Narrative: CarePlan

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:

• Condition/ConditionCKD: Chronic Kidney Disease
• Condition/encounter-diag-1: Long COVID

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:

• Procedure/dialysis-for-bundle
• Procedure/dialysis-for-bundle2
• Procedure/dialysis-for-bundle3

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