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

: Multiple Chronic Condition Care Plan Example - TTL Representation

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@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 sct: <http://snomed.info/id/> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:CarePlan;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "MCCCarePlan"]; # 
  fhir:Resource.meta [
     fhir:Element.extension [
       fhir:index 0;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/instance-name" ];
       fhir:Extension.valueString [ fhir:value "Multiple Chronic Condition Care Plan Example" ]     ], [
       fhir:index 1;
       fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/instance-description" ];
       fhir:Extension.valueMarkdown [ fhir:value "This is an example for the *MCC CarePlan Profile*." ]     ];
     fhir:Meta.versionId [ fhir:value "5" ];
     fhir:Meta.lastUpdated [ fhir:value "2022-11-16T23:03:27.124+00:00"^^xsd:dateTime ];
     fhir:Meta.source [ fhir:value "#lh8xM5mIbbHVNz84" ];
     fhir:Meta.profile [
       fhir:value "http://hl7.org/fhir/us/mcc/StructureDefinition/mccCarePlan";
       fhir:index 0;
       fhir:link <http://hl7.org/fhir/us/mcc/StructureDefinition/mccCarePlan>     ]
  ]; # 
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ];
     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: CarePlan</b><a name=\"MCCCarePlan\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource CarePlan &quot;MCCCarePlan&quot; Version &quot;5&quot; Updated &quot;2022-11-16 23:03:27+0000&quot; </p><p style=\"margin-bottom: 0px\">Information Source: #lh8xM5mIbbHVNz84!</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-mccCarePlan.html\">Multiple Chronic Care Condition Care Plan</a></p></div><p><b>status</b>: active</p><p><b>intent</b>: plan</p><p><b>category</b>: Care Plan <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#734163000; <a href=\"http://hl7.org/fhir/us/core/STU5.0.1/CodeSystem-careplan-category.html\">US Core CarePlan Category Extension Codes</a>#assess-plan)</span></p><p><b>subject</b>: <a href=\"Patient-cc-pat-pnoelle.html\">Patient/cc-pat-pnoelle: Patricia Noelle</a> &quot; NOELLE&quot;</p><p><b>period</b>: 2018-05-01 --&gt; (ongoing)</p><p><b>created</b>: 2019-01-01</p><p><b>author</b>: <a href=\"PractitionerRole-PractitionerRoleMCC2.html\">PractitionerRole/PractitionerRoleMCC2: Nancy Nurse RN</a></p><p><b>contributor</b>: </p><ul><li><a href=\"PractitionerRole-PractitionerRoleMCC1.html\">PractitionerRole/PractitionerRoleMCC1: Henry Levin VII MD Nephrologist</a></li><li><a href=\"PractitionerRole-PractitionerRoleMCC2.html\">PractitionerRole/PractitionerRoleMCC2: Nancy Nurse RN</a></li><li><a href=\"PractitionerRole-PractitionerRoleMCC3.html\">PractitionerRole/PractitionerRoleMCC3: Peter Primary MD Primary Provider</a></li></ul><p><b>careTeam</b>: <a href=\"CareTeam-MCCCareTeamexample.html\">CareTeam/MCCCareTeamexample: Longitudinal care-coordination focused care team</a> &quot;US-Core MCC example CareTeam&quot;</p><p><b>addresses</b>: <a href=\"Condition-ConditionCKD.html\">Condition/ConditionCKD: Chronic Kidney Disease</a></p><p><b>supportingInfo</b>: </p><ul><li><a href=\"Procedure-Dialysis.html\">Procedure/Dialysis: Chronic Pain</a></li><li><a href=\"Observation-bunMCC.html\">Observation/bunMCC: BUN 24 mL/min/{1.73_m2}</a></li></ul><p><b>goal</b>: <a href=\"Goal-WGT-loss.html\">Goal/WGT-loss: Lose weight, decrease chronic pain with less use of pain medication and improved lab results</a></p><blockquote><p><b>activity</b></p><p><b>outcomeReference</b>: <a href=\"Procedure-Dialysis.html\">Procedure/Dialysis: Dialysis</a></p><p><b>progress</b>: Patricia Noelle is measuring her weight daily ( @2019-01-10)</p><p><b>reference</b>: <a href=\"http://example.org/Task/123\">http://example.org/Task/123: Patricia Noelle or cargiver to perform daily weights</a></p></blockquote><blockquote><p><b>activity</b></p><p><b>outcomeReference</b>: </p><ul><li><a href=\"http://example.org/Encounter/123\">http://example.org/Encounter/123: PreOp Encounter For Creation of external arteriovenous shunt (procedure)</a></li><li><a href=\"http://example.org/Procedure/upperlimbveinUS\">http://example.org/Procedure/upperlimbveinUS: Fluoroscopic venography of bilateral upper limbs Performed. Results: Normal</a></li></ul><p><b>progress</b>: 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)</p><p><b>reference</b>: <a href=\"http://example.org/Appointment/AVShunt\">http://example.org/Appointment/AVShunt: PreOp Encounter Request For Creation of external arteriovenous shunt (procedure). Relates to overall health improvement goal and encounter requestActivity</a></p></blockquote></div>"
  ]; # 
  fhir:CarePlan.status [ fhir:value "active"]; # 
  fhir:CarePlan.intent [ fhir:value "plan"]; # 
  fhir:CarePlan.category [
     fhir:index 0;
     fhir:CodeableConcept.coding [
       fhir:index 0;
       a sct:734163000;
       fhir:Coding.system [ fhir:value "http://snomed.info/sct" ];
       fhir:Coding.code [ fhir:value "734163000" ];
       fhir:Coding.display [ fhir:value "Care Plan" ]     ], [
       fhir:index 1;
       fhir:Coding.system [ fhir:value "http://hl7.org/fhir/us/core/CodeSystem/careplan-category" ];
       fhir:Coding.code [ fhir:value "assess-plan" ]     ]
  ]; # 
  fhir:CarePlan.subject [
     fhir:Reference.reference [ fhir:value "Patient/cc-pat-pnoelle" ];
     fhir:Reference.display [ fhir:value "Patricia Noelle" ]
  ]; # 
  fhir:CarePlan.period [
     fhir:Period.start [ fhir:value "2018-05-01"^^xsd:date ]
  ]; # 
  fhir:CarePlan.created [ fhir:value "2019-01-01"^^xsd:date]; # 
  fhir:CarePlan.author [
     fhir:Reference.reference [ fhir:value "PractitionerRole/PractitionerRoleMCC2" ];
     fhir:Reference.display [ fhir:value "Nancy Nurse RN" ]
  ]; # 
  fhir:CarePlan.contributor [
     fhir:index 0;
     fhir:Reference.reference [ fhir:value "PractitionerRole/PractitionerRoleMCC1" ];
     fhir:Reference.display [ fhir:value "Henry Levin VII MD Nephrologist" ]
  ], [
     fhir:index 1;
     fhir:Reference.reference [ fhir:value "PractitionerRole/PractitionerRoleMCC2" ];
     fhir:Reference.display [ fhir:value "Nancy Nurse RN" ]
  ], [
     fhir:index 2;
     fhir:Reference.reference [ fhir:value "PractitionerRole/PractitionerRoleMCC3" ];
     fhir:Reference.display [ fhir:value "Peter Primary MD Primary Provider" ]
  ]; # 
  fhir:CarePlan.careTeam [
     fhir:index 0;
     fhir:Reference.reference [ fhir:value "CareTeam/MCCCareTeamexample" ];
     fhir:Reference.display [ fhir:value "Longitudinal care-coordination focused care team" ]
  ]; # 
  fhir:CarePlan.addresses [
     fhir:index 0;
     fhir:Reference.reference [ fhir:value "Condition/ConditionCKD" ];
     fhir:Reference.display [ fhir:value "Chronic Kidney Disease" ]
  ]; # 
  fhir:CarePlan.supportingInfo [
     fhir:index 0;
     fhir:Reference.reference [ fhir:value "Procedure/Dialysis" ];
     fhir:Reference.display [ fhir:value "Chronic Pain" ]
  ], [
     fhir:index 1;
     fhir:Reference.reference [ fhir:value "Observation/bunMCC" ];
     fhir:Reference.display [ fhir:value "BUN 24 mL/min/{1.73_m2}" ]
  ]; # 
  fhir:CarePlan.goal [
     fhir:index 0;
     fhir:Reference.reference [ fhir:value "Goal/WGT-loss" ];
     fhir:Reference.display [ fhir:value "Lose weight, decrease chronic pain with less use of pain medication and improved lab results" ]
  ]; # 
  fhir:CarePlan.activity [
     fhir:index 0;
     fhir:CarePlan.activity.outcomeReference [
       fhir:index 0;
       fhir:Reference.reference [ fhir:value "Procedure/Dialysis" ];
       fhir:Reference.display [ fhir:value "Dialysis" ]     ];
     fhir:CarePlan.activity.progress [
       fhir:index 0;
       fhir:Annotation.time [ fhir:value "2019-01-10"^^xsd:date ];
       fhir:Annotation.text [ fhir:value "Patricia Noelle is measuring her weight daily" ]     ];
     fhir:CarePlan.activity.reference [
       fhir:link <http://example.org/Task/123>;
       fhir:Reference.reference [ fhir:value "http://example.org/Task/123" ];
       fhir:Reference.display [ fhir:value "Patricia Noelle or cargiver to perform daily weights" ]     ]
  ], [
     fhir:index 1;
     fhir:CarePlan.activity.outcomeReference [
       fhir:index 0;
       fhir:link <http://example.org/Encounter/123>;
       fhir:Reference.reference [ fhir:value "http://example.org/Encounter/123" ];
       fhir:Reference.display [ fhir:value "PreOp Encounter For Creation of external arteriovenous shunt (procedure)" ]     ], [
       fhir:index 1;
       fhir:link <http://example.org/Procedure/upperlimbveinUS>;
       fhir:Reference.reference [ fhir:value "http://example.org/Procedure/upperlimbveinUS" ];
       fhir:Reference.display [ fhir:value "Fluoroscopic venography of bilateral upper limbs Performed. Results: Normal" ]     ];
     fhir:CarePlan.activity.progress [
       fhir:index 0;
       fhir:Annotation.time [ fhir:value "2019-01-10"^^xsd:date ];
       fhir:Annotation.text [ fhir:value "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" ]     ];
     fhir:CarePlan.activity.reference [
       fhir:link <http://example.org/Appointment/AVShunt>;
       fhir:Reference.reference [ fhir:value "http://example.org/Appointment/AVShunt" ];
       fhir:Reference.display [ fhir:value "PreOp Encounter Request For Creation of external arteriovenous shunt (procedure). Relates to overall health improvement goal and encounter requestActivity" ]     ]
  ]. # 

# - ontology header ------------------------------------------------------------

 a owl:Ontology;
  owl:imports fhir:fhir.ttl.