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

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix sct: <http://snomed.info/id/> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir: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 <http://hl7.org.au/fhir/core/StructureDefinition/au-core-careplan>     ] )
  ] ; # 
  fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir: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>"
  ] ; # 
  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
#    <coding>
#      <system value="http://hl7.org/fhir/us/core/CodeSystem/careplan-category"/>
#      <code value="assess-plan"/>
#    </coding> 
  fhir:subject [
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:reference [ fhir:v "PractitionerRole/np-nurse-nancy" ] ;
fhir:display [ fhir:v "Nancy Nurse RN" ]
  ] ; # 
  fhir:contributor ( [
fhir:reference [ fhir:v "PractitionerRole/nephrologist-levin-henry" ] ;
fhir:display [ fhir:v "Henry Levin VII MD Nephrologist" ]
  ] [
fhir:reference [ fhir:v "PractitionerRole/np-nurse-nancy" ] ;
fhir:display [ fhir:v "Nancy Nurse RN" ]
  ] [
fhir:reference [ fhir:v "PractitionerRole/gp-primary-peter" ] ;
fhir:display [ fhir:v "Peter Primary MD Primary Provider" ]
  ] ) ; # 
  fhir:careTeam ( [
fhir:reference [ fhir:v "CareTeam/mcc" ] ;
fhir:display [ fhir:v "Longitudinal care-coordination focused care team" ]
  ] ) ; # 
  fhir:addresses ( [
fhir:reference [ fhir:v "Condition/ckd" ] ;
fhir:display [ fhir:v "Chronic Kidney Disease" ]
  ] ) ; # 
  fhir:supportingInfo ( [
fhir:reference [ fhir:v "Procedure/dialysis" ] ;
fhir:display [ fhir:v "Chronic Pain" ]
  ] [
fhir:reference [ fhir:v "Observation/bun-mcc" ] ;
fhir:display [ fhir:v "BUN 24 mL/min/{1.73_m2}" ]
  ] ) ; # 
  fhir:goal ( [
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: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 <http://example.org/Task/123> ;
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 <http://example.org/Encounter/123> ;
fhir:reference [ fhir:v "http://example.org/Encounter/123" ] ;
fhir:display [ fhir:v "PreOp Encounter For Creation of external arteriovenous shunt (procedure)" ]     ] [
fhir:link <http://example.org/Procedure/upperlimbveinUS> ;
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 <http://example.org/Appointment/AVShunt> ;
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" ]     ]
  ] ) . #