MCC eCare Plan Implementation Guide
0.1.0 - CI Build US

MCC eCare Plan Implementation Guide - Local Development build (v0.1.0). 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: 0.1.0
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.

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 OutcomeCodeableConcept, OutcomeReference, Progress Note when using activity.reference.

OUTCOME REFERENCE (aka PERFORMED ACTIVITY reference): to be renamed in R5 to “CarePlan.performedActivity”. Please see https://jira.hl7.org/browse/FHIR-26064.) 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 CarePlan.performedActivity, the extension, “resource-pertainsToGoal” SHALL be used to reference this activity’s related goal. Within the resource referenced within performedActivity, “Procedure.reason” SHALL be used to reference the health concern or problem for which the activity is done.

ACTIVITY REFERENCE (aka PLANNED ACTIVITY reference): to be renamed in R5 to “PlannedActivityReference”. Please see https://jira.hl7.org/browse/FHIR-26064.) Within plannedActivityReference, the extension, “resource-pertainsToGoal” SHALL be used to reference this activity’s request’s related goal. “xxx.Request.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 goal).

Health Concerns represented with:

  • CarePlan.addresses
  • CarePlan.suppportingInfo
  • CarePlan.addresses (from within referenced goal)
  • Goal.addresses
  • activity.reason.reference

Goals represented with:

  • CarePlan.goal (for entire plan)
  • resource-pertainsToGoal
  • CarePlan.activity.outcomeReference.MCC Goal Profile

Interventions represented with:

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

Outcomes represented with:

  • CarePlan.ActivityOutcome
  • 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

Summary

Must-Support: 9 elements
Prohibited: 1 element

Structures

This structure refers to these other structures:

This structure is derived from USCoreCarePlanProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan 0..*USCoreCarePlanProfileHealthcare plan for patient or group
... status S1..1codedraft | active | on-hold | revoked | completed | entered-in-error | unknown
... intent S1..1codeproposal | plan | order | option
... category 1..*CodeableConceptCare Plan category code describes the type of care plan. Please see CarePlan.category detail for guidance.
... author S0..1Reference(US Core Patient Profile | US Core Practitioner Profile | US Core PractitionerRole Profile | US Core CareTeam Profile | US Core Organization Profile | RelatedPerson | Device)Who is the designated responsible party. CUSTODIAN OR CARE PLAN OWNER
... 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)Who provided the content of the care plan
... careTeam S0..*Reference(CareTeam)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)Please see the libraries of available value sets (link(s)?) 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)This CarePlan element represents a PERFORMED ACTIVITY. Please see the libraries of available value sets (insert link(s)?) 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 (insert link(s)?) pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.activityReference
.... detail 0..0

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

Additional BindingsPurpose
AllLanguagesMax Binding
... text S1..1NarrativeText summary of the resource, for human interpretation
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... status S1..1codegenerated | extensions | additional | empty
Binding: NarrativeStatus (required): The status of a resource narrative.

.... div SI1..1xhtmlLimited xhtml content
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... 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..1codedraft | active | on-hold | revoked | completed | entered-in-error | unknown
Binding: RequestStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.

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

... Slices for category Σ1..*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..1CodeableConceptType of plan
Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc.



Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://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)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 SΣ0..1Reference(US Core Patient Profile | US Core Practitioner Profile | US Core PractitionerRole Profile | US Core CareTeam Profile | US Core Organization Profile | RelatedPerson | Device)Who is the designated responsible party. CUSTODIAN OR CARE PLAN OWNER
... 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)Who provided the content of the care plan
... careTeam S0..*Reference(CareTeam)Who's involved in plan?
... addresses Σ0..*Reference(Condition)Health issues this plan addresses
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI0..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)Please see the libraries of available value sets (link(s)?) 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 SI0..*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)This CarePlan element represents a PERFORMED ACTIVITY. Please see the libraries of available value sets (insert link(s)?) 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 SI0..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 (insert link(s)?) pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.activityReference
... note 0..*AnnotationComments about the plan

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan 0..*USCoreCarePlanProfileHealthcare plan for patient or group
... text 1..1NarrativeText summary of the resource, for human interpretation
.... status 1..1codegenerated | extensions | additional | empty
Binding: NarrativeStatus (required): The status of a resource narrative.

.... div I1..1xhtmlLimited xhtml content
... status ?!Σ1..1codedraft | active | on-hold | revoked | completed | entered-in-error | unknown
Binding: RequestStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.

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

.... 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 Σ1..1Reference(US Core Patient Profile)Who the care plan is for
... author Σ0..1Reference(US Core Patient Profile | US Core Practitioner Profile | US Core PractitionerRole Profile | US Core CareTeam Profile | US Core Organization Profile | RelatedPerson | Device)Who is the designated responsible party. CUSTODIAN OR CARE PLAN OWNER
... contributor 0..*Reference(US Core Patient Profile | US Core Practitioner Profile | US Core PractitionerRole Profile | US Core CareTeam Profile | US Core Organization Profile | RelatedPerson | Device)Who provided the content of the care plan
... careTeam 0..*Reference(CareTeam)Who's involved in plan?
... supportingInfo 0..*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)Please see the libraries of available value sets (link(s)?) pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.supportingInfo
... activity I0..*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 0..*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)This CarePlan element represents a PERFORMED ACTIVITY. Please see the libraries of available value sets (insert link(s)?) pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.activity.outcomeReference
.... reference I0..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 (insert link(s)?) pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.activityReference

doco Documentation for this format

This structure is derived from USCoreCarePlanProfile

Summary

Must-Support: 9 elements
Prohibited: 1 element

Structures

This structure refers to these other structures:

Differential View

This structure is derived from USCoreCarePlanProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan 0..*USCoreCarePlanProfileHealthcare plan for patient or group
... status S1..1codedraft | active | on-hold | revoked | completed | entered-in-error | unknown
... intent S1..1codeproposal | plan | order | option
... category 1..*CodeableConceptCare Plan category code describes the type of care plan. Please see CarePlan.category detail for guidance.
... author S0..1Reference(US Core Patient Profile | US Core Practitioner Profile | US Core PractitionerRole Profile | US Core CareTeam Profile | US Core Organization Profile | RelatedPerson | Device)Who is the designated responsible party. CUSTODIAN OR CARE PLAN OWNER
... 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)Who provided the content of the care plan
... careTeam S0..*Reference(CareTeam)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)Please see the libraries of available value sets (link(s)?) 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)This CarePlan element represents a PERFORMED ACTIVITY. Please see the libraries of available value sets (insert link(s)?) 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 (insert link(s)?) pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.activityReference
.... detail 0..0

doco Documentation for this format

Snapshot View

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

Additional BindingsPurpose
AllLanguagesMax Binding
... text S1..1NarrativeText summary of the resource, for human interpretation
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... status S1..1codegenerated | extensions | additional | empty
Binding: NarrativeStatus (required): The status of a resource narrative.

.... div SI1..1xhtmlLimited xhtml content
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... 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..1codedraft | active | on-hold | revoked | completed | entered-in-error | unknown
Binding: RequestStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.

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

... Slices for category Σ1..*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..1CodeableConceptType of plan
Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc.



Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://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)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 SΣ0..1Reference(US Core Patient Profile | US Core Practitioner Profile | US Core PractitionerRole Profile | US Core CareTeam Profile | US Core Organization Profile | RelatedPerson | Device)Who is the designated responsible party. CUSTODIAN OR CARE PLAN OWNER
... 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)Who provided the content of the care plan
... careTeam S0..*Reference(CareTeam)Who's involved in plan?
... addresses Σ0..*Reference(Condition)Health issues this plan addresses
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI0..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)Please see the libraries of available value sets (link(s)?) 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 SI0..*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)This CarePlan element represents a PERFORMED ACTIVITY. Please see the libraries of available value sets (insert link(s)?) 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 SI0..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 (insert link(s)?) pertinent for use with the appropriate Multiple Chronic Condition Care Plan Profile for use within the referenced profiles at CarePlan.activityReference
... note 0..*AnnotationComments about the plan

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / Code
CarePlan.languagepreferredCommonLanguages
Max Binding: AllLanguages
CarePlan.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

IdGradePathDetailsRequirements
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-1errorCarePlan.metaAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.implicitRulesAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.languageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.textAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.text.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorCarePlan.text.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorCarePlan.text.statusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.text.divAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
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()
ele-1errorCarePlan.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorCarePlan.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorCarePlan.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorCarePlan.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorCarePlan.identifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.instantiatesCanonicalAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.instantiatesUriAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.basedOnAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.replacesAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.partOfAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.statusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.intentAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.categoryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.category:AssessPlanAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.titleAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.descriptionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.subjectAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.encounterAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.periodAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.createdAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.authorAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.contributorAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.careTeamAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.addressesAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.addresses.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorCarePlan.addresses.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorCarePlan.addresses.referenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.addresses.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.addresses.identifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.addresses.displayAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.supportingInfoAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.goalAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
cpl-3errorCarePlan.activityProvide a reference or detail, not both
: detail.empty() or reference.empty()
ele-1errorCarePlan.activityAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.activity.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorCarePlan.activity.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorCarePlan.activity.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorCarePlan.activity.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorCarePlan.activity.outcomeCodeableConceptAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.activity.outcomeReferenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.activity.progressAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.activity.referenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.activity.detail.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorCarePlan.activity.detail.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorCarePlan.activity.detail.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorCarePlan.activity.detail.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorCarePlan.activity.detail.kindAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.activity.detail.instantiatesCanonicalAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.activity.detail.instantiatesUriAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.activity.detail.codeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.activity.detail.reasonCodeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.activity.detail.reasonReferenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.activity.detail.goalAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.activity.detail.statusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.activity.detail.statusReasonAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.activity.detail.doNotPerformAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.activity.detail.scheduled[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.activity.detail.locationAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.activity.detail.performerAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.activity.detail.product[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.activity.detail.dailyAmountAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.activity.detail.quantityAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.activity.detail.descriptionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorCarePlan.noteAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())