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Simple integrated care plan with multiple goals & conditions (from Mayo)
{
"resourceType": "CarePlan",
"text": {
"status": "generated",
"div": "<div>\n <p>Patient family is not ready to commit to goal setting at this time. Goal setting will be addressed in the future</p>\n <table>\n <thead>\n <tr>\n <th>Start Date</th>\n <th>Goal</th>\n <th>Action Steps</th>\n <th>Status</th>\n <th>Date Last Updated</th>\n <th>Comments</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>10 Sep 2012</td>\n <td>Eve will lose weight and reduce her GERDS symptoms by improving her diet</td>\n <td>Eve will review photos of high and low density foods and share with her parents</td>\n <td>New Goal</td>\n <td>10 Sep 2012</td>\n <td>9/10/12 Eve eats one meal a day with her parents</td>\n </tr>\n <tr>\n <td>10 Sep 2012</td>\n <td>Eve will lose weight and reduce her GERDS symptoms by improving her diet</td>\n <td>Eve will ask her dad to asist her to put the head of her bed on blocks</td>\n <td>New Goal</td>\n <td>10 Sep 2012</td>\n <td>9/10/12 Eve will sleep in her bed more often than the couch</td>\n </tr>\n <tr>\n <td>10 Sep 2012</td>\n <td>Eve will improve her GERDS symptoms</td>\n <td>Eve will reduce her intake of coffee and chocolate</td>\n <td>In Process</td>\n <td>10 Sep 2012</td>\n <td/>\n </tr>\n <tr>\n <td>27 Aug 2012</td>\n <td>Eve will increase her energy by being more active</td>\n <td>Eve will walk her friend's dog up and down a big hill 15-30 minutes 3 days a week</td>\n <td>In Process</td>\n <td>10 Sep 2012</td>\n <td>8/27/12 Eve would like to try for 5 days a week. 9/10/12 Eve is still walking the dogs.</td>\n </tr>\n <tr>\n <td>23 Jul 2012</td>\n <td>Eve will increase her energy by being more active</td>\n <td>Eve will walk 3 blocks to her parents house twice a week</td>\n <td>In Process</td>\n <td>10 Sep 2012</td>\n <td>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</td>\n </tr>\n <tr>\n <td>23 Jul 2012</td>\n <td>Eve will set up her medications and take as prescribed</td>\n <td>Eve will us a calendar to check off after medications are taken</td>\n <td>In Process</td>\n <td>13 Aug 2012</td>\n <td/>\n </tr>\n <tr>\n <td>23 Jul 2012</td>\n <td>Eve will restart her light treatments</td>\n <td>Eve will use her lights MWF after her shower for 3 minutes</td>\n <td>In Process</td>\n <td>27 Aug 2012</td>\n <td>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</td>\n </tr>\n <tr>\n <td>10 Jul 2012</td>\n <td>Eve will set up her medications and take as prescribed</td>\n <td>Eve will use a calendar of a chart to help her remember when to take her medications</td>\n <td>In Process</td>\n <td>10 Sep 2012</td>\n <td>7/23/12 Eve created a chart as a reminer to take the medications that do not fit in her pill box</td>\n </tr>\n <tr>\n <td>23 Jul 2012</td>\n <td>Eve will increase her energy by being more active</td>\n <td>Eve will start using stretch bands and one step 2 days a week Mon/Wed 6-7am and maybe Friday afternoon</td>\n <td>On-Hold</td>\n <td>23 Aug 2012</td>\n <td>7/30/12 will be able to esume exercise. 8/13/12 Eve prefers to focus on walking at this time</td>\n </tr>\n <tr>\n <td>10 Jul 2012</td>\n <td>Eve will set up her medications and take as prescribed</td>\n <td>Eve will match a printed medication worksheet with the medication bottles at home</td>\n <td>Completed</td>\n <td>23 Jul 2012</td>\n <td/>\n </tr>\n <tr>\n <td>10 Jul 2012</td>\n <td>Eve will set up her medications and take as prescribed</td>\n <td>Eve will get a medication box to sort her pills. She will have one for scheduled medications and one for as needed</td>\n <td>Completed</td>\n <td>16 Jul 2012</td>\n <td>7/16/12 Eve now has some of her medications set up in pill packs by her pharmacist</td>\n </tr>\n <tr>\n <td>23 Jul 2012</td>\n <td>Eve will increase her energy by being more active</td>\n <td>Eve will open "The Firm" DVD workout package and listen to it</td>\n <td>Discontinued</td>\n <td>13 Aug 2012</td>\n <td>7/30/12 Eve will be able to resume exercise on 7/30/12. 8/13/12 -hold until "less busy"</td>\n </tr>\n </tbody>\n </table>\n </div>"
},
"contained": [
{
"resourceType": "Condition",
"id": "p1",
"subject": {
"reference": "Patient/1",
"display": "Eve Everywoman"
},
"code": {
"text": "GERDS"
},
"status": "confirmed"
},
{
"resourceType": "Condition",
"id": "p2",
"subject": {
"reference": "Patient/1",
"display": "Eve Everywoman"
},
"code": {
"text": "Obesity"
},
"status": "confirmed"
},
{
"resourceType": "Condition",
"id": "p3",
"subject": {
"reference": "Patient/1",
"display": "Eve Everywoman"
},
"code": {
"text": "Psoriasis"
},
"status": "confirmed"
}
],
"patient": {
"reference": "Patient/1",
"display": "Eve Everywoman"
},
"status": "active",
"modified": "2012-09-10",
"concern": [
{
"reference": "#p1",
"display": "GERDS"
},
{
"reference": "#p2",
"display": "Obesity"
},
{
"reference": "#p3",
"display": "Psoriasis"
}
],
"goal": [
{
"id": "g1",
"description": "Eve will lose weight and reduce her GERDS symptoms by improving her diet",
"status": "in progress"
},
{
"id": "g2",
"description": "Eve will improve her GERDS symptoms",
"status": "in progress"
},
{
"id": "g3",
"description": "Eve will increase her energy by being more active",
"status": "in progress"
},
{
"id": "g4",
"description": "Eve will set up her medications and take as prescribed",
"status": "in progress"
},
{
"id": "g5",
"description": "Eve will restart her light treatments",
"status": "in progress"
}
],
"activity": [
{
"status": "not started",
"prohibited": false,
"notes": "9/10/12 Eve eats one meal a day with her parents",
"simple": {
"extension": [
{
"url": "http://example.org/DoNotUse/EnhancedCarePlan/ActivityGoalLink",
"valueUri": "#g1"
},
{
"url": "http://example.org/DoNotUse/General/RevisionDate",
"valueDate": "2012-09-10"
}
],
"category": "other",
"timingPeriod": {
"start": "2012-09-10"
},
"details": "Eve will review photos of high and low density foods and share with her parents"
}
},
{
"status": "not started",
"prohibited": false,
"notes": "9/10/12 Eve will sleep in her bed more often than the couch",
"simple": {
"extension": [
{
"url": "http://example.org/DoNotUse/EnhancedCarePlan/ActivityGoalLink",
"valueUri": "#g1"
},
{
"url": "http://example.org/DoNotUse/General/RevisionDate",
"valueDate": "2012-09-10"
}
],
"category": "other",
"timingPeriod": {
"start": "2012-09-10"
},
"details": "Eve will ask her dad to asist her to put the head of her bed on blocks"
}
},
{
"status": "in progress",
"prohibited": false,
"simple": {
"extension": [
{
"url": "http://example.org/DoNotUse/EnhancedCarePlan/ActivityGoalLink",
"valueUri": "#g2"
},
{
"url": "http://example.org/DoNotUse/General/RevisionDate",
"valueDate": "2012-09-10"
}
],
"category": "other",
"timingPeriod": {
"start": "2012-09-10"
},
"details": "Eve will reduce her intake of coffee and chocolate"
}
},
{
"status": "in progress",
"prohibited": false,
"notes": "8/27/12 Eve would like to try for 5 days a week. 9/10/12 Eve is still walking the dogs.",
"simple": {
"extension": [
{
"url": "http://example.org/DoNotUse/EnhancedCarePlan/ActivityGoalLink",
"valueUri": "#g3"
},
{
"url": "http://example.org/DoNotUse/General/RevisionDate",
"valueDate": "2012-09-10"
}
],
"category": "other",
"timingPeriod": {
"start": "2012-08-27"
},
"details": "Eve will walk her friend's dog up and down a big hill 15-30 minutes 3 days a week"
}
},
{
"status": "in progress",
"prohibited": false,
"notes": "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",
"simple": {
"extension": [
{
"url": "http://example.org/DoNotUse/EnhancedCarePlan/ActivityGoalLink",
"valueUri": "#g3"
},
{
"url": "http://example.org/DoNotUse/General/RevisionDate",
"valueDate": "2012-09-10"
}
],
"category": "other",
"timingPeriod": {
"start": "2012-07-23"
},
"details": "Eve will walk 3 blocks to her parents house twice a week"
}
},
{
"status": "in progress",
"prohibited": false,
"simple": {
"extension": [
{
"url": "http://example.org/DoNotUse/EnhancedCarePlan/ActivityGoalLink",
"valueUri": "#g4"
},
{
"url": "http://example.org/DoNotUse/General/RevisionDate",
"valueDate": "2012-08-13"
}
],
"category": "other",
"timingPeriod": {
"start": "2012-07-23"
},
"details": "Eve will us a calendar to check off after medications are taken"
}
},
{
"status": "in progress",
"prohibited": false,
"notes": "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",
"simple": {
"extension": [
{
"url": "http://example.org/DoNotUse/EnhancedCarePlan/ActivityGoalLink",
"valueUri": "#g5"
},
{
"url": "http://example.org/DoNotUse/General/RevisionDate",
"valueDate": "2012-08-27"
}
],
"category": "other",
"timingPeriod": {
"start": "2012-07-23"
},
"details": "Eve will use her lights MWF after her shower for 3 minutes"
}
},
{
"status": "in progress",
"prohibited": false,
"notes": "7/23/12 Eve created a chart as a reminer to take the medications that do not fit in her pill box",
"simple": {
"extension": [
{
"url": "http://example.org/DoNotUse/EnhancedCarePlan/ActivityGoalLink",
"valueUri": "#g4"
},
{
"url": "http://example.org/DoNotUse/General/RevisionDate",
"valueDate": "2012-09-10"
}
],
"category": "other",
"timingPeriod": {
"start": "2012-07-10"
},
"details": "Eve will use a calendar of a chart to help her remember when to take her medications"
}
},
{
"status": "on hold",
"prohibited": false,
"notes": "7/30/12 will be able to esume exercise. 8/13/12 Eve prefers to focus on walking at this time",
"simple": {
"extension": [
{
"url": "http://example.org/DoNotUse/EnhancedCarePlan/ActivityGoalLink",
"valueUri": "#g3"
},
{
"url": "http://example.org/DoNotUse/General/RevisionDate",
"valueDate": "2012-08-23"
}
],
"category": "other",
"timingPeriod": {
"start": "2012-07-23"
},
"details": "Eve will start using stretch bands and one step 2 days a week Mon/Wed 6-7am and maybe Friday afternoon"
}
},
{
"status": "completed",
"prohibited": false,
"simple": {
"extension": [
{
"url": "http://example.org/DoNotUse/EnhancedCarePlan/ActivityGoalLink",
"valueUri": "#g4"
},
{
"url": "http://example.org/DoNotUse/General/RevisionDate",
"valueDate": "2012-07-23"
}
],
"category": "other",
"timingPeriod": {
"start": "2012-07-10"
},
"details": "Eve will match a printed medication worksheet with the medication bottles at home"
}
},
{
"status": "completed",
"prohibited": false,
"notes": "7/16/12 Eve now has some of her medications set up in pill packs by her pharmacist",
"simple": {
"extension": [
{
"url": "http://example.org/DoNotUse/EnhancedCarePlan/ActivityGoalLink",
"valueUri": "#g4"
},
{
"url": "http://example.org/DoNotUse/General/RevisionDate",
"valueDate": "2012-07-16"
}
],
"category": "other",
"timingPeriod": {
"start": "2012-07-10"
},
"details": "Eve will get a medication box to sort her pills. She will have one for scheduled medications and one for as needed"
}
},
{
"status": "cancelled",
"prohibited": false,
"notes": "7/30/12 Eve will be able to resume exercise on 7/30/12. 8/13/12 -hold until \"less busy\"",
"simple": {
"extension": [
{
"url": "http://example.org/DoNotUse/EnhancedCarePlan/ActivityGoalLink",
"valueUri": "#g3"
},
{
"url": "http://example.org/DoNotUse/General/RevisionDate",
"valueDate": "2012-08-13"
}
],
"category": "other",
"timingPeriod": {
"start": "2012-07-23"
},
"details": "Eve will open \"The Firm\" DVD workout package and listen to it"
}
}
],
"notes": "Patient family is not ready to commit to goal setting at this time. Goal setting will be addressed in the future"
}
© HL7.org 2011+. FHIR DSTU (v0.0.82.2943) generated on Tue, Sep 30, 2014 18:09+1000.
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