{"resourceType":"Composition","status":"preliminary","subject":{"display":"Patricia Noelle","reference":"cc-pat-pnoelle"},"date":"2024-12-15","author":[{"display":"Patricia Noelle","reference":"cc-pat-pnoelle"}],"title":"Continuity of Care Document","section":[{"reference":"Patient/cc-pat-pnoelle"},{"reference":"CarePlan/MCCCarePlan"},{"reference":"CareTeam/careteam-of-noelle"},{"reference":"CareTeam/MCCCareTeamexample"},{"reference":"Condition/ConditionCKD"},{"reference":"DiagnosticReport/BoneSurvey"},{"reference":"Immunization/immunization-1"},{"reference":"Observation/AHC-HRSN-item-example-68517-2"},{"reference":"Observation/bunMCC"},{"reference":"Observation/caregiver-consideration-obs-example"},{"reference":"Observation/caregiver-feelings-condition-status"},{"reference":"Observation/mcc-imaging-observation-example"},{"reference":"Observation/MCCweight"},{"reference":"Observation/pulse-intensity-palpation"},{"reference":"Observation/simple-observation-example"},{"reference":"Observation/Symptom1"},{"reference":"Procedure/Dialysis"},{"reference":"QuestionnaireResponse/hunger-vital-sign-example"},{"reference":"ServiceRequest/foodpantry-referral"}],"resource":{"author":[{"display":"","reference":"Patient/cc-pat-pnoelle"}]}} {"resourceType":"Patient","id":"cc-pat-pnoelle","meta":{"versionId":"6","lastUpdated":"2022-08-02T18:25:58.212+00:00","source":"#JCaZBT444ZLpgXTH","profile":["http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient"]},"text":{"status":"generated","div":"
\n
Patricia \n NOELLE \n
\n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n
Identifier103270456
Address\n 49 Meadow St \n
\n Mounds \n OK \n US \n
Date of birth\n 15 January 1955\n
\n
"},"identifier":[{"use":"usual","type":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/v2-0203","code":"MR","display":"Medical Record Number"}],"text":"Medical Record Number"},"system":"http://hospital.smarthealthit.org","value":"103270456"}],"active":true,"name":[{"family":"Noelle","given":["Patricia"]}],"telecom":[{"system":"phone","value":"555-555-5555","use":"home"}],"gender":"female","birthDate":"1955-01-15","address":[{"line":["49 Meadow St"],"city":"Mounds","state":"OK","postalCode":"74047","country":"US"}],"_id":"apgEEKvaeeydqc5qA"} {"resourceType":"CarePlan","id":"MCCCarePlan","meta":{"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/instance-name","valueString":"Multiple Chronic Condition Care Plan Example"},{"url":"http://hl7.org/fhir/StructureDefinition/instance-description","valueMarkdown":"This is an example for the *MCC CarePlan Profile*."}],"profile":["http://hl7.org/fhir/us/mcc/StructureDefinition/mccCarePlan"]},"text":{"status":"additional","div":"

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

"},"extension":[{"url":"http://hl7.org/fhir/us/mcc/StructureDefinition/custodian","valueReference":{"reference":"RelatedPerson/caregiver-of-noelle"}}],"status":"active","intent":"plan","category":[{"coding":[{"system":"http://snomed.info/sct","code":"734163000","display":"Care Plan"},{"system":"http://hl7.org/fhir/us/core/CodeSystem/careplan-category","code":"assess-plan"}]}],"subject":{"reference":"Patient/cc-pat-pnoelle","display":"Patricia Noelle"},"period":{"start":"2018-05-01"},"created":"2019-01-01","author":{"reference":"PractitionerRole/PractitionerRoleMCC2","display":"Nancy Nurse RN"},"contributor":[{"reference":"PractitionerRole/PractitionerRoleMCC1","display":"Henry Levin VII MD Nephrologist"},{"reference":"PractitionerRole/PractitionerRoleMCC2","display":"Nancy Nurse RN"},{"reference":"PractitionerRole/PractitionerRoleMCC3","display":"Peter Primary MD Primary Provider"}],"careTeam":[{"reference":"CareTeam/MCCCareTeamexample","display":"Longitudinal care-coordination focused care team"}],"addresses":[{"reference":"Condition/ConditionCKD","display":"Chronic Kidney Disease"}],"supportingInfo":[{"reference":"Procedure/Dialysis","display":"Chronic Pain"},{"reference":"Observation/bunMCC","display":"BUN 24 mL/min/{1.73_m2}"}],"goal":[{"reference":"Goal/WGT-loss","display":"Lose weight, decrease chronic pain with less use of pain medication and improved lab results"}],"activity":[{"outcomeReference":[{"reference":"Procedure/Dialysis","display":"Dialysis"}],"progress":[{"time":"2019-01-10","text":"Patricia Noelle is measuring her weight daily"}],"reference":{"reference":"http://example.org/Task/123","display":"Patricia Noelle or cargiver to perform daily weights"}},{"outcomeReference":[{"reference":"http://example.org/Encounter/123","display":"PreOp Encounter For Creation of external arteriovenous shunt (procedure)"},{"reference":"http://example.org/Procedure/upperlimbveinUS","display":"Fluoroscopic venography of bilateral upper limbs Performed. Results: Normal"}],"progress":[{"time":"2019-01-10","text":"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"}],"reference":{"reference":"http://example.org/Appointment/AVShunt","display":"PreOp Encounter Request For Creation of external arteriovenous shunt (procedure). Relates to overall health improvement goal and encounter requestActivity"}}],"_id":"bHTwGwJdB9N8pLtjN"} {"resourceType":"CareTeam","id":"careteam-of-noelle","meta":{"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/instance-name","valueString":"CareTeam Example for Noelle"},{"url":"http://hl7.org/fhir/StructureDefinition/instance-description","valueMarkdown":"This is a careteam example for the MCC CareTeam."}],"versionId":"7","lastUpdated":"2022-11-04T11:56:28.976+00:00","source":"#KKfIz9YE5wp4BiUp","profile":["http://hl7.org/fhir/us/mcc/StructureDefinition/MCCCareTeam"]},"text":{"status":"generated","div":"

Generated Narrative: CareTeam

Resource CareTeam "careteam-of-noelle" Version "7" Updated "2022-11-04 11:56:28+0000"

Information Source: #KKfIz9YE5wp4BiUp!

Profile: Multiple Chronic Condition Care Plan Care Team

status: active

name: Care Team of Noelle Example

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

participant

role: Nephrologist (SNOMED CT#11911009)

member: Practitioner/practitionerMCC-1 " LEVIN"

participant

role: Primary care provider (SNOMED CT[US rel. Oct 0012]#453231000124104)

member: Practitioner/practitionerMCC-3 " PRIMARY"

participant

role: Patient (person) (SNOMED CT#116154003)

member: Patient/cc-pat-pnoelle: Noelle " NOELLE"

participant

role: Caregiver (person) (SNOMED CT#133932002)

member: RelatedPerson/caregiver-of-noelle: Sarah van Putten " VAN PUTTEN"

"},"status":"active","name":"Care Team of Noelle Example","subject":{"reference":"Patient/cc-pat-pnoelle"},"participant":[{"role":[{"coding":[{"system":"http://snomed.info/sct","code":"11911009","display":"Nephrologist"}]}],"member":{"reference":"Practitioner/practitionerMCC-1"}},{"role":[{"coding":[{"system":"http://snomed.info/sct","version":"http://snomed.info/sct/731000124108/version/20220301","code":"453231000124104","display":"Primary care provider"}]}],"member":{"reference":"Practitioner/practitionerMCC-3"}},{"role":[{"coding":[{"system":"http://snomed.info/sct","code":"116154003","display":"Patient (person)"}]}],"member":{"reference":"Patient/cc-pat-pnoelle","display":"Noelle"}},{"role":[{"coding":[{"system":"http://snomed.info/sct","code":"133932002","display":"Caregiver (person)"}]}],"member":{"reference":"RelatedPerson/caregiver-of-noelle","display":"Sarah van Putten"}}],"_id":"tTnAn4CeHBQBPbDSM"} {"resourceType":"CareTeam","id":"MCCCareTeamexample","meta":{"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/instance-name","valueString":"CareTeam Example"},{"url":"http://hl7.org/fhir/StructureDefinition/instance-description","valueMarkdown":"This is a US Core CareTeam Example for MCC."}],"versionId":"2","lastUpdated":"2022-04-21T17:30:10.117+00:00","source":"#fOlntPRC97ZmQthM","profile":["http://hl7.org/fhir/us/core/StructureDefinition/us-core-careteam"]},"text":{"status":"generated","div":"

Generated Narrative: CareTeam

Resource CareTeam "MCCCareTeamexample" Version "2" Updated "2022-04-21 17:30:10+0000"

Information Source: #fOlntPRC97ZmQthM!

Profile: US Core CareTeam Profile

status: active

name: US-Core MCC example CareTeam

subject: Patient/cc-pat-pnoelle: Amy V. Shaw " NOELLE"

participant

role: Nephrologist (SNOMED CT#11911009)

member: Practitioner/practitionerMCC-1: Henry Levin VII, MD " LEVIN"

participant

role: Nurse Practitioner (SNOMED CT#224571005)

member: Practitioner/practitionerMCC-2: Nancy Nurse, RN NP " NURSE"

participant

role: Primary care provider (SNOMED CT#453231000124104)

member: Practitioner/practitionerMCC-3: Peter Primary, MD " PRIMARY"

participant

role: Patient (person) (SNOMED CT#116154003)

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

"},"status":"active","name":"US-Core MCC example CareTeam","subject":{"reference":"Patient/cc-pat-pnoelle","display":"Amy V. Shaw"},"participant":[{"role":[{"coding":[{"system":"http://snomed.info/sct","code":"11911009","display":"Nephrologist"}]}],"member":{"reference":"Practitioner/practitionerMCC-1","display":"Henry Levin VII, MD"}},{"role":[{"coding":[{"system":"http://snomed.info/sct","code":"224571005","display":"Nurse Practitioner"}]}],"member":{"reference":"Practitioner/practitionerMCC-2","display":"Nancy Nurse, RN NP"}},{"role":[{"coding":[{"system":"http://snomed.info/sct","code":"453231000124104","display":"Primary care provider"}]}],"member":{"reference":"Practitioner/practitionerMCC-3","display":"Peter Primary, MD"}},{"role":[{"coding":[{"system":"http://snomed.info/sct","code":"116154003","display":"Patient (person)"}]}],"member":{"reference":"Patient/cc-pat-pnoelle","display":"Patricia Noelle"}}],"_id":"4r9u5bW7yHhnb6Pk4"} {"resourceType":"Condition","id":"ConditionCKD","meta":{"versionId":"5","lastUpdated":"2022-06-17T23:22:56.193+00:00","source":"#5R98DWXS6a48AGkD","profile":["http://hl7.org/fhir/us/mcc/StructureDefinition/MCCChronicDisease"]},"text":{"status":"extensions","div":"

Generated Narrative: Condition

Resource Condition "ConditionCKD" Version "5" Updated "2022-06-17 23:22:56+0000"

Information Source: #5R98DWXS6a48AGkD!

Profile: Multiple Chronic Condition Care Plan Chronic Disease Conditions

pertains to goal: Goal/HPT-WNL

clinicalStatus: Active (Condition Clinical Status Codes#active)

verificationStatus: Confirmed (ConditionVerificationStatus#confirmed)

category: Problem (Condition Category Codes#problem-list-item "Problem List Item")

severity: Severe (SNOMED CT#24484000)

code: Chronic kidney disease stage 3B (disorder) (SNOMED CT#700379002)

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

onset: 52 years (Details: UCUM code a = 'a')

recordedDate: 2018-12-01

Evidences

-Detail
*FamilyMemberHistory/father: Father had Chronic Kidney disease, Procedure/Dialysis: Patient receives regular dialysis, Observation/bunMCC: BUN is 24 mg/dL
"},"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal","valueReference":{"reference":"Goal/HPT-WNL"}}],"clinicalStatus":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/condition-clinical","code":"active","display":"Active"}],"text":"Active"},"verificationStatus":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/condition-ver-status","code":"confirmed"}]},"category":[{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/condition-category","code":"problem-list-item","display":"Problem List Item"}],"text":"Problem"}],"severity":{"coding":[{"system":"http://snomed.info/sct","code":"24484000","display":"Severe"}]},"code":{"coding":[{"system":"http://snomed.info/sct","code":"700379002","display":"Chronic kidney disease stage 3B (disorder)"}]},"subject":{"reference":"Patient/cc-pat-pnoelle","display":"Patricia Noelle"},"onsetAge":{"value":52,"unit":"years","system":"http://unitsofmeasure.org","code":"a"},"recordedDate":"2018-12-01","evidence":[{"detail":[{"reference":"FamilyMemberHistory/father","display":"Father had Chronic Kidney disease"},{"reference":"Procedure/Dialysis","display":"Patient receives regular dialysis"},{"reference":"Observation/bunMCC","display":"BUN is 24 mg/dL"}]}],"_id":"4gAPKjCRe2mfJcKp9"} {"resourceType":"DiagnosticReport","id":"BoneSurvey","meta":{"versionId":"6","lastUpdated":"2022-08-02T18:25:58.212+00:00","source":"#IabLyRh2BJxb1PdV","profile":["http://hl7.org/fhir/us/mcc/StructureDefinition/MCCDiagnosticReportAndNote"]},"text":{"status":"generated","div":"
\n
XR Bones Survey Views
\n \n \n \n \n \n \n \n
StatusFINAL
\n
"},"status":"final","category":[{"coding":[{"system":"http://loinc.org","code":"LP29684-5","display":"Radiology"}],"text":"Radiology"}],"code":{"coding":[{"system":"http://loinc.org","code":"43518-0","display":"XR Bones Survey Views"}],"text":"XR Bones Survey Views"},"subject":{"reference":"Patient/cc-pat-pnoelle","display":"Patricia Noelle"},"effectiveDateTime":"2019-02-03T19:43:30.000Z","_id":"LsoRmm3LLa4XsYzci"} {"resourceType":"Immunization","id":"immunization-1","meta":{"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/instance-name","valueString":"Imm 1 Example"},{"url":"http://hl7.org/fhir/StructureDefinition/instance-description","valueMarkdown":"This is a example for the MCC Immunization Profile."}],"versionId":"3","lastUpdated":"2022-08-24T09:45:16.381+00:00","source":"#5lRECZtJSkDMD26t","profile":["http://hl7.org/fhir/us/mcc/StructureDefinition/MCCImmunization"]},"text":{"status":"extensions","div":"

Generated Narrative: Immunization

Resource Immunization "immunization-1" Version "3" Updated "2022-08-24 09:45:16+0000"

Information Source: #5lRECZtJSkDMD26t!

Profile: Multiple Chronic Condition Care Plan Immunization

pertains to goal: Goal/HPT-WNL

status: completed

vaccineCode: influenza, high-dose, quadrivalent (PH_VaccinesAdministeredCVX_CDC_NIP#197; National drug codes#49281012165 "FLUZONE High-Dose Quadrivalent Northern Hemisphere, 10 SYRINGE, GLASS in 1 PACKAGE (49281-121-65) > .7 mL in 1 SYRINGE, GLASS (49281-121-88) (package)")

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

occurrence: 2020-11-19 12:46:57-0800

primarySource: false

"},"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal","valueReference":{"reference":"Goal/HPT-WNL"}}],"status":"completed","vaccineCode":{"coding":[{"system":"http://hl7.org/fhir/sid/cvx","code":"197","display":"influenza, high-dose, quadrivalent"},{"system":"http://hl7.org/fhir/sid/ndc","code":"49281012165","display":"FLUZONE High-Dose Quadrivalent Northern Hemisphere, 10 SYRINGE, GLASS in 1 PACKAGE (49281-121-65) > .7 mL in 1 SYRINGE, GLASS (49281-121-88) (package)"}],"text":"influenza, high-dose, quadrivalent"},"patient":{"reference":"Patient/cc-pat-pnoelle","display":"Patricia Noelle"},"occurrenceDateTime":"2020-11-19T12:46:57-08:00","primarySource":false,"_id":"Wz9sqDjny3zczS2Wo"} {"resourceType":"Observation","id":"AHC-HRSN-item-example-68517-2","meta":{"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/instance-name","valueString":"Observation SDOH assessment Ahc-Hrsn Item Example 68517-2"},{"url":"http://hl7.org/fhir/StructureDefinition/instance-description","valueMarkdown":"This is a Ahc-Hrsn Item Example 68517-2 (How many times in the past 12 months have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)?) for the MCC Observation SDOH Assessment profile"}],"profile":["http://hl7.org/fhir/us/mcc/StructureDefinition/MCCObservationSDOHAssessment"]},"text":{"status":"extensions","div":"

Generated Narrative: Observation

Resource Observation "AHC-HRSN-item-example-68517-2"

Profile: Multiple Chronic Condition Care Plan Observation SDOH Assessment

pertains to goal: Goal/HPT-WNL

status: final

category: SDOH (US Core Category#sdoh), Survey (Observation Category Codes#survey)

code: How many times in the past 12 months have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)? (LOINC#68517-2 "How many times in the past year have you have X or more drinks in a day")

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

effective: 2022-03-29 22:38:59+0000

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

value: Never (LOINC#LA6270-8)

derivedFrom: : US Core QuestionnaireResponse AHC HRSN Screening-Example Example

"},"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal","valueReference":{"reference":"Goal/HPT-WNL"}}],"status":"final","category":[{"coding":[{"system":"http://hl7.org/fhir/us/core/CodeSystem/us-core-category","code":"sdoh","display":"SDOH"}]},{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/observation-category","code":"survey","display":"Survey"}]}],"code":{"coding":[{"system":"http://loinc.org","code":"68517-2","display":"How many times in the past year have you have X or more drinks in a day"}],"text":"How many times in the past 12 months have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)?"},"subject":{"reference":"Patient/cc-pat-pnoelle","display":"Patricia Noelle"},"effectiveDateTime":"2022-03-29T22:38:59.084000+00:00","performer":[{"reference":"Patient/cc-pat-pnoelle","display":"Patricia Noelle"}],"valueCodeableConcept":{"coding":[{"system":"http://loinc.org","code":"LA6270-8","display":"Never"}],"text":"Never"},"derivedFrom":[{"display":"US Core QuestionnaireResponse AHC HRSN Screening-Example Example"}],"_id":"ZrLQacv6cYN8xwzFp"} {"resourceType":"Observation","id":"bunMCC","meta":{"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/instance-name","valueString":"BUN Example"},{"url":"http://hl7.org/fhir/StructureDefinition/instance-description","valueMarkdown":"This is a BUN example for the *US Core Observation Lab Profile*."}],"versionId":"4","lastUpdated":"2022-05-18T23:37:12.617+00:00","source":"#qAUGMmCEAqCZRmKl","profile":["http://hl7.org/fhir/us/mcc/StructureDefinition/MCCLaboratoryResultObservation"]},"text":{"status":"generated","div":"

Generated Narrative: Observation

Resource Observation "bunMCC" Version "4" Updated "2022-05-18 23:37:12+0000"

Information Source: #qAUGMmCEAqCZRmKl!

Profile: Multiple Chronic Condition Care Plan Laboratory Result Observation

status: final

category: Laboratory (Observation Category Codes#laboratory)

code: BUN SerPl-mCnc (LOINC#3094-0)

subject: Patient/cc-pat-pnoelle: Amy Shaw " NOELLE"

effective: 2022-05-05

value: 24 mg/dL

ReferenceRanges

-LowHighType
*5 mg/dL (Details: UCUM code mg/dL = 'mg/dL')20 mg/dL (Details: UCUM code mg/dL = 'mg/dL')Treatment Range (Observation Reference Range Meaning Codes#treatment)
"},"status":"final","category":[{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/observation-category","code":"laboratory","display":"Laboratory"}],"text":"Laboratory"}],"code":{"coding":[{"system":"http://loinc.org","code":"3094-0","display":"BUN SerPl-mCnc"}],"text":"BUN SerPl-mCnc"},"subject":{"reference":"Patient/cc-pat-pnoelle","display":"Amy Shaw"},"effectiveDateTime":"2022-05-05","valueQuantity":{"value":24,"unit":"mg/dL","system":"http://unitsofmeasure.org"},"referenceRange":[{"low":{"value":5,"unit":"mg/dL","system":"http://unitsofmeasure.org","code":"mg/dL"},"high":{"value":20,"unit":"mg/dL","system":"http://unitsofmeasure.org","code":"mg/dL"},"type":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/referencerange-meaning","code":"treatment","display":"Treatment Range"}],"text":"Treatment Range"}}],"_id":"daXXZn5jfPhwJnCSR"} {"resourceType":"Observation","id":"caregiver-consideration-obs-example","meta":{"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/instance-name","valueString":"MCC Observation of caregiver consideration example"},{"url":"http://hl7.org/fhir/StructureDefinition/instance-description","valueMarkdown":"This is an example of assessing caregiver strain for the Multiple Chronic Condition Care Caregiver Considerations Observation profile."}],"versionId":"3","lastUpdated":"2022-09-09T12:12:45.266+00:00","source":"#k60DkM4brEus0tLp","profile":["http://hl7.org/fhir/us/mcc/StructureDefinition/MCCCaregiverConsiderationsObservation"]},"text":{"status":"extensions","div":"

Generated Narrative: Observation

Resource Observation "caregiver-consideration-obs-example" Version "3" Updated "2022-09-09 12:12:45+0000"

Information Source: #k60DkM4brEus0tLp!

Profile: Multiple Chronic Condition Care Plan Caregiver Considerations Observation

pertains to goal: Goal/HPT-WNL

status: final

category: Social History (Observation Category Codes#social-history), Caregiver well-being status (SNOMED CT#405193005 "Caregiver wellbeing status (observable entity)")

code: Caregiver role strain Caregiver [CCC] (LOINC#42821-9)

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

focus: RelatedPerson/caregiver-of-noelle " VAN PUTTEN"

effective: 2021-11-10 16:48:57-0800

performer: Practitioner/practitionerMCC-3 " PRIMARY"

value: Improved (LOINC#LA65-8)

"},"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal","valueReference":{"reference":"Goal/HPT-WNL"}}],"status":"final","category":[{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/observation-category","code":"social-history","display":"Social History"}]},{"coding":[{"system":"http://snomed.info/sct","code":"405193005","display":"Caregiver wellbeing status (observable entity)"}],"text":"Caregiver well-being status"}],"code":{"coding":[{"system":"http://loinc.org","code":"42821-9","display":"Caregiver role strain Caregiver [CCC]"}],"text":"Caregiver role strain Caregiver [CCC]"},"subject":{"reference":"Patient/cc-pat-pnoelle","display":"Noelle"},"focus":[{"reference":"RelatedPerson/caregiver-of-noelle"}],"effectiveDateTime":"2021-11-10T16:48:57.246958-08:00","performer":[{"reference":"Practitioner/practitionerMCC-3"}],"valueCodeableConcept":{"coding":[{"system":"http://loinc.org","code":"LA65-8","display":"Improved"}],"text":"Improved"},"_id":"jSHGTQ9tbkz9ZCnz6"} {"resourceType":"Observation","id":"caregiver-feelings-condition-status","meta":{"versionId":"10","lastUpdated":"2023-06-06T12:58:55.256Z","profile":["http://hl7.org/fhir/us/mcc/StructureDefinition/MCCPatientCaregiverConditionStatus"]},"text":{"status":"extensions","div":"

Generated Narrative: Observation

Resource Observation "caregiver-feelings-condition-status" Version "10" Updated "2023-06-06 12:58:55+0000"

Profile: Multiple Chronic Condition Care Plan Patient/Caregiver Condition Status Observation

pertains to goal: Goal/HPT-WNL

status: final

category: Caregivers thoughts on the patient's condition status (Observation Category Codes#social-history "Social History")

code: Observation on patient/caregiver feelings on the condition satus (LOINC#89253-9 "Trend")

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

focus: Condition/ConditionCKD

effective: 2021-11-10 16:48:57-0800

performer: RelatedPerson/caregiver-of-noelle " VAN PUTTEN"

value: Improved (LOINC#LA65-8)

"},"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal","valueReference":{"reference":"Goal/HPT-WNL"}}],"status":"final","category":[{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/observation-category","code":"social-history","display":"Social History"}],"text":"Caregivers thoughts on the patient's condition status"}],"code":{"coding":[{"system":"http://loinc.org","code":"89253-9","display":"Trend"}],"text":"Observation on patient/caregiver feelings on the condition satus"},"subject":{"reference":"Patient/cc-pat-pnoelle","display":"Patricia Noelle"},"focus":[{"reference":"Condition/ConditionCKD"}],"effectiveDateTime":"2021-11-10T16:48:57.246958-08:00","performer":[{"reference":"RelatedPerson/caregiver-of-noelle"}],"valueCodeableConcept":{"coding":[{"system":"http://loinc.org","code":"LA65-8","display":"Improved"}],"text":"Improved"},"_id":"BN3mczX5WXDtqFXW2"} {"resourceType":"Observation","id":"mcc-imaging-observation-example","meta":{"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/instance-name","valueString":"MCC Imaging Observation Example"},{"url":"http://hl7.org/fhir/StructureDefinition/instance-description","valueMarkdown":"This example of a MCC Observation Imaging Result Profile illustrates its use to capture information about a patient's radiology study findings."}],"versionId":"4","lastUpdated":"2022-11-16T23:42:40.247+00:00","source":"#UoU66P7pG8FUZuip","profile":["http://hl7.org/fhir/us/mcc/StructureDefinition/MCCImagingObservation"]},"text":{"status":"extensions","div":"

Generated Narrative: Observation

Resource Observation "mcc-imaging-observation-example" Version "4" Updated "2022-11-16 23:42:40+0000"

Information Source: #UoU66P7pG8FUZuip!

Profile: Multiple Chronic Condition Care Plan Clinical Imaging Observation

pertains to goal: Goal/HPT-WNL

status: final

category: Imaging (Observation Category Codes#imaging)

code: Findings (LOINC#18782-3 "Radiology Study observation (narrative)")

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

encounter: : ER Visit

effective: 2019-02-03 19:43:30+0000

performer: Practitioner/practitionerMCC-1 " LEVIN"

value: LINES AND TUBES: None.\\n LUNGS AND PLEURA:\\n Clear lungs. Normal pulmonary vascularity.\\n No pleural effusion.\\n No pneumothorax.\\n HEART, MEDIASTINUM AND HILA:\\n Heart is normal in size.\\n Normal mediastinal and hilar contour.\\n BONES AND SOFT TISSUES:\\n No acute abnormality.\\n

"},"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal","valueReference":{"reference":"Goal/HPT-WNL"}}],"status":"final","category":[{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/observation-category","code":"imaging","display":"Imaging"}],"text":"Imaging"}],"code":{"coding":[{"system":"http://loinc.org","code":"18782-3","display":"Radiology Study observation (narrative)"}],"text":"Findings"},"subject":{"reference":"Patient/cc-pat-pnoelle","display":"Patricia Noelle"},"encounter":{"display":"ER Visit"},"effectiveDateTime":"2019-02-03T19:43:30.000Z","performer":[{"reference":"Practitioner/practitionerMCC-1"}],"valueString":"LINES AND TUBES: None.\\n LUNGS AND PLEURA:\\n Clear lungs. Normal pulmonary vascularity.\\n No pleural effusion.\\n No pneumothorax.\\n HEART, MEDIASTINUM AND HILA:\\n Heart is normal in size.\\n Normal mediastinal and hilar contour.\\n BONES AND SOFT TISSUES:\\n No acute abnormality.\\n","_id":"XQWx5xwzw9zYxqvM7"} {"resourceType":"Observation","id":"MCCweight","meta":{"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/instance-name","valueString":"Weight Example"},{"url":"http://hl7.org/fhir/StructureDefinition/instance-description","valueMarkdown":"This is a weight example for the *Vitalsigns Profile*."}],"versionId":"2","lastUpdated":"2022-05-19T22:28:38.017+00:00","source":"#PFPwMgIoicORI1Kp","profile":["http://hl7.org/fhir/us/core/StructureDefinition/us-core-body-weight"]},"text":{"status":"generated","div":"

Generated Narrative: Observation

Resource Observation "MCCweight" Version "2" Updated "2022-05-19 22:28:38+0000"

Information Source: #PFPwMgIoicORI1Kp!

Profile: US Core Body Weight Profile

status: final

category: Vital Signs (Observation Category Codes#vital-signs)

code: weight (LOINC#29463-7 "Body Weight")

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

encounter: : GP Visit

effective: 1999-07-02

value: 165 Pounds (Details: UCUM code [lb_av] = '[lb_av]')

"},"status":"final","category":[{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/observation-category","code":"vital-signs","display":"Vital Signs"}],"text":"Vital Signs"}],"code":{"coding":[{"system":"http://loinc.org","code":"29463-7","display":"Body Weight"}],"text":"weight"},"subject":{"reference":"Patient/cc-pat-pnoelle","display":"Patricia Noelle"},"encounter":{"display":"GP Visit"},"effectiveDateTime":"1999-07-02","valueQuantity":{"value":165,"unit":"Pounds","system":"http://unitsofmeasure.org","code":"[lb_av]"},"_id":"LkfTk8qX7od259TB7"} {"resourceType":"Observation","id":"pulse-intensity-palpation","meta":{"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/instance-name","valueString":"Pulse intensity Palpation Example"},{"url":"http://hl7.org/fhir/StructureDefinition/instance-description","valueMarkdown":"This is a Pulse intensity Palpation Example for the *Clinical Result Observation Profile*."}],"source":"#w0KkhhmJCsYOH2OT","profile":["http://hl7.org/fhir/us/mcc/StructureDefinition/MCCClinicalResultObservation"]},"text":{"status":"extensions","div":"

Generated Narrative: Observation

Resource Observation "pulse-intensity-palpation"

Information Source: #w0KkhhmJCsYOH2OT!

Profile: Multiple Chronic Condition Care Plan Clinical Test Observation

pertains to goal: Goal/HPT-WNL

status: final

category: Clinical Result (Observation Category Codes#exam "Exam")

code: Pulse intensity Palpation (LOINC#44974-4)

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

encounter: : Diabetes Consult

effective: 2021-11-10 16:48:57-0800

performer: Practitioner/practitionerMCC-1 " LEVIN"

value: 1+ (LOINC#LA11841-6)

"},"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal","valueReference":{"reference":"Goal/HPT-WNL"}}],"status":"final","category":[{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/observation-category","code":"exam","display":"Exam"}],"text":"Clinical Result"}],"code":{"coding":[{"system":"http://loinc.org","code":"44974-4","display":"Pulse intensity Palpation"}],"text":"Pulse intensity Palpation"},"subject":{"reference":"Patient/cc-pat-pnoelle","display":"Patricia Noelle"},"encounter":{"display":"Diabetes Consult"},"effectiveDateTime":"2021-11-10T16:48:57.246958-08:00","performer":[{"reference":"Practitioner/practitionerMCC-1"}],"valueCodeableConcept":{"coding":[{"system":"http://loinc.org","code":"LA11841-6","display":"1+"}],"text":"1+"},"_id":"CrY3HaFPSGpghQDgD"} {"resourceType":"Observation","id":"simple-observation-example","meta":{"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/instance-name","valueString":"Faces Pain Scale Simple Observation Example"},{"url":"http://hl7.org/fhir/StructureDefinition/instance-description","valueMarkdown":"This is Faces Pain Scale, Revised, Example for the *MCC Simple Observation Profile*."}],"versionId":"2","lastUpdated":"2022-11-07T19:07:58.409+00:00","source":"#FvrhzeASAJxVwkbs","profile":["http://hl7.org/fhir/us/mcc/StructureDefinition/MCCSimpleObservation"]},"text":{"status":"extensions","div":"

Generated Narrative: Observation

Resource Observation "simple-observation-example" Version "2" Updated "2022-11-07 19:07:58+0000"

Information Source: #FvrhzeASAJxVwkbs!

Profile: Multiple Chronic Condition Care Plan Simple Observation

pertains to goal: Goal/HPT-WNL

status: final

category: Clinical Result (Observation Category Codes#exam "Exam")

code: Faces Pain Scale - Revised (LOINC#57696-7 "Pain severity FPS-R")

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

encounter: : Diabetes Consult

effective: 2021-11-10 16:48:57-0800

performer: Practitioner/practitionerMCC-1 " LEVIN"

value: 2 {score} (Details: UCUM code {score} = '{score}')

"},"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal","valueReference":{"reference":"Goal/HPT-WNL"}}],"status":"final","category":[{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/observation-category","code":"exam","display":"Exam"}],"text":"Clinical Result"}],"code":{"coding":[{"system":"http://loinc.org","code":"57696-7","display":"Pain severity FPS-R"}],"text":"Faces Pain Scale - Revised"},"subject":{"reference":"Patient/cc-pat-pnoelle","display":"Patricia Noelle"},"encounter":{"display":"Diabetes Consult"},"effectiveDateTime":"2021-11-10T16:48:57.246958-08:00","performer":[{"reference":"Practitioner/practitionerMCC-1"}],"valueQuantity":{"value":2,"system":"http://unitsofmeasure.org","code":"{score}"},"_id":"wCWQGE85gonJeDbT2"} {"resourceType":"Observation","id":"Symptom1","meta":{"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/instance-name","valueString":"MCC Symptom Observation Example"},{"url":"http://hl7.org/fhir/StructureDefinition/instance-description","valueMarkdown":"This example of a MCC Symptom Observation Profile illustrates its use to capture observation of a patient's symptoms study findings."}],"versionId":"5","lastUpdated":"2022-11-22T02:31:57.310+00:00","source":"#bdH6UAgNrK2m0Yu6","profile":["http://hl7.org/fhir/us/mcc/StructureDefinition/MCCSymptomObservation"]},"text":{"status":"extensions","div":"

Generated Narrative: Observation

Resource Observation "Symptom1" Version "5" Updated "2022-11-22 02:31:57+0000"

Information Source: #bdH6UAgNrK2m0Yu6!

Profile: Multiple Chronic Condition Care Plan Symptom Observation

pertains to goal: Goal/HPT-WNL

status: final

category: Symptom (LOINC#75325-1)

code: Symptom (LOINC#75325-1)

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

effective: 2022-05-18 22:33:22+0000

value: Taste Sense Altered (finding) (SNOMED CT#271801002)

"},"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal","valueReference":{"reference":"Goal/HPT-WNL"}}],"status":"final","category":[{"coding":[{"system":"http://loinc.org","code":"75325-1","display":"Symptom"}],"text":"Symptom"}],"code":{"coding":[{"system":"http://loinc.org","code":"75325-1","display":"Symptom"}]},"subject":{"reference":"Patient/cc-pat-pnoelle","display":"Patricia Noelle"},"effectiveDateTime":"2022-05-18T22:33:22Z","valueCodeableConcept":{"coding":[{"system":"http://snomed.info/sct","code":"271801002","display":"Taste Sense Altered (finding)"}]},"_id":"LNC3T75yoiMy7NYZQ"} {"resourceType":"Procedure","id":"Dialysis","meta":{"versionId":"10","lastUpdated":"2022-08-02T18:25:27.353+00:00","source":"#a5RkjLxbIWy2ffIt","profile":["http://hl7.org/fhir/us/mcc/StructureDefinition/MCCProcedure"]},"text":{"status":"generated","div":"

Generated Narrative: Procedure

Resource Procedure "Dialysis" Version "10" Updated "2022-08-02 18:25:27+0000"

Information Source: #a5RkjLxbIWy2ffIt!

Profile: Multiple Chronic Condition Care Plan Procedure

status: completed

code: Hemodialysis (SNOMED CT#302497006 "Hemodialysis (procedure)")

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

performed: 2012-08-05

recorder: Practitioner/practitionerMCC-1: Dr Henry Levin " LEVIN"

asserter: Practitioner/practitionerMCC-1: Dr Henry Levin " LEVIN"

Performers

-Actor
*Practitioner/practitionerMCC-1: Dr Henry Levin " LEVIN"

reasonReference: Condition/ConditionCKD: Chronic Kidney Disease

"},"status":"completed","code":{"coding":[{"system":"http://snomed.info/sct","code":"302497006","display":"Hemodialysis (procedure)"}],"text":"Hemodialysis"},"subject":{"reference":"Patient/cc-pat-pnoelle","display":"Patricia Noelle"},"performedDateTime":"2012-08-05","recorder":{"reference":"Practitioner/practitionerMCC-1","display":"Dr Henry Levin"},"asserter":{"reference":"Practitioner/practitionerMCC-1","display":"Dr Henry Levin"},"performer":[{"actor":{"reference":"Practitioner/practitionerMCC-1","display":"Dr Henry Levin"}}],"reasonReference":[{"reference":"Condition/ConditionCKD","display":"Chronic Kidney Disease"}],"_id":"XLCEpGCXbGD6wATc8"} {"resourceType":"QuestionnaireResponse","id":"hunger-vital-sign-example","meta":{"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/instance-name","valueString":"Hunger Vital Sign [HVS] Example"},{"url":"http://hl7.org/fhir/StructureDefinition/instance-description","valueMarkdown":"'An example of an SDC QuestionnaireResponse that represents questions and selected answers from the Hunger Vital Sign Example questionnaire represented in LOINC (code 88122-7). The example is generated using the LHC-Forms SDC Questionnaire App.'"}],"versionId":"10","lastUpdated":"2022-11-28T16:54:42.582+00:00","source":"#Sz7vloFQzLmNxe1e","profile":["http://hl7.org/fhir/us/mcc/StructureDefinition/MCCQuestionnaireResponse"]},"text":{"status":"generated","div":"
\r\n\r\n\r\n\r\n
LinkIdTextDefinitionAnswer\"doco\"
\".\"\".\" hunger-vital-sign-exampleQuestionnaire:Hunger Vital Sign [HVS]
\".\"\".\"\".\" /88122-7Within the past 12Mo we worried whether our food would run out before we got money to buy moreLogical Observation Identifiers, Names and Codes (LOINC) LA28397-0: Often true
\".\"\".\"\".\" /88123-5Within the past 12Mo the food we bought just didn't last and we didn't have money to get more [U.S. FSS]Logical Observation Identifiers, Names and Codes (LOINC) LA28397-0: Often true
\".\"\".\"\".\" /88124-3Food insecurity riskLogical Observation Identifiers, Names and Codes (LOINC) LA19952-3: At risk

\"doco\" Documentation for this format
"},"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal","valueReference":{"reference":"Goal/HPT-WNL"}}],"questionnaire":"http://hl7.org/fhir/uv/sdc/Questionnaire/questionnaire-sdc-profile-example-hunger-vital-signs","_questionnaire":{"extension":[{"url":"http://hl7.org/fhir/us/core/StructureDefinition/us-core-extension-questionnaire-uri","valueUri":"https://example.org/forms/hsv"}]},"status":"completed","subject":{"reference":"Patient/cc-pat-pnoelle"},"authored":"2020-09-10T21:56:54.671Z","author":{"reference":"RelatedPerson/caregiver-of-noelle"},"item":[{"linkId":"/88122-7","text":"Within the past 12Mo we worried whether our food would run out before we got money to buy more","answer":[{"valueCoding":{"system":"http://loinc.org","code":"LA28397-0","display":"Often true"}}]},{"linkId":"/88123-5","text":"Within the past 12Mo the food we bought just didn't last and we didn't have money to get more [U.S. FSS]","answer":[{"valueCoding":{"system":"http://loinc.org","code":"LA28397-0","display":"Often true"}}]},{"linkId":"/88124-3","text":"Food insecurity risk","answer":[{"valueCoding":{"system":"http://loinc.org","code":"LA19952-3","display":"At risk"}}]}],"_id":"4KQXjHTfy3zL6CzX6"} {"resourceType":"ServiceRequest","id":"foodpantry-referral","meta":{"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/instance-name","valueString":"ServiceRequest Example"},{"url":"http://hl7.org/fhir/StructureDefinition/instance-description","valueMarkdown":"This is a service request example for the MCC ServiceRequest Profile."}],"versionId":"10","lastUpdated":"2023-06-06T21:12:21.819Z","profile":["http://hl7.org/fhir/us/mcc/StructureDefinition/MCCServiceRequest"]},"text":{"status":"extensions","div":"

Generated Narrative: ServiceRequest

Resource ServiceRequest "foodpantry-referral" Version "10" Updated "2023-06-06 21:12:21+0000"

Profile: Multiple Chronic Condition Care Plan Service Request

pertains to goal: Goal/HPT-WNL

status: active

intent: order

category: Social Determinants Of Health (US Core Category#sdoh "SDOH")

code: Assistance with application for food pantry program (SNOMED CT[US rel. Oct 0012]#467771000124109)

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

occurrence: 2021-11-20

authoredOn: 2021-11-12 10:59:38-0800

requester: Practitioner/practitionerMCC-3 " PRIMARY"

"},"extension":[{"url":"http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal","valueReference":{"reference":"Goal/HPT-WNL"}}],"status":"active","intent":"order","category":[{"coding":[{"system":"http://hl7.org/fhir/us/core/CodeSystem/us-core-category","code":"sdoh","display":"SDOH"}],"text":"Social Determinants Of Health"}],"code":{"coding":[{"system":"http://snomed.info/sct","version":"http://snomed.info/sct/731000124108/version/20220301","code":"467771000124109","display":"Assistance with application for food pantry program"}]},"subject":{"reference":"Patient/cc-pat-pnoelle"},"occurrenceDateTime":"2021-11-20","authoredOn":"2021-11-12T10:59:38-08:00","requester":{"reference":"Practitioner/practitionerMCC-3"},"_id":"ExKNziA3z4o6eAGR8"}