{

"resourceType": "CarePlan",
"id": "integrate",
"contained": [
  {
    "resourceType": "Condition",
    "id": "p1",
    "clinicalStatus": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
          "code": "active"
        }
      ]
    },
    "verificationStatus": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
          "code": "confirmed"
        }
      ]
    },
    "code": {
      "text": "GERDS"
    },
    "subject": {
      "reference": "Patient/1",
      "display": "Eve Everywoman"
    }
  },
  {
    "resourceType": "Condition",
    "id": "p2",
    "clinicalStatus": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
          "code": "active"
        }
      ]
    },
    "verificationStatus": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
          "code": "confirmed"
        }
      ]
    },
    "code": {
      "text": "Obesity"
    },
    "subject": {
      "reference": "Patient/1",
      "display": "Eve Everywoman"
    }
  },
  {
    "resourceType": "Condition",
    "id": "p3",
    "clinicalStatus": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
          "code": "active"
        }
      ]
    },
    "verificationStatus": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
          "code": "confirmed"
        }
      ]
    },
    "code": {
      "text": "Psoriasis"
    },
    "subject": {
      "reference": "Patient/1",
      "display": "Eve Everywoman"
    }
  },
  {
    "resourceType": "Goal",
    "id": "g1",
    "lifecycleStatus": "active",
    "description": {
      "text": "Eve will lose weight and reduce her GERDS symptoms by improving her diet"
    },
    "subject": {
      "reference": "Patient/1",
      "display": "Eve Everywoman"
    }
  },
  {
    "resourceType": "Goal",
    "id": "g2",
    "lifecycleStatus": "active",
    "description": {
      "text": "Eve will improve her GERDS symptoms"
    },
    "subject": {
      "reference": "Patient/1",
      "display": "Eve Everywoman"
    }
  },
  {
    "resourceType": "Goal",
    "id": "g3",
    "lifecycleStatus": "active",
    "description": {
      "text": "Eve will increase her energy by being more active"
    },
    "subject": {
      "reference": "Patient/1",
      "display": "Eve Everywoman"
    }
  },
  {
    "resourceType": "Goal",
    "id": "g4",
    "lifecycleStatus": "active",
    "description": {
      "text": "Eve will set up her medications and take as prescribed"
    },
    "subject": {
      "reference": "Patient/1",
      "display": "Eve Everywoman"
    }
  },
  {
    "resourceType": "Goal",
    "id": "g5",
    "lifecycleStatus": "active",
    "description": {
      "text": "Eve will restart her light treatments"
    },
    "subject": {
      "reference": "Patient/1",
      "display": "Eve Everywoman"
    }
  }
],
"status": "active",
"intent": "plan",
"subject": {
  "reference": "Patient/1",
  "display": "Eve Everywoman"
},
"addresses": [
  {
    "reference": "#p1",
    "display": "GERDS"
  },
  {
    "reference": "#p2",
    "display": "Obesity"
  },
  {
    "reference": "#p3",
    "display": "Psoriasis"
  }
],
"goal": [
  {
    "reference": "#g1"
  },
  {
    "reference": "#g2"
  },
  {
    "reference": "#g3"
  },
  {
    "reference": "#g4"
  },
  {
    "reference": "#g5"
  }
],
"activity": [
  {
    "progress": [
      {
        "time": "2012-09-10",
        "text": "Eve eats one meal a day with her parents"
      }
    ],
    "detail": {
      "extension": [
        {
          "url": "http://example.org/fhir/StructureDefinition/RevisionDate",
          "valueDate": "2012-09-10"
        }
      ],
      "goal": [
        {
          "reference": "#g1"
        }
      ],
      "status": "not-started",
      "doNotPerform": false,
      "scheduledPeriod": {
        "start": "2012-09-10"
      },
      "description": "Eve will review photos of high and low density foods and share with her parents"
    }
  },
  {
    "progress": [
      {
        "time": "2012-09-10",
        "text": "Eve will sleep in her bed more often than the couch"
      }
    ],
    "detail": {
      "extension": [
        {
          "url": "http://example.org/fhir/StructureDefinition/RevisionDate",
          "valueDate": "2012-09-10"
        }
      ],
      "kind": "CommunicationRequest",
      "goal": [
        {
          "reference": "#g1"
        }
      ],
      "status": "not-started",
      "doNotPerform": false,
      "scheduledPeriod": {
        "start": "2012-09-10"
      },
      "description": "Eve will ask her dad to asist her to put the head of her bed on blocks"
    }
  },
  {
    "detail": {
      "extension": [
        {
          "url": "http://example.org/fhir/StructureDefinition/RevisionDate",
          "valueDate": "2012-09-10"
        }
      ],
      "goal": [
        {
          "reference": "#g2"
        }
      ],
      "status": "in-progress",
      "doNotPerform": false,
      "scheduledPeriod": {
        "start": "2012-09-10"
      },
      "description": "Eve will reduce her intake of coffee and chocolate"
    }
  },
  {
    "progress": [
      {
        "time": "2012-08-27",
        "text": "Eve would like to try for 5 days a week."
      },
      {
        "time": "2012-09-10",
        "text": "Eve is still walking the dogs."
      }
    ],
    "detail": {
      "extension": [
        {
          "url": "http://example.org/fhir/StructureDefinition/RevisionDate",
          "valueDate": "2012-09-10"
        }
      ],
      "goal": [
        {
          "reference": "#g3"
        }
      ],
      "status": "in-progress",
      "doNotPerform": false,
      "scheduledPeriod": {
        "start": "2012-08-27"
      },
      "description": "Eve will walk her friend's dog up and down a big hill 15-30 minutes 3 days a week"
    }
  },
  {
    "progress": [
      {
        "time": "2012-08-13",
        "text": "Eve walked 4 times the last week."
      },
      {
        "time": "2012-09-10",
        "text": "Eve did not walk to her parents the last week, but has plans to start again"
      }
    ],
    "detail": {
      "extension": [
        {
          "url": "http://example.org/fhir/StructureDefinition/RevisionDate",
          "valueDate": "2012-09-10"
        }
      ],
      "goal": [
        {
          "reference": "#g3"
        }
      ],
      "status": "in-progress",
      "doNotPerform": false,
      "scheduledPeriod": {
        "start": "2012-07-23"
      },
      "description": "Eve will walk 3 blocks to her parents house twice a week"
    }
  },
  {
    "detail": {
      "extension": [
        {
          "url": "http://example.org/fhir/StructureDefinition/RevisionDate",
          "valueDate": "2012-08-13"
        }
      ],
      "goal": [
        {
          "reference": "#g4"
        }
      ],
      "status": "in-progress",
      "doNotPerform": false,
      "scheduledPeriod": {
        "start": "2012-07-23"
      },
      "description": "Eve will use a calendar to check off after medications are taken"
    }
  },
  {
    "progress": [
      {
        "time": "2012-08-13",
        "text": "After restarting the vinegar soaks the psoriasis is improved and Eve plans to treat the remainder with light treatments.  She plans to start this week."
      },
      {
        "time": "2012-08-27",
        "text": "Since her skin is improved Eve has not been using the light treatment as often, maybe once a week.  She would like to increase to 3 times a week again"
      }
    ],
    "detail": {
      "extension": [
        {
          "url": "http://example.org/fhir/StructureDefinition/RevisionDate",
          "valueDate": "2012-08-27"
        }
      ],
      "goal": [
        {
          "reference": "#g5"
        }
      ],
      "status": "in-progress",
      "doNotPerform": false,
      "scheduledPeriod": {
        "start": "2012-07-23"
      },
      "description": "Eve will use her lights MWF after her shower for 3 minutes"
    }
  },
  {
    "progress": [
      {
        "time": "2012-07-23",
        "text": "Eve created a chart as a reminer to take the medications that do not fit in her pill box"
      }
    ],
    "detail": {
      "extension": [
        {
          "url": "http://example.org/fhir/StructureDefinition/RevisionDate",
          "valueDate": "2012-09-10"
        }
      ],
      "goal": [
        {
          "reference": "#g4"
        }
      ],
      "status": "in-progress",
      "doNotPerform": false,
      "scheduledPeriod": {
        "start": "2012-07-10"
      },
      "description": "Eve will use a calendar of a chart to help her remember when to take her medications"
    }
  },
  {
    "progress": [
      {
        "time": "2012-07-30",
        "text": "Will be able to esume exercise."
      },
      {
        "time": "2012-08-13",
        "text": "Eve prefers to focus on walking at this time"
      }
    ],
    "detail": {
      "extension": [
        {
          "url": "http://example.org/fhir/StructureDefinition/RevisionDate",
          "valueDate": "2012-08-23"
        }
      ],
      "goal": [
        {
          "reference": "#g3"
        }
      ],
      "status": "on-hold",
      "doNotPerform": false,
      "scheduledPeriod": {
        "start": "2012-07-23"
      },
      "description": "Eve will start using stretch bands and one step 2 days a week Mon/Wed 6-7am and maybe Friday afternoon"
    }
  },
  {
    "detail": {
      "extension": [
        {
          "url": "http://example.org/fhir/StructureDefinition/RevisionDate",
          "valueDate": "2012-07-23"
        }
      ],
      "goal": [
        {
          "reference": "#g4"
        }
      ],
      "status": "completed",
      "doNotPerform": false,
      "scheduledPeriod": {
        "start": "2012-07-10"
      },
      "description": "Eve will match a printed medication worksheet with the medication bottles at home"
    }
  },
  {
    "progress": [
      {
        "time": "2012-07-16",
        "text": "Eve now has some of her medications set up in pill packs by her pharmacist"
      }
    ],
    "detail": {
      "extension": [
        {
          "url": "http://example.org/fhir/StructureDefinition/RevisionDate",
          "valueDate": "2012-07-16"
        }
      ],
      "goal": [
        {
          "reference": "#g4"
        }
      ],
      "status": "completed",
      "doNotPerform": false,
      "scheduledPeriod": {
        "start": "2012-07-10"
      },
      "description": "Eve will get a medication box to sort her pills.  She will have one for scheduled medications and one for as needed"
    }
  },
  {
    "progress": [
      {
        "time": "2012-07-12",
        "text": "Eve will be able to resume exercise on 7/30/12"
      },
      {
        "time": "2012-08-13",
        "text": "hold until \"less busy\""
      }
    ],
    "detail": {
      "extension": [
        {
          "url": "http://example.org/fhir/StructureDefinition/RevisionDate",
          "valueDate": "2012-08-13"
        }
      ],
      "goal": [
        {
          "reference": "#g3"
        }
      ],
      "status": "on-hold",
      "doNotPerform": false,
      "scheduledPeriod": {
        "start": "2012-07-23"
      },
      "description": "Eve will open \"The Firm\" DVD workout package and listen to it"
    }
  }
],
"note": [
  {
    "text": "Patient family is not ready to commit to goal setting at this time.  Goal setting will be addressed in the future"
  }
],
"meta": {
  "tag": [
    {
      "system": "http://terminology.hl7.org/CodeSystem/v3-ActReason",
      "code": "HTEST",
      "display": "test health data"
    }
  ]
}

}