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.

Um conjunto de regras sob as quais este conteúdo foi criado

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.

Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas

Identificadores externos para este recurso

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.

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

The purpose of this identifier.

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Identifies the purpose for this identifier, if known .

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

Identifier.system is always case sensitive.

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.

The 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.

uri da instância do protocolo ou definição FHIR

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

O status desse Plano de Cuidado: draft | active | on-hold | revoked | completed | entered-in-error | unknown

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.

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

Propósito do Plano de Cuidado definido: proposal | plan | order | option

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.

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

Tipo de Plano de Cuidado

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.

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

Nome do Plano de Cuidado

Descrição do Plano de Cuidado

Provides more detail than conveyed by category.

Paciente referenciado pelo Plano de Cuidado

Atendimento referenciado pelo Plano de Cuidado

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.

O período de tempo que o Plano de Cuidado abrange

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).

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

Data de criação do Plano de Cuidado

Autoria do Plano de Cuidado

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

Colaboradores na definição do Plano de Cuidado

Collaborative care plans may have multiple contributors.

Problemas de saúde referenciado neste Plano de Cuidado

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.

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.

Informações adicionais do Plano de Cuidado

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

Identifies barriers and other considerations associated with the care plan.

Atividade parte do Plano de Cuidado

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

Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas

Resultados da atividade

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

Identifies the results of the activity.

Referência à 'Appointment', 'Encounter', 'Procedure', etc

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.

Links plan to resulting actions.

Comentários sobre o status/progresso da atividade

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.

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

Definição da atividade

Details in a simple form for generic care plan systems.

Extensões que não podem ser ignoradas

Tipos de recursos definidos como parte do FHIR que podem ser representados como definições em conformidade de uma atividade do Plano de Cuidados

Resource types defined as part of FHIR that can be represented as in-line definitions of a care plan activity.

May determine what types of extensions are permitted.

Código da atividade

Tends to be less relevant for activities involving particular products. Codes should not convey negation - use "prohibited" instead.

Allows matching performed to planned as well as validation against protocols.

Por quê a atividade é necessária

Conditions can be identified at the activity level that are not identified as reasons for the overall plan.

Código que reflete o estado atual de uma atividade do Planos de Cuidado

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.
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 activity.

Codes that reflect the current state of a care plan activity within its overall life cycle.

Indicates progress against the plan, whether the activity is still relevant for the plan.

Se for verdade, a atividade não deve ser realizada

This element is labeled as a modifier because it marks an activity as an activity that is not to be performed.

Captures intention to not do something that may have been previously typical.

Quando a atividade deve ocorrer

Allows prompting for activities and detection of missed planned activities.

Responsável pela atividade

A performer MAY also be a participant in the care plan.

Helps in planning of activity.

Descrição da atividade a ser realizada

Comentários sobre o Planos de Cuidado

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

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.

Identificador lógico deste artefato

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Metadados sobre o recurso

Um conjunto de regras sob as quais este conteúdo foi criado

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.

Idioma do recurso

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.

Resumo do texto do recurso em linguagem natural

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.

Recursos contidos no recurso

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.

Extensões adicionais que não fazem parte do modelo base

Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas

Identificadores externos para este recurso

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.

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

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

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.

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.

The purpose of this identifier.

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Identifies the purpose for this identifier, if known .

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

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.

Allows users to make use of identifiers when the identifier system is not known.

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

Identifier.system is always case sensitive.

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.

The 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.

Time period during which identifier is/was valid for use.

Organization 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.

Instância o protocolo ou definição FHIR

uri da instância do protocolo ou definição FHIR

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

De acordo com o Plano de Cuidado

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

Plano de Cuidado substituído por este Plano de Cuidado

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.

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

Parte do Plano de Cuidado referenciado

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.

O status desse Plano de Cuidado: draft | active | on-hold | revoked | completed | entered-in-error | unknown

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.

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

Propósito do Plano de Cuidado definido: proposal | plan | order | option

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.

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

Tipo de Plano de Cuidado

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.

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

Nome do Plano de Cuidado

Descrição do Plano de Cuidado

Provides more detail than conveyed by category.

Paciente referenciado pelo Plano de Cuidado

Atendimento referenciado pelo Plano de Cuidado

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.

O período de tempo que o Plano de Cuidado abrange

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).

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

Data de criação do Plano de Cuidado

Autoria do Plano de Cuidado

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

Colaboradores na definição do Plano de Cuidado

Collaborative care plans may have multiple contributors.

Equipe assistêncial envolvida no Plano de Cuidado

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

Problemas de saúde referenciado neste Plano de Cuidado

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.

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.

Informações adicionais do Plano de Cuidado

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

Identifies barriers and other considerations associated with the care plan.

Resultado esperado do Plano de Cuidado

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

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

Atividade parte do Plano de Cuidado

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

Identificador único para referência cruzada

Extensões adicionais que não fazem parte do modelo de dados básico

Extensões adicionais que não podem ser ignoradas, mesmo que não reconhecidas

Resultados da atividade

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

Identifies the results of the activity.

Referência à 'Appointment', 'Encounter', 'Procedure', etc

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.

Links plan to resulting actions.

Comentários sobre o status/progresso da atividade

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.

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

Detalhes da atividade definidos em recursos específicos

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.

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

Definição da atividade

Details in a simple form for generic care plan systems.

Identificador único para referência cruzada

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.

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.

Extensões que não podem ser ignoradas

Tipos de recursos definidos como parte do FHIR que podem ser representados como definições em conformidade de uma atividade do Plano de Cuidados

Resource types defined as part of FHIR that can be represented as in-line definitions of a care plan activity.

May determine what types of extensions are permitted.

Instância o protocolo ou definição FHIR

Allows Questionnaires that the patient (or practitioner) should fill in to fulfill the care plan activity.

Instância protocolo externo ou definição

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

Allows Questionnaires that the patient (or practitioner) should fill in to fulfill the care plan activity.

Código da atividade

Tends to be less relevant for activities involving particular products. Codes should not convey negation - use "prohibited" instead.

Allows matching performed to planned as well as validation against protocols.

Por quê a atividade deve ser feita ou por quê a atividade foi proibida

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.

Por quê a atividade é necessária

Conditions can be identified at the activity level that are not identified as reasons for the overall plan.

Objetivos da atividade

So that participants know the link explicitly.

Código que reflete o estado atual de uma atividade do Planos de Cuidado

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.
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 activity.

Codes that reflect the current state of a care plan activity within its overall life cycle.

Indicates progress against the plan, whether the activity is still relevant for the plan.

Motivo do status atual

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.

Se for verdade, a atividade não deve ser realizada

This element is labeled as a modifier because it marks an activity as an activity that is not to be performed.

Captures intention to not do something that may have been previously typical.

Quando a atividade deve ocorrer

Allows prompting for activities and detection of missed planned activities.

Onde a atividade deve ocorrer

May reference a specific clinical location or may identify a type of location.

Helps in planning of activity.

Responsável pela atividade

A performer MAY also be a participant in the care plan.

Helps in planning of activity.

O que deve ser administrado/fornecido

A product supplied or administered as part of a care plan activity.

Quantidade diária a ser consumida/fornecida/administrada

Allows rough dose checking.

Quantidade a ser consumida/fornecida/administrada

Descrição da atividade a ser realizada

Comentários sobre o Planos de Cuidado

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