MCC eCare Plan Implementation Guide
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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

: MCC Goal Example - Normal Hypertension - TTL Representation

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix loinc: <https://loinc.org/rdf/> .
@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:Goal ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "HPT-WNL"] ; # 
  fhir:meta [
fhir:versionId [ fhir:v "5" ] ;
fhir:lastUpdated [ fhir:v "2022-06-02T23:34:46.692+00:00"^^xsd:dateTime ] ;
fhir:source [ fhir:v "#2FWI9BsC94EqeXTg"^^xsd:anyURI ] ;
    ( fhir:profile [
fhir:v "http://hl7.org/fhir/us/mcc/StructureDefinition/MCCGoal"^^xsd:anyURI ;
fhir:link <http://hl7.org/fhir/us/mcc/StructureDefinition/MCCGoal>     ] )
  ] ; # 
  fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Goal HPT-WNL</b></p><a name=\"HPT-WNL\"> </a><a name=\"hcHPT-WNL\"> </a><a name=\"HPT-WNL-en-US\"> </a><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\">version: 5; Last updated: 2022-06-02 23:34:46+0000; </p><p style=\"margin-bottom: 0px\">Information Source: #2FWI9BsC94EqeXTg</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-MCCGoal.html\">Multiple Chronic Condition Care Plan Goal</a></p></div><p><b>lifecycleStatus</b>: Active</p><p><b>priority</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/goal-priority high-priority}\">high</span></p><p><b>description</b>: <span title=\"Codes:{http://snomed.info/sct 271651005}\">Target Systolic Blood pressure between 110 and 140 mmHg.</span></p><p><b>subject</b>: <a href=\"Patient-cc-pat-pnoelle.html\">Patricia Noelle</a></p><p><b>start</b>: 2019-10-14</p><h3>Targets</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Measure</b></td><td><b>Detail[x]</b></td><td><b>Due[x]</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://loinc.org 8480-6}\">Systolic blood pressure</span></td><td>110-140 lbs</td><td>2020-04-05</td></tr></table><p><b>statusDate</b>: 2019-10-14</p><p><b>statusReason</b>: Patient knows that normal blood pressure is important for CKD, Hypertension and diabetes control.</p><p><b>expressedBy</b>: <a href=\"Patient-cc-pat-pnoelle.html\">Patricia Noelle</a></p><p><b>addresses</b>: <a href=\"Condition-ConditionCKD.html\">chronic kidney disease condition</a></p><p><b>outcomeReference</b>: <a href=\"Observation-MCCweight.html\">Body Weight Measured - 165 Pounds</a></p></div>"
  ] ; # 
  fhir:extension ( [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/goal-acceptance"^^xsd:anyURI ] ;
    ( fhir:extension [
fhir:url [ fhir:v "individual"^^xsd:anyURI ] ;
fhir:value [
a fhir:Reference ;
fhir:reference [ fhir:v "Patient/cc-pat-pnoelle" ]       ]     ] [
fhir:url [ fhir:v "status"^^xsd:anyURI ] ;
fhir:value [ fhir:v "agree" ]     ] [
fhir:url [ fhir:v "priority"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
        ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/goal-priority"^^xsd:anyURI ] ;
fhir:code [ fhir:v "high-priority" ]         ] )       ]     ] )
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/goal-acceptance"^^xsd:anyURI ] ;
    ( fhir:extension [
fhir:url [ fhir:v "individual"^^xsd:anyURI ] ;
fhir:value [
a fhir:Reference ;
fhir:reference [ fhir:v "Practitioner/practitionerMCC-3" ]       ]     ] [
fhir:url [ fhir:v "status"^^xsd:anyURI ] ;
fhir:value [ fhir:v "agree" ]     ] [
fhir:url [ fhir:v "priority"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
        ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/goal-priority"^^xsd:anyURI ] ;
fhir:code [ fhir:v "high-priority" ]         ] )       ]     ] )
  ] [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/goal-relationship"^^xsd:anyURI ] ;
    ( fhir:extension [
fhir:url [ fhir:v "type"^^xsd:anyURI ] ;
fhir:value [
a fhir:CodeableConcept ;
        ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/goal-relationship-type"^^xsd:anyURI ] ;
fhir:code [ fhir:v "other" ]         ] ) ;
fhir:text [ fhir:v "This goal relates to the Weight loss goal" ]       ]     ] [
fhir:url [ fhir:v "target"^^xsd:anyURI ] ;
fhir:value [
a fhir:Reference ;
fhir:reference [ fhir:v "Goal/WGT-loss" ]       ]     ] )
  ] ) ; # 
  fhir:lifecycleStatus [ fhir:v "active"] ; # 
  fhir:priority [
    ( fhir:coding [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/goal-priority"^^xsd:anyURI ] ;
fhir:code [ fhir:v "high-priority" ] ;
fhir:display [ fhir:v "High Priority" ]     ] ) ;
fhir:text [ fhir:v "high" ]
  ] ; # 
  fhir:description [
    ( fhir:coding [
a sct:271651005 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "271651005" ] ;
fhir:display [ fhir:v "Stable blood pressure" ]     ] ) ;
fhir:text [ fhir:v "Target Systolic Blood pressure between 110 and 140 mmHg." ]
  ] ; # 
  fhir:subject [
fhir:reference [ fhir:v "Patient/cc-pat-pnoelle" ] ;
fhir:display [ fhir:v "Patricia Noelle" ]
  ] ; # 
  fhir:start [ fhir:v "2019-10-14"^^xsd:date] ; # 
  fhir:target ( [
fhir:measure [
      ( fhir:coding [
a loinc:8480-6 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "8480-6" ] ;
fhir:display [ fhir:v "Systolic blood pressure" ]       ] )     ] ;
fhir:detail [
a fhir:Range ;
fhir:low [
fhir:value [ fhir:v "110"^^xsd:decimal ] ;
fhir:unit [ fhir:v "lbs" ] ;
fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "mm[Hg]" ]       ] ;
fhir:high [
fhir:value [ fhir:v "140"^^xsd:decimal ] ;
fhir:unit [ fhir:v "lbs" ] ;
fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "mm[Hg]" ]       ]     ] ;
fhir:due [ fhir:v "2020-04-05"^^xsd:date ]
  ] ) ; # 
  fhir:statusDate [ fhir:v "2019-10-14"^^xsd:date] ; # 
  fhir:statusReason [ fhir:v "Patient knows that normal blood pressure is important for CKD, Hypertension and diabetes control."] ; # 
  fhir:expressedBy [
fhir:reference [ fhir:v "Patient/cc-pat-pnoelle" ] ;
fhir:display [ fhir:v "Patricia Noelle" ]
  ] ; # 
  fhir:addresses ( [
fhir:reference [ fhir:v "Condition/ConditionCKD" ] ;
fhir:display [ fhir:v "chronic kidney disease condition" ]
  ] ) ; # 
  fhir:outcomeReference ( [
fhir:reference [ fhir:v "Observation/MCCweight" ] ;
fhir:display [ fhir:v "Body Weight Measured - 165 Pounds" ]
  ] ) . #