
TypeReference(CarePlan)
Requirements

Allows tracing of the care plan and tracking whether proposals/recommendations were acted upon.

Alternate Namesfulfills
Summarytrue
CarePlan.replaces
Definition

Completed or terminated care plan whose function is taken by this new care plan.

Control0..*
TypeReference(CarePlan)
Requirements

Allows tracing the continuation of a therapy or administrative process instantiated through multiple care plans.

Alternate Namessupersedes
Summarytrue
Comments

The replacement could be because the initial care plan was immediately rejected (due to an issue) or because the previous care plan was completed, but the need for the action described by the care plan remains ongoing.

CarePlan.partOf
Definition

A larger care plan of which this particular care plan is a component or step.

Control0..*
TypeReference(CarePlan)
Summarytrue
Comments

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.

CarePlan.status
Definition

Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.

Control1..1
Terminology BindingCarePlanStatus (Required)
Typecode
Is Modifiertrue
Requirements

Allows clinicians to determine whether the plan is actionable or not.

Summarytrue
Comments

The unknown code is not to be used to convey other statuses. The unknown code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the care plan.

This element is labeled as a modifier because the status contains the code entered-in-error] that marks the plan as not currently valid.

CarePlan.intent
Definition

Indicates the level of authority/intentionality associated with the care plan and where the care plan fits into the workflow chain.

Control1..1
Terminology BindingCarePlanIntent (Required)
Typecode
Is Modifiertrue
Requirements

Proposals/recommendations, plans and orders all use the same structure and can exist in the same fulfillment chain.

Summarytrue
Comments

This element is labeled as a modifier because the intent alters when and how the resource is actually applicable.

CarePlan.category
Definition

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.

Control0..*
Terminology BindingCare Plan Category (Example)
TypeCodeableConcept
Requirements

Used for filtering what plan(s) are retrieved and displayed to different types of users.

Summarytrue
Comments

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.

CarePlan.title
Definition

Human-friendly name for the CarePlan.

Control0..1
Typestring
Summarytrue
CarePlan.description
Definition

A description of the scope and nature of the plan.

Control0..1
Typestring
Requirements

Provides more detail than conveyed by category.

Summarytrue
CarePlan.subject
Definition

Identifies the patient or group whose intended care is described by the plan.

Control1..1
TypeReference(Patient | Group)
Alternate Namespatient
Summarytrue
CarePlan.context
Definition

Identifies the original context in which this particular CarePlan was created.

Control0..1
TypeReference(Encounter | EpisodeOfCare)
Alternate Namesencounter
Summarytrue
Comments

Activities conducted as a result of the care plan may well occur as part of other encounters/episodes.

CarePlan.period
Definition

Indicates when the plan did (or is intended to) come into effect and end.

Control0..1
TypePeriod
Requirements

Allows tracking what plan(s) are in effect at a particular time.

Alternate Namestiming
Summarytrue
Comments

Any activities scheduled as part of the plan should be constrained to the specified period regardless of whether the activities are planned within a single encounter/episode or across multiple encounters/episodes (e.g. the longitudinal management of a chronic condition).

CarePlan.author
Definition

Identifies the individual(s) or ogranization who is responsible for the content of the care plan.

Control0..*
TypeReference(Patient | Practitioner | RelatedPerson | Organization | CareTeam)
Summarytrue
Comments

Collaborative care plans may have multiple authors.

CarePlan.careTeam
Definition

Identifies all people and organizations who are expected to be involved in the care envisioned by this plan.

Control0..*
TypeReference(CareTeam)
Requirements

Allows representation of care teams, helps scope care plan. In some cases may be a determiner of access permissions.

CarePlan.addresses
Definition

Identifies the conditions/problems/concerns/diagnoses/etc. whose management and/or mitigation are handled by this plan.

Control0..*
TypeReference(Condition)
Requirements

Links plan to the conditions it manages. The element can identify risks addressed by the plan as well as active conditions. (The Condition resource can include things like "at risk for hypertension" or "fall risk".) Also scopes plans - multiple plans may exist addressing different concerns.

Summarytrue
CarePlan.supportingInfo
Definition

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.

Control0..*
TypeReference(Any)
Requirements

Identifies barriers and other considerations associated with the care plan.

Comments

Use "concern" to identify specific conditions addressed by the care plan.

CarePlan.goal
Definition

Describes the intended objective(s) of carrying out the care plan.

Control0..*
TypeReference(Goal)
Requirements

Provides context for plan. Allows plan effectiveness to be evaluated by clinicians.

Comments

Goal can be achieving a particular change or merely maintaining a current state or even slowing a decline.

CarePlan.activity
Definition

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.

Control0..*
Requirements

Allows systems to prompt for performance of planned activities, and validate plans against best practice.

InvariantsDefined on this element
cpl-3: Provide a reference or detail, not both (expression : detail.empty() or reference.empty(), xpath: not(exists(f:detail)) or not(exists(f:reference)))
CarePlan.activity.outcomeCodeableConcept
Definition

Identifies the outcome at the point when the status of the activity is assessed. For example, the outcome of an education activity could be patient understands (or not).

Control0..*
Terminology BindingCare Plan Activity Outcome (Example)
TypeCodeableConcept
Comments

Note that this should not duplicate the activity status (e.g. completed or in progress).

CarePlan.activity.outcomeReference
Definition

Details of the outcome or action resulting from the activity. The reference to an "event" resource, such as Procedure or Encounter or Observation, is the result/outcome of the activity itself. The activity can be conveyed using CarePlan.activity.detail OR using the CarePlan.activity.reference (a reference to a “request” resource).

Control0..*
TypeReference(Any)
Requirements

Links plan to resulting actions.

Comments

The activity outcome is independent of the outcome of the related goal(s). For example, if the goal is to achieve a target body weight of 150 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.

CarePlan.activity.progress
Definition

Notes about the adherence/status/progress of the activity.

Control0..*
TypeAnnotation
Requirements

Can be used to capture information about adherence, progress, concerns, etc.

Comments

This element should NOT be used to describe the activity to be performed - that occurs either within the resource pointed to by activity.detail.reference or in activity.detail.description.

CarePlan.activity.reference
Definition

The details of the proposed activity represented in a specific resource.

Control0..1
TypeReference(Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ProcedureRequest | ReferralRequest | VisionPrescription | RequestGroup)
Requirements

Details in a form consistent with other applications and contexts of use.

Comments

Standard extension exists (goal-pertainstogoal) 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.

InvariantsAffect this element
cpl-3: Provide a reference or detail, not both (expression : detail.empty() or reference.empty(), xpath: not(exists(f:detail)) or not(exists(f:reference)))
CarePlan.activity.detail
Definition

A simple summary of a planned activity suitable for a general care plan system (e.g. form driven) that doesn't know about specific resources such as procedure etc.

Control0..1
Requirements

Details in a simple form for generic care plan systems.

InvariantsAffect this element
cpl-3: Provide a reference or detail, not both (expression : detail.empty() or reference.empty(), xpath: not(exists(f:detail)) or not(exists(f:reference)))
CarePlan.activity.detail.category
Definition

High-level categorization of the type of activity in a care plan.

Control0..1
Terminology BindingCarePlanActivityCategory (Example)
TypeCodeableConcept
Requirements

May determine what types of extensions are permitted.

CarePlan.activity.detail.definition
Definition

Identifies the protocol, questionnaire, guideline or other specification the planned activity should be conducted in accordance with.

Control0..1
TypeReference(PlanDefinition | ActivityDefinition | Questionnaire)
Requirements

Allows Questionnaires that the patient (or practitioner) should fill in to fulfill the care plan activity.

CarePlan.activity.detail.code
Definition

Detailed description of the type of planned activity; e.g. What lab test, what procedure, what kind of encounter.

Control0..1
Terminology BindingCare Plan Activity (Example)
TypeCodeableConcept
Requirements

Allows matching performed to planned as well as validation against protocols.

Comments

Tends to be less relevant for activities involving particular products. Codes should not convey negation - use "prohibited" instead.

CarePlan.activity.detail.reasonCode
Definition

Provides the rationale that drove the inclusion of this particular activity as part of the plan or the reason why the activity was prohibited.

Control0..*
Terminology BindingActivity Reason (Example)
TypeCodeableConcept
Comments

This could be a diagnosis code. If a full condition record exists or additional detail is needed, use reasonCondition instead.

CarePlan.activity.detail.reasonReference
Definition

Provides the health condition(s) that drove the inclusion of this particular activity as part of the plan.

Control0..*
TypeReference(Condition)
Comments

Conditions can be identified at the activity level that are not identified as reasons for the overall plan.

CarePlan.activity.detail.goal
Definition

Internal reference that identifies the goals that this activity is intended to contribute towards meeting.

Control0..*
TypeReference(Goal)
Requirements

So that participants know the link explicitly.

CarePlan.activity.detail.status
Definition

Identifies what progress is being made for the specific activity.

Control1..1
Terminology BindingCarePlanActivityStatus (Required)
Typecode
Is Modifiertrue
Requirements

Indicates progress against the plan, whether the activity is still relevant for the plan.

Comments

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.

CarePlan.activity.detail.statusReason
Definition

Provides reason why the activity isn't yet started, is on hold, was cancelled, etc.

Control0..1
Typestring
Comments

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.

CarePlan.activity.detail.prohibited
Definition

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.

Control0..1
Typeboolean
Is Modifiertrue
Default Valuefalse
Requirements

Captures intention to not do something that may have been previously typical.

Comments

This element is labeled as a modifier because it marks an activity as an activity that is not to be performed.

CarePlan.activity.detail.scheduled[x]
Definition

The period, timing or frequency upon which the described activity is to occur.

Control0..1
TypeTiming|Period|string
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Allows prompting for activities and detection of missed planned activities.

CarePlan.activity.detail.location
Definition

Identifies the facility where the activity will occur; e.g. home, hospital, specific clinic, etc.

Control0..1
TypeReference(Location)
Requirements

Helps in planning of activity.

Comments

May reference a specific clinical location or may identify a type of location.

CarePlan.activity.detail.performer
Definition

Identifies who's expected to be involved in the activity.

Control0..*
TypeReference(Practitioner | Organization | RelatedPerson | Patient | CareTeam)
Requirements

Helps in planning of activity.

Comments

A performer MAY also be a participant in the care plan.

CarePlan.activity.detail.product[x]
Definition

Identifies the food, drug or other product to be consumed or supplied in the activity.

Control0..1
Terminology BindingSNOMED CT Medication Codes (Example)
TypeCodeableConcept|Reference(Medication | Substance)
[x] NoteSee Choice of Data Types for further information about how to use [x]
CarePlan.activity.detail.dailyAmount
Definition

Identifies the quantity expected to be consumed in a given day.

Control0..1
TypeSimpleQuantity
Requirements

Allows rough dose checking.

Alternate Namesdaily dose
CarePlan.activity.detail.quantity
Definition

Identifies the quantity expected to be supplied, administered or consumed by the subject.

Control0..1
TypeSimpleQuantity
CarePlan.activity.detail.description
Definition

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.

Control0..1
Typestring
CarePlan.note
Definition

General notes about the care plan not covered elsewhere.

Control0..*
TypeAnnotation
Requirements

Used to capture information that applies to the plan as a whole that doesn't fit into discrete elements.