description: 'CARE PLAN FRAMEWORK: A Care Plan (including Home Health Plan of Care (HHPoC)) is a consensus-driven dynamic plan that represents a patient and Care Team Members prioritized concerns, goals, and planned interventions. It serves as a blueprint shared by all Care Team Members (including the patient, their caregivers and providers), to guide the patients care. A Care Plan integrates multiple interventions proposed by multiple providers and disciplines for multiple conditions.\n\nA Care Plan represents one or more Plan(s) of Care and serves to reconcile and resolve conflicts between the various Plans of Care developed for a specific patient by different providers. While both a plan of care and a care plan include the patient''s life goals and require Care Team Members (including patients) to prioritize goals and interventions, the reconciliation process becomes more complex as the number of plans of care increases. The Care Plan also serves to enable longitudinal coordination of care.\n\nThe Care Plan represents an instance of this dynamic Care Plan at a point in time. The composition itself is NOT dynamic.\n\nKey differentiators between a Care Plan profile and CCD profile (another snapshot in time document):\n\n* Requires relationships between various concepts:\n\n * Health Concerns\n\n * Interventions\n\n * Goals\n\n * Outcomes\n\n* Provides the ability to identify patient and provider priorities with each act\n\n* Provides a header participant to indicate occurrences of Care Plan review' package_name: hl7.fhir.us.ccda derivation: constraint name: CarePlan type: Composition elements: type: short: Care Plan Document binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113762.1.4.1099.10'} mustSupport: true index: 0 event: mustSupport: true index: 1 elements: period: {mustSupport: true, index: 2} detail: mustSupport: true index: 3 slicing: rules: open discriminator: - {path: reference, type: profile} min: null slices: care_plan: match: {} schema: type: Reference short: Care Plan Detail mustSupport: false refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-careplan'] index: 4 required: [period] section: mustSupport: false index: 5 slicing: rules: open discriminator: - {path: code, type: value} min: null slices: health_concerns_section: match: code: coding: - {code: 75310-3, system: 'http://loinc.org'} schema: short: Health Concerns Section mustSupport: true _required: true index: 6 elements: title: {short: title, mustSupport: true, index: 7} code: short: Health concerns section code mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 75310-3, system: 'http://loinc.org'} index: 8 text: {short: text, mustSupport: true, index: 9} entry: short: entry index: 10 slicing: rules: open discriminator: - {path: reference, type: profile} min: null slices: health_concerns_entry: match: {} schema: type: Reference short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. mustSupport: true refers: ['http://hl7.org/fhir/StructureDefinition/ClinicalImpression', 'http://hl7.org/fhir/StructureDefinition/DocumentReference', 'http://hl7.org/fhir/StructureDefinition/List', 'http://hl7.org/fhir/StructureDefinition/Observation', 'http://hl7.org/fhir/StructureDefinition/RiskAssessment', 'http://hl7.org/fhir/StructureDefinition/vitalsigns', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-smokingstatus'] index: 11 required: [text, title, code] goals_section: match: code: coding: - {code: 61146-7, system: 'http://loinc.org'} schema: short: Goals Section mustSupport: true _required: true index: 12 elements: title: {short: title, mustSupport: true, index: 13} code: short: Goals mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 61146-7, system: 'http://loinc.org'} index: 14 text: {short: text, mustSupport: true, index: 15} entry: short: entry index: 16 slicing: rules: open discriminator: - {path: reference, type: profile} min: null slices: goals_entry: match: {} schema: type: Reference short: entry mustSupport: true refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-goal'] index: 17 required: [text, title, code] interventions_section: match: code: coding: - {code: 62387-6, system: 'http://loinc.org'} schema: short: Interventions Section mustSupport: true index: 18 elements: title: {short: title, mustSupport: true, index: 19} code: short: Interventions provided mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 62387-6, system: 'http://loinc.org'} index: 20 text: {short: text, mustSupport: true, index: 21} entry: short: entry index: 22 slicing: rules: open discriminator: - {path: reference, type: profile} min: null slices: interventions_section: match: {} schema: type: Reference short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. mustSupport: true refers: ['http://hl7.org/fhir/StructureDefinition/Communication', 'http://hl7.org/fhir/StructureDefinition/List', 'http://hl7.org/fhir/StructureDefinition/MedicationDispense', 'http://hl7.org/fhir/StructureDefinition/MedicationStatement', 'http://hl7.org/fhir/StructureDefinition/RequestGroup', 'http://hl7.org/fhir/StructureDefinition/ServiceRequest', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure'] index: 23 required: [text, title, code] eval_outcomes_section: match: code: coding: - {code: 11383-7, system: 'http://loinc.org'} schema: short: Health Status Evaluations and Outcomes Section mustSupport: true index: 24 elements: title: {short: title, mustSupport: true, index: 25} code: short: Patient problem outcome mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 11383-7, system: 'http://loinc.org'} index: 26 text: {short: text, mustSupport: true, index: 27} entry: short: entry index: 28 slicing: rules: open discriminator: - {path: reference, type: profile} min: null slices: eval_outcomes_entry: match: {} schema: type: Reference short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. mustSupport: true refers: ['http://hl7.org/fhir/StructureDefinition/Observation'] index: 29 required: [text, title, code] package_version: 1.2.0-ballot class: profile kind: resource url: http://hl7.org/fhir/us/ccda/StructureDefinition/Care-Plan-Document base: http://hl7.org/fhir/us/ccda/StructureDefinition/US-Realm-Header version: 1.2.0-ballot