Nexus EMR profile for CarePlan -- the management plan tying goals, conditions and activities together (CDM flowsheets, care gaps). First pass: status/intent, category, goal/addresses linkage, minimal activity. Closed to SMART apps pending an exposure decision.
Elements / Details
Every element this profile touches, with its full definition. Element names in the tables link here.
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.
The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
A set of rules under which this content was created
Definition
A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Comments
Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
Cardinality
0..1
Type
uri
Modifier
yes — This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
The base language in which the resource is written.
Comments
Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Text summary of the resource, for human interpretation
Definition
A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Comments
Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
Comments
This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Requirements
Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Comments
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality
0..*
Type
Extension
Modifier
yes — Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
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.
Requirements
Allows identification of the care plan as it is known by various participating systems and in a way that remains consistent across servers.
Comments
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 an externally maintained protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlan.
Comments
This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
Completed or terminated care plan whose function is taken by this new care plan.
Requirements
Allows tracing the continuation of a therapy or administrative process instantiated through multiple care plans.
Comments
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.
Comments
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.
Requirements
Allows clinicians to determine whether the plan is actionable or not.
Comments
This is a modifier element. A draft plan that is being SUGGESTED rides in the transaction Bundle contained in its review Task, like every other suggested resource.
Cardinality
1..1
Type
code
Must Support
yes
Modifier
yes — This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Indicates the level of authority/intentionality associated with the care plan and where the care plan fits into the workflow chain.
Requirements
Proposals/recommendations, plans and orders all use the same structure and can exist in the same fulfillment chain.
Comments
This element is labeled as a modifier because the intent alters when and how the resource is actually applicable.
Cardinality
1..1
Type
code
Must Support
yes
Modifier
yes — This element changes the interpretation of all descriptive attributes. For example "the time the request is recommended to occur" vs. "the time the request is authorized to occur" or "who is recommended to perform the request" vs. "who is authorized to perform the request"
What kind of plan (e.g. the managed condition's domain)
Definition
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.
Requirements
Used for filtering what plan(s) are retrieved and displayed to different types of users.
Comments
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.concern.
The Encounter during which this CarePlan was created or to which the creation of this record is tightly associated.
Comments
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.
Requirements
Allows tracking what plan(s) are in effect at a particular time.
Comments
Any activities scheduled as part of the plan should be constrained to the specified period regardless of whether the activities are planned within a single encounter/episode or across multiple encounters/episodes (e.g. the longitudinal management of a chronic condition).
Identifies the conditions/problems/concerns/diagnoses/etc. whose management and/or mitigation are handled by this plan.
Requirements
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.
Comments
When the diagnosis is related to an allergy or intolerance, the Condition and AllergyIntolerance resources can both be used. However, to be actionable for decision support, using Condition alone is not sufficient as the allergy or intolerance condition needs to be represented as an AllergyIntolerance.
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.
Requirements
Identifies barriers and other considerations associated with the care plan.
Comments
Use "concern" to identify specific conditions addressed by the care plan.
May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Extensions that cannot be ignored even if unrecognized
Definition
May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Requirements
Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Comments
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality
0..*
Type
Extension
Modifier
yes — Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Identifies the outcome at the point when the status of the activity is assessed. For example, the outcome of an education activity could be patient understands (or not).
Comments
Note that this should not duplicate the activity status (e.g. completed or in progress).
Details of the outcome or action resulting from the activity. The reference to an "event" resource, such as Procedure or Encounter or Observation, is the result/outcome of the activity itself. The activity can be conveyed using CarePlan.activity.detail OR using the CarePlan.activity.reference (a reference to a “request” resource).
Requirements
Links plan to resulting actions.
Comments
The activity outcome is independent of the outcome of the related goal(s). For example, if the goal is to achieve a target body weight of 150 lbs and an activity is defined to diet, then the activity outcome could be calories consumed whereas the goal outcome is an observation for the actual body weight measured.
Notes about the adherence/status/progress of the activity.
Requirements
Can be used to capture information about adherence, progress, concerns, etc.
Comments
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 planned action as its own resource (ServiceRequest, MedicationRequest, Appointment, Task)
Definition
The details of the proposed activity represented in a specific resource.
Requirements
Details in a form consistent with other applications and contexts of use.
Comments
Standard extension exists (resource-pertainsToGoal) that allows goals to be referenced from any of the referenced resources in CarePlan.activity.reference.
The goal should be visible when the resource referenced by CarePlan.activity.reference is viewed 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.
A simple summary of a planned activity suitable for a general care plan system (e.g. form driven) that doesn't know about specific resources such as procedure etc.
Requirements
Details in a simple form for generic care plan systems.
May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Comments
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Extensions that cannot be ignored even if unrecognized
Definition
May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Requirements
Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Comments
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Cardinality
0..*
Type
Extension
Modifier
yes — Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
A description of the kind of resource the in-line definition of a care plan activity is representing. The CarePlan.activity.detail is an in-line definition when a resource is not referenced using CarePlan.activity.reference. For example, a MedicationRequest, a ServiceRequest, or a CommunicationRequest.
Requirements
May determine what types of extensions are permitted.
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 activity.
Requirements
Allows Questionnaires that the patient (or practitioner) should fill in to fulfill the care plan activity.
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 activity.
Requirements
Allows Questionnaires that the patient (or practitioner) should fill in to fulfill the care plan activity.
Comments
This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
Indicates another resource, such as the health condition(s), whose existence justifies this request and drove the inclusion of this particular activity as part of the plan.
Comments
Conditions can be identified at the activity level that are not identified as reasons for the overall plan.
Identifies what progress is being made for the specific activity.
Requirements
Indicates progress against the plan, whether the activity is still relevant for the plan.
Comments
Some aspects of status can be inferred based on the resources linked in actionTaken. Note that "status" is only as current as the plan was most recently updated.
The unknown code is not to be used to convey other statuses. The unknown code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the activity.
Cardinality
1..1
Type
code
Must Support
yes
Modifier
yes — This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the activity should not be treated as valid
Provides reason why the activity isn't yet started, is on hold, was cancelled, etc.
Comments
Will generally not be present if status is "complete". Be sure to prompt to update this (or at least remove the existing value) if the status is changed.
If true, indicates that the described activity is one that must NOT be engaged in when following the plan. If false, or missing, indicates that the described activity is one that should be engaged in when following the plan.
Requirements
Captures intention to not do something that may have been previously typical.
Comments
This element is labeled as a modifier because it marks an activity as an activity that is not to be performed.
Cardinality
0..1
Type
boolean
Modifier
yes — If true this element negates the specified action. For example, instead of a request for a procedure, it is a request for the procedure to not occur.
This provides a textual description of constraints on the intended activity occurrence, including relation to other activities. It may also include objectives, pre-conditions and end-conditions. Finally, it may convey specifics about the activity such as body site, method, route, etc.