CarePlanDAM - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Planning

Planning Use Case

The Planning use case covers the creation and management of care plan content - the goals, activities, concerns, and preferences that constitute the process of planning. It does not necesarily imply the creation of an identifiable "Care Plan" artifact.

Overview

Care planning involves identifying patient concerns, setting goals, and planning activities to achieve those goals. This use case focuses on the content elements that comprise a care plan.

Key Models

Goal

A goal represents a desired outcome for the patient. Goals:

• Address one or more Concerns
• May be based on clinical Guidelines
• Can be organized hierarchically (via PartOf)
• Have priority and revision tracking
• Can be assessed via OutcomeReview

Planned Activity

A planned activity represents an action planned as part of care. Activities:

• Support one or more Goals
• May mitigate or present Health Risks
• Can be based on clinical Guidelines
• Have target periods and frequencies
• Include pre/post conditions

Concern

A concern represents a health concern or condition being addressed. Concerns:

• Are addressed by Goals
• May be addressed by Guidelines
• Can be expressed by CareTeamMembers
• Have priority and revision tracking

Preference

A preference represents patient or care team preferences that inform planning. Preferences:

• Inform Goals and/or Activities
• Have context and priority
• Can be expressed by CareTeamMembers

Supporting Models

• Barrier - Factors that impede progress toward goals or activities
• Health Risk - Identified health risks for the patient
• Protective Factor - Factors that protect against risks or barriers
• Guideline - Clinical guidelines that inform the care plan