Clinical Resources

Care Plan

Overview

The Care Plan section captures the recommended management strategies, therapeutic interventions, and follow-up plans for a patient. Documenting care plans provides clinicians with actionable guidance, ensures continuity of care, and supports care coordination across providers. Structured representation of care plans enables better monitoring, adherence tracking, and integration into clinical decision-support systems.

Clinical Data in Source Documents

Care plan information in clinical records is often highly unstructured and embedded within narrative notes. Examples include:

• Free-text recommendations or instructions from physicians, e.g., “If the ophthalmologist does not feel that this is related to her vision, evaluate further.”
• Descriptions of ongoing or planned treatments, therapies, or medications, which may be inconsistently formatted or scattered across multiple sections.
• Follow-up instructions, including timelines and specific provider appointments, e.g., “Going to her ophthalmologist tomorrow for her normal monthly treatment.”

Variability in phrasing, incomplete documentation, and the absence of standardized templates make automated extraction essential to capture actionable care plan information consistently.

JSON Output

The platform organizes care plan data into a standardized JSON format, focusing on actionable elements:

• Recommendation : Physician or clinician guidance for the patient.
• Treatment : Medications or procedures prescribed (if any).
• Therapy : Non-pharmacologic interventions or therapies (if any).
• Follow-up : Planned follow-up actions or appointments.

This structured representation allows care plan information to be integrated into EHRs, analytics systems, and clinical decision-support tools, facilitating patient management and continuity of care.

{
  "care_plan": {
    "recommendation": "Lifestyle counseling and vaccine review",
    "therapy": "Smoking cessation counseling if applicable",
    "follow_up": "Follow up in 6 months with PCP",
    "page_number": 1
  }
}

FHIR Output

Extracted care plan data is mapped to a FHIR CarePlan resource for interoperability. Key mappings include:

• Recommendation / Description → CarePlan.description – Captures the overall guidance or rationale.
• Treatment / Therapy → CarePlan.activity.detail.description – Represents planned interventions or tasks.
• Follow-up → CarePlan.supportingInfo.display – Documents follow-up instructions or upcoming appointments.
• Status → CarePlan.status – Typically set to “active” to indicate an ongoing plan.
• Intent → CarePlan.intent – Set to “plan” to signify intended actions.
• Patient Reference → CarePlan.subject – Links the care plan to the associated patient.
• Encounter Reference → CarePlan.encounter – Associates the plan with the relevant clinical encounter.

{
  "fullUrl": "urn:uuid:4b72820f-3721-4af3-89a4-5d7f1511cba4",
  "resource": {
    "resourceType": "CarePlan",
    "status": "active",
    "intent": "plan",
    "title": "Care Plan",
    "subject": {
      "reference": "Patient/b17aaab1-311c-4d98-9c93-030277d0aeb0"
    },
    "encounter": {
      "reference": "Encounter/d4ebe08e-6db9-429a-958a-ed5a1de4cffa"
    },
    "custodian": {
      "reference": "Practitioner/9a1de72f-33fd-47d9-a0b9-b34d26985db8"
    },
    "description": "Lifestyle counseling and vaccine review",
    "activity": [
      {
        "plannedActivityReference": {
          "display": "Smoking cessation counseling if applicable"
        }
      }
    ],
    "supportingInfo": [
      {
        "display": "Follow up in 6 months with PCP"
      }
    ],
    "id": "4b72820f-3721-4af3-89a4-5d7f1511cba4"
  }
}