@prefix fhir: . @prefix owl: . @prefix rdfs: . @prefix sct: . @prefix xsd: . # - resource ------------------------------------------------------------------- a fhir:CarePlan ; fhir:nodeRole fhir:treeRoot ; fhir:id [ fhir:v "mcc"] ; # Example adapted from MCC eCare Plan Implementation Guide MCCCarePlan fhir:meta [ fhir:versionId [ fhir:v "5" ] ; fhir:lastUpdated [ fhir:v "2022-11-16T23:03:27.124+00:00"^^xsd:dateTime ] ; fhir:source [ fhir:v "#lh8xM5mIbbHVNz84"^^xsd:anyURI ] ; fhir:profile ( [ fhir:v "http://hl7.org.au/fhir/core/StructureDefinition/au-core-careplan"^^xsd:anyURI ; fhir:link ] ) ] ; # fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "

Generated Narrative: CarePlan

Resource CarePlan "mcc" Version "5" Updated "2022-11-16 23:03:27+0000"

Information Source: #lh8xM5mIbbHVNz84!

Profile: AU Core CarePlan

status: active

intent: plan

category: Care Plan (SNOMED CT#734163000)

subject: Patient/dan-harry " DAN"

period: 2018-05-01 --> (ongoing)

created: 2019-01-01

author: PractitionerRole/np-nurse-nancy: Nancy Nurse RN

contributor:

careTeam: CareTeam/mcc: Longitudinal care-coordination focused care team "Example Multiple Chronic Condition Care Team"

addresses: Condition/ckd: Chronic Kidney Disease

supportingInfo:

goal: Goal/wgt-loss: Lose weight, decrease chronic pain with less use of pain medication and improved lab results

activity
outcomeReference: Procedure/dialysis: Dialysis
progress: Harry Dan is measuring weight daily ( @2019-01-10)
reference: http://example.org/Task/123: Harry Dan or caregiver to perform daily weights

activity
outcomeReference:
http://example.org/Encounter/123: PreOp Encounter For Creation of external arteriovenous shunt (procedure)
http://example.org/Procedure/upperlimbveinUS: Fluoroscopic venography of bilateral upper limbs Performed. Results: Normal
progress: 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)
reference: http://example.org/Appointment/AVShunt: PreOp Encounter Request For Creation of external arteriovenous shunt (procedure). Relates to overall health improvement goal and encounter requestActivity

" ] ; # fhir:status [ fhir:v "active"] ; # fhir:intent [ fhir:v "plan"] ; # fhir:category ( [ fhir:coding ( [ a sct:734163000 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ; fhir:code [ fhir:v "734163000" ] ; fhir:display [ fhir:v "Care 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 # # #

 
  fhir:subject [
     fhir:link  ;
     fhir:reference [ fhir:v "Patient/dan-harry" ]
  ] ; # 
  fhir:period [
     fhir:start [ fhir:v "2018-05-01"^^xsd:date ]
  ] ; # 
  fhir:created [ fhir:v "2019-01-01"^^xsd:date] ; # 
  fhir:author [
     fhir:link  ;
     fhir:reference [ fhir:v "PractitionerRole/np-nurse-nancy" ] ;
     fhir:display [ fhir:v "Nancy Nurse RN" ]
  ] ; # 
  fhir:contributor ( [
     fhir:link  ;
     fhir:reference [ fhir:v "PractitionerRole/nephrologist-levin-henry" ] ;
     fhir:display [ fhir:v "Henry Levin VII MD Nephrologist" ]
  ] [
     fhir:link  ;
     fhir:reference [ fhir:v "PractitionerRole/np-nurse-nancy" ] ;
     fhir:display [ fhir:v "Nancy Nurse RN" ]
  ] [
     fhir:link  ;
     fhir:reference [ fhir:v "PractitionerRole/gp-primary-peter" ] ;
     fhir:display [ fhir:v "Peter Primary MD Primary Provider" ]
  ] ) ; # 
  fhir:careTeam ( [
     fhir:link  ;
     fhir:reference [ fhir:v "CareTeam/mcc" ] ;
     fhir:display [ fhir:v "Longitudinal care-coordination focused care team" ]
  ] ) ; # 
  fhir:addresses ( [
     fhir:link  ;
     fhir:reference [ fhir:v "Condition/ckd" ] ;
     fhir:display [ fhir:v "Chronic Kidney Disease" ]
  ] ) ; # 
  fhir:supportingInfo ( [
     fhir:link  ;
     fhir:reference [ fhir:v "Procedure/dialysis" ] ;
     fhir:display [ fhir:v "Chronic Pain" ]
  ] [
     fhir:link  ;
     fhir:reference [ fhir:v "Observation/bun-mcc" ] ;
     fhir:display [ fhir:v "BUN 24 mL/min/{1.73_m2}" ]
  ] ) ; # 
  fhir:goal ( [
     fhir:link  ;
     fhir:reference [ fhir:v "Goal/wgt-loss" ] ;
     fhir:display [ fhir:v "Lose weight, decrease chronic pain with less use of pain medication and improved lab results" ]
  ] ) ; # 
  fhir:activity ( [
     fhir:outcomeReference ( [
       fhir:link  ;
       fhir:reference [ fhir:v "Procedure/dialysis" ] ;
       fhir:display [ fhir:v "Dialysis" ]
     ] ) ;
     fhir:progress ( [
       fhir:time [ fhir:v "2019-01-10"^^xsd:date ] ;
       fhir:text [ fhir:v "Harry Dan is measuring weight daily" ]
     ] ) ;
     fhir:reference [
       fhir:link  ;
       fhir:reference [ fhir:v "http://example.org/Task/123" ] ;
       fhir:display [ fhir:v "Harry Dan or caregiver to perform daily weights" ]
     ]
  ] [
     fhir:outcomeReference ( [
       fhir:link  ;
       fhir:reference [ fhir:v "http://example.org/Encounter/123" ] ;
       fhir:display [ fhir:v "PreOp Encounter For Creation of external arteriovenous shunt (procedure)" ]
     ] [
       fhir:link  ;
       fhir:reference [ fhir:v "http://example.org/Procedure/upperlimbveinUS" ] ;
       fhir:display [ fhir:v "Fluoroscopic venography of bilateral upper limbs Performed. Results: Normal" ]
     ] ) ;
     fhir:progress ( [
       fhir:time [ fhir:v "2019-01-10"^^xsd:date ] ;
       fhir:text [ fhir:v "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" ]
     ] ) ;
     fhir:reference [
       fhir:link  ;
       fhir:reference [ fhir:v "http://example.org/Appointment/AVShunt" ] ;
       fhir:display [ fhir:v "PreOp Encounter Request For Creation of external arteriovenous shunt (procedure). Relates to overall health improvement goal and encounter requestActivity" ]
     ]
  ] ) . # 

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