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.

Business identifiers assigned to this care plan by the performer or other systems which remain constant as the resource is updated and propagates from server to server.

Allows identification of the care plan as it is known by various participating systems and in a way that remains consistent across servers.

This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.

The URL pointing to a FHIR-defined protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlan.

The URL pointing to an externally maintained protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlan.

This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.

A higher-level request resource (i.e. a plan, proposal or order) that is fulfilled in whole or in part by this care plan.

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

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

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

The replacement could be because the initial care plan was immediately rejected (due to an issue) or because the previous care plan was completed, but the need for the action described by the care plan remains ongoing.

A larger care plan of which this particular care plan is a component or step.

Each care plan is an independent request, such that having a care plan be part of another care plan can cause issues with cascading statuses. As such, this element is still being discussed.

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

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

The unknown code is not to be used to convey other statuses. The unknown code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the care plan.

This element is labeled as a modifier because the status contains the code entered-in-error that marks the plan as not currently valid.

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

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

This element is labeled as a modifier because the intent alters when and how the resource is actually applicable. This element is expected to be immutable. E.g. A "proposal" instance should never change to be a "plan" instance or "order" instance. Instead, a new instance 'basedOn' the prior instance should be created with the new 'intent' value.

Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", "wellness plan", etc.

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

There may be multiple axes of categorization and one plan may serve multiple purposes. In some cases, this may be redundant with references to CarePlan.addresses.

Human-friendly name for the care plan.

A description of the scope and nature of the plan.

Provides more detail than conveyed by category.

CarePlan.description is not intended to convey the entire care plan. It is possible to convey the entire care plan narrative using CarePlan.text instead.

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

The Encounter during which this CarePlan was created or to which the creation of this record is tightly associated.

This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. CarePlan activities conducted as a result of the care plan may well occur as part of other encounters.

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

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

Any activities scheduled as part of the plan should be constrained to the specified period regardless of whether the activities are planned within a single encounter/episode or across multiple encounters/episodes (e.g. the longitudinal management of a chronic condition).

Represents when this particular CarePlan record was created in the system, which is often a system-generated date.

When populated, the custodian is responsible for the care plan. The care plan is attributed to the custodian.

The custodian might or might not be a contributor.

Identifies the individual(s), organization or device who provided the contents of the care plan.

Collaborative care plans may have multiple contributors.

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

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

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

The element can identify risks addressed by the plan as well as concerns. Also scopes plans - multiple plans may exist addressing different concerns.

Use CarePlan.addresses.concept when a code sufficiently describes the concern (e.g. condition, problem, diagnosis, risk). Use CarePlan.addresses.reference when referencing a resource, which allows more information to be conveyed, such as onset date. CarePlan.addresses.concept and CarePlan.addresses.reference are not meant to be duplicative. For a single concern, either CarePlan.addresses.concept or CarePlan.addresses.reference can be used. CarePlan.addresses.concept may be a summary code, or CarePlan.addresses.reference may be used to reference a very precise definition of the concern using Condition. Both CarePlan.addresses.concept and CarePlan.addresses.reference can be used if they are describing different concerns for the care plan.

Identifies portions of the patient's record that specifically influenced the formation of the plan. These might include comorbidities, recent procedures, limitations, recent assessments, etc.

Identifies barriers and other considerations associated with the care plan.

Use "concern" to identify specific conditions addressed by the care plan. supportingInfo can be used to convey one or more Advance Directives or Medical Treatment Consent Directives by referencing Consent or any other request resource with intent = directive.

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

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

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

Identifies 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.

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

Identifies the activity that was performed. For example, an activity could be patient education, exercise, or a medication administration. The reference to an "event" resource, such as Procedure or Encounter or Observation, represents the activity that was performed. The requested activity can be conveyed using the CarePlan.activity.plannedActivityReference (a reference to a “request” resource).

Links plan to resulting actions.

Note that this should not duplicate the activity status (e.g. completed or in progress). The activity performed is independent of the outcome of the related goal(s). For example, if the goal is to achieve a target body weight of 150 lbs and an activity is defined to exercise, then the activity performed could be amount and intensity of exercise performed whereas the goal outcome is an observation for the actual body weight measured.

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

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

This element should NOT be used to describe the activity to be performed - that occurs either within the resource pointed to by activity.detail.reference or in activity.detail.description.

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

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

Standard extension exists (http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal) that allows goals to be referenced from any of the referenced resources in CarePlan.activity.plannedActivityReference.
The goal should be visible when the resource referenced by CarePlan.activity.plannedActivityReference is viewed independently from the CarePlan. Requests that are pointed to by a CarePlan using this element should not point to this CarePlan using the "basedOn" element. i.e. Requests that are part of a CarePlan are not "based on" the CarePlan.

General notes about the care plan not covered elsewhere.

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