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Patient Care Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Encounter, Patient |
Raw JSON (canonical form + also see JSON Format Specification)
Integrated care plan with multiple goals & conditions (from Mayo)
{ "resourceType" : "CarePlan", "id" : "integrate", "text" : { "status" : "generated", "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Patient family is not ready to commit to goal setting at this time. Goal setting will be addressed in the future</p>\n <table>\n <thead>\n <tr>\n <th>Start Date</th>\n <th>Goal</th>\n <th>Action Steps</th>\n <th>Status</th>\n <th>Date Last Updated</th>\n <th>Comments</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>10 Sep 2012</td>\n <td>Eve will lose weight and reduce her GERDS symptoms by improving her diet</td>\n <td>Eve will review photos of high and low density foods and share with her parents</td>\n <td>New Goal</td>\n <td>10 Sep 2012</td>\n <td>9/10/12 Eve eats one meal a day with her parents</td>\n </tr>\n <tr>\n <td>10 Sep 2012</td>\n <td>Eve will lose weight and reduce her GERDS symptoms by improving her diet</td>\n <td>Eve will ask her dad to asist her to put the head of her bed on blocks</td>\n <td>New Goal</td>\n <td>10 Sep 2012</td>\n <td>9/10/12 Eve will sleep in her bed more often than the couch</td>\n </tr>\n <tr>\n <td>10 Sep 2012</td>\n <td>Eve will improve her GERDS symptoms</td>\n <td>Eve will reduce her intake of coffee and chocolate</td>\n <td>In Process</td>\n <td>10 Sep 2012</td>\n <td/>\n </tr>\n <tr>\n <td>27 Aug 2012</td>\n <td>Eve will increase her energy by being more active</td>\n <td>Eve will walk her friend's dog up and down a big hill 15-30 minutes 3 days a week</td>\n <td>In Process</td>\n <td>10 Sep 2012</td>\n <td>8/27/12 Eve would like to try for 5 days a week. 9/10/12 Eve is still walking the dogs.</td>\n </tr>\n <tr>\n <td>23 Jul 2012</td>\n <td>Eve will increase her energy by being more active</td>\n <td>Eve will walk 3 blocks to her parents house twice a week</td>\n <td>In Process</td>\n <td>10 Sep 2012</td>\n <td>8/13/12 Eve walked 4 times the last week. 9/10/12 Eve did not walk to her parents the last week, but has plans to start again</td>\n </tr>\n <tr>\n <td>23 Jul 2012</td>\n <td>Eve will set up her medications and take as prescribed</td>\n <td>Eve will us a calendar to check off after medications are taken</td>\n <td>In Process</td>\n <td>13 Aug 2012</td>\n <td/>\n </tr>\n <tr>\n <td>23 Jul 2012</td>\n <td>Eve will restart her light treatments</td>\n <td>Eve will use her lights MWF after her shower for 3 minutes</td>\n <td>In Process</td>\n <td>27 Aug 2012</td>\n <td>8/13/12 After restarting the vinegar soaks the psoriasis is improved and Eve plans to treat the remainder with light treatments. She plans to start this week. 8/27/12 Since her skin is improved Eve has not been using the light treatment as often, maybe once a week. She would like to increase to 3 times a week again</td>\n </tr>\n <tr>\n <td>10 Jul 2012</td>\n <td>Eve will set up her medications and take as prescribed</td>\n <td>Eve will use a calendar of a chart to help her remember when to take her medications</td>\n <td>In Process</td>\n <td>10 Sep 2012</td>\n <td>7/23/12 Eve created a chart as a reminer to take the medications that do not fit in her pill box</td>\n </tr>\n <tr>\n <td>23 Jul 2012</td>\n <td>Eve will increase her energy by being more active</td>\n <td>Eve will start using stretch bands and one step 2 days a week Mon/Wed 6-7am and maybe Friday afternoon</td>\n <td>On-Hold</td>\n <td>23 Aug 2012</td>\n <td>7/30/12 will be able to esume exercise. 8/13/12 Eve prefers to focus on walking at this time</td>\n </tr>\n <tr>\n <td>10 Jul 2012</td>\n <td>Eve will set up her medications and take as prescribed</td>\n <td>Eve will match a printed medication worksheet with the medication bottles at home</td>\n <td>Completed</td>\n <td>23 Jul 2012</td>\n <td/>\n </tr>\n <tr>\n <td>10 Jul 2012</td>\n <td>Eve will set up her medications and take as prescribed</td>\n <td>Eve will get a medication box to sort her pills. She will have one for scheduled medications and one for as needed</td>\n <td>Completed</td>\n <td>16 Jul 2012</td>\n <td>7/16/12 Eve now has some of her medications set up in pill packs by her pharmacist</td>\n </tr>\n <tr>\n <td>23 Jul 2012</td>\n <td>Eve will increase her energy by being more active</td>\n <td>Eve will open "The Firm" DVD workout package and listen to it</td>\n <td>Discontinued</td>\n <td>13 Aug 2012</td>\n <td>7/30/12 Eve will be able to resume exercise on 7/30/12. 8/13/12 -hold until "less busy"</td>\n </tr>\n </tbody>\n </table>\n </div>" }, "contained" : [{ "resourceType" : "Condition", "id" : "p1", "clinicalStatus" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/condition-clinical", "code" : "active" }] }, "verificationStatus" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/condition-ver-status", "code" : "confirmed" }] }, "code" : { "text" : "GERDS" }, "subject" : { "reference" : "Patient/1", "display" : "Eve Everywoman" } }, { "resourceType" : "Condition", "id" : "p2", "clinicalStatus" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/condition-clinical", "code" : "active" }] }, "verificationStatus" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/condition-ver-status", "code" : "confirmed" }] }, "code" : { "text" : "Obesity" }, "subject" : { "reference" : "Patient/1", "display" : "Eve Everywoman" } }, { "resourceType" : "Condition", "id" : "p3", "clinicalStatus" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/condition-clinical", "code" : "active" }] }, "verificationStatus" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/condition-ver-status", "code" : "confirmed" }] }, "code" : { "text" : "Psoriasis" }, "subject" : { "reference" : "Patient/1", "display" : "Eve Everywoman" } }, { "resourceType" : "Goal", "id" : "g1", "lifecycleStatus" : "active", "description" : { "text" : "Eve will lose weight and reduce her GERDS symptoms by improving her diet" }, "subject" : { "reference" : "Patient/1", "display" : "Eve Everywoman" } }, { "resourceType" : "Goal", "id" : "g2", "lifecycleStatus" : "active", "description" : { "text" : "Eve will improve her GERDS symptoms" }, "subject" : { "reference" : "Patient/1", "display" : "Eve Everywoman" } }, { "resourceType" : "Goal", "id" : "g3", "lifecycleStatus" : "active", "description" : { "text" : "Eve will increase her energy by being more active" }, "subject" : { "reference" : "Patient/1", "display" : "Eve Everywoman" } }, { "resourceType" : "Goal", "id" : "g4", "lifecycleStatus" : "active", "description" : { "text" : "Eve will set up her medications and take as prescribed" }, "subject" : { "reference" : "Patient/1", "display" : "Eve Everywoman" } }, { "resourceType" : "Goal", "id" : "g5", "lifecycleStatus" : "active", "description" : { "text" : "Eve will restart her light treatments" }, "subject" : { "reference" : "Patient/1", "display" : "Eve Everywoman" } }], "status" : "active", "intent" : "plan", "subject" : { "reference" : "Patient/1", "display" : "Eve Everywoman" }, "addresses" : [{ "reference" : { "reference" : "#p1", "display" : "GERDS" } }, { "reference" : { "reference" : "#p2", "display" : "Obesity" } }, { "reference" : { "reference" : "#p3", "display" : "Psoriasis" } }], "goal" : [{ "reference" : "#g1" }, { "reference" : "#g2" }, { "reference" : "#g3" }, { "reference" : "#g4" }, { "reference" : "#g5" }], "activity" : [{ "progress" : [{ "time" : "2012-09-10", "text" : "Eve eats one meal a day with her parents" }], "plannedActivityReference" : { "reference" : "ServiceRequest/activity-1" } }, { "plannedActivityReference" : { "reference" : "ServiceRequest/activity-2" } }, { "plannedActivityReference" : { "reference" : "NutritionOrder/activity-3" } }, { "progress" : [{ "time" : "2012-08-27", "text" : "Eve would like to try for 5 days a week." }, { "time" : "2012-09-10", "text" : "Eve is still walking the dogs." }], "plannedActivityReference" : { "reference" : "ServiceRequest/activity-4" } }, { "progress" : [{ "time" : "2012-08-13", "text" : "Eve walked 4 times the last week." }, { "time" : "2012-09-10", "text" : "Eve did not walk to her parents the last week, but has plans to start again" }], "plannedActivityReference" : { "reference" : "ServiceRequest/activity-5" } }, { "plannedActivityReference" : { "reference" : "ServiceRequest/activity-6" } }, { "progress" : [{ "time" : "2012-08-13", "text" : "After restarting the vinegar soaks the psoriasis is improved and Eve plans to treat the remainder with light treatments. She plans to start this week." }, { "time" : "2012-08-27", "text" : "Since her skin is improved Eve has not been using the light treatment as often, maybe once a week. She would like to increase to 3 times a week again" }], "plannedActivityReference" : { "reference" : "ServiceRequest/activity-7" } }, { "progress" : [{ "time" : "2012-07-23", "text" : "Eve created a chart as a reminer to take the medications that do not fit in her pill box" }], "plannedActivityReference" : { "reference" : "ServiceRequest/activity-8" } }, { "progress" : [{ "time" : "2012-07-30", "text" : "Will be able to esume exercise." }, { "time" : "2012-08-13", "text" : "Eve prefers to focus on walking at this time" }], "plannedActivityReference" : { "reference" : "ServiceRequest/activity-9" } }, { "plannedActivityReference" : { "reference" : "ServiceRequest/activity-10" } }, { "progress" : [{ "time" : "2012-07-16", "text" : "Eve now has some of her medications set up in pill packs by her pharmacist" }], "plannedActivityReference" : { "reference" : "ServiceRequest/activity-11" } }, { "progress" : [{ "time" : "2012-07-12", "text" : "Eve will be able to resume exercise on 7/30/12" }, { "time" : "2012-08-13", "text" : "hold until \"less busy\"" }], "plannedActivityReference" : { "reference" : "ServiceRequest/activity-12" } }], "note" : [{ "text" : "Patient family is not ready to commit to goal setting at this time. Goal setting will be addressed in the future" }] }
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.
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