Narrative: CarePlan

Custodian R5 backport: RelatedPerson/caregiver-of-noelle " VAN PUTTEN"

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:

• PractitionerRole/PractitionerRoleMCC1: Henry Levin VII MD Nephrologist
• PractitionerRole/PractitionerRoleMCC2: Nancy Nurse RN
• PractitionerRole/PractitionerRoleMCC3: Peter Primary MD Primary Provider

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

addresses: Condition/ConditionCKD: Chronic Kidney Disease

supportingInfo:

• Procedure/Dialysis: Chronic Pain
• Observation/bunMCC: BUN 24 mL/min/{1.73_m2}

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:

• http://example.org/Encounter/123: PreOp Encounter For Creation of external arteriovenous shunt (procedure)
• http://example.org/Procedure/upperlimbveinUS: Fluoroscopic venography of bilateral upper limbs Performed. Results: Normal

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. The goal relationship is through resource-pertainsToGoal for the Encounter