MCC eCare Plan Draft Implementation Guide
0.1.0 - CI Build

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

: MCC FHIR Care Plan Example - XML Representation

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<CarePlan xmlns="http://hl7.org/fhir">
  <id value="cc-careplan-pnoelle-ckd"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2020-09-22T16:07:27.537+00:00"/>
    <source value="#SCrKC33XSmQLsqWF"/>
  </meta>
  <text>
    <status value="additional"/>
    <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>
  </text>
  <status value="active"/>
  <intent value="plan"/>
  <category>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="737429003"/>
    </coding>
    <text value="Chronic kidney disease clinical management plan"/>
  </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="Device/SMARTapp123"/>
    <display value="MCCSmartonFHIRApp"/>
  </author>
  <contributor>
    <reference value="PractitionerRole/HenryLevVII123"/>
    <display value="Henry Levin VII MD Nephrologist"/>
  </contributor>
  <contributor>
    <reference value="PractitionerRole/NNR123"/>
    <display value="Nancy Nurse RN"/>
  </contributor>
  <contributor>
    <reference value="PractitionerRole/PPLev54321"/>
    <display value="Peter Primary MD Primary Provider"/>
  </contributor>
  <careTeam>
    <reference value="CareTeam/cc-team-pnoelle"/>
    <display value="Longitudinal care-coordination focused care team"/>
  </careTeam>
  <addresses>
    <reference value="Condition/cc-cond-pnoelle-ckd"/>
    <display value="Chronic Kidney Disease"/>
  </addresses>
  <supportingInfo>
    <reference value="Condition/cc-cond-pnoelle-cp"/>
    <display value="Chronic Pain"/>
  </supportingInfo>
  <supportingInfo>
    <reference value="QuestionnaireResponse/cc-QR-pnoelle-pc"/>
    <display
             value="PROMIS short form - pain intensity 3a - version 1.0 - 11 Moderate to Severe"/>
  </supportingInfo>
  <supportingInfo>
    <reference value="Condition/cc-cond-pnoelle-dp"/>
    <display value="Recurrent major depressive episodes, moderate (disorder)"/>
  </supportingInfo>
  <supportingInfo>
    <reference value="Observation/cc-EstimatedGFR-pnoelle-cp"/>
    <display value="eGFR 35 mL/min/{1.73_m2}"/>
  </supportingInfo>
  <goal>
    <reference value="Goal/cc-goal-pnoelle-cp-overallgoaltext"/>
    <display
             value="(From Description text in the referenced goal resource. The patient and care team would like Patricia&#39;s overall health status to improve as much as possible with her exisitng CKD:
			Lose weight, decrease chronic pain with less use of pain medication and improved lab results"/>
  </goal>
  <activity>
    <outcomeReference>
      <reference value="Procedure/cc-actPerf-pnoelle-cp-dailyWeights"/>
      <display value="DailyWeightsPerformed"/>
    </outcomeReference>
    <progress>
      <time value="2019-01-10"/>
      <text value="Patricia Noelle is measuring her weight daily"/>
    </progress>
    <reference>
      <reference value="Task/cc-taskReq-pnoelle-cp-weight"/>
      <display value="Patricia Noelle or cargiver to perform daily weights"/>
    </reference>
  </activity>
  <activity>
    <outcomeReference>
      <reference value="Encounter/cc-actPerf-pnoelle-cp-Encounter321"/>
      <display
               value="PreOp Encounter For Creation of external arteriovenous shunt (procedure)"/>
    </outcomeReference>
    <outcomeReference>
      <reference value="Procedure/cc-actPerf-pnoelle-cp-upperlimbveinultrsound"/>
      <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="Appointment/cc-servReq-pnoelle-cp-preOp"/>
      <display
               value="PreOp Encounter Request For Creation of external arteriovenous shunt (procedure). Relates to overall health improvement goal and encounter requestActivity"/>
    </reference>
  </activity>
</CarePlan>