Care Coordination and 360 Referrals (Proof of Concept)
0.1.0 - proof-of-concept
Care Coordination and 360 Referrals (Proof of Concept)
0.1.0 - proof-of-concept
Care Coordination and 360 Referrals (Proof of Concept) - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Official URL: https://fhir.acmeexample.org.uk/PatientCareCoordination/StructureDefinition/CarePlanModel | Version: 0.1.0 | ||||
| Draft as of 2026-11-03 | Computable Name: CarePlanModel | ||||
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.
Usages:
You can also check for usages in the FHIR IG Statistics
Description Differentials, Snapshots, and other representations.
This structure is derived from Base
| Name | Flags | Card. | Type | Description & Constraints Filter:  |
|---|---|---|---|---|
  CarePlanModel |
0..* | Base | Care Plan and Execution Instances of this type can be the target of a Reference | |
  planId |
1..1 | Identifier | Care plan ID | |
| patient |
1..1 | Identifier | Patient | |
| category |
1..* | CodeableConcept | Category | |
 title |
0..1 | string | Title | |
| status |
1..1 | code | Status | |
| period |
0..1 | Period | Period | |
| reviewDate |
0..1 | date | Review date | |
| author |
1..1 | Identifier | Author | |
| agreedWithPatient |
0..1 | boolean | Agreed with the patient | |
| basedOn |
0..* | Identifier | Parent plan | |
 careTeam |
0..* | BackboneElement | Care team | |
 @id |
0..1 | string | Unique id for inter-element referencing | |
 extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
 modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| member |
1..1 | Identifier | Member | |
 role |
0..1 | CodeableConcept | Role | |
| needs |
0..* | CodeableConcept | Needs and problems | |
| goals |
0..* | BackboneElement | Goals | |
| @id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| description |
1..1 | string | Goal | |
| target |
0..1 | string | Target | |
| status |
0..1 | code | Achievement | |
 activity |
0..* | BackboneElement | Activities | |
 @id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| description |
1..1 | string | Activity | |
| kind |
0..1 | code | Kind | |
| performer |
0..* | Identifier | Performer | |
| scheduled |
0..1 | Period | When | |
| status |
1..1 | code | Status | |
 request |
0..1 | Reference(ServiceRequest | Task | Appointment | MedicationRequest) | Request | |
| outcome |
0..* | Reference(Encounter | Procedure | Observation | DiagnosticReport | DocumentReference) | Outcome | |
| progress |
0..* | string | Progress | |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Description | Expression |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
This structure is derived from Base
Differential View
This structure is derived from Base
Snapshot ViewView
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| CarePlanModel |
0..* | Base | Care Plan and Execution Instances of this type can be the target of a Reference | |
| planId |
1..1 | Identifier | Care plan ID | |
| patient |
1..1 | Identifier | Patient | |
| category |
1..* | CodeableConcept | Category | |
| title |
0..1 | string | Title | |
| status |
1..1 | code | Status | |
| period |
0..1 | Period | Period | |
| reviewDate |
0..1 | date | Review date | |
| author |
1..1 | Identifier | Author | |
| agreedWithPatient |
0..1 | boolean | Agreed with the patient | |
| basedOn |
0..* | Identifier | Parent plan | |
| careTeam |
0..* | BackboneElement | Care team | |
| @id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| member |
1..1 | Identifier | Member | |
| role |
0..1 | CodeableConcept | Role | |
| needs |
0..* | CodeableConcept | Needs and problems | |
| goals |
0..* | BackboneElement | Goals | |
| @id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| description |
1..1 | string | Goal | |
| target |
0..1 | string | Target | |
| status |
0..1 | code | Achievement | |
| activity |
0..* | BackboneElement | Activities | |
| @id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| description |
1..1 | string | Activity | |
| kind |
0..1 | code | Kind | |
| performer |
0..* | Identifier | Performer | |
| scheduled |
0..1 | Period | When | |
| status |
1..1 | code | Status | |
| request |
0..1 | Reference(ServiceRequest | Task | Appointment | MedicationRequest) | Request | |
| outcome |
0..* | Reference(Encounter | Procedure | Observation | DiagnosticReport | DocumentReference) | Outcome | |
| progress |
0..* | string | Progress | |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Description | Expression |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
This structure is derived from Base
