Integrated care plan with multiple goals & conditions (from Mayo)

{
  "resourceType" : "CarePlan",
  "id" : "integrate",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n      <p>Patient family is not ready to commit to goal setting at this time.  Goal setting will be addressed in the future</p>\n      <table>\n        <thead>\n          <tr>\n            <th>Start Date</th>\n            <th>Goal</th>\n            <th>Action Steps</th>\n            <th>Status</th>\n            <th>Date Last Updated</th>\n            <th>Comments</th>\n          </tr>\n        </thead>\n        <tbody>\n          <tr>\n            <td>10 Sep 2012</td>\n            <td>Eve will lose weight and reduce her GERDS symptoms by improving her diet</td>\n            <td>Eve will review photos of high and low density foods and share with her parents</td>\n            <td>New Goal</td>\n            <td>10 Sep 2012</td>\n            <td>9/10/12 Eve eats one meal a day with her parents</td>\n          </tr>\n          <tr>\n            <td>10 Sep 2012</td>\n            <td>Eve will lose weight and reduce her GERDS symptoms by improving her diet</td>\n            <td>Eve will ask her dad to asist her to put the head of her bed on blocks</td>\n            <td>New Goal</td>\n            <td>10 Sep 2012</td>\n            <td>9/10/12 Eve will sleep in her bed more often than the couch</td>\n          </tr>\n          <tr>\n            <td>10 Sep 2012</td>\n            <td>Eve will improve her GERDS symptoms</td>\n            <td>Eve will reduce her intake of coffee and chocolate</td>\n            <td>In Process</td>\n            <td>10 Sep 2012</td>\n            <td/>\n          </tr>\n          <tr>\n            <td>27 Aug 2012</td>\n            <td>Eve will increase her energy by being more active</td>\n            <td>Eve will walk her friend's dog up and down a big hill 15-30 minutes 3 days a week</td>\n            <td>In Process</td>\n            <td>10 Sep 2012</td>\n            <td>8/27/12 Eve would like to try for 5 days a week.  9/10/12 Eve is still walking the dogs.</td>\n          </tr>\n          <tr>\n            <td>23 Jul 2012</td>\n            <td>Eve will increase her energy by being more active</td>\n            <td>Eve will walk 3 blocks to her parents house twice a week</td>\n            <td>In Process</td>\n            <td>10 Sep 2012</td>\n            <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>\n          </tr>\n          <tr>\n            <td>23 Jul 2012</td>\n            <td>Eve will set up her medications and take as prescribed</td>\n            <td>Eve will us a calendar to check off after medications are taken</td>\n            <td>In Process</td>\n            <td>13 Aug 2012</td>\n            <td/>\n          </tr>\n          <tr>\n            <td>23 Jul 2012</td>\n            <td>Eve will restart her light treatments</td>\n            <td>Eve will use her lights MWF after her shower for 3 minutes</td>\n            <td>In Process</td>\n            <td>27 Aug 2012</td>\n            <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>\n          </tr>\n          <tr>\n            <td>10 Jul 2012</td>\n            <td>Eve will set up her medications and take as prescribed</td>\n            <td>Eve will use a calendar of a chart to help her remember when to take her medications</td>\n            <td>In Process</td>\n            <td>10 Sep 2012</td>\n            <td>7/23/12 Eve created a chart as a reminer to take the medications that do not fit in her pill box</td>\n          </tr>\n          <tr>\n            <td>23 Jul 2012</td>\n            <td>Eve will increase her energy by being more active</td>\n            <td>Eve will start using stretch bands and one step 2 days a week Mon/Wed 6-7am and maybe Friday afternoon</td>\n            <td>On-Hold</td>\n            <td>23 Aug 2012</td>\n            <td>7/30/12 will be able to esume exercise.  8/13/12 Eve prefers to focus on walking at this time</td>\n          </tr>\n          <tr>\n            <td>10 Jul 2012</td>\n            <td>Eve will set up her medications and take as prescribed</td>\n            <td>Eve will match a printed medication worksheet with the medication bottles at home</td>\n            <td>Completed</td>\n            <td>23 Jul 2012</td>\n            <td/>\n          </tr>\n          <tr>\n            <td>10 Jul 2012</td>\n            <td>Eve will set up her medications and take as prescribed</td>\n            <td>Eve will get a medication box to sort her pills.  She will have one for scheduled medications and one for as needed</td>\n            <td>Completed</td>\n            <td>16 Jul 2012</td>\n            <td>7/16/12 Eve now has some of her medications set up in pill packs by her pharmacist</td>\n          </tr>\n          <tr>\n            <td>23 Jul 2012</td>\n            <td>Eve will increase her energy by being more active</td>\n            <td>Eve will open &quot;The Firm&quot; DVD workout package and listen to it</td>\n            <td>Discontinued</td>\n            <td>13 Aug 2012</td>\n            <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>\n          </tr>\n        </tbody>\n      </table>\n    </div>"
  },
  "contained" : [{
    "resourceType" : "Condition",
    "id" : "p1",
    "clinicalStatus" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/condition-clinical",
        "code" : "active"
      }]
    },
    "verificationStatus" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/condition-ver-status",
        "code" : "confirmed"
      }]
    },
    "code" : {
      "text" : "GERDS"
    },
    "subject" : {
      "reference" : "Patient/1",
      "display" : "Eve Everywoman"
    }
  },
  {
    "resourceType" : "Condition",
    "id" : "p2",
    "clinicalStatus" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/condition-clinical",
        "code" : "active"
      }]
    },
    "verificationStatus" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/condition-ver-status",
        "code" : "confirmed"
      }]
    },
    "code" : {
      "text" : "Obesity"
    },
    "subject" : {
      "reference" : "Patient/1",
      "display" : "Eve Everywoman"
    }
  },
  {
    "resourceType" : "Condition",
    "id" : "p3",
    "clinicalStatus" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/condition-clinical",
        "code" : "active"
      }]
    },
    "verificationStatus" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/condition-ver-status",
        "code" : "confirmed"
      }]
    },
    "code" : {
      "text" : "Psoriasis"
    },
    "subject" : {
      "reference" : "Patient/1",
      "display" : "Eve Everywoman"
    }
  },
  {
    "resourceType" : "Goal",
    "id" : "g1",
    "lifecycleStatus" : "active",
    "description" : {
      "text" : "Eve will lose weight and reduce her GERDS symptoms by improving her diet"
    },
    "subject" : {
      "reference" : "Patient/1",
      "display" : "Eve Everywoman"
    }
  },
  {
    "resourceType" : "Goal",
    "id" : "g2",
    "lifecycleStatus" : "active",
    "description" : {
      "text" : "Eve will improve her GERDS symptoms"
    },
    "subject" : {
      "reference" : "Patient/1",
      "display" : "Eve Everywoman"
    }
  },
  {
    "resourceType" : "Goal",
    "id" : "g3",
    "lifecycleStatus" : "active",
    "description" : {
      "text" : "Eve will increase her energy by being more active"
    },
    "subject" : {
      "reference" : "Patient/1",
      "display" : "Eve Everywoman"
    }
  },
  {
    "resourceType" : "Goal",
    "id" : "g4",
    "lifecycleStatus" : "active",
    "description" : {
      "text" : "Eve will set up her medications and take as prescribed"
    },
    "subject" : {
      "reference" : "Patient/1",
      "display" : "Eve Everywoman"
    }
  },
  {
    "resourceType" : "Goal",
    "id" : "g5",
    "lifecycleStatus" : "active",
    "description" : {
      "text" : "Eve will restart her light treatments"
    },
    "subject" : {
      "reference" : "Patient/1",
      "display" : "Eve Everywoman"
    }
  }],
  "status" : "active",
  "intent" : "plan",
  "subject" : {
    "reference" : "Patient/1",
    "display" : "Eve Everywoman"
  },
  "addresses" : [{
    "reference" : {
      "reference" : "#p1",
      "display" : "GERDS"
    }
  },
  {
    "reference" : {
      "reference" : "#p2",
      "display" : "Obesity"
    }
  },
  {
    "reference" : {
      "reference" : "#p3",
      "display" : "Psoriasis"
    }
  }],
  "goal" : [{
    "reference" : "#g1"
  },
  {
    "reference" : "#g2"
  },
  {
    "reference" : "#g3"
  },
  {
    "reference" : "#g4"
  },
  {
    "reference" : "#g5"
  }],
  "activity" : [{
    "progress" : [{
      "time" : "2012-09-10",
      "text" : "Eve eats one meal a day with her parents"
    }],
    "plannedActivityDetail" : {
      "extension" : [{
        "url" : "http://example.org/fhir/StructureDefinition/RevisionDate",
        "valueDate" : "2012-09-10"
      }],
      "goal" : [{
        "reference" : "#g1"
      }],
      "status" : "not-started",
      "doNotPerform" : false,
      "scheduledPeriod" : {
        "start" : "2012-09-10"
      },
      "description" : "Eve will review photos of high and low density foods and share with her parents"
    }
  },
  {
    "progress" : [{
      "time" : "2012-09-10",
      "text" : "Eve will sleep in her bed more often than the couch"
    }],
    "plannedActivityDetail" : {
      "extension" : [{
        "url" : "http://example.org/fhir/StructureDefinition/RevisionDate",
        "valueDate" : "2012-09-10"
      }],
      "kind" : "CommunicationRequest",
      "goal" : [{
        "reference" : "#g1"
      }],
      "status" : "not-started",
      "doNotPerform" : false,
      "scheduledPeriod" : {
        "start" : "2012-09-10"
      },
      "description" : "Eve will ask her dad to asist her to put the head of her bed on blocks"
    }
  },
  {
    "plannedActivityDetail" : {
      "extension" : [{
        "url" : "http://example.org/fhir/StructureDefinition/RevisionDate",
        "valueDate" : "2012-09-10"
      }],
      "goal" : [{
        "reference" : "#g2"
      }],
      "status" : "in-progress",
      "doNotPerform" : false,
      "scheduledPeriod" : {
        "start" : "2012-09-10"
      },
      "description" : "Eve will reduce her intake of coffee and chocolate"
    }
  },
  {
    "progress" : [{
      "time" : "2012-08-27",
      "text" : "Eve would like to try for 5 days a week."
    },
    {
      "time" : "2012-09-10",
      "text" : "Eve is still walking the dogs."
    }],
    "plannedActivityDetail" : {
      "extension" : [{
        "url" : "http://example.org/fhir/StructureDefinition/RevisionDate",
        "valueDate" : "2012-09-10"
      }],
      "goal" : [{
        "reference" : "#g3"
      }],
      "status" : "in-progress",
      "doNotPerform" : false,
      "scheduledPeriod" : {
        "start" : "2012-08-27"
      },
      "description" : "Eve will walk her friend's dog up and down a big hill 15-30 minutes 3 days a week"
    }
  },
  {
    "progress" : [{
      "time" : "2012-08-13",
      "text" : "Eve walked 4 times the last week."
    },
    {
      "time" : "2012-09-10",
      "text" : "Eve did not walk to her parents the last week, but has plans to start again"
    }],
    "plannedActivityDetail" : {
      "extension" : [{
        "url" : "http://example.org/fhir/StructureDefinition/RevisionDate",
        "valueDate" : "2012-09-10"
      }],
      "goal" : [{
        "reference" : "#g3"
      }],
      "status" : "in-progress",
      "doNotPerform" : false,
      "scheduledPeriod" : {
        "start" : "2012-07-23"
      },
      "description" : "Eve will walk 3 blocks to her parents house twice a week"
    }
  },
  {
    "plannedActivityDetail" : {
      "extension" : [{
        "url" : "http://example.org/fhir/StructureDefinition/RevisionDate",
        "valueDate" : "2012-08-13"
      }],
      "goal" : [{
        "reference" : "#g4"
      }],
      "status" : "in-progress",
      "doNotPerform" : false,
      "scheduledPeriod" : {
        "start" : "2012-07-23"
      },
      "description" : "Eve will use a calendar to check off after medications are taken"
    }
  },
  {
    "progress" : [{
      "time" : "2012-08-13",
      "text" : "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."
    },
    {
      "time" : "2012-08-27",
      "text" : "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"
    }],
    "plannedActivityDetail" : {
      "extension" : [{
        "url" : "http://example.org/fhir/StructureDefinition/RevisionDate",
        "valueDate" : "2012-08-27"
      }],
      "goal" : [{
        "reference" : "#g5"
      }],
      "status" : "in-progress",
      "doNotPerform" : false,
      "scheduledPeriod" : {
        "start" : "2012-07-23"
      },
      "description" : "Eve will use her lights MWF after her shower for 3 minutes"
    }
  },
  {
    "progress" : [{
      "time" : "2012-07-23",
      "text" : "Eve created a chart as a reminer to take the medications that do not fit in her pill box"
    }],
    "plannedActivityDetail" : {
      "extension" : [{
        "url" : "http://example.org/fhir/StructureDefinition/RevisionDate",
        "valueDate" : "2012-09-10"
      }],
      "goal" : [{
        "reference" : "#g4"
      }],
      "status" : "in-progress",
      "doNotPerform" : false,
      "scheduledPeriod" : {
        "start" : "2012-07-10"
      },
      "description" : "Eve will use a calendar of a chart to help her remember when to take her medications"
    }
  },
  {
    "progress" : [{
      "time" : "2012-07-30",
      "text" : "Will be able to esume exercise."
    },
    {
      "time" : "2012-08-13",
      "text" : "Eve prefers to focus on walking at this time"
    }],
    "plannedActivityDetail" : {
      "extension" : [{
        "url" : "http://example.org/fhir/StructureDefinition/RevisionDate",
        "valueDate" : "2012-08-23"
      }],
      "goal" : [{
        "reference" : "#g3"
      }],
      "status" : "on-hold",
      "doNotPerform" : false,
      "scheduledPeriod" : {
        "start" : "2012-07-23"
      },
      "description" : "Eve will start using stretch bands and one step 2 days a week Mon/Wed 6-7am and maybe Friday afternoon"
    }
  },
  {
    "plannedActivityDetail" : {
      "extension" : [{
        "url" : "http://example.org/fhir/StructureDefinition/RevisionDate",
        "valueDate" : "2012-07-23"
      }],
      "goal" : [{
        "reference" : "#g4"
      }],
      "status" : "completed",
      "doNotPerform" : false,
      "scheduledPeriod" : {
        "start" : "2012-07-10"
      },
      "description" : "Eve will match a printed medication worksheet with the medication bottles at home"
    }
  },
  {
    "progress" : [{
      "time" : "2012-07-16",
      "text" : "Eve now has some of her medications set up in pill packs by her pharmacist"
    }],
    "plannedActivityDetail" : {
      "extension" : [{
        "url" : "http://example.org/fhir/StructureDefinition/RevisionDate",
        "valueDate" : "2012-07-16"
      }],
      "goal" : [{
        "reference" : "#g4"
      }],
      "status" : "completed",
      "doNotPerform" : false,
      "scheduledPeriod" : {
        "start" : "2012-07-10"
      },
      "description" : "Eve will get a medication box to sort her pills.  She will have one for scheduled medications and one for as needed"
    }
  },
  {
    "progress" : [{
      "time" : "2012-07-12",
      "text" : "Eve will be able to resume exercise on 7/30/12"
    },
    {
      "time" : "2012-08-13",
      "text" : "hold until \"less busy\""
    }],
    "plannedActivityDetail" : {
      "extension" : [{
        "url" : "http://example.org/fhir/StructureDefinition/RevisionDate",
        "valueDate" : "2012-08-13"
      }],
      "goal" : [{
        "reference" : "#g3"
      }],
      "status" : "on-hold",
      "doNotPerform" : false,
      "scheduledPeriod" : {
        "start" : "2012-07-23"
      },
      "description" : "Eve will open \"The Firm\" DVD workout package and listen to it"
    }
  }],
  "note" : [{
    "text" : "Patient family is not ready to commit to goal setting at this time.  Goal setting will be addressed in the future"
  }]
}