![.](tbl_spacer.png) 0 Table of Contents |
![.](tbl_spacer.png) ![.](tbl_vjoin.png) 1 Home Page |
![.](tbl_spacer.png) ![.](tbl_vjoin.png) 2 MCC Use Cases |
![.](tbl_spacer.png) ![.](tbl_vjoin.png) 3 Structure and Design Considerations |
![.](tbl_spacer.png) ![.](tbl_vjoin.png) 4 Alternatives for Transmitting/Collecting Aggregated Care Plans |
![.](tbl_spacer.png) ![.](tbl_vjoin.png) 5 Security |
![.](tbl_spacer.png) ![.](tbl_vjoin.png) 6 Questionnaire Response |
![.](tbl_spacer.png) ![.](tbl_vjoin.png) 7 MCC Care Plan SDOH Guidance |
![.](tbl_spacer.png) ![.](tbl_vjoin.png) 8 Note on _include and _revinclude |
![.](tbl_spacer.png) ![.](tbl_vjoin.png) 9 US Core General Requirements |
![.](tbl_spacer.png) ![.](tbl_vjoin.png) 10 MCC Must-support |
![.](tbl_spacer.png) ![.](tbl_vjoin.png) 11 Capability Statements |
![.](tbl_spacer.png) ![.](tbl_vjoin-open.png) 12 MCC Value Set Libraries and Usage |
![.](tbl_spacer.png) ![.](tbl_vline.png) ![.](tbl_vjoin.png) 12.1 MCC Chronic Condition and Health Concern Value Sets |
![.](tbl_spacer.png) ![.](tbl_vline.png) ![.](tbl_vjoin.png) 12.2 MCC Clinical Test Value Sets |
![.](tbl_spacer.png) ![.](tbl_vline.png) ![.](tbl_vjoin.png) 12.3 MCC Goal Value Sets |
![.](tbl_spacer.png) ![.](tbl_vline.png) ![.](tbl_vjoin.png) 12.4 MCC Laboratory Result Value Sets |
![.](tbl_spacer.png) ![.](tbl_vline.png) ![.](tbl_vjoin.png) 12.5 MCC Medication Request Value Sets |
![.](tbl_spacer.png) ![.](tbl_vline.png) ![.](tbl_vjoin.png) 12.6 MCC Diagnostic Report and Note Imaging Value Sets |
![.](tbl_spacer.png) ![.](tbl_vline.png) ![.](tbl_vjoin.png) 12.7 MCC Observation SDOH Assessment Value Sets |
![.](tbl_spacer.png) ![.](tbl_vline.png) ![.](tbl_vjoin.png) 12.8 MCC Procedure and Service Request Value Sets |
![.](tbl_spacer.png) ![.](tbl_vline.png) ![.](tbl_vjoin.png) 12.9 MCC Questionnaire Response Value Sets |
![.](tbl_spacer.png) ![.](tbl_vline.png) ![.](tbl_vjoin.png) 12.10 MCC Simple Observation Value Sets |
![.](tbl_spacer.png) ![.](tbl_vline.png) ![.](tbl_vjoin_end.png) 12.11 MCC Symptom Value Sets |
![.](tbl_spacer.png) ![.](tbl_vjoin.png) 13 Downloads |
![.](tbl_spacer.png) ![.](tbl_vjoin_end-open.png) 14 Artifacts Summary |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.1 Multiple Chronic Care Condition Care Plan |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.2 Multiple Chronic Condition Care Plan Caregiver Considerations Observation |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.3 MCCCareTeam |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.4 MCC Chronic Condition and Health Concern Profile |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.5 Multiple Chronic Condition Care Plan Clinical Impression |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.6 Multiple Chronic Condition Care Plan Clinical Result Observation |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.7 Multiple Chronic Condition Care Plan Diagnostic Report and Note |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.8 Document Reference to Patient's Personal Advance Care Plan (Advance Directive) |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.9 Multiple Chronic Condition Care Plan Family History |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.10 Multiple Chronic Condition Care Plan Goal |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.11 Multiple Chronic Condition Care Plan Immunization |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.12 Multiple Chronic Condition Care Plan Laboratory Result Observation |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.13 Multiple Chronic Condition Care Plan Medication Request |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.14 Multiple Chronic Condition Care Plan Nutrition Order |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.15 Multiple Chronic Condition Care Plan Observation SDOH Assessment |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.16 Multiple Chronic Condition Care Plan Patient/Caregiver Condition Status Observation |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.17 Multiple Chronic Condition Care Plan Procedure |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.18 Multiple Chronic Condition Care Plan Questionnaire Response |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.19 Multiple Chronic Condition Care Plan Service Request |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.20 Multiple Chronic Condition Care Plan Simple Observation |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.21 Multiple Chronic Condition Care Plan Symptom Observation |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.22 Multiple Chronic Condition Care Plan Clinical Imaging Observation |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.23 long-covid-and-ckd-bundle |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.24 observation-moca |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.25 questionnnaire-res-moca |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.26 obs-response-moca |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.27 observation-moca-original |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.28 questionnnaire-res-moca-original |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.29 obs-response-moca-original |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.30 dialysis-request |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.31 dialysis-for-bundle |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.32 dialysis-for-bundle2 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.33 dialysis-for-bundle3 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.34 ckd-app-education |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.35 dietitian-referral |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.36 dietitian-consult |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.37 better-diet |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.38 long-covid-request |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.39 med-for-chilblains |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.40 pt-3x-wk |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.41 counseling-1x-wk |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.42 meditation-7x-wk |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.43 careplan-for-bundle |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.44 daughter1 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.45 practitionerMCC-V |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.46 dr-vince-jones |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.47 practitionerMCC-3v |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.48 careCoordinator1 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.49 funding1 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.50 communitysite |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.51 careCoordinator-1 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.52 careteam-for-bundle |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.53 patient-health-concern-1 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.54 patient-health-concern-2 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.55 patient-health-concern-3 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.56 patient-health-concern-4 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.57 careTeam-concerns-1 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.58 careTeam-concerns-2 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.59 careTeam-concerns-3 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.60 careTeam-concerns-4 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.61 careTeam-concerns-5 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.62 problem-list-1 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.63 problem-list-2 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.64 encounter-diag-1 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.65 arterial-blood-gas-panel |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.66 ph-lab-observation |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.67 hco3-arterial-observation |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.68 pCO2-arterial-observation |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.69 pO2-arterial-observation |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.70 serum-lactate-observation |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.71 blood-ketones-observation |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.72 serum-electrolytes-panel |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.73 sodium-serum-observation |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.74 potassium-serum-observation |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.75 chloride-serum-observation |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.76 bicarbonate-serum-observation |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.77 carbon-dioxide-serum-observation |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.78 anion-gap-serum-observation |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.79 protein-serum-observation |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.80 albumin-serum-observation |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.81 glomerular-filtration-observation |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.82 symptom2 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.83 symptom3 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.84 symptom4 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.85 symptom5 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.86 symptom6 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.87 symptom7 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.88 symptom8 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.89 symptom9 |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.90 chilblain-found |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.91 chilblain-resolved |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.92 lower-pain-minimal-opioids |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.93 reduced-pain |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.94 appetite-to-normal |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.95 electrolyte-protein-normal-range |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.96 bmi-normal-range |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.97 access-affordable-healthy-food |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.98 MCCServerCapabilityStatement |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.99 MCCClientCapabilityStatement |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.100 Change Pattern R5 backport |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.101 Custodian R5 backport |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.102 Multiple Chronic Condition Care Plan Example |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.103 MCC Procedure Example - Dialysis |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.104 MCC Diagnostic Report and Note Example |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.105 MCC Family Member History Example - Father |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.106 MCC Document Reference to Advance Directives Example |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.107 MCC Chronic Condition - CKD Example |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.108 MCC Goal Example - Weight Loss |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.109 MCC Practitioner - Nephrologist |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.110 MCC Practitioner - Nurse Practitioner |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.111 MCC Practitioner - Primary Care Provider |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.112 MCC Practitioner - Nephrologist Provider Role |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.113 MCC Practitioner - Nurse Practitioner Role |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.114 MCC Practitioner - Primary Care Provider Role |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.115 MCC Lab Observation - BUN |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.116 MCC Patient |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.117 Multiple Chronic Condition Care Plan Care Team |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.118 MCC Goal Example - Normal Hypertension |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.119 US-Core MCC Weight Example |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.120 MCC Medication Request Example |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.121 MCC Symptom Observation Example - Taste Sense Altered |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.122 Multiple Chronic Condition Care Plan Immunization Example |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.123 Multiple Chronic Condition Care Plan Nutrition Order Example |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.124 Multiple Chronic Condition Care Plan Clinical Impression Example |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.125 MCC Care Team Example |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.126 Caregiver Example |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.127 MCC QuestionnaireResponse Example |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.128 Multiple Chronic Condition Care Plan Imagining Observation Example |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.129 Expansion Parameters SNOMED US Version |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.130 MCC Clinical Result Observation example |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.131 MCC Caregiver Feelings on Condition Observation example |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.132 MCC SDOH assessment example Observation |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.133 Multiple Chronic Condition Service Request - Food Pantry |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin.png) 14.134 Multiple Chronic Condition Care Plan Simple Observation Example |
![.](tbl_spacer.png) ![.](tbl_blank.png) ![.](tbl_vjoin_end.png) 14.135 MCC Observation of Caregiver considerations example |