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Care Plan - C-CDA Templates Implementation

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Back to: Patient Care

NOTE: This is an in-process project and frequent changes are expected


Concept Requests

There is active engagement with NLM (US SNOMED-CT authority) and LOINC for needed codes.

Concept Request Tracking

SNOMED-CT Requests

Request Management System

LOINC Requests

Value Sets

Type of Care Plan


  • Case Management
  • Disease Management
  • Care Plans
    • Management of Health Concern
    • Management of Specific Intervention


Case Management
Disease Management
Care Plan

Patient Engagement in Care Plan

OID: 2.16.840.1.113883.13.234.92

 305060004 |Patient care statuses (finding) |

This value set provides details on what role the patient plays in the specific Care Plan, and their ongoing activity in the plan.

Representative Concepts

  1. Unavailable or unable to reach
  2. Wants additional information
  3. Has been reached
  4. Patient not interested or unwilling to engage

Value Set definition status

Patient Enrollment in Management Plan


Value set to describe the patient (or plan member) enrollment in a specific care/case/management program.

Representative Concepts

  1. Eligible for enrollment
  2. Not eligible for enrollment
  3. Currently eligible
  4. Opt-out of enrollment
  5. No longer enrolled

Care Plan Review By Care Team and Patient

OID: 2.16.840.1.113883.13.234.94

Value set to capture results of a Care Plan review.

Representative Concepts

  1. Patient acknowledged receipt
  2. Clinician team acknowledgement of receipt
  3. Patient agrees to the goals
  4. Patient disagrees with one or more goals in the plan
  5. Patient agrees to the interventions
  6. Patient disagrees with one or more interventions in the plan
  7. Care plan not acceptable to patient
  8. Patient agrees to the care plan, as presented
  9. Clinician team member agrees to the care plan, as presented
  10. Patient agrees to the care plan, with patient requested revisions to goals or interventions


Every Care Plan requires one or more associated Health Concerns. The Health Concern has an associated Condition which provides the semantics of what the Health Concern is in regards to (i.e. it names the health concern). For Disease Management plans, this would be the specific diagnosis of interest.

Abnormal Clinical Finding

OID: 2.16.840.1.113883.13.234.87

Abnormal Screening or Diagnostic Study

Barrier to Care

OID: 2.16.840.1.113883.13.234.91

Risk of Disease

OID: 2.16.840.1.113883.13.234.90




Health Status Evaluation Type


Intervention Type

OID: 2.16.840.1.113883.13.234.88 For Care Plans which are focused on the management a specific procedure (e.g. perioperative clinical pathways), the focal procedure will be indicated.