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 - XML Representation

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<Goal xmlns="http://hl7.org/fhir">
  <id value="HPT-WNL"/>
  <meta>
    <versionId value="5"/>
    <lastUpdated value="2022-06-02T23:34:46.692+00:00"/>
    <source value="#2FWI9BsC94EqeXTg"/>
    <profile value="http://hl7.org/fhir/us/mcc/StructureDefinition/MCCGoal"/>
  </meta>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: Goal</b><a name="HPT-WNL"> </a><a name="hcHPT-WNL"> </a></p><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">ResourceGoal &quot;HPT-WNL&quot; Version &quot;5&quot; Updated &quot;2022-06-02 23:34:46+0000&quot; </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><blockquote><p><b>Goal acceptance</b></p><blockquote><p><b>url</b></p><code>individual</code></blockquote><p><b>value</b>: <a href="Patient-cc-pat-pnoelle.html">Patient/cc-pat-pnoelle</a> &quot; NOELLE&quot;</p><blockquote><p><b>url</b></p><code>status</code></blockquote><p><b>value</b>: agree</p><blockquote><p><b>url</b></p><code>priority</code></blockquote><p><b>value</b>: High Priority <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.5.0/CodeSystem-goal-priority.html">Goal priority</a>#high-priority)</span></p></blockquote><blockquote><p><b>Goal acceptance</b></p><blockquote><p><b>url</b></p><code>individual</code></blockquote><p><b>value</b>: <a href="Practitioner-practitionerMCC-3.html">Practitioner/practitionerMCC-3</a> &quot; PRIMARY&quot;</p><blockquote><p><b>url</b></p><code>status</code></blockquote><p><b>value</b>: agree</p><blockquote><p><b>url</b></p><code>priority</code></blockquote><p><b>value</b>: High Priority <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.5.0/CodeSystem-goal-priority.html">Goal priority</a>#high-priority)</span></p></blockquote><blockquote><p><b>Goal: Related Goal</b></p><blockquote><p><b>url</b></p><code>type</code></blockquote><p><b>value</b>: This goal relates to the Weight loss goal <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.5.0/CodeSystem-goal-relationship-type.html">GoalRelationshipType</a>#other)</span></p><blockquote><p><b>url</b></p><code>target</code></blockquote><p><b>value</b>: <a href="Goal-WGT-loss.html">Goal/WGT-loss</a></p></blockquote><p><b>lifecycleStatus</b>: active</p><p><b>priority</b>: high <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.5.0/CodeSystem-goal-priority.html">Goal priority</a>#high-priority &quot;High Priority&quot;)</span></p><p><b>description</b>: Target Systolic Blood pressure between 110 and 140 mmHg. <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOWMED CT</a>#271651005 &quot;Stable blood pressure&quot;)</span></p><p><b>subject</b>: <a href="Patient-cc-pat-pnoelle.html">Patient/cc-pat-pnoelle: Patricia Noelle</a> &quot; NOELLE&quot;</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>Systolic blood pressure <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://loinc.org/">LOINC</a>#8480-6)</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">Patient/cc-pat-pnoelle: Patricia Noelle</a> &quot; NOELLE&quot;</p><p><b>addresses</b>: <a href="Condition-ConditionCKD.html">Condition/ConditionCKD: chronic kidney disease condition</a></p><p><b>outcomeReference</b>: <a href="Observation-MCCweight.html">Observation/MCCweight: Body Weight Measured - 165 Pounds</a></p></div>
  </text>
  <extension url="http://hl7.org/fhir/StructureDefinition/goal-acceptance">
    <extension url="individual">
      <valueReference>🔗 
        <reference value="Patient/cc-pat-pnoelle"/>
      </valueReference>
    </extension>
    <extension url="status">
      <valueCode value="agree"/>
    </extension>
    <extension url="priority">
      <valueCodeableConcept>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/goal-priority"/>
          <code value="high-priority"/>
        </coding>
      </valueCodeableConcept>
    </extension>
  </extension>
  <extension url="http://hl7.org/fhir/StructureDefinition/goal-acceptance">
    <extension url="individual">
      <valueReference>🔗 
        <reference value="Practitioner/practitionerMCC-3"/>
      </valueReference>
    </extension>
    <extension url="status">
      <valueCode value="agree"/>
    </extension>
    <extension url="priority">
      <valueCodeableConcept>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/goal-priority"/>
          <code value="high-priority"/>
        </coding>
      </valueCodeableConcept>
    </extension>
  </extension>
  <extension url="http://hl7.org/fhir/StructureDefinition/goal-relationship">
    <extension url="type">
      <valueCodeableConcept>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/goal-relationship-type"/>
          <code value="other"/>
        </coding>
        <text value="This goal relates to the Weight loss goal"/>
      </valueCodeableConcept>
    </extension>
    <extension url="target">
      <valueReference>🔗 
        <reference value="Goal/WGT-loss"/>
      </valueReference>
    </extension>
  </extension>
  <lifecycleStatus value="active"/>
  <priority>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/goal-priority"/>
      <code value="high-priority"/>
      <display value="High Priority"/>
    </coding>
    <text value="high"/>
  </priority>
  <description>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="271651005"/>
      <display value="Stable blood pressure"/>
    </coding>
    <text value="Target Systolic Blood pressure between 110 and 140 mmHg."/>
  </description>
  <subject>🔗 
    <reference value="Patient/cc-pat-pnoelle"/>
    <display value="Patricia Noelle"/>
  </subject>
  <startDate value="2019-10-14"/>
  <target>
    <measure>
      <coding>
        <system value="http://loinc.org"/>
        <code value="8480-6"/>
        <display value="Systolic blood pressure"/>
      </coding>
    </measure>
    <detailRange>
      <low>
        <value value="110"/>
        <unit value="lbs"/>
        <system value="http://unitsofmeasure.org"/>
        <code value="mm[Hg]"/>
      </low>
      <high>
        <value value="140"/>
        <unit value="lbs"/>
        <system value="http://unitsofmeasure.org"/>
        <code value="mm[Hg]"/>
      </high>
    </detailRange>
    <dueDate value="2020-04-05"/>
  </target>
  <statusDate value="2019-10-14"/>
  <statusReason
                value="Patient knows that normal blood pressure is important for CKD, Hypertension and diabetes control."/>
  <expressedBy>🔗 
    <reference value="Patient/cc-pat-pnoelle"/>
    <display value="Patricia Noelle"/>
  </expressedBy>
  <addresses>🔗 
    <reference value="Condition/ConditionCKD"/>
    <display value="chronic kidney disease condition"/>
  </addresses>
  <outcomeReference>🔗 
    <reference value="Observation/MCCweight"/>
    <display value="Body Weight Measured - 165 Pounds"/>
  </outcomeReference>
</Goal>