Austrian Patient Summary (R4)
1.0.0 - STU1

Austrian Patient Summary (R4) - Downloaded Version 1.0.0 See the Directory of published versions

## Resource Profile: AtApsCarePlan - Detailed Descriptions

Active as of 2026-02-17

Definitions for the at-aps-careplan resource profile.

- Key Elements Table
- Differential Elements Table
- Snapshot Elements Table

Guidance on how to interpret the contents of this table can be foundhere

0. CarePlan
Definition | 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.
Short | AT APS CarePlanHealthcare plan for patient or group
Control | 0..*
Is Modifier | false
Summary | false
Alternate Names | Care Team
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty()) dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()) dom-4: 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()) dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. CarePlan.implicitRules
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.
Short | A set of rules under which this content was created
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.
Control | 0..1
Type | uri
Is Modifier | true because 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
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
4. CarePlan.extension
Definition | An Extension 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.
Short | ExtensionAdditional content defined by implementations
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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
Slicing | This element introduces a set of slices on `CarePlan.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
6. CarePlan.extension:shallComplyWith
Slice Name | shallComplyWith
Definition | In satisfying this request or instantiating this definition, the expectations defined in the Definition resource are expected to be met. (This allows requirements defined elsewhere to be brought into play by reference rather than providing all of the detail in-line necessary to satisfy the referenced Definition.).
Short | Resulting event shall comply with
Comments | See the notes in the workflow extensions area for more guidance on this element.
Control | 0..*
Type | Extension(Shall comply with) (Extension Type: Choice of: canonical(ActivityDefinition, Measure, ObservationDefinition, PlanDefinition, Questionnaire), Reference(ActivityDefinition, Measure, ObservationDefinition, PlanDefinition, Questionnaire), uri)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
8. CarePlan.extension:adheresTo
Slice Name | adheresTo
Definition | The action represented by this resource has been determined to satisfy the expectations established by the referenced Definition resource.
Short | Follows rules from
Comments | If changes are made to this event record, the determination must be made whether, with the change, the action still complies with the referenced Definition. Revisions may result in adheresTo assertions being removed, or - if the system has an algorithm for determining which targets are appropriate - being added. Adherence may be asserted after the fact. It is possible for a Request or Event to adhere to a Definition even if the author/performer of the action was not aware of the Definition at the time the action was taken/requested. Also see the notes in the workflow extensions area for more guidance on this element.
Control | 0..*
Type | Extension(adheres to) (Extension Type: Choice of: canonical(ActivityDefinition, Measure, ObservationDefinition, PlanDefinition, Questionnaire), Reference(ActivityDefinition, Measure, ObservationDefinition, PlanDefinition, Questionnaire), uri)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
10. CarePlan.modifierExtension
Definition | 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).
Short | Extensions that cannot be ignored
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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summary | false
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.
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
12. CarePlan.instantiatesCanonical
Definition | 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.
Short | Instantiates FHIR protocol or definition
Control | 0..0*
Type | canonical(PlanDefinition, Questionnaire, Measure, ActivityDefinition, OperationDefinition)
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
14. CarePlan.instantiatesUri
Definition | 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.
Short | Instantiates external protocol or definition
Comments | This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
Control | 0..0*
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
16. CarePlan.basedOn
Definition | A care plan that is fulfilled in whole or in part by this care plan.
Short | Fulfills CarePlan
Control | 0..*
Type | Reference(AT APS CarePlan, CarePlan)
Is Modifier | false
Summary | true
Requirements | Allows tracing of the care plan and tracking whether proposals/recommendations were acted upon.
Alternate Names | fulfills
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
18. CarePlan.replaces
Definition | Completed or terminated care plan whose function is taken by this new care plan.
Short | CarePlan replaced by this CarePlan
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.
Control | 0..*
Type | Reference(AT APS CarePlan, CarePlan)
Is Modifier | false
Summary | true
Requirements | Allows tracing the continuation of a therapy or administrative process instantiated through multiple care plans.
Alternate Names | supersedes
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. CarePlan.partOf
Definition | A larger care plan of which this particular care plan is a component or step.
Short | Part of referenced CarePlan
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.
Control | 0..*
Type | Reference(AT APS CarePlan, CarePlan)
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. CarePlan.status
Definition | Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.
Short | draft | active | on-hold | revoked | completed | entered-in-error | unknown
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.
Control | 1..1
Binding | The codes SHALL be taken from RequestStatus http://hl7.org/fhir/ValueSet/request-status|4.0.1 (required to `http://hl7.org/fhir/ValueSet/request-status|4.0.1` ) Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.
Type | code
Is Modifier | true because 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
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Allows clinicians to determine whether the plan is actionable or not.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
24. CarePlan.intent
Definition | Indicates the level of authority/intentionality associated with the care plan and where the care plan fits into the workflow chain.
Short | proposal | plan | order | option
Comments | This element is labeled as a modifier because the intent alters when and how the resource is actually applicable.
Control | 1..1
Binding | The codes SHALL be taken from CarePlanIntent http://hl7.org/fhir/ValueSet/care-plan-intent|4.0.1 (required to `http://hl7.org/fhir/ValueSet/care-plan-intent|4.0.1` ) Codes indicating the degree of authority/intentionality associated with a care plan.
Type | code
Is Modifier | true because 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"
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Proposals/recommendations, plans and orders all use the same structure and can exist in the same fulfillment chain.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
26. CarePlan.subject
Definition | Identifies the patient or group whose intended care is described by the plan.
Short | Who the care plan is for
Control | 1..1
Type | Reference(AT APS Patient, Group, Patient, Group)
Is Modifier | false
Summary | true
Alternate Names | patient
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
28. CarePlan.author
Definition | When populated, the author is responsible for the care plan. The care plan is attributed to the author.
Short | Who is the designated responsible party
Comments | The author may also be a contributor. For example, an organization can be an author, but not listed as a contributor.
Control | 0..1
Type | Reference(AT APS Patient, AT APS Practitioner, AT APS PractitionerRole, Device, RelatedPerson, AT APS Organization, CareTeam, Patient, Practitioner, PractitionerRole, Device, RelatedPerson, Organization, CareTeam)
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. CarePlan.contributor
Definition | Identifies the individual(s) or organization who provided the contents of the care plan.
Short | Who provided the content of the care plan
Comments | Collaborative care plans may have multiple contributors.
Control | 0..*
Type | Reference(AT APS Patient, AT APS Practitioner, AT APS PractitionerRole, Device, RelatedPerson, AT APS Organization, CareTeam, Patient, Practitioner, PractitionerRole, Device, RelatedPerson, Organization, CareTeam)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
32. CarePlan.addresses
Definition | Identifies the conditions/problems/concerns/diagnoses/etc. whose management and/or mitigation are handled by this plan.
Short | Health issues this plan addresses
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.
Control | 0..*
Type | Reference(AT APS Condition, Condition)
Is Modifier | false
Summary | true
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.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

Guidance on how to interpret the contents of this table can be foundhere

0. CarePlan
Short | AT APS CarePlan
2. CarePlan.extension
Slicing | This element introduces a set of slices on `CarePlan.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
4. CarePlan.extension:shallComplyWith
Slice Name | shallComplyWith
Control | 0..*
Type | Extension(Shall comply with) (Extension Type: Choice of: canonical(ActivityDefinition, Measure, ObservationDefinition, PlanDefinition, Questionnaire), Reference(ActivityDefinition, Measure, ObservationDefinition, PlanDefinition, Questionnaire), uri)
6. CarePlan.extension:adheresTo
Slice Name | adheresTo
Control | 0..*
Type | Extension(adheres to) (Extension Type: Choice of: canonical(ActivityDefinition, Measure, ObservationDefinition, PlanDefinition, Questionnaire), Reference(ActivityDefinition, Measure, ObservationDefinition, PlanDefinition, Questionnaire), uri)
8. CarePlan.instantiatesCanonical
Control | 0..0
10. CarePlan.instantiatesUri
Control | 0..0
12. CarePlan.basedOn
Type | Reference(AT APS CarePlan)
14. CarePlan.replaces
Type | Reference(AT APS CarePlan)
16. CarePlan.partOf
Type | Reference(AT APS CarePlan)
18. CarePlan.subject
Type | Reference(AT APS Patient, Group)
20. CarePlan.author
Type | Reference(AT APS Patient, AT APS Practitioner, AT APS PractitionerRole, Device, RelatedPerson, AT APS Organization, CareTeam)
22. CarePlan.contributor
Type | Reference(AT APS Patient, AT APS Practitioner, AT APS PractitionerRole, Device, RelatedPerson, AT APS Organization, CareTeam)
24. CarePlan.addresses
Type | Reference(AT APS Condition)
26. CarePlan.activity
28. CarePlan.activity.reference
Type | Reference(Appointment, CommunicationRequest, DeviceRequest, AT APS MedicationRequest, NutritionOrder, Task, ServiceRequest, VisionPrescription, RequestGroup)
30. CarePlan.activity.detail
Control | 0..0

Guidance on how to interpret the contents of this table can be foundhere

0. CarePlan
Definition | 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.
Short | AT APS CarePlan
Control | 0..*
Is Modifier | false
Summary | false
Alternate Names | Care Team
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (`contained.contained.empty()`) dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (`contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`) dom-4: 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()`) dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (`contained.meta.security.empty()`) dom-6: A resource should have narrative for robust management (`text.`div`.exists()`)
2. CarePlan.id
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
Short | Logical id of this artifact
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.
Control | 0..1
Type | id
Is Modifier | false
Summary | true
4. CarePlan.meta
Definition | 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.
Short | Metadata about the resource
Control | 0..1
Type | Meta
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
6. CarePlan.implicitRules
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.
Short | A set of rules under which this content was created
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.
Control | 0..1
Type | uri
Is Modifier | true because 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
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
8. CarePlan.language
Definition | The base language in which the resource is written.
Short | Language of the resource content
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).
Control | 0..1
Binding | The codes SHOULD be taken from CommonLanguages (preferred to `http://hl7.org/fhir/ValueSet/languages|4.0.1` ) A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
10. CarePlan.text
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.
Short | Text summary of the resource, for human interpretation
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.
Control | 0..1
Type | Narrative
Is Modifier | false
Summary | false
Alternate Names | narrative, html, xhtml, display
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
12. CarePlan.contained
Definition | 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.
Short | Contained, inline Resources
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.
Control | 0..*
Type | Resource
Is Modifier | false
Summary | false
Alternate Names | inline resources, anonymous resources, contained resources
14. CarePlan.extension
Definition | An Extension
Short | Extension
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `CarePlan.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
16. CarePlan.extension:shallComplyWith
Slice Name | shallComplyWith
Definition | In satisfying this request or instantiating this definition, the expectations defined in the Definition resource are expected to be met. (This allows requirements defined elsewhere to be brought into play by reference rather than providing all of the detail in-line necessary to satisfy the referenced Definition.).
Short | Resulting event shall comply with
Comments | See the notes in the workflow extensions area for more guidance on this element.
Control | 0..*
Type | Extension(Shall comply with) (Extension Type: Choice of: canonical(ActivityDefinition, Measure, ObservationDefinition, PlanDefinition, Questionnaire), Reference(ActivityDefinition, Measure, ObservationDefinition, PlanDefinition, Questionnaire), uri)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
18. CarePlan.extension:adheresTo
Slice Name | adheresTo
Definition | The action represented by this resource has been determined to satisfy the expectations established by the referenced Definition resource.
Short | Follows rules from
Comments | If changes are made to this event record, the determination must be made whether, with the change, the action still complies with the referenced Definition. Revisions may result in adheresTo assertions being removed, or - if the system has an algorithm for determining which targets are appropriate - being added. Adherence may be asserted after the fact. It is possible for a Request or Event to adhere to a Definition even if the author/performer of the action was not aware of the Definition at the time the action was taken/requested. Also see the notes in the workflow extensions area for more guidance on this element.
Control | 0..*
Type | Extension(adheres to) (Extension Type: Choice of: canonical(ActivityDefinition, Measure, ObservationDefinition, PlanDefinition, Questionnaire), Reference(ActivityDefinition, Measure, ObservationDefinition, PlanDefinition, Questionnaire), uri)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
20. CarePlan.modifierExtension
Definition | 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).
Short | Extensions that cannot be ignored
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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summary | false
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.
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
22. CarePlan.identifier
Definition | 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.
Short | External Ids for this plan
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.
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..*
Type | Identifier
Is Modifier | false
Summary | true
Requirements | Allows identification of the care plan as it is known by various participating systems and in a way that remains consistent across servers.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
24. CarePlan.instantiatesCanonical
Definition | 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.
Short | Instantiates FHIR protocol or definition
Control | 0..0
Type | canonical(PlanDefinition, Questionnaire, Measure, ActivityDefinition, OperationDefinition)
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
26. CarePlan.instantiatesUri
Definition | 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.
Short | Instantiates external protocol or definition
Comments | This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
Control | 0..0
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
28. CarePlan.basedOn
Definition | A care plan that is fulfilled in whole or in part by this care plan.
Short | Fulfills CarePlan
Control | 0..*
Type | Reference(AT APS CarePlan)
Is Modifier | false
Summary | true
Requirements | Allows tracing of the care plan and tracking whether proposals/recommendations were acted upon.
Alternate Names | fulfills
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
30. CarePlan.replaces
Definition | Completed or terminated care plan whose function is taken by this new care plan.
Short | CarePlan replaced by this CarePlan
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.
Control | 0..*
Type | Reference(AT APS CarePlan)
Is Modifier | false
Summary | true
Requirements | Allows tracing the continuation of a therapy or administrative process instantiated through multiple care plans.
Alternate Names | supersedes
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
32. CarePlan.partOf
Definition | A larger care plan of which this particular care plan is a component or step.
Short | Part of referenced CarePlan
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.
Control | 0..*
Type | Reference(AT APS CarePlan)
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
34. CarePlan.status
Definition | Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.
Short | draft | active | on-hold | revoked | completed | entered-in-error | unknown
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.
Control | 1..1
Binding | The codes SHALL be taken from RequestStatus (required to `http://hl7.org/fhir/ValueSet/request-status|4.0.1` ) Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.
Type | code
Is Modifier | true because 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
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Allows clinicians to determine whether the plan is actionable or not.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
36. CarePlan.intent
Definition | Indicates the level of authority/intentionality associated with the care plan and where the care plan fits into the workflow chain.
Short | proposal | plan | order | option
Comments | This element is labeled as a modifier because the intent alters when and how the resource is actually applicable.
Control | 1..1
Binding | The codes SHALL be taken from CarePlanIntent (required to `http://hl7.org/fhir/ValueSet/care-plan-intent|4.0.1` ) Codes indicating the degree of authority/intentionality associated with a care plan.
Type | code
Is Modifier | true because 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"
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Proposals/recommendations, plans and orders all use the same structure and can exist in the same fulfillment chain.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
38. CarePlan.category
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.
Short | Type of plan
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.
Control | 0..*
Binding | For example codes, see CarePlanCategory (example to `http://hl7.org/fhir/ValueSet/care-plan-category|4.0.1` ) Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc.
Type | CodeableConcept
Is Modifier | false
Summary | true
Requirements | Used for filtering what plan(s) are retrieved and displayed to different types of users.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
40. CarePlan.title
Definition | Human-friendly name for the care plan.
Short | Human-friendly name for the care plan
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
42. CarePlan.description
Definition | A description of the scope and nature of the plan.
Short | Summary of nature of plan
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Provides more detail than conveyed by category.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
44. CarePlan.subject
Definition | Identifies the patient or group whose intended care is described by the plan.
Short | Who the care plan is for
Control | 1..1
Type | Reference(AT APS Patient, Group)
Is Modifier | false
Summary | true
Alternate Names | patient
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
46. CarePlan.encounter
Definition | The Encounter during which this CarePlan was created or to which the creation of this record is tightly associated.
Short | Encounter created as part of
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.
Control | 0..1
Type | Reference(Encounter)
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
48. CarePlan.period
Definition | Indicates when the plan did (or is intended to) come into effect and end.
Short | Time period plan covers
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).
Control | 0..1
Type | Period
Is Modifier | false
Summary | true
Requirements | Allows tracking what plan(s) are in effect at a particular time.
Alternate Names | timing
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
50. CarePlan.created
Definition | Represents when this particular CarePlan record was created in the system, which is often a system-generated date.
Short | Date record was first recorded
Control | 0..1
Type | dateTime
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Alternate Names | authoredOn
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
52. CarePlan.author
Definition | When populated, the author is responsible for the care plan. The care plan is attributed to the author.
Short | Who is the designated responsible party
Comments | The author may also be a contributor. For example, an organization can be an author, but not listed as a contributor.
Control | 0..1
Type | Reference(AT APS Patient, AT APS Practitioner, AT APS PractitionerRole, Device, RelatedPerson, AT APS Organization, CareTeam)
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
54. CarePlan.contributor
Definition | Identifies the individual(s) or organization who provided the contents of the care plan.
Short | Who provided the content of the care plan
Comments | Collaborative care plans may have multiple contributors.
Control | 0..*
Type | Reference(AT APS Patient, AT APS Practitioner, AT APS PractitionerRole, Device, RelatedPerson, AT APS Organization, CareTeam)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
56. CarePlan.careTeam
Definition | Identifies all people and organizations who are expected to be involved in the care envisioned by this plan.
Short | Who's involved in plan?
Control | 0..*
Type | Reference(CareTeam)
Is Modifier | false
Summary | false
Requirements | Allows representation of care teams, helps scope care plan. In some cases may be a determiner of access permissions.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
58. CarePlan.addresses
Definition | Identifies the conditions/problems/concerns/diagnoses/etc. whose management and/or mitigation are handled by this plan.
Short | Health issues this plan addresses
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.
Control | 0..*
Type | Reference(AT APS Condition)
Is Modifier | false
Summary | true
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.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
60. CarePlan.supportingInfo
Definition | 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.
Short | Information considered as part of plan
Comments | Use "concern" to identify specific conditions addressed by the care plan.
Control | 0..*
Type | Reference(Resource)
Is Modifier | false
Summary | false
Requirements | Identifies barriers and other considerations associated with the care plan.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
62. CarePlan.goal
Definition | Describes the intended objective(s) of carrying out the care plan.
Short | Desired outcome of plan
Comments | Goal can be achieving a particular change or merely maintaining a current state or even slowing a decline.
Control | 0..*
Type | Reference(Goal)
Is Modifier | false
Summary | false
Requirements | Provides context for plan. Allows plan effectiveness to be evaluated by clinicians.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
64. CarePlan.activity
Definition | 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.
Short | Action to occur as part of plan
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | Allows systems to prompt for performance of planned activities, and validate plans against best practice.
Invariants | cpl-3: Provide a reference or detail, not both (`detail.empty() or reference.empty()`) ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
66. CarePlan.activity.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
68. CarePlan.activity.extension
Definition | 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.
Short | Additional content defined by implementations
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.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
70. CarePlan.activity.modifierExtension
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).
Short | Extensions that cannot be ignored even if unrecognized
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.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
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.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
72. CarePlan.activity.outcomeCodeableConcept
Definition | 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).
Short | Results of the activity
Comments | Note that this should not duplicate the activity status (e.g. completed or in progress).
Control | 0..*
Binding | For example codes, see CarePlanActivityOutcome (example to `http://hl7.org/fhir/ValueSet/care-plan-activity-outcome|4.0.1` ) Identifies the results of the activity.
Type | CodeableConcept
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
74. CarePlan.activity.outcomeReference
Definition | 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).
Short | Appointment, Encounter, Procedure, etc.
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.
Control | 0..*
Type | Reference(Resource)
Is Modifier | false
Summary | false
Requirements | Links plan to resulting actions.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
76. CarePlan.activity.progress
Definition | Notes about the adherence/status/progress of the activity.
Short | Comments about the activity status/progress
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.
Control | 0..*
Type | Annotation
Is Modifier | false
Summary | false
Requirements | Can be used to capture information about adherence, progress, concerns, etc.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
78. CarePlan.activity.reference
Definition | The details of the proposed activity represented in a specific resource.
Short | Activity details defined in specific resource
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.
Control | 0..1 This element is affected by the following invariants: cpl-3
Type | Reference(Appointment, CommunicationRequest, DeviceRequest, AT APS MedicationRequest, NutritionOrder, Task, ServiceRequest, VisionPrescription, RequestGroup)
Is Modifier | false
Summary | false
Requirements | Details in a form consistent with other applications and contexts of use.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
80. CarePlan.activity.detail
Definition | 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.
Short | In-line definition of activity
Control | 0..0 This element is affected by the following invariants: cpl-3
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | Details in a simple form for generic care plan systems.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
102. CarePlan.note
Definition | General notes about the care plan not covered elsewhere.
Short | Comments about the plan
Control | 0..*
Type | Annotation
Is Modifier | false
Summary | false
Requirements | Used to capture information that applies to the plan as a whole that doesn't fit into discrete elements.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)