Care Plans, Goals, and Progress

A work queue tells the team what to do next. A CarePlan helps explain how those activities fit into the patient's care: what they are working toward, which services are planned, and how they will assess progress. Add one when people need to review goals and activities together. Independent work can stay in a Task queue.

Start with What the Patient Is Working Toward

Field	Use
subject	Patient receiving the planned care
status and intent	Whether the plan is draft, active, or ended, and whether it is a proposal, plan, or order
addresses	Conditions the plan addresses
goal	References to independently tracked Goals
careTeam	Teams expected to participate
activity.reference	Requests, Tasks, or a RequestGroup describing intended activities
supportingInfo	Context used in forming the plan, including an EpisodeOfCare under the convention in the longitudinal guide

CarePlan.encounter records the encounter associated with plan creation. It is not a substitute for the longitudinal association in case tracking.

Give an activity its own resource when it needs one

Choose either activity.reference or activity.detail for an activity; R4 does not allow both on the same activity. Prefer a referenced resource when the activity needs independent assignment, search, or lifecycle. Use inline detail for a simple planned activity that does not yet need its own resource.

Give Planned Activities a Place in the Queue

For a manually authored plan, reference an operational Task from CarePlan.activity.reference. Use Task.basedOn for the plan that authorizes the work and Task.focus for the specific request or resource being acted on. Keep Task.for populated for patient work.

A clinical order should have its own request resource. A CarePlan may reference a ServiceRequest, while several Tasks act on that request for scheduling, preparation, or review. Avoid listing both an order and every fulfillment Task as independent clinical activities if this would count the same intended service multiple times.

Plans generated by Medplum's $apply use a RequestGroup between CarePlan and Tasks. Understand the generated graph rather than assuming it matches the manually authored pattern. See Automating Care Workflows.

Make Progress Something You Can Assess

A goal should let the team answer whether the patient is making progress. Each Goal has its own subject, description, and lifecycleStatus. Use target to define the measure, desired value, and due date or duration. A numeric target uses detailQuantity with a meaningful unit; a qualitative target can use another permitted detail type.

The clinical team chooses the target and validated terminology. Do not infer a clinical goal from a workflow deadline or reuse an illustrative threshold as clinical guidance.

achievementStatus describes progress toward the goal. It is distinct from lifecycleStatus: a goal can be ended without being achieved. Link supporting Observations through outcomeReference. That field accepts Observations in R4; it does not accept arbitrary documents or QuestionnaireResponses.

When an assessment supports a goal, retain the QuestionnaireResponse and use the chosen extraction approach to produce the appropriate Observation. Choose one extraction strategy per form to avoid duplicate downstream records. Clinical evidence and its interpretation remain distinct.

Update the Plan and Check the Open Work

Use resource version history for routine edits to an existing plan. When a new plan replaces a prior completed or terminated plan, link the new plan's replaces to the old one and set the old lifecycle explicitly. Use partOf for a real broader plan; it does not mean revision or replacement.

A plan change can leave old work in the queue

Suppose a clinician changes the follow-up schedule. The old outreach Task may still be sitting in a coordinator's queue. Review open Tasks when changing the plan. Decide which remain valid, which should be cancelled with a reason, and which require replacement. Neither editing a CarePlan nor updating a PlanDefinition migrates existing work automatically.

Close Each Record When Its Work Is Done

Close an activity when its work and evidence meet the completion criteria. Update each Goal according to its clinical assessment, and close the CarePlan when its scope has ended. Close an EpisodeOfCare only when the period of responsibility ends. A completed Task does not automatically achieve a Goal or finish a case.

See the R4 CarePlan definitions for activity constraints and Operational Reporting for measuring work and outcomes separately.