MCC eCare Plan Draft Implementation Guide
0.1.0 - CI Build

MCC eCare Plan Draft Implementation Guide - Local Development build (v0.1.0). See the Directory of published versions

Resource Profile: Multiple Chronic Condition Care Plan

Defining URL:http://hl7.org/fhir/us/mcc/StructureDefinition/mccCarePlan
Version:0.1.0
Name:MCCCarePLan
Title:Multiple Chronic Care Condition Care Plan
Status:Active as of 2020-03-29
Definition:

This profile constrains the FHIR Care Plan Resource to represent the requirements of a care plan for patients with multiple chronic conditions.

Publisher:HL7 International - Patient Care WG
Source Resource:XML / JSON / Turtle

The official URL for this profile is: 

http://hl7.org/fhir/us/mcc/StructureDefinition/mccCarePlan

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 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, 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

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

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from CarePlan

Summary

Must-Support: 10 elements
Prohibited: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element CarePlan.addresses is sliced based on the value of profile:$this.resource

This structure is derived from CarePlan

NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan 0..*CarePlanHealthcare plan for patient or group
... status S1..1codedraft | active | on-hold | revoked | completed | entered-in-error | unknown
... intent S1..1codeproposal | plan | order | option
... category 0..*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 0..*(Slice Definition)Health issues this plan addresses
Slice: Unordered, Open by profile:$this.resource
.... addresses:sliceChronicKidneyDisease S0..*Reference(Chronic Kidney Disease Conditions)Health issues this plan addresses
... supportingInfo S0..*Reference(Blood Pressure Panel | BodyWeight | BodyMassIndex | US Core Condition Profile | US Core Laboratory Result Observation Profile | US Core DiagnosticReport Profile for Laboratory Results Reporting | US Core DiagnosticReport Profile for Report and Note exchange | US Core Procedure Profile | US Core Immunization Profile | Family Member History of Chronic Kidney Disease | Document Reference to Patient's Personal Advance Care Plan (Advance Directive) | Resource | SDC Questionnaire Response)Please see library of available MCC US Core conformant profiles to use for supportingInfo on the Artifact Index page. Any of the MCC defined profiles may be used to represent supporting information
... goal 0..*Reference(US Core Goal Profile)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(US Core Procedure Profile | US Core Laboratory Result Observation Profile | US Core Immunization Profile | US Core DiagnosticReport Profile for Report and Note exchange | US Core DiagnosticReport Profile for Laboratory Results Reporting | US Core Immunization Profile | MedicationStatement | Resource | Blood Pressure Panel | BodyWeight | BodyMassIndex | US Core Goal Profile)PERFORMED ACTIVITY. Please see library of available MCC US Core conformant profiles to use for CarePlan.outcomeReference on the Artifact Index page.
.... reference S0..1Reference(NutritionOrder | US Core MedicationRequest Profile | CommunicationRequest | DeviceRequest | Task | ServiceRequest | VisionPrescription | RequestGroup | Appointment)PLANNED ACTIVITY. Please see library of available MCC US Core conformant profiles to use for CarePlan.activityReference on the Artifact Index page.
.... detail 0..0

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan 0..*CarePlanHealthcare 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)
Max Binding: AllLanguages
... text 0..1NarrativeText summary of the resource, for human interpretation
... 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)
... intent ?!SΣ1..1codeproposal | plan | order | option
Binding: CarePlanIntent (required)
... category Σ0..*CodeableConceptCare Plan category code describes the type of care plan. Please see CarePlan.category detail for guidance.
Binding: CarePlanCategory (example)
... title Σ0..1stringHuman-friendly name for the care plan
... description Σ0..1stringSummary of nature of plan
... subject Σ1..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..*(Slice Definition)Health issues this plan addresses
Slice: Unordered, Open by profile:$this.resource
.... addresses:sliceChronicKidneyDisease SΣ0..*Reference(Chronic Kidney Disease Conditions)Health issues this plan addresses
... supportingInfo S0..*Reference(Blood Pressure Panel | BodyWeight | BodyMassIndex | US Core Condition Profile | US Core Laboratory Result Observation Profile | US Core DiagnosticReport Profile for Laboratory Results Reporting | US Core DiagnosticReport Profile for Report and Note exchange | US Core Procedure Profile | US Core Immunization Profile | Family Member History of Chronic Kidney Disease | Document Reference to Patient's Personal Advance Care Plan (Advance Directive) | Resource | SDC Questionnaire Response)Please see library of available MCC US Core conformant profiles to use for supportingInfo on the Artifact Index page. Any of the MCC defined profiles may be used to represent supporting information
... goal 0..*Reference(US Core Goal Profile)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)
.... outcomeReference S0..*Reference(US Core Procedure Profile | US Core Laboratory Result Observation Profile | US Core Immunization Profile | US Core DiagnosticReport Profile for Report and Note exchange | US Core DiagnosticReport Profile for Laboratory Results Reporting | US Core Immunization Profile | MedicationStatement | Resource | Blood Pressure Panel | BodyWeight | BodyMassIndex | US Core Goal Profile)PERFORMED ACTIVITY. Please see library of available MCC US Core conformant profiles to use for CarePlan.outcomeReference on the Artifact Index page.
.... progress 0..*AnnotationComments about the activity status/progress
.... reference SI0..1Reference(NutritionOrder | US Core MedicationRequest Profile | CommunicationRequest | DeviceRequest | Task | ServiceRequest | VisionPrescription | RequestGroup | Appointment)PLANNED ACTIVITY. Please see library of available MCC US Core conformant profiles to use for CarePlan.activityReference on the Artifact Index page.
... note 0..*AnnotationComments about the plan

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan 0..*CarePlanHealthcare plan for patient or group
... status ?!Σ1..1codedraft | active | on-hold | revoked | completed | entered-in-error | unknown
Binding: RequestStatus (required)
... intent ?!Σ1..1codeproposal | plan | order | option
Binding: CarePlanIntent (required)
... 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
... careTeam 0..*Reference(CareTeam)Who's involved in plan?
... addresses:sliceChronicKidneyDisease Σ0..*Reference(Chronic Kidney Disease Conditions)Health issues this plan addresses
... supportingInfo 0..*Reference(Blood Pressure Panel | BodyWeight | BodyMassIndex | US Core Condition Profile | US Core Laboratory Result Observation Profile | US Core DiagnosticReport Profile for Laboratory Results Reporting | US Core DiagnosticReport Profile for Report and Note exchange | US Core Procedure Profile | US Core Immunization Profile | Family Member History of Chronic Kidney Disease | Document Reference to Patient's Personal Advance Care Plan (Advance Directive) | Resource | SDC Questionnaire Response)Please see library of available MCC US Core conformant profiles to use for supportingInfo on the Artifact Index page. Any of the MCC defined profiles may be used to represent supporting information
... 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(US Core Procedure Profile | US Core Laboratory Result Observation Profile | US Core Immunization Profile | US Core DiagnosticReport Profile for Report and Note exchange | US Core DiagnosticReport Profile for Laboratory Results Reporting | US Core Immunization Profile | MedicationStatement | Resource | Blood Pressure Panel | BodyWeight | BodyMassIndex | US Core Goal Profile)PERFORMED ACTIVITY. Please see library of available MCC US Core conformant profiles to use for CarePlan.outcomeReference on the Artifact Index page.
.... reference I0..1Reference(NutritionOrder | US Core MedicationRequest Profile | CommunicationRequest | DeviceRequest | Task | ServiceRequest | VisionPrescription | RequestGroup | Appointment)PLANNED ACTIVITY. Please see library of available MCC US Core conformant profiles to use for CarePlan.activityReference on the Artifact Index page.

doco Documentation for this format

This structure is derived from CarePlan

Summary

Must-Support: 10 elements
Prohibited: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element CarePlan.addresses is sliced based on the value of profile:$this.resource

Differential View

This structure is derived from CarePlan

NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan 0..*CarePlanHealthcare plan for patient or group
... status S1..1codedraft | active | on-hold | revoked | completed | entered-in-error | unknown
... intent S1..1codeproposal | plan | order | option
... category 0..*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 0..*(Slice Definition)Health issues this plan addresses
Slice: Unordered, Open by profile:$this.resource
.... addresses:sliceChronicKidneyDisease S0..*Reference(Chronic Kidney Disease Conditions)Health issues this plan addresses
... supportingInfo S0..*Reference(Blood Pressure Panel | BodyWeight | BodyMassIndex | US Core Condition Profile | US Core Laboratory Result Observation Profile | US Core DiagnosticReport Profile for Laboratory Results Reporting | US Core DiagnosticReport Profile for Report and Note exchange | US Core Procedure Profile | US Core Immunization Profile | Family Member History of Chronic Kidney Disease | Document Reference to Patient's Personal Advance Care Plan (Advance Directive) | Resource | SDC Questionnaire Response)Please see library of available MCC US Core conformant profiles to use for supportingInfo on the Artifact Index page. Any of the MCC defined profiles may be used to represent supporting information
... goal 0..*Reference(US Core Goal Profile)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(US Core Procedure Profile | US Core Laboratory Result Observation Profile | US Core Immunization Profile | US Core DiagnosticReport Profile for Report and Note exchange | US Core DiagnosticReport Profile for Laboratory Results Reporting | US Core Immunization Profile | MedicationStatement | Resource | Blood Pressure Panel | BodyWeight | BodyMassIndex | US Core Goal Profile)PERFORMED ACTIVITY. Please see library of available MCC US Core conformant profiles to use for CarePlan.outcomeReference on the Artifact Index page.
.... reference S0..1Reference(NutritionOrder | US Core MedicationRequest Profile | CommunicationRequest | DeviceRequest | Task | ServiceRequest | VisionPrescription | RequestGroup | Appointment)PLANNED ACTIVITY. Please see library of available MCC US Core conformant profiles to use for CarePlan.activityReference on the Artifact Index page.
.... detail 0..0

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan 0..*CarePlanHealthcare 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)
Max Binding: AllLanguages
... text 0..1NarrativeText summary of the resource, for human interpretation
... 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)
... intent ?!SΣ1..1codeproposal | plan | order | option
Binding: CarePlanIntent (required)
... category Σ0..*CodeableConceptCare Plan category code describes the type of care plan. Please see CarePlan.category detail for guidance.
Binding: CarePlanCategory (example)
... title Σ0..1stringHuman-friendly name for the care plan
... description Σ0..1stringSummary of nature of plan
... subject Σ1..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..*(Slice Definition)Health issues this plan addresses
Slice: Unordered, Open by profile:$this.resource
.... addresses:sliceChronicKidneyDisease SΣ0..*Reference(Chronic Kidney Disease Conditions)Health issues this plan addresses
... supportingInfo S0..*Reference(Blood Pressure Panel | BodyWeight | BodyMassIndex | US Core Condition Profile | US Core Laboratory Result Observation Profile | US Core DiagnosticReport Profile for Laboratory Results Reporting | US Core DiagnosticReport Profile for Report and Note exchange | US Core Procedure Profile | US Core Immunization Profile | Family Member History of Chronic Kidney Disease | Document Reference to Patient's Personal Advance Care Plan (Advance Directive) | Resource | SDC Questionnaire Response)Please see library of available MCC US Core conformant profiles to use for supportingInfo on the Artifact Index page. Any of the MCC defined profiles may be used to represent supporting information
... goal 0..*Reference(US Core Goal Profile)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)
.... outcomeReference S0..*Reference(US Core Procedure Profile | US Core Laboratory Result Observation Profile | US Core Immunization Profile | US Core DiagnosticReport Profile for Report and Note exchange | US Core DiagnosticReport Profile for Laboratory Results Reporting | US Core Immunization Profile | MedicationStatement | Resource | Blood Pressure Panel | BodyWeight | BodyMassIndex | US Core Goal Profile)PERFORMED ACTIVITY. Please see library of available MCC US Core conformant profiles to use for CarePlan.outcomeReference on the Artifact Index page.
.... progress 0..*AnnotationComments about the activity status/progress
.... reference SI0..1Reference(NutritionOrder | US Core MedicationRequest Profile | CommunicationRequest | DeviceRequest | Task | ServiceRequest | VisionPrescription | RequestGroup | Appointment)PLANNED ACTIVITY. Please see library of available MCC US Core conformant profiles to use for CarePlan.activityReference on the Artifact Index page.
... note 0..*AnnotationComments about the plan

doco Documentation for this format

 

Other representations of profile: Schematron

Terminology Bindings

PathConformanceValueSet
CarePlan.languagepreferredCommonLanguages
Max Binding: AllLanguages
CarePlan.statusrequiredRequestStatus
CarePlan.intentrequiredCarePlanIntent
CarePlan.categoryexampleCarePlanCategory
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

IdPathDetailsRequirements
dom-2CarePlanIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3CarePlanIf 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-4CarePlanIf 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-5CarePlanIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6CarePlanA resource should have narrative for robust management
: text.`div`.exists()
ele-1CarePlan.metaAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.implicitRulesAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.languageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.textAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1CarePlan.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1CarePlan.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1CarePlan.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1CarePlan.identifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.instantiatesCanonicalAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.instantiatesUriAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.basedOnAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.replacesAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.partOfAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.statusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.intentAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.categoryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.titleAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.descriptionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.subjectAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.encounterAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.periodAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.createdAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.authorAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.contributorAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.careTeamAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.addressesAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.addresses:sliceChronicKidneyDiseaseAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.supportingInfoAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.goalAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
cpl-3CarePlan.activityProvide a reference or detail, not both
: detail.empty() or reference.empty()
ele-1CarePlan.activityAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.activity.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1CarePlan.activity.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1CarePlan.activity.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1CarePlan.activity.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1CarePlan.activity.outcomeCodeableConceptAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.activity.outcomeReferenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.activity.progressAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.activity.referenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.activity.detail.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1CarePlan.activity.detail.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1CarePlan.activity.detail.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1CarePlan.activity.detail.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1CarePlan.activity.detail.kindAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.activity.detail.instantiatesCanonicalAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.activity.detail.instantiatesUriAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.activity.detail.codeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.activity.detail.reasonCodeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.activity.detail.reasonReferenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.activity.detail.goalAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.activity.detail.statusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.activity.detail.statusReasonAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.activity.detail.doNotPerformAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.activity.detail.scheduled[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.activity.detail.locationAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.activity.detail.performerAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.activity.detail.product[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.activity.detail.dailyAmountAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.activity.detail.quantityAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.activity.detail.descriptionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1CarePlan.noteAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())