MCC eCare Plan Implementation Guide
1.0.0-ballot - Comment only US

This page is part of the MCC eCare Plan Implementation Guide (v1.0.0-ballot: STU 1 Ballot 1) based on FHIR R4. . For a full list of available versions, see the Directory of published versions

Example CarePlan: Multiple Chronic Condition Care Plan Example

Generated Narrative: CarePlan

Resource CarePlan "MCCCarePlan" Version "5" Updated "2022-11-16 23:03:27+0000"

Information Source: #lh8xM5mIbbHVNz84!

Profile: Multiple Chronic Care Condition Care Plan

status: active

intent: plan

category: Care Plan (SNOMED CT#734163000; US Core CarePlan Category Extension Codes#assess-plan)

subject: Patient/cc-pat-pnoelle: Patricia Noelle " NOELLE"

period: 2018-05-01 --> (ongoing)

created: 2019-01-01

author: PractitionerRole/PractitionerRoleMCC2: Nancy Nurse RN

contributor:

careTeam: CareTeam/MCCCareTeamexample: Longitudinal care-coordination focused care team "US-Core MCC example CareTeam"

addresses: Condition/ConditionCKD: Chronic Kidney Disease

supportingInfo:

goal: Goal/WGT-loss: Lose weight, decrease chronic pain with less use of pain medication and improved lab results

activity

outcomeReference: Procedure/Dialysis: Dialysis

progress: Patricia Noelle is measuring her weight daily ( @2019-01-10)

reference: http://example.org/Task/123: Patricia Noelle or cargiver to perform daily weights

activity

outcomeReference:

progress: Patricia Noelle Completed prep for an AV Shunt. She needs the shunt due to the need for diayalis related to the goal to improve her health related to CKD ( @2019-01-10)

reference: http://example.org/Appointment/AVShunt: PreOp Encounter Request For Creation of external arteriovenous shunt (procedure). Relates to overall health improvement goal and encounter requestActivity