Proof of concept - not an authoritative source.

A care plan - who is doing what, for which needs, towards which goals - and its execution: the referrals, tasks, appointments and encounters that carry out each activity, and their progress. A referral is one activity of a care plan.

This is the care plan of IHE Dynamic Care Planning, FHIR CarePlan and social care, and the PRSB Personalised Care and Support Plan. It is not a care assessment: in the NHS "care plan" is often the name for an assessment form, which is a QuestionnaireResponse (see Referral Forms and the BaRS review). The Mappings tab shows each element in FHIR.

Unique identifier of the plan

NHS Number and local identifiers

e.g. virtual ward treatment plan, long term condition, social care support plan

Human readable name

draft, active, on-hold, completed, revoked

When the plan applies

When the plan is next reviewed

Lead professional or organisation

The patient (or representative) has agreed the plan

The plan this one implements, e.g. the GP or community care plan

The people and organisations involved

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.

• value @ url

May 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).

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.

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.

Practitioner, organisation, carer or the patient

e.g. lead professional, key worker, carer

Conditions, needs or concerns the plan addresses

What the plan is trying to achieve

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.

• value @ url

May 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).

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.

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.

Described in the patient's words where possible

Measure and date

in-progress, achieved, not-achieved

The actions agreed

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.

• value @ url

May 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).

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.

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.

What will be done

referral, task, appointment, monitoring, medication, education

Who carries it out

Timing or frequency

not-started, scheduled, in-progress, on-hold, completed, cancelled

The request that carries out the activity, e.g. a referral (Clinical Referral)

What was done - e.g. the Discharge Report from a referral

Notes on progress

Proof of concept - not an authoritative source.

A care plan - who is doing what, for which needs, towards which goals - and its execution: the referrals, tasks, appointments and encounters that carry out each activity, and their progress. A referral is one activity of a care plan.

This is the care plan of IHE Dynamic Care Planning, FHIR CarePlan and social care, and the PRSB Personalised Care and Support Plan. It is not a care assessment: in the NHS "care plan" is often the name for an assessment form, which is a QuestionnaireResponse (see Referral Forms and the BaRS review). The Mappings tab shows each element in FHIR.

Unique identifier of the plan

NHS Number and local identifiers

e.g. virtual ward treatment plan, long term condition, social care support plan

Human readable name

draft, active, on-hold, completed, revoked

When the plan applies

When the plan is next reviewed

Lead professional or organisation

The patient (or representative) has agreed the plan

The plan this one implements, e.g. the GP or community care plan

The people and organisations involved

Practitioner, organisation, carer or the patient

e.g. lead professional, key worker, carer

Conditions, needs or concerns the plan addresses

What the plan is trying to achieve

Described in the patient's words where possible

Measure and date

in-progress, achieved, not-achieved

The actions agreed

What will be done

referral, task, appointment, monitoring, medication, education

Who carries it out

Timing or frequency

not-started, scheduled, in-progress, on-hold, completed, cancelled

The request that carries out the activity, e.g. a referral (Clinical Referral)

What was done - e.g. the Discharge Report from a referral

Notes on progress

Proof of concept - not an authoritative source.

A care plan - who is doing what, for which needs, towards which goals - and its execution: the referrals, tasks, appointments and encounters that carry out each activity, and their progress. A referral is one activity of a care plan.

This is the care plan of IHE Dynamic Care Planning, FHIR CarePlan and social care, and the PRSB Personalised Care and Support Plan. It is not a care assessment: in the NHS "care plan" is often the name for an assessment form, which is a QuestionnaireResponse (see Referral Forms and the BaRS review). The Mappings tab shows each element in FHIR.

Unique identifier of the plan

NHS Number and local identifiers

e.g. virtual ward treatment plan, long term condition, social care support plan

Human readable name

draft, active, on-hold, completed, revoked

When the plan applies

When the plan is next reviewed

Lead professional or organisation

The patient (or representative) has agreed the plan

The plan this one implements, e.g. the GP or community care plan

The people and organisations involved

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.

• value @ url

May 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).

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.

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.

Practitioner, organisation, carer or the patient

e.g. lead professional, key worker, carer

Conditions, needs or concerns the plan addresses

What the plan is trying to achieve

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.

• value @ url

May 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).

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.

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.

Described in the patient's words where possible

Measure and date

in-progress, achieved, not-achieved

The actions agreed

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.

• value @ url

May 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).

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.

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.

What will be done

referral, task, appointment, monitoring, medication, education

Who carries it out

Timing or frequency

not-started, scheduled, in-progress, on-hold, completed, cancelled

The request that carries out the activity, e.g. a referral (Clinical Referral)

What was done - e.g. the Discharge Report from a referral

Notes on progress