CarePlan resource implementation guidance
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CarePlan: Implementation Guidance
Usage
Within the Clinical Decision Support API implementation, the CarePlan resource will be used to carry the care advice recommendation given by the CDSS.
This resource may also carry a recommendation of self-care.
Self-care
When the outcome of triage is to recommend self care, this will be carried as follows:
- A
GuidanceResponsereturned to the EMS by the CDSS will carry a reference to aRequestGroupresource which will reference a relevantCarePlan - Identifying the
CarePlanwhich specifically represents self-care as opposed to general care advice can be done by checking thecareTeam.participantelement within theCarePlan - If there is only a single instance of
participantand theparticipant.roleis ‘Patient’ (Snomed CT code of 116154003), then the recommendation is for self-care
The table below gives implementation guidance in relation to the elements within a CarePlan:
| Name | Cardinality | Type | FHIR Documentation | CDS Implementation Guidance |
|---|---|---|---|---|
identifier |
0..* |
Identifier | External Ids for this plan | |
definition |
0..* |
Reference (PlanDefinition | Questionnaire) |
Protocol or definition | |
basedOn |
0..* |
Reference (CarePlan) |
Fulfils care plan | |
replaces |
0..* |
Reference (CarePlan) |
CarePlan replaced by this CarePlan | |
partOf |
0..* |
Reference (CarePlan) |
Part of referenced CarePlan | |
status |
1..1 |
code | draft | active | suspended | completed | entered-in-error | cancelled | unknown CarePlanStatus (Required) | This element SHOULD be populated with 'active' when the advice is given by the CDSS. Once the advice has been given, it SHOULD be updated by the EMS to show a value of 'completed'. |
intent |
1..1 |
code | proposal | plan | order | option CarePlanIntent (Required) | |
title |
0..1 |
string | Human-friendly name for the CarePlan | |
description |
0..1 |
string | Summary of nature of plan | |
subject |
1..1 |
Reference (Patient | Group) |
Who care plan is for | This MUST be populated with a reference to the Patient resource. |
context |
0..1 |
Reference (Encounter | EpisodeOfCare) |
Created in context of |
This MUST be populated with the Encounter for this journey, from the ServiceDefinition.$evaluate.encounter
|
period |
0..1 |
Period | Time period plan covers | |
author |
0..* |
Reference (Patient | Practitioner | RelatedPerson | Organization | CareTeam) |
Who is responsible for contents of the plan | |
careTeam |
0..* |
Reference (CareTeam) |
Who's involved in plan? | A CareTeam resource having a single instance of a participant element with a participant.role of 'Patient' indicates a triage outcome of self-care. |
addresses |
0..* |
Reference (Condition) |
Health issues this plan addresses | |
supportingInfo |
0..* |
Reference (Any) |
||
goal |
0..* |
Reference (Goal) |
Desired outcome of plan | |
activity |
0..* |
BackboneElement | Action to occur as part of plan - provide a reference or detail, not both | This SHOULD be populated by the CDSS using either the reference or the detail element. For example, it could carry a medication to be used, self-monitoring activities, laboratory tests planned. |
activity.outcomeCodeableConcept |
0..* |
CodeableConcept | Results of the activity Care Plan Activity Outcome (Example) | |
activity.outcomeReference |
0..* |
Reference (Any) |
Appointment, Encounter, Procedure, etc. | |
activity.progress |
0..* |
Annotation | Comments about the activity status/progress | |
activity.reference |
0..1 |
Reference (Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ProcedureRequest | ReferralRequest | VisionPrescription | RequestGroup) |
Activity details defined in specific resource | This element of note SHOULD be populated by the CDSS, if the information relating to the planned activity is to be carried in a resource. |
activity.detail |
0..1 |
BackboneElement | In-line definition of activity | This element of note SHOULD be populated by the CDSS, if the planned activity is not linked to specific resources such as a MedicationRequest or a Procedure. |
activity.detail.category |
0..1 |
CodeableConcept | diet | drug | encounter | observation | procedure | supply | other CarePlanActivityCategory (Example) | This element of note SHOULD be populated by the CDSS to provide a high-level categorisation of the type of planned activity. |
activity.detail.definition |
0..1 |
Reference (PlanDefinition | ActivityDefinition | Questionnaire) |
Protocol or definition | |
activity.detail.code |
0..1 |
CodeableConcept | Detail type of activity Care Plan Activity (Example) | |
activity.detail.reasonCode |
0..* |
CodeableConcept | Why activity should be done or why activity was prohibited Activity Reason (Example) | |
activity.detail.reasonReference |
0..* |
Reference (Condition) |
Condition triggering need for activity | |
activity.detail.goal |
0..* |
Reference (Goal) |
Goals this activity relates to | |
activity.detail.status |
1..1 |
code | not-started | scheduled | in-progress | on-hold | completed | cancelled | unknown CarePlanActivityStatus (Required) | |
activity.detail.statusReason |
0..1 |
string | Reason for current status | |
activity.detail.prohibited |
0..1 |
boolean | Do NOT do | |
activity.detail.scheduled[x] |
0..1 |
Timing Period string |
When activity is to occur | |
activity.detail.location |
0..1 |
Reference (Location) |
Where it should happen | |
activity.detail.performer |
0..* |
Reference (Practitioner | Organization | RelatedPerson | Patient | CareTeam) |
Who will be responsible? | |
activity.detail.product[x] |
0..1 |
CodeableConcept Reference (Medication) | Substance) |
What is to be administered/supplied SNOMED CT Medication Codes (Example) | |
activity.detail.dailyAmount |
0..1 |
SimpleQuantity | How to consume/day? | |
activity.detail.quantity |
0..1 |
SimpleQuantity | How much to administer/supply/consume | |
activity.detail.description |
0..1 |
string | Extra info describing activity to perform | |
note |
0..* |
Annotation | Comments about the plan |
CarePlan Elements of Note
Activity.reference element of the CarePlan
This element carries details of the proposed activity represented in a specific referenced resource. For example, if care advice which is a component of a triage outcome involves advice about how to give CPR, this could be modelled as a ProcedureRequest which could be referenced from the element.
Activity.detail element of the CarePlan
This element carries a simple summary of a planned activity which would be suited for a general care plan system, for example a form-driven system. Such a system would not know about a specific resource and therefore this element would be populated, as an alternative to the activity.reference element in a CarePlan.
Note that the above two elements are mutually exclusive within a FHIR CarePlan, so it is not possible to populate both elements within one CarePlan.
Activity.detail.category element of the CarePlan
This element carries a high-level categorisation of the type of activity in a CarePlan, for example describing whether it relates to diet, drug, procedure, etc. An example could be care advice about administering epi-pens to a patient suffering an allergic reaction, which might be modelled as a drug category.
