Integrated care plan with multiple goals & conditions (from Mayo) (id = "integrate")

<?xml version="1.0" encoding="UTF-8"?>

<CarePlan xmlns="http://hl7.org/fhir">
  <id value="integrate"/> 
  <text> 
    <status value="generated"/> 
    <div xmlns="http://www.w3.org/1999/xhtml">
      <p> Patient family is not ready to commit to goal setting at this time.  Goal setting will
         be addressed in the future</p> 
      <table> 
        <thead> 
          <tr> 
            <th> Start Date</th> 
            <th> Goal</th> 
            <th> Action Steps</th> 
            <th> Status</th> 
            <th> Date Last Updated</th> 
            <th> Comments</th> 
          </tr> 
        </thead> 
        <tbody> 
          <tr> 
            <td> 10 Sep 2012</td> 
            <td> Eve will lose weight and reduce her GERDS symptoms by improving her diet</td> 
            <td> Eve will review photos of high and low density foods and share with her parents</td> 
            <td> New Goal</td> 
            <td> 10 Sep 2012</td> 
            <td> 9/10/12 Eve eats one meal a day with her parents</td> 
          </tr> 
          <tr> 
            <td> 10 Sep 2012</td> 
            <td> Eve will lose weight and reduce her GERDS symptoms by improving her diet</td> 
            <td> Eve will ask her dad to asist her to put the head of her bed on blocks</td> 
            <td> New Goal</td> 
            <td> 10 Sep 2012</td> 
            <td> 9/10/12 Eve will sleep in her bed more often than the couch</td> 
          </tr> 
          <tr> 
            <td> 10 Sep 2012</td> 
            <td> Eve will improve her GERDS symptoms</td> 
            <td> Eve will reduce her intake of coffee and chocolate</td> 
            <td> In Process</td> 
            <td> 10 Sep 2012</td> 
            <td/>  
          </tr> 
          <tr> 
            <td> 27 Aug 2012</td> 
            <td> Eve will increase her energy by being more active</td> 
            <td> Eve will walk her friend's dog up and down a big hill 15-30 minutes 3 days a week</td> 
            <td> In Process</td> 
            <td> 10 Sep 2012</td> 
            <td> 8/27/12 Eve would like to try for 5 days a week.  9/10/12 Eve is still walking the dogs.</td> 
          </tr> 
          <tr> 
            <td> 23 Jul 2012</td> 
            <td> Eve will increase her energy by being more active</td> 
            <td> Eve will walk 3 blocks to her parents house twice a week</td> 
            <td> In Process</td> 
            <td> 10 Sep 2012</td> 
            <td> 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</td> 
          </tr> 
          <tr> 
            <td> 23 Jul 2012</td> 
            <td> Eve will set up her medications and take as prescribed</td> 
            <td> Eve will us a calendar to check off after medications are taken</td> 
            <td> In Process</td> 
            <td> 13 Aug 2012</td> 
            <td/>  
          </tr> 
          <tr> 
            <td> 23 Jul 2012</td> 
            <td> Eve will restart her light treatments</td> 
            <td> Eve will use her lights MWF after her shower for 3 minutes</td> 
            <td> In Process</td> 
            <td> 27 Aug 2012</td> 
            <td> 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</td> 
          </tr> 
          <tr> 
            <td> 10 Jul 2012</td> 
            <td> Eve will set up her medications and take as prescribed</td> 
            <td> Eve will use a calendar of a chart to help her remember when to take her medications</td> 
            <td> In Process</td> 
            <td> 10 Sep 2012</td> 
            <td> 7/23/12 Eve created a chart as a reminer to take the medications that do not fit in her
               pill box</td> 
          </tr> 
          <tr> 
            <td> 23 Jul 2012</td> 
            <td> Eve will increase her energy by being more active</td> 
            <td> Eve will start using stretch bands and one step 2 days a week Mon/Wed 6-7am and maybe
               Friday afternoon</td> 
            <td> On-Hold</td> 
            <td> 23 Aug 2012</td> 
            <td> 7/30/12 will be able to esume exercise.  8/13/12 Eve prefers to focus on walking at this
               time</td> 
          </tr> 
          <tr> 
            <td> 10 Jul 2012</td> 
            <td> Eve will set up her medications and take as prescribed</td> 
            <td> Eve will match a printed medication worksheet with the medication bottles at home</td> 
            <td> Completed</td> 
            <td> 23 Jul 2012</td> 
            <td/>  
          </tr> 
          <tr> 
            <td> 10 Jul 2012</td> 
            <td> Eve will set up her medications and take as prescribed</td> 
            <td> Eve will get a medication box to sort her pills.  She will have one for scheduled medications
               and one for as needed</td> 
            <td> Completed</td> 
            <td> 16 Jul 2012</td> 
            <td> 7/16/12 Eve now has some of her medications set up in pill packs by her pharmacist</td> 
          </tr> 
          <tr> 
            <td> 23 Jul 2012</td> 
            <td> Eve will increase her energy by being more active</td> 
            <td> Eve will open &quot;The Firm&quot; DVD workout package and listen to it</td> 
            <td> Discontinued</td> 
            <td> 13 Aug 2012</td> 
            <td> 7/30/12 Eve will be able to resume exercise on 7/30/12.  8/13/12 -hold until &quot;less
               busy&quot;</td> 
          </tr> 
        </tbody> 
      </table> 
    </div> 
  </text> 
  <contained> 
    <!--   Conditions could be further encoded and detailed.  
      Could also be handled as references to external resources.
      And not essential to have them captured at all.
      For purposes of example, will represent this way.   -->
    <Condition> 
      <id value="p1"/> 
      <clinicalStatus> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/condition-clinical"/> 
      <code value="active"/> 
    </coding> 
    </clinicalStatus> 

    <verificationStatus> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/condition-ver-status"/> 
      <code value="confirmed"/> 
    </coding> 
    </verificationStatus> 
      <code> 
        <text value="GERDS"/> 
      </code> 
      <subject> 
        <reference value="Patient/1"/> 
        <display value="Eve Everywoman"/> 
      </subject> 
    </Condition> 
  </contained> 
  <contained> 
    <Condition> 
      <id value="p2"/> 
      <clinicalStatus> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/condition-clinical"/> 
      <code value="active"/> 
    </coding> 
    </clinicalStatus> 

    <verificationStatus> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/condition-ver-status"/> 
      <code value="confirmed"/> 
    </coding> 
    </verificationStatus> 
      <code> 
        <text value="Obesity"/> 
      </code> 
      <subject> 
        <reference value="Patient/1"/> 
        <display value="Eve Everywoman"/> 
      </subject> 
    </Condition> 
  </contained> 
  <contained> 
    <Condition> 
      <id value="p3"/> 
      <clinicalStatus> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/condition-clinical"/> 
      <code value="active"/> 
    </coding> 
    </clinicalStatus> 

    <verificationStatus> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/condition-ver-status"/> 
      <code value="confirmed"/> 
    </coding> 
    </verificationStatus> 
      <code> 
        <text value="Psoriasis"/> 
      </code> 
      <subject> 
        <reference value="Patient/1"/> 
        <display value="Eve Everywoman"/> 
      </subject> 
    </Condition> 
  </contained> 
  <contained> 
    <Goal> 
      <id value="g1"/> 
      <lifecycleStatus value="active"/> 
    <description> 
        <text value="Eve will lose weight and reduce her GERDS symptoms by improving her diet"/> 
      </description> 
    <subject> 
        <reference value="Patient/1"/> 
        <display value="Eve Everywoman"/> 
      </subject> 
    </Goal> 
  </contained> 
  <contained> 
    <Goal> 
      <id value="g2"/> 
    <lifecycleStatus value="active"/> 
      <description> 
        <text value="Eve will improve her GERDS symptoms"/> 
      </description> 
    <subject> 
        <reference value="Patient/1"/> 
        <display value="Eve Everywoman"/> 
      </subject> 
    </Goal> 
  </contained> 
  <contained> 
    <Goal> 
      <id value="g3"/> 
      <lifecycleStatus value="active"/> 
    <description> 
        <text value="Eve will increase her energy by being more active"/> 
      </description> 
    <subject> 
        <reference value="Patient/1"/> 
        <display value="Eve Everywoman"/> 
      </subject> 
    </Goal> 
  </contained> 
  <contained> 
    <Goal> 
      <id value="g4"/> 
      <lifecycleStatus value="active"/> 
    <description> 
        <text value="Eve will set up her medications and take as prescribed"/> 
      </description> 
    <subject> 
        <reference value="Patient/1"/> 
        <display value="Eve Everywoman"/> 
      </subject> 
    </Goal> 
  </contained> 
  <contained> 
    <Goal> 
      <id value="g5"/> 
      <lifecycleStatus value="active"/> 
    <description> 
        <text value="Eve will restart her light treatments"/> 
      </description> 
    <subject> 
        <reference value="Patient/1"/> 
        <display value="Eve Everywoman"/> 
      </subject> 
    </Goal> 
  </contained> 
  <status value="active"/> 
  <intent value="plan"/> 
  <subject> 
    <reference value="Patient/1"/> 
    <display value="Eve Everywoman"/> 
  </subject> 
  <addresses> 
    <reference> 
      <reference value="#p1"/>     
      <!--   Local reference   -->
      <display value="GERDS"/> 
    </reference> 
  </addresses> 
  <addresses> 
    <reference> 
      <reference value="#p2"/> 
      <!--   Local reference   -->
      <display value="Obesity"/> 
    </reference> 
  </addresses> 
  <addresses> 
    <reference> 
      <reference value="#p3"/> 
      <!--   Local reference   -->
      <display value="Psoriasis"/> 
    </reference> 
  </addresses> 
  <goal> 
    <reference value="#g1"/> 
  </goal> 
  <goal> 
    <reference value="#g2"/> 
  </goal> 
  <goal> 
    <reference value="#g3"/> 
  </goal> 
  <goal> 
    <reference value="#g4"/> 
  </goal> 
  <goal> 
    <reference value="#g5"/> 
  </goal> 
  <activity> 
    <progress> 
      <time value="2012-09-10"/> 
      <text value="Eve eats one meal a day with her parents"/> 
    </progress> 
    <plannedActivityDetail> 
      <extension url="http://example.org/fhir/StructureDefinition/RevisionDate">
        <valueDate value="2012-09-10"/> 
      </extension> 
      <goal> 
        <reference value="#g1"/> 
      </goal> 
      <status value="not-started"/> 
      <doNotPerform value="false"/> 
      <scheduledPeriod> 
        <start value="2012-09-10"/> 
      </scheduledPeriod> 
      <description value="Eve will review photos of high and low density foods and share with her parents"/> 
    </plannedActivityDetail> 
  </activity> 
  <activity> 
    <progress> 
      <time value="2012-09-10"/> 
      <text value="Eve will sleep in her bed more often than the couch"/> 
    </progress> 
    <plannedActivityDetail> 
      <extension url="http://example.org/fhir/StructureDefinition/RevisionDate">
        <valueDate value="2012-09-10"/> 
      </extension> 
      <kind value="CommunicationRequest"/> 
      <goal> 
        <reference value="#g1"/> 
      </goal> 
      <status value="not-started"/> 
      <doNotPerform value="false"/> 
      <scheduledPeriod> 
        <start value="2012-09-10"/> 
      </scheduledPeriod> 
      <description value="Eve will ask her dad to asist her to put the head of her bed on blocks"/> 
    </plannedActivityDetail> 
  </activity> 
  <activity> 
    <plannedActivityDetail> 
      <extension url="http://example.org/fhir/StructureDefinition/RevisionDate">
        <valueDate value="2012-09-10"/> 
      </extension> 
      <goal> 
        <reference value="#g2"/> 
      </goal> 
      <status value="in-progress"/> 
      <doNotPerform value="false"/> 
      <scheduledPeriod> 
        <start value="2012-09-10"/> 
      </scheduledPeriod> 
      <description value="Eve will reduce her intake of coffee and chocolate"/> 
    </plannedActivityDetail> 
  </activity> 
  <activity> 
    <progress> 
      <time value="2012-08-27"/> 
      <text value="Eve would like to try for 5 days a week."/> 
    </progress> 
    <progress> 
      <time value="2012-09-10"/> 
      <text value="Eve is still walking the dogs."/> 
    </progress> 
    <plannedActivityDetail> 
      <extension url="http://example.org/fhir/StructureDefinition/RevisionDate">
        <valueDate value="2012-09-10"/> 
      </extension> 
      <goal> 
        <reference value="#g3"/> 
      </goal> 
      <status value="in-progress"/> 
      <doNotPerform value="false"/> 
      <scheduledPeriod> 
        <start value="2012-08-27"/> 
      </scheduledPeriod> 
      <description value="Eve will walk her friend's dog up and down a big hill 15-30 minutes 3 days a week"/> 
    </plannedActivityDetail> 
  </activity> 
  <activity> 
    <progress> 
      <time value="2012-08-13"/> 
      <text value="Eve walked 4 times the last week."/> 
    </progress> 
    <progress> 
      <time value="2012-09-10"/> 
      <text value="Eve did not walk to her parents the last week, but has plans to start again"/> 
    </progress> 
    <plannedActivityDetail> 
      <extension url="http://example.org/fhir/StructureDefinition/RevisionDate">
        <valueDate value="2012-09-10"/> 
      </extension> 
      <goal> 
        <reference value="#g3"/> 
      </goal> 
      <status value="in-progress"/> 
      <doNotPerform value="false"/> 
      <scheduledPeriod> 
        <start value="2012-07-23"/> 
      </scheduledPeriod> 
      <description value="Eve will walk 3 blocks to her parents house twice a week"/> 
    </plannedActivityDetail> 
  </activity> 
  <activity> 
    <plannedActivityDetail> 
      <extension url="http://example.org/fhir/StructureDefinition/RevisionDate">
        <valueDate value="2012-08-13"/> 
      </extension> 
      <goal> 
        <reference value="#g4"/> 
      </goal> 
      <status value="in-progress"/> 
      <doNotPerform value="false"/> 
      <scheduledPeriod> 
        <start value="2012-07-23"/> 
      </scheduledPeriod> 
      <description value="Eve will use a calendar to check off after medications are taken"/> 
    </plannedActivityDetail> 
  </activity> 
  <activity> 
    <progress> 
      <time value="2012-08-13"/> 
      <text value="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."/> 
    </progress> 
    <progress> 
      <time value="2012-08-27"/> 
      <text value="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"/> 
    </progress> 
    <plannedActivityDetail> 
      <extension url="http://example.org/fhir/StructureDefinition/RevisionDate">
        <valueDate value="2012-08-27"/> 
      </extension> 
      <goal> 
        <reference value="#g5"/> 
      </goal> 
      <status value="in-progress"/> 
      <doNotPerform value="false"/> 
      <scheduledPeriod> 
        <start value="2012-07-23"/> 
      </scheduledPeriod> 
      <description value="Eve will use her lights MWF after her shower for 3 minutes"/> 
    </plannedActivityDetail> 
  </activity> 
  <activity> 
    <progress> 
      <time value="2012-07-23"/> 
      <text value="Eve created a chart as a reminer to take the medications that do not fit in her pill box"/> 
    </progress> 
    <plannedActivityDetail> 
      <extension url="http://example.org/fhir/StructureDefinition/RevisionDate">
        <valueDate value="2012-09-10"/> 
      </extension> 
      <goal> 
        <reference value="#g4"/> 
      </goal> 
      <status value="in-progress"/> 
      <doNotPerform value="false"/> 
      <scheduledPeriod> 
        <start value="2012-07-10"/> 
      </scheduledPeriod> 
      <description value="Eve will use a calendar of a chart to help her remember when to take her medications"/> 
    </plannedActivityDetail> 
  </activity> 
  <activity> 
    <progress> 
      <time value="2012-07-30"/> 
      <text value="Will be able to esume exercise."/> 
    </progress> 
    <progress> 
      <time value="2012-08-13"/> 
      <text value="Eve prefers to focus on walking at this time"/> 
    </progress> 
    <plannedActivityDetail> 
      <extension url="http://example.org/fhir/StructureDefinition/RevisionDate">
        <valueDate value="2012-08-23"/> 
      </extension> 
      <goal> 
        <reference value="#g3"/> 
      </goal> 
      <status value="on-hold"/> 
      <doNotPerform value="false"/> 
      <scheduledPeriod> 
        <start value="2012-07-23"/> 
      </scheduledPeriod> 
      <description value="Eve will start using stretch bands and one step 2 days a week Mon/Wed 6-7am and maybe
       Friday afternoon"/> 
    </plannedActivityDetail> 
  </activity> 
  <activity> 
    <plannedActivityDetail> 
      <extension url="http://example.org/fhir/StructureDefinition/RevisionDate">
        <valueDate value="2012-07-23"/> 
      </extension> 
      <goal> 
        <reference value="#g4"/> 
      </goal> 
      <status value="completed"/> 
      <doNotPerform value="false"/> 
      <scheduledPeriod> 
        <start value="2012-07-10"/> 
      </scheduledPeriod> 
      <description value="Eve will match a printed medication worksheet with the medication bottles at home"/> 
    </plannedActivityDetail> 
  </activity> 
  <activity> 
    <progress> 
      <time value="2012-07-16"/> 
      <text value="Eve now has some of her medications set up in pill packs by her pharmacist"/> 
    </progress> 
    <plannedActivityDetail> 
      <extension url="http://example.org/fhir/StructureDefinition/RevisionDate">
        <valueDate value="2012-07-16"/> 
      </extension> 
      <goal> 
        <reference value="#g4"/> 
      </goal> 
      <status value="completed"/> 
      <doNotPerform value="false"/> 
      <scheduledPeriod> 
        <start value="2012-07-10"/> 
      </scheduledPeriod> 
      <description value="Eve will get a medication box to sort her pills.  She will have one for scheduled medications
       and one for as needed"/> 
    </plannedActivityDetail> 
  </activity> 
  <activity> 
    <progress> 
      <time value="2012-07-12"/> 
      <text value="Eve will be able to resume exercise on 7/30/12"/> 
    </progress> 
    <progress> 
      <time value="2012-08-13"/> 
      <text value="hold until &quot;less busy&quot;"/> 
    </progress> 
    <plannedActivityDetail> 
      <extension url="http://example.org/fhir/StructureDefinition/RevisionDate">
        <valueDate value="2012-08-13"/> 
      </extension> 
      <goal> 
        <reference value="#g3"/> 
      </goal> 
      <status value="on-hold"/> 
      <doNotPerform value="false"/> 
      <scheduledPeriod> 
        <start value="2012-07-23"/> 
      </scheduledPeriod> 
      <description value="Eve will open &quot;The Firm&quot; DVD workout package and listen to it"/> 
    </plannedActivityDetail> 
  </activity> 
  <note> 
    <text value="Patient family is not ready to commit to goal setting at this time.  Goal setting will
     be addressed in the future"/> 
  </note> 
</CarePlan>