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Patient Care Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Encounter, Patient |
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Integrated care plan with multiple goals & conditions (from Mayo)
@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 xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- [a fhir:CarePlan ; fhir:nodeRole fhir:treeRoot ; fhir:id [ fhir:v "integrate"] ; # fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir: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>" ] ; # fhir:contained ( [ a fhir:Condition ; fhir:id [ fhir:v "p1" ] ; fhir:clinicalStatus [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/condition-clinical"^^xsd:anyURI ] ; fhir:code [ fhir:v "active" ] ] ) ] ; fhir:verificationStatus [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/condition-ver-status"^^xsd:anyURI ] ; fhir:code [ fhir:v "confirmed" ] ] ) ] ; fhir:code [ fhir:text [ fhir:v "GERDS" ] ] ; fhir:subject [ fhir:reference [ fhir:v "Patient/1" ] ; fhir:display [ fhir:v "Eve Everywoman" ] ] ] [ a fhir:Condition ; fhir:id [ fhir:v "p2" ] ; fhir:clinicalStatus [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/condition-clinical"^^xsd:anyURI ] ; fhir:code [ fhir:v "active" ] ] ) ] ; fhir:verificationStatus [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/condition-ver-status"^^xsd:anyURI ] ; fhir:code [ fhir:v "confirmed" ] ] ) ] ; fhir:code [ fhir:text [ fhir:v "Obesity" ] ] ; fhir:subject [ fhir:reference [ fhir:v "Patient/1" ] ; fhir:display [ fhir:v "Eve Everywoman" ] ] ] [ a fhir:Condition ; fhir:id [ fhir:v "p3" ] ; fhir:clinicalStatus [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/condition-clinical"^^xsd:anyURI ] ; fhir:code [ fhir:v "active" ] ] ) ] ; fhir:verificationStatus [ fhir:coding ( [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/condition-ver-status"^^xsd:anyURI ] ; fhir:code [ fhir:v "confirmed" ] ] ) ] ; fhir:code [ fhir:text [ fhir:v "Psoriasis" ] ] ; fhir:subject [ fhir:reference [ fhir:v "Patient/1" ] ; fhir:display [ fhir:v "Eve Everywoman" ] ] ] [ a fhir:Goal ; fhir:id [ fhir:v "g1" ] ; fhir:lifecycleStatus [ fhir:v "active" ] ; fhir:description [ fhir:text [ fhir:v "Eve will lose weight and reduce her GERDS symptoms by improving her diet" ] ] ; fhir:subject [ fhir:reference [ fhir:v "Patient/1" ] ; fhir:display [ fhir:v "Eve Everywoman" ] ] ] [ a fhir:Goal ; fhir:id [ fhir:v "g2" ] ; fhir:lifecycleStatus [ fhir:v "active" ] ; fhir:description [ fhir:text [ fhir:v "Eve will improve her GERDS symptoms" ] ] ; fhir:subject [ fhir:reference [ fhir:v "Patient/1" ] ; fhir:display [ fhir:v "Eve Everywoman" ] ] ] [ a fhir:Goal ; fhir:id [ fhir:v "g3" ] ; fhir:lifecycleStatus [ fhir:v "active" ] ; fhir:description [ fhir:text [ fhir:v "Eve will increase her energy by being more active" ] ] ; fhir:subject [ fhir:reference [ fhir:v "Patient/1" ] ; fhir:display [ fhir:v "Eve Everywoman" ] ] ] [ a fhir:Goal ; fhir:id [ fhir:v "g4" ] ; fhir:lifecycleStatus [ fhir:v "active" ] ; fhir:description [ fhir:text [ fhir:v "Eve will set up her medications and take as prescribed" ] ] ; fhir:subject [ fhir:reference [ fhir:v "Patient/1" ] ; fhir:display [ fhir:v "Eve Everywoman" ] ] ] [ a fhir:Goal ; fhir:id [ fhir:v "g5" ] ; fhir:lifecycleStatus [ fhir:v "active" ] ; fhir:description [ fhir:text [ fhir:v "Eve will restart her light treatments" ] ] ; fhir:subject [ fhir:reference [ fhir:v "Patient/1" ] ; fhir:display [ fhir:v "Eve Everywoman" ] ] ] ) ; # fhir:status [ fhir:v "active"] ; # fhir:intent [ fhir:v "plan"] ; # fhir:subject [ fhir:reference [ fhir:v "Patient/1" ] ; fhir:display [ fhir:v "Eve Everywoman" ] ] ; # fhir:addresses ( [ fhir:reference [ fhir:reference [ fhir:v "#p1" ] ; fhir:display [ fhir:v "GERDS" ] # Local reference ] ] [ fhir:reference [ fhir:reference [ fhir:v "#p2" ] ; fhir:display [ fhir:v "Obesity" ] # Local reference ] ] [ fhir:reference [ fhir:reference [ fhir:v "#p3" ] ; fhir:display [ fhir:v "Psoriasis" ] # Local reference ] ] ) ; # fhir:goal ( [ fhir:reference [ fhir:v "#g1" ] ] [ fhir:reference [ fhir:v "#g2" ] ] [ fhir:reference [ fhir:v "#g3" ] ] [ fhir:reference [ fhir:v "#g4" ] ] [ fhir:reference [ fhir:v "#g5" ] ] ) ; # fhir:activity ( [ fhir:progress ( [ fhir:time [ fhir:v "2012-09-10"^^xsd:date ] ; fhir:text [ fhir:v "Eve eats one meal a day with her parents" ] ] ) ; fhir:plannedActivityReference [ fhir:reference [ fhir:v "ServiceRequest/activity-1" ] ] # Eve will review photos of high and low density foods and share with her parents ] [ fhir:plannedActivityReference [ fhir:reference [ fhir:v "ServiceRequest/activity-2" ] ] # Eve will ask her dad to asist her to put the head of her bed on blocks ] [ fhir:plannedActivityReference [ fhir:reference [ fhir:v "NutritionOrder/activity-3" ] ] # Eve will reduce her intake of coffee and chocolate ] [ fhir:progress ( [ fhir:time [ fhir:v "2012-08-27"^^xsd:date ] ; fhir:text [ fhir:v "Eve would like to try for 5 days a week." ] ] [ fhir:time [ fhir:v "2012-09-10"^^xsd:date ] ; fhir:text [ fhir:v "Eve is still walking the dogs." ] ] ) ; fhir:plannedActivityReference [ fhir:reference [ fhir:v "ServiceRequest/activity-4" ] ] # Eve will walk her friend's dog up and down a big hill 15-30 minutes 3 days a week ] [ fhir:progress ( [ fhir:time [ fhir:v "2012-08-13"^^xsd:date ] ; fhir:text [ fhir:v "Eve walked 4 times the last week." ] ] [ fhir:time [ fhir:v "2012-09-10"^^xsd:date ] ; fhir:text [ fhir:v "Eve did not walk to her parents the last week, but has plans to start again" ] ] ) ; fhir:plannedActivityReference [ fhir:reference [ fhir:v "ServiceRequest/activity-5" ] ] # Eve will walk 3 blocks to her parents house twice a week ] [ fhir:plannedActivityReference [ fhir:reference [ fhir:v "ServiceRequest/activity-6" ] ] # Eve will use a calendar to check off after medications are taken ] [ fhir:progress ( [ fhir:time [ fhir:v "2012-08-13"^^xsd:date ] ; fhir:text [ fhir:v "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." ] ] [ fhir:time [ fhir:v "2012-08-27"^^xsd:date ] ; fhir:text [ fhir:v "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" ] ] ) ; fhir:plannedActivityReference [ fhir:reference [ fhir:v "ServiceRequest/activity-7" ] ] # Eve will use her lights MWF after her shower for 3 minutes ] [ fhir:progress ( [ fhir:time [ fhir:v "2012-07-23"^^xsd:date ] ; fhir:text [ fhir:v "Eve created a chart as a reminer to take the medications that do not fit in her pill box" ] ] ) ; fhir:plannedActivityReference [ fhir:reference [ fhir:v "ServiceRequest/activity-8" ] ] # Eve will use a calendar of a chart to help her remember when to take her medications ] [ fhir:progress ( [ fhir:time [ fhir:v "2012-07-30"^^xsd:date ] ; fhir:text [ fhir:v "Will be able to esume exercise." ] ] [ fhir:time [ fhir:v "2012-08-13"^^xsd:date ] ; fhir:text [ fhir:v "Eve prefers to focus on walking at this time" ] ] ) ; fhir:plannedActivityReference [ fhir:reference [ fhir:v "ServiceRequest/activity-9" ] ] # Eve will start using stretch bands and one step 2 days a week Mon\/Wed 6-7am and maybe Friday afternoon ] [ fhir:plannedActivityReference [ fhir:reference [ fhir:v "ServiceRequest/activity-10" ] ] # Eve will match a printed medication worksheet with the medication bottles at home ] [ fhir:progress ( [ fhir:time [ fhir:v "2012-07-16"^^xsd:date ] ; fhir:text [ fhir:v "Eve now has some of her medications set up in pill packs by her pharmacist" ] ] ) ; fhir:plannedActivityReference [ fhir:reference [ fhir:v "ServiceRequest/activity-11" ] ] # Eve will get a medication box to sort her pills. She will have one for scheduled medications and one for as needed ] [ fhir:progress ( [ fhir:time [ fhir:v "2012-07-12"^^xsd:date ] ; fhir:text [ fhir:v "Eve will be able to resume exercise on 7/30/12" ] ] [ fhir:time [ fhir:v "2012-08-13"^^xsd:date ] ; fhir:text [ fhir:v "hold until \"less busy\"" ] ] ) ; fhir:plannedActivityReference [ fhir:reference [ fhir:v "ServiceRequest/activity-12" ] ] # Eve will open execersie DVD workout package and listen to it ] ) ; # fhir:note ( [ fhir:text [ fhir:v "Patient family is not ready to commit to goal setting at this time. Goal setting will be addressed in the future" ] ] )] . # # -------------------------------------------------------------------------------------
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