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

• Narrative Content
• XML
• JSON
• TTL

: MCC FHIR Care Plan Example - JSON Representation

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{
  "resourceType" : "CarePlan",
  "id" : "cc-careplan-pnoelle-ckd",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2020-09-22T16:07:27.537+00:00",
    "source" : "#SCrKC33XSmQLsqWF"
  },
  "text" : {
    "status" : "additional",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><strong>Multiple Chronic Condition Care Plan</strong><ol><li>Addresses: Chronic Kidney Disease.</li><li>Narrative Block information will be developed in a later draft.</li><li>Supplemental Information:</li><li>Supplemental Information:</li><li>Supplemental Information:</li></ol></div>"
  },
  "status" : "active",
  "intent" : "plan",
  "category" : [
    {
      "coding" : [
        {
          "system" : "http://snomed.info/sct",
          "code" : "737429003"
        }
      ],
      "text" : "Chronic kidney disease clinical management plan"
    }
  ],
  "subject" : {
    "reference" : "Patient/cc-pat-pnoelle",
    "display" : "Patricia Noelle"
  },
  "period" : {
    "start" : "2018-05-01"
  },
  "created" : "2019-01-01",
  "author" : {
    "reference" : "Device/SMARTapp123",
    "display" : "MCCSmartonFHIRApp"
  },
  "contributor" : [
    {
      "reference" : "PractitionerRole/HenryLevVII123",
      "display" : "Henry Levin VII MD Nephrologist"
    },
    {
      "reference" : "PractitionerRole/NNR123",
      "display" : "Nancy Nurse RN"
    },
    {
      "reference" : "PractitionerRole/PPLev54321",
      "display" : "Peter Primary MD Primary Provider"
    }
  ],
  "careTeam" : [
    {
      "reference" : "CareTeam/cc-team-pnoelle",
      "display" : "Longitudinal care-coordination focused care team"
    }
  ],
  "addresses" : [
    {
      "reference" : "Condition/cc-cond-pnoelle-ckd",
      "display" : "Chronic Kidney Disease"
    }
  ],
  "supportingInfo" : [
    {
      "reference" : "Condition/cc-cond-pnoelle-cp",
      "display" : "Chronic Pain"
    },
    {
      "reference" : "QuestionnaireResponse/cc-QR-pnoelle-pc",
      "display" : "PROMIS short form - pain intensity 3a - version 1.0 - 11 Moderate to Severe"
    },
    {
      "reference" : "Condition/cc-cond-pnoelle-dp",
      "display" : "Recurrent major depressive episodes, moderate (disorder)"
    },
    {
      "reference" : "Observation/cc-EstimatedGFR-pnoelle-cp",
      "display" : "eGFR 35 mL/min/{1.73_m2}"
    }
  ],
  "goal" : [
    {
      "reference" : "Goal/cc-goal-pnoelle-cp-overallgoaltext",
      "display" : "(From Description text in the referenced goal resource. The patient and care team would like Patricia's overall health status to improve as much as possible with her exisitng CKD:\n\t\t\tLose weight, decrease chronic pain with less use of pain medication and improved lab results"
    }
  ],
  "activity" : [
    {
      "outcomeReference" : [
        {
          "reference" : "Procedure/cc-actPerf-pnoelle-cp-dailyWeights",
          "display" : "DailyWeightsPerformed"
        }
      ],
      "progress" : [
        {
          "time" : "2019-01-10",
          "text" : "Patricia Noelle is measuring her weight daily"
        }
      ],
      "reference" : {
        "reference" : "Task/cc-taskReq-pnoelle-cp-weight",
        "display" : "Patricia Noelle or cargiver to perform daily weights"
      }
    },
    {
      "outcomeReference" : [
        {
          "reference" : "Encounter/cc-actPerf-pnoelle-cp-Encounter321",
          "display" : "PreOp Encounter For Creation of external arteriovenous shunt (procedure)"
        },
        {
          "reference" : "Procedure/cc-actPerf-pnoelle-cp-upperlimbveinultrsound",
          "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" : "Appointment/cc-servReq-pnoelle-cp-preOp",
        "display" : "PreOp Encounter Request For Creation of external arteriovenous shunt (procedure). Relates to overall health improvement goal and encounter requestActivity"
      }
    }
  ]
}