Care Plan

A Care Plan is a consensus-driven dynamic plan that represents a patient's and Care Team Member's prioritized concerns, goals, and planned interventions. It serves as a blueprint shared by all Care Team Members (including the patient, their caregivers and providers), to guide the patient'ss care. A Care Plan integrates multiple interventions proposed by multiple providers and disciplines for multiple conditions.

A Care Plan represents one or more Plan(s) of Care and serves to reconcile and resolve conflicts between the various Plans of Care developed for a specific patient by different providers. While both a plan of care and a care plan include the patients life goals and require Care Team Members (including patients) to prioritize goals and interventions, the reconciliation process becomes more complex as the number of plans of care increases. The Care Plan also serves to enable longitudinal coordination of care.

The CDA Care Plan represents an instance of this dynamic Care Plan at a point in time. The CDA document itself is NOT dynamic.

Key differentiators between a Care Plan CDA and CCD (another snapshot in time document):

• There are 2 required sections:

Health Concerns Goals

• There are 2 optional sections:

Activities Outcomes

• Provides the ability to identify patient and provider priorities with each act
• Provides a header participant to indicate occurrences of Care Plan review

A care plan document can include entry references from the information in these sections to the information (entries) in other sections.

#### Document Sections Although document templates may contain any section, the following sections are specifically called out by this template:

Required Sections

• HealthConcernsSection
• GoalsSection

Recommended Sections

• OutcomesSection

Additional Sections

• ActivitiesSection
• AdvanceDirectivesSection