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

Example CarePlan: Multiple Chronic Condition Care Plan Example

Narrative: CarePlan

Resource CarePlan "MCCCarePlan"

Profile: Multiple Chronic Care Condition Care Plan

Custodian R5 backport: RelatedPerson/caregiver-of-noelle " VAN PUTTEN"

status: active

intent: plan

category: Care Plan (SNOMED CT#734163000; US Core CarePlan Category Extension Codes#assess-plan)

subject: Patient/cc-pat-pnoelle: Patricia Noelle " NOELLE"

period: 2018-05-01 --> (ongoing)

created: 2019-01-01

author: PractitionerRole/PractitionerRoleMCC2: Nancy Nurse RN

contributor:

careTeam: CareTeam/MCCCareTeamexample: Longitudinal care-coordination focused care team "US-Core MCC example CareTeam"

addresses: Condition/ConditionCKD: Chronic Kidney Disease

supportingInfo:

goal: Goal/WGT-loss: Lose weight, decrease chronic pain with less use of pain medication and improved lab results

activity

outcomeReference: Procedure/Dialysis: Dialysis

progress: Patricia Noelle is measuring her weight daily ( @2019-01-10)

reference: http://example.org/Task/123: Patricia Noelle or cargiver to perform daily weights

activity

outcomeReference:

progress: 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 ( @2019-01-10)

reference: http://example.org/Appointment/AVShunt: PreOp Encounter Request For Creation of external arteriovenous shunt (procedure). Relates to overall health improvement goal and encounter requestActivity. The goal relationship is through resource-pertainsToGoal for the Encounter