CareplanCordinatedCareSe
Introduction
The CareplanCordinatedCareSe profile is used for retrieving data about Link care plans in COSMIC. This profile is based on the FHIR resource CarePlan. It includes information like referral date, requester, receiver and also references a QuestionaireResponse resource with care note data.
COSMIC Link supports processes and routines in terms of coordination between actors which provides healthcare and social services to ensure an uninterrupted chain of care.
Intended Use
The intended use for this API is to get information about a patient's coordinated careplans, both active and completed. The coordination plan may contain multiple care notes. List of literal IDs will be returned under the Supporting info so that consumers can fetch each note using the GET API for QuestionnaireResponse. Additionally the API consumer has the possibility to contain these care notes by specifying it in the include parameters.
The intended use for reading data with this API is in first hand that the API is applied for direct access and should not be used to transfer data between caregivers. If it should be used for "data copying" between care providers, patient consent must be handled outside the API.
Specific Rules and Limitations
Type | Description |
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Limitation | This API is bound to provide only the coordinated care plans created through the LINK module in COSMIC |
Rule | The consumer of the API is responsible for making sure data retrieved is filtered in compliance with laws and regulations prior to presenting it to any end-users. |
Rule | For reading coordinated careplans, the external system needs to be able to evaluate PDL. This means whether the information can be displayed for a healthcare professional with a specific assignment. PDL data needed (HSA care unit and HSA care provider) is retrieved by including the organization referenced from Careplan.contributer.PractitionerRoleLiteSe(PractitionerRoleLiteSe.OrganizationSEVendorLite). |
Profile Overview
CareplanCordinatedCareSe (CarePlan) | I | CarePlanCore | There are no (further) constraints on this element Element idCarePlan Healthcare plan for patient or group Alternate namesCare Team DefinitionDescribes 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.
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id | Σ | 0..1 | string | There are no (further) constraints on this element Element idCarePlan.id Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idCarePlan.meta Metadata about the resource DefinitionThe 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.
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implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idCarePlan.implicitRules A set of rules under which this content was created DefinitionA 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. 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.
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language | 0..1 | codeBinding | There are no (further) constraints on this element Element idCarePlan.language Language of the resource content DefinitionThe base language in which the resource is written. 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). A human language.
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text | 0..1 | Narrative | There are no (further) constraints on this element Element idCarePlan.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA 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. 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.
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contained | 0..* | Resource | There are no (further) constraints on this element Element idCarePlan.contained Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese 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. 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.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCarePlan.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCarePlan.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay 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). 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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identifier | Σ | 0..0 | Identifier | There are no (further) constraints on this element Element idCarePlan.identifier External Ids for this plan DefinitionBusiness 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. Allows identification of the care plan as it is known by various participating systems and in a way that remains consistent across servers. 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.
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instantiatesCanonical | Σ | 0..0 | canonical(PlanDefinition | Questionnaire | Measure | ActivityDefinition | OperationDefinition) | There are no (further) constraints on this element Element idCarePlan.instantiatesCanonical Instantiates FHIR protocol or definition DefinitionThe URL pointing to a FHIR-defined protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlan. canonical(PlanDefinition | Questionnaire | Measure | ActivityDefinition | OperationDefinition) Constraints
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instantiatesUri | Σ | 0..0 | uri | There are no (further) constraints on this element Element idCarePlan.instantiatesUri Instantiates external protocol or definition DefinitionThe URL pointing to an externally maintained protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlan. This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
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basedOn | Σ I | 0..0 | Reference(CarePlan) | There are no (further) constraints on this element Element idCarePlan.basedOn Fulfills CarePlan Alternate namesfulfills DefinitionA care plan that is fulfilled in whole or in part by this care plan. Allows tracing of the care plan and tracking whether proposals/recommendations were acted upon. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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replaces | Σ I | 0..0 | Reference(CarePlan) | There are no (further) constraints on this element Element idCarePlan.replaces CarePlan replaced by this CarePlan Alternate namessupersedes DefinitionCompleted or terminated care plan whose function is taken by this new care plan. Allows tracing the continuation of a therapy or administrative process instantiated through multiple care plans. 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.
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partOf | Σ I | 0..0 | Reference(CarePlan) | There are no (further) constraints on this element Element idCarePlan.partOf Part of referenced CarePlan DefinitionA larger care plan of which this particular care plan is a component or step. 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.
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status | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idCarePlan.status draft | active | on-hold | revoked | completed | entered-in-error | unknown DefinitionIndicates whether the plan is currently being acted upon, represents future intentions or is now a historical record. Allows clinicians to determine whether the plan is actionable or not. 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. Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.
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intent | Σ ?! | 1..1 | codeBindingFixed Value | Element idCarePlan.intent proposal | plan | order | option DefinitionIndicates the level of authority/intentionality associated with the care plan and where the care plan fits into the workflow chain. Proposals/recommendations, plans and orders all use the same structure and can exist in the same fulfillment chain. This element is labeled as a modifier because the intent alters when and how the resource is actually applicable. Codes indicating the degree of authority/intentionality associated with a care plan.
plan
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category | Σ | 0..* | CodeableConceptBinding | Element idCarePlan.category Type of plan DefinitionIdentifies 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. Used for filtering what plan(s) are retrieved and displayed to different types of users. 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. Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans; e.g. "Home health", "psychiatric", "asthma", "disease management", etc.
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title | Σ | 0..1 | string | There are no (further) constraints on this element Element idCarePlan.title Human-friendly name for the care plan DefinitionHuman-friendly name for the care plan. Note that FHIR strings SHALL NOT exceed 1MB in size
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description | Σ | 0..1 | string | There are no (further) constraints on this element Element idCarePlan.description Summary of nature of plan DefinitionA description of the scope and nature of the plan. Provides more detail than conveyed by category. Note that FHIR strings SHALL NOT exceed 1MB in size
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subject | Σ I | 1..1 | Reference(Patient | Group) | There are no (further) constraints on this element Element idCarePlan.subject Who the care plan is for Alternate namespatient DefinitionIdentifies the patient or group whose intended care is described by the plan. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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id | 0..1 | string | There are no (further) constraints on this element Element idCarePlan.subject.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCarePlan.subject.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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reference | Σ I | 0..1 | string | There are no (further) constraints on this element Element idCarePlan.subject.reference Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
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type | Σ | 0..1 | uriBindingFixed Value | Element idCarePlan.subject.type Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model).
Patient
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identifier | Σ | 0..1 | Identifier | Element idCarePlan.subject.identifier Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). Unordered, Open, by system(Value) Constraints
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personnummer | Σ | 0..1 | Identifier | Element idCarePlan.subject.identifier:personnummer Personnummer/Personal identity number for the patient DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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id | 0..1 | string | There are no (further) constraints on this element Element idCarePlan.subject.identifier:personnummer.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCarePlan.subject.identifier:personnummer.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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use | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idCarePlan.subject.identifier:personnummer.use usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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type | Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idCarePlan.subject.identifier:personnummer.type Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
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system | Σ | 1..1 | uriFixed Value | Element idCarePlan.subject.identifier:personnummer.system The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, a URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
urn:oid:1.2.752.129.2.1.3.1
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value | Σ | 1..1 | string | There are no (further) constraints on this element Element idCarePlan.subject.identifier:personnummer.value The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
General 123456 Mappings
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period | Σ I | 0..1 | Period | There are no (further) constraints on this element Element idCarePlan.subject.identifier:personnummer.period Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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assigner | Σ I | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idCarePlan.subject.identifier:personnummer.assigner Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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samordningsnummer | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idCarePlan.subject.identifier:samordningsnummer Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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id | 0..1 | string | There are no (further) constraints on this element Element idCarePlan.subject.identifier:samordningsnummer.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCarePlan.subject.identifier:samordningsnummer.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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use | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idCarePlan.subject.identifier:samordningsnummer.use usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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type | Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idCarePlan.subject.identifier:samordningsnummer.type Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
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system | Σ | 1..1 | uriFixed Value | Element idCarePlan.subject.identifier:samordningsnummer.system The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, a URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
urn:oid:1.2.752.129.2.1.3.3
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value | Σ | 1..1 | string | There are no (further) constraints on this element Element idCarePlan.subject.identifier:samordningsnummer.value The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
General 123456 Mappings
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period | Σ I | 0..1 | Period | There are no (further) constraints on this element Element idCarePlan.subject.identifier:samordningsnummer.period Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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assigner | Σ I | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idCarePlan.subject.identifier:samordningsnummer.assigner Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element idCarePlan.subject.display Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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encounter | Σ I | 0..0 | Reference(Encounter) | There are no (further) constraints on this element Element idCarePlan.encounter Encounter created as part of DefinitionThe Encounter during which this CarePlan was created or to which the creation of this record is tightly associated. 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.
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period | Σ I | 0..0 | Period | There are no (further) constraints on this element Element idCarePlan.period Time period plan covers Alternate namestiming DefinitionIndicates when the plan did (or is intended to) come into effect and end. Allows tracking what plan(s) are in effect at a particular time. 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).
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created | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element idCarePlan.created Date record was first recorded Alternate namesauthoredOn DefinitionRepresents when this particular CarePlan record was created in the system, which is often a system-generated date.
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author | Σ I | 0..0 | Reference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam) | There are no (further) constraints on this element Element idCarePlan.author Who is the designated responsible party DefinitionWhen populated, the author is responsible for the care plan. The care plan is attributed to the author. The author may also be a contributor. For example, an organization can be an author, but not listed as a contributor. Reference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam) Constraints
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contributor | I | 0..* | Reference(PractitionerRoleLiteSe) | Element idCarePlan.contributor Who provided the content of the care plan DefinitionIdentifies the individual(s) or organization who provided the contents of the care plan. Collaborative care plans may have multiple contributors. Reference(PractitionerRoleLiteSe) Constraints
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careTeam | I | 0..0 | Reference(CareTeam) | There are no (further) constraints on this element Element idCarePlan.careTeam Who's involved in plan? DefinitionIdentifies all people and organizations who are expected to be involved in the care envisioned by this plan. Allows representation of care teams, helps scope care plan. In some cases may be a determiner of access permissions. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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addresses | Σ I | 0..0 | Reference(Condition) | There are no (further) constraints on this element Element idCarePlan.addresses Health issues this plan addresses DefinitionIdentifies the conditions/problems/concerns/diagnoses/etc. whose management and/or mitigation are handled by this plan. 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. 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.
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supportingInfo | I | 0..* | Reference(QuestionnaireResponseSe) | Element idCarePlan.supportingInfo Information considered as part of plan DefinitionIdentifies portions of the patient's record that specifically influenced the formation of the plan. These might include comorbidities, recent procedures, limitations, recent assessments, etc. Identifies barriers and other considerations associated with the care plan. Use "concern" to identify specific conditions addressed by the care plan. Reference(QuestionnaireResponseSe) Allowed aggregation: bundled Constraints
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goal | I | 0..* | Reference(Goal) | There are no (further) constraints on this element Element idCarePlan.goal Desired outcome of plan DefinitionDescribes the intended objective(s) of carrying out the care plan. Provides context for plan. Allows plan effectiveness to be evaluated by clinicians. Goal can be achieving a particular change or merely maintaining a current state or even slowing a decline.
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activity | I | 0..* | BackboneElement | There are no (further) constraints on this element Element idCarePlan.activity Action to occur as part of plan DefinitionIdentifies 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. Allows systems to prompt for performance of planned activities, and validate plans against best practice.
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id | 0..1 | string | There are no (further) constraints on this element Element idCarePlan.activity.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCarePlan.activity.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCarePlan.activity.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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.
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outcomeCodeableConcept | 0..* | CodeableConcept | There are no (further) constraints on this element Element idCarePlan.activity.outcomeCodeableConcept Results of the activity DefinitionIdentifies 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). Note that this should not duplicate the activity status (e.g. completed or in progress). Identifies the results of the activity.
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outcomeReference | I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element idCarePlan.activity.outcomeReference Appointment, Encounter, Procedure, etc. DefinitionDetails 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). Links plan to resulting actions. 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.
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progress | 0..* | Annotation | There are no (further) constraints on this element Element idCarePlan.activity.progress Comments about the activity status/progress DefinitionNotes about the adherence/status/progress of the activity. Can be used to capture information about adherence, progress, concerns, etc. 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.
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reference | I | 0..1 | Reference(Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup | https://www.hl7.org/fhir/questionnaire.html) | Element idCarePlan.activity.reference Activity details defined in specific resource DefinitionThe details of the proposed activity represented in a specific resource. Details in a form consistent with other applications and contexts of use. Standard extension exists (resource-pertainsToGoal) that allows goals to be referenced from any of the referenced resources in CarePlan.activity.reference. Reference(Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup | https://www.hl7.org/fhir/questionnaire.html) Constraints
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detail | I | 0..1 | BackboneElement | There are no (further) constraints on this element Element idCarePlan.activity.detail In-line definition of activity DefinitionA 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. Details in a simple form for generic care plan systems.
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id | 0..1 | string | There are no (further) constraints on this element Element idCarePlan.activity.detail.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCarePlan.activity.detail.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCarePlan.activity.detail.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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.
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kind | 0..1 | codeBindingFixed Value | Element idCarePlan.activity.detail.kind Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription DefinitionA description of the kind of resource the in-line definition of a care plan activity is representing. The CarePlan.activity.detail is an in-line definition when a resource is not referenced using CarePlan.activity.reference. For example, a MedicationRequest, a ServiceRequest, or a CommunicationRequest. May determine what types of extensions are permitted. Note that FHIR strings SHALL NOT exceed 1MB in size Resource types defined as part of FHIR that can be represented as in-line definitions of a care plan activity.
Task
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instantiatesCanonical | 0..0 | canonical(PlanDefinition | ActivityDefinition | Questionnaire | Measure | OperationDefinition) | There are no (further) constraints on this element Element idCarePlan.activity.detail.instantiatesCanonical Instantiates FHIR protocol or definition DefinitionThe URL pointing to a FHIR-defined protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlan activity. Allows Questionnaires that the patient (or practitioner) should fill in to fulfill the care plan activity. canonical(PlanDefinition | ActivityDefinition | Questionnaire | Measure | OperationDefinition) Constraints
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instantiatesUri | 0..0 | uri | There are no (further) constraints on this element Element idCarePlan.activity.detail.instantiatesUri Instantiates external protocol or definition DefinitionThe URL pointing to an externally maintained protocol, guideline, questionnaire or other definition that is adhered to in whole or in part by this CarePlan activity. Allows Questionnaires that the patient (or practitioner) should fill in to fulfill the care plan activity. This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
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code | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idCarePlan.activity.detail.code Detail type of activity DefinitionDetailed description of the type of planned activity; e.g. what lab test, what procedure, what kind of encounter. Allows matching performed to planned as well as validation against protocols. Tends to be less relevant for activities involving particular products. Codes should not convey negation - use "prohibited" instead. Detailed description of the type of activity; e.g. What lab test, what procedure, what kind of encounter.
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reasonCode | 0..0 | CodeableConcept | There are no (further) constraints on this element Element idCarePlan.activity.detail.reasonCode Why activity should be done or why activity was prohibited DefinitionProvides the rationale that drove the inclusion of this particular activity as part of the plan or the reason why the activity was prohibited. This could be a diagnosis code. If a full condition record exists or additional detail is needed, use reasonCondition instead. Identifies why a care plan activity is needed. Can include any health condition codes as well as such concepts as "general wellness", prophylaxis, surgical preparation, etc.
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reasonReference | I | 0..0 | Reference(Condition | Observation | DiagnosticReport | DocumentReference) | There are no (further) constraints on this element Element idCarePlan.activity.detail.reasonReference Why activity is needed DefinitionIndicates another resource, such as the health condition(s), whose existence justifies this request and drove the inclusion of this particular activity as part of the plan. Conditions can be identified at the activity level that are not identified as reasons for the overall plan. Reference(Condition | Observation | DiagnosticReport | DocumentReference) Constraints
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goal | I | 0..* | Reference(Goal) | There are no (further) constraints on this element Element idCarePlan.activity.detail.goal Goals this activity relates to DefinitionInternal reference that identifies the goals that this activity is intended to contribute towards meeting. So that participants know the link explicitly. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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status | ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idCarePlan.activity.detail.status not-started | scheduled | in-progress | on-hold | completed | cancelled | stopped | unknown | entered-in-error DefinitionIdentifies what progress is being made for the specific activity. Indicates progress against the plan, whether the activity is still relevant for the plan. Some aspects of status can be inferred based on the resources linked in actionTaken. Note that "status" is only as current as the plan was most recently updated. Codes that reflect the current state of a care plan activity within its overall life cycle.
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statusReason | 0..0 | CodeableConcept | There are no (further) constraints on this element Element idCarePlan.activity.detail.statusReason Reason for current status DefinitionProvides reason why the activity isn't yet started, is on hold, was cancelled, etc. Will generally not be present if status is "complete". Be sure to prompt to update this (or at least remove the existing value) if the status is changed.
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doNotPerform | ?! | 0..0 | boolean | There are no (further) constraints on this element Element idCarePlan.activity.detail.doNotPerform If true, activity is prohibiting action DefinitionIf true, indicates that the described activity is one that must NOT be engaged in when following the plan. If false, or missing, indicates that the described activity is one that should be engaged in when following the plan. Captures intention to not do something that may have been previously typical. This element is labeled as a modifier because it marks an activity as an activity that is not to be performed. If missing indicates that the described activity is one that should be engaged in when following the plan.
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scheduled[x] | 0..0 | There are no (further) constraints on this element Element idCarePlan.activity.detail.scheduled[x] When activity is to occur DefinitionThe period, timing or frequency upon which the described activity is to occur. Allows prompting for activities and detection of missed planned activities.
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location | I | 0..0 | Reference(Location) | There are no (further) constraints on this element Element idCarePlan.activity.detail.location Where it should happen DefinitionIdentifies the facility where the activity will occur; e.g. home, hospital, specific clinic, etc. Helps in planning of activity. May reference a specific clinical location or may identify a type of location.
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performer | I | 0..0 | Reference(Practitioner | PractitionerRole | Organization | RelatedPerson | Patient | CareTeam | HealthcareService | Device) | There are no (further) constraints on this element Element idCarePlan.activity.detail.performer Who will be responsible? DefinitionIdentifies who's expected to be involved in the activity. Helps in planning of activity. A performer MAY also be a participant in the care plan. Reference(Practitioner | PractitionerRole | Organization | RelatedPerson | Patient | CareTeam | HealthcareService | Device) Constraints
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product[x] | 0..0 | There are no (further) constraints on this element Element idCarePlan.activity.detail.product[x] What is to be administered/supplied DefinitionIdentifies the food, drug or other product to be consumed or supplied in the activity. A product supplied or administered as part of a care plan activity.
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dailyAmount | I | 0..0 | SimpleQuantity | There are no (further) constraints on this element Element idCarePlan.activity.detail.dailyAmount How to consume/day? Alternate namesdaily dose DefinitionIdentifies the quantity expected to be consumed in a given day. Allows rough dose checking. The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.
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quantity | I | 0..0 | SimpleQuantity | There are no (further) constraints on this element Element idCarePlan.activity.detail.quantity How much to administer/supply/consume DefinitionIdentifies the quantity expected to be supplied, administered or consumed by the subject. The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.
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description | 0..1 | string | There are no (further) constraints on this element Element idCarePlan.activity.detail.description Extra info describing activity to perform DefinitionThis provides a textual description of constraints on the intended activity occurrence, including relation to other activities. It may also include objectives, pre-conditions and end-conditions. Finally, it may convey specifics about the activity such as body site, method, route, etc. Note that FHIR strings SHALL NOT exceed 1MB in size
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note | 0..* | Annotation | There are no (further) constraints on this element Element idCarePlan.note Comments about the plan DefinitionGeneral notes about the care plan not covered elsewhere. Used to capture information that applies to the plan as a whole that doesn't fit into discrete elements. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
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Versions
COS version | Profile version | Required COSMIC version | Date | Description |
---|---|---|---|---|
3.2.0 | 1.0.0 | R8.3.05 | Apr 2022 | Initial version, Support for GET and search. |
ValueSet
The profile includes bindings to the following Cambio defined value set: CarePlanCategories
Code | Display |
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SIP | Samordnad individuell plan |
SPLPTLRV | LPT and LRV |
SPU | Samordnad plan vid utskrivning |
VP | Vårdplan |
RP | Rehabiliteringsplan |
GP | Genomförandeplan |
SVP | Standardiserad vårdplan |
Supported Operations
HTTP Methods
Method | Description |
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GET | Support for GET Coordination plan by specific patient ID, and also to search by period and Type. |
Query Operations
Search Parameters
Parameter | Format | Mandatory | Comment |
---|---|---|---|
_profile | string | Yes | |
Subject | reference | Yes | The subject that the coordination plan is about. |
category | string | No | supported types :SPLPTLRV, SIP, SPU |
Supported Queries
GET [baseURL]/CarePlan/?subject=[id]&_profile=[]
(Search)GET [baseURL]/CarePlan/?subject=[id]&_profile=[]&category=[]
(Search)GET [baseURL]/CarePlan/?subject=[id]&_profile=[]&category=[]&_include=supportingInfo
(Search)GET [baseURL]/CarePlan/?subject=[id]&_profile=[]&category=[]&_include=supportingInfo&_include=contributor
(Search)GET [baseURL]/CarePlan/?subject=[id]&_profile=[]&category=[]&_include=contributor
(Search)GET [baseURL]/CarePlan/?subject=[id]&_profile=[]&_include=contributor
(Search)
Supported SearchInclude Operations
The following searchInclude parameters are supported:
- supportingInfo
- contributor
Supported RevInclude Operations
N/A
Error Codes
No specific error codes for Careplan. For common codes, refer to Error handling section.