gpccmp-form-foreman-caterina
type: QuestionnaireResponse
node role: treeRoot
id:
  v: gpccmp-form-foreman-caterina
meta:
  profile:
    v: https://gpccmp.csiro.au/ig/StructureDefinition/GPCCMPQuestionnaireResponse
    l: GPCCMPQuestionnaireResponse
text:
  status:
    v: generated
  div:
    v: Generated Narrative: QuestionnaireResponse gpccmp-form-foreman-caterina Profile: GP CCMP QuestionnaireResponse LinkID Text Definition Answer<img src="[binary]" alt="doco" style="background-color: inherit"/> gpccmp-form-foreman-caterina Questionnaire:GP Chronic Condition Management Plan #xD; container #xD; patient Patient details #xD; patient-consent Consent #xD; patient-consent-consentforplan Consent given to proceed with plan after discussion of the purpose, benefits, process and costs true #xD; patient-name Name Caterina FOREMAN #xD; patient-preferredpronouns Preferred pronouns LOINC: LA29519-8 (she/her/her/hers/herself) #xD; patient-dob Date of birth 1970-07-24 #xD; patient-age Age 55 #xD; patient-sexatbirth Sex assigned at birth SNOMED CT: 248152002 (Female) #xD; patient-genderidentity Gender identity SNOMED CT: 446141000124107 (Identifies as female gender) #xD; patient-firstnationsstatus Aboriginal and/or Torres Strait Islander status australian-indigenous-status-1: 4 (Neither Aboriginal nor Torres Strait Islander origin) #xD; patient-medicare Medicare card number #xD; patient-medicare-number Number 3951333701 #xD; patient-medicare-referencenumber Reference number 1 #xD; patient-medicare-expiry Expiry 2028-08 #xD; patient-contact Contact information #xD; patient-contact-homephone Home phone 0370109077 #xD; patient-contact-mobilephone Mobile phone 0491576801 #xD; patient-contact-email Email caterina.foreman@my-own-personal-domain.com #xD; patient-contact-homeaddress Home address #xD; patient-contact-homeaddress-details Home address #xD; patient-contact-homeaddress-details-streetaddress Street address 149 Farmer Cnr #xD; patient-contact-homeaddress-details-city City Sunshine #xD; patient-contact-homeaddress-details-state State australian-states-territories-1: VIC (Victoria) #xD; patient-contact-homeaddress-details-postcode Postcode 3020 #xD; practitioner Practitioner details #xD; practitioner-name Name Peter Primary #xD; practitioner-phone Phone (08) 7010 5556 #x…
questionnaire:
  v: http://www.health.gov.au/assessments/GPChronicConditionManagementPlan
  l: GPChronicConditionManagementPlan
status:
  v: in-progress
subject:
  l: foreman-caterina
  reference:
    v: Patient/foreman-caterina
  type:
    v: Patient
    l: Patient
  display:
    v: Caterina FOREMAN
authored:
  v: 2026-03-09T13:10:27+10:00
author:
  l: primary-peter
  reference:
    v: Practitioner/primary-peter
  type:
    v: Practitioner
    l: Practitioner
  display:
    v: Dr Peter Primary
item:
  link id:
    v: container
  item:
    link id:
      v: patient
    text:
      v: Patient details
    item:
      link id:
        v: patient-consent
      text:
        v: Consent
    item:
      link id:
        v: patient-name
      text:
        v: Name
      answer:
        value: String
    item:
      link id:
        v: patient-preferredpronouns
      text:
        v: Preferred pronouns
      answer:
        value: Coding
    item:
      link id:
        v: patient-dob
      text:
        v: Date of birth
      answer:
        value: Date
    item:
      link id:
        v: patient-age
      text:
        v: Age
      answer:
        value: Integer
    item:
      link id:
        v: patient-sexatbirth
      text:
        v: Sex assigned at birth
      answer:
        value: Coding
    item:
      link id:
        v: patient-genderidentity
      text:
        v: Gender identity
      answer:
        value: Coding
    item:
      link id:
        v: patient-firstnationsstatus
      text:
        v: Aboriginal and/or Torres Strait Islander status
      answer:
        value: Coding
    item:
      link id:
        v: patient-medicare
      text:
        v: Medicare card number
    item:
      link id:
        v: patient-contact
      text:
        v: Contact information
  item:
    link id:
      v: practitioner
    text:
      v: Practitioner details
    item:
      link id:
        v: practitioner-name
      text:
        v: Name
      answer:
        value: String
    item:
      link id:
        v: practitioner-phone
      text:
        v: Phone
      answer:
        value: String
    item:
      link id:
        v: practitioner-email
      text:
        v: Email
      answer:
        value: String
    item:
      link id:
        v: practitioner-medicareprovidernumber
      text:
        v: Medicare provider number
      answer:
        value: String
  item:
    link id:
      v: clinicaldetails
    text:
      v: Clinical details
    item:
      link id:
        v: clinicaldetails-problemsdiagnoses
      text:
        v: Problems/Diagnoses
    item:
      link id:
        v: clinicaldetails-allergies
      text:
        v: Adverse reaction risks
    item:
      link id:
        v: clinicaldetails-medications
      text:
        v: Medications (current)
    item:
      link id:
        v: clinicaldetails-observations
      text:
        v: Observations
  item:
    link id:
      v: plan
    text:
      v: Plan
    item:
      link id:
        v: plandetails-commenceddate
      text:
        v: Date this plan commenced
      answer:
        value: Date
    item:
      link id:
        v: plandetails-inprogress
      text:
        v: Incomplete draft plan already exists?
      answer:
        value: Boolean
    item:
      link id:
        v: plan-conditions
      text:
        v: Conditions addressed
    item:
      link id:
        v: plan-conditions
      text:
        v: Conditions addressed
    item:
      link id:
        v: plan-conditions
      text:
        v: Conditions addressed

v: patient-consent-consentforplan

v: Consent given to proceed with plan after discussion of the purpose, benefits, process and costs

value: Boolean
  v: true

String
v: Caterina FOREMAN

Coding
type: LA29519-8
system:
  v: http://loinc.org
  l: loinc.org
code:
  v: LA29519-8
display:
  v: she/her/her/hers/herself

Date
v: 1970-07-24

Integer
v: 55

Coding
type: http://snomed.info/id/248152002
system:
  v: http://snomed.info/sct
  l: sct
code:
  v: 248152002
display:
  v: Female

Coding
type: http://snomed.info/id/446141000124107
system:
  v: http://snomed.info/sct
  l: sct
code:
  v: 446141000124107
display:
  v: Identifies as female gender

Coding
system:
  v: https://healthterminologies.gov.au/fhir/CodeSystem/australian-indigenous-status-1
  l: australian-indigenous-status-1
code:
  v: 4
display:
  v: Neither Aboriginal nor Torres Strait Islander origin

v: patient-medicare-number

v: Number

value: String
  v: 3951333701

v: patient-medicare-referencenumber

v: Reference number

value: String
  v: 1

v: patient-medicare-expiry

v: Expiry

value: String
  v: 2028-08

v: patient-contact-homephone

v: Home phone

value: String
  v: 0370109077

v: patient-contact-mobilephone

v: Mobile phone

value: String
  v: 0491576801

v: patient-contact-email

v: Email

v: patient-contact-homeaddress

v: Home address

link id:
  v: patient-contact-homeaddress-details
text:
  v: Home address
item:
  link id:
    v: patient-contact-homeaddress-details-streetaddress
  text:
    v: Street address
  answer:
    value: String
      v: 149 Farmer Cnr
item:
  link id:
    v: patient-contact-homeaddress-details-city
  text:
    v: City
  answer:
    value: String
      v: Sunshine
item:
  link id:
    v: patient-contact-homeaddress-details-state
  text:
    v: State
  answer:
    value: Coding
      system:
        v: https://healthterminologies.gov.au/fhir/CodeSystem/australian-states-territories-1
        l: australian-states-territories-1
      code:
        v: VIC
      display:
        v: Victoria
item:
  link id:
    v: patient-contact-homeaddress-details-postcode
  text:
    v: Postcode
  answer:
    value: String
      v: 3020

String
v: Peter Primary

String
v: (08) 7010 5556

String
v: 2426621B

v: clinicaldetails-problemsdiagnoses-recordedproblems

v: Recorded problems/diagnoses

link id:
  v: clinicaldetails-problemsdiagnoses-recordedproblems-condition
text:
  v: Condition
answer:
  value: Coding
    type: http://snomed.info/id/278860009
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 278860009
    display:
      v: Chronic lower back pain

link id:
  v: clinicaldetails-problemsdiagnoses-recordedproblems-clinicalstatus
text:
  v: Clinical status
answer:
  value: Coding
    system:
      v: http://terminology.hl7.org/CodeSystem/condition-clinical
      l: condition-clinical
    code:
      v: active
    display:
      v: Active

link id:
  v: clinicaldetails-problemsdiagnoses-recordedproblems-onsetdate
text:
  v: Onset date
answer:
  value: Date
    v: 2021-01-01

v: clinicaldetails-problemsdiagnoses-recordedproblems

v: Recorded problems/diagnoses

link id:
  v: clinicaldetails-problemsdiagnoses-recordedproblems-condition
text:
  v: Condition
answer:
  value: Coding
    type: http://snomed.info/id/235595009
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 235595009
    display:
      v: Gastro-oesophageal reflux disease

link id:
  v: clinicaldetails-problemsdiagnoses-recordedproblems-clinicalstatus
text:
  v: Clinical status
answer:
  value: Coding
    system:
      v: http://terminology.hl7.org/CodeSystem/condition-clinical
      l: condition-clinical
    code:
      v: active
    display:
      v: Active

link id:
  v: clinicaldetails-problemsdiagnoses-recordedproblems-onsetdate
text:
  v: Onset date
answer:
  value: Date
    v: 2013-08-01

v: clinicaldetails-problemsdiagnoses-newproblems

v: New problems/diagnoses

link id:
  v: clinicaldetails-problemsdiagnoses-newproblems-condition
text:
  v: Condition
answer:
  value: Coding
    type: http://snomed.info/id/443694000
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 443694000
    display:
      v: Type 2 diabetes mellitus uncontrolled

link id:
  v: clinicaldetails-problemsdiagnoses-newproblems-onsetdate
text:
  v: Onset date
answer:
  value: Date
    v: 2026-01-25

v: clinicaldetails-problemsdiagnoses-newproblems

v: New problems/diagnoses

link id:
  v: clinicaldetails-problemsdiagnoses-newproblems-condition
text:
  v: Condition
answer:
  value: Coding
    type: http://snomed.info/id/424736006
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 424736006
    display:
      v: Diabetic peripheral neuropathy

link id:
  v: clinicaldetails-problemsdiagnoses-newproblems-onsetdate
text:
  v: Onset date
answer:
  value: Date
    v: 2026-02-20

v: clinicaldetails-problemsdiagnoses-newproblems

v: New problems/diagnoses

link id:
  v: clinicaldetails-problemsdiagnoses-newproblems-condition
text:
  v: Condition
answer:
  value: Coding
    type: http://snomed.info/id/238131007
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 238131007
    display:
      v: Overweight

link id:
  v: clinicaldetails-problemsdiagnoses-newproblems-onsetdate
text:
  v: Onset date
answer:
  value: Date
    v: 2025-11-25

v: clinicaldetails-allergies-recordedallergies

v: Recorded adverse reaction risks

link id:
  v: clinicaldetails-allergies-recordedallergies-substance
text:
  v: Substance
answer:
  value: Coding
    type: http://snomed.info/id/111088007
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 111088007
    display:
      v: Latex

link id:
  v: clinicaldetails-allergies-recordedallergies-status
text:
  v: Status
answer:
  value: Coding
    system:
      v: http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical
      l: allergyintolerance-clinical
    code:
      v: active
    display:
      v: Active

link id:
  v: clinicaldetails-allergies-recordedallergies-manifestation
text:
  v: Manifestation
answer:
  value: Coding
    type: http://snomed.info/id/271807003
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 271807003
    display:
      v: Rash

link id:
  v: clinicaldetails-allergies-recordedallergies-comment
text:
  v: Comment
answer:
  value: String
    v: Has reacted soon after exposure as well as a delayed reaction to latex, with a rash appearing 24 hours after exposure.

v: clinicaldetails-medications-recordedmedications

v: Recorded medications

link id:
  v: clinicaldetails-medications-recordedmedications-medication
text:
  v: Medication
answer:
  value: Coding
    type: http://snomed.info/id/5848011000036106
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 5848011000036106
    display:
      v: Panadol Osteo 665 mg modified release tablet

link id:
  v: clinicaldetails-medications-recordedmedications-status
text:
  v: Status
answer:
  value: Coding
    system:
      v: http://hl7.org/fhir/CodeSystem/medication-statement-status
      l: medication-statement-status
    code:
      v: active
    display:
      v: Active

link id:
  v: clinicaldetails-medications-recordedmedications-dosage
text:
  v: Dosage
answer:
  value: String
    v: 2 tabs PRN/TDS

link id:
  v: clinicaldetails-medications-recordedmedications-indication
text:
  v: Indication
answer:
  value: Coding
    type: http://snomed.info/id/278860009
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 278860009
    display:
      v: Chronic lower back pain

v: clinicaldetails-medications-recordedmedications

v: Recorded medications

link id:
  v: clinicaldetails-medications-recordedmedications-medication
text:
  v: Medication
answer:
  value: Coding
    type: http://snomed.info/id/5848011000036106
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 5848011000036106
    display:
      v: Panadol Osteo 665 mg modified release tablet

link id:
  v: clinicaldetails-medications-recordedmedications-status
text:
  v: Status
answer:
  value: Coding
    system:
      v: http://hl7.org/fhir/CodeSystem/medication-statement-status
      l: medication-statement-status
    code:
      v: active
    display:
      v: Active

link id:
  v: clinicaldetails-medications-recordedmedications-dosage
text:
  v: Dosage
answer:
  value: String
    v: 2 tabs PRN/TDS

link id:
  v: clinicaldetails-medications-recordedmedications-indication
text:
  v: Indication
answer:
  value: Coding
    type: http://snomed.info/id/278860009
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 278860009
    display:
      v: Chronic lower back pain

v: clinicaldetails-medications-recordedmedications

v: Recorded medications

link id:
  v: clinicaldetails-medications-recordedmedications-medication
text:
  v: Medication
answer:
  value: Coding
    type: http://snomed.info/id/682641000168107
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 682641000168107

link id:
  v: clinicaldetails-medications-recordedmedications-status
text:
  v: Status
answer:
  value: Coding
    system:
      v: http://hl7.org/fhir/CodeSystem/medication-statement-status
      l: medication-statement-status
    code:
      v: active
    display:
      v: Active

link id:
  v: clinicaldetails-medications-recordedmedications-dosage
text:
  v: Dosage
answer:
  value: String
    v: 1 tab daily

link id:
  v: clinicaldetails-medications-recordedmedications-indication
text:
  v: Indication
answer:
  value: Coding
    type: http://snomed.info/id/235595009
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 235595009
    display:
      v: Gastro-oesophageal reflux disease

link id:
  v: clinicaldetails-medications-recordedmedications-comment
text:
  v: Comment
answer:
  value: String
    v: Gastroscopy 2013 - mild reflux esophagitis, H pylori negative

v: clinicaldetails-medications-newmedications

v: New medications

link id:
  v: clinicaldetails-medications-newmedications-medication
text:
  v: Medication
answer:
  value: Coding
    type: http://snomed.info/id/23358011000036102
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 23358011000036102
    display:
      v: Metformin hydrochloride 500 mg tablet

link id:
  v: clinicaldetails-medications-newmedications-dosage
text:
  v: Dosage
answer:
  value: String
    v: 1 tab BD

link id:
  v: clinicaldetails-medications-newmedications-indication
text:
  v: Indication
answer:
  value: Coding
    type: http://snomed.info/id/443694000
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 443694000
    display:
      v: Type 2 diabetes mellitus uncontrolled

v: clinicaldetails-medications-newmedications

v: New medications

link id:
  v: clinicaldetails-medications-newmedications-medication
text:
  v: Medication
answer:
  value: Coding
    type: http://snomed.info/id/77436011000036106
    system:
      v: http://snomed.info/sct
      l: sct
    code:
      v: 77436011000036106
    display:
      v: Fish oil

link id:
  v: clinicaldetails-medications-newmedications-dosage
text:
  v: Dosage
answer:
  value: String
    v: 2 caps daily

link id:
  v: clinicaldetails-medications-newmedications-comment
text:
  v: Comment
answer:
  value: String
    v: Self-initiated for heart health

v: clinicaldetails-observations-maingrid

v: Observations

link id:
  v: clinicaldetails-observations-maingrid-height
text:
  v: Height
item:
  link id:
    v: clinicaldetails-observations-maingrid-height-lastresultvalue
  answer:
    value: Decimal
      v: 165
item:
  link id:
    v: clinicaldetails-observations-maingrid-height-lastresultdate
  answer:
    value: Date
      v: 2025-11-25
item:
  link id:
    v: clinicaldetails-observations-maingrid-height-newresultvalue
  text:
    v: New result
  answer:
    value: Decimal
      v: 165
item:
  link id:
    v: clinicaldetails-observations-maingrid-height-newresultdate
  text:
    v: New result date
  answer:
    value: Date
      v: 2026-03-09

link id:
  v: clinicaldetails-observations-maingrid-weight
text:
  v: Weight
item:
  link id:
    v: clinicaldetails-observations-maingrid-weight-lastresultvalue
  answer:
    value: Decimal
      v: 74
item:
  link id:
    v: clinicaldetails-observations-maingrid-weight-lastresultdate
  answer:
    value: Date
      v: 2025-11-25
item:
  link id:
    v: clinicaldetails-observations-maingrid-weight-newresultvalue
  text:
    v: New result
  answer:
    value: Decimal
      v: 75.2
item:
  link id:
    v: clinicaldetails-observations-maingrid-weight-newresultdate
  text:
    v: New result date
  answer:
    value: Date
      v: 2026-03-09

link id:
  v: clinicaldetails-observations-maingrid-bmi
text:
  v: BMI (calculated)
item:
  link id:
    v: clinicaldetails-observations-maingrid-bmi-lastresultvalue
  answer:
    value: Decimal
      v: 27.2
item:
  link id:
    v: clinicaldetails-observations-maingrid-bmi-newresultvalue
  text:
    v: New result
  answer:
    value: Decimal
      v: 27.6

link id:
  v: clinicaldetails-observations-maingrid-waistcircumference
text:
  v: Waist circumference
item:
  link id:
    v: clinicaldetails-observations-maingrid-waistcircumference-lastresultvalue
  answer:
    value: Decimal
      v: 82
item:
  link id:
    v: clinicaldetails-observations-maingrid-waistcircumference-lastresultdate
  answer:
    value: Date
      v: 2025-11-25
item:
  link id:
    v: clinicaldetails-observations-maingrid-waistcircumference-newresultvalue
  text:
    v: New result
  answer:
    value: Decimal
      v: 82.5
item:
  link id:
    v: clinicaldetails-observations-maingrid-waistcircumference-newdate
  text:
    v: New result date
  answer:
    value: Date
      v: 2026-03-09

link id:
  v: clinicaldetails-observations-maingrid-pulserate
text:
  v: Pulse rate
item:
  link id:
    v: clinicaldetails-observations-maingrid-pulserate-lastresultvalue
  answer:
    value: Decimal
      v: 74
item:
  link id:
    v: clinicaldetails-observations-maingrid-pulserate-lastresultdate
  answer:
    value: Date
      v: 2025-11-25
item:
  link id:
    v: clinicaldetails-observations-maingrid-pulserate-newresultvalue
  text:
    v: New result
  answer:
    value: Integer
      v: 76
item:
  link id:
    v: clinicaldetails-observations-maingrid-pulserate-newresultdate
  text:
    v: New result date
  answer:
    value: Date
      v: 2026-03-09

link id:
  v: clinicaldetails-observations-maingrid-pulserhythm
text:
  v: Pulse rhythm
item:
  link id:
    v: clinicaldetails-observations-maingrid-pulserhythm-lastresultvalue
  answer:
    value: Coding
      type: http://snomed.info/id/271636001
      system:
        v: http://snomed.info/sct
        l: sct
      code:
        v: 271636001
      display:
        v: Pulse regular
item:
  link id:
    v: clinicaldetails-observations-maingrid-pulserhythm-lastresultdate
  answer:
    value: Date
      v: 2025-11-25
item:
  link id:
    v: clinicaldetails-observations-maingrid-pulserhythm-newresultvalue
  text:
    v: New result
  answer:
    value: Coding
      type: http://snomed.info/id/271636001
      system:
        v: http://snomed.info/sct
        l: sct
      code:
        v: 271636001
      display:
        v: Pulse regular
item:
  link id:
    v: clinicaldetails-observations-maingrid-pulserhythm-newresultdate
  text:
    v: New result date
  answer:
    value: Date
      v: 2026-03-09

link id:
  v: clinicaldetails-observations-maingrid-oxygensaturation
text:
  v: Oxygen saturation
item:
  link id:
    v: clinicaldetails-observations-maingrid-oxygensaturation-lastresultvalue
  answer:
    value: Decimal
      v: 98
item:
  link id:
    v: clinicaldetails-observations-maingrid-oxygensaturation-lastresultdate
  answer:
    value: Date
      v: 2026-06-20
item:
  link id:
    v: clinicaldetails-observations-maingrid-oxygensaturation-newresultvalue
  text:
    v: New result
  answer:
    value: Integer
      v: 98
item:
  link id:
    v: clinicaldetails-observations-maingrid-oxygensaturation-newresultdate
  text:
    v: New result date
  answer:
    value: Date
      v: 2026-03-09

v: clinicaldetails-observations-bpgrid

v: Blood pressure

link id:
  v: clinicaldetails-observations-bpgrid-bp
text:
  v: Blood pressure
item:
  link id:
    v: clinicaldetails-observations-bpgrid-bp-lastresultvaluesystolic
  answer:
    value: Decimal
      v: 128
item:
  link id:
    v: clinicaldetails-observations-bpgrid-bp-lastresultvaluediastolic
  answer:
    value: Decimal
      v: 72
item:
  link id:
    v: clinicaldetails-observations-bpgrid-bp-lastresultdate
  answer:
    value: Date
      v: 2025-11-25
item:
  link id:
    v: clinicaldetails-observations-bpgrid-bp-newresultsystolic
  text:
    v: Systolic
  answer:
    value: Integer
      v: 130
item:
  link id:
    v: clinicaldetails-observations-bpgrid-bp-newresultdiastolic
  text:
    v: Diastolic
  answer:
    value: Integer
      v: 72
item:
  link id:
    v: clinicaldetails-observations-bpgrid-bp-newresultdate
  text:
    v: Date performed
  answer:
    value: Date
      v: 2026-03-09

v: clinicaldetails-observations-substanceusegrid

v: Substance use

link id:
  v: clinicaldetails-observations-substanceusegrid-smokingstatus
text:
  v: Smoking status
item:
  link id:
    v: clinicaldetails-observations-substanceusegrid-smokingstatus-lastresultvalue
  answer:
    value: Coding
      type: http://snomed.info/id/77176002
      system:
        v: http://snomed.info/sct
        l: sct
      code:
        v: 77176002
      display:
        v: Current smoker
item:
  link id:
    v: clinicaldetails-observations-substanceusegrid-smokingstatus-lastresultdate
  answer:
    value: Date
      v: 2026-02-20
item:
  link id:
    v: clinicaldetails-observations-substanceusegrid-smokingstatus-newresultdate
  text:
    v: New status date
  answer:
    id:
      v: clinicaldetails-observations-substanceusegrid-smokingstatus-newresultdate-calculatedExpression-ChphPRAMHlBUt_ACXcBpk
item:
  link id:
    v: clinicaldetails-observations-smokingstatusgrid-smokingstatus-newresultcomment
  text:
    v: Comment
  answer:
    value: String
      v: Smoking - 20 cigarettes per day since 17yo

link id:
  v: clinicaldetails-observations-substanceusegrid-alcoholstatus
text:
  v: Alcohol consumption status
item:
  link id:
    v: clinicaldetails-observations-substanceusegrid-alcoholstatus-lastresultvalue
  answer:
    value: Coding
      type: http://snomed.info/id/219006
      system:
        v: http://snomed.info/sct
        l: sct
      code:
        v: 219006
      display:
        v: Current drinker
item:
  link id:
    v: clinicaldetails-observations-substanceusegrid-alcoholstatus-lastresultdate
  answer:
    value: Date
      v: 2026-02-20
item:
  link id:
    v: clinicaldetails-observations-substanceusegrid-alcoholstatus-newresultdate
  text:
    v: New status date
item:
  link id:
    v: clinicaldetails-observations-substanceusegrid-alcoholstatus-newresultcomment
  text:
    v: Comment
  answer:
    value: String
      v: 2 drinks, 2 days per week (on weekends

Date
v: 2026-02-20

Boolean
v: true

v: plan-conditions-condition

v: Condition

value: Coding
  type: http://snomed.info/id/443694000
  system:
    v: http://snomed.info/sct
    l: sct
  code:
    v: 443694000
  display:
    v: Type 2 diabetes mellitus uncontrolled

v: plan-conditions-onsetdate

v: Onset date

value: Date
  v: 2026-01-25

v: plan-conditions-condition

v: Condition

value: Coding
  type: http://snomed.info/id/278860009
  system:
    v: http://snomed.info/sct
    l: sct
  code:
    v: 278860009
  display:
    v: Chronic lower back pain

v: plan-conditions-onsetdate

v: Onset date

value: Date
  v: 2021-01-01

v: plan-conditions-condition

v: Condition

value: Coding
  type: http://snomed.info/id/235595009
  system:
    v: http://snomed.info/sct
    l: sct
  code:
    v: 235595009
  display:
    v: Gastro-oesophageal reflux disease

v: plan-conditions-onsetdate

v: Onset date

value: Date
  v: 2013-08-01

link id:
  v: plan-conditions
text:
  v: Conditions addressed
item:
  link id:
    v: plan-conditions-condition
  text:
    v: Condition
  answer:
    value: Coding
      type: http://snomed.info/id/238131007
      system:
        v: http://snomed.info/sct
        l: sct
      code:
        v: 238131007
      display:
        v: Overweight
item:
  link id:
    v: plan-conditions-onsetdate
  text:
    v: Onset date
  answer:
    value: Date
      v: 2025-11-25

link id:
  v: plan-goalstasks
text:
  v: Goals and tasks
item:
  link id:
    v: plan-goalstasks-problemneed
  text:
    v: Problems/Needs
  answer:
    value: Coding
      type: http://snomed.info/id/443694000
      system:
        v: http://snomed.info/sct
        l: sct
      code:
        v: 443694000
      display:
        v: Type 2 diabetes mellitus uncontrolled
  answer:
    value: Coding
      type: http://snomed.info/id/235595009
      system:
        v: http://snomed.info/sct
        l: sct
      code:
        v: 235595009
      display:
        v: Gastro-oesophageal reflux disease
  answer:
    value: Coding
      type: http://snomed.info/id/278860009
      system:
        v: http://snomed.info/sct
        l: sct
      code:
        v: 278860009
      display:
        v: Chronic lower back pain
  answer:
    value: Coding
      type: http://snomed.info/id/238131007
      system:
        v: http://snomed.info/sct
        l: sct
      code:
        v: 238131007
      display:
        v: Overweight
item:
  link id:
    v: plan-goalstasks-details-goalsetting
  text:
    v: Goal setting
  item:
    link id:
      v: plan-goalstasks-details-goalsetting-goals
    text:
      v: Goals
    answer:
      value: String
        v: 5-10% weight loss (target weight 73.8-77.9kg) and decrease waist circumference (long term target <80cm)
  item:
    link id:
      v: plan-goalstasks-details-goalsetting-initiator
    text:
      v: Initiator
    answer:
      value: String
        v: GP
  item:
    link id:
      v: plan-goalstasks-details-goalsetting-targetdate
    text:
      v: Target date
    answer:
      value: Date
        v: 2027-02-24
  item:
    link id:
      v: plan-goalstasks-details-goalsetting-status
    text:
      v: Status
    answer:
      value: Coding
item:
  link id:
    v: plan-goalstasks-details-interventionsactions
  text:
    v: Interventions and actions
  item:
    link id:
      v: plan-goalstasks-details-interventionsactions-interventionsactions
    text:
      v: Interventions/Actions
    answer:
      value: Coding
        type: http://snomed.info/id/183065007
  item:
    link id:
      v: plan-goalstasks-details-interventionsactions-owner
    text:
      v: Owner
    answer:
      value: String
        v: Caterina, dietitian
  item:
    link id:
      v: plan-goalstasks-details-interventionsactions-duedate
    text:
      v: Due date
    answer:
      value: Date
        v: 2026-05-24
item:
  link id:
    v: plan-goalstasks-details-interventionsactions
  text:
    v: Interventions and actions
  item:
    link id:
      v: plan-goalstasks-details-interventionsactions-interventionsactions
    text:
      v: Interventions/Actions
    answer:
      value: String
        v: Reduce ratio of carbohydrates in each meal - ¼ plate carbs, ¼ plate protein, ½ plate vegetables/salad
  item:
    link id:
      v: plan-goalstasks-details-interventionsactions-owner
    text:
      v: Owner
    answer:
      value: String
        v: Caterina
  item:
    link id:
      v: plan-goalstasks-details-interventionsactions-duedate
    text:
      v: Due date
    answer:
      value: Date
        v: 2026-05-24
item:
  link id:
    v: plan-goalstasks-details-interventionsactions
  text:
    v: Interventions and actions
  item:
    link id:
      v: plan-goalstasks-details-interventionsactions-interventionsactions
    text:
      v: Interventions/Actions
    answer:
      value: String
        v: Substitute high GI for low GI carbohydrates where possible
  item:
    link id:
      v: plan-goalstasks-details-interventionsactions-owner
    text:
      v: Owner
    answer:
      value: String
        v: Caterina
  item:
    link id:
      v: plan-goalstasks-details-interventionsactions-duedate
    text:
      v: Due date
    answer:
      value: Date
        v: 2026-05-24
item:
  link id:
    v: plan-goalstasks-details-interventionsactions
  text:
    v: Interventions and actions
  item:
    link id:
      v: plan-goalstasks-details-interventionsactions-interventionsactions
    text:
      v: Interventions/Actions
    answer:
      value: String
        v: Physical activity guidance
  item:
    link id:
      v: plan-goalstasks-details-interventionsactions-owner
    text:
      v: Owner
    answer:
      value: String
        v: Caterina, exercise physiologist
  item:
    link id:
      v: plan-goalstasks-details-interventionsactions-duedate
    text:
      v: Due date
    answer:
      value: Date
        v: 2026-08-24

v: active

v: active

v: 183065007

v: Low carbohydrate diet education

link id:
  v: plan-goalstasks-details-interventionsactions
text:
  v: Interventions and actions
item:
  link id:
    v: plan-goalstasks-details-interventionsactions-interventionsactions
  text:
    v: Interventions/Actions
  answer:
    value: String
      v: Aim for 150 mins of aerobic activity per week
item:
  link id:
    v: plan-goalstasks-details-interventionsactions-owner
  text:
    v: Owner
  answer:
    value: String
      v: Caterina
item:
  link id:
    v: plan-goalstasks-details-interventionsactions-duedate
  text:
    v: Due date
  answer:
    value: Date
      v: 2026-08-24

link id:
  v: plan-goalstasks-details-interventionsactions
text:
  v: Interventions and actions
item:
  link id:
    v: plan-goalstasks-details-interventionsactions-interventionsactions
  text:
    v: Interventions/Actions
  answer:
    value: String
      v: 2-3 sessions of resistance exercise per week
item:
  link id:
    v: plan-goalstasks-details-interventionsactions-owner
  text:
    v: Owner
  answer:
    value: String
      v: Caterina
item:
  link id:
    v: plan-goalstasks-details-interventionsactions-duedate
  text:
    v: Due date
  answer:
    value: Date
      v: 2026-08-24

link id:
  v: plan-goalstasks-details-interventionsactions
text:
  v: Interventions and actions
item:
  link id:
    v: plan-goalstasks-details-interventionsactions-interventionsactions
  text:
    v: Interventions/Actions
  answer:
    value: String
      v: Management of impulse control
item:
  link id:
    v: plan-goalstasks-details-interventionsactions-owner
  text:
    v: Owner
  answer:
    value: String
      v: Caterina
item:
  link id:
    v: plan-goalstasks-details-interventionsactions-duedate
  text:
    v: Due date
  answer:
    value: Date
      v: 2026-08-24
item:
  link id:
    v: plan-goalstasks-details-interventionsactions-comment
  text:
    v: Comment
  answer:
    value: String
      v: Manage impulsivity/desire to eat when not actually hungry. Consider psychology input in future.

link id:
  v: plan-goalstasks-details-servicestreatments
text:
  v: Services and treatments
item:
  link id:
    v: plan-goalstasks-details-servicestreatments-servicestreatments
  text:
    v: Required services and treatments
  answer:
    value: Coding
      type: http://snomed.info/id/310090003
      system:
        v: http://snomed.info/sct
        l: sct
      code:
        v: 310090003
      display:
        v: Dietetics service
item:
  link id:
    v: plan-goalstasks-details-servicestreatments-activity
  text:
    v: Activity
  answer:
    value: Coding
      type: http://snomed.info/id/103699006
      system:
        v: http://snomed.info/sct
        l: sct
      code:
        v: 103699006
      display:
        v: Referral to dietitian
item:
  link id:
    v: plan-goalstasks-details-servicestreatments-provider
  text:
    v: Provider
  answer:
    value: String
      v: Dietitian

link id:
  v: plan-goalstasks-details-servicestreatments
text:
  v: Services and treatments
item:
  link id:
    v: plan-goalstasks-details-servicestreatments-servicestreatments
  text:
    v: Required services and treatments
  answer:
    value: Coding
      type: http://snomed.info/id/310090003
      system:
        v: http://snomed.info/sct
        l: sct
      code:
        v: 310090003
      display:
        v: Dietetics service
item:
  link id:
    v: plan-goalstasks-details-servicestreatments-activity
  text:
    v: Activity
  answer:
    value: Coding
      type: http://snomed.info/id/11816003
      system:
        v: http://snomed.info/sct
        l: sct
      code:
        v: 11816003
      display:
        v: Diet education
item:
  link id:
    v: plan-goalstasks-details-servicestreatments-provider
  text:
    v: Provider
  answer:
    value: String
      v: Dietitian

link id:
  v: plan-goalstasks-details-servicestreatments
text:
  v: Services and treatments
item:
  link id:
    v: plan-goalstasks-details-servicestreatments-servicestreatments
  text:
    v: Required services and treatments
  answer:
    value: String
      v: Exercise physiologist
item:
  link id:
    v: plan-goalstasks-details-servicestreatments-activity
  text:
    v: Activity
  answer:
    value: Coding
      type: http://snomed.info/id/1100681000168103
      system:
        v: http://snomed.info/sct
        l: sct
      code:
        v: 1100681000168103
      display:
        v: Referral to exercise physiologist
item:
  link id:
    v: plan-goalstasks-details-servicestreatments-provider
  text:
    v: Provider
  answer:
    value: String
      v: Exercise physiologist

link id:
  v: plan-goalstasks-details-servicestreatments
text:
  v: Services and treatments
item:
  link id:
    v: plan-goalstasks-details-servicestreatments-servicestreatments
  text:
    v: Required services and treatments
  answer:
    value: String
      v: Exercise physiologist
item:
  link id:
    v: plan-goalstasks-details-servicestreatments-activity
  text:
    v: Activity
  answer:
    value: Coding
      type: http://snomed.info/id/229080003
      system:
        v: http://snomed.info/sct
        l: sct
      code:
        v: 229080003
      display:
        v: Exercise regime
item:
  link id:
    v: plan-goalstasks-details-servicestreatments-provider
  text:
    v: Provider
  answer:
    value: String
      v: Exercise physiologist

link id:
  v: plan-goalstasks
text:
  v: Goals and tasks
item:
  link id:
    v: plan-goalstasks-problemneed
  text:
    v: Problems/Needs
  answer:
    value: Coding
      type: http://snomed.info/id/286647002
      system:
        v: http://snomed.info/sct
        l: sct
      code:
        v: 286647002
      display:
        v: Low self-esteem
  answer:
    value: Coding
      type: http://snomed.info/id/238131007
      system:
        v: http://snomed.info/sct
        l: sct
      code:
        v: 238131007
      display:
        v: Overweight
item:
  link id:
    v: plan-goalstasks-details-goalsetting
  text:
    v: Goal setting
  item:
    link id:
      v: plan-goalstasks-details-goalsetting-goals
    text:
      v: Goals
    answer:
      value: String
        v: Comfortably wear dress purchased for niece’s wedding next year
  item:
    link id:
      v: plan-goalstasks-details-goalsetting-initiator
    text:
      v: Initiator
    answer:
      value: String
        v: Caterina
  item:
    link id:
      v: plan-goalstasks-details-goalsetting-targetdate
    text:
      v: Target date
    answer:
      value: Date
        v: 2027-02-24
  item:
    link id:
      v: plan-goalstasks-details-goalsetting-status
    text:
      v: Status
    answer:
      value: Coding

v: active

v: active

link id:
  v: completion
text:
  v: Completion
item:
  link id:
    v: completion-consentforsharing
  text:
    v: Consent given for sharing of information with relevant healthcare providers
  answer:
    value: Boolean
      v: true
item:
  link id:
    v: completion-review
  text:
    v: Review
  item:
    link id:
      v: completion-review-appointmentstatus
    text:
      v: Appointment status
    answer:
      value: Coding
  item:
    link id:
      v: completion-review-date
    text:
      v: Date
    answer:
      value: Date
        v: 2027-03-09
item:
  link id:
    v: completion-copyoffered
  text:
    v: Patient has been offered a copy of this plan
  answer:
    value: String
      v: Yes, copy provided

v: proposed

v: Proposed