Care Plan Implementation Guidance | Clinical Decision Support API

CarePlan resource implementation guidance

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CarePlan: Implementation Guidance

Usage

Within the Clinical Decision Support API implementation, the CareConnect-CarePlan-1 profile will be used to carry the care advice recommendation given by the CDSS. This resource may also carry a recommendation of self-care.

Self-care

When the outcome of triage is to recommend self care, this will be carried as follows:

A GuidanceResponse returned to the EMS by the CDSS will carry a reference to a RequestGroup resource which will reference a relevant CarePlan
Identifying the CarePlan which specifically represents self-care as opposed to general care advice can be done by checking the careTeam.participant element within the CarePlan
If there is only a single instance of participant and the participant.role is ‘Patient’ (Snomed CT code of 116154003), then the recommendation is for self-care

The table below gives implementation guidance in relation to the elements within a CarePlan:

Name	Cardinality	Type	FHIR Documentation	CDS Implementation Guidance
`identifier`	`0..*`	Identifier	External Ids for this plan
`definition`	`0..*`	Reference (PlanDefinition \| Questionnaire)	Protocol or definition
`basedOn`	`0..*`	Reference (CarePlan)	Fulfils care plan
`replaces`	`0..*`	Reference (CarePlan)	CarePlan replaced by this CarePlan
`partOf`	`0..*`	Reference (CarePlan)	Part of referenced CarePlan
`status`	`1..1`	code	draft \| active \| suspended \| completed \| entered-in-error \| cancelled \| unknown CarePlanStatus (Required)	This element SHOULD be populated with 'active' when the advice is given by the CDSS. Once the advice has been given, it SHOULD be updated by the EMS to show a value of 'completed'.
`intent`	`1..1`	code	proposal \| plan \| order \| option CarePlanIntent (Required)
`title`	`0..1`	string	Human-friendly name for the CarePlan
`description`	`0..1`	string	Summary of nature of plan
`subject`	`1..1`	Reference (Patient \| Group)	Who care plan is for	This MUST be populated with a reference to the `Patient` resource.
`context`	`0..1`	Reference (Encounter \| EpisodeOfCare)	Created in context of	This MUST be populated with the Encounter for this journey, from the `ServiceDefinition.$evaluate.encounter`
`period`	`0..1`	Period	Time period plan covers
`author`	`0..*`	Reference (Patient \| Practitioner \| RelatedPerson \| Organization \| CareTeam)	Who is responsible for contents of the plan
`careTeam`	`0..*`	Reference (CareTeam)	Who's involved in plan?	A `CareTeam` resource having a single instance of a `participant` element with a `participant.role` of 'Patient' indicates a triage outcome of self-care.
`addresses`	`0..*`	Reference (Condition)	Health issues this plan addresses
`supportingInfo`	`0..*`	Reference (Any)
`goal`	`0..*`	Reference (Goal)	Desired outcome of plan
`activity`	`0..*`	BackboneElement	Action to occur as part of plan - provide a reference or detail, not both	This SHOULD be populated by the CDSS using the detail element. If required, the reference element can be used. For example, it could carry a medication to be used, self-monitoring activities, laboratory tests planned.
`activity. outcomeCodeableConcept`	`0..*`	CodeableConcept	Results of the activity Care Plan Activity Outcome (Example)
`activity. outcomeReference`	`0..*`	Reference (Any)	Appointment, Encounter, Procedure, etc.
`activity. progress`	`0..*`	Annotation	Comments about the activity status/progress
`activity. reference`	`0..1`	Reference (Appointment \| CommunicationRequest \| DeviceRequest \| MedicationRequest \| NutritionOrder \| Task \| ProcedureRequest \| ReferralRequest \| VisionPrescription \| RequestGroup)	Activity details defined in specific resource	This element of note SHOULD be populated by the CDSS, if the information relating to the planned activity is to be carried in a resource.
`activity.detail`	`0..1`	BackboneElement	In-line definition of activity	This element of note SHOULD be populated by the CDSS, if the planned activity is not linked to specific resources such as a `MedicationRequest` or a `Procedure`.
`activity. detail.category`	`0..1`	CodeableConcept	diet \| drug \| encounter \| observation \| procedure \| supply \| other CarePlanActivityCategory (Example)	This element of note SHOULD be populated by the CDSS to provide a high-level categorisation of the type of planned activity.
`activity. detail.definition`	`0..1`	Reference (PlanDefinition \| ActivityDefinition \| Questionnaire)	Protocol or definition
`activity. detail.code`	`0..1`	CodeableConcept	Detail type of activity Care Plan Activity (Example)
`activity. detail.reasonCode`	`0..*`	CodeableConcept	Why activity should be done or why activity was prohibited Activity Reason (Example)
`activity. detail.reasonReference`	`0..*`	Reference (Condition)	Condition triggering need for activity
`activity. detail.goal`	`0..*`	Reference (Goal)	Goals this activity relates to
`activity. detail.status`	`1..1`	code	not-started \| scheduled \| in-progress \| on-hold \| completed \| cancelled \| unknown CarePlanActivityStatus (Required)
`activity. detail.statusReason`	`0..1`	string	Reason for current status
`activity. detail.prohibited`	`0..1`	boolean	Do NOT do
`activity. detail.scheduled[x]`	`0..1`	Timing Period string	When activity is to occur
`activity. detail.location`	`0..1`	Reference (Location)	Where it should happen
`activity. detail.performer`	`0..*`	Reference (Practitioner \| Organization \| RelatedPerson \| Patient \| CareTeam)	Who will be responsible?
`activity. detail.product[x]`	`0..1`	CodeableConcept Reference (Medication) \| Substance)	What is to be administered/supplied SNOMED CT Medication Codes (Example)
`activity. detail.dailyAmount`	`0..1`	SimpleQuantity	How to consume/day?
`activity. detail.quantity`	`0..1`	SimpleQuantity	How much to administer/supply/consume
`activity. detail.description`	`0..1`	string	Extra info describing activity to perform
`note`	`0..*`	Annotation	Comments about the plan

CarePlan Elements of note

Activity.reference element of the CarePlan

This element carries details of the proposed activity represented in a specific referenced resource. For example, if care advice which is a component of a triage outcome involves advice about how to give CPR, this could be modelled as a ProcedureRequest which could be referenced from the element.

Activity.detail element of the CarePlan

This element carries a simple summary of a planned activity which would be suited for a general care plan system, for example a form-driven system. Such a system would not know about a specific resource and therefore this element would be populated, as an alternative to the activity.reference element in a CarePlan.

Note that the above two elements are mutually exclusive within a FHIR CarePlan, so it is not possible to populate both elements within one CarePlan.

Activity.detail.category element of the CarePlan

This element carries a high-level categorisation of the type of activity in a CarePlan, for example describing whether it relates to diet, drug, procedure, etc. An example could be care advice about administering epi-pens to a patient suffering an allergic reaction, which might be modelled as a drug category.

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