MCC eCare Plan Implementation Guide
1.0.0 - STU1 United States of America flag

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

: careplan-for-bundle - XML Representation

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