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
{
"resourceType" : "CarePlan",
"id" : "careplan-for-bundle",
"meta" : {
"profile" : [
🔗 "http://hl7.org/fhir/us/mcc/StructureDefinition/mccCarePlan"
]
},
"text" : {
"status" : "additional",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Narrative: CarePlan </b><a name=\"careplan-for-bundle\"></a><a name=\"hccareplan-for-bundle\"></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\">ResourceCarePlan \"careplan-for-bundle\"</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-mccCarePlan.html\">Multiple Chronic Care Condition Care Plan</a></p></div><p><b>Custodian R5 backport</b>: <a href=\"Practitioner-practitionerMCC-3v.html\">Practitioner/practitionerMCC-3v: Dr. John Carlson</a> \" CARLSON\"</p><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/STU6.1/CodeSystem-careplan-category.html\">US Core CarePlan Category Extension Codes[6.1.0]</a>#assess-plan)</span></p><p><b>subject</b>: <a href=\"Patient-cc-pat-pnoelle.html\">Patient/cc-pat-pnoelle: Patricia Noelle</a> \" NOELLE\"</p><p><b>period</b>: 2022-05-20 --> (ongoing)</p><p><b>created</b>: 2022-05-20</p><p><b>contributor</b>:</p><ul><li><a href=\"Practitioner-practitionerMCC-3v.html\">Practitioner/practitionerMCC-3v: Dr John Carlson, Primary Care Physician</a> \" CARLSON\"</li><li><a href=\"PractitionerRole-careCoordinator-1.html\">PractitionerRole/careCoordinator-1: Care-coordinator, served by Julie Smith</a></li><li><a href=\"Patient-cc-pat-pnoelle.html\">Patient/cc-pat-pnoelle: Noelle</a> \" NOELLE\"</li><li><a href=\"PractitionerRole-dr-vince-jones.html\">PractitionerRole/dr-vince-jones: Nephrologist Role, served by Dr Vince Jones</a></li><li><a href=\"RelatedPerson-daughter1.html\">RelatedPerson/daughter1: Rose Noelle, Daughter</a> \" ROSE\"</li></ul><p><b>careTeam</b>: <a href=\"CareTeam-careteam-for-bundle.html\">CareTeam/careteam-for-bundle: Long-COVID and CKD focused care team</a> \"Care Team of Noelle Example for LONG-COVID bundle\"</p><p><b>addresses</b>:</p><ul><li><a href=\"Condition-ConditionCKD.html\">Condition/ConditionCKD: Chronic Kidney Disease</a></li><li><a href=\"Condition-encounter-diag-1.html\">Condition/encounter-diag-1: Long COVID</a></li></ul><p><b>supportingInfo</b>:</p><ul><li><a href=\"Observation-arterial-blood-gas-panel.html\">Observation/arterial-blood-gas-panel</a></li><li><a href=\"Observation-reduced-pain.html\">Observation/reduced-pain: Outcome example. Caregiver's observed thoughts on pain</a></li><li><a href=\"Condition-patient-health-concern-1.html\">Condition/patient-health-concern-1: Patient Health Concern: Worry that Long Covid symptoms will effect CKD</a></li><li><a href=\"Condition-patient-health-concern-2.html\">Condition/patient-health-concern-2: Patient Health Concern: Hard to exercise due to pain</a></li><li><a href=\"Condition-patient-health-concern-3.html\">Condition/patient-health-concern-3: Patient Health Concern: Struggles to manage her diet and find affordable healthy food choices under her financial strain</a></li><li><a href=\"Condition-patient-health-concern-4.html\">Condition/patient-health-concern-4: Patient Health Concern: Poor appetite for healthy CKD appropriate foods, likes cola, cake and chips</a></li><li><a href=\"Condition-careTeam-concerns-1.html\">Condition/careTeam-concerns-1: CareTeam Health Concern: Imbalanced Nutrition</a></li><li><a href=\"Condition-careTeam-concerns-2.html\">Condition/careTeam-concerns-2: CareTeam Health Concern: Dyspnea</a></li><li><a href=\"Condition-careTeam-concerns-3.html\">Condition/careTeam-concerns-3: CareTeam Health Concern: Pain in Legs</a></li><li><a href=\"Condition-careTeam-concerns-4.html\">Condition/careTeam-concerns-4: CareTeam Health Concern: Pain in Hands</a></li><li><a href=\"Condition-careTeam-concerns-5.html\">Condition/careTeam-concerns-5: CareTeam Health Concern: Pain in arms</a></li><li><a href=\"Condition-problem-list-1.html\">Condition/problem-list-1: Finding: Food aversion and cravings</a></li><li><a href=\"Condition-problem-list-2.html\">Condition/problem-list-2: Diagnosis: Metabolic acidosis</a></li><li><a href=\"Condition-chilblain-resolved.html\">Condition/chilblain-resolved: Long Covid related condition: Pustular chilblain resolved</a></li><li><a href=\"Observation-symptom2.html\">Observation/symptom2: Long Covid symptom: Dyspnea</a></li><li><a href=\"Observation-symptom3.html\">Observation/symptom3: Long Covid symptom: Pain in Legs</a></li><li><a href=\"Observation-symptom4.html\">Observation/symptom4: Long Covid symptom: Pain in hands</a></li><li><a href=\"Observation-symptom5.html\">Observation/symptom5: Long Covid symptom: Pain in arms</a></li><li><a href=\"Observation-symptom6.html\">Observation/symptom6: Long Covid symptom: Brain Fog - Intermittent confusion</a></li><li><a href=\"Observation-symptom7.html\">Observation/symptom7: Long Covid symptom: Brain Fog - Memory impairment</a></li><li><a href=\"Observation-symptom8.html\">Observation/symptom8: Long Covid symptom: Covid Toes - Toe swelling</a></li><li><a href=\"Observation-symptom9.html\">Observation/symptom9: Long Covid symptom: Covid Toes - Pustular chilblain</a></li></ul><p><b>goal</b>:</p><ul><li><a href=\"Goal-lower-pain-minimal-opioids.html\">Goal/lower-pain-minimal-opioids: Lower pain with minimal opioids</a></li><li><a href=\"Goal-appetite-to-normal.html\">Goal/appetite-to-normal: Return appetite to normal</a></li><li><a href=\"Goal-electrolyte-protein-normal-range.html\">Goal/electrolyte-protein-normal-range: Get Electrolyte and proteins back to normal</a></li><li><a href=\"Goal-bmi-normal-range.html\">Goal/bmi-normal-range: Get BMI into healthy range</a></li><li><a href=\"Goal-access-affordable-healthy-food.html\">Goal/access-affordable-healthy-food: Improve access to affordable, healthy food</a></li></ul><blockquote><p><b>activity</b></p><p><b>outcomeReference</b>:</p><ul><li><a href=\"Procedure-dietitian-consult.html\">Procedure/dietitian-consult: Dietitian consult</a></li><li><a href=\"Observation-better-diet.html\">Observation/better-diet: Observation by caregiver (daughter) of improvement in diet</a></li></ul><p><b>reference</b>: <a href=\"ServiceRequest-dietitian-referral.html\">ServiceRequest/dietitian-referral: Dietitian Referral</a></p></blockquote><blockquote><p><b>activity</b></p><p><b>outcomeReference</b>:</p><ul><li><a href=\"Procedure-dialysis-for-bundle.html\">Procedure/dialysis-for-bundle</a></li><li><a href=\"Procedure-dialysis-for-bundle2.html\">Procedure/dialysis-for-bundle2</a></li><li><a href=\"Procedure-dialysis-for-bundle3.html\">Procedure/dialysis-for-bundle3</a></li></ul><p><b>reference</b>: <a href=\"ServiceRequest-dialysis-request.html\">ServiceRequest/dialysis-request</a></p></blockquote><blockquote><p><b>activity</b></p><p><b>outcomeReference</b>: <a href=\"Procedure-ckd-app-education.html\">Procedure/ckd-app-education</a></p></blockquote><blockquote><p><b>activity</b></p><p><b>outcomeReference</b>:</p><ul><li><a href=\"MedicationRequest-med-for-chilblains.html\">MedicationRequest/med-for-chilblains: Treatment for chilblains</a></li><li><a href=\"Condition-chilblain-resolved.html\">Condition/chilblain-resolved</a></li><li><a href=\"ServiceRequest-pt-3x-wk.html\">ServiceRequest/pt-3x-wk: PT 3x per week</a></li><li><a href=\"ServiceRequest-counseling-1x-wk.html\">ServiceRequest/counseling-1x-wk: Counseling 1x per week</a></li><li><a href=\"Task-meditation-7x-wk.html\">Task/meditation-7x-wk: Meditation 7x per week</a></li><li><a href=\"Observation-observation-moca.html\">Observation/observation-moca: MOCA new result showing improvement</a></li><li><a href=\"Observation-observation-moca-original.html\">Observation/observation-moca-original: MOCA initial result showing impairment</a></li></ul><p><b>progress</b>: Long COVID symptoms improving ( @2022-12-10)</p><p><b>reference</b>: <a href=\"ServiceRequest-long-covid-request.html\">ServiceRequest/long-covid-request: Long Covid Clinic Referral serviceRequest</a></p></blockquote></div>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/us/mcc/StructureDefinition/custodian",
"valueReference" : {
🔗 "reference" : "Practitioner/practitionerMCC-3v",
"display" : "Dr. John Carlson"
}
}
],
"status" : "active",
"intent" : "plan",
"category" : [
{
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "734163000",
"display" : "Care Plan"
},
{
"system" : "http://hl7.org/fhir/us/core/CodeSystem/careplan-category",
"version" : "6.1.0",
"code" : "assess-plan"
}
]
}
],
"subject" : {
🔗 "reference" : "Patient/cc-pat-pnoelle",
"display" : "Patricia Noelle"
},
"period" : {
"start" : "2022-05-20"
},
"created" : "2022-05-20",
"contributor" : [
{
🔗 "reference" : "Practitioner/practitionerMCC-3v",
"display" : "Dr John Carlson, Primary Care Physician"
},
{
🔗 "reference" : "PractitionerRole/careCoordinator-1",
"display" : "Care-coordinator, served by Julie Smith"
},
{
🔗 "reference" : "Patient/cc-pat-pnoelle",
"display" : "Noelle"
},
{
🔗 "reference" : "PractitionerRole/dr-vince-jones",
"display" : "Nephrologist Role, served by Dr Vince Jones"
},
{
🔗 "reference" : "RelatedPerson/daughter1",
"display" : "Rose Noelle, Daughter"
}
],
"careTeam" : [
{
🔗 "reference" : "CareTeam/careteam-for-bundle",
"display" : "Long-COVID and CKD focused care team"
}
],
"addresses" : [
{
🔗 "reference" : "Condition/ConditionCKD",
"display" : "Chronic Kidney Disease"
},
{
🔗 "reference" : "Condition/encounter-diag-1",
"display" : "Long COVID"
}
],
"supportingInfo" : [
{
🔗 "reference" : "Observation/arterial-blood-gas-panel"
},
{
🔗 "reference" : "Observation/reduced-pain",
"display" : "Outcome example. Caregiver's observed thoughts on pain"
},
{
🔗 "reference" : "Condition/patient-health-concern-1",
"display" : "Patient Health Concern: Worry that Long Covid symptoms will effect CKD"
},
{
🔗 "reference" : "Condition/patient-health-concern-2",
"display" : "Patient Health Concern: Hard to exercise due to pain"
},
{
🔗 "reference" : "Condition/patient-health-concern-3",
"display" : "Patient Health Concern: Struggles to manage her diet and find affordable healthy food choices under her financial strain"
},
{
🔗 "reference" : "Condition/patient-health-concern-4",
"display" : "Patient Health Concern: Poor appetite for healthy CKD appropriate foods, likes cola, cake and chips"
},
{
🔗 "reference" : "Condition/careTeam-concerns-1",
"display" : "CareTeam Health Concern: Imbalanced Nutrition"
},
{
🔗 "reference" : "Condition/careTeam-concerns-2",
"display" : "CareTeam Health Concern: Dyspnea"
},
{
🔗 "reference" : "Condition/careTeam-concerns-3",
"display" : "CareTeam Health Concern: Pain in Legs"
},
{
🔗 "reference" : "Condition/careTeam-concerns-4",
"display" : "CareTeam Health Concern: Pain in Hands"
},
{
🔗 "reference" : "Condition/careTeam-concerns-5",
"display" : "CareTeam Health Concern: Pain in arms"
},
{
🔗 "reference" : "Condition/problem-list-1",
"display" : "Finding: Food aversion and cravings"
},
{
🔗 "reference" : "Condition/problem-list-2",
"display" : "Diagnosis: Metabolic acidosis"
},
{
🔗 "reference" : "Condition/chilblain-resolved",
"display" : "Long Covid related condition: Pustular chilblain resolved"
},
{
🔗 "reference" : "Observation/symptom2",
"display" : "Long Covid symptom: Dyspnea"
},
{
🔗 "reference" : "Observation/symptom3",
"display" : "Long Covid symptom: Pain in Legs"
},
{
🔗 "reference" : "Observation/symptom4",
"display" : "Long Covid symptom: Pain in hands"
},
{
🔗 "reference" : "Observation/symptom5",
"display" : "Long Covid symptom: Pain in arms"
},
{
🔗 "reference" : "Observation/symptom6",
"display" : "Long Covid symptom: Brain Fog - Intermittent confusion"
},
{
🔗 "reference" : "Observation/symptom7",
"display" : "Long Covid symptom: Brain Fog - Memory impairment"
},
{
🔗 "reference" : "Observation/symptom8",
"display" : "Long Covid symptom: Covid Toes - Toe swelling"
},
{
🔗 "reference" : "Observation/symptom9",
"display" : "Long Covid symptom: Covid Toes - Pustular chilblain"
}
],
"goal" : [
{
🔗 "reference" : "Goal/lower-pain-minimal-opioids",
"display" : "Lower pain with minimal opioids"
},
{
🔗 "reference" : "Goal/appetite-to-normal",
"display" : "Return appetite to normal"
},
{
🔗 "reference" : "Goal/electrolyte-protein-normal-range",
"display" : "Get Electrolyte and proteins back to normal"
},
{
🔗 "reference" : "Goal/bmi-normal-range",
"display" : "Get BMI into healthy range"
},
{
🔗 "reference" : "Goal/access-affordable-healthy-food",
"display" : "Improve access to affordable, healthy food"
}
],
"activity" : [
{
"outcomeReference" : [
{
🔗 "reference" : "Procedure/dietitian-consult",
"display" : "Dietitian consult"
},
{
🔗 "reference" : "Observation/better-diet",
"display" : "Observation by caregiver (daughter) of improvement in diet"
}
],
"reference" : {
🔗 "reference" : "ServiceRequest/dietitian-referral",
"display" : "Dietitian Referral"
}
},
{
"outcomeReference" : [
{
🔗 "reference" : "Procedure/dialysis-for-bundle"
},
{
🔗 "reference" : "Procedure/dialysis-for-bundle2"
},
{
🔗 "reference" : "Procedure/dialysis-for-bundle3"
}
],
"reference" : {
🔗 "reference" : "ServiceRequest/dialysis-request"
}
},
{
"outcomeReference" : [
{
🔗 "reference" : "Procedure/ckd-app-education"
}
]
},
{
"outcomeReference" : [
{
🔗 "reference" : "MedicationRequest/med-for-chilblains",
"display" : "Treatment for chilblains"
},
{
🔗 "reference" : "Condition/chilblain-resolved"
},
{
🔗 "reference" : "ServiceRequest/pt-3x-wk",
"display" : "PT 3x per week"
},
{
🔗 "reference" : "ServiceRequest/counseling-1x-wk",
"display" : "Counseling 1x per week"
},
{
🔗 "reference" : "Task/meditation-7x-wk",
"display" : "Meditation 7x per week"
},
{
🔗 "reference" : "Observation/observation-moca",
"display" : "MOCA new result showing improvement"
},
{
🔗 "reference" : "Observation/observation-moca-original",
"display" : "MOCA initial result showing impairment"
}
],
"progress" : [
{
"time" : "2022-12-10",
"text" : "Long COVID symptoms improving"
}
],
"reference" : {
🔗 "reference" : "ServiceRequest/long-covid-request",
"display" : "Long Covid Clinic Referral serviceRequest"
}
}
]
}
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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