CarePlan

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. Refer to the US Core CarePlan profile.

Schema

Elements

Name	Required	Type	Description
identifier		Identifier[]	External Ids for this plan Details Business identifiers assigned to this care plan by the performer or other systems which remain constant as the resource is updated and propagates from server to server. This is a business identifier, not a resource identifier (see [discussion](resource.html#identifiers)). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.
instantiatesCanonical		canonical[]	Instantiates FHIR protocol or definition Details The URL pointing to a FHIR-defined protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlan.
instantiatesUri		uri[]	Instantiates external protocol or definition Details The URL pointing to an externally maintained protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlan. This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
basedOn		Reference<CarePlan>[]	Fulfills CarePlan Details A care plan that is fulfilled in whole or in part by this care plan.
replaces		Reference<CarePlan>[]	CarePlan replaced by this CarePlan Details 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.
partOf		Reference<CarePlan>[]	Part of referenced CarePlan Details 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.
status	✓	code	draft | active | on-hold | revoked | completed | entered-in-error | unknown Details 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.
intent	✓	code	proposal | plan | order | option Details 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.
category		CodeableConcept[]	Type of plan Details 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. There may be multiple axes of categorization and one plan may serve multiple purposes. In some cases, this may be redundant with references to CarePlan.concern.
title		string	Human-friendly name for the care plan Details Human-friendly name for the care plan.
description		string	Summary of nature of plan Details A description of the scope and nature of the plan.
subject	✓	Reference<Patient | Group>	Who the care plan is for Details Identifies the patient or group whose intended care is described by the plan.
encounter		Reference<Encounter>	Encounter created as part of Details The Encounter during which this CarePlan was created or to which the creation of this record is tightly associated. This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. CarePlan activities conducted as a result of the care plan may well occur as part of other encounters.
period		Period	Time period plan covers Details 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).
created		dateTime	Date record was first recorded Details Represents when this particular CarePlan record was created in the system, which is often a system-generated date.
author		Reference< Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam >	Who is the designated responsible party Details When populated, the author is responsible for the care plan. The care plan is attributed to the author. The author may also be a contributor. For example, an organization can be an author, but not listed as a contributor.
contributor		Reference< Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam >[]	Who provided the content of the care plan Details Identifies the individual(s) or organization who provided the contents of the care plan. Collaborative care plans may have multiple contributors.
careTeam		Reference<CareTeam>[]	Who's involved in plan? Details Identifies all people and organizations who are expected to be involved in the care envisioned by this plan.
addresses		Reference<Condition>[]	Health issues this plan addresses Details Identifies the conditions/problems/concerns/diagnoses/etc. whose management and/or mitigation are handled by this plan. When the diagnosis is related to an allergy or intolerance, the Condition and AllergyIntolerance resources can both be used. However, to be actionable for decision support, using Condition alone is not sufficient as the allergy or intolerance condition needs to be represented as an AllergyIntolerance.
supportingInfo		Reference<Resource>[]	Information considered as part of plan Details Identifies portions of the patient's record that specifically influenced the formation of the plan. These might include comorbidities, recent procedures, limitations, recent assessments, etc. Use "concern" to identify specific conditions addressed by the care plan.
goal		Reference<Goal>[]	Desired outcome of plan Details 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.
activity		CarePlanActivity[]	Action to occur as part of plan Details 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.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. 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 can 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.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details 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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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.
outcomeCodeableConcept		CodeableConcept[]	Results of the activity Details 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).
outcomeReference		Reference<Resource>[]	Appointment, Encounter, Procedure, etc. Details 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 lbs 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.
progress		Annotation[]	Comments about the activity status/progress Details 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.
reference		Reference< Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup >	Activity details defined in specific resource Details The details of the proposed activity represented in a specific resource. Standard extension exists ([resource-pertainsToGoal](extension-resource-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 independently 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.
detail		CarePlanActivityDetail	In-line definition of activity Details 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.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. 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 can 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.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details 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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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.
kind		code	Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription Details A description of the kind of resource the in-line definition of a care plan activity is representing. The CarePlan.activity.detail is an in-line definition when a resource is not referenced using CarePlan.activity.reference. For example, a MedicationRequest, a ServiceRequest, or a CommunicationRequest.
instantiatesCanonical		canonical[]	Instantiates FHIR protocol or definition Details The URL pointing to a FHIR-defined protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlan activity.
instantiatesUri		uri[]	Instantiates external protocol or definition Details The URL pointing to an externally maintained protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlan activity. This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
code		CodeableConcept	Detail type of activity Details 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.
reasonCode		CodeableConcept[]	Why activity should be done or why activity was prohibited Details 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.
reasonReference		Reference< Condition | Observation | DiagnosticReport | DocumentReference >[]	Why activity is needed Details Indicates another resource, such as the health condition(s), whose existence justifies this request and 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.
goal		Reference<Goal>[]	Goals this activity relates to Details Internal reference that identifies the goals that this activity is intended to contribute towards meeting.
status	✓	code	not-started | scheduled | in-progress | on-hold | completed | cancelled | stopped | unknown | entered-in-error Details 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.
statusReason		CodeableConcept	Reason for current status Details 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.
doNotPerform		boolean	If true, activity is prohibiting action Details If true, indicates that the described activity is one that must NOT be engaged in when following the plan. If false, or missing, 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.
scheduled[x]		Timing, Period, string	When activity is to occur Details The period, timing or frequency upon which the described activity is to occur.
location		Reference<Location>	Where it should happen Details 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.
performer		Reference< Practitioner | PractitionerRole | Organization | RelatedPerson | Patient | CareTeam | HealthcareService | Device >[]	Who will be responsible? Details Identifies who's expected to be involved in the activity. A performer MAY also be a participant in the care plan.
product[x]		CodeableConcept, Reference<Medication | Substance>	What is to be administered/supplied Details Identifies the food, drug or other product to be consumed or supplied in the activity.
dailyAmount		Quantity	How to consume/day? Details Identifies the quantity expected to be consumed in a given day.
quantity		Quantity	How much to administer/supply/consume Details Identifies the quantity expected to be supplied, administered or consumed by the subject.
description		string	Extra info describing activity to perform Details 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.
note		Annotation[]	Comments about the plan Details General notes about the care plan not covered elsewhere.

Search Parameters

Name	Type	Description	Expression
date	date	Time period plan covers	CarePlan.period
identifier	token	External Ids for this plan	CarePlan.identifier
patient	reference	Who the care plan is for	CarePlan.subject.where(resolve() is Patient)
activity-code	token	Detail type of activity	CarePlan.activity.detail.code
activity-date	date	Specified date occurs within period specified by CarePlan.activity.detail.scheduled[x]	CarePlan.activity.detail.scheduled
activity-reference	reference	Activity details defined in specific resource	CarePlan.activity.reference
based-on	reference	Fulfills CarePlan	CarePlan.basedOn
care-team	reference	Who's involved in plan?	CarePlan.careTeam
category	token	Type of plan	CarePlan.category
condition	reference	Health issues this plan addresses	CarePlan.addresses
encounter	reference	Encounter created as part of	CarePlan.encounter
goal	reference	Desired outcome of plan	CarePlan.goal
instantiates-canonical	reference	Instantiates FHIR protocol or definition	CarePlan.instantiatesCanonical
instantiates-uri	uri	Instantiates external protocol or definition	CarePlan.instantiatesUri
intent	token	proposal | plan | order | option	CarePlan.intent
part-of	reference	Part of referenced CarePlan	CarePlan.partOf
performer	reference	Matches if the practitioner is listed as a performer in any of the "simple" activities. (For performers of the detailed activities, chain through the activitydetail search parameter.)	CarePlan.activity.detail.performer
replaces	reference	CarePlan replaced by this CarePlan	CarePlan.replaces
status	token	draft | active | on-hold | revoked | completed | entered-in-error | unknown	CarePlan.status
subject	reference	Who the care plan is for	CarePlan.subject

Inherited Elements

Name	Required	Type	Description
id		string	Logical id of this artifact Details 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.
meta		Meta	Metadata about the resource Details The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
implicitRules		uri	A set of rules under which this content was created Details A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. 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. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
language		code	Language of the resource content Details 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		Narrative	Text summary of the resource, for human interpretation Details A human-readable narrative that contains a summary of the resource and can 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 information is added later.
contained		Resource[]	Contained, inline Resources Details 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. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the resource. 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 can 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.
modifierExtension		Extension[]	Extensions that cannot be ignored Details 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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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.

Usage

CarePlan is one of the request resources in the FHIR workflow specification.

Care Plans are used in many areas of healthcare with a variety of scopes. They can be as simple as a general practitioner keeping track of when their patient is next due for a tetanus immunization through to a detailed plan for an oncology patient covering diet, chemotherapy, radiation, lab work and counseling with detailed timing relationships, pre-conditions and goals. They may be used in veterinary care or clinical research to describe the care of a herd or other collection of animals. In public health, they may describe education or immunization campaigns.

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

The scope of care plans may vary widely. Examples include:

• Multi-disciplinary cross-organizational care plans; e.g. An oncology plan including the oncologist, home nursing staff, pharmacy and others
• Plans to manage specific disease/condition(s) (e.g. nutritional plan for a patient post bowel resection, neurological plan post head injury, pre-natal plan, post-partum plan, grief management plan, etc.)
• Decision support generated plans following specific practice guidelines (e.g. stroke care plan, diabetes plan, falls prevention, etc.)
• Self-maintained patient or care-giver authored plans identifying their goals and an integrated understanding of actions to be taken

This resource can be used to represent both proposed plans (for example, recommendations from a decision support engine or returned as part of a consult report) as well as active plans. The nature of the plan is communicated by the status. Some systems may need to filter CarePlans to ensure that only appropriate plans are exposed via a given user interface.

Relationships

For simplicity's sake, CarePlan allows the inline definition of activities as part of a plan using the activity.detail element. However, activities can also be defined using references to the various "request" resources. These references could be to resources with a status of "planned" or to an active order. It is possible for planned activities to exist (e.g. appointments) without needing a CarePlan at all. CarePlans are used when there's a need to group activities, goals and/or participants together to provide some degree of context.

CarePlans can be tied to specific Conditions, however they can also be condition-independent and instead focused on a particular type of care (e.g. psychological, nutritional) or the care delivered by a particular practitioner or group of practitioners.

An ImmunizationRecommendation can be interpreted as a narrow type of CarePlan dealing only with immunization events. Where such information could appear in either resource, the immunization-specific resource is preferred.

CarePlans represent a specific plan instance for a particular patient or group. It is not intended to be used to define generic plans or protocols that are independent of a specific individual or group. CarePlan represents a specific intent, not a general definition. Protocols and order sets are supported through PlanDefinition.

Referenced By

• DiagnosticReport
• GuidanceResponse
• ImagingStudy
• Media
• MedicationRequest
• MedicationStatement
• Observation
• Procedure
• QuestionnaireResponse
• ServiceRequest