GP Chronic Condition Management Plan
0.1.0 - CI Build
GP Chronic Condition Management Plan, published by AEHRC CSIRO. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/aehrc/gpccmp-fhir-ig/ and changes regularly. See the Directory of published versions
@prefix fhir: <http://hl7.org/fhir/> . @prefix loinc: <https://loinc.org/rdf/> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> . @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> . @prefix sct: <http://snomed.info/id/> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- a fhir:QuestionnaireResponse ; fhir:nodeRole fhir:treeRoot ; fhir:id [ fhir:v "gpccmp-form-foreman-caterina"] ; # fhir:meta [ ( fhir:profile [ fhir:v "https://gpccmp.csiro.au/ig/StructureDefinition/GPCCMPQuestionnaireResponse"^^xsd:anyURI ; fhir:l <https://gpccmp.csiro.au/ig/StructureDefinition/GPCCMPQuestionnaireResponse> ] ) ] ; # fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div [ fhir:v "<div xmlns=\"http://www.w3.org/1999/xhtml\"><article style=\"color-scheme: light; -ms-text-size-adjust: 100%; -webkit-text-size-adjust: 100%; margin: 0; color: #1f2328; background-color: #ffffff; font-family: -apple-system,BlinkMacSystemFont,'Segoe UI','Noto Sans',Helvetica,Arial,sans-serif,'Apple Color Emoji','Segoe UI Emoji'; font-size: 16px; line-height: 1.5; word-wrap: break-word;\"><h1 style=\"margin-top: 0; margin-bottom: .67em; font-weight: 600; padding-bottom: .3em; font-size: 2em; border-bottom: 1px solid #d1d9e0b3;\">\n GP Chronic Condition Management Plan \n </h1><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Patient</strong>: Caterina FOREMAN<br/><strong style=\"font-weight: 600;\">Author</strong>: Dr Peter Primary<br/><strong style=\"font-weight: 600;\">Date Authored</strong>: 25/05/2026 11:39</p><section><h2 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; padding-bottom: 0.3em; font-size: 1.5em; border-bottom: 1px solid #d1d9e0b3;\">Patient details</h2><section><h3 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1.25em;\">Consent</h3><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Consent given to proceed with plan after discussion of the purpose, benefits, process and costs</strong><br/>Yes</p><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Name</strong><br/>Caterina FOREMAN</p><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Preferred pronouns</strong><br/>she/her/her/hers/herself</p><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Date of birth</strong><br/>24/07/1970</p><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Age</strong><br/>55</p><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Sex assigned at birth</strong><br/>Female</p><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Gender identity</strong><br/>Identifies as female gender</p><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Aboriginal and/or Torres Strait Islander status</strong><br/>Neither Aboriginal nor Torres Strait Islander origin</p></section><section><h3 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1.25em;\">My Aged Care</h3><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Registered for My Aged Care</strong><br/>No</p></section><section><h3 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1.25em;\">National Disability Insurance Scheme</h3><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Registered for NDIS</strong><br/>No</p></section><section><h3 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1.25em;\">Medicare card number</h3><table style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400; border-spacing: 0; border-collapse: collapse; display: block; width: max-content; max-width: 100%; overflow: auto; font-variant: tabular-nums;\"><thead><tr style=\"background-color: #f6f8fa; border-top: 1px solid #d1d9e0b3;\"><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Number</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Reference number</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Expiry</th></tr></thead><tbody><tr style=\"background-color: #fff; border-top: 1px solid #d1d9e0b3;\"><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">3951333701</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">1</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">2028-08</td></tr></tbody></table></section><section><h3 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1.25em;\">Contact information</h3><div style=\"margin-bottom: 0.5em;\"><strong style=\"font-weight: 600;\">Home phone</strong></div><ul style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400; padding-left: 2em;\"><li>0370109077</li></ul><div style=\"margin-bottom: 0.5em;\"><strong style=\"font-weight: 600;\">Mobile phone</strong></div><ul style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400; padding-left: 2em;\"><li>0491576801</li></ul><div style=\"margin-bottom: 0.5em;\"><strong style=\"font-weight: 600;\">Email</strong></div><ul style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400; padding-left: 2em;\"><li>caterina.foreman@my-own-personal-domain.com</li></ul><section><h4 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1em;\">Home address</h4><section><h4 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1em;\">Home address</h4><table style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400; border-spacing: 0; border-collapse: collapse; display: block; width: max-content; max-width: 100%; overflow: auto; font-variant: tabular-nums;\"><thead><tr style=\"background-color: #f6f8fa; border-top: 1px solid #d1d9e0b3;\"><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Street address</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">City</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">State</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Postcode</th></tr></thead><tbody><tr style=\"background-color: #fff; border-top: 1px solid #d1d9e0b3;\"><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">149 Farmer Cnr</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Sunshine</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Victoria</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">3020</td></tr></tbody></table></section></section></section><section><h3 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1.25em;\">Carers and key contacts</h3><table style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400; border-spacing: 0; border-collapse: collapse; display: block; width: max-content; max-width: 100%; overflow: auto; font-variant: tabular-nums;\"><thead><tr style=\"background-color: #f6f8fa; border-top: 1px solid #d1d9e0b3;\"><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Preferred contact</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Role</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Name</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Phone</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Email</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Relationship to patient</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Present at appointment</th></tr></thead><tbody><tr style=\"background-color: #fff; border-top: 1px solid #d1d9e0b3;\"><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Yes</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Contact person</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Mia LEANNE BANKS</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">0270107520</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\"/><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\"/><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\"/></tr><tr style=\"background-color: #fff; border-top: 1px solid #d1d9e0b3;\"><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\"/><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Emergency Contact</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Heather MACKAY</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">0370108075</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\"/><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\"/><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\"/></tr></tbody></table></section></section><section><h2 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; padding-bottom: 0.3em; font-size: 1.5em; border-bottom: 1px solid #d1d9e0b3;\">Practitioner details</h2><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Name</strong><br/>Peter Primary</p><div style=\"margin-bottom: 0.5em;\"><strong style=\"font-weight: 600;\">Phone</strong></div><ul style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400; padding-left: 2em;\"><li>(08) 7010 5556</li></ul><div style=\"margin-bottom: 0.5em;\"><strong style=\"font-weight: 600;\">Email</strong></div><ul style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400; padding-left: 2em;\"><li>PPP@example.org</li></ul><div style=\"margin-bottom: 0.5em;\"><strong style=\"font-weight: 600;\">Medicare provider number</strong></div><ul style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400; padding-left: 2em;\"><li>2426621B</li></ul><section><h3 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1.25em;\">Clinic details</h3><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Name</strong><br/>Quinninup Medical Clinic</p><section><h4 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1em;\">Address</h4><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Street address</strong><br/>24 Grande Pl</p><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">City</strong><br/>Quinninup</p><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">State</strong><br/>Western Australia</p><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Postcode</strong><br/>6258</p></section></section></section><section><h2 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; padding-bottom: 0.3em; font-size: 1.5em; border-bottom: 1px solid #d1d9e0b3;\">Clinical details</h2><section><h3 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1.25em;\">Problems/Diagnoses</h3><section><h4 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1em;\">Recorded problems/diagnoses</h4><table style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400; border-spacing: 0; border-collapse: collapse; display: block; width: max-content; max-width: 100%; overflow: auto; font-variant: tabular-nums;\"><thead><tr style=\"background-color: #f6f8fa; border-top: 1px solid #d1d9e0b3;\"><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Condition</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Clinical status</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Onset date</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Abatement date</th></tr></thead><tbody><tr style=\"background-color: #fff; border-top: 1px solid #d1d9e0b3;\"><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Chronic lower back pain</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Active</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">01/01/2021</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\"/></tr><tr style=\"background-color: #fff; border-top: 1px solid #d1d9e0b3;\"><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Gastro-oesophageal reflux disease</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Active</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">01/08/2013</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\"/></tr></tbody></table></section><section><h4 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1em;\">New problems/diagnoses</h4><table style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400; border-spacing: 0; border-collapse: collapse; display: block; width: max-content; max-width: 100%; overflow: auto; font-variant: tabular-nums;\"><thead><tr style=\"background-color: #f6f8fa; border-top: 1px solid #d1d9e0b3;\"><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Condition</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Onset date</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Comment</th></tr></thead><tbody><tr style=\"background-color: #fff; border-top: 1px solid #d1d9e0b3;\"><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Uncontrolled type 2 diabetes</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">25/01/2026</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\"/></tr><tr style=\"background-color: #fff; border-top: 1px solid #d1d9e0b3;\"><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Peripheral neuropathy due to diabetes</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">20/02/2026</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\"/></tr><tr style=\"background-color: #fff; border-top: 1px solid #d1d9e0b3;\"><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Overweight</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">25/11/2025</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\"/></tr></tbody></table></section></section><section><h3 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1.25em;\">Adverse reaction risks</h3><section><h4 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1em;\">Recorded adverse reaction risks</h4><table style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400; border-spacing: 0; border-collapse: collapse; display: block; width: max-content; max-width: 100%; overflow: auto; font-variant: tabular-nums;\"><thead><tr style=\"background-color: #f6f8fa; border-top: 1px solid #d1d9e0b3;\"><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Substance</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Status</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Manifestation</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Comment</th></tr></thead><tbody><tr style=\"background-color: #fff; border-top: 1px solid #d1d9e0b3;\"><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Latex</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Active</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Rash</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Has reacted soon after exposure as well as a delayed reaction to latex, with a rash appearing 24 hours after exposure.</td></tr></tbody></table></section></section><section><h3 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1.25em;\">Medications (current)</h3><section><h4 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1em;\">Recorded medications</h4><table style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400; border-spacing: 0; border-collapse: collapse; display: block; width: max-content; max-width: 100%; overflow: auto; font-variant: tabular-nums;\"><thead><tr style=\"background-color: #f6f8fa; border-top: 1px solid #d1d9e0b3;\"><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Medication</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Status</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Dosage</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Indication</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Comment</th></tr></thead><tbody><tr style=\"background-color: #fff; border-top: 1px solid #d1d9e0b3;\"><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Panadol Osteo 665 mg modified release tablet</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Active</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">2 tabs PRN/TDS</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Chronic lower back pain</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\"/></tr><tr style=\"background-color: #fff; border-top: 1px solid #d1d9e0b3;\"><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Esomeprazole 20 mg enteric capsule</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Active</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">1 tab daily</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Gastro-oesophageal reflux disease</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Gastroscopy 2013 - mild reflux esophagitis, H pylori negative</td></tr></tbody></table></section><section><h4 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1em;\">New medications</h4><table style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400; border-spacing: 0; border-collapse: collapse; display: block; width: max-content; max-width: 100%; overflow: auto; font-variant: tabular-nums;\"><thead><tr style=\"background-color: #f6f8fa; border-top: 1px solid #d1d9e0b3;\"><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Medication</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Dosage</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Indication</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Comment</th></tr></thead><tbody><tr style=\"background-color: #fff; border-top: 1px solid #d1d9e0b3;\"><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Metformin hydrochloride 500 mg tablet</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">1 tab BD</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Uncontrolled type 2 diabetes</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\"/></tr><tr style=\"background-color: #fff; border-top: 1px solid #d1d9e0b3;\"><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Fish oil</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">2 caps daily</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\"/><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Self-initiated for heart health</td></tr></tbody></table></section></section><section><h3 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1.25em;\">Observations</h3><section><h4 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1em;\">Observations</h4><section><h4 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1em;\">Height</h4><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">New result</strong><br/>165</p><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">New result date</strong><br/>25/05/2026</p></section><section><h4 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1em;\">Weight</h4><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">New result</strong><br/>75.2</p><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">New result date</strong><br/>25/05/2026</p></section><section><h4 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1em;\">BMI (calculated)</h4><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">New result</strong><br/>27.6</p></section><section><h4 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1em;\">Waist circumference</h4><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">New result</strong><br/>82.5</p><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">New result date</strong><br/>25/05/2026</p></section><section><h4 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1em;\">Pulse rate</h4><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">New result</strong><br/>76</p><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">New result date</strong><br/>25/05/2026</p></section><section><h4 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1em;\">Pulse rhythm</h4><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">New result</strong><br/>Pulse regular</p><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">New result date</strong><br/>25/05/2026</p></section><section><h4 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1em;\">Oxygen saturation</h4><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">New result</strong><br/>98</p><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">New result date</strong><br/>25/05/2026</p></section></section><section><h4 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1em;\">Blood pressure</h4><section><h4 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1em;\">Blood pressure</h4><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Systolic</strong><br/>130</p><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Diastolic</strong><br/>72</p><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Date performed</strong><br/>25/05/2026</p></section></section><section><h4 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1em;\">Substance use</h4><section><h4 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1em;\">Smoking status</h4><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">New status date</strong><br/></p><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Comment</strong><br/>20 cigarettes per day since 17yo</p></section><section><h4 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1em;\">Alcohol consumption status</h4><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">New status date</strong><br/></p><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Comment</strong><br/>2 drinks, 2 days per week (on weekends)</p><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Additional information</strong><br/>Family history: Mother - diabetes, stroke; Father - heart attack, depression; Paternal grandmother - breast cancer\nWork: Receptionist in building business</p></section></section></section></section><section><h2 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; padding-bottom: 0.3em; font-size: 1.5em; border-bottom: 1px solid #d1d9e0b3;\">Plan</h2><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">New plan or a review of an existing plan?</strong><br/>New</p><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Incomplete draft plan already exists?</strong><br/>Yes</p><section><h3 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1.25em;\">Conditions addressed</h3><table style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400; border-spacing: 0; border-collapse: collapse; display: block; width: max-content; max-width: 100%; overflow: auto; font-variant: tabular-nums;\"><thead><tr style=\"background-color: #f6f8fa; border-top: 1px solid #d1d9e0b3;\"><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Condition</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Onset date</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Comments</th></tr></thead><tbody><tr style=\"background-color: #fff; border-top: 1px solid #d1d9e0b3;\"><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Uncontrolled type 2 diabetes</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">25/01/2026</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\"/></tr><tr style=\"background-color: #fff; border-top: 1px solid #d1d9e0b3;\"><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Chronic lower back pain</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">01/01/2021</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\"/></tr><tr style=\"background-color: #fff; border-top: 1px solid #d1d9e0b3;\"><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Gastro-oesophageal reflux disease</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">01/08/2013</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\"/></tr><tr style=\"background-color: #fff; border-top: 1px solid #d1d9e0b3;\"><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Overweight</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">25/11/2025</td><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\"/></tr></tbody></table></section><section><h3 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1.25em;\">Goals and tasks</h3><table style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400; border-spacing: 0; border-collapse: collapse; display: block; width: max-content; max-width: 100%; overflow: auto; font-variant: tabular-nums;\"><thead><tr style=\"background-color: #f6f8fa; border-top: 1px solid #d1d9e0b3;\"><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Problems/Needs</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Goal setting</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Interventions and actions</th><th style=\"padding: 6px 13px; border: 1px solid #d1d9e0; font-weight: 600;\">Services and treatments</th></tr></thead><tbody><tr style=\"background-color: #fff; border-top: 1px solid #d1d9e0b3;\"><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Uncontrolled type 2 diabetes</td><td colspan=\"1\" style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Nested repeat groups not supported in narrative</td><td colspan=\"7\" style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Nested repeat groups not supported in narrative</td><td colspan=\"9\" style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Nested repeat groups not supported in narrative</td></tr><tr style=\"background-color: #fff; border-top: 1px solid #d1d9e0b3;\"><td style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Uncontrolled type 2 diabetes</td><td colspan=\"2\" style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Nested repeat groups not supported in narrative</td><td colspan=\"7\" style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Nested repeat groups not supported in narrative</td><td colspan=\"4\" style=\"padding: 6px 13px; border: 1px solid #d1d9e0;\">Nested repeat groups not supported in narrative</td></tr></tbody></table></section><section><h3 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1.25em;\">Completion</h3><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Consent given for sharing of information with relevant healthcare providers</strong><br/>Yes</p><section><h4 style=\"margin-top: 1.5rem; margin-bottom: 1rem; font-weight: 600; line-height: 1.25; font-size: 1em;\">Review</h4><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Appointment status</strong><br/>Proposed</p><p style=\"margin-top: 0; margin-bottom: 1rem; font-weight: 400;\"><strong style=\"font-weight: 600;\">Date</strong><br/>20/05/2027</p></section></section></section></article></div>"^^rdf:XMLLiteral ] ] ; # fhir:questionnaire [ fhir:v "http://www.health.gov.au/assessments/GPChronicConditionManagementPlan|0.1.0"^^xsd:anyURI ; fhir:l <http://www.health.gov.au/assessments/GPChronicConditionManagementPlan?version=0.1.0> ; ( fhir:extension [ fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/display"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/StructureDefinition/display> ] ; fhir:value [ a fhir:String ; fhir:v "GP Chronic Condition Management Plan" ] ] ) ] ; # fhir:status [ fhir:v "in-progress"] ; # fhir:subject [ fhir:l fhir:Patient/foreman-caterina ; fhir:reference [ fhir:v "Patient/foreman-caterina" ] ; fhir:type [ fhir:v "Patient"^^xsd:anyURI ; fhir:l fhir:Patient ] ; fhir:display [ fhir:v "Caterina FOREMAN" ] ] ; # fhir:authored [ fhir:v "2026-05-25T14:50:52+10:00"^^xsd:dateTime] ; # fhir:author [ fhir:l fhir:Practitioner/primary-peter ; fhir:reference [ fhir:v "Practitioner/primary-peter" ] ; fhir:type [ fhir:v "Practitioner"^^xsd:anyURI ; fhir:l fhir:Practitioner ] ; fhir:display [ fhir:v "Dr Peter Primary" ] ] ; # fhir:item ( [ fhir:linkId [ fhir:v "container" ] ; ( fhir:item [ fhir:linkId [ fhir:v "patient" ] ; fhir:text [ fhir:v "Patient details" ] ; ( fhir:item [ fhir:linkId [ fhir:v "patient-consent" ] ; fhir:text [ fhir:v "Consent" ] ; ( fhir:item [ fhir:linkId [ fhir:v "patient-consent-consentforplan" ] ; fhir:text [ fhir:v "Consent given to proceed with plan after discussion of the purpose, benefits, process and costs" ] ; ( fhir:answer [ fhir:value [ a fhir:Boolean ; fhir:v true ] ] ) ] ) ] [ fhir:linkId [ fhir:v "patient-name" ] ; fhir:text [ fhir:v "Name" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Caterina FOREMAN" ] ] ) ] [ fhir:linkId [ fhir:v "patient-preferredpronouns" ] ; fhir:text [ fhir:v "Preferred pronouns" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, loinc:LA29519-8 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ; fhir:l <http://loinc.org> ] ; fhir:code [ fhir:v "LA29519-8" ] ; fhir:display [ fhir:v "she/her/her/hers/herself" ] ] ] ) ] [ fhir:linkId [ fhir:v "patient-dob" ] ; fhir:text [ fhir:v "Date of birth" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "1970-07-24"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "patient-age" ] ; fhir:text [ fhir:v "Age" ] ; ( fhir:answer [ fhir:value [ a fhir:Integer ; fhir:v 55 ] ] ) ] [ fhir:linkId [ fhir:v "patient-sexatbirth" ] ; fhir:text [ fhir:v "Sex assigned at birth" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:248152002 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "248152002" ] ; fhir:display [ fhir:v "Female" ] ] ] ) ] [ fhir:linkId [ fhir:v "patient-genderidentity" ] ; fhir:text [ fhir:v "Gender identity" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:446141000124107 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "446141000124107" ] ; fhir:display [ fhir:v "Identifies as female gender" ] ] ] ) ] [ fhir:linkId [ fhir:v "patient-firstnationsstatus" ] ; fhir:text [ fhir:v "Aboriginal and/or Torres Strait Islander status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "https://healthterminologies.gov.au/fhir/CodeSystem/australian-indigenous-status-1"^^xsd:anyURI ; fhir:l <https://healthterminologies.gov.au/fhir/CodeSystem/australian-indigenous-status-1> ] ; fhir:code [ fhir:v "4" ] ; fhir:display [ fhir:v "Neither Aboriginal nor Torres Strait Islander origin" ] ] ] ) ] [ fhir:linkId [ fhir:v "patient-myagedcare" ] ; fhir:text [ fhir:v "My Aged Care" ] ; ( fhir:item [ fhir:linkId [ fhir:v "patient-myagedcare-registered" ] ; fhir:text [ fhir:v "Registered for My Aged Care" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/v2-0532"^^xsd:anyURI ; fhir:l <http://terminology.hl7.org/CodeSystem/v2-0532> ] ; fhir:code [ fhir:v "N" ] ; fhir:display [ fhir:v "No" ] ] ] ) ] ) ] [ fhir:linkId [ fhir:v "patient-ndis" ] ; fhir:text [ fhir:v "National Disability Insurance Scheme" ] ; ( fhir:item [ fhir:linkId [ fhir:v "patient-ndis-registered" ] ; fhir:text [ fhir:v "Registered for NDIS" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/v2-0532"^^xsd:anyURI ; fhir:l <http://terminology.hl7.org/CodeSystem/v2-0532> ] ; fhir:code [ fhir:v "N" ] ; fhir:display [ fhir:v "No" ] ] ] ) ] ) ] [ fhir:linkId [ fhir:v "patient-medicare" ] ; fhir:text [ fhir:v "Medicare card number" ] ; ( fhir:item [ fhir:linkId [ fhir:v "patient-medicare-number" ] ; fhir:text [ fhir:v "Number" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "3951333701" ] ] ) ] [ fhir:linkId [ fhir:v "patient-medicare-referencenumber" ] ; fhir:text [ fhir:v "Reference number" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "1" ] ] ) ] [ fhir:linkId [ fhir:v "patient-medicare-expiry" ] ; fhir:text [ fhir:v "Expiry" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "2028-08" ] ] ) ] ) ] [ fhir:linkId [ fhir:v "patient-contact" ] ; fhir:text [ fhir:v "Contact information" ] ; ( fhir:item [ fhir:linkId [ fhir:v "patient-contact-homephone" ] ; fhir:text [ fhir:v "Home phone" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "0370109077" ] ] ) ] [ fhir:linkId [ fhir:v "patient-contact-mobilephone" ] ; fhir:text [ fhir:v "Mobile phone" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "0491576801" ] ] ) ] [ fhir:linkId [ fhir:v "patient-contact-email" ] ; fhir:text [ fhir:v "Email" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "caterina.foreman@my-own-personal-domain.com" ] ] ) ] [ fhir:linkId [ fhir:v "patient-contact-homeaddress" ] ; fhir:text [ fhir:v "Home address" ] ; ( fhir:item [ fhir:linkId [ fhir:v "patient-contact-homeaddress-details" ] ; fhir:text [ fhir:v "Home address" ] ; ( fhir:item [ fhir:linkId [ fhir:v "patient-contact-homeaddress-details-streetaddress" ] ; fhir:text [ fhir:v "Street address" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "149 Farmer Cnr" ] ] ) ] [ fhir:linkId [ fhir:v "patient-contact-homeaddress-details-city" ] ; fhir:text [ fhir:v "City" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Sunshine" ] ] ) ] [ fhir:linkId [ fhir:v "patient-contact-homeaddress-details-state" ] ; fhir:text [ fhir:v "State" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "https://healthterminologies.gov.au/fhir/CodeSystem/australian-states-territories-1"^^xsd:anyURI ; fhir:l <https://healthterminologies.gov.au/fhir/CodeSystem/australian-states-territories-1> ] ; fhir:code [ fhir:v "VIC" ] ; fhir:display [ fhir:v "Victoria" ] ] ] ) ] [ fhir:linkId [ fhir:v "patient-contact-homeaddress-details-postcode" ] ; fhir:text [ fhir:v "Postcode" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "3020" ] ] ) ] ) ] ) ] ) ] [ fhir:linkId [ fhir:v "patient-contacts" ] ; fhir:text [ fhir:v "Carers and key contacts" ] ; ( fhir:item [ fhir:linkId [ fhir:v "patient-contacts-role" ] ; fhir:text [ fhir:v "Role" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/v2-0131"^^xsd:anyURI ; fhir:l <http://terminology.hl7.org/CodeSystem/v2-0131> ] ; fhir:code [ fhir:v "CP" ] ; fhir:display [ fhir:v "Contact person" ] ] ] [ fhir:value [ a fhir:Coding, sct:133932002 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "133932002" ] ; fhir:display [ fhir:v "Carer" ] ] ] ) ] [ fhir:linkId [ fhir:v "patient-contacts-name" ] ; fhir:text [ fhir:v "Name" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Mia LEANNE BANKS" ] ] ) ] [ fhir:linkId [ fhir:v "patient-contacts-phone" ] ; fhir:text [ fhir:v "Phone" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "0270107520" ] ] [ fhir:value [ a fhir:String ; fhir:v "0491574632" ] ] [ fhir:value [ a fhir:String ; fhir:v "0270102724" ] ] ) ] ) ] [ fhir:linkId [ fhir:v "patient-contacts" ] ; fhir:text [ fhir:v "Carers and key contacts" ] ; ( fhir:item [ fhir:linkId [ fhir:v "patient-contacts-role" ] ; fhir:text [ fhir:v "Role" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/v2-0131"^^xsd:anyURI ; fhir:l <http://terminology.hl7.org/CodeSystem/v2-0131> ] ; fhir:code [ fhir:v "C" ] ; fhir:display [ fhir:v "Emergency Contact" ] ] ] ) ] [ fhir:linkId [ fhir:v "patient-contacts-name" ] ; fhir:text [ fhir:v "Name" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Heather MACKAY" ] ] ) ] [ fhir:linkId [ fhir:v "patient-contacts-phone" ] ; fhir:text [ fhir:v "Phone" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "0370108075" ] ] [ fhir:value [ a fhir:String ; fhir:v "0491578148" ] ] [ fhir:value [ a fhir:String ; fhir:v "0370103228" ] ] ) ] ) ] ) ] [ fhir:linkId [ fhir:v "practitioner" ] ; fhir:text [ fhir:v "Practitioner details" ] ; ( fhir:item [ fhir:linkId [ fhir:v "practitioner-name" ] ; fhir:text [ fhir:v "Name" ] ; ( fhir:answer [ fhir:id [ fhir:v "practitioner-name-calculatedExpression-8D3FBElCUrLv1_eC5UV27" ] ; fhir:value [ a fhir:String ; fhir:v "Peter Primary" ] ] ) ] [ fhir:linkId [ fhir:v "practitioner-phone" ] ; fhir:text [ fhir:v "Phone" ] ; ( fhir:answer [ fhir:id [ fhir:v "practitioner-phone-calculatedExpression-pXL5hXh_jQ7qb7uht3Tnc" ] ; fhir:value [ a fhir:String ; fhir:v "(08) 7010 5556" ] ] ) ] [ fhir:linkId [ fhir:v "practitioner-email" ] ; fhir:text [ fhir:v "Email" ] ; ( fhir:answer [ fhir:id [ fhir:v "practitioner-email-calculatedExpression-iKT3aoXLu-MAQjlKbIJav" ] ; fhir:value [ a fhir:String ; fhir:v "PPP@example.org" ] ] ) ] [ fhir:linkId [ fhir:v "practitioner-medicareprovidernumber" ] ; fhir:text [ fhir:v "Medicare provider number" ] ; ( fhir:answer [ fhir:id [ fhir:v "practitioner-medicareprovidernumber-calculatedExpression-NbVRyrfUcRerVxYxg8kS7" ] ; fhir:value [ a fhir:String ; fhir:v "2426621B" ] ] ) ] [ fhir:linkId [ fhir:v "practitioner-clinicdetails" ] ; fhir:text [ fhir:v "Clinic details" ] ; ( fhir:item [ fhir:linkId [ fhir:v "practitioner-clinicdetails-name" ] ; fhir:text [ fhir:v "Name" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Quinninup Medical Clinic" ] ] ) ] [ fhir:linkId [ fhir:v "practitioner-clinicdetails-address" ] ; fhir:text [ fhir:v "Address" ] ; ( fhir:item [ fhir:linkId [ fhir:v "practitioner-clinicdetails-address-streetaddress" ] ; fhir:text [ fhir:v "Street address" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "24 Grande Pl" ] ] ) ] [ fhir:linkId [ fhir:v "practitioner-clinicdetails-address-city" ] ; fhir:text [ fhir:v "City" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Quinninup" ] ] ) ] [ fhir:linkId [ fhir:v "practitioner-clinicdetails-address-state" ] ; fhir:text [ fhir:v "State" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "https://healthterminologies.gov.au/fhir/CodeSystem/australian-states-territories-1"^^xsd:anyURI ; fhir:l <https://healthterminologies.gov.au/fhir/CodeSystem/australian-states-territories-1> ] ; fhir:code [ fhir:v "WA" ] ; fhir:display [ fhir:v "Western Australia" ] ] ] ) ] [ fhir:linkId [ fhir:v "practitioner-clinicdetails-address-postcode" ] ; fhir:text [ fhir:v "Postcode" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "6258" ] ] ) ] ) ] ) ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails" ] ; fhir:text [ fhir:v "Clinical details" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-problemsdiagnoses" ] ; fhir:text [ fhir:v "Problems/Diagnoses" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-problemsdiagnoses-recordedproblems" ] ; fhir:text [ fhir:v "Recorded problems/diagnoses" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-problemsdiagnoses-recordedproblems-condition" ] ; fhir:text [ fhir:v "Condition" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:278860009 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "278860009" ] ; fhir:display [ fhir:v "Chronic lower back pain" ] ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-problemsdiagnoses-recordedproblems-clinicalstatus" ] ; fhir:text [ fhir:v "Clinical status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/condition-clinical"^^xsd:anyURI ; fhir:l <http://terminology.hl7.org/CodeSystem/condition-clinical> ] ; fhir:code [ fhir:v "active" ] ; fhir:display [ fhir:v "Active" ] ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-problemsdiagnoses-recordedproblems-onsetdate" ] ; fhir:text [ fhir:v "Onset date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2021-01-01"^^xsd:date ] ] ) ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-problemsdiagnoses-recordedproblems" ] ; fhir:text [ fhir:v "Recorded problems/diagnoses" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-problemsdiagnoses-recordedproblems-condition" ] ; fhir:text [ fhir:v "Condition" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:235595009 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "235595009" ] ; fhir:display [ fhir:v "Gastro-oesophageal reflux disease" ] ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-problemsdiagnoses-recordedproblems-clinicalstatus" ] ; fhir:text [ fhir:v "Clinical status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/condition-clinical"^^xsd:anyURI ; fhir:l <http://terminology.hl7.org/CodeSystem/condition-clinical> ] ; fhir:code [ fhir:v "active" ] ; fhir:display [ fhir:v "Active" ] ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-problemsdiagnoses-recordedproblems-onsetdate" ] ; fhir:text [ fhir:v "Onset date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2013-08-01"^^xsd:date ] ] ) ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-problemsdiagnoses-newproblems" ] ; fhir:text [ fhir:v "New problems/diagnoses" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-problemsdiagnoses-newproblems-condition" ] ; fhir:text [ fhir:v "Condition" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:443694000 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "443694000" ] ; fhir:display [ fhir:v "Uncontrolled type 2 diabetes" ] ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-problemsdiagnoses-newproblems-onsetdate" ] ; fhir:text [ fhir:v "Onset date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2026-01-25"^^xsd:date ] ] ) ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-problemsdiagnoses-newproblems" ] ; fhir:text [ fhir:v "New problems/diagnoses" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-problemsdiagnoses-newproblems-condition" ] ; fhir:text [ fhir:v "Condition" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:424736006 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "424736006" ] ; fhir:display [ fhir:v "Peripheral neuropathy due to diabetes" ] ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-problemsdiagnoses-newproblems-onsetdate" ] ; fhir:text [ fhir:v "Onset date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2026-02-20"^^xsd:date ] ] ) ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-problemsdiagnoses-newproblems" ] ; fhir:text [ fhir:v "New problems/diagnoses" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-problemsdiagnoses-newproblems-condition" ] ; fhir:text [ fhir:v "Condition" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:238131007 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "238131007" ] ; fhir:display [ fhir:v "Overweight" ] ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-problemsdiagnoses-newproblems-onsetdate" ] ; fhir:text [ fhir:v "Onset date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2025-11-25"^^xsd:date ] ] ) ] ) ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-allergies" ] ; fhir:text [ fhir:v "Adverse reaction risks" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-allergies-recordedallergies" ] ; fhir:text [ fhir:v "Recorded adverse reaction risks" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-allergies-recordedallergies-substance" ] ; fhir:text [ fhir:v "Substance" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:111088007 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "111088007" ] ; fhir:display [ fhir:v "Latex" ] ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-allergies-recordedallergies-status" ] ; fhir:text [ fhir:v "Status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical"^^xsd:anyURI ; fhir:l <http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical> ] ; fhir:code [ fhir:v "active" ] ; fhir:display [ fhir:v "Active" ] ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-allergies-recordedallergies-manifestation" ] ; fhir:text [ fhir:v "Manifestation" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:271807003 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "271807003" ] ; fhir:display [ fhir:v "Rash" ] ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-allergies-recordedallergies-comment" ] ; fhir:text [ fhir:v "Comment" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Has reacted soon after exposure as well as a delayed reaction to latex, with a rash appearing 24 hours after exposure." ] ] ) ] ) ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-medications" ] ; fhir:text [ fhir:v "Medications (current)" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-medications-recordedmedications" ] ; fhir:text [ fhir:v "Recorded medications" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-medications-recordedmedications-medication" ] ; fhir:text [ fhir:v "Medication" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:5848011000036106 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "5848011000036106" ] ; fhir:display [ fhir:v "Panadol Osteo 665 mg modified release tablet" ] ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-medications-recordedmedications-status" ] ; fhir:text [ fhir:v "Status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/CodeSystem/medication-statement-status"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/CodeSystem/medication-statement-status> ] ; fhir:code [ fhir:v "active" ] ; fhir:display [ fhir:v "Active" ] ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-medications-recordedmedications-dosage" ] ; fhir:text [ fhir:v "Dosage" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "2 tabs PRN/TDS" ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-medications-recordedmedications-indication" ] ; fhir:text [ fhir:v "Indication" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:278860009 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "278860009" ] ; fhir:display [ fhir:v "Chronic lower back pain" ] ] ] ) ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-medications-recordedmedications" ] ; fhir:text [ fhir:v "Recorded medications" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-medications-recordedmedications-medication" ] ; fhir:text [ fhir:v "Medication" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:5848011000036106 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "5848011000036106" ] ; fhir:display [ fhir:v "Panadol Osteo 665 mg modified release tablet" ] ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-medications-recordedmedications-status" ] ; fhir:text [ fhir:v "Status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/CodeSystem/medication-statement-status"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/CodeSystem/medication-statement-status> ] ; fhir:code [ fhir:v "active" ] ; fhir:display [ fhir:v "Active" ] ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-medications-recordedmedications-dosage" ] ; fhir:text [ fhir:v "Dosage" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "2 tabs PRN/TDS" ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-medications-recordedmedications-indication" ] ; fhir:text [ fhir:v "Indication" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:278860009 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "278860009" ] ; fhir:display [ fhir:v "Chronic lower back pain" ] ] ] ) ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-medications-recordedmedications" ] ; fhir:text [ fhir:v "Recorded medications" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-medications-recordedmedications-medication" ] ; fhir:text [ fhir:v "Medication" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:682641000168107 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "682641000168107" ] ; fhir:display [ fhir:v "Esomeprazole 20 mg enteric capsule" ] ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-medications-recordedmedications-status" ] ; fhir:text [ fhir:v "Status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/CodeSystem/medication-statement-status"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/CodeSystem/medication-statement-status> ] ; fhir:code [ fhir:v "active" ] ; fhir:display [ fhir:v "Active" ] ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-medications-recordedmedications-dosage" ] ; fhir:text [ fhir:v "Dosage" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "1 tab daily" ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-medications-recordedmedications-indication" ] ; fhir:text [ fhir:v "Indication" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:235595009 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "235595009" ] ; fhir:display [ fhir:v "Gastro-oesophageal reflux disease" ] ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-medications-recordedmedications-comment" ] ; fhir:text [ fhir:v "Comment" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Gastroscopy 2013 - mild reflux esophagitis, H pylori negative" ] ] ) ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-medications-newmedications" ] ; fhir:text [ fhir:v "New medications" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-medications-newmedications-medication" ] ; fhir:text [ fhir:v "Medication" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:23358011000036102 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "23358011000036102" ] ; fhir:display [ fhir:v "Metformin hydrochloride 500 mg tablet" ] ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-medications-newmedications-dosage" ] ; fhir:text [ fhir:v "Dosage" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "1 tab BD" ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-medications-newmedications-indication" ] ; fhir:text [ fhir:v "Indication" ] ; ( fhir:answer [ fhir:id [ fhir:v "clinicaldetails-medications-newmedications-indication-repeat-gXGDcl_GVQjMVeCu7AXYA" ] ; fhir:value [ a fhir:Coding, sct:443694000 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "443694000" ] ; fhir:display [ fhir:v "Uncontrolled type 2 diabetes" ] ] ] ) ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-medications-newmedications" ] ; fhir:text [ fhir:v "New medications" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-medications-newmedications-medication" ] ; fhir:text [ fhir:v "Medication" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:77436011000036106 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "77436011000036106" ] ; fhir:display [ fhir:v "Fish oil" ] ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-medications-newmedications-dosage" ] ; fhir:text [ fhir:v "Dosage" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "2 caps daily" ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-medications-newmedications-comment" ] ; fhir:text [ fhir:v "Comment" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Self-initiated for heart health" ] ] ) ] ) ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations" ] ; fhir:text [ fhir:v "Observations" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid" ] ; fhir:text [ fhir:v "Observations" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-height" ] ; fhir:text [ fhir:v "Height" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-height-lastresultvalue" ] ; ( fhir:answer [ fhir:value [ a fhir:Decimal ; fhir:v "165"^^xsd:decimal ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-height-lastresultdate" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2025-11-25"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-height-newresultvalue" ] ; fhir:text [ fhir:v "New result" ] ; ( fhir:answer [ fhir:value [ a fhir:Decimal ; fhir:v "165"^^xsd:decimal ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-height-newresultdate" ] ; fhir:text [ fhir:v "New result date" ] ; ( fhir:answer [ fhir:id [ fhir:v "clinicaldetails-observations-maingrid-height-newresultdate-calculatedExpression-xtMXwEIrATvoIiIBzaan0" ] ; fhir:value [ a fhir:Date ; fhir:v "2026-05-25"^^xsd:date ] ] ) ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-weight" ] ; fhir:text [ fhir:v "Weight" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-weight-lastresultvalue" ] ; ( fhir:answer [ fhir:value [ a fhir:Decimal ; fhir:v "74"^^xsd:decimal ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-weight-lastresultdate" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2025-11-25"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-weight-newresultvalue" ] ; fhir:text [ fhir:v "New result" ] ; ( fhir:answer [ fhir:value [ a fhir:Decimal ; fhir:v 75.2 ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-weight-newresultdate" ] ; fhir:text [ fhir:v "New result date" ] ; ( fhir:answer [ fhir:id [ fhir:v "clinicaldetails-observations-maingrid-weight-newresultdate-calculatedExpression-nIgP9dQYLCz42G-GvOZOQ" ] ; fhir:value [ a fhir:Date ; fhir:v "2026-05-25"^^xsd:date ] ] ) ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-bmi" ] ; fhir:text [ fhir:v "BMI (calculated)" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-bmi-lastresultvalue" ] ; ( fhir:answer [ fhir:value [ a fhir:Decimal ; fhir:v 27.2 ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-bmi-newresultvalue" ] ; fhir:text [ fhir:v "New result" ] ; ( fhir:answer [ fhir:id [ fhir:v "clinicaldetails-observations-maingrid-bmi-newresultvalue-calculatedExpression-FY_-GLEI4pIod2c5bStCC" ] ; fhir:value [ a fhir:Decimal ; fhir:v 27.6 ] ] ) ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-waistcircumference" ] ; fhir:text [ fhir:v "Waist circumference" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-waistcircumference-lastresultvalue" ] ; ( fhir:answer [ fhir:value [ a fhir:Decimal ; fhir:v "82"^^xsd:decimal ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-waistcircumference-lastresultdate" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2025-11-25"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-waistcircumference-newresultvalue" ] ; fhir:text [ fhir:v "New result" ] ; ( fhir:answer [ fhir:value [ a fhir:Decimal ; fhir:v 82.5 ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-waistcircumference-newdate" ] ; fhir:text [ fhir:v "New result date" ] ; ( fhir:answer [ fhir:id [ fhir:v "clinicaldetails-observations-maingrid-waistcircumference-newdate-calculatedExpression-Eiu7YYZCzG8sWG9-wfNAW" ] ; fhir:value [ a fhir:Date ; fhir:v "2026-05-25"^^xsd:date ] ] ) ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-pulserate" ] ; fhir:text [ fhir:v "Pulse rate" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-pulserate-lastresultvalue" ] ; ( fhir:answer [ fhir:value [ a fhir:Decimal ; fhir:v "74"^^xsd:decimal ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-pulserate-lastresultdate" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2025-11-25"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-pulserate-newresultvalue" ] ; fhir:text [ fhir:v "New result" ] ; ( fhir:answer [ fhir:value [ a fhir:Integer ; fhir:v 76 ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-pulserate-newresultdate" ] ; fhir:text [ fhir:v "New result date" ] ; ( fhir:answer [ fhir:id [ fhir:v "clinicaldetails-observations-maingrid-pulserate-newresultdate-calculatedExpression-34UvegIOIDUKnmkUrUZq8" ] ; fhir:value [ a fhir:Date ; fhir:v "2026-05-25"^^xsd:date ] ] ) ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-pulserhythm" ] ; fhir:text [ fhir:v "Pulse rhythm" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-pulserhythm-lastresultvalue" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:271636001 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "271636001" ] ; fhir:display [ fhir:v "Pulse regular" ] ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-pulserhythm-lastresultdate" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2025-11-25"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-pulserhythm-newresultvalue" ] ; fhir:text [ fhir:v "New result" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:271636001 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "271636001" ] ; fhir:display [ fhir:v "Pulse regular" ] ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-pulserhythm-newresultdate" ] ; fhir:text [ fhir:v "New result date" ] ; ( fhir:answer [ fhir:id [ fhir:v "clinicaldetails-observations-maingrid-pulserhythm-newresultdate-calculatedExpression-UWNBrqxvJKv6nvG1CeBjD" ] ; fhir:value [ a fhir:Date ; fhir:v "2026-05-25"^^xsd:date ] ] ) ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-oxygensaturation" ] ; fhir:text [ fhir:v "Oxygen saturation" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-oxygensaturation-lastresultvalue" ] ; ( fhir:answer [ fhir:value [ a fhir:Decimal ; fhir:v "98"^^xsd:decimal ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-oxygensaturation-lastresultdate" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2026-06-20"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-oxygensaturation-newresultvalue" ] ; fhir:text [ fhir:v "New result" ] ; ( fhir:answer [ fhir:value [ a fhir:Integer ; fhir:v 98 ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-maingrid-oxygensaturation-newresultdate" ] ; fhir:text [ fhir:v "New result date" ] ; ( fhir:answer [ fhir:id [ fhir:v "clinicaldetails-observations-maingrid-oxygensaturation-newresultdate-calculatedExpression-Gz6fyQXZnbuBhxR1MlKOL" ] ; fhir:value [ a fhir:Date ; fhir:v "2026-05-25"^^xsd:date ] ] ) ] ) ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-bpgrid" ] ; fhir:text [ fhir:v "Blood pressure" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-observations-bpgrid-bp" ] ; fhir:text [ fhir:v "Blood pressure" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-observations-bpgrid-bp-lastresultvaluesystolic" ] ; ( fhir:answer [ fhir:value [ a fhir:Decimal ; fhir:v "128"^^xsd:decimal ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-bpgrid-bp-lastresultvaluediastolic" ] ; ( fhir:answer [ fhir:value [ a fhir:Decimal ; fhir:v "72"^^xsd:decimal ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-bpgrid-bp-lastresultdate" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2025-11-25"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-bpgrid-bp-newresultsystolic" ] ; fhir:text [ fhir:v "Systolic" ] ; ( fhir:answer [ fhir:value [ a fhir:Integer ; fhir:v 130 ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-bpgrid-bp-newresultdiastolic" ] ; fhir:text [ fhir:v "Diastolic" ] ; ( fhir:answer [ fhir:value [ a fhir:Integer ; fhir:v 72 ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-bpgrid-bp-newresultdate" ] ; fhir:text [ fhir:v "Date performed" ] ; ( fhir:answer [ fhir:id [ fhir:v "clinicaldetails-observations-bpgrid-bp-newresultdate-calculatedExpression-Y28BYlwCNoGPjqR8n-YyI" ] ; fhir:value [ a fhir:Date ; fhir:v "2026-05-25"^^xsd:date ] ] ) ] ) ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-substanceusegrid" ] ; fhir:text [ fhir:v "Substance use" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-observations-substanceusegrid-smokingstatus" ] ; fhir:text [ fhir:v "Smoking status" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-observations-substanceusegrid-smokingstatus-lastresultvalue" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:77176002 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "77176002" ] ; fhir:display [ fhir:v "Current smoker" ] ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-substanceusegrid-smokingstatus-lastresultdate" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2026-02-20"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-substanceusegrid-smokingstatus-newresultdate" ] ; fhir:text [ fhir:v "New status date" ] ; ( fhir:answer [ fhir:id [ fhir:v "clinicaldetails-observations-substanceusegrid-smokingstatus-newresultdate-calculatedExpression-ZASuZR1cTqqiPw8-IhRYE" ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-smokingstatusgrid-smokingstatus-newresultcomment" ] ; fhir:text [ fhir:v "Comment" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "20 cigarettes per day since 17yo" ] ] ) ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-substanceusegrid-alcoholstatus" ] ; fhir:text [ fhir:v "Alcohol consumption status" ] ; ( fhir:item [ fhir:linkId [ fhir:v "clinicaldetails-observations-substanceusegrid-alcoholstatus-lastresultvalue" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:219006 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "219006" ] ; fhir:display [ fhir:v "Current drinker" ] ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-substanceusegrid-alcoholstatus-lastresultdate" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2026-02-20"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-substanceusegrid-alcoholstatus-newresultdate" ] ; fhir:text [ fhir:v "New status date" ] ; ( fhir:answer [ fhir:id [ fhir:v "clinicaldetails-observations-substanceusegrid-alcoholstatus-newresultdate-calculatedExpression-IQbl4AX0YqnJo7DiwuVCr" ] ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-substanceusegrid-alcoholstatus-newresultcomment" ] ; fhir:text [ fhir:v "Comment" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "2 drinks, 2 days per week (on weekends)" ] ] ) ] ) ] ) ] ) ] [ fhir:linkId [ fhir:v "clinicaldetails-observations-additionalinformation" ] ; fhir:text [ fhir:v "Additional information" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Family history: Mother - diabetes, stroke; Father - heart attack, depression; Paternal grandmother - breast cancer\nWork: Receptionist in building business" ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan" ] ; fhir:text [ fhir:v "Plan" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-type" ] ; fhir:text [ fhir:v "New plan or a review of an existing plan?" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "New" ] ] ) ] [ fhir:linkId [ fhir:v "plan-inprogress" ] ; fhir:text [ fhir:v "Incomplete draft plan already exists?" ] ; ( fhir:answer [ fhir:value [ a fhir:Boolean ; fhir:v true ] ] ) ] [ fhir:linkId [ fhir:v "plan-conditions" ] ; fhir:text [ fhir:v "Conditions addressed" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-conditions-condition" ] ; fhir:text [ fhir:v "Condition" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:443694000 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "443694000" ] ; fhir:display [ fhir:v "Uncontrolled type 2 diabetes" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-conditions-onsetdate" ] ; fhir:text [ fhir:v "Onset date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2026-01-25"^^xsd:date ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-conditions" ] ; fhir:text [ fhir:v "Conditions addressed" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-conditions-condition" ] ; fhir:text [ fhir:v "Condition" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:278860009 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "278860009" ] ; fhir:display [ fhir:v "Chronic lower back pain" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-conditions-onsetdate" ] ; fhir:text [ fhir:v "Onset date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2021-01-01"^^xsd:date ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-conditions" ] ; fhir:text [ fhir:v "Conditions addressed" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-conditions-condition" ] ; fhir:text [ fhir:v "Condition" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:235595009 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "235595009" ] ; fhir:display [ fhir:v "Gastro-oesophageal reflux disease" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-conditions-onsetdate" ] ; fhir:text [ fhir:v "Onset date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2013-08-01"^^xsd:date ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-conditions" ] ; fhir:text [ fhir:v "Conditions addressed" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-conditions-condition" ] ; fhir:text [ fhir:v "Condition" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:238131007 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "238131007" ] ; fhir:display [ fhir:v "Overweight" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-conditions-onsetdate" ] ; fhir:text [ fhir:v "Onset date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2025-11-25"^^xsd:date ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks" ] ; fhir:text [ fhir:v "Goals and tasks" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-problemneed" ] ; fhir:text [ fhir:v "Problems/Needs" ] ; ( fhir:answer [ fhir:id [ fhir:v "plan-goalstasks-problemneed-repeat-Sr9JIDYmhKLPJ6An9exHM" ] ; fhir:value [ a fhir:Coding, sct:443694000 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "443694000" ] ; fhir:display [ fhir:v "Uncontrolled type 2 diabetes" ] ] ] [ fhir:id [ fhir:v "plan-goalstasks-problemneed-repeat-SEwMPioQ72kX-AYelOqvH" ] ; fhir:value [ a fhir:Coding, sct:80394007 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "80394007" ] ; fhir:display [ fhir:v "Hyperglycaemia" ] ] ] [ fhir:id [ fhir:v "plan-goalstasks-problemneed-repeat-rQ5fyiwTTHDWZKLnrZbIv" ] ; fhir:value [ a fhir:Coding, sct:424736006 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "424736006" ] ; fhir:display [ fhir:v "Peripheral neuropathy due to diabetes" ] ] ] [ fhir:id [ fhir:v "plan-goalstasks-problemneed-repeat-FzJSY57DfMsFzBuNXmVUT" ] ; fhir:value [ a fhir:Coding, sct:238131007 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "238131007" ] ; fhir:display [ fhir:v "Overweight" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-goalsetting" ] ; fhir:text [ fhir:v "Goal setting" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-goalsetting-goals" ] ; fhir:text [ fhir:v "Goals" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Controlled diabetes - aim HbA1c ≤7.0 and fasting BGL 4.0-7.0" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-goalsetting-initiator" ] ; fhir:text [ fhir:v "Initiator" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "GP" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-goalsetting-targetdate" ] ; fhir:text [ fhir:v "Target date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2027-05-20"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-goalsetting-status" ] ; fhir:text [ fhir:v "Status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/goal-status"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/goal-status> ] ; fhir:code [ fhir:v "active" ] ; fhir:display [ fhir:v "active" ] ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions" ] ; fhir:text [ fhir:v "Interventions and actions" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-interventionsactions" ] ; fhir:text [ fhir:v "Interventions/Actions" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:6143009 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "6143009" ] ; fhir:display [ fhir:v "Diabetic education" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-owner" ] ; fhir:text [ fhir:v "Owner" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Caterina, diabetes educator" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-targetdate" ] ; fhir:text [ fhir:v "Target date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2026-08-20"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-status" ] ; fhir:text [ fhir:v "Status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/care-plan-activity-status"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/care-plan-activity-status> ] ; fhir:code [ fhir:v "not-started" ] ; fhir:display [ fhir:v "Planned" ] ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions" ] ; fhir:text [ fhir:v "Interventions and actions" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-interventionsactions" ] ; fhir:text [ fhir:v "Interventions/Actions" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:11816003 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "11816003" ] ; fhir:display [ fhir:v "Diet education" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-owner" ] ; fhir:text [ fhir:v "Owner" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Caterina, dietitian" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-targetdate" ] ; fhir:text [ fhir:v "Target date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2026-08-20"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-status" ] ; fhir:text [ fhir:v "Status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/care-plan-activity-status"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/care-plan-activity-status> ] ; fhir:code [ fhir:v "not-started" ] ; fhir:display [ fhir:v "Planned" ] ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions" ] ; fhir:text [ fhir:v "Interventions and actions" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-interventionsactions" ] ; fhir:text [ fhir:v "Interventions/Actions" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Exercise regime" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-owner" ] ; fhir:text [ fhir:v "Owner" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Caterina, exercise physiologist" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-targetdate" ] ; fhir:text [ fhir:v "Target date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2026-11-20"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-status" ] ; fhir:text [ fhir:v "Status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/care-plan-activity-status"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/care-plan-activity-status> ] ; fhir:code [ fhir:v "not-started" ] ; fhir:display [ fhir:v "Planned" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-comment" ] ; fhir:text [ fhir:v "Comment" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Aim for 150 mins moderate physical activity per week" ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions" ] ; fhir:text [ fhir:v "Interventions and actions" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-interventionsactions" ] ; fhir:text [ fhir:v "Interventions/Actions" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Weight management program" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-owner" ] ; fhir:text [ fhir:v "Owner" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Caterina, GP" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-targetdate" ] ; fhir:text [ fhir:v "Target date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2027-05-20"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-status" ] ; fhir:text [ fhir:v "Status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/care-plan-activity-status"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/care-plan-activity-status> ] ; fhir:code [ fhir:v "not-started" ] ; fhir:display [ fhir:v "Planned" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-comment" ] ; fhir:text [ fhir:v "Comment" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Aim for 5-10% weight loss, waist circumference <80cm" ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions" ] ; fhir:text [ fhir:v "Interventions and actions" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-interventionsactions" ] ; fhir:text [ fhir:v "Interventions/Actions" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Diabetes medicine review" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-owner" ] ; fhir:text [ fhir:v "Owner" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Caterina, GP, pharmacist" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-targetdate" ] ; fhir:text [ fhir:v "Target date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2026-08-20"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-status" ] ; fhir:text [ fhir:v "Status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/care-plan-activity-status"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/care-plan-activity-status> ] ; fhir:code [ fhir:v "not-started" ] ; fhir:display [ fhir:v "Planned" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-comment" ] ; fhir:text [ fhir:v "Comment" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Consider Home Medicines Review in 3-6 months" ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions" ] ; fhir:text [ fhir:v "Interventions and actions" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-interventionsactions" ] ; fhir:text [ fhir:v "Interventions/Actions" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:1340186004 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "1340186004" ] ; fhir:display [ fhir:v "Metformin therapy" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-owner" ] ; fhir:text [ fhir:v "Owner" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Caterina, GP, pharmacist" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-targetdate" ] ; fhir:text [ fhir:v "Target date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2026-06-03"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-status" ] ; fhir:text [ fhir:v "Status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/care-plan-activity-status"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/care-plan-activity-status> ] ; fhir:code [ fhir:v "not-started" ] ; fhir:display [ fhir:v "Planned" ] ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions" ] ; fhir:text [ fhir:v "Interventions and actions" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-interventionsactions" ] ; fhir:text [ fhir:v "Interventions/Actions" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Detecting complications early" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-owner" ] ; fhir:text [ fhir:v "Owner" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Caterina, GP, podiatrist, optometrist" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-targetdate" ] ; fhir:text [ fhir:v "Target date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2027-05-20"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-status" ] ; fhir:text [ fhir:v "Status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/care-plan-activity-status"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/care-plan-activity-status> ] ; fhir:code [ fhir:v "not-started" ] ; fhir:display [ fhir:v "Planned" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-comment" ] ; fhir:text [ fhir:v "Comment" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Regular screening for diabetic nephropathy, neuropathy and retinopathy" ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments" ] ; fhir:text [ fhir:v "Services and treatments" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-servicestreatments" ] ; fhir:text [ fhir:v "Required services and treatments" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:734920002 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "734920002" ] ; fhir:display [ fhir:v "Diabetes education service" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-activity" ] ; fhir:text [ fhir:v "Activity" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:312856000 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "312856000" ] ; fhir:display [ fhir:v "Referral to diabetes nurse" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-provider" ] ; fhir:text [ fhir:v "Provider" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Diabetes educator" ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments" ] ; fhir:text [ fhir:v "Services and treatments" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-servicestreatments" ] ; fhir:text [ fhir:v "Required services and treatments" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:734920002 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "734920002" ] ; fhir:display [ fhir:v "Diabetes education service" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-activity" ] ; fhir:text [ fhir:v "Activity" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:284350006 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "284350006" ] ; fhir:display [ fhir:v "Diabetes diet education" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-provider" ] ; fhir:text [ fhir:v "Provider" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Diabetes educator" ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments" ] ; fhir:text [ fhir:v "Services and treatments" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-servicestreatments" ] ; fhir:text [ fhir:v "Required services and treatments" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:310090003 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "310090003" ] ; fhir:display [ fhir:v "Dietetics service" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-activity" ] ; fhir:text [ fhir:v "Activity" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:103699006 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "103699006" ] ; fhir:display [ fhir:v "Referral to dietitian" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-provider" ] ; fhir:text [ fhir:v "Provider" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Dietitian" ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments" ] ; fhir:text [ fhir:v "Services and treatments" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-servicestreatments" ] ; fhir:text [ fhir:v "Required services and treatments" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:310090003 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "310090003" ] ; fhir:display [ fhir:v "Dietetics service" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-activity" ] ; fhir:text [ fhir:v "Activity" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:11816003 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "11816003" ] ; fhir:display [ fhir:v "Diet education" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-provider" ] ; fhir:text [ fhir:v "Provider" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Dietitian" ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments" ] ; fhir:text [ fhir:v "Services and treatments" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-servicestreatments" ] ; fhir:text [ fhir:v "Required services and treatments" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:1240761000168106 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "1240761000168106" ] ; fhir:display [ fhir:v "Exercise physiology service" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-activity" ] ; fhir:text [ fhir:v "Activity" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:1100681000168103 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "1100681000168103" ] ; fhir:display [ fhir:v "Referral to exercise physiologist" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-provider" ] ; fhir:text [ fhir:v "Provider" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Exercise physiologist" ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments" ] ; fhir:text [ fhir:v "Services and treatments" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-servicestreatments" ] ; fhir:text [ fhir:v "Required services and treatments" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:1240761000168106 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "1240761000168106" ] ; fhir:display [ fhir:v "Exercise physiology service" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-activity" ] ; fhir:text [ fhir:v "Activity" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:229080003 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "229080003" ] ; fhir:display [ fhir:v "Exercise regime" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-provider" ] ; fhir:text [ fhir:v "Provider" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Exercise physiologist" ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments" ] ; fhir:text [ fhir:v "Services and treatments" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-servicestreatments" ] ; fhir:text [ fhir:v "Required services and treatments" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:23911000087104 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "23911000087104" ] ; fhir:display [ fhir:v "Medicine review service" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-activity" ] ; fhir:text [ fhir:v "Activity" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:306362008 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "306362008" ] ; fhir:display [ fhir:v "Referral to pharmacist" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-provider" ] ; fhir:text [ fhir:v "Provider" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Pharmacist" ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments" ] ; fhir:text [ fhir:v "Services and treatments" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-servicestreatments" ] ; fhir:text [ fhir:v "Required services and treatments" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:23911000087104 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "23911000087104" ] ; fhir:display [ fhir:v "Medicine review service" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-activity" ] ; fhir:text [ fhir:v "Activity" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:1348931000168107 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "1348931000168107" ] ; fhir:display [ fhir:v "Home medicines review" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-provider" ] ; fhir:text [ fhir:v "Provider" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Pharmacist" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-comment" ] ; fhir:text [ fhir:v "Comment" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Consider Home Medicines Review in 3-6 months" ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments" ] ; fhir:text [ fhir:v "Services and treatments" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-servicestreatments" ] ; fhir:text [ fhir:v "Required services and treatments" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:788007007 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "788007007" ] ; fhir:display [ fhir:v "General practice service" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-activity" ] ; fhir:text [ fhir:v "Activity" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:395101001 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "395101001" ] ; fhir:display [ fhir:v "Ongoing review" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-provider" ] ; fhir:text [ fhir:v "Provider" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "GP, practice nurse" ] ] ) ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks" ] ; fhir:text [ fhir:v "Goals and tasks" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-problemneed" ] ; fhir:text [ fhir:v "Problems/Needs" ] ; ( fhir:answer [ fhir:id [ fhir:v "plan-goalstasks-problemneed-repeat-9g64YCvHill3V992KwhdT" ] ; fhir:value [ a fhir:Coding, sct:443694000 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "443694000" ] ; fhir:display [ fhir:v "Uncontrolled type 2 diabetes" ] ] ] [ fhir:id [ fhir:v "plan-goalstasks-problemneed-repeat-YV0DNHjxVa4d-xxo0cKnu" ] ; fhir:value [ a fhir:Coding, sct:238131007 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "238131007" ] ; fhir:display [ fhir:v "Overweight" ] ] ] [ fhir:id [ fhir:v "plan-goalstasks-problemneed-repeat-47mdKuLSYw0dnl3VlkLHt" ] ; fhir:value [ a fhir:Coding, sct:235595009 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "235595009" ] ; fhir:display [ fhir:v "Gastro-oesophageal reflux disease" ] ] ] [ fhir:id [ fhir:v "plan-goalstasks-problemneed-repeat-nNu5Y4c2JCEp-DhqTFk2b" ] ; fhir:value [ a fhir:Coding, sct:278860009 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "278860009" ] ; fhir:display [ fhir:v "Chronic lower back pain" ] ] ] [ fhir:id [ fhir:v "plan-goalstasks-problemneed-repeat-ObITmA57Lkq0iaTX5Po8A" ] ; fhir:value [ a fhir:Coding, sct:286647002 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "286647002" ] ; fhir:display [ fhir:v "Low self-esteem" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-goalsetting" ] ; fhir:text [ fhir:v "Goal setting" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-goalsetting-goals" ] ; fhir:text [ fhir:v "Goals" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "5-10% weight loss (target weight 73.8-77.9kg) and decrease waist circumference (long term target <80cm)" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-goalsetting-initiator" ] ; fhir:text [ fhir:v "Initiator" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "GP" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-goalsetting-targetdate" ] ; fhir:text [ fhir:v "Target date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2027-05-20"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-goalsetting-status" ] ; fhir:text [ fhir:v "Status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/goal-status"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/goal-status> ] ; fhir:code [ fhir:v "active" ] ; fhir:display [ fhir:v "active" ] ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-goalsetting" ] ; fhir:text [ fhir:v "Goal setting" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-goalsetting-goals" ] ; fhir:text [ fhir:v "Goals" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Comfortably wear dress purchased for niece’s wedding next year" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-goalsetting-initiator" ] ; fhir:text [ fhir:v "Initiator" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Caterina" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-goalsetting-targetdate" ] ; fhir:text [ fhir:v "Target date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2027-05-20"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-goalsetting-status" ] ; fhir:text [ fhir:v "Status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/goal-status"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/goal-status> ] ; fhir:code [ fhir:v "active" ] ; fhir:display [ fhir:v "active" ] ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions" ] ; fhir:text [ fhir:v "Interventions and actions" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-interventionsactions" ] ; fhir:text [ fhir:v "Interventions/Actions" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:183065007 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "183065007" ] ; fhir:display [ fhir:v "Low carbohydrate diet education" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-owner" ] ; fhir:text [ fhir:v "Owner" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Caterina, dietitian" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-targetdate" ] ; fhir:text [ fhir:v "Target date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2026-08-20"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-status" ] ; fhir:text [ fhir:v "Status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/care-plan-activity-status"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/care-plan-activity-status> ] ; fhir:code [ fhir:v "not-started" ] ; fhir:display [ fhir:v "Planned" ] ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions" ] ; fhir:text [ fhir:v "Interventions and actions" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-interventionsactions" ] ; fhir:text [ fhir:v "Interventions/Actions" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Reduce ratio of carbohydrates in each meal – ¼ plate carbs, ¼ plate protein, ½ plate vegetables/salad" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-owner" ] ; fhir:text [ fhir:v "Owner" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Caterina" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-targetdate" ] ; fhir:text [ fhir:v "Target date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2026-08-20"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-status" ] ; fhir:text [ fhir:v "Status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/care-plan-activity-status"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/care-plan-activity-status> ] ; fhir:code [ fhir:v "not-started" ] ; fhir:display [ fhir:v "Planned" ] ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions" ] ; fhir:text [ fhir:v "Interventions and actions" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-interventionsactions" ] ; fhir:text [ fhir:v "Interventions/Actions" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Substitute high GI for low GI carbohydrates where possible" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-owner" ] ; fhir:text [ fhir:v "Owner" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Caterina" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-targetdate" ] ; fhir:text [ fhir:v "Target date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2026-08-20"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-status" ] ; fhir:text [ fhir:v "Status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/care-plan-activity-status"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/care-plan-activity-status> ] ; fhir:code [ fhir:v "not-started" ] ; fhir:display [ fhir:v "Planned" ] ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions" ] ; fhir:text [ fhir:v "Interventions and actions" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-interventionsactions" ] ; fhir:text [ fhir:v "Interventions/Actions" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Physical activity guidance" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-owner" ] ; fhir:text [ fhir:v "Owner" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Caterina, exercise physiologist" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-targetdate" ] ; fhir:text [ fhir:v "Target date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2026-11-20"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-status" ] ; fhir:text [ fhir:v "Status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/care-plan-activity-status"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/care-plan-activity-status> ] ; fhir:code [ fhir:v "not-started" ] ; fhir:display [ fhir:v "Planned" ] ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions" ] ; fhir:text [ fhir:v "Interventions and actions" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-interventionsactions" ] ; fhir:text [ fhir:v "Interventions/Actions" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Aim for 150 mins of aerobic activity per week" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-owner" ] ; fhir:text [ fhir:v "Owner" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Caterina" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-targetdate" ] ; fhir:text [ fhir:v "Target date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2026-11-20"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-status" ] ; fhir:text [ fhir:v "Status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/care-plan-activity-status"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/care-plan-activity-status> ] ; fhir:code [ fhir:v "not-started" ] ; fhir:display [ fhir:v "Planned" ] ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions" ] ; fhir:text [ fhir:v "Interventions and actions" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-interventionsactions" ] ; fhir:text [ fhir:v "Interventions/Actions" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "2-3 sessions of resistance exercise per week" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-owner" ] ; fhir:text [ fhir:v "Owner" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Caterina" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-targetdate" ] ; fhir:text [ fhir:v "Target date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2026-11-20"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-status" ] ; fhir:text [ fhir:v "Status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/care-plan-activity-status"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/care-plan-activity-status> ] ; fhir:code [ fhir:v "not-started" ] ; fhir:display [ fhir:v "Planned" ] ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions" ] ; fhir:text [ fhir:v "Interventions and actions" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-interventionsactions" ] ; fhir:text [ fhir:v "Interventions/Actions" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Management of impulse control" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-owner" ] ; fhir:text [ fhir:v "Owner" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Caterina" ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-targetdate" ] ; fhir:text [ fhir:v "Target date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2026-11-20"^^xsd:date ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-status" ] ; fhir:text [ fhir:v "Status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/care-plan-activity-status"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/care-plan-activity-status> ] ; fhir:code [ fhir:v "not-started" ] ; fhir:display [ fhir:v "Planned" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-interventionsactions-comment" ] ; fhir:text [ fhir:v "Comment" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Manage impulsivity/desire to eat when not actually hungry. Consider psychology input in future" ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments" ] ; fhir:text [ fhir:v "Services and treatments" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-servicestreatments" ] ; fhir:text [ fhir:v "Required services and treatments" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:310090003 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "310090003" ] ; fhir:display [ fhir:v "Dietetics service" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-activity" ] ; fhir:text [ fhir:v "Activity" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:103699006 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "103699006" ] ; fhir:display [ fhir:v "Referral to dietitian" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-provider" ] ; fhir:text [ fhir:v "Provider" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Dietitian" ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments" ] ; fhir:text [ fhir:v "Services and treatments" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-servicestreatments" ] ; fhir:text [ fhir:v "Required services and treatments" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:310090003 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "310090003" ] ; fhir:display [ fhir:v "Dietetics service" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-activity" ] ; fhir:text [ fhir:v "Activity" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:11816003 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "11816003" ] ; fhir:display [ fhir:v "Diet education" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-provider" ] ; fhir:text [ fhir:v "Provider" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Dietitian" ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments" ] ; fhir:text [ fhir:v "Services and treatments" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-servicestreatments" ] ; fhir:text [ fhir:v "Required services and treatments" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:1240761000168106 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "1240761000168106" ] ; fhir:display [ fhir:v "Exercise physiology service" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-activity" ] ; fhir:text [ fhir:v "Activity" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:1100681000168103 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "1100681000168103" ] ; fhir:display [ fhir:v "Referral to exercise physiologist" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-provider" ] ; fhir:text [ fhir:v "Provider" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Exercise physiologist" ] ] ) ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments" ] ; fhir:text [ fhir:v "Services and treatments" ] ; ( fhir:item [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-servicestreatments" ] ; fhir:text [ fhir:v "Required services and treatments" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:1240761000168106 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "1240761000168106" ] ; fhir:display [ fhir:v "Exercise physiology service" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-activity" ] ; fhir:text [ fhir:v "Activity" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding, sct:229080003 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ; fhir:l <http://snomed.info/sct> ] ; fhir:code [ fhir:v "229080003" ] ; fhir:display [ fhir:v "Exercise regime" ] ] ] ) ] [ fhir:linkId [ fhir:v "plan-goalstasks-details-servicestreatments-provider" ] ; fhir:text [ fhir:v "Provider" ] ; ( fhir:answer [ fhir:value [ a fhir:String ; fhir:v "Exercise physiologist" ] ] ) ] ) ] ) ] [ fhir:linkId [ fhir:v "completion" ] ; fhir:text [ fhir:v "Completion" ] ; ( fhir:item [ fhir:linkId [ fhir:v "completion-consentforsharing" ] ; fhir:text [ fhir:v "Consent given for sharing of information with relevant healthcare providers" ] ; ( fhir:answer [ fhir:value [ a fhir:Boolean ; fhir:v true ] ] ) ] [ fhir:linkId [ fhir:v "completion-review" ] ; fhir:text [ fhir:v "Review" ] ; ( fhir:item [ fhir:linkId [ fhir:v "completion-review-appointmentstatus" ] ; fhir:text [ fhir:v "Appointment status" ] ; ( fhir:answer [ fhir:value [ a fhir:Coding ; fhir:system [ fhir:v "http://hl7.org/fhir/appointmentstatus"^^xsd:anyURI ; fhir:l <http://hl7.org/fhir/appointmentstatus> ] ; fhir:code [ fhir:v "proposed" ] ; fhir:display [ fhir:v "Proposed" ] ] ] ) ] [ fhir:linkId [ fhir:v "completion-review-date" ] ; fhir:text [ fhir:v "Date" ] ; ( fhir:answer [ fhir:value [ a fhir:Date ; fhir:v "2027-05-20"^^xsd:date ] ] ) ] ) ] ) ] ) ] ) ] ) . #
IG © 2025+ AEHRC CSIRO. Package csiro.fhir.au.gpccmp#0.1.0 based on FHIR 4.0.1. Generated 2026-06-04
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