Status: Active: Approved (STU)

Introduction

This profile sets minimum expectations for the CarePlan resource.

Mandatory fields

The following mandatory fields are defined in order to properly describe a Condition:

1. status - Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record. Thus, allowing clinicians to determine whether the plan is actionable or not.

2. intent - 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.

3. Subject - every CarePlan must be linked to a Patient (not a Group).

Must Support fields

In addition the following fields are “Must Support” - ie they must be populated if relevant and known:

1. Identifier - a Local Id should be provided, such that could be quoted if manually getting in touch to find out more

2. category - 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. We have pre-adopted UK Core R4 list of SNOMED codes, as the snomed parent code used within CareConnect have been discontinued.

3. Context - a link to the Encounter when the condition was first asserted. Will not be relevant to all Conditions (eg historical lists), but should be populated if applicable. Should link to the lowest level possible in any hierarchy, thus providing maximum detail about where the condition was noted.

   Note: Do not link to an Episode of Care, as this is deprecated in FHIR R4

Optional fields

Other fields are optional and may be populated if known - on the understanding that not all data consumers will necessarily make use of them. Points of note include:

• basedOn - A care plan that is fulfilled in whole or in part by this care plan. This allows tracing of the care plan and tracking whether proposals/recommendations were acted upon.

• replaces - Completed or terminated care plan whose function is taken by/ supersedes this new care plan. This allows tracing of the care plan and tracking whether proposals/recommendations were acted upon.

• title - Human-friendly name for the care plan.

• description - A description of the scope and nature of the plan. It provides more detail than conveyed by category.

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

• activity - 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.

Discouraged or Removed fields

• supportingInfo - removed to avoid unnecessary hierarchy complexity.

• definition - removed.

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from CareConnect-CarePlan-1

Name	Flags	Card.	Type	Description & Constraints
CarePlan		0..*	CareConnect-CarePlan-1	Healthcare plan for patient or group
id	S	0..1	id	Logical id of this artifact
meta
versionId	S	0..1	id	Version specific identifier
lastUpdated	S	0..1	instant	MANDATORY except in Contained Resources. When the resource version last changed.
profile	S	0..*	uri	Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile
security		0..*	Coding	DISCOURAGED - may not be honoured by Data Consumers
Slices for tag		0..*	Coding	Tags applied to this resource Slice: Unordered, Open by value:system
tag:Source	S	0..1	Coding	MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data
system		1..1	uri	Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Source
code	S	1..1	code	The Data Provider Id of the system supplying the data
display	S	1..1	string	Name of the system supplying the data
tag:Provenance	S	0..1	Coding	MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data
system		1..1	uri	Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Provenance
code	S	1..1	code	The ODS Code of the organisation responsible for the data
display	S	1..1	string	Name of the organisation supplying the data
implicitRules		0..1	uri	DISCOURAGED - may not be honoured by Data Consumers
language		0..1	code	English is assumed (not currently a multi-lingual implementation)
text		0..1	Narrative	DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users
definition		0..0
category	S	0..*	CodeableConcept	Type of plan Binding: Interweave R4 CarePlan Category Code (preferred)
coding
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
subject	S	1..1	Reference(CareConnectPatient1)	The patient whose characteristics (direct or indirect) are described by the observation and into whose record the observation is placed.
reference		1..1	string	Reference to a resource (could be Contained)
identifier		0..1	Identifier	If relevant could include an id
display		1..1	string	Description of the referenced resource
context	S	0..1	Reference(CareConnect-Encounter-1)	Created in context of
reference		1..1	string	Reference to a resource (could be Contained)
identifier		0..1	Identifier	If relevant could include an id
display		0..1	string	If relevant, description of the referenced resource
supportingInfo		0..0
activity
detail	S	0..1	BackboneElement	In-line definition of activity
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
CarePlan.category	preferred	Interweave R4 CarePlan Category Code

Name	Flags	Card.	Type	Description & Constraints
CarePlan		0..*	CareConnect-CarePlan-1	Healthcare plan for patient or group
id	SΣ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
versionId	SΣ	0..1	id	Version specific identifier
lastUpdated	SΣ	0..1	instant	MANDATORY except in Contained Resources. When the resource version last changed.
profile	SΣ	0..*	uri	Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile
security	Σ	0..*	Coding	DISCOURAGED - may not be honoured by Data Consumers Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
Slices for tag	Σ	0..*	Coding	Tags applied to this resource Slice: Unordered, Open by value:system Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"
tag:Source	SΣ	0..1	Coding	MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Source
code	SΣ	1..1	code	The Data Provider Id of the system supplying the data
display	SΣ	1..1	string	Name of the system supplying the data
tag:Provenance	SΣ	0..1	Coding	MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Provenance
code	SΣ	1..1	code	The ODS Code of the organisation responsible for the data
display	SΣ	1..1	string	Name of the organisation supplying the data
implicitRules	?!Σ	0..1	uri	DISCOURAGED - may not be honoured by Data Consumers
language		0..1	code	English is assumed (not currently a multi-lingual implementation) Binding: Common Languages (extensible): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	draft | active | suspended | completed | entered-in-error | cancelled | unknown Binding: CarePlanStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.
intent	?!Σ	1..1	code	proposal | plan | order | option Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan
category	SΣ	0..*	CodeableConcept	Type of plan Binding: Interweave R4 CarePlan Category Code (preferred)
subject	SΣ	1..1	Reference(CareConnectPatient1)	The patient whose characteristics (direct or indirect) are described by the observation and into whose record the observation is placed.
reference	ΣC	1..1	string	Reference to a resource (could be Contained)
identifier	Σ	0..1	Identifier	If relevant could include an id
display	Σ	1..1	string	Description of the referenced resource
context	SΣ	0..1	Reference(CareConnect-Encounter-1)	Created in context of
reference	ΣC	1..1	string	Reference to a resource (could be Contained)
identifier	Σ	0..1	Identifier	If relevant could include an id
display	Σ	0..1	string	If relevant, description of the referenced resource
activity	C	0..*	BackboneElement	Action to occur as part of plan
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
detail	SC	0..1	BackboneElement	In-line definition of activity
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
status	?!	1..1	code	not-started | scheduled | in-progress | on-hold | completed | cancelled | unknown Binding: CarePlanActivityStatus (required): Indicates where the activity is at in its overall life cycle.
prohibited	?!	0..1	boolean	Do NOT do
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
CarePlan.meta.security	extensible	All Security Labels
CarePlan.meta.tag	example	Common Tags
CarePlan.meta.tag:Source	example	Common Tags
CarePlan.meta.tag:Provenance	example	Common Tags
CarePlan.language	extensible	Common Languages Additional Bindings Purpose AllLanguages Max Binding
CarePlan.status	required	CarePlanStatus
CarePlan.intent	required	CarePlanIntent
CarePlan.category	preferred	Interweave R4 CarePlan Category Code
CarePlan.activity.detail.status	required	CarePlanActivityStatus

Constraints

Id	Grade	Path(s)	Details	Requirements
cpl-3	error	CarePlan.activity	Provide a reference or detail, not both : detail.empty() or reference.empty()
dom-1	error	CarePlan	If the resource is contained in another resource, it SHALL NOT contain any narrative : contained.text.empty()
dom-2	error	CarePlan	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	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()
dom-4	error	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()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count())

Name	Flags	Card.	Type	Description & Constraints
CarePlan		0..*	CareConnect-CarePlan-1	Healthcare plan for patient or group
id	SΣ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations Slice: Unordered, Open by value:url
versionId	SΣ	0..1	id	Version specific identifier
lastUpdated	SΣ	0..1	instant	MANDATORY except in Contained Resources. When the resource version last changed.
profile	SΣ	0..*	uri	Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile
security	Σ	0..*	Coding	DISCOURAGED - may not be honoured by Data Consumers Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
Slices for tag	Σ	0..*	Coding	Tags applied to this resource Slice: Unordered, Open by value:system Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"
tag:Source	SΣ	0..1	Coding	MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Source
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	The Data Provider Id of the system supplying the data
display	SΣ	1..1	string	Name of the system supplying the data
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
tag:Provenance	SΣ	0..1	Coding	MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Provenance
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	The ODS Code of the organisation responsible for the data
display	SΣ	1..1	string	Name of the organisation supplying the data
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
implicitRules	?!Σ	0..1	uri	DISCOURAGED - may not be honoured by Data Consumers
language		0..1	code	English is assumed (not currently a multi-lingual implementation) Binding: Common Languages (extensible): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional Content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Ids for this 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
use	?!Σ	0..1	code	usual | official | temp | secondary (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	0..1	string	The value that is unique Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(CareConnect-Organization-1)	Organization that issued id (may be just text)
basedOn	Σ	0..*	Reference(CareConnect-CarePlan-1)	Fulfills care plan
replaces	Σ	0..*	Reference(CareConnect-CarePlan-1)	CarePlan replaced by this CarePlan
partOf	Σ	0..*	Reference(CareConnect-CarePlan-1)	Part of referenced CarePlan
status	?!Σ	1..1	code	draft | active | suspended | completed | entered-in-error | cancelled | unknown Binding: CarePlanStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.
intent	?!Σ	1..1	code	proposal | plan | order | option Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan
category	SΣ	0..*	CodeableConcept	Type of plan Binding: Interweave R4 CarePlan Category Code (preferred)
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
title	Σ	0..1	string	Human-friendly name for the CarePlan
description	Σ	0..1	string	Summary of nature of plan
subject	SΣ	1..1	Reference(CareConnectPatient1)	The patient whose characteristics (direct or indirect) are described by the observation and into whose record the observation is placed.
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Reference to a resource (could be Contained)
identifier	Σ	0..1	Identifier	If relevant could include an id
display	Σ	1..1	string	Description of the referenced resource
context	SΣ	0..1	Reference(CareConnect-Encounter-1)	Created in context of
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Reference to a resource (could be Contained)
identifier	Σ	0..1	Identifier	If relevant could include an id
display	Σ	0..1	string	If relevant, description of the referenced resource
period	Σ	0..1	Period	Time period plan covers
author	Σ	0..*	Reference(CareConnect-Organization-1 | CareConnectPatient1 | CareConnect-Practitioner-1 | CareConnect-CareTeam-1 | CareConnect-RelatedPerson-1)	Who is responsible for contents of the plan
careTeam		0..*	Reference(CareConnect-CareTeam-1)	Who's involved in plan?
addresses	Σ	0..*	Reference(CareConnect-Condition-1)	Health issues this plan addresses
goal		0..*	Reference(Goal)	Desired outcome of plan
activity	C	0..*	BackboneElement	Action to occur as part of plan
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): Identifies the results of the activity
outcomeReference		0..*	Reference(Resource)	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		Individual responsible for the annotation
authorString			string
authorReference			Reference(CareConnectPatient1 | CareConnect-Practitioner-1 | CareConnect-RelatedPerson-1)
time	Σ	0..1	dateTime	When the annotation was made
text		1..1	string	The annotation - text content
reference	C	0..1	Reference(Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ReferralRequest | VisionPrescription | RequestGroup | CareConnect-ProcedureRequest-1 | CareConnect-MedicationRequest-1)	Activity details defined in specific resource
detail	SC	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): High-level categorization of the type of activity in a care plan.
definition		0..1	Reference(PlanDefinition | ActivityDefinition | Questionnaire)	Protocol or definition
code		0..1	CodeableConcept	Detail type of activity Binding: Care Plan Activity (example): Detailed description of the type of activity; e.g. What lab test, what procedure, what kind of encounter.
reasonCode		0..*	CodeableConcept	Why activity should be done or why activity was prohibited Binding: Activity Reason (example): Identifies why a care plan activity is needed. Can include any health condition codes as well as such concepts as "general wellness", prophylaxis, surgical preparation, etc.
reasonReference		0..*	Reference(CareConnect-Condition-1)	Condition triggering need for activity
goal		0..*	Reference(Goal)	Goals this activity relates to
status	?!	1..1	code	not-started | scheduled | in-progress | on-hold | completed | cancelled | unknown Binding: CarePlanActivityStatus (required): Indicates where the activity is at in its overall life cycle.
statusReason		0..1	string	Reason for current status
prohibited	?!	0..1	boolean	Do NOT do
scheduled[x]		0..1		When activity is to occur
scheduledTiming			Timing
scheduledPeriod			Period
scheduledString			string
location		0..1	Reference(CareConnect-Location-1)	Where it should happen
performer		0..*	Reference(CareConnect-Organization-1 | CareConnectPatient1 | CareConnect-Practitioner-1 | CareConnect-CareTeam-1 | CareConnect-RelatedPerson-1)	Who will be responsible?
product[x]		0..1		What is to be administered/supplied Binding: SNOMED CT Medication Codes (example): A product supplied or administered as part of a care plan activity.
productCodeableConcept			CodeableConcept
productReference			Reference(Substance | CareConnect-Medication-1)
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		Individual responsible for the annotation
authorString			string
authorReference			Reference(CareConnectPatient1 | CareConnect-Practitioner-1 | CareConnect-RelatedPerson-1)
time	Σ	0..1	dateTime	When the annotation was made
text		1..1	string	The annotation - text content
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
CarePlan.meta.security	extensible	All Security Labels
CarePlan.meta.tag	example	Common Tags
CarePlan.meta.tag:Source	example	Common Tags
CarePlan.meta.tag:Provenance	example	Common Tags
CarePlan.language	extensible	Common Languages Additional Bindings Purpose AllLanguages Max Binding
CarePlan.identifier.use	required	IdentifierUse
CarePlan.identifier.type	extensible	Identifier Type Codes
CarePlan.status	required	CarePlanStatus
CarePlan.intent	required	CarePlanIntent
CarePlan.category	preferred	Interweave R4 CarePlan Category Code
CarePlan.activity.outcomeCodeableConcept	example	Care Plan Activity Outcome
CarePlan.activity.detail.category	example	CarePlanActivityCategory
CarePlan.activity.detail.code	example	Care Plan Activity
CarePlan.activity.detail.reasonCode	example	Activity Reason
CarePlan.activity.detail.status	required	CarePlanActivityStatus
CarePlan.activity.detail.product[x]	example	SNOMED CT Medication Codes

Constraints

Id	Grade	Path(s)	Details	Requirements
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count())

Differential View

This structure is derived from CareConnect-CarePlan-1

Name	Flags	Card.	Type	Description & Constraints
CarePlan		0..*	CareConnect-CarePlan-1	Healthcare plan for patient or group
id	S	0..1	id	Logical id of this artifact
meta
versionId	S	0..1	id	Version specific identifier
lastUpdated	S	0..1	instant	MANDATORY except in Contained Resources. When the resource version last changed.
profile	S	0..*	uri	Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile
security		0..*	Coding	DISCOURAGED - may not be honoured by Data Consumers
Slices for tag		0..*	Coding	Tags applied to this resource Slice: Unordered, Open by value:system
tag:Source	S	0..1	Coding	MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data
system		1..1	uri	Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Source
code	S	1..1	code	The Data Provider Id of the system supplying the data
display	S	1..1	string	Name of the system supplying the data
tag:Provenance	S	0..1	Coding	MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data
system		1..1	uri	Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Provenance
code	S	1..1	code	The ODS Code of the organisation responsible for the data
display	S	1..1	string	Name of the organisation supplying the data
implicitRules		0..1	uri	DISCOURAGED - may not be honoured by Data Consumers
language		0..1	code	English is assumed (not currently a multi-lingual implementation)
text		0..1	Narrative	DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users
definition		0..0
category	S	0..*	CodeableConcept	Type of plan Binding: Interweave R4 CarePlan Category Code (preferred)
coding
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
subject	S	1..1	Reference(CareConnectPatient1)	The patient whose characteristics (direct or indirect) are described by the observation and into whose record the observation is placed.
reference		1..1	string	Reference to a resource (could be Contained)
identifier		0..1	Identifier	If relevant could include an id
display		1..1	string	Description of the referenced resource
context	S	0..1	Reference(CareConnect-Encounter-1)	Created in context of
reference		1..1	string	Reference to a resource (could be Contained)
identifier		0..1	Identifier	If relevant could include an id
display		0..1	string	If relevant, description of the referenced resource
supportingInfo		0..0
activity
detail	S	0..1	BackboneElement	In-line definition of activity
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
CarePlan.category	preferred	Interweave R4 CarePlan Category Code

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
CarePlan		0..*	CareConnect-CarePlan-1	Healthcare plan for patient or group
id	SΣ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
versionId	SΣ	0..1	id	Version specific identifier
lastUpdated	SΣ	0..1	instant	MANDATORY except in Contained Resources. When the resource version last changed.
profile	SΣ	0..*	uri	Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile
security	Σ	0..*	Coding	DISCOURAGED - may not be honoured by Data Consumers Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
Slices for tag	Σ	0..*	Coding	Tags applied to this resource Slice: Unordered, Open by value:system Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"
tag:Source	SΣ	0..1	Coding	MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Source
code	SΣ	1..1	code	The Data Provider Id of the system supplying the data
display	SΣ	1..1	string	Name of the system supplying the data
tag:Provenance	SΣ	0..1	Coding	MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Provenance
code	SΣ	1..1	code	The ODS Code of the organisation responsible for the data
display	SΣ	1..1	string	Name of the organisation supplying the data
implicitRules	?!Σ	0..1	uri	DISCOURAGED - may not be honoured by Data Consumers
language		0..1	code	English is assumed (not currently a multi-lingual implementation) Binding: Common Languages (extensible): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	draft | active | suspended | completed | entered-in-error | cancelled | unknown Binding: CarePlanStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.
intent	?!Σ	1..1	code	proposal | plan | order | option Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan
category	SΣ	0..*	CodeableConcept	Type of plan Binding: Interweave R4 CarePlan Category Code (preferred)
subject	SΣ	1..1	Reference(CareConnectPatient1)	The patient whose characteristics (direct or indirect) are described by the observation and into whose record the observation is placed.
reference	ΣC	1..1	string	Reference to a resource (could be Contained)
identifier	Σ	0..1	Identifier	If relevant could include an id
display	Σ	1..1	string	Description of the referenced resource
context	SΣ	0..1	Reference(CareConnect-Encounter-1)	Created in context of
reference	ΣC	1..1	string	Reference to a resource (could be Contained)
identifier	Σ	0..1	Identifier	If relevant could include an id
display	Σ	0..1	string	If relevant, description of the referenced resource
activity	C	0..*	BackboneElement	Action to occur as part of plan
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
detail	SC	0..1	BackboneElement	In-line definition of activity
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
status	?!	1..1	code	not-started | scheduled | in-progress | on-hold | completed | cancelled | unknown Binding: CarePlanActivityStatus (required): Indicates where the activity is at in its overall life cycle.
prohibited	?!	0..1	boolean	Do NOT do
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
CarePlan.meta.security	extensible	All Security Labels
CarePlan.meta.tag	example	Common Tags
CarePlan.meta.tag:Source	example	Common Tags
CarePlan.meta.tag:Provenance	example	Common Tags
CarePlan.language	extensible	Common Languages Additional Bindings Purpose AllLanguages Max Binding
CarePlan.status	required	CarePlanStatus
CarePlan.intent	required	CarePlanIntent
CarePlan.category	preferred	Interweave R4 CarePlan Category Code
CarePlan.activity.detail.status	required	CarePlanActivityStatus

Constraints

Id	Grade	Path(s)	Details	Requirements
cpl-3	error	CarePlan.activity	Provide a reference or detail, not both : detail.empty() or reference.empty()
dom-1	error	CarePlan	If the resource is contained in another resource, it SHALL NOT contain any narrative : contained.text.empty()
dom-2	error	CarePlan	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	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()
dom-4	error	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()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count())

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
CarePlan		0..*	CareConnect-CarePlan-1	Healthcare plan for patient or group
id	SΣ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations Slice: Unordered, Open by value:url
versionId	SΣ	0..1	id	Version specific identifier
lastUpdated	SΣ	0..1	instant	MANDATORY except in Contained Resources. When the resource version last changed.
profile	SΣ	0..*	uri	Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile
security	Σ	0..*	Coding	DISCOURAGED - may not be honoured by Data Consumers Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
Slices for tag	Σ	0..*	Coding	Tags applied to this resource Slice: Unordered, Open by value:system Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"
tag:Source	SΣ	0..1	Coding	MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Source
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	The Data Provider Id of the system supplying the data
display	SΣ	1..1	string	Name of the system supplying the data
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
tag:Provenance	SΣ	0..1	Coding	MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Provenance
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	The ODS Code of the organisation responsible for the data
display	SΣ	1..1	string	Name of the organisation supplying the data
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
implicitRules	?!Σ	0..1	uri	DISCOURAGED - may not be honoured by Data Consumers
language		0..1	code	English is assumed (not currently a multi-lingual implementation) Binding: Common Languages (extensible): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional Content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Ids for this 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
use	?!Σ	0..1	code	usual | official | temp | secondary (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	0..1	string	The value that is unique Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(CareConnect-Organization-1)	Organization that issued id (may be just text)
basedOn	Σ	0..*	Reference(CareConnect-CarePlan-1)	Fulfills care plan
replaces	Σ	0..*	Reference(CareConnect-CarePlan-1)	CarePlan replaced by this CarePlan
partOf	Σ	0..*	Reference(CareConnect-CarePlan-1)	Part of referenced CarePlan
status	?!Σ	1..1	code	draft | active | suspended | completed | entered-in-error | cancelled | unknown Binding: CarePlanStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.
intent	?!Σ	1..1	code	proposal | plan | order | option Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan
category	SΣ	0..*	CodeableConcept	Type of plan Binding: Interweave R4 CarePlan Category Code (preferred)
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
title	Σ	0..1	string	Human-friendly name for the CarePlan
description	Σ	0..1	string	Summary of nature of plan
subject	SΣ	1..1	Reference(CareConnectPatient1)	The patient whose characteristics (direct or indirect) are described by the observation and into whose record the observation is placed.
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Reference to a resource (could be Contained)
identifier	Σ	0..1	Identifier	If relevant could include an id
display	Σ	1..1	string	Description of the referenced resource
context	SΣ	0..1	Reference(CareConnect-Encounter-1)	Created in context of
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Reference to a resource (could be Contained)
identifier	Σ	0..1	Identifier	If relevant could include an id
display	Σ	0..1	string	If relevant, description of the referenced resource
period	Σ	0..1	Period	Time period plan covers
author	Σ	0..*	Reference(CareConnect-Organization-1 | CareConnectPatient1 | CareConnect-Practitioner-1 | CareConnect-CareTeam-1 | CareConnect-RelatedPerson-1)	Who is responsible for contents of the plan
careTeam		0..*	Reference(CareConnect-CareTeam-1)	Who's involved in plan?
addresses	Σ	0..*	Reference(CareConnect-Condition-1)	Health issues this plan addresses
goal		0..*	Reference(Goal)	Desired outcome of plan
activity	C	0..*	BackboneElement	Action to occur as part of plan
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): Identifies the results of the activity
outcomeReference		0..*	Reference(Resource)	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		Individual responsible for the annotation
authorString			string
authorReference			Reference(CareConnectPatient1 | CareConnect-Practitioner-1 | CareConnect-RelatedPerson-1)
time	Σ	0..1	dateTime	When the annotation was made
text		1..1	string	The annotation - text content
reference	C	0..1	Reference(Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ReferralRequest | VisionPrescription | RequestGroup | CareConnect-ProcedureRequest-1 | CareConnect-MedicationRequest-1)	Activity details defined in specific resource
detail	SC	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): High-level categorization of the type of activity in a care plan.
definition		0..1	Reference(PlanDefinition | ActivityDefinition | Questionnaire)	Protocol or definition
code		0..1	CodeableConcept	Detail type of activity Binding: Care Plan Activity (example): Detailed description of the type of activity; e.g. What lab test, what procedure, what kind of encounter.
reasonCode		0..*	CodeableConcept	Why activity should be done or why activity was prohibited Binding: Activity Reason (example): Identifies why a care plan activity is needed. Can include any health condition codes as well as such concepts as "general wellness", prophylaxis, surgical preparation, etc.
reasonReference		0..*	Reference(CareConnect-Condition-1)	Condition triggering need for activity
goal		0..*	Reference(Goal)	Goals this activity relates to
status	?!	1..1	code	not-started | scheduled | in-progress | on-hold | completed | cancelled | unknown Binding: CarePlanActivityStatus (required): Indicates where the activity is at in its overall life cycle.
statusReason		0..1	string	Reason for current status
prohibited	?!	0..1	boolean	Do NOT do
scheduled[x]		0..1		When activity is to occur
scheduledTiming			Timing
scheduledPeriod			Period
scheduledString			string
location		0..1	Reference(CareConnect-Location-1)	Where it should happen
performer		0..*	Reference(CareConnect-Organization-1 | CareConnectPatient1 | CareConnect-Practitioner-1 | CareConnect-CareTeam-1 | CareConnect-RelatedPerson-1)	Who will be responsible?
product[x]		0..1		What is to be administered/supplied Binding: SNOMED CT Medication Codes (example): A product supplied or administered as part of a care plan activity.
productCodeableConcept			CodeableConcept
productReference			Reference(Substance | CareConnect-Medication-1)
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		Individual responsible for the annotation
authorString			string
authorReference			Reference(CareConnectPatient1 | CareConnect-Practitioner-1 | CareConnect-RelatedPerson-1)
time	Σ	0..1	dateTime	When the annotation was made
text		1..1	string	The annotation - text content
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
CarePlan.meta.security	extensible	All Security Labels
CarePlan.meta.tag	example	Common Tags
CarePlan.meta.tag:Source	example	Common Tags
CarePlan.meta.tag:Provenance	example	Common Tags
CarePlan.language	extensible	Common Languages Additional Bindings Purpose AllLanguages Max Binding
CarePlan.identifier.use	required	IdentifierUse
CarePlan.identifier.type	extensible	Identifier Type Codes
CarePlan.status	required	CarePlanStatus
CarePlan.intent	required	CarePlanIntent
CarePlan.category	preferred	Interweave R4 CarePlan Category Code
CarePlan.activity.outcomeCodeableConcept	example	Care Plan Activity Outcome
CarePlan.activity.detail.category	example	CarePlanActivityCategory
CarePlan.activity.detail.code	example	Care Plan Activity
CarePlan.activity.detail.reasonCode	example	Activity Reason
CarePlan.activity.detail.status	required	CarePlanActivityStatus
CarePlan.activity.detail.product[x]	example	SNOMED CT Medication Codes

Constraints

Id	Grade	Path(s)	Details	Requirements
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count())

This structure is derived from CareConnect-CarePlan-1

Summary

Mandatory: 2 elements (10 nested mandatory elements)
Must-Support: 14 elements
Fixed Value: 2 elements
Prohibited: 2 elements

Structures

This structure refers to these other structures:

• CareConnectPatient1 (https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Patient-1)
• CareConnect-Encounter-1 (https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Encounter-1)

Slices

This structure defines the following Slices:

• The element CarePlan.meta.tag is sliced based on the value of value:system