A Care Plan is a coordinated map of healthcare activities designed to address specific patient health concerns. At its core, it's an organized collection of intended activities that healthcare providers plan to perform, are performing, or have performed for a patient.

The key purpose of care plan are to:

• Organize and track patient care activities
• Coordinate between different healthcare providers
• Document care progress and outcomes
• Ensure continuity of care

Activities

Activities are the fundamental building blocks of a Care Plan.

The supported activities as per HL7 FHIR Spec are: Appointment, CommunicationRequest, DeviceRequest, ImmunizationRecommendation, MedicationRequest, NutritionOrder, RequestOrchestration, ServiceRequest, SupplyRequest, Task, VisionPrescription.

The first version of the care plan implementation will only support following resources.

Medication Request

Task

Care Plan Structure:

Version 1

{
  "identifier": "<uuid4>", // The ID of the care plan in care
  "status": "options", // draft|active|completed|on-hold|cancelled|entered-in-error|unknown <https://hl7.org/fhir/valueset-care-plan-status.html>
  "intent": "options", // proposal|plan|order|option|directive <https://hl7.org/fhir/valueset-care-plan-intent.html>
  "title": "string", // The title of the care plan
  "description": "string", // Detailed description of the care plan
  "period": { "start": "dateTime", "end": "dateTime" }, // Duration for which the Care Plan is intended
  "subject": "patient_id", // The patient id from care
  "encounter": "encounter_id", // Specific encounter where the Care Plan was created
  "custodian": "organization_id", // Organization responsible for the care plan
  "addresses": [{ "system": "SNOMED-CT", "code": "str", "display": "str" }], // 'Clinical finding' from SNOMED CT (concept code: 404684003)
  "goal": [{ "reference": "Goal/678" }], // Goals of the care plan
  "activity": [
    { // Action to occur or has occurred as part of plan;
      "plannedActivityReference": { 
			  "reference": "id" // reference id of the model. Can be a polimorphic table clubbed with the type. 
			  "type": "option" // MedicationRequest | ServiceRequest | Task 
			}, // We will only support Task, Medication Request and Service Request to start with. 
      "progress": [{ "text": "markdown", "author": "user_id", "time": "dateTIme" }], // Textual descriptions of progress
      "performedActivity": [{ "reference": "MedicationAdmistation/234" }] // Activities that have already been performed. Schema to be defined. 
    }
  ],
  "note": [{ "text": "str" }] // General comments about the care plan
}

Top level Relationships

flowchart TD
    P["Patient"] --- CP(("Care Plan"))
    E["Encounter"] --- CP
    O["Organization/Custodian"] --- CP
    G["Goals"] --- CP
    CP --> A["Activities"]
    A --> T["Tasks"] & M["Medication Requests"] & S["Service Requests"] & Q["...more"]

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Care will introduce support for more activities over time.

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Status Lifecycle

The possible states for a care plan