A factor that impedes progress toward goals or planned activities. Examples include a food desert that prevents a healthy eating, an injury that prevents exercise, and lack of transportation to rehabilitation center.

A resource used in care provision, such as a provider, a medication, or a third-party service

A goal in the care plan. Possible relationship to concern, planned activity, performed activity, observation.

A person under the care of one or more healthcare service providers

A team of individuals involved in the patient's care. For more details, consult the Care Team Domain Analysis Model.

A person, including the patient, responsible for clinical or ancillary healthcare services for a patient. A care team member may have various roles in the Care Plan process, such as authoring a plan element or performing an activity execution.

A health concern or condition addressed by the care plan

A risk identified to the patient's health, not to include risks to care team members, intervention efficacy, etc.

Abstract pattern for elements that can be organized in hierarchical compositions

An activity planned as part of the care plan

A patient or care team preference that informs care planning

Abstract pattern for elements that can be prioritized

A characteristic of the patient or patient's community that reduces health risks or overcomes barriers

A resource needed to perform an activity

A care plan manifested as a digital payload for system exchange

A definition or template for care plans

A manifestation of a care plan as a Paper Document, User Interface, or API Payload. May be curated (explicitly authored) or generated (rule-based). Follows the MVC pattern where data flows through controllers to produce views.

Data tracking changes and reconciliation of curated plan data

A clinician's assertion that specific items should be included in the plan

Base class for the Controller layer in MVC pattern, representing specifications that control how persisted data shows up in manifestations

Data explicitly incuded in a plan, typically with signature and date representing acceptance

Profile, Template, Pathway, Protocol - specifications that define the structure and content of care plan data

Specification for generating plan documents (e.g., CCD, C-CDA templates)

An external clinical protocol or pathway that informs the care plan

Abstract representation of human intention that drives care planning

Base class for the Model layer in MVC pattern representing data persistence

Specification for API payloads

A document representing a care plan that has been explicitly curated by a provider

A document generated automatically by rules or queries to represent a care plan

Abstract base class for all care plan content elements to support modeling general capabilities, such as the possibility of being the subject of communication. All plan elements are specific to a Patient.

Controller specification for a planning form UI

A user interface form for viewing and entering care plan data

Data from clinical records (EHR, CarePlan Application), including record items such as problems, goals, medications, procedures

Clinician plan in text. May be used to authorize orders or to create an explicit structured Plan.

Clinical data conforming to a data model that can be processed programmatically

A user interface view of the care plan

Rules that control how data is presented in a UI plan view

Clinical data not conforming to a structured data model, such as free text notes

Base class for the View layer in MVC pattern representing plan manifestations such as paper documents, user interfaces,or API payloads

An organization involved in care delivery

An act of assessing multiple plans and determining when respective elements should be merged, superseded, or removed

A record of reconciliation activities

A review where acknowledgment decisions are made about plan elements

An execution of a planned activity

An observation characterizing the outcome of an activity execution

A communication event related to the care plan. A communication can refer to any care plan element, and may belong to a thread of related communications.

A collection of related communications in which later communications are aware of earlier ones, within security and privacy constraints

A change made to a plan element adopted from a Guideline

A review assessing outcomes of performable elements

Abstract pattern for elements that can be revised over time

NICU patient - premature infant

Observation of infant body weight (LOINC 29463-7)

Supporting goal: caregivers are educated on infant care

Primary goal for NICU patient: discharge from the unit

Execution of oral feeding activity

Observation of infant formula intake over 24 hours (LOINC 80469-0)

Primary NICU nurse caring for the infant

Attending neonatologist

Outcome review: oral nutrition intake improved

Supporting goal: infant can take nutrition orally

Supporting goal: infant can breathe room air without supplemental oxygen

Gradual advancement of oral feeding

Health concern: infant born prematurely

Regular respiratory status assessment

Execution of respiratory status assessment

Observation of respiratory status (LOINC 53756-3)

Outcome review: respiratory issues resolved

Daily weight measurement activity

Supporting goal: infant achieves adequate weight gain

Execution of daily weight measurement

Outcome review: weight has stabilized

Value set for acknowledgment decisions

Value set for activity completion status

Value set for activity order status

Value set for care plan definitions

Value set for decision modes

Value set for modification types

Value set for outcome assessment

Value set for performance status

Value set for plan purposes

Value set for preference contexts

Value set for review events

Value set for specification types

Codes for acknowledgment decisions

Codes for activity completion status

Codes for activity order status

Codes for types of care plan definitions

Codes for how decisions are made

Codes for types of modifications

Codes for outcome assessment

Codes for performance status of activities

Codes for care plan purposes

Codes for preference contexts

Codes for events that trigger reviews

Codes for care plan specification types