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

Table of Contents

.. 0 Table of Contents
... 1 Home Page
... 2 MCC Use Cases
... 3 Structure and Design Considerations
... 4 Alternatives for Transmitting/Collecting Aggregated Care Plans
... 5 Security
... 6 Questionnaire Response
... 7 MCC Care Plan SDOH Guidance
... 8 Note on _include and _revinclude
... 9 US Core General Requirements
... 10 MCC Must-support
... 11 Capability Statements
... 12 MCC Value Set Libraries and Usage
.... 12.1 MCC Chronic Condition and Health Concern Value Sets
.... 12.2 MCC Clinical Test Value Sets
.... 12.3 MCC Goal Value Sets
.... 12.4 MCC Laboratory Result Value Sets
.... 12.5 MCC Medication Request Value Sets
.... 12.6 MCC Diagnostic Report and Note Imaging Value Sets
.... 12.7 MCC Observation SDOH Assessment Value Sets
.... 12.8 MCC Procedure and Service Request Value Sets
.... 12.9 MCC Questionnaire Response Value Sets
.... 12.10 MCC Simple Observation Value Sets
.... 12.11 MCC Symptom Value Sets
... 13 Downloads
... 14 Artifacts Summary
.... 14.1 Multiple Chronic Care Condition Care Plan
.... 14.2 Multiple Chronic Condition Care Plan Caregiver Considerations Observation
.... 14.3 MCCCareTeam
.... 14.4 MCC Chronic Condition and Health Concern Profile
.... 14.5 Multiple Chronic Condition Care Plan Clinical Impression
.... 14.6 Multiple Chronic Condition Care Plan Clinical Result Observation
.... 14.7 Multiple Chronic Condition Care Plan Diagnostic Report and Note
.... 14.8 Document Reference to Patient's Personal Advance Care Plan (Advance Directive)
.... 14.9 Multiple Chronic Condition Care Plan Family History
.... 14.10 Multiple Chronic Condition Care Plan Goal
.... 14.11 Multiple Chronic Condition Care Plan Immunization
.... 14.12 Multiple Chronic Condition Care Plan Laboratory Result Observation
.... 14.13 Multiple Chronic Condition Care Plan Medication Request
.... 14.14 Multiple Chronic Condition Care Plan Nutrition Order
.... 14.15 Multiple Chronic Condition Care Plan Observation SDOH Assessment
.... 14.16 Multiple Chronic Condition Care Plan Patient/Caregiver Condition Status Observation
.... 14.17 Multiple Chronic Condition Care Plan Procedure
.... 14.18 Multiple Chronic Condition Care Plan Questionnaire Response
.... 14.19 Multiple Chronic Condition Care Plan Service Request
.... 14.20 Multiple Chronic Condition Care Plan Simple Observation
.... 14.21 Multiple Chronic Condition Care Plan Symptom Observation
.... 14.22 Multiple Chronic Condition Care Plan Clinical Imaging Observation
.... 14.23 long-covid-and-ckd-bundle
.... 14.24 observation-moca
.... 14.25 questionnnaire-res-moca
.... 14.26 obs-response-moca
.... 14.27 observation-moca-original
.... 14.28 questionnnaire-res-moca-original
.... 14.29 obs-response-moca-original
.... 14.30 dialysis-request
.... 14.31 dialysis-for-bundle
.... 14.32 dialysis-for-bundle2
.... 14.33 dialysis-for-bundle3
.... 14.34 ckd-app-education
.... 14.35 dietitian-referral
.... 14.36 dietitian-consult
.... 14.37 better-diet
.... 14.38 long-covid-request
.... 14.39 med-for-chilblains
.... 14.40 pt-3x-wk
.... 14.41 counseling-1x-wk
.... 14.42 meditation-7x-wk
.... 14.43 careplan-for-bundle
.... 14.44 daughter1
.... 14.45 practitionerMCC-V
.... 14.46 dr-vince-jones
.... 14.47 practitionerMCC-3v
.... 14.48 careCoordinator1
.... 14.49 funding1
.... 14.50 communitysite
.... 14.51 careCoordinator-1
.... 14.52 careteam-for-bundle
.... 14.53 patient-health-concern-1
.... 14.54 patient-health-concern-2
.... 14.55 patient-health-concern-3
.... 14.56 patient-health-concern-4
.... 14.57 careTeam-concerns-1
.... 14.58 careTeam-concerns-2
.... 14.59 careTeam-concerns-3
.... 14.60 careTeam-concerns-4
.... 14.61 careTeam-concerns-5
.... 14.62 problem-list-1
.... 14.63 problem-list-2
.... 14.64 encounter-diag-1
.... 14.65 arterial-blood-gas-panel
.... 14.66 ph-lab-observation
.... 14.67 hco3-arterial-observation
.... 14.68 pCO2-arterial-observation
.... 14.69 pO2-arterial-observation
.... 14.70 serum-lactate-observation
.... 14.71 blood-ketones-observation
.... 14.72 serum-electrolytes-panel
.... 14.73 sodium-serum-observation
.... 14.74 potassium-serum-observation
.... 14.75 chloride-serum-observation
.... 14.76 bicarbonate-serum-observation
.... 14.77 carbon-dioxide-serum-observation
.... 14.78 anion-gap-serum-observation
.... 14.79 protein-serum-observation
.... 14.80 albumin-serum-observation
.... 14.81 glomerular-filtration-observation
.... 14.82 symptom2
.... 14.83 symptom3
.... 14.84 symptom4
.... 14.85 symptom5
.... 14.86 symptom6
.... 14.87 symptom7
.... 14.88 symptom8
.... 14.89 symptom9
.... 14.90 chilblain-found
.... 14.91 chilblain-resolved
.... 14.92 lower-pain-minimal-opioids
.... 14.93 reduced-pain
.... 14.94 appetite-to-normal
.... 14.95 electrolyte-protein-normal-range
.... 14.96 bmi-normal-range
.... 14.97 access-affordable-healthy-food
.... 14.98 MCCServerCapabilityStatement
.... 14.99 MCCClientCapabilityStatement
.... 14.100 Change Pattern R5 backport
.... 14.101 Custodian R5 backport
.... 14.102 Multiple Chronic Condition Care Plan Example
.... 14.103 MCC Procedure Example - Dialysis
.... 14.104 MCC Diagnostic Report and Note Example
.... 14.105 MCC Family Member History Example - Father
.... 14.106 MCC Document Reference to Advance Directives Example
.... 14.107 MCC Chronic Condition - CKD Example
.... 14.108 MCC Goal Example - Weight Loss
.... 14.109 MCC Practitioner - Nephrologist
.... 14.110 MCC Practitioner - Nurse Practitioner
.... 14.111 MCC Practitioner - Primary Care Provider
.... 14.112 MCC Practitioner - Nephrologist Provider Role
.... 14.113 MCC Practitioner - Nurse Practitioner Role
.... 14.114 MCC Practitioner - Primary Care Provider Role
.... 14.115 MCC Lab Observation - BUN
.... 14.116 MCC Patient
.... 14.117 Multiple Chronic Condition Care Plan Care Team
.... 14.118 MCC Goal Example - Normal Hypertension
.... 14.119 US-Core MCC Weight Example
.... 14.120 MCC Medication Request Example
.... 14.121 MCC Symptom Observation Example - Taste Sense Altered
.... 14.122 Multiple Chronic Condition Care Plan Immunization Example
.... 14.123 Multiple Chronic Condition Care Plan Nutrition Order Example
.... 14.124 Multiple Chronic Condition Care Plan Clinical Impression Example
.... 14.125 MCC Care Team Example
.... 14.126 Caregiver Example
.... 14.127 MCC QuestionnaireResponse Example
.... 14.128 Multiple Chronic Condition Care Plan Imagining Observation Example
.... 14.129 Expansion Parameters SNOMED US Version
.... 14.130 MCC Clinical Result Observation example
.... 14.131 MCC Caregiver Feelings on Condition Observation example
.... 14.132 MCC SDOH assessment example Observation
.... 14.133 Multiple Chronic Condition Service Request - Food Pantry
.... 14.134 Multiple Chronic Condition Care Plan Simple Observation Example
.... 14.135 MCC Observation of Caregiver considerations example