<?xml version=“1.0” encoding=“UTF-8”?> <CarePlan xmlns=“hl7.org/fhir”>

<id value="integrate"/>
<meta>
  <security>
    <system value="http://terminology.hl7.org/CodeSystem/v3-ActReason"/>
    <code value="HTEST"/>
    <display value="test health data"/>
  </security>
</meta>

<contained>
  <!--  Conditions could be further encoded and detailed.  
    Could also be handled as references to external resources.
    And not essential to have them captured at all.
    For purposes of example, will represent this way.  -->
  <Condition>
    <id value="p1"/>
    <clinicalStatus>
              <coding>
                <system value="http://terminology.hl7.org/CodeSystem/condition-clinical"/>
                <code value="active"/>
              </coding>
        </clinicalStatus>

        <verificationStatus>
              <coding>
                <system value="http://terminology.hl7.org/CodeSystem/condition-ver-status"/>
                <code value="confirmed"/>
              </coding>
        </verificationStatus>
    <code>
      <text value="GERDS"/>
    </code>
    <subject>
      <reference value="Patient/1"/>
      <display value="Eve Everywoman"/>
    </subject>
  </Condition>
</contained>
<contained>
  <Condition>
    <id value="p2"/>
    <clinicalStatus>
              <coding>
                <system value="http://terminology.hl7.org/CodeSystem/condition-clinical"/>
                <code value="active"/>
              </coding>
        </clinicalStatus>

        <verificationStatus>
              <coding>
                <system value="http://terminology.hl7.org/CodeSystem/condition-ver-status"/>
                <code value="confirmed"/>
              </coding>
        </verificationStatus>
    <code>
      <text value="Obesity"/>
    </code>
    <subject>
      <reference value="Patient/1"/>
      <display value="Eve Everywoman"/>
    </subject>
  </Condition>
</contained>
<contained>
  <Condition>
    <id value="p3"/>
    <clinicalStatus>
              <coding>
                <system value="http://terminology.hl7.org/CodeSystem/condition-clinical"/>
                <code value="active"/>
              </coding>
        </clinicalStatus>

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

</CarePlan>