MCC eCare Plan Implementation Guide
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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 in its permanent home (it will always be available at this URL). 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:id [ fhir:v "MCCCarePlan"] ; # 
  fhir:meta [
    ( fhir:extension [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/instance-name"^^xsd:anyURI ] ;
fhir:value [ fhir:v "Multiple Chronic Condition Care Plan Example" ]     ] [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/instance-description"^^xsd:anyURI ] ;
fhir:value [ fhir:v "This is an example for the *MCC CarePlan Profile*." ]     ] ) ;
    ( fhir:profile [
fhir:v "http://hl7.org/fhir/us/mcc/StructureDefinition/mccCarePlan"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/mcc/StructureDefinition/mccCarePlan>     ] )
  ] ; # 
  fhir:text [
fhir:status [ fhir:v "additional" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>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; </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=\"RelatedPerson-caregiver-of-noelle.html\">RelatedPerson/caregiver-of-noelle</a> &quot; VAN PUTTEN&quot;</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</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. The goal relationship is through resource-pertainsToGoal for the Encounter</a></p></blockquote></div>"
  ] ; # 
  fhir:extension ( [
fhir:url [ fhir:v "http://hl7.org/fhir/us/mcc/StructureDefinition/custodian"^^xsd:anyURI ] ;
fhir:value [
a fhir:Reference ;
fhir:reference [ fhir:v "RelatedPerson/caregiver-of-noelle" ]     ]
  ] ) ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:intent [ fhir:v "plan"] ; # 
  fhir:category ( [
    ( fhir:coding [
a sct:734163000 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "734163000" ] ;
fhir:display [ fhir:v "Care Plan" ]     ] [
fhir:system [ fhir:v "http://hl7.org/fhir/us/core/CodeSystem/careplan-category"^^xsd:anyURI ] ;
fhir:version [ fhir:v "6.1.0" ] ;
fhir:code [ fhir:v "assess-plan" ]     ] )
  ] ) ; # 
  fhir:subject [
fhir:reference [ fhir:v "Patient/cc-pat-pnoelle" ] ;
fhir:display [ fhir:v "Patricia Noelle" ]
  ] ; # 
  fhir:period [
fhir:start [ fhir:v "2018-05-01"^^xsd:date ]
  ] ; # 
  fhir:created [ fhir:v "2019-01-01"^^xsd:date] ; # 
  fhir:contributor ( [
fhir:reference [ fhir:v "PractitionerRole/PractitionerRoleMCC1" ] ;
fhir:display [ fhir:v "Henry Levin VII MD Nephrologist" ]
  ] [
fhir:reference [ fhir:v "PractitionerRole/PractitionerRoleMCC2" ] ;
fhir:display [ fhir:v "Nancy Nurse RN" ]
  ] [
fhir:reference [ fhir:v "PractitionerRole/PractitionerRoleMCC3" ] ;
fhir:display [ fhir:v "Peter Primary MD Primary Provider" ]
  ] ) ; # author>
#        <reference value="PractitionerRole/PractitionerRoleMCC2"/>
#        <display value="Nancy Nurse RN"/>
#    </author
  fhir:careTeam ( [
fhir:reference [ fhir:v "CareTeam/MCCCareTeamexample" ] ;
fhir:display [ fhir:v "Longitudinal care-coordination focused care team" ]
  ] ) ; # 
  fhir:addresses ( [
fhir:reference [ fhir:v "Condition/ConditionCKD" ] ;
fhir:display [ fhir:v "Chronic Kidney Disease" ]
  ] ) ; # 
  fhir:supportingInfo ( [
fhir:reference [ fhir:v "Procedure/Dialysis" ] ;
fhir:display [ fhir:v "Chronic Pain" ]
  ] [
fhir:reference [ fhir:v "Observation/bunMCC" ] ;
fhir:display [ fhir:v "BUN 24 mL/min/{1.73_m2}" ]
  ] ) ; # 
  fhir:goal ( [
fhir:reference [ fhir:v "Goal/WGT-loss" ] ;
fhir:display [ fhir:v "Lose weight, decrease chronic pain with less use of pain medication and improved lab results" ]
  ] ) ; # 
  fhir:activity ( [
    ( fhir:outcomeReference [
fhir:reference [ fhir:v "Procedure/Dialysis" ] ;
fhir:display [ fhir:v "Dialysis" ]     ] ) ;
    ( fhir:progress [
fhir:time [ fhir:v "2019-01-10"^^xsd:date ] ;
fhir:text [ fhir:v "Patricia Noelle is measuring her weight daily" ]     ] ) ;
fhir:reference [
fhir:link <http://example.org/Task/123> ;
fhir:reference [ fhir:v "http://example.org/Task/123" ] ;
fhir:display [ fhir:v "Patricia Noelle or cargiver to perform daily weights" ]     ]
  ] [
    ( fhir:outcomeReference [
fhir:link <http://example.org/Encounter/123> ;
fhir:reference [ fhir:v "http://example.org/Encounter/123" ] ;
fhir:display [ fhir:v "PreOp Encounter For Creation of external arteriovenous shunt (procedure)" ]     ] [
fhir:link <http://example.org/Procedure/upperlimbveinUS> ;
fhir:reference [ fhir:v "http://example.org/Procedure/upperlimbveinUS" ] ;
fhir:display [ fhir:v "Fluoroscopic venography of bilateral upper limbs Performed. Results: Normal" ]     ] ) ;
    ( fhir:progress [
fhir:time [ fhir:v "2019-01-10"^^xsd:date ] ;
fhir:text [ fhir:v "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:reference [
fhir:link <http://example.org/Appointment/AVShunt> ;
fhir:reference [ fhir:v "http://example.org/Appointment/AVShunt" ] ;
fhir:display [ fhir:v "PreOp Encounter Request For Creation of external arteriovenous shunt (procedure). Relates to overall health improvement goal and encounter requestActivity" ]     ]
  ] ) . #