A 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.
In scope of the eHealth infrastructure CarePlans represent specific tele-medicine plans prepared by a Practitioner and applied to a specific patient for the treatment a condition such as chronic obstructive pulmonary disease (COPD).
CarePlans can be constructed as a hierarchy of subplans. The initial hierarchy is inherited from the PlanDefinition, but can be modified for the specific patient. This modification is possible both when instantiating the CarePlan and during execution of the plan.
Subplans can be attached by making them partOf the parent plan.
In order to preserve the context and history, it is not allowed to delete subplans or procedureRequests. The status attribute can be used to either cancel or complete a plan or procedureRequest, if it is no longer relevant for the patient.
A careplan can have a number of responsible CareTeams, Practitioners or Organizations with different roles who are responsible for monitoring or otherwise facilitate different aspects of the CarePlan. For instance a Practitioner could have the role of “monitoringResponsible”. All responsibles referenced from element responsible
currently hold the responsibility defined by their role.
Historically responsible CareTeams, Practitioners or Organizations are referenced from element responsibleHistory
. This structure is identical to values of the responsible
element except that entries in responsibleHistory
also carry a “period” which states the period during which the referenced party was responsible for the CarePlan.
The official URL for this profile is:
http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-careplan
This profile builds on CarePlan.
This profile was published on Fri Jun 07 11:10:06 UTC 2019 as a draft by ehealth.sundhed.dk.
Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work.
This structure is derived from CarePlan
Summary
Mandatory: 4 elements (1 nested mandatory element)
Prohibited: 2 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
This structure is derived from CarePlan
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
CarePlan | 0..* | The intention of how one or more practitioners intend to deliver care for a particular patient, group or community for a period of time. | ||
extension | 0..* | Extension | Slice: Unordered, Open by value:url | |
ehealth-careplan-statusHistory | 0..* | (Complex) | Historical statuses of this careplan. URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-careplan-statusHistory | |
ehealth-responsible | 0..* | (Complex) | Individuals, careteam and/or organization responsible for monitoring this plan. URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-responsible | |
ehealth-responsibleHistory | 0..* | (Complex) | Individuals, careteam and/or organization historically responsible for monitoring this plan. URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-responsibleHistory | |
ehealth-careplan-responsibilitySummary | 0..* | (Complex) | High level summary of responsibilities presented to patient. URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-careplan-responsibilitySummary | |
definition | 1..1 | Reference(eHealth PlanDefinition | eHealth Questionnaire) {r} | Plan Definition | |
basedOn | 0..0 | |||
replaces | 0..0 | |||
partOf | 0..1 | Reference(eHealth CarePlan) {r} | ||
status | 1..1 | code | draft | active | suspended | completed | entered-in-error | cancelled | |
intent | 1..1 | code | order | |
category | 0..* | CodeableConcept | Binding: CareplanCategory (required) | |
subject | 1..1 | Reference(eHealth Patient) {r} | ||
context | 1..1 | Reference(eHealth EpisodeOfCare) {r} | ||
period | 1..1 | Period | ||
author | 0..* | Reference(eHealth Patient | eHealth Practitioner | eHealth RelatedPerson | eHealth Organization | eHealth CareTeam) {r} | ||
careTeam | 0..* | Reference(eHealth CareTeam) {r} | ||
addresses | 1..1 | Reference(eHealth Condition) {r} | ||
supportingInfo | 0..* | Reference(Resource) {r} | ||
goal | 0..* | Reference(Goal) {r} | ||
Documentation for this format |
This structure is derived from CarePlan
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
CarePlan | I | 0..* | The intention of how one or more practitioners intend to deliver care for a particular patient, group or community for a period of time. | |
id | Σ | 0..1 | id | Logical id of this artifact |
meta | Σ | 0..1 | Meta | Metadata about the resource |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
language | 0..1 | code | Language of the resource content Binding: Common Languages (extensible) | |
text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
contained | 0..* | Resource | Contained, inline Resources | |
extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
ehealth-careplan-statusHistory | 0..* | (Complex) | Historical statuses of this careplan. URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-careplan-statusHistory | |
ehealth-responsible | 0..* | (Complex) | Individuals, careteam and/or organization responsible for monitoring this plan. URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-responsible | |
ehealth-responsibleHistory | 0..* | (Complex) | Individuals, careteam and/or organization historically responsible for monitoring this plan. URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-responsibleHistory | |
ehealth-careplan-responsibilitySummary | 0..* | (Complex) | High level summary of responsibilities presented to patient. URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-careplan-responsibilitySummary | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | Σ | 0..* | Identifier | External Ids for this plan |
definition | Σ | 1..1 | Reference(eHealth PlanDefinition | eHealth Questionnaire) {r} | Plan Definition |
partOf | Σ | 0..1 | Reference(eHealth CarePlan) {r} | Part of referenced CarePlan |
status | ?!Σ | 1..1 | code | draft | active | suspended | completed | entered-in-error | cancelled Binding: CarePlanStatus (required) |
intent | ?!Σ | 1..1 | code | order Binding: CarePlanIntent (required) |
category | Σ | 0..* | CodeableConcept | Type of plan Binding: CareplanCategory (required) |
title | Σ | 0..1 | string | Human-friendly name for the CarePlan |
description | Σ | 0..1 | string | Summary of nature of plan |
subject | Σ | 1..1 | Reference(eHealth Patient) {r} | Who care plan is for |
context | Σ | 1..1 | Reference(eHealth EpisodeOfCare) {r} | Created in context of |
period | Σ | 1..1 | Period | Time period plan covers |
author | Σ | 0..* | Reference(eHealth Patient | eHealth Practitioner | eHealth RelatedPerson | eHealth Organization | eHealth CareTeam) {r} | Who is responsible for contents of the plan |
careTeam | 0..* | Reference(eHealth CareTeam) {r} | Who's involved in plan? | |
addresses | Σ | 1..1 | Reference(eHealth Condition) {r} | Health issues this plan addresses |
supportingInfo | 0..* | Reference(Resource) {r} | Information considered as part of plan | |
goal | 0..* | Reference(Goal) {r} | Desired outcome of plan | |
activity | I | 0..* | BackboneElement | Action to occur as part of plan cpl-3: Provide a reference or detail, not both |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
outcomeCodeableConcept | 0..* | CodeableConcept | Results of the activity Binding: Care Plan Activity Outcome (example) | |
outcomeReference | 0..* | Reference(Resource) {r} | Appointment, Encounter, Procedure, etc. | |
progress | 0..* | Annotation | Comments about the activity status/progress | |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
author[x] | Σ | 0..1 | Reference(eHealth Practitioner | eHealth Patient | eHealth RelatedPerson) {r}, string | Individual responsible for the annotation |
time | Σ | 0..1 | dateTime | When the annotation was made |
text | 1..1 | string | The annotation - text content | |
reference | I | 1..1 | Reference(eHealth ProcedureRequest) {rb} | Activity details defined in specific resource |
detail | I | 0..1 | BackboneElement | In-line definition of activity |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
category | 0..1 | CodeableConcept | diet | drug | encounter | observation | procedure | supply | other Binding: CarePlanActivityCategory (example) | |
definition | 0..1 | Reference(eHealth PlanDefinition | eHealth ActivityDefinition | eHealth Questionnaire) {r} | Protocol or definition | |
code | 0..1 | CodeableConcept | Detail type of activity Binding: Care Plan Activity (example) | |
reasonCode | 0..* | CodeableConcept | Why activity should be done or why activity was prohibited Binding: Activity Reason (example) | |
reasonReference | 0..* | Reference(eHealth Condition) {r} | Condition triggering need for activity | |
goal | 0..* | Reference(Goal) {r} | Goals this activity relates to | |
status | ?! | 1..1 | code | not-started | scheduled | in-progress | on-hold | completed | cancelled | unknown Binding: CarePlanActivityStatus (required) |
statusReason | 0..1 | string | Reason for current status | |
prohibited | ?! | 0..1 | boolean | Do NOT do |
scheduled[x] | 0..1 | Timing, Period, string | When activity is to occur | |
location | 0..1 | Reference(Location) {r} | Where it should happen | |
performer | 0..* | Reference(eHealth Practitioner | eHealth Organization | eHealth RelatedPerson | eHealth Patient | eHealth CareTeam) {r} | Who will be responsible? | |
product[x] | 0..1 | CodeableConcept, Reference(Medication | Substance) {r} | What is to be administered/supplied Binding: SNOMED CT Medication Codes (example) | |
dailyAmount | 0..1 | SimpleQuantity | How to consume/day? | |
quantity | 0..1 | SimpleQuantity | How much to administer/supply/consume | |
description | 0..1 | string | Extra info describing activity to perform | |
note | 0..* | Annotation | Comments about the plan | |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
author[x] | Σ | 0..1 | Reference(eHealth Practitioner | eHealth Patient | eHealth RelatedPerson) {r}, string | Individual responsible for the annotation |
time | Σ | 0..1 | dateTime | When the annotation was made |
text | 1..1 | string | The annotation - text content | |
Documentation for this format |
This structure is derived from CarePlan
Summary
Mandatory: 4 elements (1 nested mandatory element)
Prohibited: 2 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Differential View
This structure is derived from CarePlan
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
CarePlan | 0..* | The intention of how one or more practitioners intend to deliver care for a particular patient, group or community for a period of time. | ||
extension | 0..* | Extension | Slice: Unordered, Open by value:url | |
ehealth-careplan-statusHistory | 0..* | (Complex) | Historical statuses of this careplan. URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-careplan-statusHistory | |
ehealth-responsible | 0..* | (Complex) | Individuals, careteam and/or organization responsible for monitoring this plan. URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-responsible | |
ehealth-responsibleHistory | 0..* | (Complex) | Individuals, careteam and/or organization historically responsible for monitoring this plan. URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-responsibleHistory | |
ehealth-careplan-responsibilitySummary | 0..* | (Complex) | High level summary of responsibilities presented to patient. URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-careplan-responsibilitySummary | |
definition | 1..1 | Reference(eHealth PlanDefinition | eHealth Questionnaire) {r} | Plan Definition | |
basedOn | 0..0 | |||
replaces | 0..0 | |||
partOf | 0..1 | Reference(eHealth CarePlan) {r} | ||
status | 1..1 | code | draft | active | suspended | completed | entered-in-error | cancelled | |
intent | 1..1 | code | order | |
category | 0..* | CodeableConcept | Binding: CareplanCategory (required) | |
subject | 1..1 | Reference(eHealth Patient) {r} | ||
context | 1..1 | Reference(eHealth EpisodeOfCare) {r} | ||
period | 1..1 | Period | ||
author | 0..* | Reference(eHealth Patient | eHealth Practitioner | eHealth RelatedPerson | eHealth Organization | eHealth CareTeam) {r} | ||
careTeam | 0..* | Reference(eHealth CareTeam) {r} | ||
addresses | 1..1 | Reference(eHealth Condition) {r} | ||
supportingInfo | 0..* | Reference(Resource) {r} | ||
goal | 0..* | Reference(Goal) {r} | ||
Documentation for this format |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
CarePlan | I | 0..* | The intention of how one or more practitioners intend to deliver care for a particular patient, group or community for a period of time. | |
id | Σ | 0..1 | id | Logical id of this artifact |
meta | Σ | 0..1 | Meta | Metadata about the resource |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
language | 0..1 | code | Language of the resource content Binding: Common Languages (extensible) | |
text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
contained | 0..* | Resource | Contained, inline Resources | |
extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
ehealth-careplan-statusHistory | 0..* | (Complex) | Historical statuses of this careplan. URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-careplan-statusHistory | |
ehealth-responsible | 0..* | (Complex) | Individuals, careteam and/or organization responsible for monitoring this plan. URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-responsible | |
ehealth-responsibleHistory | 0..* | (Complex) | Individuals, careteam and/or organization historically responsible for monitoring this plan. URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-responsibleHistory | |
ehealth-careplan-responsibilitySummary | 0..* | (Complex) | High level summary of responsibilities presented to patient. URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-careplan-responsibilitySummary | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | Σ | 0..* | Identifier | External Ids for this plan |
definition | Σ | 1..1 | Reference(eHealth PlanDefinition | eHealth Questionnaire) {r} | Plan Definition |
partOf | Σ | 0..1 | Reference(eHealth CarePlan) {r} | Part of referenced CarePlan |
status | ?!Σ | 1..1 | code | draft | active | suspended | completed | entered-in-error | cancelled Binding: CarePlanStatus (required) |
intent | ?!Σ | 1..1 | code | order Binding: CarePlanIntent (required) |
category | Σ | 0..* | CodeableConcept | Type of plan Binding: CareplanCategory (required) |
title | Σ | 0..1 | string | Human-friendly name for the CarePlan |
description | Σ | 0..1 | string | Summary of nature of plan |
subject | Σ | 1..1 | Reference(eHealth Patient) {r} | Who care plan is for |
context | Σ | 1..1 | Reference(eHealth EpisodeOfCare) {r} | Created in context of |
period | Σ | 1..1 | Period | Time period plan covers |
author | Σ | 0..* | Reference(eHealth Patient | eHealth Practitioner | eHealth RelatedPerson | eHealth Organization | eHealth CareTeam) {r} | Who is responsible for contents of the plan |
careTeam | 0..* | Reference(eHealth CareTeam) {r} | Who's involved in plan? | |
addresses | Σ | 1..1 | Reference(eHealth Condition) {r} | Health issues this plan addresses |
supportingInfo | 0..* | Reference(Resource) {r} | Information considered as part of plan | |
goal | 0..* | Reference(Goal) {r} | Desired outcome of plan | |
activity | I | 0..* | BackboneElement | Action to occur as part of plan cpl-3: Provide a reference or detail, not both |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
outcomeCodeableConcept | 0..* | CodeableConcept | Results of the activity Binding: Care Plan Activity Outcome (example) | |
outcomeReference | 0..* | Reference(Resource) {r} | Appointment, Encounter, Procedure, etc. | |
progress | 0..* | Annotation | Comments about the activity status/progress | |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
author[x] | Σ | 0..1 | Reference(eHealth Practitioner | eHealth Patient | eHealth RelatedPerson) {r}, string | Individual responsible for the annotation |
time | Σ | 0..1 | dateTime | When the annotation was made |
text | 1..1 | string | The annotation - text content | |
reference | I | 1..1 | Reference(eHealth ProcedureRequest) {rb} | Activity details defined in specific resource |
detail | I | 0..1 | BackboneElement | In-line definition of activity |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
category | 0..1 | CodeableConcept | diet | drug | encounter | observation | procedure | supply | other Binding: CarePlanActivityCategory (example) | |
definition | 0..1 | Reference(eHealth PlanDefinition | eHealth ActivityDefinition | eHealth Questionnaire) {r} | Protocol or definition | |
code | 0..1 | CodeableConcept | Detail type of activity Binding: Care Plan Activity (example) | |
reasonCode | 0..* | CodeableConcept | Why activity should be done or why activity was prohibited Binding: Activity Reason (example) | |
reasonReference | 0..* | Reference(eHealth Condition) {r} | Condition triggering need for activity | |
goal | 0..* | Reference(Goal) {r} | Goals this activity relates to | |
status | ?! | 1..1 | code | not-started | scheduled | in-progress | on-hold | completed | cancelled | unknown Binding: CarePlanActivityStatus (required) |
statusReason | 0..1 | string | Reason for current status | |
prohibited | ?! | 0..1 | boolean | Do NOT do |
scheduled[x] | 0..1 | Timing, Period, string | When activity is to occur | |
location | 0..1 | Reference(Location) {r} | Where it should happen | |
performer | 0..* | Reference(eHealth Practitioner | eHealth Organization | eHealth RelatedPerson | eHealth Patient | eHealth CareTeam) {r} | Who will be responsible? | |
product[x] | 0..1 | CodeableConcept, Reference(Medication | Substance) {r} | What is to be administered/supplied Binding: SNOMED CT Medication Codes (example) | |
dailyAmount | 0..1 | SimpleQuantity | How to consume/day? | |
quantity | 0..1 | SimpleQuantity | How much to administer/supply/consume | |
description | 0..1 | string | Extra info describing activity to perform | |
note | 0..* | Annotation | Comments about the plan | |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
author[x] | Σ | 0..1 | Reference(eHealth Practitioner | eHealth Patient | eHealth RelatedPerson) {r}, string | Individual responsible for the annotation |
time | Σ | 0..1 | dateTime | When the annotation was made |
text | 1..1 | string | The annotation - text content | |
Documentation for this format |
Path | Name | Conformance | ValueSet |
CarePlan.language | Common Languages | extensible | Common Languages |
CarePlan.status | CarePlanStatus | required | CarePlanStatus |
CarePlan.intent | CarePlanIntent | required | CarePlanIntent |
CarePlan.category | CareplanCategory | required | CareplanCategory |
CarePlan.activity.outcomeCodeableConcept | Care Plan Activity Outcome | example | Care Plan Activity Outcome |
CarePlan.activity.detail.category | CarePlanActivityCategory | example | CarePlanActivityCategory |
CarePlan.activity.detail.code | Care Plan Activity | example | Care Plan Activity |
CarePlan.activity.detail.reasonCode | Activity Reason | example | Activity Reason |
CarePlan.activity.detail.status | CarePlanActivityStatus | required | CarePlanActivityStatus |
CarePlan.activity.detail.product[x] | SNOMED CT Medication Codes | example | SNOMED CT Medication Codes |
Id | Path | Details | Requirements |
dom-2 | CarePlan | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-1 | CarePlan | If the resource is contained in another resource, it SHALL NOT contain any narrative : contained.text.empty() | |
dom-4 | CarePlan | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-3 | CarePlan | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource : contained.where(('#'+id in %resource.descendants().reference).not()).empty() | |
ele-1 | CarePlan.activity | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
cpl-3 | CarePlan.activity | Provide a reference or detail, not both : detail.empty() or reference.empty() | |
ele-1 | CarePlan.activity.detail | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) |