Careplan-example-integrated.json

Simple integrated care plan with multiple goals & conditions (from Mayo)

{
  "resourceType": "CarePlan",
  "id": "integrate",
  "text": {
    "status": "generated",
    "div": "<div>!-- Snipped for Brevity --></div>"
  },
  "contained": [
    {
      "resourceType": "Condition",
      "id": "p1",
      "patient": {
        "reference": "Patient/1",
        "display": "Eve Everywoman"
      },
      "code": {
        "text": "GERDS"
      },
      "clinicalStatus": "confirmed"
    },
    {
      "resourceType": "Condition",
      "id": "p2",
      "patient": {
        "reference": "Patient/1",
        "display": "Eve Everywoman"
      },
      "code": {
        "text": "Obesity"
      },
      "clinicalStatus": "confirmed"
    },
    {
      "resourceType": "Condition",
      "id": "p3",
      "patient": {
        "reference": "Patient/1",
        "display": "Eve Everywoman"
      },
      "code": {
        "text": "Psoriasis"
      },
      "clinicalStatus": "confirmed"
    },
    {
      "resourceType": "Goal",
      "id": "g1",
      "patient": {
        "reference": "Patient/1",
        "display": "Eve Everywoman"
      },
      "description": "Eve will lose weight and reduce her GERDS symptoms by improving her diet",
      "status": "in-progress"
    },
    {
      "resourceType": "Goal",
      "id": "g2",
      "patient": {
        "reference": "Patient/1",
        "display": "Eve Everywoman"
      },
      "description": "Eve will improve her GERDS symptoms",
      "status": "in-progress"
    },
    {
      "resourceType": "Goal",
      "id": "g3",
      "patient": {
        "reference": "Patient/1",
        "display": "Eve Everywoman"
      },
      "description": "Eve will increase her energy by being more active",
      "status": "in-progress"
    },
    {
      "resourceType": "Goal",
      "id": "g4",
      "patient": {
        "reference": "Patient/1",
        "display": "Eve Everywoman"
      },
      "description": "Eve will set up her medications and take as prescribed",
      "status": "in-progress"
    },
    {
      "resourceType": "Goal",
      "id": "g5",
      "patient": {
        "reference": "Patient/1",
        "display": "Eve Everywoman"
      },
      "description": "Eve will restart her light treatments",
      "status": "in-progress"
    }
  ],
  "patient": {
    "reference": "Patient/1",
    "display": "Eve Everywoman"
  },
  "status": "active",
  "modified": "2012-09-10",
  "concern": [
    {
      "reference": "#p1",
      "display": "GERDS"
    },
    {
      "reference": "#p2",
      "display": "Obesity"
    },
    {
      "reference": "#p3",
      "display": "Psoriasis"
    }
  ],
  "goal": [
    {
      "reference": "#g1"
    },
    {
      "reference": "#g2"
    },
    {
      "reference": "#g3"
    },
    {
      "reference": "#g4"
    },
    {
      "reference": "#g5"
    }
  ],
  "activity": [
    {
      "notes": "9/10/12 Eve eats one meal a day with her parents",
      "detail": {
        "extension": [
          {
            "url": "http://example.org/DoNotUse/StructureDefinition/RevisionDate",
            "valueDate": "2012-09-10"
          }
        ],
        "category": "other",
        "goal": [
          {
            "reference": "#g1"
          }
        ],
        "status": "not-started",
        "prohibited": false,
        "scheduledPeriod": {
          "start": "2012-09-10"
        },
        "note": "Eve will review photos of high and low density foods and share with her parents"
      }
    },
    {
      "notes": "9/10/12 Eve will sleep in her bed more often than the couch",
      "detail": {
        "extension": [
          {
            "url": "http://example.org/DoNotUse/General/RevisionDate",
            "valueDate": "2012-09-10"
          }
        ],
        "category": "other",
        "goal": [
          {
            "reference": "#g1"
          }
        ],
        "status": "not-started",
        "prohibited": false,
        "scheduledPeriod": {
          "start": "2012-09-10"
        },
        "note": "Eve will ask her dad to asist her to put the head of her bed on blocks"
      }
    },
    {
      "detail": {
        "extension": [
          {
            "url": "http://example.org/DoNotUse/General/RevisionDate",
            "valueDate": "2012-09-10"
          }
        ],
        "category": "other",
        "goal": [
          {
            "reference": "#g2"
          }
        ],
        "status": "in-progress",
        "prohibited": false,
        "scheduledPeriod": {
          "start": "2012-09-10"
        },
        "note": "Eve will reduce her intake of coffee and chocolate"
      }
    },
    {
      "notes": "8/27/12 Eve would like to try for 5 days a week.  9/10/12 Eve is still walking the dogs.",
      "detail": {
        "extension": [
          {
            "url": "http://example.org/DoNotUse/General/RevisionDate",
            "valueDate": "2012-09-10"
          }
        ],
        "category": "other",
        "goal": [
          {
            "reference": "#g3"
          }
        ],
        "status": "in-progress",
        "prohibited": false,
        "scheduledPeriod": {
          "start": "2012-08-27"
        },
        "note": "Eve will walk her friend's dog up and down a big hill 15-30 minutes 3 days a week"
      }
    },
    {
      "notes": "8/13/12 Eve walked 4 times the last week.  9/10/12 Eve did not walk to her parents the last week, but has plans to start again",
      "detail": {
        "extension": [
          {
            "url": "http://example.org/DoNotUse/General/RevisionDate",
            "valueDate": "2012-09-10"
          }
        ],
        "category": "other",
        "goal": [
          {
            "reference": "#g3"
          }
        ],
        "status": "in-progress",
        "prohibited": false,
        "scheduledPeriod": {
          "start": "2012-07-23"
        },
        "note": "Eve will walk 3 blocks to her parents house twice a week"
      }
    },
    {
      "detail": {
        "extension": [
          {
            "url": "http://example.org/DoNotUse/General/RevisionDate",
            "valueDate": "2012-08-13"
          }
        ],
        "category": "other",
        "goal": [
          {
            "reference": "#g4"
          }
        ],
        "status": "in-progress",
        "prohibited": false,
        "scheduledPeriod": {
          "start": "2012-07-23"
        },
        "note": "Eve will us a calendar to check off after medications are taken"
      }
    },
    {
      "notes": "8/13/12 After restarting the vinegar soaks the psoriasis is improved and Eve plans to treat the remainder with light treatments.  She plans to start this week.  8/27/12 Since her skin is improved Eve has not been using the light treatment as often, maybe once a week.  She would like to increase to 3 times a week again",
      "detail": {
        "extension": [
          {
            "url": "http://example.org/DoNotUse/General/RevisionDate",
            "valueDate": "2012-08-27"
          }
        ],
        "category": "other",
        "goal": [
          {
            "reference": "#g5"
          }
        ],
        "status": "in-progress",
        "prohibited": false,
        "scheduledPeriod": {
          "start": "2012-07-23"
        },
        "note": "Eve will use her lights MWF after her shower for 3 minutes"
      }
    },
    {
      "notes": "7/23/12 Eve created a chart as a reminer to take the medications that do not fit in her pill box",
      "detail": {
        "extension": [
          {
            "url": "http://example.org/DoNotUse/General/RevisionDate",
            "valueDate": "2012-09-10"
          }
        ],
        "category": "other",
        "goal": [
          {
            "reference": "#g4"
          }
        ],
        "status": "in-progress",
        "prohibited": false,
        "scheduledPeriod": {
          "start": "2012-07-10"
        },
        "note": "Eve will use a calendar of a chart to help her remember when to take her medications"
      }
    },
    {
      "notes": "7/30/12 will be able to esume exercise.  8/13/12 Eve prefers to focus on walking at this time",
      "detail": {
        "extension": [
          {
            "url": "http://example.org/DoNotUse/General/RevisionDate",
            "valueDate": "2012-08-23"
          }
        ],
        "category": "other",
        "goal": [
          {
            "reference": "#g3"
          }
        ],
        "status": "on-hold",
        "prohibited": false,
        "scheduledPeriod": {
          "start": "2012-07-23"
        },
        "note": "Eve will start using stretch bands and one step 2 days a week Mon/Wed 6-7am and maybe Friday afternoon"
      }
    },
    {
      "detail": {
        "extension": [
          {
            "url": "http://example.org/DoNotUse/General/RevisionDate",
            "valueDate": "2012-07-23"
          }
        ],
        "category": "other",
        "goal": [
          {
            "reference": "#g4"
          }
        ],
        "status": "completed",
        "prohibited": false,
        "scheduledPeriod": {
          "start": "2012-07-10"
        },
        "note": "Eve will match a printed medication worksheet with the medication bottles at home"
      }
    },
    {
      "notes": "7/16/12 Eve now has some of her medications set up in pill packs by her pharmacist",
      "detail": {
        "extension": [
          {
            "url": "http://example.org/DoNotUse/General/RevisionDate",
            "valueDate": "2012-07-16"
          }
        ],
        "category": "other",
        "goal": [
          {
            "reference": "#g4"
          }
        ],
        "status": "completed",
        "prohibited": false,
        "scheduledPeriod": {
          "start": "2012-07-10"
        },
        "note": "Eve will get a medication box to sort her pills.  She will have one for scheduled medications and one for as needed"
      }
    },
    {
      "notes": "7/30/12 Eve will be able to resume exercise on 7/30/12.  8/13/12 -hold until \"less busy\"",
      "detail": {
        "extension": [
          {
            "url": "http://example.org/DoNotUse/General/RevisionDate",
            "valueDate": "2012-08-13"
          }
        ],
        "category": "other",
        "goal": [
          {
            "reference": "#g3"
          }
        ],
        "status": "on-hold",
        "prohibited": false,
        "scheduledPeriod": {
          "start": "2012-07-23"
        },
        "note": "Eve will open \"The Firm\" DVD workout package and listen to it"
      }
    }
  ],
  "notes": "Patient family is not ready to commit to goal setting at this time.  Goal setting will be addressed in the future"
}