Integrierte Versorgung Diabetes (R4)
0.1.1 - ci-build

Integrierte Versorgung Diabetes (R4) - Local Development build (v0.1.1) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Resource Profile: DiabCareplan - Detailed Descriptions

Draft as of 2025-06-06

Definitions for the diab-careplan resource profile.

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

0. CarePlan
Definition

Dokumentation eines Diabetes-Behandlungsplans (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.

ShortDiabetes BehandlungsplanHealthcare plan for patient or group
Control0..*
Is Modifierfalse
Summaryfalse
Alternate NamesCare Team
Invariantsdom-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.

ShortA 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.

Control0..1
Typeuri
Is Modifiertrue 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 ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
4. 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).

ShortExtensions 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.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
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 Namesextensions, user content
Invariantsele-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())
6. CarePlan.status
Definition

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

Shortdraft | 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.

Control1..1
BindingThe codes SHALL be taken from RequestStatushttp://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.

Typecode
Is Modifiertrue 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 ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

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

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. CarePlan.intent
Definition

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

Shortproposal | plan | order | option
Comments

This element is labeled as a modifier because the intent alters when and how the resource is actually applicable.

Control1..1
BindingThe codes SHALL be taken from CarePlanIntenthttp://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.

Typecode
Is Modifiertrue 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 ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

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

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. CarePlan.title
Definition

Human-friendly name for the care plan.

ShortBezeichnung des Behandlungsplans / der SchulungHuman-friendly name for the care plan
Control10..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. CarePlan.description
Definition

A description of the scope and nature of the plan.

ShortInhalte des Behandlungsplans / der SchulungSummary of nature of plan
Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

Provides more detail than conveyed by category.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
14. CarePlan.subject
Definition

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

ShortIV Patient, für den die Behandlung / Schulung bestimmt istWho the care plan is for
Control1..1
TypeReference(AT APS Patient, Patient, Group)
Is Modifierfalse
Summarytrue
Alternate Namespatient
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
16. CarePlan.period
Definition

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

ShortBehandlung / Schulung für den ZeitraumTime 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).

Control0..1
TypePeriod
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

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

Alternate Namestiming
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
18. CarePlan.created
Definition

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

ShortBehandlung / Schulung festgelegt am (Datum)Date record was first recorded
Control0..1
TypedateTime
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Alternate NamesauthoredOn
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. CarePlan.author
Definition

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

ShortVerantwortlicher GDAWho 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.

Control10..1
TypeReference(AT APS Practitioner, AT APS PractitionerRole, Patient, Practitioner, PractitionerRole, Device, RelatedPerson, Organization, CareTeam)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. CarePlan.addresses
Definition

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

ShortGesundheitsproblem, das dieser Behandlungsplan / die Schulung adressiertHealth 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.

Control0..*
TypeReference(AT APS Condition, Condition)
Is Modifierfalse
Summarytrue
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.

Invariantsele-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
Definition

Dokumentation eines Diabetes-Behandlungsplans (Careplan).

ShortDiabetes Behandlungsplan
2. CarePlan.title
ShortBezeichnung des Behandlungsplans / der Schulung
Control1..?
Must Supporttrue
4. CarePlan.description
ShortInhalte des Behandlungsplans / der Schulung
6. CarePlan.subject
ShortIV Patient, für den die Behandlung / Schulung bestimmt ist
TypeReference(AT APS Patient)
8. CarePlan.period
ShortBehandlung / Schulung für den Zeitraum
Must Supporttrue
10. CarePlan.created
ShortBehandlung / Schulung festgelegt am (Datum)
Must Supporttrue
12. CarePlan.author
ShortVerantwortlicher GDA
Control1..?
TypeReference(AT APS Practitioner, AT APS PractitionerRole)
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
14. CarePlan.addresses
ShortGesundheitsproblem, das dieser Behandlungsplan / die Schulung adressiert
TypeReference(AT APS Condition)
16. CarePlan.activity
18. CarePlan.activity.detail
Control0..0

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

0. CarePlan
Definition

Dokumentation eines Diabetes-Behandlungsplans (Careplan).

ShortDiabetes Behandlungsplan
Control0..*
Is Modifierfalse
Summaryfalse
Alternate NamesCare Team
Invariantsdom-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.

ShortLogical 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.

Control0..1
Typeid
Is Modifierfalse
Summarytrue
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.

ShortMetadata about the resource
Control0..1
TypeMeta
Is Modifierfalse
Summarytrue
Invariantsele-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.

ShortA 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.

Control0..1
Typeuri
Is Modifiertrue 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 ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-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.

ShortLanguage 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).

Control0..1
BindingThe codes SHOULD be taken from CommonLanguages
(preferred to http://hl7.org/fhir/ValueSet/languages)

A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Invariantsele-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.

ShortText 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.

Control0..1
TypeNarrative
Is Modifierfalse
Summaryfalse
Alternate Namesnarrative, html, xhtml, display
Invariantsele-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.

ShortContained, 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.

Control0..*
TypeResource
Is Modifierfalse
Summaryfalse
Alternate Namesinline resources, anonymous resources, contained resources
14. CarePlan.extension
Definition

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.

ShortAdditional 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.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-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())
16. 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).

ShortExtensions 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.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
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 Namesextensions, user content
Invariantsele-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.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.

ShortExternal 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.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Is Modifierfalse
Summarytrue
Requirements

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

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. 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.

ShortInstantiates FHIR protocol or definition
Control0..*
Typecanonical(PlanDefinition, Questionnaire, Measure, ActivityDefinition, OperationDefinition)
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. 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.

ShortInstantiates external protocol or definition
Comments

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

Control0..*
Typeuri
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
24. CarePlan.basedOn
Definition

A care plan that is fulfilled in whole or in part by this care plan.

ShortFulfills CarePlan
Control0..*
TypeReference(CarePlan)
Is Modifierfalse
Summarytrue
Requirements

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

Alternate Namesfulfills
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
26. CarePlan.replaces
Definition

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

ShortCarePlan 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.

Control0..*
TypeReference(CarePlan)
Is Modifierfalse
Summarytrue
Requirements

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

Alternate Namessupersedes
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
28. CarePlan.partOf
Definition

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

ShortPart 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.

Control0..*
TypeReference(CarePlan)
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. CarePlan.status
Definition

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

Shortdraft | 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.

Control1..1
BindingThe 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.

Typecode
Is Modifiertrue 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 ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

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

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
32. CarePlan.intent
Definition

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

Shortproposal | plan | order | option
Comments

This element is labeled as a modifier because the intent alters when and how the resource is actually applicable.

Control1..1
BindingThe 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.

Typecode
Is Modifiertrue 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 ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

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

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
34. 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.

ShortType 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.

Control0..*
BindingFor example codes, see CarePlanCategory
(example to http://hl7.org/fhir/ValueSet/care-plan-category)

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

TypeCodeableConcept
Is Modifierfalse
Summarytrue
Requirements

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

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
36. CarePlan.title
Definition

Human-friendly name for the care plan.

ShortBezeichnung des Behandlungsplans / der Schulung
Control1..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
38. CarePlan.description
Definition

A description of the scope and nature of the plan.

ShortInhalte des Behandlungsplans / der Schulung
Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

Provides more detail than conveyed by category.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
40. CarePlan.subject
Definition

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

ShortIV Patient, für den die Behandlung / Schulung bestimmt ist
Control1..1
TypeReference(AT APS Patient)
Is Modifierfalse
Summarytrue
Alternate Namespatient
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
42. CarePlan.encounter
Definition

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

ShortEncounter 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.

Control0..1
TypeReference(Encounter)
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
44. CarePlan.period
Definition

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

ShortBehandlung / Schulung für den Zeitraum
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).

Control0..1
TypePeriod
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

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

Alternate Namestiming
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
46. CarePlan.created
Definition

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

ShortBehandlung / Schulung festgelegt am (Datum)
Control0..1
TypedateTime
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Alternate NamesauthoredOn
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
48. CarePlan.author
Definition

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

ShortVerantwortlicher GDA
Comments

The author may also be a contributor. For example, an organization can be an author, but not listed as a contributor.

Control1..1
TypeReference(AT APS Practitioner, AT APS PractitionerRole)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
50. CarePlan.contributor
Definition

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

ShortWho provided the content of the care plan
Comments

Collaborative care plans may have multiple contributors.

Control0..*
TypeReference(Patient, Practitioner, PractitionerRole, Device, RelatedPerson, Organization, CareTeam)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
52. CarePlan.careTeam
Definition

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

ShortWho's involved in plan?
Control0..*
TypeReference(CareTeam)
Is Modifierfalse
Summaryfalse
Requirements

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

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
54. CarePlan.addresses
Definition

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

ShortGesundheitsproblem, das dieser Behandlungsplan / die Schulung adressiert
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.

Control0..*
TypeReference(AT APS Condition)
Is Modifierfalse
Summarytrue
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.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
56. 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.

ShortInformation considered as part of plan
Comments

Use "concern" to identify specific conditions addressed by the care plan.

Control0..*
TypeReference(Resource)
Is Modifierfalse
Summaryfalse
Requirements

Identifies barriers and other considerations associated with the care plan.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
58. CarePlan.goal
Definition

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

ShortDesired outcome of plan
Comments

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

Control0..*
TypeReference(Goal)
Is Modifierfalse
Summaryfalse
Requirements

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

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
60. 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.

ShortAction to occur as part of plan
Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Requirements

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

Invariantscpl-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()))
62. 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.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
64. 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.

ShortAdditional 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.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-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())
66. 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).

ShortExtensions 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.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
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 Namesextensions, user content, modifiers
Invariantsele-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())
68. 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).

ShortResults of the activity
Comments

Note that this should not duplicate the activity status (e.g. completed or in progress).

Control0..*
BindingFor example codes, see CarePlanActivityOutcome
(example to http://hl7.org/fhir/ValueSet/care-plan-activity-outcome)

Identifies the results of the activity.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
70. 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).

ShortAppointment, 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.

Control0..*
TypeReference(Resource)
Is Modifierfalse
Summaryfalse
Requirements

Links plan to resulting actions.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
72. CarePlan.activity.progress
Definition

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

ShortComments 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.

Control0..*
TypeAnnotation
Is Modifierfalse
Summaryfalse
Requirements

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

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
74. CarePlan.activity.reference
Definition

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

ShortActivity 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.

Control0..1
This element is affected by the following invariants: cpl-3
TypeReference(Appointment, CommunicationRequest, DeviceRequest, MedicationRequest, NutritionOrder, Task, ServiceRequest, VisionPrescription, RequestGroup)
Is Modifierfalse
Summaryfalse
Requirements

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

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
76. 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.

ShortIn-line definition of activity
Control0..0
This element is affected by the following invariants: cpl-3
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Requirements

Details in a simple form for generic care plan systems.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
98. CarePlan.note
Definition

General notes about the care plan not covered elsewhere.

ShortComments about the plan
Control0..*
TypeAnnotation
Is Modifierfalse
Summaryfalse
Requirements

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

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))