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

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: MCC Goal Example - Normal Hypertension - JSON Representation

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{
  "resourceType" : "Goal",
  "id" : "HPT-WNL",
  "meta" : {
    "versionId" : "5",
    "lastUpdated" : "2022-06-02T23:34:46.692+00:00",
    "source" : "#2FWI9BsC94EqeXTg",
    "profile" : [
      🔗 "http://hl7.org/fhir/us/mcc/StructureDefinition/MCCGoal"
    ]
  },
  "text" : {
    "status" : "generated",
    "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>"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/goal-acceptance",
      "extension" : [
        {
          "url" : "individual",
          "valueReference" : {
            🔗 "reference" : "Patient/cc-pat-pnoelle"
          }
        },
        {
          "url" : "status",
          "valueCode" : "agree"
        },
        {
          "url" : "priority",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/goal-priority",
                "code" : "high-priority"
              }
            ]
          }
        }
      ]
    },
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/goal-acceptance",
      "extension" : [
        {
          "url" : "individual",
          "valueReference" : {
            🔗 "reference" : "Practitioner/practitionerMCC-3"
          }
        },
        {
          "url" : "status",
          "valueCode" : "agree"
        },
        {
          "url" : "priority",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/goal-priority",
                "code" : "high-priority"
              }
            ]
          }
        }
      ]
    },
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/goal-relationship",
      "extension" : [
        {
          "url" : "type",
          "valueCodeableConcept" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/goal-relationship-type",
                "code" : "other"
              }
            ],
            "text" : "This goal relates to the Weight loss goal"
          }
        },
        {
          "url" : "target",
          "valueReference" : {
            🔗 "reference" : "Goal/WGT-loss"
          }
        }
      ]
    }
  ],
  "lifecycleStatus" : "active",
  "priority" : {
    "coding" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/goal-priority",
        "code" : "high-priority",
        "display" : "High Priority"
      }
    ],
    "text" : "high"
  },
  "description" : {
    "coding" : [
      {
        "system" : "http://snomed.info/sct",
        "code" : "271651005",
        "display" : "Stable blood pressure"
      }
    ],
    "text" : "Target Systolic Blood pressure between 110 and 140 mmHg."
  },
  "subject" : {
    🔗 "reference" : "Patient/cc-pat-pnoelle",
    "display" : "Patricia Noelle"
  },
  "startDate" : "2019-10-14",
  "target" : [
    {
      "measure" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "8480-6",
            "display" : "Systolic blood pressure"
          }
        ]
      },
      "detailRange" : {
        "low" : {
          "value" : 110,
          "unit" : "lbs",
          "system" : "http://unitsofmeasure.org",
          "code" : "mm[Hg]"
        },
        "high" : {
          "value" : 140,
          "unit" : "lbs",
          "system" : "http://unitsofmeasure.org",
          "code" : "mm[Hg]"
        }
      },
      "dueDate" : "2020-04-05"
    }
  ],
  "statusDate" : "2019-10-14",
  "statusReason" : "Patient knows that normal blood pressure is important for CKD, Hypertension and diabetes control.",
  "expressedBy" : {
    🔗 "reference" : "Patient/cc-pat-pnoelle",
    "display" : "Patricia Noelle"
  },
  "addresses" : [
    {
      🔗 "reference" : "Condition/ConditionCKD",
      "display" : "chronic kidney disease condition"
    }
  ],
  "outcomeReference" : [
    {
      🔗 "reference" : "Observation/MCCweight",
      "display" : "Body Weight Measured - 165 Pounds"
    }
  ]
}