{
"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" } ] }
}