MCC eCare Plan Implementation Guide
1.0.0-ballot2 - ballot United States of America flag

This page is part of the MCC eCare Plan Implementation Guide (v1.0.0-ballot2: STU 1 Ballot 2) based on FHIR R4. . For a full list of available versions, see the Directory of published versions

: Multiple Chronic Condition Care Plan Example - JSON Representation

Raw json | Download


{
  "resourceType" : "CarePlan",
  "id" : "MCCCarePlan",
  "meta" : {
    "extension" : [
      {
        "url" : "http://hl7.org/fhir/StructureDefinition/instance-name",
        "valueString" : "Multiple Chronic Condition Care Plan Example"
      },
      {
        "url" : "http://hl7.org/fhir/StructureDefinition/instance-description",
        "valueMarkdown" : "This is an example for the *MCC CarePlan Profile*."
      }
    ],
    "profile" : [
      "http://hl7.org/fhir/us/mcc/StructureDefinition/mccCarePlan"
    ]
  },
  "text" : {
    "status" : "additional",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Narrative: CarePlan</b><a name=\"MCCCarePlan\"> </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\">Resource CarePlan &quot;MCCCarePlan&quot; </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=\"RelatedPerson-caregiver-of-noelle.html\">RelatedPerson/caregiver-of-noelle</a> &quot; VAN PUTTEN&quot;</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</a>#assess-plan)</span></p><p><b>subject</b>: <a href=\"Patient-cc-pat-pnoelle.html\">Patient/cc-pat-pnoelle: Patricia Noelle</a> &quot; NOELLE&quot;</p><p><b>period</b>: 2018-05-01 --&gt; (ongoing)</p><p><b>created</b>: 2019-01-01</p><p><b>author</b>: <a href=\"PractitionerRole-PractitionerRoleMCC2.html\">PractitionerRole/PractitionerRoleMCC2: Nancy Nurse RN</a></p><p><b>contributor</b>: </p><ul><li><a href=\"PractitionerRole-PractitionerRoleMCC1.html\">PractitionerRole/PractitionerRoleMCC1: Henry Levin VII MD Nephrologist</a></li><li><a href=\"PractitionerRole-PractitionerRoleMCC2.html\">PractitionerRole/PractitionerRoleMCC2: Nancy Nurse RN</a></li><li><a href=\"PractitionerRole-PractitionerRoleMCC3.html\">PractitionerRole/PractitionerRoleMCC3: Peter Primary MD Primary Provider</a></li></ul><p><b>careTeam</b>: <a href=\"CareTeam-MCCCareTeamexample.html\">CareTeam/MCCCareTeamexample: Longitudinal care-coordination focused care team</a> &quot;US-Core MCC example CareTeam&quot;</p><p><b>addresses</b>: <a href=\"Condition-ConditionCKD.html\">Condition/ConditionCKD: Chronic Kidney Disease</a></p><p><b>supportingInfo</b>: </p><ul><li><a href=\"Procedure-Dialysis.html\">Procedure/Dialysis: Chronic Pain</a></li><li><a href=\"Observation-bunMCC.html\">Observation/bunMCC: BUN 24 mL/min/{1.73_m2}</a></li></ul><p><b>goal</b>: <a href=\"Goal-WGT-loss.html\">Goal/WGT-loss: Lose weight, decrease chronic pain with less use of pain medication and improved lab results</a></p><blockquote><p><b>activity</b></p><p><b>outcomeReference</b>: <a href=\"Procedure-Dialysis.html\">Procedure/Dialysis: Dialysis</a></p><p><b>progress</b>: Patricia Noelle is measuring her weight daily ( @2019-01-10)</p><p><b>reference</b>: <a href=\"http://example.org/Task/123\">http://example.org/Task/123: Patricia Noelle or cargiver to perform daily weights</a></p></blockquote><blockquote><p><b>activity</b></p><p><b>outcomeReference</b>: </p><ul><li><a href=\"http://example.org/Encounter/123\">http://example.org/Encounter/123: PreOp Encounter For Creation of external arteriovenous shunt (procedure)</a></li><li><a href=\"http://example.org/Procedure/upperlimbveinUS\">http://example.org/Procedure/upperlimbveinUS: Fluoroscopic venography of bilateral upper limbs Performed. Results: Normal</a></li></ul><p><b>progress</b>: Patricia Noelle Completed prep for an AV Shunt. She needs the shunt due to the need for diayalis related to the goal to improve her health related to CKD ( @2019-01-10)</p><p><b>reference</b>: <a href=\"http://example.org/Appointment/AVShunt\">http://example.org/Appointment/AVShunt: PreOp Encounter Request For Creation of external arteriovenous shunt (procedure). Relates to overall health improvement goal and encounter requestActivity. The goal relationship is through resource-pertainsToGoal for the Encounter</a></p></blockquote></div>"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/us/mcc/StructureDefinition/custodian",
      "valueReference" : {
        "reference" : "RelatedPerson/caregiver-of-noelle"
      }
    }
  ],
  "status" : "active",
  "intent" : "plan",
  "category" : [
    {
      "coding" : [
        {
          "system" : "http://snomed.info/sct",
          "code" : "734163000",
          "display" : "Care Plan"
        },
        {
          "system" : "http://hl7.org/fhir/us/core/CodeSystem/careplan-category",
          "code" : "assess-plan"
        }
      ]
    }
  ],
  "subject" : {
    "reference" : "Patient/cc-pat-pnoelle",
    "display" : "Patricia Noelle"
  },
  "period" : {
    "start" : "2018-05-01"
  },
  "created" : "2019-01-01",
  "author" : {
    "reference" : "PractitionerRole/PractitionerRoleMCC2",
    "display" : "Nancy Nurse RN"
  },
  "contributor" : [
    {
      "reference" : "PractitionerRole/PractitionerRoleMCC1",
      "display" : "Henry Levin VII MD Nephrologist"
    },
    {
      "reference" : "PractitionerRole/PractitionerRoleMCC2",
      "display" : "Nancy Nurse RN"
    },
    {
      "reference" : "PractitionerRole/PractitionerRoleMCC3",
      "display" : "Peter Primary MD Primary Provider"
    }
  ],
  "careTeam" : [
    {
      "reference" : "CareTeam/MCCCareTeamexample",
      "display" : "Longitudinal care-coordination focused care team"
    }
  ],
  "addresses" : [
    {
      "reference" : "Condition/ConditionCKD",
      "display" : "Chronic Kidney Disease"
    }
  ],
  "supportingInfo" : [
    {
      "reference" : "Procedure/Dialysis",
      "display" : "Chronic Pain"
    },
    {
      "reference" : "Observation/bunMCC",
      "display" : "BUN 24 mL/min/{1.73_m2}"
    }
  ],
  "goal" : [
    {
      "reference" : "Goal/WGT-loss",
      "display" : "Lose weight, decrease chronic pain with less use of pain medication and improved lab results"
    }
  ],
  "activity" : [
    {
      "outcomeReference" : [
        {
          "reference" : "Procedure/Dialysis",
          "display" : "Dialysis"
        }
      ],
      "progress" : [
        {
          "time" : "2019-01-10",
          "text" : "Patricia Noelle is measuring her weight daily"
        }
      ],
      "reference" : {
        "reference" : "http://example.org/Task/123",
        "display" : "Patricia Noelle or cargiver to perform daily weights"
      }
    },
    {
      "outcomeReference" : [
        {
          "reference" : "http://example.org/Encounter/123",
          "display" : "PreOp Encounter For Creation of external arteriovenous shunt (procedure)"
        },
        {
          "reference" : "http://example.org/Procedure/upperlimbveinUS",
          "display" : "Fluoroscopic venography of bilateral upper limbs Performed. Results: Normal"
        }
      ],
      "progress" : [
        {
          "time" : "2019-01-10",
          "text" : "Patricia Noelle Completed prep for an AV Shunt. She needs the shunt due to the need for diayalis related to the goal to improve her health related to CKD"
        }
      ],
      "reference" : {
        "reference" : "http://example.org/Appointment/AVShunt",
        "display" : "PreOp Encounter Request For Creation of external arteriovenous shunt (procedure). Relates to overall health improvement goal and encounter requestActivity"
      }
    }
  ]
}