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Care Plan / Episode

vr.wm-act-049 · wm-act-049-care-plan-episode

Represent a governed care-context aggregate so agents can distinguish subject-specific planning from provider episode responsibility while connecting goals, participants, intended activities, progress and transitions without treating intent as performance or outcome.

World Models Activities and processes ACT.HCR
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

6 bundles · 12 layers · 24 findings · 72 questions

Aggregate identity, boundary and constituent types Groups governed care context for aggregate identity, boundary and constituent types.

Aggregate profile, identifiers, versions, sources and lineage

Groups source-qualified care context for aggregate profile, identifiers, versions, sources and lineage.

Care context aggregate profile and plan or episode constituent kinds

Records care context aggregate profile and plan or episode constituent kinds as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.

  1. Which stable identities, record class, source-qualified assertions and explicit unknowns establish care context aggregate profile and plan or episode constituent kinds? classification
  2. Who proposed, authored, accepted, owns, performs, reviews or is affected by care context aggregate profile and plan or episode constituent kinds, with which role, authority, preference and limits? composition
  3. Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to care context aggregate profile and plan or episode constituent kinds, and how is it validated or corrected? privacy

Aggregate, plan and episode identifiers, versions, sources and lineage

Records aggregate, plan and episode identifiers, versions, sources and lineage as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.

  1. Which stable identities, record class, source-qualified assertions and explicit unknowns establish aggregate, plan and episode identifiers, versions, sources and lineage? identity
  2. Who proposed, authored, accepted, owns, performs, reviews or is affected by aggregate, plan and episode identifiers, versions, sources and lineage, with which role, authority, preference and limits? evidence
  3. Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to aggregate, plan and episode identifiers, versions, sources and lineage, and how is it validated or corrected? lifecycle

Subject, scope, care setting and plan, episode or encounter boundary

Groups source-qualified care context for subject, scope, care setting and plan, episode or encounter boundary.

Subject, population, care setting, category, title, description and period

Records subject, population, care setting, category, title, description and period as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.

  1. Which stable identities, record class, source-qualified assertions and explicit unknowns establish subject, population, care setting, category, title, description and period? definition
  2. Who proposed, authored, accepted, owns, performs, reviews or is affected by subject, population, care setting, category, title, description and period, with which role, authority, preference and limits? ownership
  3. Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to subject, population, care setting, category, title, description and period, and how is it validated or corrected? quality

Planning, responsibility, encounter, work item and performed-event distinction

Records planning, responsibility, encounter, work item and performed-event distinction as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.

  1. Which stable identities, record class, source-qualified assertions and explicit unknowns establish planning, responsibility, encounter, work item and performed-event distinction? relationship
  2. Who proposed, authored, accepted, owns, performs, reviews or is affected by planning, responsibility, encounter, work item and performed-event distinction, with which role, authority, preference and limits? measurement
  3. Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to planning, responsibility, encounter, work item and performed-event distinction, and how is it validated or corrected? security
Concerns, assessment, goals, targets, preferences and decisions Groups governed care context for concerns, assessment, goals, targets, preferences and decisions.

Conditions, concerns, reasons, assessment and supporting evidence

Groups source-qualified care context for conditions, concerns, reasons, assessment and supporting evidence.

Condition, problem, concern, reason and health-need references

Records condition, problem, concern, reason and health-need references as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.

  1. Which stable identities, record class, source-qualified assertions and explicit unknowns establish condition, problem, concern, reason and health-need references? relationship
  2. Who proposed, authored, accepted, owns, performs, reviews or is affected by condition, problem, concern, reason and health-need references, with which role, authority, preference and limits? exception
  3. Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to condition, problem, concern, reason and health-need references, and how is it validated or corrected? retention

Clinical impression, baseline, risk, priority and supporting information

Records clinical impression, baseline, risk, priority and supporting information as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.

  1. Which stable identities, record class, source-qualified assertions and explicit unknowns establish clinical impression, baseline, risk, priority and supporting information? evidence
  2. Who proposed, authored, accepted, owns, performs, reviews or is affected by clinical impression, baseline, risk, priority and supporting information, with which role, authority, preference and limits? provenance
  3. Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to clinical impression, baseline, risk, priority and supporting information, and how is it validated or corrected? interoperability

Goals, targets, outcomes, preferences and shared decisions

Groups source-qualified care context for goals, targets, outcomes, preferences and shared decisions.

Goal identity, description, priority, lifecycle, achievement, source and addresses

Records goal identity, description, priority, lifecycle, achievement, source and addresses as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.

  1. Which stable identities, record class, source-qualified assertions and explicit unknowns establish goal identity, description, priority, lifecycle, achievement, source and addresses? lifecycle
  2. Who proposed, authored, accepted, owns, performs, reviews or is affected by goal identity, description, priority, lifecycle, achievement, source and addresses, with which role, authority, preference and limits? process
  3. Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to goal identity, description, priority, lifecycle, achievement, source and addresses, and how is it validated or corrected? decision

Target measure, value, timeframe, outcome, preference and decision rationale

Records target measure, value, timeframe, outcome, preference and decision rationale as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.

  1. Which stable identities, record class, source-qualified assertions and explicit unknowns establish target measure, value, timeframe, outcome, preference and decision rationale? measurement
  2. Who proposed, authored, accepted, owns, performs, reviews or is affected by target measure, value, timeframe, outcome, preference and decision rationale, with which role, authority, preference and limits? validation
  3. Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to target measure, value, timeframe, outcome, preference and decision rationale, and how is it validated or corrected? state
Participants, responsibility, authority and person-centred governance Groups governed care context for participants, responsibility, authority and person-centred governance.

Care-team participants, roles, periods and responsibilities

Groups source-qualified care context for care-team participants, roles, periods and responsibilities.

Care-team member, role, on-behalf-of, contact, availability and period

Records care-team member, role, on-behalf-of, contact, availability and period as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.

  1. Which stable identities, record class, source-qualified assertions and explicit unknowns establish care-team member, role, on-behalf-of, contact, availability and period? ownership
  2. Who proposed, authored, accepted, owns, performs, reviews or is affected by care-team member, role, on-behalf-of, contact, availability and period, with which role, authority, preference and limits? privacy
  3. Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to care-team member, role, on-behalf-of, contact, availability and period, and how is it validated or corrected? identity

Care manager, managing organization, custodian, author, contributor and reviewer

Records care manager, managing organization, custodian, author, contributor and reviewer as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.

  1. Which stable identities, record class, source-qualified assertions and explicit unknowns establish care manager, managing organization, custodian, author, contributor and reviewer? authority
  2. Who proposed, authored, accepted, owns, performs, reviews or is affected by care manager, managing organization, custodian, author, contributor and reviewer, with which role, authority, preference and limits? lifecycle
  3. Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to care manager, managing organization, custodian, author, contributor and reviewer, and how is it validated or corrected? classification

Subject participation, consent, preferences, access and exceptions

Groups source-qualified care context for subject participation, consent, preferences, access and exceptions.

Subject, representative, participation, shared decision and disagreement

Records subject, representative, participation, shared decision and disagreement as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.

  1. Which stable identities, record class, source-qualified assertions and explicit unknowns establish subject, representative, participation, shared decision and disagreement? decision
  2. Who proposed, authored, accepted, owns, performs, reviews or is affected by subject, representative, participation, shared decision and disagreement, with which role, authority, preference and limits? quality
  3. Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to subject, representative, participation, shared decision and disagreement, and how is it validated or corrected? relationship

Consent, purpose, access scope, redaction, emergency and legal exception

Records consent, purpose, access scope, redaction, emergency and legal exception as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.

  1. Which stable identities, record class, source-qualified assertions and explicit unknowns establish consent, purpose, access scope, redaction, emergency and legal exception? privacy
  2. Who proposed, authored, accepted, owns, performs, reviews or is affected by consent, purpose, access scope, redaction, emergency and legal exception, with which role, authority, preference and limits? security
  3. Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to consent, purpose, access scope, redaction, emergency and legal exception, and how is it validated or corrected? authority
Planned activities, protocols, timing and coordination Groups governed care context for planned activities, protocols, timing and coordination.

Activity intent, request links, definitions and deviations

Groups source-qualified care context for activity intent, request links, definitions and deviations.

Planned activity, request reference, intent, status, owner and focus

Records planned activity, request reference, intent, status, owner and focus as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.

  1. Which stable identities, record class, source-qualified assertions and explicit unknowns establish planned activity, request reference, intent, status, owner and focus? requirement
  2. Who proposed, authored, accepted, owns, performs, reviews or is affected by planned activity, request reference, intent, status, owner and focus, with which role, authority, preference and limits? retention
  3. Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to planned activity, request reference, intent, status, owner and focus, and how is it validated or corrected? requirement

Protocol, order set, plan-definition instantiation, version and deviation

Records protocol, order set, plan-definition instantiation, version and deviation as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.

  1. Which stable identities, record class, source-qualified assertions and explicit unknowns establish protocol, order set, plan-definition instantiation, version and deviation? provenance
  2. Who proposed, authored, accepted, owns, performs, reviews or is affected by protocol, order set, plan-definition instantiation, version and deviation, with which role, authority, preference and limits? interoperability
  3. Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to protocol, order set, plan-definition instantiation, version and deviation, and how is it validated or corrected? constraint

Timing, recurrence, dependencies, conditions, options and coordination

Groups source-qualified care context for timing, recurrence, dependencies, conditions, options and coordination.

Planned window, schedule, recurrence, duration, deadline and flexibility

Records planned window, schedule, recurrence, duration, deadline and flexibility as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.

  1. Which stable identities, record class, source-qualified assertions and explicit unknowns establish planned window, schedule, recurrence, duration, deadline and flexibility? temporal
  2. Who proposed, authored, accepted, owns, performs, reviews or is affected by planned window, schedule, recurrence, duration, deadline and flexibility, with which role, authority, preference and limits? decision
  3. Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to planned window, schedule, recurrence, duration, deadline and flexibility, and how is it validated or corrected? event

Related action, sequence, prerequisite, condition, selection, alternative and stop rule

Records related action, sequence, prerequisite, condition, selection, alternative and stop rule as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.

  1. Which stable identities, record class, source-qualified assertions and explicit unknowns establish related action, sequence, prerequisite, condition, selection, alternative and stop rule? constraint
  2. Who proposed, authored, accepted, owns, performs, reviews or is affected by related action, sequence, prerequisite, condition, selection, alternative and stop rule, with which role, authority, preference and limits? state
  3. Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to related action, sequence, prerequisite, condition, selection, alternative and stop rule, and how is it validated or corrected? temporal
Realization, progress, evaluation, transitions and closure Groups governed care context for realization, progress, evaluation, transitions and closure.

Encounters, tasks, performed events, progress and goal evaluation

Groups source-qualified care context for encounters, tasks, performed events, progress and goal evaluation.

Encounter, task, request and performed-activity reference with independent state

Records encounter, task, request and performed-activity reference with independent state as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.

  1. Which stable identities, record class, source-qualified assertions and explicit unknowns establish encounter, task, request and performed-activity reference with independent state? event
  2. Who proposed, authored, accepted, owns, performs, reviews or is affected by encounter, task, request and performed-activity reference with independent state, with which role, authority, preference and limits? identity
  3. Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to encounter, task, request and performed-activity reference with independent state, and how is it validated or corrected? composition

Progress note, observation, goal evaluation, outcome, variance and uncertainty

Records progress note, observation, goal evaluation, outcome, variance and uncertainty as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.

  1. Which stable identities, record class, source-qualified assertions and explicit unknowns establish progress note, observation, goal evaluation, outcome, variance and uncertainty? validation
  2. Who proposed, authored, accepted, owns, performs, reviews or is affected by progress note, observation, goal evaluation, outcome, variance and uncertainty, with which role, authority, preference and limits? classification
  3. Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to progress note, observation, goal evaluation, outcome, variance and uncertainty, and how is it validated or corrected? evidence

Referral, handoff, transfer, responsibility transition and closure

Groups source-qualified care context for referral, handoff, transfer, responsibility transition and closure.

Referral, handoff, transfer, sender, receiver, acknowledgement and pending work

Records referral, handoff, transfer, sender, receiver, acknowledgement and pending work as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.

  1. Which stable identities, record class, source-qualified assertions and explicit unknowns establish referral, handoff, transfer, sender, receiver, acknowledgement and pending work? process
  2. Who proposed, authored, accepted, owns, performs, reviews or is affected by referral, handoff, transfer, sender, receiver, acknowledgement and pending work, with which role, authority, preference and limits? relationship
  3. Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to referral, handoff, transfer, sender, receiver, acknowledgement and pending work, and how is it validated or corrected? ownership

Episode status history, responsibility period, closure, outcome and unresolved items

Records episode status history, responsibility period, closure, outcome and unresolved items as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.

  1. Which stable identities, record class, source-qualified assertions and explicit unknowns establish episode status history, responsibility period, closure, outcome and unresolved items? lifecycle
  2. Who proposed, authored, accepted, owns, performs, reviews or is affected by episode status history, responsibility period, closure, outcome and unresolved items, with which role, authority, preference and limits? authority
  3. Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to episode status history, responsibility period, closure, outcome and unresolved items, and how is it validated or corrected? measurement
Independent lifecycles, correction, provenance, retention and projection Groups governed care context for independent lifecycles, correction, provenance, retention and projection.

Plan and episode status, version, change, cancellation and correction

Groups source-qualified care context for plan and episode status, version, change, cancellation and correction.

Independent plan, episode, goal, request, task and activity status axes

Records independent plan, episode, goal, request, task and activity status axes as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.

  1. Which stable identities, record class, source-qualified assertions and explicit unknowns establish independent plan, episode, goal, request, task and activity status axes? state
  2. Who proposed, authored, accepted, owns, performs, reviews or is affected by independent plan, episode, goal, request, task and activity status axes, with which role, authority, preference and limits? requirement
  3. Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to independent plan, episode, goal, request, task and activity status axes, and how is it validated or corrected? exception

Amend, replace, hold, revoke, cancel, entered-in-error, supersede and non-cascade

Records amend, replace, hold, revoke, cancel, entered-in-error, supersede and non-cascade as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.

  1. Which stable identities, record class, source-qualified assertions and explicit unknowns establish amend, replace, hold, revoke, cancel, entered-in-error, supersede and non-cascade? exception
  2. Who proposed, authored, accepted, owns, performs, reviews or is affected by amend, replace, hold, revoke, cancel, entered-in-error, supersede and non-cascade, with which role, authority, preference and limits? constraint
  3. Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to amend, replace, hold, revoke, cancel, entered-in-error, supersede and non-cascade, and how is it validated or corrected? provenance

Source quality, privacy, retention, interoperability and agent controls

Groups source-qualified care context for source quality, privacy, retention, interoperability and agent controls.

Source confidence, provenance, disclosure, audit, legal hold, retention and disposition

Records source confidence, provenance, disclosure, audit, legal hold, retention and disposition as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.

  1. Which stable identities, record class, source-qualified assertions and explicit unknowns establish source confidence, provenance, disclosure, audit, legal hold, retention and disposition? retention
  2. Who proposed, authored, accepted, owns, performs, reviews or is affected by source confidence, provenance, disclosure, audit, legal hold, retention and disposition, with which role, authority, preference and limits? event
  3. Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to source confidence, provenance, disclosure, audit, legal hold, retention and disposition, and how is it validated or corrected? process

FHIR, IHE, openEHR, WHO and NICE projection, version, maturity, loss and round trip

Records fhir, ihe, openehr, who and nice projection, version, maturity, loss and round trip as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.

  1. Which stable identities, record class, source-qualified assertions and explicit unknowns establish fhir, ihe, openehr, who and nice projection, version, maturity, loss and round trip? interoperability
  2. Who proposed, authored, accepted, owns, performs, reviews or is affected by fhir, ihe, openehr, who and nice projection, version, maturity, loss and round trip, with which role, authority, preference and limits? temporal
  3. Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to fhir, ihe, openehr, who and nice projection, version, maturity, loss and round trip, and how is it validated or corrected? validation

Classifiers Filled

Family
World Models
Category
Activities and processes
Entry kind
aggregate
Navigation path
NAV.ACT.HCR
Domain
ACT.HCR
Industry
Cross-industry
Tags
careplanepisodeact.hcr

What it is Filled

Owns aggregate identity and links between a care-plan record and an episode-of-care record, plus subject-specific goals, participant-role assertions, coordination context, progress summaries, transition assertions and correction lineage. Each constituent keeps independent identity, source, status, authority and times. Patient, practitioner, organization, condition, observation, encounter, consent, reusable protocol, request, task, appointment, procedure, medication, communication, adverse-event, provenance, audit and record masters remain external.

In scope

  • Aggregate, care-plan and episode identity; subject and setting; concerns, goals, targets and preferences; care-team and responsibility bindings; intended activity references and dependencies
  • Independent statuses and times; progress and performed-event links; referral, handoff, transfer and closure context; correction, privacy, retention and loss-aware projections

Out of scope

  • Independent patient, practitioner, organization, condition, observation, encounter, consent, protocol, request, task, appointment, procedure, medication, communication, adverse-event, provenance, audit and record lifecycles
  • Treating a plan as performed care, an episode as an encounter, a goal as an observation, a status as clinical outcome or an association as causation
  • Providing diagnosis, care authorization, treatment change, clinical assignment, workflow execution, outcome inference or medical advice

Why it exists Filled

Represent a governed care-context aggregate so agents can distinguish subject-specific planning from provider episode responsibility while connecting goals, participants, intended activities, progress and transitions without treating intent as performance or outcome.

Distinguishing features Filled

  • Joins a subject-specific care plan with the provider's episode of care, two records that other systems often keep apart.
  • Holds intended activities and goals, not the performed events, which belong to encounters, procedures and observations.
  • Differs from a plan definition or clinical protocol, which is a reusable template not bound to one person.
  • Differs from Medication Order / Administration, which tracks drug supply and doses inside the plan.

What robots and AI may and may not do Filled

Must not

  • Diagnose, authorize care or change treatment.
  • Assign clinical responsibility to a practitioner or organization.
  • Mark a goal as achieved or a plan as completed without source evidence.
  • Treat a planned activity as performed.
  • Disclose the plan to parties outside the care team and permitted purpose.

Only with a human decision

  • Approving a care plan or a change to its goals.
  • Accepting a transfer or closing an episode of care.
  • Resolving conflicting plans from different providers.

May

  • Draft a care plan revision from goals and activities agreed by the care team, marked as a proposal.
  • Track progress by linking performed events and observations to planned activities.
  • Remind responsible team members of overdue planned activities or goal reviews.
  • Prepare a handoff summary for a transfer of care.

Moral aspects Filled

  • Care plans should reflect the patient's own goals and preferences, not only provider targets.
  • Gaps in handoff are a known source of harm, so responsibility must stay explicit at every transition.
  • Plans often hold social and family details that are sensitive beyond the clinical data.

Who is affected

  • Patients and their families or carers
  • Care team members
  • Provider organizations accountable for the episode

Owners Filled

Steward

Dimension owner and care-governance mandate

Roles

Care context aggregate steward
Own aggregate boundary, namespace, composition and quality rules.
Plan author or custodian
Own care-plan intent, concerns, goals, participants, activity references and revision basis within authority.
Episode manager or managing organization
Own provider-responsibility periods, episode status and transfer evidence.
Subject or authorized representative
Contribute goals, preferences, decisions, disagreement and consent within applicable capacity and policy.
Care-team participant
Own attributable role, availability, acknowledgement and progress contributions within scope.
Clinical reviewer
Review concerns, goals, targets, progress, variance and closure evidence without inventing outcomes.
Interoperability steward
Own versioned FHIR, IHE and other projections with maturity and loss declarations.
Privacy, records and assurance steward
Own protected views, disclosures, holds, retention and auditability.

Links to other meta-models Filled

references

  • WM-LIV-021 Disease / Condition - Record the candidate condition relation as clinical goal context without approving the edge or copying condition lifecycle.
  • WM-ACT-047 Medical Procedure - Record intended or performed procedure references while the candidate containment edge and all cascade semantics remain deferred.
  • WM-ACT-048 Medication Order / Administration - Record medication request and administration references while the candidate containment edge and all medication lifecycles remain deferred.
  • Patient, Practitioner, Organization, Condition, Observation, Encounter, Consent, CareTeam, Goal, Request, Task, Appointment, Communication, AdverseEvent, Provenance, Audit and Record models - Resolve authoritative subjects, actors, clinical assertions, work, evidence, communication and governance without copying their lifecycles.

aligned

  • FHIR R5, IHE Dynamic Care Planning, openEHR Task Planning, WHO continuity guidance and NICE NG197 - Project version-pinned clinical, continuity, shared-decision and workflow views with maturity, retirement, jurisdiction and information-loss declarations.

neighbor

  • FHIR CarePlan and EpisodeOfCare - CarePlan is a planning request and EpisodeOfCare tracks provider association and responsibility. Each retains its own identity, status and period inside the aggregate.
  • Encounter, Task, Request and performed clinical events - Encounters record activities, Tasks track work, Requests authorize intent and performed-event records evidence occurrence. The aggregate stores typed references and coordination context only.
  • Goal, Condition, ClinicalImpression and Observation - Goals own desired states, conditions own concerns, clinical impressions own assessment reasoning and observations own measurements. The aggregate links them without copying clinical assertion lifecycles.
  • CareTeam, patient, practitioner and organization masters - CareTeam owns dynamic participant membership and roles; party masters own identity. The aggregate records plan and episode role bindings, responsibility and effective periods.
  • PlanDefinition, RequestOrchestration and openEHR Task Planning - Reusable protocols and detailed executable orchestration stay external. The aggregate records versioned instantiation, coordination constraints and deviations; the openEHR source is retired and is not a conformance target.
  • WM-LIV-021, WM-ACT-047 and WM-ACT-048 - Condition, procedure and medication references may supply care context, but all three registry relations remain candidate, transfer no lifecycle ownership and permit no cascade mutation.

parent

  • WM-ACT-014

contains

  • WM-ACT-047
  • WM-ACT-048

What else AI and robots need to interact with it Filled

Identity and identifiers required Filled

  • Authoritative master-system identifier for each care plan, episode, goal, participant assertion or transition, qualified by source organization and record kind.
  • Governed globally resolvable care-context record IRI.
  • Dimension UUID when neither preceding identifier exists.

Direct properties not applicable Not applicable

Not applicable

Institutional or informational subject: no invented physical properties.

Recognition optional Filled

  • A care plan names a subject, goals, intended activities and a care team; an episode names a provider organization and a period of responsibility.
  • Often confused with an encounter (a single contact), a referral, a clinical protocol or a care pathway template.

Capabilities and actions required Filled

  • Register care context aggregate: Governed operation to register care context aggregate without hidden mutation or execution of external clinical masters.
  • Create or revise care plan: Governed operation to create or revise care plan without hidden mutation or execution of external clinical masters.
  • Open or track episode: Governed operation to open or track episode without hidden mutation or execution of external clinical masters.
  • Establish or evaluate goal: Governed operation to establish or evaluate goal without hidden mutation or execution of external clinical masters.
  • Bind care team and responsibilities: Governed operation to bind care team and responsibilities without hidden mutation or execution of external clinical masters.
  • Coordinate planned requests: Governed operation to coordinate planned requests without hidden mutation or execution of external clinical masters.
  • Record progress and link performance: Governed operation to record progress and link performance without hidden mutation or execution of external clinical masters.
  • Handoff, transfer or close care context: Governed operation to handoff, transfer or close care context without hidden mutation or execution of external clinical masters.
  • Correct, hold, cancel or supersede: Governed operation to correct, hold, cancel or supersede without hidden mutation or execution of external clinical masters.
  • Project, retain, disclose and audit: Governed operation to project, retain, disclose and audit without hidden mutation or execution of external clinical masters.

Hazards and failure modes required Filled

  • Lost responsibility when an episode closes or transfers without a receiving owner.
  • Duplicate or conflicting plans from different providers for the same patient.
  • Planned activities reported as done, hiding missed care.

Standards and interfaces required Filled

  • HL7 FHIR R5 CarePlan, EpisodeOfCare, Goal and CareTeam resources.
  • HL7 FHIR PlanDefinition and RequestOrchestration for protocol-based plans.
  • openEHR archetypes and Task Planning specification.
  • SNOMED CT and LOINC for coding goals, problems and observations.

Context of use required Filled

  • Care authority, capacity, guardianship, consent, scope of practice, assignment, transfer, reporting, retention and disclosure depend on jurisdiction and setting.
  • NICE NG197 is an England and Wales guideline and IHE DCP is an interoperability profile, not universal clinical or legal policy.
  • Local care pathways, terminologies, role codes, responsibility rules, availability and escalation practices require versioned organization profiles.

Sources Filled

  1. FHIR R5 CarePlan - Health Level Seven International
  2. FHIR R5 EpisodeOfCare - Health Level Seven International
  3. FHIR R5 Goal - Health Level Seven International
  4. FHIR R5 CareTeam - Health Level Seven International
  5. FHIR R5 RequestOrchestration - Health Level Seven International
  6. FHIR R5 PlanDefinition - Health Level Seven International
  7. FHIR R5 Task - Health Level Seven International
  8. FHIR R5 Workflow - Health Level Seven International
  9. FHIR R5 ClinicalImpression - Health Level Seven International
  10. FHIR R5 Condition - Health Level Seven International
  11. FHIR R5 Observation - Health Level Seven International
  12. Continuity and coordination of care - World Health Organization
  13. UHC service planning and models of care - World Health Organization
  14. Shared decision making - National Institute for Health and Care Excellence
  15. Dynamic Care Planning - Integrating the Healthcare Enterprise
  16. Task Planning Specification - openEHR Foundation
  17. Regulation (EU) 2016/679 General Data Protection Regulation - European Union
  18. PROV-O: The PROV Ontology - World Wide Web Consortium
  19. Date and Time on the Internet: Timestamps - Internet Engineering Task Force

Open questions

  • Approve or reject the three candidate relation-ledger edges and define cardinality, membership, ownership and non-cascade semantics.
  • Create specialty profiles for oncology, mental health, maternity, pediatric, geriatric, rehabilitation, palliative, public-health, social-care, veterinary and research care contexts.
  • Create jurisdiction and institution profiles for capacity, consent, care authority, roles, assignment, transfer, escalation, correction, retention and access.
  • Test release-pinned FHIR, IHE DCP and any successor workflow mappings with round-trip, maturity and information-loss evidence.
  • Obtain supplemental independent external review and resolve any material challenge before canonical promotion.
  • Claude and Grok each timed out on one bounded attempt; no independent external result was admitted.
  • WM-ACT-049 REFERENCE WM-LIV-021 and CONTAINS WM-ACT-047 and WM-ACT-048 are candidate metadata and not approved composition edges.
  • Oncology, mental health, maternity, pediatric, geriatric, rehabilitation, palliative, public-health, social-care, veterinary and research planning require specialty profiles.
  • FHIR R5 planning resources are Trial Use at varied maturity; IHE DCP is an implementation profile and openEHR Task Planning Release-1.7.0 is retired, so mappings require release-pinned testing.

Machine files

Card as JSON Specification AGENTS.md Source Card backlog vercy.card/1

Provenance

world-models research · reviewable-draft

Built from: models/wm-act-049-care-plan-episode/spec.yaml, ver-cy/world-models/card-supplements/wm-act-049-care-plan-episode.json