Release 5
Clinical SummaryThis page is part of the FHIR Specification (v5.0.0: R5 - STU). This is the current published version. For a full list of available versions, see the Directory of published versions 
. Page versions: R5 R4B R4 R3
| Patient Care Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Encounter, Patient |
Raw Turtle (+ also see Turtle/RDF Format Specification)
Integrated care plan with multiple goals & conditions (from Mayo)
@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
[a fhir:CarePlan ;
fhir:nodeRole fhir:treeRoot ;
fhir:id [ fhir:v "integrate"] ; #
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir: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 "The Firm" 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 "less busy"</td>\n </tr>\n </tbody>\n </table>\n </div>"
] ; #
fhir:contained ( [
a fhir:Condition ;
fhir:id [ fhir:v "p1" ] ;
fhir:clinicalStatus [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/condition-clinical"^^xsd:anyURI ] ;
fhir:code [ fhir:v "active" ]
] )
] ;
fhir:verificationStatus [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/condition-ver-status"^^xsd:anyURI ] ;
fhir:code [ fhir:v "confirmed" ]
] )
] ;
fhir:code [
fhir:text [ fhir:v "GERDS" ]
] ;
fhir:subject [
fhir:reference [ fhir:v "Patient/1" ] ;
fhir:display [ fhir:v "Eve Everywoman" ]
]
] [
a fhir:Condition ;
fhir:id [ fhir:v "p2" ] ;
fhir:clinicalStatus [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/condition-clinical"^^xsd:anyURI ] ;
fhir:code [ fhir:v "active" ]
] )
] ;
fhir:verificationStatus [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/condition-ver-status"^^xsd:anyURI ] ;
fhir:code [ fhir:v "confirmed" ]
] )
] ;
fhir:code [
fhir:text [ fhir:v "Obesity" ]
] ;
fhir:subject [
fhir:reference [ fhir:v "Patient/1" ] ;
fhir:display [ fhir:v "Eve Everywoman" ]
]
] [
a fhir:Condition ;
fhir:id [ fhir:v "p3" ] ;
fhir:clinicalStatus [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/condition-clinical"^^xsd:anyURI ] ;
fhir:code [ fhir:v "active" ]
] )
] ;
fhir:verificationStatus [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/condition-ver-status"^^xsd:anyURI ] ;
fhir:code [ fhir:v "confirmed" ]
] )
] ;
fhir:code [
fhir:text [ fhir:v "Psoriasis" ]
] ;
fhir:subject [
fhir:reference [ fhir:v "Patient/1" ] ;
fhir:display [ fhir:v "Eve Everywoman" ]
]
] [
a fhir:Goal ;
fhir:id [ fhir:v "g1" ] ;
fhir:lifecycleStatus [ fhir:v "active" ] ;
fhir:description [
fhir:text [ fhir:v "Eve will lose weight and reduce her GERDS symptoms by improving her diet" ]
] ;
fhir:subject [
fhir:reference [ fhir:v "Patient/1" ] ;
fhir:display [ fhir:v "Eve Everywoman" ]
]
] [
a fhir:Goal ;
fhir:id [ fhir:v "g2" ] ;
fhir:lifecycleStatus [ fhir:v "active" ] ;
fhir:description [
fhir:text [ fhir:v "Eve will improve her GERDS symptoms" ]
] ;
fhir:subject [
fhir:reference [ fhir:v "Patient/1" ] ;
fhir:display [ fhir:v "Eve Everywoman" ]
]
] [
a fhir:Goal ;
fhir:id [ fhir:v "g3" ] ;
fhir:lifecycleStatus [ fhir:v "active" ] ;
fhir:description [
fhir:text [ fhir:v "Eve will increase her energy by being more active" ]
] ;
fhir:subject [
fhir:reference [ fhir:v "Patient/1" ] ;
fhir:display [ fhir:v "Eve Everywoman" ]
]
] [
a fhir:Goal ;
fhir:id [ fhir:v "g4" ] ;
fhir:lifecycleStatus [ fhir:v "active" ] ;
fhir:description [
fhir:text [ fhir:v "Eve will set up her medications and take as prescribed" ]
] ;
fhir:subject [
fhir:reference [ fhir:v "Patient/1" ] ;
fhir:display [ fhir:v "Eve Everywoman" ]
]
] [
a fhir:Goal ;
fhir:id [ fhir:v "g5" ] ;
fhir:lifecycleStatus [ fhir:v "active" ] ;
fhir:description [
fhir:text [ fhir:v "Eve will restart her light treatments" ]
] ;
fhir:subject [
fhir:reference [ fhir:v "Patient/1" ] ;
fhir:display [ fhir:v "Eve Everywoman" ]
]
] ) ; # 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.
fhir:status [ fhir:v "active"] ; #
fhir:intent [ fhir:v "plan"] ; #
fhir:subject [
fhir:reference [ fhir:v "Patient/1" ] ;
fhir:display [ fhir:v "Eve Everywoman" ]
] ; #
fhir:addresses ( [
fhir:reference [
fhir:reference [ fhir:v "#p1" ] ;
fhir:display [ fhir:v "GERDS" ] # Local reference
]
] [
fhir:reference [
fhir:reference [ fhir:v "#p2" ] ;
fhir:display [ fhir:v "Obesity" ] # Local reference
]
] [
fhir:reference [
fhir:reference [ fhir:v "#p3" ] ;
fhir:display [ fhir:v "Psoriasis" ] # Local reference
]
] ) ; #
fhir:goal ( [
fhir:reference [ fhir:v "#g1" ]
] [
fhir:reference [ fhir:v "#g2" ]
] [
fhir:reference [ fhir:v "#g3" ]
] [
fhir:reference [ fhir:v "#g4" ]
] [
fhir:reference [ fhir:v "#g5" ]
] ) ; #
fhir:activity ( [
fhir:progress ( [
fhir:time [ fhir:v "2012-09-10"^^xsd:date ] ;
fhir:text [ fhir:v "Eve eats one meal a day with her parents" ]
] ) ;
fhir:plannedActivityReference [
fhir:reference [ fhir:v "ServiceRequest/activity-1" ]
] # Eve will review photos of high and low density foods and share with her parents
] [
fhir:plannedActivityReference [
fhir:reference [ fhir:v "ServiceRequest/activity-2" ]
] # Eve will ask her dad to asist her to put the head of her bed on blocks
] [
fhir:plannedActivityReference [
fhir:reference [ fhir:v "NutritionOrder/activity-3" ]
] # Eve will reduce her intake of coffee and chocolate
] [
fhir:progress ( [
fhir:time [ fhir:v "2012-08-27"^^xsd:date ] ;
fhir:text [ fhir:v "Eve would like to try for 5 days a week." ]
] [
fhir:time [ fhir:v "2012-09-10"^^xsd:date ] ;
fhir:text [ fhir:v "Eve is still walking the dogs." ]
] ) ;
fhir:plannedActivityReference [
fhir:reference [ fhir:v "ServiceRequest/activity-4" ]
] # Eve will walk her friend's dog up and down a big hill 15-30 minutes 3 days a week
] [
fhir:progress ( [
fhir:time [ fhir:v "2012-08-13"^^xsd:date ] ;
fhir:text [ fhir:v "Eve walked 4 times the last week." ]
] [
fhir:time [ fhir:v "2012-09-10"^^xsd:date ] ;
fhir:text [ fhir:v "Eve did not walk to her parents the last week, but has plans to start again" ]
] ) ;
fhir:plannedActivityReference [
fhir:reference [ fhir:v "ServiceRequest/activity-5" ]
] # Eve will walk 3 blocks to her parents house twice a week
] [
fhir:plannedActivityReference [
fhir:reference [ fhir:v "ServiceRequest/activity-6" ]
] # Eve will use a calendar to check off after medications are taken
] [
fhir:progress ( [
fhir:time [ fhir:v "2012-08-13"^^xsd:date ] ;
fhir:text [ fhir:v "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." ]
] [
fhir:time [ fhir:v "2012-08-27"^^xsd:date ] ;
fhir:text [ fhir:v "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" ]
] ) ;
fhir:plannedActivityReference [
fhir:reference [ fhir:v "ServiceRequest/activity-7" ]
] # Eve will use her lights MWF after her shower for 3 minutes
] [
fhir:progress ( [
fhir:time [ fhir:v "2012-07-23"^^xsd:date ] ;
fhir:text [ fhir:v "Eve created a chart as a reminer to take the medications that do not fit in her pill box" ]
] ) ;
fhir:plannedActivityReference [
fhir:reference [ fhir:v "ServiceRequest/activity-8" ]
] # Eve will use a calendar of a chart to help her remember when to take her medications
] [
fhir:progress ( [
fhir:time [ fhir:v "2012-07-30"^^xsd:date ] ;
fhir:text [ fhir:v "Will be able to esume exercise." ]
] [
fhir:time [ fhir:v "2012-08-13"^^xsd:date ] ;
fhir:text [ fhir:v "Eve prefers to focus on walking at this time" ]
] ) ;
fhir:plannedActivityReference [
fhir:reference [ fhir:v "ServiceRequest/activity-9" ]
] # Eve will start using stretch bands and one step 2 days a week Mon\/Wed 6-7am and maybe Friday afternoon
] [
fhir:plannedActivityReference [
fhir:reference [ fhir:v "ServiceRequest/activity-10" ]
] # Eve will match a printed medication worksheet with the medication bottles at home
] [
fhir:progress ( [
fhir:time [ fhir:v "2012-07-16"^^xsd:date ] ;
fhir:text [ fhir:v "Eve now has some of her medications set up in pill packs by her pharmacist" ]
] ) ;
fhir:plannedActivityReference [
fhir:reference [ fhir:v "ServiceRequest/activity-11" ]
] # Eve will get a medication box to sort her pills. She will have one for scheduled medications and one for as needed
] [
fhir:progress ( [
fhir:time [ fhir:v "2012-07-12"^^xsd:date ] ;
fhir:text [ fhir:v "Eve will be able to resume exercise on 7/30/12" ]
] [
fhir:time [ fhir:v "2012-08-13"^^xsd:date ] ;
fhir:text [ fhir:v "hold until \"less busy\"" ]
] ) ;
fhir:plannedActivityReference [
fhir:reference [ fhir:v "ServiceRequest/activity-12" ]
] # Eve will open execersie DVD workout package and listen to it
] ) ; #
fhir:note ( [
fhir:text [ fhir:v "Patient family is not ready to commit to goal setting at this time. Goal setting will be addressed in the future" ]
] )] . #
# -------------------------------------------------------------------------------------
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.
FHIR ®© HL7.org 2011+. FHIR R5 hl7.fhir.core#5.0.0 generated on Sun, Mar 26, 2023 15:24+1100.
Links: Search |
Version History |
Contents |
Glossary |
QA |
Compare to R4 |
Compare to R4B |
|
Propose a change