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

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<CarePlan xmlns="http://hl7.org/fhir">
  <!--   Example adapted from MCC eCare Plan Implementation Guide MCCCarePlan   -->
  <id value="mcc"/>
  <meta>
    <versionId value="5"/>
    <lastUpdated value="2022-11-16T23:03:27.124+00:00"/>
    <source value="#lh8xM5mIbbHVNz84"/>
    <profile
             value="http://hl7.org.au/fhir/core/StructureDefinition/au-core-careplan"/>
  </meta>
  <text>
    <status value="generated"/>
    <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>
  </text>
  <status value="active"/>
  <intent value="plan"/>
  <!--  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>  -->
  <category>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="734163000"/>
      <display value="Care Plan"/>
    </coding>
  </category>
  <subject>
    <reference value="Patient/dan-harry"/>
  </subject>
  <period>
    <start value="2018-05-01"/>
  </period>
  <created value="2019-01-01"/>
  <author>
    <reference value="PractitionerRole/np-nurse-nancy"/>
    <display value="Nancy Nurse RN"/>
  </author>
  <contributor>
    <reference value="PractitionerRole/nephrologist-levin-henry"/>
    <display value="Henry Levin VII MD Nephrologist"/>
  </contributor>
  <contributor>
    <reference value="PractitionerRole/np-nurse-nancy"/>
    <display value="Nancy Nurse RN"/>
  </contributor>
  <contributor>
    <reference value="PractitionerRole/gp-primary-peter"/>
    <display value="Peter Primary MD Primary Provider"/>
  </contributor>
  <careTeam>
    <reference value="CareTeam/mcc"/>
    <display value="Longitudinal care-coordination focused care team"/>
  </careTeam>
  <addresses>
    <reference value="Condition/ckd"/>
    <display value="Chronic Kidney Disease"/>
  </addresses>
  <supportingInfo>
    <reference value="Procedure/dialysis"/>
    <display value="Chronic Pain"/>
  </supportingInfo>
  <supportingInfo>
    <reference value="Observation/bun-mcc"/>
    <display value="BUN 24 mL/min/{1.73_m2}"/>
  </supportingInfo>
  <goal>
    <reference value="Goal/wgt-loss"/>
    <display
             value="Lose weight, decrease chronic pain with less use of pain medication and improved lab results"/>
  </goal>
  <activity>
    <outcomeReference>
      <reference value="Procedure/dialysis"/>
      <display value="Dialysis"/>
    </outcomeReference>
    <progress>
      <time value="2019-01-10"/>
      <text value="Harry Dan is measuring weight daily"/>
    </progress>
    <reference>
      <reference value="http://example.org/Task/123"/>
      <display value="Harry Dan or caregiver to perform daily weights"/>
    </reference>
  </activity>
  <activity>
    <outcomeReference>
      <reference value="http://example.org/Encounter/123"/>
      <display
               value="PreOp Encounter For Creation of external arteriovenous shunt (procedure)"/>
    </outcomeReference>
    <outcomeReference>
      <reference value="http://example.org/Procedure/upperlimbveinUS"/>
      <display
               value="Fluoroscopic venography of bilateral upper limbs Performed. Results: Normal"/>
    </outcomeReference>
    <progress>
      <time value="2019-01-10"/>
      <text
            value="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"/>
    </progress>
    <reference>
      <reference value="http://example.org/Appointment/AVShunt"/>
      <display
               value="PreOp Encounter Request For Creation of external arteriovenous shunt (procedure). Relates to overall health improvement goal and encounter requestActivity"/>
    </reference>
  </activity>
</CarePlan>