MCC eCare Plan Implementation Guide
1.0.0 - STU1
MCC eCare Plan Implementation Guide
1.0.0 - STU1
This page is part of the MCC eCare Plan Implementation Guide (v1.0.0: STU 1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions
Generated Narrative: Bundle long-covid-and-ckd-bundle
Bundle long-covid-and-ckd-bundle of type collection
Entry 1 - fullUrl = https://hl7.org/fhir/Observation/observation-moca
Resource Observation:
Generated Narrative: Observation observation-moca
status: Final
category: Survey, Cognitive Status
code: Montreal Cognitive Assessment [MoCA]
subject: Patricia Noelle
effective: 2022-12-08 17:32:00-0500
performer: Julie Smith
hasMember: Observation Total score [MoCA]
derivedFrom: Response to Questionnaire 'http://example.org/Questionnaire/MDS3.0-NC-1.17' about '->Patricia Noelle'
Entry 2 - fullUrl = https://hl7.org/fhir/QuestionnaireResponse/questionnnaire-res-moca
Resource QuestionnaireResponse:
Generated Narrative: QuestionnaireResponse questionnnaire-res-moca
LinkID Text Definition Answer questionnnaire-res-moca
Questionnaire:http://example.org/Questionnaire/MDS3.0-NC-1.17 MoCA
Montreal Cognitive Assessment [MoCA] MoCA/TotalScore
Total score [MoCA] 25 score (Details: UCUM code{score} = '{score}') Documentation for this format
Entry 3 - fullUrl = https://hl7.org/fhir/Observation/obs-response-moca
Resource Observation:
Generated Narrative: Observation obs-response-moca
status: Final
category: Survey, Cognitive Status
code: Total score [MoCA]
subject: Patricia Noelle
effective: 2022-12-08 17:32:00-0500
performer: Julie Smith
value: 25 score (Details: UCUM code{score} = '{score}')
derivedFrom: Response to Questionnaire 'http://example.org/Questionnaire/MDS3.0-NC-1.17' about '->Patricia Noelle'
Entry 4 - fullUrl = https://hl7.org/fhir/Observation/observation-moca-original
Resource Observation:
Generated Narrative: Observation observation-moca-original
status: Final
category: Survey, Cognitive Status
code: Montreal Cognitive Assessment [MoCA]
subject: Patricia Noelle
effective: 2022-04-28 17:32:00-0500
performer: Julie Smith
hasMember: Observation Total score [MoCA]
derivedFrom: Response to Questionnaire 'http://example.org/Questionnaire/MDS3.0-NC-1.17' about '->Patricia Noelle'
Entry 5 - fullUrl = https://hl7.org/fhir/QuestionnaireResponse/questionnnaire-res-moca-original
Resource QuestionnaireResponse:
Generated Narrative: QuestionnaireResponse questionnnaire-res-moca-original
LinkID Text Definition Answer Questionnaire:http://example.org/Questionnaire/MDS3.0-NC-1.17 Montreal Cognitive Assessment [MoCA] Total score [MoCA] score (Details: UCUM code{score} = '{score}')
Entry 6 - fullUrl = https://hl7.org/fhir/Observation/obs-response-moca-original
Resource Observation:
Generated Narrative: Observation obs-response-moca-original
status: Final
category: Survey, Cognitive Status
code: Total score [MoCA]
subject: Patricia Noelle
effective: 2022-04-28 17:32:00-0500
performer: Julie Smith
value: 10 score (Details: UCUM code{score} = '{score}')
derivedFrom: Response to Questionnaire 'http://example.org/Questionnaire/MDS3.0-NC-1.17' about '->Patricia Noelle'
Entry 7 - fullUrl = https://hl7.org/fhir/ServiceRequest/dialysis-request
Resource ServiceRequest:
Generated Narrative: ServiceRequest dialysis-request
status: Active
intent: Plan
code: No display for ServiceRequest.code (concept: Referral for dialysis (procedure))
subject: Patricia Noelle
occurrence: Count 20 times, 3 per1 weeks
authoredOn: 2022-06-18
requester: Dr. Vince Jones
patientInstruction: No display for ServiceRequest.patientInstruction (instruction[x]: Call the clinic at 555-555-5555 to set up your appointments)
Entry 8 - fullUrl = https://hl7.org/fhir/Procedure/dialysis-for-bundle
Resource Procedure:
Generated Narrative: Procedure dialysis-for-bundle
basedOn: ServiceRequest Referral for dialysis (procedure)
status: Completed
code: Hemodialysis
subject: Patricia Noelle
recorder: Dr Henry Levin
Performers
Actor Dr Henry Levin
Entry 9 - fullUrl = https://hl7.org/fhir/Procedure/dialysis-for-bundle2
Resource Procedure:
Generated Narrative: Procedure dialysis-for-bundle2
basedOn: ServiceRequest Referral for dialysis (procedure)
status: Completed
code: Hemodialysis
subject: Patricia Noelle
recorder: Dr Henry Levin
Performers
Actor Dr Henry Levin
Entry 10 - fullUrl = https://hl7.org/fhir/Procedure/dialysis-for-bundle3
Resource Procedure:
Generated Narrative: Procedure dialysis-for-bundle3
basedOn: ServiceRequest Referral for dialysis (procedure)
status: Completed
code: Hemodialysis
subject: Patricia Noelle
recorder: Dr Henry Levin
Performers
Actor Dr Henry Levin
Entry 11 - fullUrl = https://hl7.org/fhir/Procedure/ckd-app-education
Resource Procedure:
Generated Narrative: Procedure ckd-app-education
basedOn: ServiceRequest Referral for dialysis (procedure)
status: Completed
category: Education
code: Patient education (procedure)
subject: Patricia Noelle
recorder: Dr Henry Levin
Performers
Actor Dr Henry Levin note: Demonstrated (taught) to use CKD app
Entry 12 - fullUrl = https://hl7.org/fhir/ServiceRequest/dietitian-referral
Resource ServiceRequest:
Generated Narrative: ServiceRequest dietitian-referral
status: Active
intent: Plan
code: No display for ServiceRequest.code (concept: Referral to dietitian nutritionist)
subject: Patricia Noelle
authoredOn: 2022-05-05
requester: Dr. John Carlson
patientInstruction: No display for ServiceRequest.patientInstruction (instruction[x]: Call the clinic at 1-800-LUV-DIET to set up your appointments)
Entry 13 - fullUrl = https://hl7.org/fhir/Procedure/dietitian-consult
Resource Procedure:
Generated Narrative: Procedure dietitian-consult
basedOn: ServiceRequest Referral to dietitian nutritionist
status: Completed
category: Education
code: Dietary needs education (procedure)
subject: Patricia Noelle
Performers
Actor Dietitian ProviderRole reference note: Instructions given on how to achieve a protein intake of 1-1.2g/kg per day and an increased fiber intake of 20-25g/day. Also, recommended to eat small frequent meals and to drink liquid between meals. (By Dietitian ProviderRole reference)
Entry 14 - fullUrl = https://hl7.org/fhir/Observation/better-diet
Resource Observation:
Generated Narrative: Observation better-diet
status: Final
category: Caregivers thoughts on the patient's condition status
code: Observation on patient/caregiver feelings on the condition status
subject: Patricia Noelle
focus:
effective: 2022-11-10 16:48:57-0800
performer: RelatedPerson Rose Noelle
value: Patty has made diet changes and has an improved appetite. She is logging meals and the logs show protein intake of about 1g/kg/day and fiber intake of about 23g/day
Entry 15 - fullUrl = https://hl7.org/fhir/ServiceRequest/long-covid-request
Resource ServiceRequest:
Generated Narrative: ServiceRequest long-covid-request
status: Active
intent: Plan
code: No display for ServiceRequest.code (concept: Referral to infectious disease clinic (procedure))
subject: Patricia Noelle
authoredOn: 2022-05-20
requester: Dr. John Carlson
patientInstruction: No display for ServiceRequest.patientInstruction (instruction[x]: Call the clinic at 444-COV-ID19 to set up your appointments)
Entry 16 - fullUrl = https://hl7.org/fhir/MedicationRequest/med-for-chilblains
Resource MedicationRequest:
Generated Narrative: MedicationRequest med-for-chilblains
identifier:
urn:oid:1.2.840.114350.1.13.861.1.7.2.798268/2454978 (use: usual, )status: Active
intent: Order
category: Outpatient
subject: Patricia Noelle
authoredOn: 2022-05-03 15:41:39+0000
requester: Dr. John Carlson
recorder: Dr. John Carlson
dosageInstruction
Entry 17 - fullUrl = https://hl7.org/fhir/ServiceRequest/pt-3x-wk
Resource ServiceRequest:
Generated Narrative: ServiceRequest pt-3x-wk
status: Active
intent: Plan
code: No display for ServiceRequest.code (concept: Referral for physical therapy (procedure))
subject: Patricia Noelle
occurrence: Count 20 times, 3 per1 weeks
authoredOn: 2022-05-03
requester: Dr. John Carlson
patientInstruction: No display for ServiceRequest.patientInstruction (instruction[x]: Call the clinic at 444-COV-ID19 to set up your appointments)
Entry 18 - fullUrl = https://hl7.org/fhir/ServiceRequest/counseling-1x-wk
Resource ServiceRequest:
Generated Narrative: ServiceRequest counseling-1x-wk
status: Active
intent: Plan
code: No display for ServiceRequest.code (concept: Counseling (procedure))
subject: Patricia Noelle
occurrence: Count 20 times, 3 per1 weeks
authoredOn: 2022-05-03
requester: Dr. John Carlson
patientInstruction: No display for ServiceRequest.patientInstruction (instruction[x]: Call the clinic at 444-COV-ID19 to set up your appointments)
Entry 19 - fullUrl = https://hl7.org/fhir/Task/meditation-7x-wk
Resource Task:
Generated Narrative: Task meditation-7x-wk
status: Ready
intent: Order
priority: Routine
code: Fulfill the focal request
description: Practice self-guided meditation every day
for: Patricia Noelle
authoredOn: 2022-05-03
requester: Dr. John Carlson
owner: Patricia Noelle
Entry 20 - fullUrl = https://hl7.org/fhir/CarePlan/careplan-for-bundle
Resource CarePlan:
ResourceCarePlan "careplan-for-bundle"
Custodian R5 backport: Practitioner/practitionerMCC-3v: Dr. John Carlson " CARLSON"
status: active
intent: plan
category: Care Plan (SNOMED CT#734163000; US Core CarePlan Category Extension Codes[6.1.0]#assess-plan)
subject: Patient/cc-pat-pnoelle: Patricia Noelle " NOELLE"
period: 2022-05-20 --> (ongoing)
created: 2022-05-20
contributor:
- Practitioner/practitionerMCC-3v: Dr John Carlson, Primary Care Physician " CARLSON"
- PractitionerRole/careCoordinator-1: Care-coordinator, served by Julie Smith
- Patient/cc-pat-pnoelle: Noelle " NOELLE"
- PractitionerRole/dr-vince-jones: Nephrologist Role, served by Dr Vince Jones
- RelatedPerson/daughter1: Rose Noelle, Daughter " ROSE"
careTeam: CareTeam/careteam-for-bundle: Long-COVID and CKD focused care team "Care Team of Noelle Example for LONG-COVID bundle"
addresses:
supportingInfo:
- Observation/arterial-blood-gas-panel
- Observation/reduced-pain: Outcome example. Caregiver's observed thoughts on pain
- Condition/patient-health-concern-1: Patient Health Concern: Worry that Long Covid symptoms will effect CKD
- Condition/patient-health-concern-2: Patient Health Concern: Hard to exercise due to pain
- Condition/patient-health-concern-3: Patient Health Concern: Struggles to manage her diet and find affordable healthy food choices under her financial strain
- Condition/patient-health-concern-4: Patient Health Concern: Poor appetite for healthy CKD appropriate foods, likes cola, cake and chips
- Condition/careTeam-concerns-1: CareTeam Health Concern: Imbalanced Nutrition
- Condition/careTeam-concerns-2: CareTeam Health Concern: Dyspnea
- Condition/careTeam-concerns-3: CareTeam Health Concern: Pain in Legs
- Condition/careTeam-concerns-4: CareTeam Health Concern: Pain in Hands
- Condition/careTeam-concerns-5: CareTeam Health Concern: Pain in arms
- Condition/problem-list-1: Finding: Food aversion and cravings
- Condition/problem-list-2: Diagnosis: Metabolic acidosis
- Condition/chilblain-resolved: Long Covid related condition: Pustular chilblain resolved
- Observation/symptom2: Long Covid symptom: Dyspnea
- Observation/symptom3: Long Covid symptom: Pain in Legs
- Observation/symptom4: Long Covid symptom: Pain in hands
- Observation/symptom5: Long Covid symptom: Pain in arms
- Observation/symptom6: Long Covid symptom: Brain Fog - Intermittent confusion
- Observation/symptom7: Long Covid symptom: Brain Fog - Memory impairment
- Observation/symptom8: Long Covid symptom: Covid Toes - Toe swelling
- Observation/symptom9: Long Covid symptom: Covid Toes - Pustular chilblain
goal:
- Goal/lower-pain-minimal-opioids: Lower pain with minimal opioids
- Goal/appetite-to-normal: Return appetite to normal
- Goal/electrolyte-protein-normal-range: Get Electrolyte and proteins back to normal
- Goal/bmi-normal-range: Get BMI into healthy range
- Goal/access-affordable-healthy-food: Improve access to affordable, healthy food
activity
outcomeReference:
- Procedure/dietitian-consult: Dietitian consult
- Observation/better-diet: Observation by caregiver (daughter) of improvement in diet
reference: ServiceRequest/dietitian-referral: Dietitian Referral
activity
outcomeReference:
reference: ServiceRequest/dialysis-request
activity
outcomeReference: Procedure/ckd-app-education
activity
outcomeReference:
- MedicationRequest/med-for-chilblains: Treatment for chilblains
- Condition/chilblain-resolved
- ServiceRequest/pt-3x-wk: PT 3x per week
- ServiceRequest/counseling-1x-wk: Counseling 1x per week
- Task/meditation-7x-wk: Meditation 7x per week
- Observation/observation-moca: MOCA new result showing improvement
- Observation/observation-moca-original: MOCA initial result showing impairment
progress: Long COVID symptoms improving ( @2022-12-10)
reference: ServiceRequest/long-covid-request: Long Covid Clinic Referral serviceRequest
Entry 21 - fullUrl = https://hl7.org/fhir/RelatedPerson/daughter1
Resource RelatedPerson:
Generated Narrative: RelatedPerson daughter1
active: true
patient: Patricia Noelle Female, DoB: 1955-01-15 ( Medical Record Number: 103270456 (use: usual, ))
relationship: daughter
name: Rose Noelle
Entry 22 - fullUrl = https://hl7.org/fhir/Practitioner/practitionerMCC-V
Resource Practitioner:
Generated Narrative: Practitioner practitionerMCC-V
identifier: NPI/9941339100,
http://www.acme.org/practitioners/254567name: Vince Jones
address: 1003 Healthcare Drive Amherst MA 01002 (home)
Entry 23 - fullUrl = https://hl7.org/fhir/PractitionerRole/dr-vince-jones
Resource PractitionerRole:
Generated Narrative: PractitionerRole dr-vince-jones
version: 1
Profile: US Core PractitionerRole Profile
identifier:
http://www.acme.org/practitioners/23active: true
period: 2012-01-01 --> 2012-03-31
practitioner: Dr Vince Jones
organization: http://example.org/Organization/123
code: Nephrologist (occupation)
specialty: Nephrology Specialist/Technologist, Nephrology
location: South Wing, second floor
healthcareService: http://example.org/HealthcareService/123
Entry 24 - fullUrl = https://hl7.org/fhir/Practitioner/practitionerMCC-3v
Resource Practitioner:
Generated Narrative: Practitioner practitionerMCC-3v
identifier: NPI/9941339100,
http://www.acme.org/practitioners/25456name: John Carlson
address: 1003 Healthcare Drive Amherst MA 01002 (home)
Entry 25 - fullUrl = https://hl7.org/fhir/Practitioner/careCoordinator1
Resource Practitioner:
Generated Narrative: Practitioner careCoordinator1
identifier: NPI/1144221847,
http://www.acme.org/practitioners/25457name: Julie Smith
telecom: ph: (210) 224 1599
Entry 26 - fullUrl = https://hl7.org/fhir/Organization/funding1
Resource Organization:
Generated Narrative: Organization funding1
identifier: NPI/1144221847, CLIA/12D4567890
active: true
name: Texas Department of Community Health
Contacts
Address 7430 Louis Pasteur Dr, San Antonio, TX 78229
Entry 27 - fullUrl = https://hl7.org/fhir/Location/communitysite
Resource Location:
Generated Narrative: Location communitysite
name: community site
address: 7430 Louis Pasteur Dr, San Antonio, TX 78229
Entry 28 - fullUrl = https://hl7.org/fhir/PractitionerRole/careCoordinator-1
Resource PractitionerRole:
Generated Narrative: PractitionerRole careCoordinator-1
practitioner: Julie Smith
organization: Texas Department of Community Health
code: Community Health Worker
specialty: Case Manager/Care Coordinator
location: Health Level Seven International
Entry 29 - fullUrl = https://hl7.org/fhir/CareTeam/careteam-for-bundle
Resource CareTeam:
Generated Narrative: CareTeam careteam-for-bundle
status: Active
name: Care Team of Noelle Example for LONG-COVID bundle
subject: Patricia Noelle Female, DoB: 1955-01-15 ( Medical Record Number: 103270456 (use: usual, ))
participant
role: Primary care physician (occupation)
member: Dr. John Carlson
participant
role: Patient (person)
member: Noelle
participant
role: Care coordinator (occupation)
member: Julie Smith
participant
role: Caregiver (person)
member: Rose Noelle
Entry 30 - fullUrl = https://hl7.org/fhir/Condition/patient-health-concern-1
Resource Condition:
Generated Narrative: Condition patient-health-concern-1
clinicalStatus: Active
verificationStatus: Confirmed
category: Health Concern, SDOH
code: Worried and depressed regarding her progressive CKD and that Long Covid will make CKD worse due to decreased activity, shortness of breath and pain.
subject: Patricia Noelle
recordedDate: 2022-07-01
Entry 31 - fullUrl = https://hl7.org/fhir/Condition/patient-health-concern-2
Resource Condition:
Generated Narrative: Condition patient-health-concern-2
clinicalStatus: Active
verificationStatus: Confirmed
category: Health Concern, SDOH
code: Struggles to exercise due to pain.
subject: Patricia Noelle
recordedDate: 2022-01-01
Entry 32 - fullUrl = https://hl7.org/fhir/Condition/patient-health-concern-3
Resource Condition:
Generated Narrative: Condition patient-health-concern-3
clinicalStatus: Active
verificationStatus: Confirmed
category: Health Concern, SDOH
code: Struggles to manage her diet and find affordable healthy food choices under her financial strain.
subject: Patricia Noelle
recordedDate: 2022-01-01
Entry 33 - fullUrl = https://hl7.org/fhir/Condition/patient-health-concern-4
Resource Condition:
Generated Narrative: Condition patient-health-concern-4
clinicalStatus: Active
verificationStatus: Confirmed
category: Health Concern, SDOH
code: Poor appetite for healthy CKD appropriate foods, likes cola, cake and chips.
subject: Patricia Noelle
recordedDate: 2022-01-01
Entry 34 - fullUrl = https://hl7.org/fhir/Condition/careTeam-concerns-1
Resource Condition:
Generated Narrative: Condition careTeam-concerns-1
clinicalStatus: Active
verificationStatus: Confirmed
category: Health Concern
code: Alteration in nutrition: less than body requirements (finding)
subject: Patricia Noelle
recordedDate: 2022-05-01
Entry 35 - fullUrl = https://hl7.org/fhir/Condition/careTeam-concerns-2
Resource Condition:
Generated Narrative: Condition careTeam-concerns-2
clinicalStatus: Active
verificationStatus: Confirmed
category: Health Concern
code: Dyspnea (finding)
subject: Patricia Noelle
recordedDate: 2022-05-01
Entry 36 - fullUrl = https://hl7.org/fhir/Condition/careTeam-concerns-3
Resource Condition:
Generated Narrative: Condition careTeam-concerns-3
clinicalStatus: Active
verificationStatus: Confirmed
category: Health Concern
code: Pain in bilateral legs (finding)
subject: Patricia Noelle
recordedDate: 2022-05-01
Entry 37 - fullUrl = https://hl7.org/fhir/Condition/careTeam-concerns-4
Resource Condition:
Generated Narrative: Condition careTeam-concerns-4
clinicalStatus: Active
verificationStatus: Confirmed
category: Health Concern
code: Pain of bilateral hands (finding)
subject: Patricia Noelle
recordedDate: 2022-05-01
Entry 38 - fullUrl = https://hl7.org/fhir/Condition/careTeam-concerns-5
Resource Condition:
Generated Narrative: Condition careTeam-concerns-5
clinicalStatus: Active
verificationStatus: Confirmed
category: Health Concern
code: Pain in bilateral upper arms (finding)
subject: Patricia Noelle
recordedDate: 2022-05-01
Entry 39 - fullUrl = https://hl7.org/fhir/Condition/problem-list-1
Resource Condition:
Generated Narrative: Condition problem-list-1
clinicalStatus: Active
verificationStatus: Confirmed
category: Problem
code: Finding of food aversion and cravings (finding)
subject: Patricia Noelle
recordedDate: 2022-05-01
Entry 40 - fullUrl = https://hl7.org/fhir/Condition/problem-list-2
Resource Condition:
Generated Narrative: Condition problem-list-2
clinicalStatus: Active
verificationStatus: Confirmed
category: Problem
code: Metabolic acidosis (disorder)
subject: Patricia Noelle
onset: 2022-05-01
recordedDate: 2022-05-08
evidence
evidence
evidence
evidence
evidence
evidence
evidence
evidence
evidence
evidence
evidence
evidence
evidence
evidence
evidence
evidence
evidence
Entry 41 - fullUrl = https://hl7.org/fhir/Condition/encounter-diag-1
Resource Condition:
Generated Narrative: Condition encounter-diag-1
clinicalStatus: Active
verificationStatus: Confirmed
category: Encounter Diagnosis
code: Post-acute COVID-19 (disorder)
subject: Patricia Noelle
encounter: Encounter Reference
onset: 2022-06-01
recordedDate: 2022-06-01
evidence
evidence
evidence
evidence
evidence
evidence
evidence
evidence
Entry 42 - fullUrl = https://hl7.org/fhir/Observation/arterial-blood-gas-panel
Resource Observation:
Generated Narrative: Observation arterial-blood-gas-panel
status: Final
category: Lab, Hematology
code: Arterial Blood Gas
subject: Patricia Noelle Female, DoB: 1955-01-15 ( Medical Record Number: 103270456 (use: usual, ))
effective: 2022-05-01
performer: Performer Reference
specimen: Specimen Reference
hasMember:
Entry 43 - fullUrl = https://hl7.org/fhir/Observation/ph-lab-observation
Resource Observation:
Generated Narrative: Observation ph-lab-observation
status: Final
category: Lab, Hematology
code: pH of Arterial blood
subject: Patricia Noelle Female, DoB: 1955-01-15 ( Medical Record Number: 103270456 (use: usual, ))
effective: 2022-05-01
performer: Performer Reference
value: 7.29 pH (Details: UCUM code[pH] = '[pH]')
specimen: Specimen Reference
ReferenceRanges
Text A real test should include a reference range
Entry 44 - fullUrl = https://hl7.org/fhir/Observation/hco3-arterial-observation
Resource Observation:
Generated Narrative: Observation hco3-arterial-observation
status: Final
category: Lab, Hematology
code: Bicarbonate [Moles/volume] in Arterial blood
subject: Patricia Noelle Female, DoB: 1955-01-15 ( Medical Record Number: 103270456 (use: usual, ))
effective: 2022-05-01
performer: Performer Reference
value: 20 mmol/L (Details: UCUM codemmol/L = 'mmol/L')
specimen: Specimen Reference
ReferenceRanges
Text A real test should include a reference range
Entry 45 - fullUrl = https://hl7.org/fhir/Observation/pCO2-arterial-observation
Resource Observation:
Generated Narrative: Observation pCO2-arterial-observation
status: Final
category: Lab, Hematology
code: Carbon dioxide [Partial pressure] in Arterial blood
subject: Patricia Noelle Female, DoB: 1955-01-15 ( Medical Record Number: 103270456 (use: usual, ))
effective: 2022-05-01
performer: Performer Reference
value: 35 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')
specimen: Specimen Reference
ReferenceRanges
Text A real test should include a reference range
Entry 46 - fullUrl = https://hl7.org/fhir/Observation/pO2-arterial-observation
Resource Observation:
Generated Narrative: Observation pO2-arterial-observation
status: Final
category: Lab, Hematology
code: Oxygen [Partial pressure] in Arterial blood
subject: Patricia Noelle Female, DoB: 1955-01-15 ( Medical Record Number: 103270456 (use: usual, ))
effective: 2022-05-01
performer: Performer Reference
value: 89 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')
specimen: Specimen Reference
ReferenceRanges
Text A real test should include a reference range
Entry 47 - fullUrl = https://hl7.org/fhir/Observation/serum-lactate-observation
Resource Observation:
Generated Narrative: Observation serum-lactate-observation
status: Final
category: Lab, Hematology
code: Lactate [Moles/volume] in Serum or Plasma
subject: Patricia Noelle Female, DoB: 1955-01-15 ( Medical Record Number: 103270456 (use: usual, ))
effective: 2022-05-01
performer: Performer Reference
value: 5 mmol/L (Details: UCUM codemmol/L = 'mmol/L')
specimen: Specimen Reference
ReferenceRanges
Text A real test should include a reference range
Entry 48 - fullUrl = https://hl7.org/fhir/Observation/blood-ketones-observation
Resource Observation:
Generated Narrative: Observation blood-ketones-observation
status: Final
category: Lab, Hematology
code: Ketones [Moles/volume] in Blood
subject: Patricia Noelle Female, DoB: 1955-01-15 ( Medical Record Number: 103270456 (use: usual, ))
effective: 2022-05-01
performer: Performer Reference
value: 3.1 mmol/L (Details: UCUM codemmol/L = 'mmol/L')
specimen: Specimen Reference
ReferenceRanges
Text A real test should include a reference range
Entry 49 - fullUrl = https://hl7.org/fhir/Observation/serum-electrolytes-panel
Resource Observation:
Generated Narrative: Observation serum-electrolytes-panel
status: Final
category: Lab, Chemistry
code: Serum electrolytes
subject: Patricia Noelle Female, DoB: 1955-01-15 ( Medical Record Number: 103270456 (use: usual, ))
effective: 2022-05-01
performer: Performer Reference
specimen: Specimen Reference
hasMember:
- Observation Sodium [Moles/volume] in Serum or Plasma
- Observation Potassium [Moles/volume] in Serum or Plasma
- Observation Chloride [Moles/volume] in Serum or Plasma
- Observation Bicarbonate [Moles/volume] in Serum or Plasma
- Observation Carbon dioxide, total [Moles/volume] in Serum or Plasma
- Observation Carbon dioxide, total [Moles/volume] in Serum or Plasma
Entry 50 - fullUrl = https://hl7.org/fhir/Observation/sodium-serum-observation
Resource Observation:
Generated Narrative: Observation sodium-serum-observation
status: Final
category: Lab, Chemistry
code: Sodium [Moles/volume] in Serum or Plasma
subject: Patricia Noelle Female, DoB: 1955-01-15 ( Medical Record Number: 103270456 (use: usual, ))
effective: 2022-05-01
performer: Performer Reference
value: 135 mmol/L (Details: UCUM codemmol/L = 'mmol/L')
specimen: Specimen Reference
ReferenceRanges
Text A real test should include a reference range
Entry 51 - fullUrl = https://hl7.org/fhir/Observation/potassium-serum-observation
Resource Observation:
Generated Narrative: Observation potassium-serum-observation
status: Final
category: Lab, Chemistry
code: Potassium [Moles/volume] in Serum or Plasma
subject: Patricia Noelle Female, DoB: 1955-01-15 ( Medical Record Number: 103270456 (use: usual, ))
effective: 2022-05-01
performer: Performer Reference
value: 6 mmol/L (Details: UCUM codemmol/L = 'mmol/L')
specimen: Specimen Reference
ReferenceRanges
Text A real test should include a reference range
Entry 52 - fullUrl = https://hl7.org/fhir/Observation/chloride-serum-observation
Resource Observation:
Generated Narrative: Observation chloride-serum-observation
status: Final
category: Lab, Chemistry
code: Chloride [Moles/volume] in Serum or Plasma
subject: Patricia Noelle Female, DoB: 1955-01-15 ( Medical Record Number: 103270456 (use: usual, ))
effective: 2022-05-01
performer: Performer Reference
value: 110 mmol/L (Details: UCUM codemmol/L = 'mmol/L')
specimen: Specimen Reference
ReferenceRanges
Text A real test should include a reference range
Entry 53 - fullUrl = https://hl7.org/fhir/Observation/bicarbonate-serum-observation
Resource Observation:
Generated Narrative: Observation bicarbonate-serum-observation
status: Final
category: Lab, Chemistry
code: Bicarbonate [Moles/volume] in Serum or Plasma
subject: Patricia Noelle Female, DoB: 1955-01-15 ( Medical Record Number: 103270456 (use: usual, ))
effective: 2022-05-01
performer: Performer Reference
value: 20 mmol/L (Details: UCUM codemmol/L = 'mmol/L')
specimen: Specimen Reference
ReferenceRanges
Text A real test should include a reference range
Entry 54 - fullUrl = https://hl7.org/fhir/Observation/carbon-dioxide-serum-observation
Resource Observation:
Generated Narrative: Observation carbon-dioxide-serum-observation
status: Final
category: Lab, Chemistry
code: Carbon dioxide, total [Moles/volume] in Serum or Plasma
subject: Patricia Noelle Female, DoB: 1955-01-15 ( Medical Record Number: 103270456 (use: usual, ))
effective: 2022-05-01
performer: Performer Reference
value: 20 mmol/L (Details: UCUM codemmol/L = 'mmol/L')
specimen: Specimen Reference
ReferenceRanges
Text A real test should include a reference range
Entry 55 - fullUrl = https://hl7.org/fhir/Observation/anion-gap-serum-observation
Resource Observation:
Generated Narrative: Observation anion-gap-serum-observation
status: Final
category: Lab, Chemistry
code: Carbon dioxide, total [Moles/volume] in Serum or Plasma
subject: Patricia Noelle Female, DoB: 1955-01-15 ( Medical Record Number: 103270456 (use: usual, ))
effective: 2022-05-01
performer: Performer Reference
value: 14 mEq/L (Details: UCUM codemeq/L = 'meq/L')
specimen: Specimen Reference
ReferenceRanges
Text A real test should include a reference range
Entry 56 - fullUrl = https://hl7.org/fhir/Observation/protein-serum-observation
Resource Observation:
Generated Narrative: Observation protein-serum-observation
status: Final
category: Lab, Hematology
code: Protein [Mass/volume] in Serum or Plasma
subject: Patricia Noelle Female, DoB: 1955-01-15 ( Medical Record Number: 103270456 (use: usual, ))
effective: 2022-05-01
performer: Performer Reference
value: 4 g/dL (Details: UCUM codeg/dL = 'g/dL')
specimen: Specimen Reference
ReferenceRanges
Text A real test should include a reference range
Entry 57 - fullUrl = https://hl7.org/fhir/Observation/albumin-serum-observation
Resource Observation:
Generated Narrative: Observation albumin-serum-observation
status: Final
category: Lab, Hematology
code: Albumin [Mass/volume] in Serum or Plasma
subject: Patricia Noelle Female, DoB: 1955-01-15 ( Medical Record Number: 103270456 (use: usual, ))
effective: 2022-05-01
performer: Performer Reference
value: 3 g/dL (Details: UCUM codeg/dL = 'g/dL')
specimen: Specimen Reference
ReferenceRanges
Text A real test should include a reference range
Entry 58 - fullUrl = https://hl7.org/fhir/Observation/glomerular-filtration-observation
Resource Observation:
Generated Narrative: Observation glomerular-filtration-observation
status: Final
category: Lab, Hematology
code: Glomerular filtration rate/1.73 sq M.predicted among females [Volume Rate/Area] in Serum, Plasma or Blood by Creatinine-based formula (MDRD)
subject: Patricia Noelle Female, DoB: 1955-01-15 ( Medical Record Number: 103270456 (use: usual, ))
effective: 2022-05-01
performer: Performer Reference
value: 15 mL/min/{1.73_m2} (Details: UCUM codemL/min/{1.73_m2} = 'mL/min/{1.73_m2}')
specimen: Specimen Reference
ReferenceRanges
Text A real test should include a reference range
Entry 59 - fullUrl = https://hl7.org/fhir/Observation/symptom2
Resource Observation:
Generated Narrative: Observation symptom2
status: Final
category: Symptom
code: Symptom
subject: Patricia Noelle
effective: 2022-05-01
performer: Dr. John Carlson
value: Dyspnea (finding)
Entry 60 - fullUrl = https://hl7.org/fhir/Observation/symptom3
Resource Observation:
Generated Narrative: Observation symptom3
status: Final
category: Symptom
code: Symptom
subject: Patricia Noelle
effective: 2022-05-01
performer: Dr. John Carlson
value: Pain in bilateral legs (finding)
Entry 61 - fullUrl = https://hl7.org/fhir/Observation/symptom4
Resource Observation:
Generated Narrative: Observation symptom4
status: Final
category: Symptom
code: Symptom
subject: Patricia Noelle
effective: 2022-05-01
performer: Dr. John Carlson
value: Pain of bilateral hands (finding)
Entry 62 - fullUrl = https://hl7.org/fhir/Observation/symptom5
Resource Observation:
Generated Narrative: Observation symptom5
status: Final
category: Symptom
code: Symptom
subject: Patricia Noelle
effective: 2022-05-01
performer: Dr. John Carlson
value: Pain in bilateral upper arms (finding)
Entry 63 - fullUrl = https://hl7.org/fhir/Observation/symptom6
Resource Observation:
Generated Narrative: Observation symptom6
status: Final
category: Symptom
code: Symptom
subject: Patricia Noelle
effective: 2022-05-01
performer: Dr. Vince Jones
value: Intermittent confusion (finding)
Entry 64 - fullUrl = https://hl7.org/fhir/Observation/symptom7
Resource Observation:
Generated Narrative: Observation symptom7
status: Final
category: Symptom
code: Symptom
subject: Patricia Noelle
effective: 2022-05-01
performer: Dr. Vince Jones
value: Memory impairment (finding)
derivedFrom: Observation Montreal Cognitive Assessment [MoCA]
Entry 65 - fullUrl = https://hl7.org/fhir/Observation/symptom8
Resource Observation:
Generated Narrative: Observation symptom8
status: Final
category: Symptom
code: Symptom
subject: Patricia Noelle
effective: 2022-05-01
performer: Dr. Vince Jones
value: Toe swelling (finding)
Entry 66 - fullUrl = https://hl7.org/fhir/Observation/symptom9
Resource Observation:
Generated Narrative: Observation symptom9
status: Final
category: Symptom
code: Symptom
subject: Patricia Noelle
effective: 2022-05-01
performer: Dr. Vince Jones
value: Pustular chilblain (disorder)
Entry 67 - fullUrl = https://hl7.org/fhir/Condition/chilblain-resolved
Resource Condition:
Generated Narrative: Condition chilblain-resolved
identifier:
http://www.acme.org/businessIdentifiers/aConditionIdentifierToTrackThisChangingConditionclinicalStatus: Resolved
verificationStatus: Confirmed
category: Problem
code: Pustular chilblain (disorder)
subject: Patricia Noelle
onset: 2022-05-01
abatement: 2022-12-12
recordedDate: 2022-05-01
Entry 68 - fullUrl = https://hl7.org/fhir/Goal/lower-pain-minimal-opioids
Resource Goal:
Generated Narrative: Goal lower-pain-minimal-opioids
Last updated: 2020-12-14 00:00:00+0000
lifecycleStatus: Completed
achievementStatus: Achieved
priority: high
description: Decrease Pain with minimal opioids and alternative methods
subject: Patricia Noelle
start: 2020-05-14
statusDate: 2020-12-14
statusReason: Goal met
addresses:
Entry 69 - fullUrl = https://hl7.org/fhir/Observation/reduced-pain
Resource Observation:
Generated Narrative: Observation reduced-pain
status: Final
category: Caregivers thoughts on the patient's condition status
code: Observation on patient/caregiver feelings on the condition status
subject: Patricia Noelle
focus:
- Condition Pain in bilateral legs (finding)
- Condition Pain of bilateral hands (finding)
- Condition Pain in bilateral upper arms (finding)
- Condition
- Condition
effective: 2022-11-10 16:48:57-0800
performer: RelatedPerson Rose Noelle
value: Improved
Entry 70 - fullUrl = https://hl7.org/fhir/Goal/appetite-to-normal
Resource Goal:
Generated Narrative: Goal appetite-to-normal
Last updated: 2020-12-14 00:00:00+0000
lifecycleStatus: Active
achievementStatus: In Progress
priority: high
description: Achieve adequate appetite level
subject: Patricia Noelle
start: 2020-05-08
statusReason: Goal initiated
addresses:
Entry 71 - fullUrl = https://hl7.org/fhir/Goal/electrolyte-protein-normal-range
Resource Goal:
Generated Narrative: Goal electrolyte-protein-normal-range
Last updated: 2020-12-14 00:00:00+0000
lifecycleStatus: Active
achievementStatus: In Progress
priority: high
description: Achieve electrolyte and protein levels in normal range
subject: Patricia Noelle
start: 2020-05-08
Targets
Measure Detail[x] Albumin [Mass/volume] in Serum or Plasma 3.5-5.5 g/dL statusReason: Goal initiated
addresses:
Entry 72 - fullUrl = https://hl7.org/fhir/Goal/bmi-normal-range
Resource Goal:
Generated Narrative: Goal bmi-normal-range
Last updated: 2020-12-14 00:00:00+0000
lifecycleStatus: Active
achievementStatus: In Progress
priority: high
description: Lower high BMI count by losing 10 lbs. in 1 year
subject: Patricia Noelle
start: 2020-05-08
Targets
Measure Detail[x] Due[x] Body Weight 60-64 kg 2021-05-12 statusReason: Goal initiated
addresses:
Entry 73 - fullUrl = https://hl7.org/fhir/Goal/access-affordable-healthy-food
Resource Goal:
Generated Narrative: Goal access-affordable-healthy-food
Last updated: 2020-12-14 00:00:00+0000
lifecycleStatus: Active
achievementStatus: In Progress
priority: high
description: Improve access to affordable healthy food
subject: Patricia Noelle
start: 2020-05-08
statusReason: Goal initiated
addresses:
IG © 2020+ HL7 International / Patient Care. Package hl7.fhir.us.mcc#1.0.0 based on FHIR 4.0.1. Generated 2024-08-13
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