MCC eCare Plan Implementation Guide
1.0.0 - STU1 United States of America flag

MCC eCare Plan Implementation Guide, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-us-mcc/ and changes regularly. See the Directory of published versions

: careplan-for-bundle - TTL Representation

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix sct: <http://snomed.info/id/> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:CarePlan ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "careplan-for-bundle"] ; # 
  fhir:meta [
    ( fhir:profile [
fhir:v "http://hl7.org/fhir/us/mcc/StructureDefinition/mccCarePlan"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/mcc/StructureDefinition/mccCarePlan>     ] )
  ] ; # 
  fhir:text [
fhir:status [ fhir:v "additional" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Narrative: CarePlan </b><a name=\"careplan-for-bundle\"></a><a name=\"hccareplan-for-bundle\"></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\">ResourceCarePlan \"careplan-for-bundle\"</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=\"Practitioner-practitionerMCC-3v.html\">Practitioner/practitionerMCC-3v: Dr. John Carlson</a> \" CARLSON\"</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[6.1.0]</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>: 2022-05-20 --&gt; (ongoing)</p><p><b>created</b>: 2022-05-20</p><p><b>contributor</b>:</p><ul><li><a href=\"Practitioner-practitionerMCC-3v.html\">Practitioner/practitionerMCC-3v: Dr John Carlson, Primary Care Physician</a> \" CARLSON\"</li><li><a href=\"PractitionerRole-careCoordinator-1.html\">PractitionerRole/careCoordinator-1: Care-coordinator, served by Julie Smith</a></li><li><a href=\"Patient-cc-pat-pnoelle.html\">Patient/cc-pat-pnoelle: Noelle</a> \" NOELLE\"</li><li><a href=\"PractitionerRole-dr-vince-jones.html\">PractitionerRole/dr-vince-jones: Nephrologist Role, served by Dr Vince Jones</a></li><li><a href=\"RelatedPerson-daughter1.html\">RelatedPerson/daughter1: Rose Noelle, Daughter</a> \" ROSE\"</li></ul><p><b>careTeam</b>: <a href=\"CareTeam-careteam-for-bundle.html\">CareTeam/careteam-for-bundle: Long-COVID and CKD focused care team</a> \"Care Team of Noelle Example for LONG-COVID bundle\"</p><p><b>addresses</b>:</p><ul><li><a href=\"Condition-ConditionCKD.html\">Condition/ConditionCKD: Chronic Kidney Disease</a></li><li><a href=\"Condition-encounter-diag-1.html\">Condition/encounter-diag-1: Long COVID</a></li></ul><p><b>supportingInfo</b>:</p><ul><li><a href=\"Observation-arterial-blood-gas-panel.html\">Observation/arterial-blood-gas-panel</a></li><li><a href=\"Observation-reduced-pain.html\">Observation/reduced-pain: Outcome example. Caregiver's observed thoughts on pain</a></li><li><a href=\"Condition-patient-health-concern-1.html\">Condition/patient-health-concern-1: Patient Health Concern: Worry that Long Covid symptoms will effect CKD</a></li><li><a href=\"Condition-patient-health-concern-2.html\">Condition/patient-health-concern-2: Patient Health Concern: Hard to exercise due to pain</a></li><li><a href=\"Condition-patient-health-concern-3.html\">Condition/patient-health-concern-3: Patient Health Concern: Struggles to manage her diet and find affordable healthy food choices under her financial strain</a></li><li><a href=\"Condition-patient-health-concern-4.html\">Condition/patient-health-concern-4: Patient Health Concern: Poor appetite for healthy CKD appropriate foods, likes cola, cake and chips</a></li><li><a href=\"Condition-careTeam-concerns-1.html\">Condition/careTeam-concerns-1: CareTeam Health Concern: Imbalanced Nutrition</a></li><li><a href=\"Condition-careTeam-concerns-2.html\">Condition/careTeam-concerns-2: CareTeam Health Concern: Dyspnea</a></li><li><a href=\"Condition-careTeam-concerns-3.html\">Condition/careTeam-concerns-3: CareTeam Health Concern: Pain in Legs</a></li><li><a href=\"Condition-careTeam-concerns-4.html\">Condition/careTeam-concerns-4: CareTeam Health Concern: Pain in Hands</a></li><li><a href=\"Condition-careTeam-concerns-5.html\">Condition/careTeam-concerns-5: CareTeam Health Concern: Pain in arms</a></li><li><a href=\"Condition-problem-list-1.html\">Condition/problem-list-1: Finding: Food aversion and cravings</a></li><li><a href=\"Condition-problem-list-2.html\">Condition/problem-list-2: Diagnosis: Metabolic acidosis</a></li><li><a href=\"Condition-chilblain-resolved.html\">Condition/chilblain-resolved: Long Covid related condition: Pustular chilblain resolved</a></li><li><a href=\"Observation-symptom2.html\">Observation/symptom2: Long Covid symptom: Dyspnea</a></li><li><a href=\"Observation-symptom3.html\">Observation/symptom3: Long Covid symptom: Pain in Legs</a></li><li><a href=\"Observation-symptom4.html\">Observation/symptom4: Long Covid symptom: Pain in hands</a></li><li><a href=\"Observation-symptom5.html\">Observation/symptom5: Long Covid symptom: Pain in arms</a></li><li><a href=\"Observation-symptom6.html\">Observation/symptom6: Long Covid symptom: Brain Fog - Intermittent confusion</a></li><li><a href=\"Observation-symptom7.html\">Observation/symptom7: Long Covid symptom: Brain Fog - Memory impairment</a></li><li><a href=\"Observation-symptom8.html\">Observation/symptom8: Long Covid symptom: Covid Toes - Toe swelling</a></li><li><a href=\"Observation-symptom9.html\">Observation/symptom9: Long Covid symptom: Covid Toes - Pustular chilblain</a></li></ul><p><b>goal</b>:</p><ul><li><a href=\"Goal-lower-pain-minimal-opioids.html\">Goal/lower-pain-minimal-opioids: Lower pain with minimal opioids</a></li><li><a href=\"Goal-appetite-to-normal.html\">Goal/appetite-to-normal: Return appetite to normal</a></li><li><a href=\"Goal-electrolyte-protein-normal-range.html\">Goal/electrolyte-protein-normal-range: Get Electrolyte and proteins back to normal</a></li><li><a href=\"Goal-bmi-normal-range.html\">Goal/bmi-normal-range: Get BMI into healthy range</a></li><li><a href=\"Goal-access-affordable-healthy-food.html\">Goal/access-affordable-healthy-food: Improve access to affordable, healthy food</a></li></ul><blockquote><p><b>activity</b></p><p><b>outcomeReference</b>:</p><ul><li><a href=\"Procedure-dietitian-consult.html\">Procedure/dietitian-consult: Dietitian consult</a></li><li><a href=\"Observation-better-diet.html\">Observation/better-diet: Observation by caregiver (daughter) of improvement in diet</a></li></ul><p><b>reference</b>: <a href=\"ServiceRequest-dietitian-referral.html\">ServiceRequest/dietitian-referral: Dietitian Referral</a></p></blockquote><blockquote><p><b>activity</b></p><p><b>outcomeReference</b>:</p><ul><li><a href=\"Procedure-dialysis-for-bundle.html\">Procedure/dialysis-for-bundle</a></li><li><a href=\"Procedure-dialysis-for-bundle2.html\">Procedure/dialysis-for-bundle2</a></li><li><a href=\"Procedure-dialysis-for-bundle3.html\">Procedure/dialysis-for-bundle3</a></li></ul><p><b>reference</b>: <a href=\"ServiceRequest-dialysis-request.html\">ServiceRequest/dialysis-request</a></p></blockquote><blockquote><p><b>activity</b></p><p><b>outcomeReference</b>: <a href=\"Procedure-ckd-app-education.html\">Procedure/ckd-app-education</a></p></blockquote><blockquote><p><b>activity</b></p><p><b>outcomeReference</b>:</p><ul><li><a href=\"MedicationRequest-med-for-chilblains.html\">MedicationRequest/med-for-chilblains: Treatment for chilblains</a></li><li><a href=\"Condition-chilblain-resolved.html\">Condition/chilblain-resolved</a></li><li><a href=\"ServiceRequest-pt-3x-wk.html\">ServiceRequest/pt-3x-wk: PT 3x per week</a></li><li><a href=\"ServiceRequest-counseling-1x-wk.html\">ServiceRequest/counseling-1x-wk: Counseling 1x per week</a></li><li><a href=\"Task-meditation-7x-wk.html\">Task/meditation-7x-wk: Meditation 7x per week</a></li><li><a href=\"Observation-observation-moca.html\">Observation/observation-moca: MOCA new result showing improvement</a></li><li><a href=\"Observation-observation-moca-original.html\">Observation/observation-moca-original: MOCA initial result showing impairment</a></li></ul><p><b>progress</b>: Long COVID symptoms improving ( @2022-12-10)</p><p><b>reference</b>: <a href=\"ServiceRequest-long-covid-request.html\">ServiceRequest/long-covid-request: Long Covid Clinic Referral serviceRequest</a></p></blockquote></div>"
  ] ; # 
  fhir:extension ( [
fhir:url [ fhir:v "http://hl7.org/fhir/us/mcc/StructureDefinition/custodian"^^xsd:anyURI ] ;
fhir:value [
a fhir:Reference ;
fhir:reference [ fhir:v "Practitioner/practitionerMCC-3v" ] ;
fhir:display [ fhir:v "Dr. John Carlson" ]     ]
  ] ) ; # 
  fhir:status [ fhir:v "active"] ; # 
  fhir:intent [ fhir:v "plan"] ; # 
  fhir:category ( [
    ( fhir:coding [
a sct:734163000 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "734163000" ] ;
fhir:display [ fhir:v "Care Plan" ]     ] [
fhir:system [ fhir:v "http://hl7.org/fhir/us/core/CodeSystem/careplan-category"^^xsd:anyURI ] ;
fhir:version [ fhir:v "6.1.0" ] ;
fhir:code [ fhir:v "assess-plan" ]     ] )
  ] ) ; # 
  fhir:subject [
fhir:reference [ fhir:v "Patient/cc-pat-pnoelle" ] ;
fhir:display [ fhir:v "Patricia Noelle" ]
  ] ; # 
  fhir:period [
fhir:start [ fhir:v "2022-05-20"^^xsd:date ]
  ] ; # 
  fhir:created [ fhir:v "2022-05-20"^^xsd:date] ; # 
  fhir:contributor ( [
fhir:reference [ fhir:v "Practitioner/practitionerMCC-3v" ] ;
fhir:display [ fhir:v "Dr John Carlson, Primary Care Physician" ]
  ] [
fhir:reference [ fhir:v "PractitionerRole/careCoordinator-1" ] ;
fhir:display [ fhir:v "Care-coordinator, served by Julie Smith" ]
  ] [
fhir:reference [ fhir:v "Patient/cc-pat-pnoelle" ] ;
fhir:display [ fhir:v "Noelle" ]
  ] [
fhir:reference [ fhir:v "PractitionerRole/dr-vince-jones" ] ;
fhir:display [ fhir:v "Nephrologist Role, served by Dr Vince Jones" ]
  ] [
fhir:reference [ fhir:v "RelatedPerson/daughter1" ] ;
fhir:display [ fhir:v "Rose Noelle, Daughter" ]
  ] ) ; # 
  fhir:careTeam ( [
fhir:reference [ fhir:v "CareTeam/careteam-for-bundle" ] ;
fhir:display [ fhir:v "Long-COVID and CKD focused care team" ]
  ] ) ; # 
  fhir:addresses ( [
fhir:reference [ fhir:v "Condition/ConditionCKD" ] ;
fhir:display [ fhir:v "Chronic Kidney Disease" ]
  ] [
fhir:reference [ fhir:v "Condition/encounter-diag-1" ] ;
fhir:display [ fhir:v "Long COVID" ]
  ] ) ; # 
  fhir:supportingInfo ( [
fhir:reference [ fhir:v "Observation/arterial-blood-gas-panel" ]
  ] [
fhir:reference [ fhir:v "Observation/reduced-pain" ] ;
fhir:display [ fhir:v "Outcome example. Caregiver's observed thoughts on pain" ]
  ] [
fhir:reference [ fhir:v "Condition/patient-health-concern-1" ] ;
fhir:display [ fhir:v "Patient Health Concern: Worry that Long Covid symptoms will effect CKD" ]
  ] [
fhir:reference [ fhir:v "Condition/patient-health-concern-2" ] ;
fhir:display [ fhir:v "Patient Health Concern: Hard to exercise due to pain" ]
  ] [
fhir:reference [ fhir:v "Condition/patient-health-concern-3" ] ;
fhir:display [ fhir:v "Patient Health Concern: Struggles to manage her diet and find affordable healthy food choices under her financial strain" ]
  ] [
fhir:reference [ fhir:v "Condition/patient-health-concern-4" ] ;
fhir:display [ fhir:v "Patient Health Concern: Poor appetite for healthy CKD appropriate foods, likes cola, cake and chips" ]
  ] [
fhir:reference [ fhir:v "Condition/careTeam-concerns-1" ] ;
fhir:display [ fhir:v "CareTeam Health Concern: Imbalanced Nutrition" ]
  ] [
fhir:reference [ fhir:v "Condition/careTeam-concerns-2" ] ;
fhir:display [ fhir:v "CareTeam Health Concern: Dyspnea" ]
  ] [
fhir:reference [ fhir:v "Condition/careTeam-concerns-3" ] ;
fhir:display [ fhir:v "CareTeam Health Concern: Pain in Legs" ]
  ] [
fhir:reference [ fhir:v "Condition/careTeam-concerns-4" ] ;
fhir:display [ fhir:v "CareTeam Health Concern: Pain in Hands" ]
  ] [
fhir:reference [ fhir:v "Condition/careTeam-concerns-5" ] ;
fhir:display [ fhir:v "CareTeam Health Concern: Pain in arms" ]
  ] [
fhir:reference [ fhir:v "Condition/problem-list-1" ] ;
fhir:display [ fhir:v "Finding: Food aversion and cravings" ]
  ] [
fhir:reference [ fhir:v "Condition/problem-list-2" ] ;
fhir:display [ fhir:v "Diagnosis: Metabolic acidosis" ]
  ] [
fhir:reference [ fhir:v "Condition/chilblain-resolved" ] ;
fhir:display [ fhir:v "Long Covid related condition: Pustular chilblain resolved" ]
  ] [
fhir:reference [ fhir:v "Observation/symptom2" ] ;
fhir:display [ fhir:v "Long Covid symptom: Dyspnea" ]
  ] [
fhir:reference [ fhir:v "Observation/symptom3" ] ;
fhir:display [ fhir:v "Long Covid symptom: Pain in Legs" ]
  ] [
fhir:reference [ fhir:v "Observation/symptom4" ] ;
fhir:display [ fhir:v "Long Covid symptom: Pain in hands" ]
  ] [
fhir:reference [ fhir:v "Observation/symptom5" ] ;
fhir:display [ fhir:v "Long Covid symptom: Pain in arms" ]
  ] [
fhir:reference [ fhir:v "Observation/symptom6" ] ;
fhir:display [ fhir:v "Long Covid symptom: Brain Fog - Intermittent confusion" ]
  ] [
fhir:reference [ fhir:v "Observation/symptom7" ] ;
fhir:display [ fhir:v "Long Covid symptom: Brain Fog - Memory impairment" ]
  ] [
fhir:reference [ fhir:v "Observation/symptom8" ] ;
fhir:display [ fhir:v "Long Covid symptom: Covid Toes - Toe swelling" ]
  ] [
fhir:reference [ fhir:v "Observation/symptom9" ] ;
fhir:display [ fhir:v "Long Covid symptom: Covid Toes - Pustular chilblain" ]
  ] ) ; # 
  fhir:goal ( [
fhir:reference [ fhir:v "Goal/lower-pain-minimal-opioids" ] ;
fhir:display [ fhir:v "Lower pain with minimal opioids" ]
  ] [
fhir:reference [ fhir:v "Goal/appetite-to-normal" ] ;
fhir:display [ fhir:v "Return appetite to normal" ]
  ] [
fhir:reference [ fhir:v "Goal/electrolyte-protein-normal-range" ] ;
fhir:display [ fhir:v "Get Electrolyte and proteins back to normal" ]
  ] [
fhir:reference [ fhir:v "Goal/bmi-normal-range" ] ;
fhir:display [ fhir:v "Get BMI into healthy range" ]
  ] [
fhir:reference [ fhir:v "Goal/access-affordable-healthy-food" ] ;
fhir:display [ fhir:v "Improve access to affordable, healthy food" ]
  ] ) ; # 
  fhir:activity ( [
    ( fhir:outcomeReference [
fhir:reference [ fhir:v "Procedure/dietitian-consult" ] ;
fhir:display [ fhir:v "Dietitian consult" ]     ] [
fhir:reference [ fhir:v "Observation/better-diet" ] ;
fhir:display [ fhir:v "Observation by caregiver (daughter) of improvement in diet" ]     ] ) ;
fhir:reference [
fhir:reference [ fhir:v "ServiceRequest/dietitian-referral" ] ;
fhir:display [ fhir:v "Dietitian Referral" ]     ]
  ] [
    ( fhir:outcomeReference [
fhir:reference [ fhir:v "Procedure/dialysis-for-bundle" ]     ] [
fhir:reference [ fhir:v "Procedure/dialysis-for-bundle2" ]     ] [
fhir:reference [ fhir:v "Procedure/dialysis-for-bundle3" ]     ] ) ;
fhir:reference [
fhir:reference [ fhir:v "ServiceRequest/dialysis-request" ]     ]
  ] [
    ( fhir:outcomeReference [
fhir:reference [ fhir:v "Procedure/ckd-app-education" ]     ] )
  ] [
    ( fhir:outcomeReference [
fhir:reference [ fhir:v "MedicationRequest/med-for-chilblains" ] ;
fhir:display [ fhir:v "Treatment for chilblains" ]     ] [
fhir:reference [ fhir:v "Condition/chilblain-resolved" ]     ] [
fhir:reference [ fhir:v "ServiceRequest/pt-3x-wk" ] ;
fhir:display [ fhir:v "PT 3x per week" ]     ] [
fhir:reference [ fhir:v "ServiceRequest/counseling-1x-wk" ] ;
fhir:display [ fhir:v "Counseling 1x per week" ]     ] [
fhir:reference [ fhir:v "Task/meditation-7x-wk" ] ;
fhir:display [ fhir:v "Meditation 7x per week" ]     ] [
fhir:reference [ fhir:v "Observation/observation-moca" ] ;
fhir:display [ fhir:v "MOCA new result showing improvement" ]     ] [
fhir:reference [ fhir:v "Observation/observation-moca-original" ] ;
fhir:display [ fhir:v "MOCA initial result showing impairment" ]     ] ) ;
    ( fhir:progress [
fhir:time [ fhir:v "2022-12-10"^^xsd:date ] ;
fhir:text [ fhir:v "Long COVID symptoms improving" ]     ] ) ;
fhir:reference [
fhir:reference [ fhir:v "ServiceRequest/long-covid-request" ] ;
fhir:display [ fhir:v "Long Covid Clinic Referral serviceRequest" ]     ]
  ] ) . #