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
| Draft as of 2026-11-03 |
XML representation of the CarePlanModel logical model.
<StructureDefinition xmlns="http://hl7.org/fhir">
<id value="CarePlanModel"/>
<language value="en"/>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: StructureDefinition CarePlanModel</b></p><table border="0" cellpadding="0" cellspacing="0" class="xhtTableBorder0"><tr class="xhtRowBorder1"><th scope="col" style="" class="hierarchy xhtCellBorder0"><a href="https://build.fhir.org/ig/FHIR/ig-guidance/readingIgs.html#table-views" title="The logical name of the element">Name</a></th><th scope="col" style="" class="hierarchy xhtCellBorder0"><a href="https://build.fhir.org/ig/FHIR/ig-guidance/readingIgs.html#table-views" title="Information about the use of the element">Flags</a></th><th scope="col" style="" class="hierarchy xhtCellBorder0"><a href="https://build.fhir.org/ig/FHIR/ig-guidance/readingIgs.html#table-views" title="Minimum and Maximum # of times the element can appear in the instance">Card.</a></th><th scope="col" style="; width: 100px" class="hierarchy xhtCellBorder0"><a href="https://build.fhir.org/ig/FHIR/ig-guidance/readingIgs.html#table-views" title="Reference to the type of the element">Type</a></th><th scope="col" style="" class="hierarchy xhtCellBorder0"><a href="https://build.fhir.org/ig/FHIR/ig-guidance/readingIgs.html#table-views" title="Additional information about the element">Description & Constraints</a><span style="float: right"><a href="https://build.fhir.org/ig/FHIR/ig-guidance/readingIgs.html#table-views" title="Legend for this format"><img src="data:image/png;base64,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" alt="doco" style="background-color: inherit"/></a></span></th></tr><tr class="xhtRowBorder0 xhtRowEven"><td style="background-image: url(tbl_bck1.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_element.gif" alt="" style="background-color: white; background-color: inherit" title="Element" class="hierarchy"/> <a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel" title="**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](DCP.html), FHIR `CarePlan` and
social care, and the PRSB
[Personalised Care and Support Plan](https://theprsb.org/standards/personalisedcareandsupportplan).
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](ReferralForms.html)
and the [BaRS review](BaRS.html#3-careplan-is-the-assessment-not-a-plan)).
The **Mappings** tab shows each element in FHIR.">CarePlanModel</a><a name="CarePlanModel"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0"><span class="xhtPieceDeEmphasized">0</span><span class="xhtPieceDeEmphasized">..</span><span class="xhtPieceDeEmphasized">*</span></td><td style="" class="hierarchy xhtCellBorder0"><a href="http://build.fhir.org/types.html#Base">Base</a></td><td style="" class="hierarchy xhtCellBorder0">Care Plan and Execution<br/><span class="xhtPieceBold">Instances of this type can be the target of a Reference</span></td></tr>
<tr class="xhtRowBorder0 xhtRowOdd"><td style="background-image: url(tbl_bck10.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_datatype.gif" alt="" style="background-color: #F7F7F7; background-color: inherit" title="Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.planId" title="Unique identifier of the plan">planId</a><a name="CarePlanModel.planId"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">1..1</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#Identifier">Identifier</a></td><td style="" class="hierarchy xhtCellBorder0">Care plan ID</td></tr>
<tr class="xhtRowBorder0 xhtRowEven"><td style="background-image: url(tbl_bck10.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_datatype.gif" alt="" style="background-color: white; background-color: inherit" title="Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.patient" title="NHS Number and local identifiers">patient</a><a name="CarePlanModel.patient"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">1..1</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#Identifier">Identifier</a></td><td style="" class="hierarchy xhtCellBorder0">Patient</td></tr>
<tr class="xhtRowBorder0 xhtRowOdd"><td style="background-image: url(tbl_bck10.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_datatype.gif" alt="" style="background-color: #F7F7F7; background-color: inherit" title="Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.category" title="e.g. virtual ward treatment plan, long term condition, social care support plan">category</a><a name="CarePlanModel.category"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">1..*</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#CodeableConcept">CodeableConcept</a></td><td style="" class="hierarchy xhtCellBorder0">Category<br/></td></tr>
<tr class="xhtRowBorder0 xhtRowEven"><td style="background-image: url(tbl_bck10.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_primitive.png" alt="" style="background-color: white; background-color: inherit" title="Primitive Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.title" title="Human readable name">title</a><a name="CarePlanModel.title"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">0..1</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#string">string</a></td><td style="" class="hierarchy xhtCellBorder0">Title</td></tr>
<tr class="xhtRowBorder0 xhtRowOdd"><td style="background-image: url(tbl_bck10.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_primitive.png" alt="" style="background-color: #F7F7F7; background-color: inherit" title="Primitive Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.status" title="draft, active, on-hold, completed, revoked">status</a><a name="CarePlanModel.status"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">1..1</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#code">code</a></td><td style="" class="hierarchy xhtCellBorder0">Status</td></tr>
<tr class="xhtRowBorder0 xhtRowEven"><td style="background-image: url(tbl_bck10.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_datatype.gif" alt="" style="background-color: white; background-color: inherit" title="Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.period" title="When the plan applies">period</a><a name="CarePlanModel.period"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">0..1</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#Period">Period</a></td><td style="" class="hierarchy xhtCellBorder0">Period</td></tr>
<tr class="xhtRowBorder0 xhtRowOdd"><td style="background-image: url(tbl_bck10.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_primitive.png" alt="" style="background-color: #F7F7F7; background-color: inherit" title="Primitive Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.reviewDate" title="When the plan is next reviewed">reviewDate</a><a name="CarePlanModel.reviewDate"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">0..1</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#date">date</a></td><td style="" class="hierarchy xhtCellBorder0">Review date</td></tr>
<tr class="xhtRowBorder0 xhtRowEven"><td style="background-image: url(tbl_bck10.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_datatype.gif" alt="" style="background-color: white; background-color: inherit" title="Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.author" title="Lead professional or organisation">author</a><a name="CarePlanModel.author"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">1..1</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#Identifier">Identifier</a></td><td style="" class="hierarchy xhtCellBorder0">Author</td></tr>
<tr class="xhtRowBorder0 xhtRowOdd"><td style="background-image: url(tbl_bck10.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_primitive.png" alt="" style="background-color: #F7F7F7; background-color: inherit" title="Primitive Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.agreedWithPatient" title="The patient (or representative) has agreed the plan">agreedWithPatient</a><a name="CarePlanModel.agreedWithPatient"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">0..1</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#boolean">boolean</a></td><td style="" class="hierarchy xhtCellBorder0">Agreed with the patient</td></tr>
<tr class="xhtRowBorder0 xhtRowEven"><td style="background-image: url(tbl_bck10.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_datatype.gif" alt="" style="background-color: white; background-color: inherit" title="Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.basedOn" title="The plan this one implements, e.g. the GP or community care plan">basedOn</a><a name="CarePlanModel.basedOn"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">0..*</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#Identifier">Identifier</a></td><td style="" class="hierarchy xhtCellBorder0">Parent plan<br/></td></tr>
<tr class="xhtRowBorder0 xhtRowOdd"><td style="background-image: url(tbl_bck11.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_datatype.gif" alt="" style="background-color: #F7F7F7; background-color: inherit" title="Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.careTeam" title="The people and organisations involved">careTeam</a><a name="CarePlanModel.careTeam"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">0..*</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#BackboneElement">BackboneElement</a></td><td style="" class="hierarchy xhtCellBorder0">Care team<br/></td></tr>
<tr class="xhtRowBorder0 xhtRowEven"><td style="background-image: url(tbl_bck110.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_datatype.gif" alt="" style="background-color: white; background-color: inherit" title="Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.careTeam.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.careTeam.member" title="Practitioner, organisation, carer or the patient">member</a><a name="CarePlanModel.careTeam.member"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">1..1</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#Identifier">Identifier</a></td><td style="" class="hierarchy xhtCellBorder0">Member</td></tr>
<tr class="xhtRowBorder0 xhtRowOdd"><td style="background-image: url(tbl_bck100.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_datatype.gif" alt="" style="background-color: #F7F7F7; background-color: inherit" title="Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.careTeam.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.careTeam.role" title="e.g. lead professional, key worker, carer">role</a><a name="CarePlanModel.careTeam.role"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">0..1</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#CodeableConcept">CodeableConcept</a></td><td style="" class="hierarchy xhtCellBorder0">Role</td></tr>
<tr class="xhtRowBorder0 xhtRowEven"><td style="background-image: url(tbl_bck10.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_datatype.gif" alt="" style="background-color: white; background-color: inherit" title="Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.needs" title="Conditions, needs or concerns the plan addresses">needs</a><a name="CarePlanModel.needs"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">0..*</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#CodeableConcept">CodeableConcept</a></td><td style="" class="hierarchy xhtCellBorder0">Needs and problems<br/></td></tr>
<tr class="xhtRowBorder0 xhtRowOdd"><td style="background-image: url(tbl_bck11.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_datatype.gif" alt="" style="background-color: #F7F7F7; background-color: inherit" title="Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.goals" title="What the plan is trying to achieve">goals</a><a name="CarePlanModel.goals"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">0..*</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#BackboneElement">BackboneElement</a></td><td style="" class="hierarchy xhtCellBorder0">Goals<br/></td></tr>
<tr class="xhtRowBorder0 xhtRowEven"><td style="background-image: url(tbl_bck110.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_primitive.png" alt="" style="background-color: white; background-color: inherit" title="Primitive Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.goals.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.goals.description" title="Described in the patient's words where possible">description</a><a name="CarePlanModel.goals.description"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">1..1</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#string">string</a></td><td style="" class="hierarchy xhtCellBorder0">Goal</td></tr>
<tr class="xhtRowBorder0 xhtRowOdd"><td style="background-image: url(tbl_bck110.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_primitive.png" alt="" style="background-color: #F7F7F7; background-color: inherit" title="Primitive Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.goals.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.goals.target" title="Measure and date">target</a><a name="CarePlanModel.goals.target"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">0..1</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#string">string</a></td><td style="" class="hierarchy xhtCellBorder0">Target</td></tr>
<tr class="xhtRowBorder0 xhtRowEven"><td style="background-image: url(tbl_bck100.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vline.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_primitive.png" alt="" style="background-color: white; background-color: inherit" title="Primitive Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.goals.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.goals.status" title="in-progress, achieved, not-achieved">status</a><a name="CarePlanModel.goals.status"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">0..1</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#code">code</a></td><td style="" class="hierarchy xhtCellBorder0">Achievement</td></tr>
<tr class="xhtRowBorder0 xhtRowOdd"><td style="background-image: url(tbl_bck01.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_datatype.gif" alt="" style="background-color: #F7F7F7; background-color: inherit" title="Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.activity" title="The actions agreed">activity</a><a name="CarePlanModel.activity"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">0..*</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#BackboneElement">BackboneElement</a></td><td style="" class="hierarchy xhtCellBorder0">Activities<br/></td></tr>
<tr class="xhtRowBorder0 xhtRowEven"><td style="background-image: url(tbl_bck010.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_blank.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_primitive.png" alt="" style="background-color: white; background-color: inherit" title="Primitive Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.activity.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.activity.description" title="What will be done">description</a><a name="CarePlanModel.activity.description"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">1..1</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#string">string</a></td><td style="" class="hierarchy xhtCellBorder0">Activity</td></tr>
<tr class="xhtRowBorder0 xhtRowOdd"><td style="background-image: url(tbl_bck010.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_blank.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_primitive.png" alt="" style="background-color: #F7F7F7; background-color: inherit" title="Primitive Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.activity.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.activity.kind" title="referral, task, appointment, monitoring, medication, education">kind</a><a name="CarePlanModel.activity.kind"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">0..1</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#code">code</a></td><td style="" class="hierarchy xhtCellBorder0">Kind</td></tr>
<tr class="xhtRowBorder0 xhtRowEven"><td style="background-image: url(tbl_bck010.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_blank.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_datatype.gif" alt="" style="background-color: white; background-color: inherit" title="Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.activity.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.activity.performer" title="Who carries it out">performer</a><a name="CarePlanModel.activity.performer"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">0..*</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#Identifier">Identifier</a></td><td style="" class="hierarchy xhtCellBorder0">Performer<br/></td></tr>
<tr class="xhtRowBorder0 xhtRowOdd"><td style="background-image: url(tbl_bck010.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_blank.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_datatype.gif" alt="" style="background-color: #F7F7F7; background-color: inherit" title="Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.activity.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.activity.scheduled" title="Timing or frequency">scheduled</a><a name="CarePlanModel.activity.scheduled"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">0..1</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#Period">Period</a></td><td style="" class="hierarchy xhtCellBorder0">When</td></tr>
<tr class="xhtRowBorder0 xhtRowEven"><td style="background-image: url(tbl_bck010.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_blank.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_primitive.png" alt="" style="background-color: white; background-color: inherit" title="Primitive Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.activity.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.activity.status" title="not-started, scheduled, in-progress, on-hold, completed, cancelled">status</a><a name="CarePlanModel.activity.status"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">1..1</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#code">code</a></td><td style="" class="hierarchy xhtCellBorder0">Status</td></tr>
<tr class="xhtRowBorder0 xhtRowOdd"><td style="background-image: url(tbl_bck010.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_blank.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_reference.png" alt="" style="background-color: #F7F7F7; background-color: inherit" title="Reference to another Resource" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.activity.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.activity.request" title="The request that carries out the activity, e.g. a referral (Clinical Referral)">request</a><a name="CarePlanModel.activity.request"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">0..1</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/references.html">Reference</a>(<a href="http://hl7.org/fhir/R4/servicerequest.html">ServiceRequest</a> | <a href="http://hl7.org/fhir/R4/task.html">Task</a> | <a href="http://hl7.org/fhir/R4/appointment.html">Appointment</a> | <a href="http://hl7.org/fhir/R4/medicationrequest.html">MedicationRequest</a>)</td><td style="" class="hierarchy xhtCellBorder0">Request</td></tr>
<tr class="xhtRowBorder0 xhtRowEven"><td style="background-image: url(tbl_bck010.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_blank.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_reference.png" alt="" style="background-color: white; background-color: inherit" title="Reference to another Resource" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.activity.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.activity.outcome" title="What was done - e.g. the Discharge Report from a referral">outcome</a><a name="CarePlanModel.activity.outcome"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">0..*</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/references.html">Reference</a>(<a href="StructureDefinition-Encounter.html">Encounter</a> | <a href="http://hl7.org/fhir/R4/procedure.html">Procedure</a> | <a href="StructureDefinition-Observation.html">Observation</a> | <a href="http://hl7.org/fhir/R4/diagnosticreport.html">DiagnosticReport</a> | <a href="http://hl7.org/fhir/R4/documentreference.html">DocumentReference</a>)</td><td style="" class="hierarchy xhtCellBorder0">Outcome<br/></td></tr>
<tr class="xhtRowBorder0 xhtRowOdd"><td style="background-image: url(tbl_bck000.png)" class="hierarchy xhtCellBorder0 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_blank.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_primitive.png" alt="" style="background-color: #F7F7F7; background-color: inherit" title="Primitive Data Type" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">CarePlanModel.activity.</span><a href="StructureDefinition-CarePlanModel-definitions.html#CarePlanModel.activity.progress" title="Notes on progress">progress</a><a name="CarePlanModel.activity.progress"> </a></td><td style="" class="hierarchy xhtCellBorder0"/><td style="" class="hierarchy xhtCellBorder0">0..*</td><td style="" class="hierarchy xhtCellBorder0"><a href="http://hl7.org/fhir/R4/datatypes.html#string">string</a></td><td style="" class="hierarchy xhtCellBorder0">Progress<br/></td></tr>
<tr><td colspan="5" class="hierarchy"><br/><a href="https://build.fhir.org/ig/FHIR/ig-guidance/readingIgs.html#table-views" title="Legend for this format"><img src="data:image/png;base64,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" alt="doco" style="background-color: inherit"/> Documentation for this format</a></td></tr></table></div>
</text>
<extension
url="http://hl7.org/fhir/StructureDefinition/structuredefinition-type-characteristics">
<valueCode value="can-be-target"/>
</extension>
<url
value="https://fhir.acmeexample.org.uk/PatientCareCoordination/StructureDefinition/CarePlanModel"/>
<version value="0.1.0"/>
<name value="CarePlanModel"/>
<title value="Care Plan and Execution"/>
<status value="draft"/>
<experimental value="true"/>
<date value="2026-11-03T05:48:20+00:00"/>
<publisher value="Kevin Mayfield"/>
<contact>
<telecom>
<system value="url"/>
<value
value="https://github.com/KevinMayfield/PatientCareCoordination"/>
</telecom>
</contact>
<description
value="**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](DCP.html), FHIR `CarePlan` and
social care, and the PRSB
[Personalised Care and Support Plan](https://theprsb.org/standards/personalisedcareandsupportplan).
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](ReferralForms.html)
and the [BaRS review](BaRS.html#3-careplan-is-the-assessment-not-a-plan)).
The **Mappings** tab shows each element in FHIR."/>
<jurisdiction>
<coding>
<system value="urn:iso:std:iso:3166"/>
<code value="GB"/>
<display value="United Kingdom of Great Britain and Northern Ireland"/>
</coding>
</jurisdiction>
<fhirVersion value="4.0.1"/>
<mapping>
<identity value="fhir"/>
<uri value="http://hl7.org/fhir/R4"/>
<name value="FHIR R4 (CarePlan, IHE DCP)"/>
</mapping>
<kind value="logical"/>
<abstract value="false"/>
<type
value="https://fhir.acmeexample.org.uk/PatientCareCoordination/StructureDefinition/CarePlanModel"/>
<baseDefinition value="http://hl7.org/fhir/StructureDefinition/Base"/>
<derivation value="specialization"/>
<snapshot>
<extension
url="http://hl7.org/fhir/tools/StructureDefinition/snapshot-base-version">
<valueString value="4.0.1"/>
</extension>
<element id="CarePlanModel">
<path value="CarePlanModel"/>
<short value="Care Plan and Execution"/>
<definition
value="**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](DCP.html), FHIR `CarePlan` and
social care, and the PRSB
[Personalised Care and Support Plan](https://theprsb.org/standards/personalisedcareandsupportplan).
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](ReferralForms.html)
and the [BaRS review](BaRS.html#3-careplan-is-the-assessment-not-a-plan)).
The **Mappings** tab shows each element in FHIR."/>
<min value="0"/>
<max value="*"/>
<base>
<path value="Base"/>
<min value="0"/>
<max value="*"/>
</base>
<isModifier value="false"/>
</element>
<element id="CarePlanModel.planId">
<path value="CarePlanModel.planId"/>
<short value="Care plan ID"/>
<definition value="Unique identifier of the plan"/>
<min value="1"/>
<max value="1"/>
<base>
<path value="CarePlanModel.planId"/>
<min value="1"/>
<max value="1"/>
</base>
<type>
<code value="Identifier"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.identifier"/>
</mapping>
</element>
<element id="CarePlanModel.patient">
<path value="CarePlanModel.patient"/>
<short value="Patient"/>
<definition value="NHS Number and local identifiers"/>
<min value="1"/>
<max value="1"/>
<base>
<path value="CarePlanModel.patient"/>
<min value="1"/>
<max value="1"/>
</base>
<type>
<code value="Identifier"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.subject"/>
</mapping>
</element>
<element id="CarePlanModel.category">
<path value="CarePlanModel.category"/>
<short value="Category"/>
<definition
value="e.g. virtual ward treatment plan, long term condition, social care support plan"/>
<min value="1"/>
<max value="*"/>
<base>
<path value="CarePlanModel.category"/>
<min value="1"/>
<max value="*"/>
</base>
<type>
<code value="CodeableConcept"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.category"/>
</mapping>
</element>
<element id="CarePlanModel.title">
<path value="CarePlanModel.title"/>
<short value="Title"/>
<definition value="Human readable name"/>
<min value="0"/>
<max value="1"/>
<base>
<path value="CarePlanModel.title"/>
<min value="0"/>
<max value="1"/>
</base>
<type>
<code value="string"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.title"/>
</mapping>
</element>
<element id="CarePlanModel.status">
<path value="CarePlanModel.status"/>
<short value="Status"/>
<definition value="draft, active, on-hold, completed, revoked"/>
<min value="1"/>
<max value="1"/>
<base>
<path value="CarePlanModel.status"/>
<min value="1"/>
<max value="1"/>
</base>
<type>
<code value="code"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.status"/>
</mapping>
</element>
<element id="CarePlanModel.period">
<path value="CarePlanModel.period"/>
<short value="Period"/>
<definition value="When the plan applies"/>
<min value="0"/>
<max value="1"/>
<base>
<path value="CarePlanModel.period"/>
<min value="0"/>
<max value="1"/>
</base>
<type>
<code value="Period"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.period"/>
</mapping>
</element>
<element id="CarePlanModel.reviewDate">
<path value="CarePlanModel.reviewDate"/>
<short value="Review date"/>
<definition value="When the plan is next reviewed"/>
<min value="0"/>
<max value="1"/>
<base>
<path value="CarePlanModel.reviewDate"/>
<min value="0"/>
<max value="1"/>
</base>
<type>
<code value="date"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.activity (review) or extension - To confirm"/>
</mapping>
</element>
<element id="CarePlanModel.author">
<path value="CarePlanModel.author"/>
<short value="Author"/>
<definition value="Lead professional or organisation"/>
<min value="1"/>
<max value="1"/>
<base>
<path value="CarePlanModel.author"/>
<min value="1"/>
<max value="1"/>
</base>
<type>
<code value="Identifier"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.author"/>
</mapping>
</element>
<element id="CarePlanModel.agreedWithPatient">
<path value="CarePlanModel.agreedWithPatient"/>
<short value="Agreed with the patient"/>
<definition
value="The patient (or representative) has agreed the plan"/>
<min value="0"/>
<max value="1"/>
<base>
<path value="CarePlanModel.agreedWithPatient"/>
<min value="0"/>
<max value="1"/>
</base>
<type>
<code value="boolean"/>
</type>
<mapping>
<identity value="fhir"/>
<map
value="Consent, or CarePlan.contributor including the patient - To confirm"/>
</mapping>
</element>
<element id="CarePlanModel.basedOn">
<path value="CarePlanModel.basedOn"/>
<short value="Parent plan"/>
<definition
value="The plan this one implements, e.g. the GP or community care plan"/>
<min value="0"/>
<max value="*"/>
<base>
<path value="CarePlanModel.basedOn"/>
<min value="0"/>
<max value="*"/>
</base>
<type>
<code value="Identifier"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.basedOn / partOf"/>
</mapping>
</element>
<element id="CarePlanModel.careTeam">
<path value="CarePlanModel.careTeam"/>
<short value="Care team"/>
<definition value="The people and organisations involved"/>
<min value="0"/>
<max value="*"/>
<base>
<path value="CarePlanModel.careTeam"/>
<min value="0"/>
<max value="*"/>
</base>
<type>
<code value="BackboneElement"/>
</type>
<constraint>
<key value="ele-1"/>
<severity value="error"/>
<human value="All FHIR elements must have a @value or children"/>
<expression
value="hasValue() or (children().count() > id.count())"/>
<xpath value="@value|f:*|h:div"/>
<source value="http://hl7.org/fhir/StructureDefinition/Element"/>
</constraint>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.careTeam (CareTeam)"/>
</mapping>
</element>
<element id="CarePlanModel.careTeam.id">
<path value="CarePlanModel.careTeam.id"/>
<representation value="xmlAttr"/>
<short value="Unique id for inter-element referencing"/>
<definition
value="Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/>
<min value="0"/>
<max value="1"/>
<base>
<path value="Element.id"/>
<min value="0"/>
<max value="1"/>
</base>
<type>
<extension
url="http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type">
<valueUrl value="string"/>
</extension>
<code value="http://hl7.org/fhirpath/System.String"/>
</type>
<isModifier value="false"/>
<isSummary value="false"/>
<mapping>
<identity value="rim"/>
<map value="n/a"/>
</mapping>
</element>
<element id="CarePlanModel.careTeam.extension">
<path value="CarePlanModel.careTeam.extension"/>
<slicing>
<discriminator>
<type value="value"/>
<path value="url"/>
</discriminator>
<description value="Extensions are always sliced by (at least) url"/>
<rules value="open"/>
</slicing>
<short value="Additional content defined by implementations"/>
<definition
value="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."/>
<comment
value="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."/>
<alias value="extensions"/>
<alias value="user content"/>
<min value="0"/>
<max value="*"/>
<base>
<path value="Element.extension"/>
<min value="0"/>
<max value="*"/>
</base>
<type>
<code value="Extension"/>
</type>
<constraint>
<key value="ele-1"/>
<severity value="error"/>
<human value="All FHIR elements must have a @value or children"/>
<expression
value="hasValue() or (children().count() > id.count())"/>
<xpath value="@value|f:*|h:div"/>
<source value="http://hl7.org/fhir/StructureDefinition/Element"/>
</constraint>
<constraint>
<key value="ext-1"/>
<severity value="error"/>
<human value="Must have either extensions or value[x], not both"/>
<expression value="extension.exists() != value.exists()"/>
<xpath
value="exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])"/>
<source value="http://hl7.org/fhir/StructureDefinition/Extension"/>
</constraint>
<isModifier value="false"/>
<isSummary value="false"/>
<mapping>
<identity value="rim"/>
<map value="n/a"/>
</mapping>
</element>
<element id="CarePlanModel.careTeam.modifierExtension">
<path value="CarePlanModel.careTeam.modifierExtension"/>
<short value="Extensions that cannot be ignored even if unrecognized"/>
<definition
value="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)."/>
<comment
value="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."/>
<requirements
value="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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension)."/>
<alias value="extensions"/>
<alias value="user content"/>
<alias value="modifiers"/>
<min value="0"/>
<max value="*"/>
<base>
<path value="BackboneElement.modifierExtension"/>
<min value="0"/>
<max value="*"/>
</base>
<type>
<code value="Extension"/>
</type>
<constraint>
<key value="ele-1"/>
<severity value="error"/>
<human value="All FHIR elements must have a @value or children"/>
<expression
value="hasValue() or (children().count() > id.count())"/>
<xpath value="@value|f:*|h:div"/>
<source value="http://hl7.org/fhir/StructureDefinition/Element"/>
</constraint>
<constraint>
<key value="ext-1"/>
<severity value="error"/>
<human value="Must have either extensions or value[x], not both"/>
<expression value="extension.exists() != value.exists()"/>
<xpath
value="exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])"/>
<source value="http://hl7.org/fhir/StructureDefinition/Extension"/>
</constraint>
<isModifier value="true"/>
<isModifierReason
value="Modifier extensions are expected to modify the meaning or interpretation of the element that contains them"/>
<isSummary value="true"/>
<mapping>
<identity value="rim"/>
<map value="N/A"/>
</mapping>
</element>
<element id="CarePlanModel.careTeam.member">
<path value="CarePlanModel.careTeam.member"/>
<short value="Member"/>
<definition value="Practitioner, organisation, carer or the patient"/>
<min value="1"/>
<max value="1"/>
<base>
<path value="CarePlanModel.careTeam.member"/>
<min value="1"/>
<max value="1"/>
</base>
<type>
<code value="Identifier"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CareTeam.participant.member"/>
</mapping>
</element>
<element id="CarePlanModel.careTeam.role">
<path value="CarePlanModel.careTeam.role"/>
<short value="Role"/>
<definition value="e.g. lead professional, key worker, carer"/>
<min value="0"/>
<max value="1"/>
<base>
<path value="CarePlanModel.careTeam.role"/>
<min value="0"/>
<max value="1"/>
</base>
<type>
<code value="CodeableConcept"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CareTeam.participant.role"/>
</mapping>
</element>
<element id="CarePlanModel.needs">
<path value="CarePlanModel.needs"/>
<short value="Needs and problems"/>
<definition value="Conditions, needs or concerns the plan addresses"/>
<min value="0"/>
<max value="*"/>
<base>
<path value="CarePlanModel.needs"/>
<min value="0"/>
<max value="*"/>
</base>
<type>
<code value="CodeableConcept"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.addresses (Condition)"/>
</mapping>
</element>
<element id="CarePlanModel.goals">
<path value="CarePlanModel.goals"/>
<short value="Goals"/>
<definition value="What the plan is trying to achieve"/>
<min value="0"/>
<max value="*"/>
<base>
<path value="CarePlanModel.goals"/>
<min value="0"/>
<max value="*"/>
</base>
<type>
<code value="BackboneElement"/>
</type>
<constraint>
<key value="ele-1"/>
<severity value="error"/>
<human value="All FHIR elements must have a @value or children"/>
<expression
value="hasValue() or (children().count() > id.count())"/>
<xpath value="@value|f:*|h:div"/>
<source value="http://hl7.org/fhir/StructureDefinition/Element"/>
</constraint>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.goal (Goal)"/>
</mapping>
</element>
<element id="CarePlanModel.goals.id">
<path value="CarePlanModel.goals.id"/>
<representation value="xmlAttr"/>
<short value="Unique id for inter-element referencing"/>
<definition
value="Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/>
<min value="0"/>
<max value="1"/>
<base>
<path value="Element.id"/>
<min value="0"/>
<max value="1"/>
</base>
<type>
<extension
url="http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type">
<valueUrl value="string"/>
</extension>
<code value="http://hl7.org/fhirpath/System.String"/>
</type>
<isModifier value="false"/>
<isSummary value="false"/>
<mapping>
<identity value="rim"/>
<map value="n/a"/>
</mapping>
</element>
<element id="CarePlanModel.goals.extension">
<path value="CarePlanModel.goals.extension"/>
<slicing>
<discriminator>
<type value="value"/>
<path value="url"/>
</discriminator>
<description value="Extensions are always sliced by (at least) url"/>
<rules value="open"/>
</slicing>
<short value="Additional content defined by implementations"/>
<definition
value="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."/>
<comment
value="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."/>
<alias value="extensions"/>
<alias value="user content"/>
<min value="0"/>
<max value="*"/>
<base>
<path value="Element.extension"/>
<min value="0"/>
<max value="*"/>
</base>
<type>
<code value="Extension"/>
</type>
<constraint>
<key value="ele-1"/>
<severity value="error"/>
<human value="All FHIR elements must have a @value or children"/>
<expression
value="hasValue() or (children().count() > id.count())"/>
<xpath value="@value|f:*|h:div"/>
<source value="http://hl7.org/fhir/StructureDefinition/Element"/>
</constraint>
<constraint>
<key value="ext-1"/>
<severity value="error"/>
<human value="Must have either extensions or value[x], not both"/>
<expression value="extension.exists() != value.exists()"/>
<xpath
value="exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])"/>
<source value="http://hl7.org/fhir/StructureDefinition/Extension"/>
</constraint>
<isModifier value="false"/>
<isSummary value="false"/>
<mapping>
<identity value="rim"/>
<map value="n/a"/>
</mapping>
</element>
<element id="CarePlanModel.goals.modifierExtension">
<path value="CarePlanModel.goals.modifierExtension"/>
<short value="Extensions that cannot be ignored even if unrecognized"/>
<definition
value="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)."/>
<comment
value="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."/>
<requirements
value="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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension)."/>
<alias value="extensions"/>
<alias value="user content"/>
<alias value="modifiers"/>
<min value="0"/>
<max value="*"/>
<base>
<path value="BackboneElement.modifierExtension"/>
<min value="0"/>
<max value="*"/>
</base>
<type>
<code value="Extension"/>
</type>
<constraint>
<key value="ele-1"/>
<severity value="error"/>
<human value="All FHIR elements must have a @value or children"/>
<expression
value="hasValue() or (children().count() > id.count())"/>
<xpath value="@value|f:*|h:div"/>
<source value="http://hl7.org/fhir/StructureDefinition/Element"/>
</constraint>
<constraint>
<key value="ext-1"/>
<severity value="error"/>
<human value="Must have either extensions or value[x], not both"/>
<expression value="extension.exists() != value.exists()"/>
<xpath
value="exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])"/>
<source value="http://hl7.org/fhir/StructureDefinition/Extension"/>
</constraint>
<isModifier value="true"/>
<isModifierReason
value="Modifier extensions are expected to modify the meaning or interpretation of the element that contains them"/>
<isSummary value="true"/>
<mapping>
<identity value="rim"/>
<map value="N/A"/>
</mapping>
</element>
<element id="CarePlanModel.goals.description">
<path value="CarePlanModel.goals.description"/>
<short value="Goal"/>
<definition value="Described in the patient's words where possible"/>
<min value="1"/>
<max value="1"/>
<base>
<path value="CarePlanModel.goals.description"/>
<min value="1"/>
<max value="1"/>
</base>
<type>
<code value="string"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="Goal.description"/>
</mapping>
</element>
<element id="CarePlanModel.goals.target">
<path value="CarePlanModel.goals.target"/>
<short value="Target"/>
<definition value="Measure and date"/>
<min value="0"/>
<max value="1"/>
<base>
<path value="CarePlanModel.goals.target"/>
<min value="0"/>
<max value="1"/>
</base>
<type>
<code value="string"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="Goal.target"/>
</mapping>
</element>
<element id="CarePlanModel.goals.status">
<path value="CarePlanModel.goals.status"/>
<short value="Achievement"/>
<definition value="in-progress, achieved, not-achieved"/>
<min value="0"/>
<max value="1"/>
<base>
<path value="CarePlanModel.goals.status"/>
<min value="0"/>
<max value="1"/>
</base>
<type>
<code value="code"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="Goal.achievementStatus"/>
</mapping>
</element>
<element id="CarePlanModel.activity">
<path value="CarePlanModel.activity"/>
<short value="Activities"/>
<definition value="The actions agreed"/>
<min value="0"/>
<max value="*"/>
<base>
<path value="CarePlanModel.activity"/>
<min value="0"/>
<max value="*"/>
</base>
<type>
<code value="BackboneElement"/>
</type>
<constraint>
<key value="ele-1"/>
<severity value="error"/>
<human value="All FHIR elements must have a @value or children"/>
<expression
value="hasValue() or (children().count() > id.count())"/>
<xpath value="@value|f:*|h:div"/>
<source value="http://hl7.org/fhir/StructureDefinition/Element"/>
</constraint>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.activity"/>
</mapping>
</element>
<element id="CarePlanModel.activity.id">
<path value="CarePlanModel.activity.id"/>
<representation value="xmlAttr"/>
<short value="Unique id for inter-element referencing"/>
<definition
value="Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces."/>
<min value="0"/>
<max value="1"/>
<base>
<path value="Element.id"/>
<min value="0"/>
<max value="1"/>
</base>
<type>
<extension
url="http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type">
<valueUrl value="string"/>
</extension>
<code value="http://hl7.org/fhirpath/System.String"/>
</type>
<isModifier value="false"/>
<isSummary value="false"/>
<mapping>
<identity value="rim"/>
<map value="n/a"/>
</mapping>
</element>
<element id="CarePlanModel.activity.extension">
<path value="CarePlanModel.activity.extension"/>
<slicing>
<discriminator>
<type value="value"/>
<path value="url"/>
</discriminator>
<description value="Extensions are always sliced by (at least) url"/>
<rules value="open"/>
</slicing>
<short value="Additional content defined by implementations"/>
<definition
value="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."/>
<comment
value="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."/>
<alias value="extensions"/>
<alias value="user content"/>
<min value="0"/>
<max value="*"/>
<base>
<path value="Element.extension"/>
<min value="0"/>
<max value="*"/>
</base>
<type>
<code value="Extension"/>
</type>
<constraint>
<key value="ele-1"/>
<severity value="error"/>
<human value="All FHIR elements must have a @value or children"/>
<expression
value="hasValue() or (children().count() > id.count())"/>
<xpath value="@value|f:*|h:div"/>
<source value="http://hl7.org/fhir/StructureDefinition/Element"/>
</constraint>
<constraint>
<key value="ext-1"/>
<severity value="error"/>
<human value="Must have either extensions or value[x], not both"/>
<expression value="extension.exists() != value.exists()"/>
<xpath
value="exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])"/>
<source value="http://hl7.org/fhir/StructureDefinition/Extension"/>
</constraint>
<isModifier value="false"/>
<isSummary value="false"/>
<mapping>
<identity value="rim"/>
<map value="n/a"/>
</mapping>
</element>
<element id="CarePlanModel.activity.modifierExtension">
<path value="CarePlanModel.activity.modifierExtension"/>
<short value="Extensions that cannot be ignored even if unrecognized"/>
<definition
value="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)."/>
<comment
value="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."/>
<requirements
value="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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension)."/>
<alias value="extensions"/>
<alias value="user content"/>
<alias value="modifiers"/>
<min value="0"/>
<max value="*"/>
<base>
<path value="BackboneElement.modifierExtension"/>
<min value="0"/>
<max value="*"/>
</base>
<type>
<code value="Extension"/>
</type>
<constraint>
<key value="ele-1"/>
<severity value="error"/>
<human value="All FHIR elements must have a @value or children"/>
<expression
value="hasValue() or (children().count() > id.count())"/>
<xpath value="@value|f:*|h:div"/>
<source value="http://hl7.org/fhir/StructureDefinition/Element"/>
</constraint>
<constraint>
<key value="ext-1"/>
<severity value="error"/>
<human value="Must have either extensions or value[x], not both"/>
<expression value="extension.exists() != value.exists()"/>
<xpath
value="exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])"/>
<source value="http://hl7.org/fhir/StructureDefinition/Extension"/>
</constraint>
<isModifier value="true"/>
<isModifierReason
value="Modifier extensions are expected to modify the meaning or interpretation of the element that contains them"/>
<isSummary value="true"/>
<mapping>
<identity value="rim"/>
<map value="N/A"/>
</mapping>
</element>
<element id="CarePlanModel.activity.description">
<path value="CarePlanModel.activity.description"/>
<short value="Activity"/>
<definition value="What will be done"/>
<min value="1"/>
<max value="1"/>
<base>
<path value="CarePlanModel.activity.description"/>
<min value="1"/>
<max value="1"/>
</base>
<type>
<code value="string"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.activity.detail.description"/>
</mapping>
</element>
<element id="CarePlanModel.activity.kind">
<path value="CarePlanModel.activity.kind"/>
<short value="Kind"/>
<definition
value="referral, task, appointment, monitoring, medication, education"/>
<min value="0"/>
<max value="1"/>
<base>
<path value="CarePlanModel.activity.kind"/>
<min value="0"/>
<max value="1"/>
</base>
<type>
<code value="code"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.activity.detail.kind"/>
</mapping>
</element>
<element id="CarePlanModel.activity.performer">
<path value="CarePlanModel.activity.performer"/>
<short value="Performer"/>
<definition value="Who carries it out"/>
<min value="0"/>
<max value="*"/>
<base>
<path value="CarePlanModel.activity.performer"/>
<min value="0"/>
<max value="*"/>
</base>
<type>
<code value="Identifier"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.activity.detail.performer"/>
</mapping>
</element>
<element id="CarePlanModel.activity.scheduled">
<path value="CarePlanModel.activity.scheduled"/>
<short value="When"/>
<definition value="Timing or frequency"/>
<min value="0"/>
<max value="1"/>
<base>
<path value="CarePlanModel.activity.scheduled"/>
<min value="0"/>
<max value="1"/>
</base>
<type>
<code value="Period"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.activity.detail.scheduled[x]"/>
</mapping>
</element>
<element id="CarePlanModel.activity.status">
<path value="CarePlanModel.activity.status"/>
<short value="Status"/>
<definition
value="not-started, scheduled, in-progress, on-hold, completed, cancelled"/>
<min value="1"/>
<max value="1"/>
<base>
<path value="CarePlanModel.activity.status"/>
<min value="1"/>
<max value="1"/>
</base>
<type>
<code value="code"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.activity.detail.status"/>
</mapping>
</element>
<element id="CarePlanModel.activity.request">
<path value="CarePlanModel.activity.request"/>
<short value="Request"/>
<definition
value="The request that carries out the activity, e.g. a referral (Clinical Referral)"/>
<min value="0"/>
<max value="1"/>
<base>
<path value="CarePlanModel.activity.request"/>
<min value="0"/>
<max value="1"/>
</base>
<type>
<code value="Reference"/>
<targetProfile
value="http://hl7.org/fhir/StructureDefinition/ServiceRequest"/>
<targetProfile value="http://hl7.org/fhir/StructureDefinition/Task"/>
<targetProfile
value="http://hl7.org/fhir/StructureDefinition/Appointment"/>
<targetProfile
value="http://hl7.org/fhir/StructureDefinition/MedicationRequest"/>
</type>
<mapping>
<identity value="fhir"/>
<map
value="CarePlan.activity.reference (ServiceRequest - the referral; ServiceRequest.basedOn the CarePlan)"/>
</mapping>
</element>
<element id="CarePlanModel.activity.outcome">
<path value="CarePlanModel.activity.outcome"/>
<short value="Outcome"/>
<definition
value="What was done - e.g. the Discharge Report from a referral"/>
<min value="0"/>
<max value="*"/>
<base>
<path value="CarePlanModel.activity.outcome"/>
<min value="0"/>
<max value="*"/>
</base>
<type>
<code value="Reference"/>
<targetProfile
value="https://fhir.acmeexample.org.uk/PatientCareCoordination/StructureDefinition/Encounter"/>
<targetProfile
value="http://hl7.org/fhir/StructureDefinition/Procedure"/>
<targetProfile
value="https://fhir.acmeexample.org.uk/PatientCareCoordination/StructureDefinition/Observation"/>
<targetProfile
value="http://hl7.org/fhir/StructureDefinition/DiagnosticReport"/>
<targetProfile
value="http://hl7.org/fhir/StructureDefinition/DocumentReference"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.activity.outcomeReference"/>
</mapping>
</element>
<element id="CarePlanModel.activity.progress">
<path value="CarePlanModel.activity.progress"/>
<short value="Progress"/>
<definition value="Notes on progress"/>
<min value="0"/>
<max value="*"/>
<base>
<path value="CarePlanModel.activity.progress"/>
<min value="0"/>
<max value="*"/>
</base>
<type>
<code value="string"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.activity.progress"/>
</mapping>
</element>
</snapshot>
<differential>
<element id="CarePlanModel">
<path value="CarePlanModel"/>
<short value="Care Plan and Execution"/>
<definition
value="**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](DCP.html), FHIR `CarePlan` and
social care, and the PRSB
[Personalised Care and Support Plan](https://theprsb.org/standards/personalisedcareandsupportplan).
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](ReferralForms.html)
and the [BaRS review](BaRS.html#3-careplan-is-the-assessment-not-a-plan)).
The **Mappings** tab shows each element in FHIR."/>
</element>
<element id="CarePlanModel.planId">
<path value="CarePlanModel.planId"/>
<short value="Care plan ID"/>
<definition value="Unique identifier of the plan"/>
<min value="1"/>
<max value="1"/>
<type>
<code value="Identifier"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.identifier"/>
</mapping>
</element>
<element id="CarePlanModel.patient">
<path value="CarePlanModel.patient"/>
<short value="Patient"/>
<definition value="NHS Number and local identifiers"/>
<min value="1"/>
<max value="1"/>
<type>
<code value="Identifier"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.subject"/>
</mapping>
</element>
<element id="CarePlanModel.category">
<path value="CarePlanModel.category"/>
<short value="Category"/>
<definition
value="e.g. virtual ward treatment plan, long term condition, social care support plan"/>
<min value="1"/>
<max value="*"/>
<type>
<code value="CodeableConcept"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.category"/>
</mapping>
</element>
<element id="CarePlanModel.title">
<path value="CarePlanModel.title"/>
<short value="Title"/>
<definition value="Human readable name"/>
<min value="0"/>
<max value="1"/>
<type>
<code value="string"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.title"/>
</mapping>
</element>
<element id="CarePlanModel.status">
<path value="CarePlanModel.status"/>
<short value="Status"/>
<definition value="draft, active, on-hold, completed, revoked"/>
<min value="1"/>
<max value="1"/>
<type>
<code value="code"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.status"/>
</mapping>
</element>
<element id="CarePlanModel.period">
<path value="CarePlanModel.period"/>
<short value="Period"/>
<definition value="When the plan applies"/>
<min value="0"/>
<max value="1"/>
<type>
<code value="Period"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.period"/>
</mapping>
</element>
<element id="CarePlanModel.reviewDate">
<path value="CarePlanModel.reviewDate"/>
<short value="Review date"/>
<definition value="When the plan is next reviewed"/>
<min value="0"/>
<max value="1"/>
<type>
<code value="date"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.activity (review) or extension - To confirm"/>
</mapping>
</element>
<element id="CarePlanModel.author">
<path value="CarePlanModel.author"/>
<short value="Author"/>
<definition value="Lead professional or organisation"/>
<min value="1"/>
<max value="1"/>
<type>
<code value="Identifier"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.author"/>
</mapping>
</element>
<element id="CarePlanModel.agreedWithPatient">
<path value="CarePlanModel.agreedWithPatient"/>
<short value="Agreed with the patient"/>
<definition
value="The patient (or representative) has agreed the plan"/>
<min value="0"/>
<max value="1"/>
<type>
<code value="boolean"/>
</type>
<mapping>
<identity value="fhir"/>
<map
value="Consent, or CarePlan.contributor including the patient - To confirm"/>
</mapping>
</element>
<element id="CarePlanModel.basedOn">
<path value="CarePlanModel.basedOn"/>
<short value="Parent plan"/>
<definition
value="The plan this one implements, e.g. the GP or community care plan"/>
<min value="0"/>
<max value="*"/>
<type>
<code value="Identifier"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.basedOn / partOf"/>
</mapping>
</element>
<element id="CarePlanModel.careTeam">
<path value="CarePlanModel.careTeam"/>
<short value="Care team"/>
<definition value="The people and organisations involved"/>
<min value="0"/>
<max value="*"/>
<type>
<code value="BackboneElement"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.careTeam (CareTeam)"/>
</mapping>
</element>
<element id="CarePlanModel.careTeam.member">
<path value="CarePlanModel.careTeam.member"/>
<short value="Member"/>
<definition value="Practitioner, organisation, carer or the patient"/>
<min value="1"/>
<max value="1"/>
<type>
<code value="Identifier"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CareTeam.participant.member"/>
</mapping>
</element>
<element id="CarePlanModel.careTeam.role">
<path value="CarePlanModel.careTeam.role"/>
<short value="Role"/>
<definition value="e.g. lead professional, key worker, carer"/>
<min value="0"/>
<max value="1"/>
<type>
<code value="CodeableConcept"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CareTeam.participant.role"/>
</mapping>
</element>
<element id="CarePlanModel.needs">
<path value="CarePlanModel.needs"/>
<short value="Needs and problems"/>
<definition value="Conditions, needs or concerns the plan addresses"/>
<min value="0"/>
<max value="*"/>
<type>
<code value="CodeableConcept"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.addresses (Condition)"/>
</mapping>
</element>
<element id="CarePlanModel.goals">
<path value="CarePlanModel.goals"/>
<short value="Goals"/>
<definition value="What the plan is trying to achieve"/>
<min value="0"/>
<max value="*"/>
<type>
<code value="BackboneElement"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.goal (Goal)"/>
</mapping>
</element>
<element id="CarePlanModel.goals.description">
<path value="CarePlanModel.goals.description"/>
<short value="Goal"/>
<definition value="Described in the patient's words where possible"/>
<min value="1"/>
<max value="1"/>
<type>
<code value="string"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="Goal.description"/>
</mapping>
</element>
<element id="CarePlanModel.goals.target">
<path value="CarePlanModel.goals.target"/>
<short value="Target"/>
<definition value="Measure and date"/>
<min value="0"/>
<max value="1"/>
<type>
<code value="string"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="Goal.target"/>
</mapping>
</element>
<element id="CarePlanModel.goals.status">
<path value="CarePlanModel.goals.status"/>
<short value="Achievement"/>
<definition value="in-progress, achieved, not-achieved"/>
<min value="0"/>
<max value="1"/>
<type>
<code value="code"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="Goal.achievementStatus"/>
</mapping>
</element>
<element id="CarePlanModel.activity">
<path value="CarePlanModel.activity"/>
<short value="Activities"/>
<definition value="The actions agreed"/>
<min value="0"/>
<max value="*"/>
<type>
<code value="BackboneElement"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.activity"/>
</mapping>
</element>
<element id="CarePlanModel.activity.description">
<path value="CarePlanModel.activity.description"/>
<short value="Activity"/>
<definition value="What will be done"/>
<min value="1"/>
<max value="1"/>
<type>
<code value="string"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.activity.detail.description"/>
</mapping>
</element>
<element id="CarePlanModel.activity.kind">
<path value="CarePlanModel.activity.kind"/>
<short value="Kind"/>
<definition
value="referral, task, appointment, monitoring, medication, education"/>
<min value="0"/>
<max value="1"/>
<type>
<code value="code"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.activity.detail.kind"/>
</mapping>
</element>
<element id="CarePlanModel.activity.performer">
<path value="CarePlanModel.activity.performer"/>
<short value="Performer"/>
<definition value="Who carries it out"/>
<min value="0"/>
<max value="*"/>
<type>
<code value="Identifier"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.activity.detail.performer"/>
</mapping>
</element>
<element id="CarePlanModel.activity.scheduled">
<path value="CarePlanModel.activity.scheduled"/>
<short value="When"/>
<definition value="Timing or frequency"/>
<min value="0"/>
<max value="1"/>
<type>
<code value="Period"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.activity.detail.scheduled[x]"/>
</mapping>
</element>
<element id="CarePlanModel.activity.status">
<path value="CarePlanModel.activity.status"/>
<short value="Status"/>
<definition
value="not-started, scheduled, in-progress, on-hold, completed, cancelled"/>
<min value="1"/>
<max value="1"/>
<type>
<code value="code"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.activity.detail.status"/>
</mapping>
</element>
<element id="CarePlanModel.activity.request">
<path value="CarePlanModel.activity.request"/>
<short value="Request"/>
<definition
value="The request that carries out the activity, e.g. a referral (Clinical Referral)"/>
<min value="0"/>
<max value="1"/>
<type>
<code value="Reference"/>
<targetProfile
value="http://hl7.org/fhir/StructureDefinition/ServiceRequest"/>
<targetProfile value="http://hl7.org/fhir/StructureDefinition/Task"/>
<targetProfile
value="http://hl7.org/fhir/StructureDefinition/Appointment"/>
<targetProfile
value="http://hl7.org/fhir/StructureDefinition/MedicationRequest"/>
</type>
<mapping>
<identity value="fhir"/>
<map
value="CarePlan.activity.reference (ServiceRequest - the referral; ServiceRequest.basedOn the CarePlan)"/>
</mapping>
</element>
<element id="CarePlanModel.activity.outcome">
<path value="CarePlanModel.activity.outcome"/>
<short value="Outcome"/>
<definition
value="What was done - e.g. the Discharge Report from a referral"/>
<min value="0"/>
<max value="*"/>
<type>
<code value="Reference"/>
<targetProfile
value="https://fhir.acmeexample.org.uk/PatientCareCoordination/StructureDefinition/Encounter"/>
<targetProfile
value="http://hl7.org/fhir/StructureDefinition/Procedure"/>
<targetProfile
value="https://fhir.acmeexample.org.uk/PatientCareCoordination/StructureDefinition/Observation"/>
<targetProfile
value="http://hl7.org/fhir/StructureDefinition/DiagnosticReport"/>
<targetProfile
value="http://hl7.org/fhir/StructureDefinition/DocumentReference"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.activity.outcomeReference"/>
</mapping>
</element>
<element id="CarePlanModel.activity.progress">
<path value="CarePlanModel.activity.progress"/>
<short value="Progress"/>
<definition value="Notes on progress"/>
<min value="0"/>
<max value="*"/>
<type>
<code value="string"/>
</type>
<mapping>
<identity value="fhir"/>
<map value="CarePlan.activity.progress"/>
</mapping>
</element>
</differential>
</StructureDefinition>