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