MCC eCare Plan Implementation Guide
0.1.0 - CI Build US

MCC eCare Plan Implementation Guide - Local Development build (v0.1.0). See the Directory of published versions

: Multiple Chronic Condition Care Plan Example - XML Representation

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<CarePlan xmlns="http://hl7.org/fhir">
  <id value="MCCCarePlan"/>
  <meta>
    <extension url="http://hl7.org/fhir/StructureDefinition/instance-name">
      <valueString value="Multiple Chronic Condition Care Plan Example"/>
    </extension>
    <extension
               url="http://hl7.org/fhir/StructureDefinition/instance-description">
      <valueMarkdown value="This is an example for the *MCC CarePlan Profile*."/>
    </extension>
    <versionId value="3"/>
    <lastUpdated value="2022-04-21T17:36:21.612+00:00"/>
    <source value="#RnawHckMdX9QjJoN"/>
    <profile value="http://hl7.org/fhir/us/mcc/StructureDefinition/mccCarePlan"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></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 "MCCCarePlan" Version "3" Updated "2022-04-21 05:36:21+0000" </p><p style="margin-bottom: 0px">Information Source: #RnawHckMdX9QjJoN!</p><p style="margin-bottom: 0px">Profile: <a href="StructureDefinition-mccCarePlan.html">Multiple Chronic Care Condition Care Plan</a></p></div><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/STU4/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> " NOELLE"</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> "US-Core MCC example CareTeam"</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="http://hl7.org/fhir/uv/sdc/QuestionnaireResponse/questionnaireresponse-sdc-profile-example-PHQ9">http://hl7.org/fhir/uv/sdc/QuestionnaireResponse/questionnaireresponse-sdc-profile-example-PHQ9: Patient health questionnaire 9 item total score: 13 Moderate Depression</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</a></p></blockquote></div>
  </text>
  <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"/>
      <code value="assess-plan"/>
    </coding>
  </category>
  <subject>
    <reference value="Patient/cc-pat-pnoelle"/>
    <display value="Patricia Noelle"/>
  </subject>
  <period>
    <start value="2018-05-01"/>
  </period>
  <created value="2019-01-01"/>
  <author>
    <reference value="PractitionerRole/PractitionerRoleMCC2"/>
    <display value="Nancy Nurse RN"/>
  </author>
  <contributor>
    <reference value="PractitionerRole/PractitionerRoleMCC1"/>
    <display value="Henry Levin VII MD Nephrologist"/>
  </contributor>
  <contributor>
    <reference value="PractitionerRole/PractitionerRoleMCC2"/>
    <display value="Nancy Nurse RN"/>
  </contributor>
  <contributor>
    <reference value="PractitionerRole/PractitionerRoleMCC3"/>
    <display value="Peter Primary MD Primary Provider"/>
  </contributor>
  <careTeam>
    <reference value="CareTeam/MCCCareTeamexample"/>
    <display value="Longitudinal care-coordination focused care team"/>
  </careTeam>
  <addresses>
    <reference value="Condition/ConditionCKD"/>
    <display value="Chronic Kidney Disease"/>
  </addresses>
  <supportingInfo>
    <reference value="Procedure/Dialysis"/>
    <display value="Chronic Pain"/>
  </supportingInfo>
  <supportingInfo>
    <reference
               value="http://hl7.org/fhir/uv/sdc/QuestionnaireResponse/questionnaireresponse-sdc-profile-example-PHQ9"/>
    <display
             value="Patient health questionnaire 9 item total score: 13 Moderate Depression"/>
  </supportingInfo>
  <supportingInfo>
    <reference value="Observation/bunMCC"/>
    <display value="BUN 24 mL/min/{1.73_m2}"/>
  </supportingInfo>
  <goal>
    <reference value="Goal/WGT-loss"/>
    <display
             value="Lose weight, decrease chronic pain with less use of pain medication and improved lab results"/>
  </goal>
  <activity>
    <outcomeReference>
      <reference value="Procedure/Dialysis"/>
      <display value="Dialysis"/>
    </outcomeReference>
    <progress>
      <time value="2019-01-10"/>
      <text value="Patricia Noelle is measuring her weight daily"/>
    </progress>
    <reference>
      <reference value="http://example.org/Task/123"/>
      <display value="Patricia Noelle or cargiver to perform daily weights"/>
    </reference>
  </activity>
  <activity>
    <outcomeReference>
      <reference value="http://example.org/Encounter/123"/>
      <display
               value="PreOp Encounter For Creation of external arteriovenous shunt (procedure)"/>
    </outcomeReference>
    <outcomeReference>
      <reference value="http://example.org/Procedure/upperlimbveinUS"/>
      <display
               value="Fluoroscopic venography of bilateral upper limbs Performed. Results: Normal"/>
    </outcomeReference>
    <progress>
      <time value="2019-01-10"/>
      <text
            value="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"/>
    </progress>
    <reference>
      <reference value="http://example.org/Appointment/AVShunt"/>
      <display
               value="PreOp Encounter Request For Creation of external arteriovenous shunt (procedure). Relates to overall health improvement goal and encounter requestActivity"/>
    </reference>
  </activity>
</CarePlan>