{"schema":"https://ver.cy/schemas/card/1.0.0","id":"EM-HCP-04","code":"em-hcp-04","url":"https://ver.cy/models/em-hcp-04/","name":"Care episode and care plan","alternateNames":[],"kind":"enterprise-contour","status":"published","version":"research-checkpoint","language":"en","classifiers":{"family":"Enterprise profiles","category":"Enterprise subject","entryKind":"subject","plane":"","domain":["Enterprise","HCP"],"industry":["Healthcare provider"],"navPath":"","tags":["EM-HCP-04","W-IND","subject","EpisodeOfCare","CareTeam","CarePlan","CareGoal","PlannedActivity"],"facets":{}},"whatItIs":"A period of responsibility of a provider or care team for a patient's health issue, with planned activities, goals and reviews, referencing diagnosis or condition records separately from clinical observations.","purpose":"Show who is responsible for a patient's health issue over time and what has been decided to do about it, so that care stays coordinated.","scope":{"in":[],"out":[],"boundaries":[]},"distinguishingFeatures":["An episode records responsibility over time, while an encounter records one interaction.","Plan versions are kept, so past decisions stay visible.","Planned activities link to the orders and appointments that perform them.","Diagnoses are referenced through diagnosis or condition records, while clinical observations provide separately referenced findings or evidence."],"structure":{"bundles":[{"id":"episode","name":"Episode","description":"Responsibility for a health issue over time.","layers":[{"id":"responsibility","name":"Responsibility","description":"Period, managing organization and care team.","findings":[{"id":"episode-period","name":"Episode period","description":"Start, end, managing organization and health issue.","questions":[{"text":"When did this episode of care start and end, and which organization manages it?","id":"episode-period-q1"},{"text":"Which health issue or condition record is this episode of care about?","id":"episode-period-q2"}]},{"id":"care-team","name":"Care team","description":"Practitioners and roles in the episode.","questions":[{"text":"Which practitioners and roles are in the care team of this episode, and for which periods?","id":"care-team-q1"}]}]}]},{"id":"plan","name":"Plan","description":"What has been decided to do.","layers":[{"id":"goals-and-activities","name":"Goals and activities","description":"Plan versions, review and links to execution.","findings":[{"id":"plan-content","name":"Plan content","description":"Goals, activities and authorship of a plan version.","questions":[{"text":"Which goals and planned activities are in the current version of this care plan?","id":"plan-content-q1"},{"text":"Which clinician authored or approved this care plan version?","id":"plan-content-q2"}]},{"id":"plan-review","name":"Plan review","description":"Reviews, changes and agreement of the patient.","questions":[{"text":"When was this care plan last reviewed, and what changed from the previous version?","id":"plan-review-q1"},{"text":"Which orders or appointments carry out each planned activity of this plan?","id":"plan-review-q2"},{"text":"Has the patient agreed to this care plan, and where is that recorded?","id":"plan-review-q3"}]}]}]}]},"agentConduct":{"may":["Summarize the current plan and its open activities.","Flag plans that are past their review date.","Draft proposed plan updates, marked as unapproved proposals, for clinician review."],"mustNot":["Create, change or approve clinical goals or activities in the approved care plan.","Give treatment advice to patients.","Present a template as the patient's actual plan.","Present a drafted proposal as part of the approved care plan."],"requiresHuman":["Care plans are authored and approved by responsible clinicians.","Transfer of episode responsibility requires the agreement of both providers."]},"ethics":{"considerations":["Plans should reflect the patient's own goals and agreement.","Shared care plans expose sensitive information to more parties."],"affectedParties":["Patients and carers","Care team members","Other providers"]},"owners":{"steward":"The medical director who answers for coordinated care records.","roles":[],"masterSystems":["Electronic health record system","Care management system"]},"relations":[{"target":"EM-HCP-03","type":"neighbor"},{"target":"EM-HCP-05","type":"neighbor"},{"target":"EM-HCP-06","type":"neighbor"},{"target":"EM-HCP-07","type":"neighbor"},{"target":"EM-HCP-02","type":"neighbor"},{"target":"EM-ORG-05","type":"neighbor"},{"target":"WM-ACT-049","type":"references","note":"conceptual-candidate"},{"target":"WM-ACT-046","type":"references","note":"conceptual-candidate"}],"interaction":{"identity":{"applicability":"required","items":["An episode of care has an identifier unique within the managing organization.","A care plan is identified by its identifier and version."]},"properties":{"applicability":"not-applicable","items":[]},"recognition":{"applicability":"required","items":["Records show a patient, a managing organization, a period, a care team and a plan with goals.","An episode of care must be distinguished from a single encounter and from a billing case."]},"capabilities":{"applicability":"required","items":["The contour supports care coordination, review scheduling and continuity across providers."]},"hazards":{"applicability":"required","items":["Outdated plans can lead to duplicated or missed care.","Unclear responsibility can leave tasks without an owner."]},"interfaces":{"applicability":"optional","items":["HL7 International publishes the FHIR EpisodeOfCare, CareTeam and CarePlan resources."]},"context":{"applicability":"required","items":["The contour is used in chronic care, rehabilitation, home care and maternity care.","Integrated care programs may share plans across organizations."]}},"sources":[{"title":"HL7 FHIR: EpisodeOfCare, CareTeam and CarePlan resources"},{"title":"openEHR: care plan and instruction archetypes"},{"title":"Integrated care and case management practice"},{"title":"HL7 FHIR R4 EpisodeOfCare resource","url":"https://hl7.org/fhir/R4/episodeofcare.html","note":"Checked live (HTTP 200) on 2026-10-21."},{"title":"HL7 FHIR R4 CarePlan resource","url":"https://hl7.org/fhir/R4/careplan.html","note":"Checked live (HTTP 200) on 2026-10-21."}],"openQuestions":["When does an episode start and end, and who decides?","How are plan revisions kept so that past decisions remain visible?","How are activities of several providers combined without taking over each other's records?","Settle the boundary and the reuse, extend or new decision against the current specifications.","Confirm the semantic crosswalk, rights and source mastership.","Choose immutable references and run fixture checks before claiming publication readiness."],"resources":{"source":"https://ver.cy/enterprise/models/em-hcp-04/"},"provenance":{"origin":"enterprise research programme","builtFrom":["enterprise/models/em-hcp-04/brief.json","ver-cy/world-models/card-supplements/em-hcp-04.json"],"providers":[],"researchStatus":"published-partial","generatedAt":"","builder":"tools/build_cards.py@1.0.0"},"completeness":{"sections":{"classifiers":"filled","whatItIs":"filled","purpose":"filled","distinguishingFeatures":"filled","structure":"filled","agentConduct":"filled","ethics":"filled","owners":"filled","relations":"filled","interaction.identity":"filled","interaction.properties":"not-applicable","interaction.recognition":"filled","interaction.capabilities":"filled","interaction.hazards":"filled","interaction.interfaces":"filled","interaction.context":"filled","sources":"filled"},"notes":{"interaction.properties":"Enterprise record contour: physical properties belong to referenced world models.","_supplement":"Sections authored in card supplement 1.1.0 by Claude (Opus 5.5) (2026-10-21, unreviewed). Written from the industry contour brief and established practice in the field; source pages were checked live on 2026-10-21. Unreviewed. Revised against an independent Codex review on 2026-10-21. Agent conduct and identity wording corrected by hand after the second review on 2026-10-21.","_gate":"Published through the contour publication gate 1.0 on 2026-10-21T19:02:23+00:00: completeness 1.00; subject: research brief; 2 live sources; review by codex: pass"},"score":1.0}}