Copy of 'GP Connect Data Model | FHIR STU3 Representation'

Notice: This guidance is under active development by NHS England and content may be added or updated on a regular basis.

Profile: CareConnect-Careplan-1

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Data model element usage

Element Use CareConnect (STU3) UK Core (R4)
identifier
definition
basedOn
replaces
partOf
status
intent
category
title
description
subject
context
period
author
careTeam
addresses
supportingInfo
goal
activity
note

identifier

Usage

Optional

Guidance

All relevant business identifier details for the care plan, where available.

Example
<identifier>
    <value value="123456" />
</identifier>

definition

Usage

Optional

Guidance

Identifies the protocol, questionnaire, guideline or other specification the care plan should be conducted in accordance with.

Example
 <definition> 
    <display value="A PlanDefinition protocol for obesity"/> 
  </definition>

basedOn

Usage

Optional

Guidance

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

Example
  <basedOn> 
    <display value="Management of Type 2 Diabetes"/> 
  </basedOn>

replaces

Usage

Optional

Guidance

A care plan whose function is taken on by this new care plan.

Example
  <replaces> 
    <display value="Plan from urgent care clinic"/> 
  </replaces>

partOf

Usage

Optional

Guidance

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

Example
  <partOf> 
    <display value="Overall health and wellbeing plan"/> 
  </partOf>

status

Usage

Mandatory

Guidance

Indicates whether the care plan is currently being acted upon, future plans or is now historical.

Example
  <status value="active"/>

intent

Usage

Mandatory

Guidance

Indicates how much authority, or what purpose, is behind the care plan and how it fits into the overall workflow.

Example
  <intent value="plan"/>

category

Usage

Optional

Guidance

Identifies what "kind" of plan this is to support differentiation between multiple co-existing plans. e.g. Mental health crisis plan, Cancer care plan or Clinical management plan.

Example
<category> 
    <text value="Weight management plan"/> 
  </category>

title

Usage

Optional

Guidance

Human friendly name for the Care plan.

Example
<category> 
    <text value="Weight management Care plan"/> 
  </category>

description

Usage

Optional

Guidance

A description of the scope and nature of the plan.

Example
<category> 
    <description value="Manage obesity and weight loss"/>
  </category>

subject

Usage

Mandatory

Guidance

Identifies who, which patient, the care plan is intended for.

Example
 <subject> 
    <reference value="Patient/example"/> 
    <display value="Peter John Smith"/> 
  </subject>

context

Usage

Optional

Guidance

Identifies the original context (encounter/episode of care) in which this Care plan was created.

Example
  <context> 
    <reference value="Encounter/GPvisit"/> 
  </context>

period

Usage

Optional

Guidance

Indicates when the plan did (or is intended to) start and end.

Example
  <period> 
    <start value="2023-10-26"/> 
    <end value="2023-10-29"/> 
  </period>

author

Usage

Optional

Guidance

Identifies the individual(s) or ogranization who is responsible for the content of the Care plan.

Example
   <author> 
     <reference value="Practitioner/Dr M Jones"/> 
   </author>

careTeam

Usage

Optional

Guidance

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

Example
  <careTeam> 
    <reference value="CareTeam/example"/> 
  </careTeam>

addresses

Usage

Optional

Guidance

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

Example
  <careTeam> 
    <reference value="CareTeam/example"/> 
  </careTeam>

supportingInfo

Usage

Optional

Guidance
Identifies parts of the patient's record that specifically influenced the formation of the Care plan. These might include co-morbidities or recent procedures.
Example
  <supportingInfo> 
    <reference value="Condition/example"/>
    <display value="Hypertension"/> 
  </supportingInfo>

goal

Usage

Optional

Guidance
Describes the intended objective(s) of carrying out the care plan.
Example
  <goal> 
    <reference value="Goal/example"/> 
  </goal>

activity

Usage

Optional

Guidance
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.
Example
 <activity> 
    <outcomeCodeableConcept> 
      <coding> 
        <system value="http://snomed.info/sct"/> 
        <code value="161832001"/> 
        <display value="Progressive weight loss"/> 
      </coding> 
    </outcomeCodeableConcept> 
    <outcomeReference> 
      <reference value="Observation/example"/> 
      <display value="Weight Measured"/> 
    </outcomeReference>
    <status value="completed"/> 
    <statusReason value="Achieved weight loss to mitigate diabetes risk."/> 
  </activity>

note

Usage

Optional

Guidance
General notes about the Care plan not covered by any other element.
Example
 <note> 
    <text value="Patient family have been informed about the Care plan and are aware of the intentions"/> 
  </note>
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