CarePlan

CarePlan describes the intention of how one or more practitioners intend to deliver care for a particular patient, group or community for a period of time, possibly limited to care for a specific condition or set of conditions.

Overview

CarePlan can represent both proposed plans (for example, recommendations from a decision support engine or returned as part of a consult report) as well as active plans.

This profile is used to define the content that will be returned by the API Server in response to requests to access CarePlan resources. All elements described in the Definition and Detailed Definitions below are supported, which means that the API Server is capable of supplying these fields from the product database when they have been populated via the product or its APIs.

List of profiles we support:

Definition

The official URL for this profile is:

https://fhir.athena.io/StructureDefinition/ah-careplan

The base definition for this profile is:

CarePlan

NameFlagsCard.TypeDescription & Constraintsdoco
.. CarePlan0..*CarePlanHealthcare plan for patient or group
... idΣ0..1stringLogical id of this artifact
... metaΣ0..1MetaMetadata about the resource
... implicitRules?!Σ0..1uriA set of rules under which this content was created
... text0..1NarrativeText summary of the resource, for human interpretation
... contained0..*ResourceContained, inline Resources
... Slices for extension0..*ExtensionExtension
Slice: Unordered, Open by value:url
... ahChartSharingGroup0..1Reference(Organization)athenahealth Chart Sharing Group
URL: https://fhir.athena.io/StructureDefinition/ah-chart-sharing-group
... ahPractice0..1Reference(Organization)athenahealth Practice
URL: https://fhir.athena.io/StructureDefinition/ah-practice
... modifierExtension?!0..*ExtensionExtensions that cannot be ignored
... identifierΣ0..*IdentifierExternal Ids for this plan
... status?!Σ1..1codedraft | active | on-hold | revoked | completed | entered-in-error | unknown
Binding: RequestStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.

... intent?!Σ1..1codeproposal | plan | order | option
Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan.

... categoryΣ0..*CodeableConceptType of plan
Binding: CarePlanCategory (example): Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc.


... titleΣ0..1stringHuman-friendly name for the care plan
... subjectΣ1..1Reference(Patient)Who the care plan is for
... careTeam0..*Reference(CareTeam)Who's involved in plan?
... addressesΣ0..*Reference(Condition)Health issues this plan addresses
... goal0..*Reference(Goal)Desired outcome of plan

doco Documentation for this format

Detailed Definitions


CarePlan

Describes the intention of how one or more practitioners intend to deliver care for a particular patient, group or community for a period of time, possibly limited to care for a specific condition or set of conditions.

Cardinality 0..*
Type Root

CarePlan.id

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Cardinality 0..1
Type string
Comments The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

CarePlan.meta

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.

Cardinality 0..1
Type Meta

CarePlan.implicitRules

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.

Cardinality 0..1
Type uri
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.

CarePlan.language

The base language in which the resource is written.

Cardinality 0..1
Type code Binding: CommonLanguages (preferred)
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).

CarePlan.text

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.

Cardinality 0..1
Type Narrative
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.

CarePlan.contained

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.

Cardinality 0..*
Type Resource
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.

CarePlan.extension

An Extension

Cardinality 0..*
Type Extension

CarePlan.extension:ahChartSharingGroup

An Extension used to reference a specific athenahealth chart sharing group Organization.

Cardinality 0..1
Type Extension(AthenaChartSharingGroup)

CarePlan.extension:ahPractice

An Extension used to reference a specific athenahealth practice Organization.

Cardinality 0..1
Type Extension(AthenaPractice)

CarePlan.modifierExtension

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).

Cardinality 0..*
Type 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.
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.

CarePlan.identifier

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.

Cardinality 0..*
Type Identifier
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.
Requirements Allows identification of the care plan as it is known by various participating systems and in a way that remains consistent across servers.

CarePlan.status

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

Cardinality 1..1
Type code Binding: RequestStatus (required)
Comments 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.
Requirements Allows clinicians to determine whether the plan is actionable or not.

CarePlan.intent

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

Cardinality 1..1
Type code Binding: CarePlanIntent (required)
Comments This element is labeled as a modifier because the intent alters when and how the resource is actually applicable.
Requirements Proposals/recommendations, plans and orders all use the same structure and can exist in the same fulfillment chain.

CarePlan.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.

Cardinality 0..*
Type CodeableConcept Binding: CarePlanCategory (example)
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.
Requirements Used for filtering what plan(s) are retrieved and displayed to different types of users.

CarePlan.title

Human-friendly name for the care plan.

Cardinality 0..1
Type string

CarePlan.subject

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

Cardinality 1..1
Type Reference(Patient)

CarePlan.careTeam

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

Cardinality 0..*
Type Reference(CareTeam)
Requirements Allows representation of care teams, helps scope care plan. In some cases may be a determiner of access permissions.

CarePlan.addresses

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

Cardinality 0..*
Type Reference(Condition)
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.
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.

CarePlan.goal

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

Cardinality 0..*
Type Reference(Goal)
Comments Goal can be achieving a particular change or merely maintaining a current state or even slowing a decline.
Requirements Provides context for plan. Allows plan effectiveness to be evaluated by clinicians.

Interactions

READ

Read interactions are executed as specified in the HL7 FHIR RESTful API read specification. To read CarePlan resources, an application will perform an HTTP GET specifying the logical ID of the CarePlan being retrieved.

The [patient|user|system]/CarePlan.read authorization scope is required.

GET
/fhir/r4/CarePlan/{logicalId}
Try in Postman

Parameters

required

conditional required

Name Type Description
logicalId string (REQUIRED) The logical ID of the resource (alias: Resource.id). It is specified in the URL path and not as a query parameter.

Response Codes

Response code Description
200 OK The requested CarePlan resource was found and is contained within the body of the HTTP response.
400 Bad Request The server could not understand the request due to invalid syntax. The body of the HTTP response will contain an OperationOutcome resource that indicates the invalid request could not be processed.
404 Not Found The requested resource does not exist. The body of the HTTP response will contain an OperationOutcome resource that indicates the resource could not be found.
410 Gone The requested resource has been permanently deleted from server with no forwarding address. The body of the HTTP response will contain an OperationOutcome resource that indicates the resource could not be found.
500 Internal Server Error The server has encountered a situation it doesn't know how to handle. The body of the HTTP response will contain an OperationOutcome resource that indicates the nature of the error.
5xx Server Error The server may return other error codes to indicate other error conditions. The body of the HTTP response will contain an OperationOutcome resource that indicates the nature of the error.

GET SEARCH

Search interactions are executed as specified in the HL7 FHIR RESTful API search specification. To search for CarePlan resources using the HTTP GET method, an application will perform the HTTP GET specifying the query parameters associated with the CarePlan in the URL.

The [patient|user|system]/CarePlan.read authorization scope is required.

The following additional authorization scopes might be required depending on _include and/or _revinclude search parameters used:

  • [patient|user|system]/Organization.read
  • [patient|user|system]/Patient.read
  • [patient|user|system]/Provenance.read

GET
/fhir/r4/CarePlan
Try in Postman

Parameters

CarePlan search requests conditionally require one of the following search parameters or search parameter combinations in order to match and return a result set:
  • patient
  • _id

required

conditional required

Name Type Description
ah-practice reference Identify the athenahealth Practice Organization (e.g., 'ah-practice=Organization/a-1.Practice-[practiceId]')
patient reference (CONDITIONAL REQUIRED) CarePlan.patient resource reference to FHIR Patient resource
category token CarePlan.category is assess-plan
_count number The number of CarePlan resources to return per page for paged search results.
_id token (CONDITIONAL REQUIRED) CarePlan._id resource reference to FHIR CarePlan resource
cursor token Search by cursor token for first resource to return in a paged search result
ah-brand reference Search by athenahealth Brand (e.g., 'ah-brand=Organization/a-[practiceId].Brand-[brandId]') for resources containing the 'Athena Brand' Extension
ah-chart-sharing-group reference Search by athenahealth Chart Sharing Group (e.g., 'ah-chart-sharing-group=Organization/a-[practiceId].CSG-[csgId]') for resources containing the 'Athena Chart Sharing Group' Extension
ah-department reference Search by athenahealth Department (e.g., 'ah-department=Organization/a-[practiceId].Department-[deptId]') for resources containing the 'Athena Department' Extension
ah-provider-group reference Search by athenahealth Provider Group (e.g., 'ah-provider-group=Organization/a-[practiceId].PG-[providerGroupId]') for resources containing the 'Athena Provider Group' Extension
_include string Requests the server to include the referenced resource(s) in the search results according to the specified search parameter. Additional authorization scope(s) will be required. The supported _include parameter values are:
  • CarePlan:patient - Included resource(s) Patient and required scope(s) [patient|user|system]/Patient.read
  • CarePlan:ah-brand - Included resource(s) Organization and required scope(s) [patient|user|system]/Organization.read
  • CarePlan:ah-chart-sharing-group - Included resource(s) Organization and required scope(s) [patient|user|system]/Organization.read
  • CarePlan:ah-department - Included resource(s) Organization and required scope(s) [patient|user|system]/Organization.read
  • CarePlan:ah-practice - Included resource(s) Organization and required scope(s) [patient|user|system]/Organization.read
  • CarePlan:ah-provider-group - Included resource(s) Organization and required scope(s) [patient|user|system]/Organization.read
_revinclude string Requests the server to include the associated resource(s) in the search results according to the specified search parameter. Additional authorization scope(s) will be required. The supported _revinclude parameter values are:
  • Provenance:target - Associated resource(s) Provenance and required scope(s) [patient|user|system]/Provenance.read

Response Codes

Response code Description
200 OK The search request succeeded. The body of the HTTP response will contain a Bundle resource containing the results of the search.
403 Forbidden The server refused to perform the search due to a missing required search parameter. The body of the HTTP response will contain an OperationOutcome resource that includes the required search parameters.
500 Internal Server Error The server has encountered a situation it doesn't know how to handle. The body of the HTTP response will contain an OperationOutcome resource that indicates the nature of the error.
5xx Server Error The server may return other error codes to indicate other error conditions. The body of the HTTP response will contain an OperationOutcome resource that indicates the nature of the error.

POST SEARCH

Search interactions are executed as specified in the HL7 FHIR RESTful API search specification. To search for CarePlan resources using the HTTP POST method, an application will perform the HTTP POST specifying the query parameters associated with the CarePlan in the request body.

The [patient|user|system]/CarePlan.read authorization scope is required.

The following additional authorization scopes might be required depending on _include and/or _revinclude search parameters used:

  • [patient|user|system]/Organization.read
  • [patient|user|system]/Patient.read
  • [patient|user|system]/Provenance.read

POST
/fhir/r4/CarePlan/_search
Try in Postman

Request Header

Content-Type: application/x-www-form-urlencoded

Request Body

param1=value1&param2=value2...

Parameters

CarePlan search requests conditionally require one of the following search parameters or search parameter combinations in order to match and return a result set:
  • patient
  • _id

required

conditional required

Name Type Description
ah-practice reference Identify the athenahealth Practice Organization (e.g., 'ah-practice=Organization/a-1.Practice-[practiceId]')
patient reference (CONDITIONAL REQUIRED) CarePlan.patient resource reference to FHIR Patient resource
category token CarePlan.category is assess-plan
_count number The number of CarePlan resources to return per page for paged search results.
_id token (CONDITIONAL REQUIRED) CarePlan._id resource reference to FHIR CarePlan resource
cursor token Search by cursor token for first resource to return in a paged search result
ah-brand reference Search by athenahealth Brand (e.g., 'ah-brand=Organization/a-[practiceId].Brand-[brandId]') for resources containing the 'Athena Brand' Extension
ah-chart-sharing-group reference Search by athenahealth Chart Sharing Group (e.g., 'ah-chart-sharing-group=Organization/a-[practiceId].CSG-[csgId]') for resources containing the 'Athena Chart Sharing Group' Extension
ah-department reference Search by athenahealth Department (e.g., 'ah-department=Organization/a-[practiceId].Department-[deptId]') for resources containing the 'Athena Department' Extension
ah-provider-group reference Search by athenahealth Provider Group (e.g., 'ah-provider-group=Organization/a-[practiceId].PG-[providerGroupId]') for resources containing the 'Athena Provider Group' Extension
_include string Requests the server to include the referenced resource(s) in the search results according to the specified search parameter. Additional authorization scope(s) will be required. The supported _include parameter values are:
  • CarePlan:patient - Included resource(s) Patient and required scope(s) [patient|user|system]/Patient.read
  • CarePlan:ah-brand - Included resource(s) Organization and required scope(s) [patient|user|system]/Organization.read
  • CarePlan:ah-chart-sharing-group - Included resource(s) Organization and required scope(s) [patient|user|system]/Organization.read
  • CarePlan:ah-department - Included resource(s) Organization and required scope(s) [patient|user|system]/Organization.read
  • CarePlan:ah-practice - Included resource(s) Organization and required scope(s) [patient|user|system]/Organization.read
  • CarePlan:ah-provider-group - Included resource(s) Organization and required scope(s) [patient|user|system]/Organization.read
_revinclude string Requests the server to include the associated resource(s) in the search results according to the specified search parameter. Additional authorization scope(s) will be required. The supported _revinclude parameter values are:
  • Provenance:target - Associated resource(s) Provenance and required scope(s) [patient|user|system]/Provenance.read

Response Codes

Response code Description
200 OK The search request succeeded. The body of the HTTP response will contain a Bundle resource containing the results of the search.
403 Forbidden The server refused to perform the search due to a missing required search parameter. The body of the HTTP response will contain an OperationOutcome resource that includes the required search parameters.
500 Internal Server Error The server has encountered a situation it doesn't know how to handle. The body of the HTTP response will contain an OperationOutcome resource that indicates the nature of the error.
5xx Server Error The server may return other error codes to indicate other error conditions. The body of the HTTP response will contain an OperationOutcome resource that indicates the nature of the error.
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