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Care episode and care plan

EM-HCP-04 · em-hcp-04

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.

Enterprise profiles Enterprise subject EnterpriseHCP
Bundle → Layer → Finding → QuestionsClassifiersWhat it isWhy it existsDistinguishing featuresWhat robots and AI may and may not doMoral aspectsOwnersLinks to other meta-modelsIdentity and identifiersDirect propertiesRecognitionCapabilities and actionsHazards and failure modesStandards and interfacesContext of useSources

Bundle → Layer → Finding → Questions Filled

2 bundles · 2 layers · 4 findings · 8 questions

Episode Responsibility for a health issue over time.

Responsibility

Period, managing organization and care team.

Episode period

Start, end, managing organization and health issue.

  1. When did this episode of care start and end, and which organization manages it?
  2. Which health issue or condition record is this episode of care about?

Care team

Practitioners and roles in the episode.

  1. Which practitioners and roles are in the care team of this episode, and for which periods?
Plan What has been decided to do.

Goals and activities

Plan versions, review and links to execution.

Plan content

Goals, activities and authorship of a plan version.

  1. Which goals and planned activities are in the current version of this care plan?
  2. Which clinician authored or approved this care plan version?

Plan review

Reviews, changes and agreement of the patient.

  1. When was this care plan last reviewed, and what changed from the previous version?
  2. Which orders or appointments carry out each planned activity of this plan?
  3. Has the patient agreed to this care plan, and where is that recorded?

Classifiers Filled

Family
Enterprise profiles
Category
Enterprise subject
Entry kind
subject
Domain
EnterpriseHCP
Industry
Healthcare provider
Tags
EM-HCP-04W-INDsubjectEpisodeOfCareCareTeamCarePlanCareGoalPlannedActivity

What it is Filled

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.

Why it exists Filled

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.

Distinguishing features Filled

  • 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.

What robots and AI may and may not do Filled

Must not

  • 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.

Only with a human decision

  • Care plans are authored and approved by responsible clinicians.
  • Transfer of episode responsibility requires the agreement of both providers.

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.

Moral aspects Filled

  • Plans should reflect the patient's own goals and agreement.
  • Shared care plans expose sensitive information to more parties.

Who is affected

  • Patients and carers
  • Care team members
  • Other providers

Owners Filled

Steward

The medical director who answers for coordinated care records.

Master systems

  • Electronic health record system
  • Care management system

Links to other meta-models Filled

neighbor

  • EM-HCP-03
  • EM-HCP-05
  • EM-HCP-06
  • EM-HCP-07
  • EM-HCP-02
  • EM-ORG-05

references

  • WM-ACT-049 - conceptual-candidate
  • WM-ACT-046 - conceptual-candidate

What else AI and robots need to interact with it Filled

Identity and identifiers required Filled

  • An episode of care has an identifier unique within the managing organization.
  • A care plan is identified by its identifier and version.

Direct properties not applicable Not applicable

Not applicable

Enterprise record contour: physical properties belong to referenced world models.

Recognition required Filled

  • 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 and actions required Filled

  • The contour supports care coordination, review scheduling and continuity across providers.

Hazards and failure modes required Filled

  • Outdated plans can lead to duplicated or missed care.
  • Unclear responsibility can leave tasks without an owner.

Standards and interfaces optional Filled

  • HL7 International publishes the FHIR EpisodeOfCare, CareTeam and CarePlan resources.

Context of use required Filled

  • The contour is used in chronic care, rehabilitation, home care and maternity care.
  • Integrated care programs may share plans across organizations.

Sources Filled

  1. HL7 FHIR: EpisodeOfCare, CareTeam and CarePlan resources
  2. openEHR: care plan and instruction archetypes
  3. Integrated care and case management practice
  4. HL7 FHIR R4 EpisodeOfCare resource - Checked live (HTTP 200) on 2026-10-21.
  5. HL7 FHIR R4 CarePlan resource - Checked live (HTTP 200) on 2026-10-21.

Open questions

  • 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.

Machine files

Card as JSON Source Card backlog vercy.card/1

Provenance

enterprise research programme · published-partial

Built from: enterprise/models/em-hcp-04/brief.json, ver-cy/world-models/card-supplements/em-hcp-04.json