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

: MCC Goal Example - Normal Hypertension - TTL Representation

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix loinc: <http://loinc.org/rdf#> .
@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:Goal;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "HPT-WNL"]; # 
  fhir:Resource.meta [
     fhir:Meta.versionId [ fhir:value "5" ];
     fhir:Meta.lastUpdated [ fhir:value "2022-06-02T23:34:46.692+00:00"^^xsd:dateTime ];
     fhir:Meta.source [ fhir:value "#2FWI9BsC94EqeXTg" ];
     fhir:Meta.profile [
       fhir:value "http://hl7.org/fhir/us/mcc/StructureDefinition/MCCGoal";
       fhir:index 0;
       fhir:link <http://hl7.org/fhir/us/mcc/StructureDefinition/MCCGoal>     ]
  ]; # 
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "extensions" ];
     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Goal</b><a name=\"HPT-WNL\"> </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 Goal &quot;HPT-WNL&quot; Version &quot;5&quot; Updated &quot;2022-06-02 23:34:46+0000&quot; </p><p style=\"margin-bottom: 0px\">Information Source: #2FWI9BsC94EqeXTg!</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-MCCGoal.html\">Multiple Chronic Condition Care Plan Goal</a></p></div><blockquote><p><b>Goal acceptance</b></p><p><b>value</b>: <a href=\"Patient-cc-pat-pnoelle.html\">Patient/cc-pat-pnoelle</a> &quot; NOELLE&quot;</p><p><b>value</b>: agree</p><p><b>value</b>: High Priority <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.1.0/CodeSystem-goal-priority.html\">Goal priority</a>#high-priority)</span></p></blockquote><blockquote><p><b>Goal acceptance</b></p><p><b>value</b>: <a href=\"Practitioner-practitionerMCC-3.html\">Practitioner/practitionerMCC-3</a> &quot; PRIMARY&quot;</p><p><b>value</b>: agree</p><p><b>value</b>: High Priority <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.1.0/CodeSystem-goal-priority.html\">Goal priority</a>#high-priority)</span></p></blockquote><blockquote><p><b>related goal</b></p><p><b>value</b>: This goal relates to the Weight loss goal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.1.0/CodeSystem-goal-relationship-type.html\">GoalRelationshipType</a>#other)</span></p><p><b>value</b>: <a href=\"Goal-WGT-loss.html\">Goal/WGT-loss</a></p></blockquote><p><b>lifecycleStatus</b>: active</p><p><b>priority</b>: high <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.1.0/CodeSystem-goal-priority.html\">Goal priority</a>#high-priority &quot;High Priority&quot;)</span></p><p><b>description</b>: Target Systolic Blood pressure between 110 and 140 mmHg. <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#271651005 &quot;Stable blood pressure&quot;)</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>start</b>: 2019-10-14</p><h3>Targets</h3><table class=\"grid\"><tr><td>-</td><td><b>Measure</b></td><td><b>Detail[x]</b></td><td><b>Due[x]</b></td></tr><tr><td>*</td><td>Systolic blood pressure <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#8480-6)</span></td><td>110-140 lbs</td><td>2020-04-05</td></tr></table><p><b>statusDate</b>: 2019-10-14</p><p><b>statusReason</b>: Patient knows that normal blood pressure is important for CKD, Hypertension and diabetes control.</p><p><b>expressedBy</b>: <a href=\"Patient-cc-pat-pnoelle.html\">Patient/cc-pat-pnoelle: Patricia Noelle</a> &quot; NOELLE&quot;</p><p><b>addresses</b>: <a href=\"Condition-ConditionCKD.html\">Condition/ConditionCKD: chronic kidney disease condition</a></p><p><b>outcomeReference</b>: <a href=\"Observation-MCCweight.html\">Observation/MCCweight: Body Weight Measured - 165 Pounds</a></p></div>"
  ]; # 
  fhir:DomainResource.extension [
     fhir:index 0;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/goal-acceptance" ];
     fhir:Element.extension [
       fhir:index 0;
       fhir:Extension.url [ fhir:value "individual" ];
       fhir:Extension.valueReference [
         fhir:Reference.reference [ fhir:value "Patient/cc-pat-pnoelle" ]       ]     ], [
       fhir:index 1;
       fhir:Extension.url [ fhir:value "status" ];
       fhir:Extension.valueCode [ fhir:value "agree" ]     ], [
       fhir:index 2;
       fhir:Extension.url [ fhir:value "priority" ];
       fhir:Extension.valueCodeableConcept [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/goal-priority" ];
           fhir:Coding.code [ fhir:value "high-priority" ]         ]       ]     ]
  ], [
     fhir:index 1;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/goal-acceptance" ];
     fhir:Element.extension [
       fhir:index 0;
       fhir:Extension.url [ fhir:value "individual" ];
       fhir:Extension.valueReference [
         fhir:Reference.reference [ fhir:value "Practitioner/practitionerMCC-3" ]       ]     ], [
       fhir:index 1;
       fhir:Extension.url [ fhir:value "status" ];
       fhir:Extension.valueCode [ fhir:value "agree" ]     ], [
       fhir:index 2;
       fhir:Extension.url [ fhir:value "priority" ];
       fhir:Extension.valueCodeableConcept [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/goal-priority" ];
           fhir:Coding.code [ fhir:value "high-priority" ]         ]       ]     ]
  ], [
     fhir:index 2;
     fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/goal-relationship" ];
     fhir:Element.extension [
       fhir:index 0;
       fhir:Extension.url [ fhir:value "type" ];
       fhir:Extension.valueCodeableConcept [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/goal-relationship-type" ];
           fhir:Coding.code [ fhir:value "other" ]         ];
         fhir:CodeableConcept.text [ fhir:value "This goal relates to the Weight loss goal" ]       ]     ], [
       fhir:index 1;
       fhir:Extension.url [ fhir:value "target" ];
       fhir:Extension.valueReference [
         fhir:Reference.reference [ fhir:value "Goal/WGT-loss" ]       ]     ]
  ]; # 
  fhir:Goal.lifecycleStatus [ fhir:value "active"]; # 
  fhir:Goal.priority [
     fhir:CodeableConcept.coding [
       fhir:index 0;
       fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/goal-priority" ];
       fhir:Coding.code [ fhir:value "high-priority" ];
       fhir:Coding.display [ fhir:value "High Priority" ]     ];
     fhir:CodeableConcept.text [ fhir:value "high" ]
  ]; # 
  fhir:Goal.description [
     fhir:CodeableConcept.coding [
       fhir:index 0;
       a sct:271651005;
       fhir:Coding.system [ fhir:value "http://snomed.info/sct" ];
       fhir:Coding.code [ fhir:value "271651005" ];
       fhir:Coding.display [ fhir:value "Stable blood pressure" ]     ];
     fhir:CodeableConcept.text [ fhir:value "Target Systolic Blood pressure between 110 and 140 mmHg." ]
  ]; # 
  fhir:Goal.subject [
     fhir:Reference.reference [ fhir:value "Patient/cc-pat-pnoelle" ];
     fhir:Reference.display [ fhir:value "Patricia Noelle" ]
  ]; # 
  fhir:Goal.startDate [ fhir:value "2019-10-14"^^xsd:date]; # 
  fhir:Goal.target [
     fhir:index 0;
     fhir:Goal.target.measure [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         a loinc:8480-6;
         fhir:Coding.system [ fhir:value "http://loinc.org" ];
         fhir:Coding.code [ fhir:value "8480-6" ];
         fhir:Coding.display [ fhir:value "Systolic blood pressure" ]       ]     ];
     fhir:Goal.target.detailRange [
       fhir:Range.low [
         fhir:Quantity.value [ fhir:value "110"^^xsd:decimal ];
         fhir:Quantity.unit [ fhir:value "lbs" ];
         fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
         fhir:Quantity.code [ fhir:value "mm[Hg]" ]       ];
       fhir:Range.high [
         fhir:Quantity.value [ fhir:value "140"^^xsd:decimal ];
         fhir:Quantity.unit [ fhir:value "lbs" ];
         fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
         fhir:Quantity.code [ fhir:value "mm[Hg]" ]       ]     ];
     fhir:Goal.target.dueDate [ fhir:value "2020-04-05"^^xsd:date ]
  ]; # 
  fhir:Goal.statusDate [ fhir:value "2019-10-14"^^xsd:date]; # 
  fhir:Goal.statusReason [ fhir:value "Patient knows that normal blood pressure is important for CKD, Hypertension and diabetes control."]; # 
  fhir:Goal.expressedBy [
     fhir:Reference.reference [ fhir:value "Patient/cc-pat-pnoelle" ];
     fhir:Reference.display [ fhir:value "Patricia Noelle" ]
  ]; # 
  fhir:Goal.addresses [
     fhir:index 0;
     fhir:Reference.reference [ fhir:value "Condition/ConditionCKD" ];
     fhir:Reference.display [ fhir:value "chronic kidney disease condition" ]
  ]; # 
  fhir:Goal.outcomeReference [
     fhir:index 0;
     fhir:Reference.reference [ fhir:value "Observation/MCCweight" ];
     fhir:Reference.display [ fhir:value "Body Weight Measured - 165 Pounds" ]
  ]. # 

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

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