Careplan-example-integrated.xml

Simple integrated care plan with multiple goals & conditions (from Mayo) (id = "integrate")

Raw XML

<CarePlan xmlns="http://hl7.org/fhir">
  <id value="integrate"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
  </text>
  <contained>
    <Condition><!--    Conditions could be further encoded and detailed.  
      Could also be handled as references to external resources.
      And not essential to have them captured at all.
      For purposes of example, will represent this way.    -->
      <id value="p1"/>
      <patient>
        <reference value="Patient/1"/>
        <display value="Eve Everywoman"/>
      </patient>
      <code>
        <text value="GERDS"/>
      </code>
      <clinicalStatus value="confirmed"/>
    </Condition>
  </contained>
  <contained>
    <Condition>
      <id value="p2"/>
      <patient>
        <reference value="Patient/1"/>
        <display value="Eve Everywoman"/>
      </patient>
      <code>
        <text value="Obesity"/>
      </code>
      <clinicalStatus value="confirmed"/>
    </Condition>
  </contained>
  <contained>
    <Condition>
      <id value="p3"/>
      <patient>
        <reference value="Patient/1"/>
        <display value="Eve Everywoman"/>
      </patient>
      <code>
        <text value="Psoriasis"/>
      </code>
      <clinicalStatus value="confirmed"/>
    </Condition>
  </contained>
  <contained>
    <Goal>
      <id value="g1"/>
      <patient>
        <reference value="Patient/1"/>
        <display value="Eve Everywoman"/>
      </patient>
      <description value="Eve will lose weight and reduce her GERDS symptoms by improving her diet"/>
      <status value="in-progress"/>
    </Goal>
  </contained>
  <contained>
    <Goal>
      <id value="g2"/>
      <patient>
        <reference value="Patient/1"/>
        <display value="Eve Everywoman"/>
      </patient>
      <description value="Eve will improve her GERDS symptoms"/>
      <status value="in-progress"/>
    </Goal>
  </contained>
  <contained>
    <Goal>
      <id value="g3"/>
      <patient>
        <reference value="Patient/1"/>
        <display value="Eve Everywoman"/>
      </patient>
      <description value="Eve will increase her energy by being more active"/>
      <status value="in-progress"/>
    </Goal>
  </contained>
  <contained>
    <Goal>
      <id value="g4"/>
      <patient>
        <reference value="Patient/1"/>
        <display value="Eve Everywoman"/>
      </patient>
      <description value="Eve will set up her medications and take as prescribed"/>
      <status value="in-progress"/>
    </Goal>
  </contained>
  <contained>
    <Goal>
      <id value="g5"/>
      <patient>
        <reference value="Patient/1"/>
        <display value="Eve Everywoman"/>
      </patient>
      <description value="Eve will restart her light treatments"/>
      <status value="in-progress"/>
    </Goal>
  </contained>
  <patient>
    <reference value="Patient/1"/>
    <display value="Eve Everywoman"/>
  </patient>
  <status value="active"/>
  <modified value="2012-09-10"/>
  <concern>
    <reference value="#p1"/><!--    Local reference    -->
    <display value="GERDS"/>
  </concern>
  <concern>
    <reference value="#p2"/><!--    Local reference    -->
    <display value="Obesity"/>
  </concern>
  <concern>
    <reference value="#p3"/><!--    Local reference    -->
    <display value="Psoriasis"/>
  </concern>
  <goal>
    <reference value="#g1"/>
  </goal>
  <goal>
    <reference value="#g2"/>
  </goal>
  <goal>
    <reference value="#g3"/>
  </goal>
  <goal>
    <reference value="#g4"/>
  </goal>
  <goal>
    <reference value="#g5"/>
  </goal>
  <activity>
    <notes value="9/10/12 Eve eats one meal a day with her parents"/>
    <detail>
      <extension url="http://example.org/DoNotUse/StructureDefinition/RevisionDate">
        <valueDate value="2012-09-10"/>
      </extension>
      <category value="other"/>
      <goal>
        <reference value="#g1"/>
      </goal>
      <status value="not-started"/>
      <prohibited value="false"/>
      <scheduledPeriod>
        <start value="2012-09-10"/>
      </scheduledPeriod>
      <note value="Eve will review photos of high and low density foods and share with her parents"/>
    </detail>
  </activity>
  <activity>
    <notes value="9/10/12 Eve will sleep in her bed more often than the couch"/>
    <detail>
      <extension url="http://example.org/DoNotUse/General/RevisionDate">
        <valueDate value="2012-09-10"/>
      </extension>
      <category value="other"/>
      <goal>
        <reference value="#g1"/>
      </goal>
      <status value="not-started"/>
      <prohibited value="false"/>
      <scheduledPeriod>
        <start value="2012-09-10"/>
      </scheduledPeriod>
      <note value="Eve will ask her dad to asist her to put the head of her bed on blocks"/>
    </detail>
  </activity>
  <activity>
    <detail>
      <extension url="http://example.org/DoNotUse/General/RevisionDate">
        <valueDate value="2012-09-10"/>
      </extension>
      <category value="other"/>
      <goal>
        <reference value="#g2"/>
      </goal>
      <status value="in-progress"/>
      <prohibited value="false"/>
      <scheduledPeriod>
        <start value="2012-09-10"/>
      </scheduledPeriod>
      <note value="Eve will reduce her intake of coffee and chocolate"/>
    </detail>
  </activity>
  <activity>
    <notes value="8/27/12 Eve would like to try for 5 days a week.  9/10/12 Eve is still walking the dogs."/>
    <detail>
      <extension url="http://example.org/DoNotUse/General/RevisionDate">
        <valueDate value="2012-09-10"/>
      </extension>
      <category value="other"/>
      <goal>
        <reference value="#g3"/>
      </goal>
      <status value="in-progress"/>
      <prohibited value="false"/>
      <scheduledPeriod>
        <start value="2012-08-27"/>
      </scheduledPeriod>
      <note value="Eve will walk her friend's dog up and down a big hill 15-30 minutes 3 days a week"/>
    </detail>
  </activity>
  <activity>
    <notes value="8/13/12 Eve walked 4 times the last week.  9/10/12 Eve did not walk to her parents the
     last week, but has plans to start again"/>
    <detail>
      <extension url="http://example.org/DoNotUse/General/RevisionDate">
        <valueDate value="2012-09-10"/>
      </extension>
      <category value="other"/>
      <goal>
        <reference value="#g3"/>
      </goal>
      <status value="in-progress"/>
      <prohibited value="false"/>
      <scheduledPeriod>
        <start value="2012-07-23"/>
      </scheduledPeriod>
      <note value="Eve will walk 3 blocks to her parents house twice a week"/>
    </detail>
  </activity>
  <activity>
    <detail>
      <extension url="http://example.org/DoNotUse/General/RevisionDate">
        <valueDate value="2012-08-13"/>
      </extension>
      <category value="other"/>
      <goal>
        <reference value="#g4"/>
      </goal>
      <status value="in-progress"/>
      <prohibited value="false"/>
      <scheduledPeriod>
        <start value="2012-07-23"/>
      </scheduledPeriod>
      <note value="Eve will us a calendar to check off after medications are taken"/>
    </detail>
  </activity>
  <activity>
    <notes value="8/13/12 After restarting the vinegar soaks the psoriasis is improved and Eve plans to
     treat the remainder with light treatments.  She plans to start this week.  8/27/12 Since
     her skin is improved Eve has not been using the light treatment as often, maybe once a
     week.  She would like to increase to 3 times a week again"/>
    <detail>
      <extension url="http://example.org/DoNotUse/General/RevisionDate">
        <valueDate value="2012-08-27"/>
      </extension>
      <category value="other"/>
      <goal>
        <reference value="#g5"/>
      </goal>
      <status value="in-progress"/>
      <prohibited value="false"/>
      <scheduledPeriod>
        <start value="2012-07-23"/>
      </scheduledPeriod>
      <note value="Eve will use her lights MWF after her shower for 3 minutes"/>
    </detail>
  </activity>
  <activity>
    <notes value="7/23/12 Eve created a chart as a reminer to take the medications that do not fit in her
     pill box"/>
    <detail>
      <extension url="http://example.org/DoNotUse/General/RevisionDate">
        <valueDate value="2012-09-10"/>
      </extension>
      <category value="other"/>
      <goal>
        <reference value="#g4"/>
      </goal>
      <status value="in-progress"/>
      <prohibited value="false"/>
      <scheduledPeriod>
        <start value="2012-07-10"/>
      </scheduledPeriod>
      <note value="Eve will use a calendar of a chart to help her remember when to take her medications"/>
    </detail>
  </activity>
  <activity>
    <notes value="7/30/12 will be able to esume exercise.  8/13/12 Eve prefers to focus on walking at this
     time"/>
    <detail>
      <extension url="http://example.org/DoNotUse/General/RevisionDate">
        <valueDate value="2012-08-23"/>
      </extension>
      <category value="other"/>
      <goal>
        <reference value="#g3"/>
      </goal>
      <status value="on-hold"/>
      <prohibited value="false"/>
      <scheduledPeriod>
        <start value="2012-07-23"/>
      </scheduledPeriod>
      <note value="Eve will start using stretch bands and one step 2 days a week Mon/Wed 6-7am and maybe
       Friday afternoon"/>
    </detail>
  </activity>
  <activity>
    <detail>
      <extension url="http://example.org/DoNotUse/General/RevisionDate">
        <valueDate value="2012-07-23"/>
      </extension>
      <category value="other"/>
      <goal>
        <reference value="#g4"/>
      </goal>
      <status value="completed"/>
      <prohibited value="false"/>
      <scheduledPeriod>
        <start value="2012-07-10"/>
      </scheduledPeriod>
      <note value="Eve will match a printed medication worksheet with the medication bottles at home"/>
    </detail>
  </activity>
  <activity>
    <notes value="7/16/12 Eve now has some of her medications set up in pill packs by her pharmacist"/>
    <detail>
      <extension url="http://example.org/DoNotUse/General/RevisionDate">
        <valueDate value="2012-07-16"/>
      </extension>
      <category value="other"/>
      <goal>
        <reference value="#g4"/>
      </goal>
      <status value="completed"/>
      <prohibited value="false"/>
      <scheduledPeriod>
        <start value="2012-07-10"/>
      </scheduledPeriod>
      <note value="Eve will get a medication box to sort her pills.  She will have one for scheduled medications
       and one for as needed"/>
    </detail>
  </activity>
  <activity>
    <notes value="7/30/12 Eve will be able to resume exercise on 7/30/12.  8/13/12 -hold until &quot;less
     busy&quot;"/>
    <detail>
      <extension url="http://example.org/DoNotUse/General/RevisionDate">
        <valueDate value="2012-08-13"/>
      </extension>
      <category value="other"/>
      <goal>
        <reference value="#g3"/>
      </goal>
      <status value="on-hold"/>
      <prohibited value="false"/>
      <scheduledPeriod>
        <start value="2012-07-23"/>
      </scheduledPeriod>
      <note value="Eve will open &quot;The Firm&quot; DVD workout package and listen to it"/>
    </detail>
  </activity>
  <notes value="Patient family is not ready to commit to goal setting at this time.  Goal setting will
   be addressed in the future"/>
</CarePlan>