AU Core Implementation Guide
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: CarePlan - multiple chronic conditions - JSON Representation

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{
  "resourceType" : "CarePlan",
  "id" : "mcc",
  "meta" : //   Example adapted from MCC eCare Plan Implementation Guide MCCCarePlan  
  {
    "versionId" : "5",
    "lastUpdated" : "2022-11-16T23:03:27.124+00:00",
    "source" : "#lh8xM5mIbbHVNz84",
    "profile" : [
      "http://hl7.org.au/fhir/core/StructureDefinition/au-core-careplan"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: CarePlan</b><a name=\"mcc\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource CarePlan &quot;mcc&quot; Version &quot;5&quot; Updated &quot;2022-11-16 23:03:27+0000&quot; </p><p style=\"margin-bottom: 0px\">Information Source: #lh8xM5mIbbHVNz84!</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-au-core-careplan.html\">AU Core CarePlan</a></p></div><p><b>status</b>: active</p><p><b>intent</b>: plan</p><p><b>category</b>: Care Plan <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#734163000)</span></p><p><b>subject</b>: <a href=\"Patient-dan-harry.html\">Patient/dan-harry</a> &quot; DAN&quot;</p><p><b>period</b>: 2018-05-01 --&gt; (ongoing)</p><p><b>created</b>: 2019-01-01</p><p><b>author</b>: <a href=\"PractitionerRole-np-nurse-nancy.html\">PractitionerRole/np-nurse-nancy: Nancy Nurse RN</a></p><p><b>contributor</b>: </p><ul><li><a href=\"PractitionerRole-nephrologist-levin-henry.html\">PractitionerRole/nephrologist-levin-henry: Henry Levin VII MD Nephrologist</a></li><li><a href=\"PractitionerRole-np-nurse-nancy.html\">PractitionerRole/np-nurse-nancy: Nancy Nurse RN</a></li><li><a href=\"PractitionerRole-gp-primary-peter.html\">PractitionerRole/gp-primary-peter: Peter Primary MD Primary Provider</a></li></ul><p><b>careTeam</b>: <a href=\"CareTeam-mcc.html\">CareTeam/mcc: Longitudinal care-coordination focused care team</a> &quot;Example Multiple Chronic Condition Care Team&quot;</p><p><b>addresses</b>: <a href=\"Condition-ckd.html\">Condition/ckd: Chronic Kidney Disease</a></p><p><b>supportingInfo</b>: </p><ul><li><a href=\"Procedure-dialysis.html\">Procedure/dialysis: Chronic Pain</a></li><li><a href=\"Observation-bun-mcc.html\">Observation/bun-mcc: BUN 24 mL/min/{1.73_m2}</a></li></ul><p><b>goal</b>: <a href=\"Goal-wgt-loss.html\">Goal/wgt-loss: Lose weight, decrease chronic pain with less use of pain medication and improved lab results</a></p><blockquote><p><b>activity</b></p><p><b>outcomeReference</b>: <a href=\"Procedure-dialysis.html\">Procedure/dialysis: Dialysis</a></p><p><b>progress</b>: Harry Dan is measuring weight daily ( @2019-01-10)</p><p><b>reference</b>: <a href=\"http://example.org/Task/123\">http://example.org/Task/123: Harry Dan or caregiver to perform daily weights</a></p></blockquote><blockquote><p><b>activity</b></p><p><b>outcomeReference</b>: </p><ul><li><a href=\"http://example.org/Encounter/123\">http://example.org/Encounter/123: PreOp Encounter For Creation of external arteriovenous shunt (procedure)</a></li><li><a href=\"http://example.org/Procedure/upperlimbveinUS\">http://example.org/Procedure/upperlimbveinUS: Fluoroscopic venography of bilateral upper limbs Performed. Results: Normal</a></li></ul><p><b>progress</b>: Harry Dan Completed prep for an AV Shunt. Harry needs the shunt due to the need for dialysis related to the goal to improve Harry's health related to CKD ( @2019-01-10)</p><p><b>reference</b>: <a href=\"http://example.org/Appointment/AVShunt\">http://example.org/Appointment/AVShunt: PreOp Encounter Request For Creation of external arteriovenous shunt (procedure). Relates to overall health improvement goal and encounter requestActivity</a></p></blockquote></div>"
  },
  "status" : "active",
  "intent" : "plan",
  "category" : [
    //  US Core specific content is commented in HL7 AU examples - US Core content does
    validate against the AU Core CarePlan profile if a server supports both AU Core & US Core
    <coding>
      <system value="http://hl7.org/fhir/us/core/CodeSystem/careplan-category"/>
      <code value="assess-plan"/>
    </coding> 
    {
      "coding" : [
        {
          "system" : "http://snomed.info/sct",
          "code" : "734163000",
          "display" : "Care Plan"
        }
      ]
    }
  ],
  "subject" : {
    "reference" : "Patient/dan-harry"
  },
  "period" : {
    "start" : "2018-05-01"
  },
  "created" : "2019-01-01",
  "author" : {
    "reference" : "PractitionerRole/np-nurse-nancy",
    "display" : "Nancy Nurse RN"
  },
  "contributor" : [
    {
      "reference" : "PractitionerRole/nephrologist-levin-henry",
      "display" : "Henry Levin VII MD Nephrologist"
    },
    {
      "reference" : "PractitionerRole/np-nurse-nancy",
      "display" : "Nancy Nurse RN"
    },
    {
      "reference" : "PractitionerRole/gp-primary-peter",
      "display" : "Peter Primary MD Primary Provider"
    }
  ],
  "careTeam" : [
    {
      "reference" : "CareTeam/mcc",
      "display" : "Longitudinal care-coordination focused care team"
    }
  ],
  "addresses" : [
    {
      "reference" : "Condition/ckd",
      "display" : "Chronic Kidney Disease"
    }
  ],
  "supportingInfo" : [
    {
      "reference" : "Procedure/dialysis",
      "display" : "Chronic Pain"
    },
    {
      "reference" : "Observation/bun-mcc",
      "display" : "BUN 24 mL/min/{1.73_m2}"
    }
  ],
  "goal" : [
    {
      "reference" : "Goal/wgt-loss",
      "display" : "Lose weight, decrease chronic pain with less use of pain medication and improved lab results"
    }
  ],
  "activity" : [
    {
      "outcomeReference" : [
        {
          "reference" : "Procedure/dialysis",
          "display" : "Dialysis"
        }
      ],
      "progress" : [
        {
          "time" : "2019-01-10",
          "text" : "Harry Dan is measuring weight daily"
        }
      ],
      "reference" : {
        "reference" : "http://example.org/Task/123",
        "display" : "Harry Dan or caregiver to perform daily weights"
      }
    },
    {
      "outcomeReference" : [
        {
          "reference" : "http://example.org/Encounter/123",
          "display" : "PreOp Encounter For Creation of external arteriovenous shunt (procedure)"
        },
        {
          "reference" : "http://example.org/Procedure/upperlimbveinUS",
          "display" : "Fluoroscopic venography of bilateral upper limbs Performed. Results: Normal"
        }
      ],
      "progress" : [
        {
          "time" : "2019-01-10",
          "text" : "Harry Dan Completed prep for an AV Shunt. Harry needs the shunt due to the need for dialysis related to the goal to improve Harry's health related to CKD"
        }
      ],
      "reference" : {
        "reference" : "http://example.org/Appointment/AVShunt",
        "display" : "PreOp Encounter Request For Creation of external arteriovenous shunt (procedure). Relates to overall health improvement goal and encounter requestActivity"
      }
    }
  ]
}