MCC eCare Plan Implementation Guide
1.0.0 - ballot 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 Goal: MCC Goal Example - Normal Hypertension

Generated Narrative: Goal

Resource Goal "HPT-WNL" Version "5" Updated "2022-06-02 23:34:46+0000"

Information Source: #2FWI9BsC94EqeXTg!

Profile: Multiple Chronic Condition Care Plan Goal

Goal acceptance

url

individual

value: Patient/cc-pat-pnoelle " NOELLE"

url

status

value: agree

url

priority

value: High Priority (Goal priority#high-priority)

Goal acceptance

url

individual

value: Practitioner/practitionerMCC-3 " PRIMARY"

url

status

value: agree

url

priority

value: High Priority (Goal priority#high-priority)

Goal: Related Goal

url

type

value: This goal relates to the Weight loss goal (GoalRelationshipType#other)

url

target

value: Goal/WGT-loss

lifecycleStatus: active

priority: high (Goal priority#high-priority "High Priority")

description: Target Systolic Blood pressure between 110 and 140 mmHg. (SNOMED CT#271651005 "Stable blood pressure")

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

start: 2019-10-14

Targets

-MeasureDetail[x]Due[x]
*Systolic blood pressure (LOINC#8480-6)110-140 lbs2020-04-05

statusDate: 2019-10-14

statusReason: Patient knows that normal blood pressure is important for CKD, Hypertension and diabetes control.

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

addresses: Condition/ConditionCKD: chronic kidney disease condition

outcomeReference: Observation/MCCweight: Body Weight Measured - 165 Pounds