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.

This records identifiers associated with this care plan that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation).

Need to allow connection to a wider workflow.

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

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

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

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

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

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.

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.

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

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

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.

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

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

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

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.

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

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.

Human-friendly name for the CarePlan.

A description of the scope and nature of the plan.

Provides more detail than conveyed by category.

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

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

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

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

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

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).

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

Collaborative care plans may have multiple authors.

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

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

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

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

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.

Identifies barriers and other considerations associated with the care plan.

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

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

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

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

Identifies a planned action to occur as part of the plan. For example, a medication to be used, lab tests to perform, self-monitoring, education, etc.

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

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

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

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

Links plan to resulting actions.

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.

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

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

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.

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

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

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.

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

Details in a simple form for generic care plan systems.

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

May determine what types of extensions are permitted.

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

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

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

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

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

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.

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

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

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

So that participants know the link explicitly.

Identifies what progress is being made for the specific activity.

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

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.

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

Will generally not be present if status is "complete". Be sure to prompt to update this (or at least remove the existing value) if the status is changed.

If true, indicates that the described activity is one that must NOT be engaged in when following the plan. If false, indicates that the described activity is one that should be engaged in when following the plan.

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

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

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

Allows prompting for activities and detection of missed planned activities.

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

Helps in planning of activity.

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

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

Helps in planning of activity.

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

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

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

Allows rough dose checking.

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

This provides a textual description of constraints on the intended activity occurrence, including relation to other activities. It may also include objectives, pre-conditions and end-conditions. Finally, it may convey specifics about the activity such as body site, method, route, etc.

General notes about the care plan not covered elsewhere.

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