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Resource "integrate" Version "1" (CarePlan)

Tags:

XML or JSON representation . provenance for this resource

Patient family is not ready to commit to goal setting at this time. Goal setting will be addressed in the future

Start Date Goal Action Steps Status Date Last Updated Comments
10 Sep 2012 Eve will lose weight and reduce her GERDS symptoms by improving her diet Eve will review photos of high and low density foods and share with her parents New Goal 10 Sep 2012 9/10/12 Eve eats one meal a day with her parents
10 Sep 2012 Eve will lose weight and reduce her GERDS symptoms by improving her diet Eve will ask her dad to asist her to put the head of her bed on blocks New Goal 10 Sep 2012 9/10/12 Eve will sleep in her bed more often than the couch
10 Sep 2012 Eve will improve her GERDS symptoms Eve will reduce her intake of coffee and chocolate In Process 10 Sep 2012
27 Aug 2012 Eve will increase her energy by being more active Eve will walk her friend's dog up and down a big hill 15-30 minutes 3 days a week In Process 10 Sep 2012 8/27/12 Eve would like to try for 5 days a week. 9/10/12 Eve is still walking the dogs.
23 Jul 2012 Eve will increase her energy by being more active Eve will walk 3 blocks to her parents house twice a week In Process 10 Sep 2012 8/13/12 Eve walked 4 times the last week. 9/10/12 Eve did not walk to her parents the last week, but has plans to start again
23 Jul 2012 Eve will set up her medications and take as prescribed Eve will us a calendar to check off after medications are taken In Process 13 Aug 2012
23 Jul 2012 Eve will restart her light treatments Eve will use her lights MWF after her shower for 3 minutes In Process 27 Aug 2012 8/13/12 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. 8/27/12 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
10 Jul 2012 Eve will set up her medications and take as prescribed Eve will use a calendar of a chart to help her remember when to take her medications In Process 10 Sep 2012 7/23/12 Eve created a chart as a reminer to take the medications that do not fit in her pill box
23 Jul 2012 Eve will increase her energy by being more active Eve will start using stretch bands and one step 2 days a week Mon/Wed 6-7am and maybe Friday afternoon On-Hold 23 Aug 2012 7/30/12 will be able to esume exercise. 8/13/12 Eve prefers to focus on walking at this time
10 Jul 2012 Eve will set up her medications and take as prescribed Eve will match a printed medication worksheet with the medication bottles at home Completed 23 Jul 2012
10 Jul 2012 Eve will set up her medications and take as prescribed Eve will get a medication box to sort her pills. She will have one for scheduled medications and one for as needed Completed 16 Jul 2012 7/16/12 Eve now has some of her medications set up in pill packs by her pharmacist
23 Jul 2012 Eve will increase her energy by being more active Eve will open "The Firm" DVD workout package and listen to it Discontinued 13 Aug 2012 7/30/12 Eve will be able to resume exercise on 7/30/12. 8/13/12 -hold until "less busy"

{
  "resourceType" : "CarePlan",
  "id" : "integrate",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:33.020Z"
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Patient family is not ready to commit to goal setting at this time. Goal setting will be addressed in the future</p>\n <table>\n <thead>\n <tr>\n <th>Start Date</th>\n <th>Goal</th>\n <th>Action Steps</th>\n <th>Status</th>\n <th>Date Last Updated</th>\n <th>Comments</th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>10 Sep 2012</td>\n <td>Eve will lose weight and reduce her GERDS symptoms by improving her diet</td>\n <td>Eve will review photos of high and low density foods and share with her parents</td>\n <td>New Goal</td>\n <td>10 Sep 2012</td>\n <td>9/10/12 Eve eats one meal a day with her parents</td>\n </tr>\n <tr>\n <td>10 Sep 2012</td>\n <td>Eve will lose weight and reduce her GERDS symptoms by improving her diet</td>\n <td>Eve will ask her dad to asist her to put the head of her bed on blocks</td>\n <td>New Goal</td>\n <td>10 Sep 2012</td>\n <td>9/10/12 Eve will sleep in her bed more often than the couch</td>\n </tr>\n <tr>\n <td>10 Sep 2012</td>\n <td>Eve will improve her GERDS symptoms</td>\n <td>Eve will reduce her intake of coffee and chocolate</td>\n <td>In Process</td>\n <td>10 Sep 2012</td>\n <td/>\n </tr>\n <tr>\n <td>27 Aug 2012</td>\n <td>Eve will increase her energy by being more active</td>\n <td>Eve will walk her friend's dog up and down a big hill 15-30 minutes 3 days a week</td>\n <td>In Process</td>\n <td>10 Sep 2012</td>\n <td>8/27/12 Eve would like to try for 5 days a week. 9/10/12 Eve is still walking the dogs.</td>\n </tr>\n <tr>\n <td>23 Jul 2012</td>\n <td>Eve will increase her energy by being more active</td>\n <td>Eve will walk 3 blocks to her parents house twice a week</td>\n <td>In Process</td>\n <td>10 Sep 2012</td>\n <td>8/13/12 Eve walked 4 times the last week. 9/10/12 Eve did not walk to her parents the last week, but has plans to start again</td>\n </tr>\n <tr>\n <td>23 Jul 2012</td>\n <td>Eve will set up her medications and take as prescribed</td>\n <td>Eve will us a calendar to check off after medications are taken</td>\n <td>In Process</td>\n <td>13 Aug 2012</td>\n <td/>\n </tr>\n <tr>\n <td>23 Jul 2012</td>\n <td>Eve will restart her light treatments</td>\n <td>Eve will use her lights MWF after her shower for 3 minutes</td>\n <td>In Process</td>\n <td>27 Aug 2012</td>\n <td>8/13/12 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. 8/27/12 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</td>\n </tr>\n <tr>\n <td>10 Jul 2012</td>\n <td>Eve will set up her medications and take as prescribed</td>\n <td>Eve will use a calendar of a chart to help her remember when to take her medications</td>\n <td>In Process</td>\n <td>10 Sep 2012</td>\n <td>7/23/12 Eve created a chart as a reminer to take the medications that do not fit in her pill box</td>\n </tr>\n <tr>\n <td>23 Jul 2012</td>\n <td>Eve will increase her energy by being more active</td>\n <td>Eve will start using stretch bands and one step 2 days a week Mon/Wed 6-7am and maybe Friday afternoon</td>\n <td>On-Hold</td>\n <td>23 Aug 2012</td>\n <td>7/30/12 will be able to esume exercise. 8/13/12 Eve prefers to focus on walking at this time</td>\n </tr>\n <tr>\n <td>10 Jul 2012</td>\n <td>Eve will set up her medications and take as prescribed</td>\n <td>Eve will match a printed medication worksheet with the medication bottles at home</td>\n <td>Completed</td>\n <td>23 Jul 2012</td>\n <td/>\n </tr>\n <tr>\n <td>10 Jul 2012</td>\n <td>Eve will set up her medications and take as prescribed</td>\n <td>Eve will get a medication box to sort her pills. She will have one for scheduled medications and one for as needed</td>\n <td>Completed</td>\n <td>16 Jul 2012</td>\n <td>7/16/12 Eve now has some of her medications set up in pill packs by her pharmacist</td>\n </tr>\n <tr>\n <td>23 Jul 2012</td>\n <td>Eve will increase her energy by being more active</td>\n <td>Eve will open \"The Firm\" DVD workout package and listen to it</td>\n <td>Discontinued</td>\n <td>13 Aug 2012</td>\n <td>7/30/12 Eve will be able to resume exercise on 7/30/12. 8/13/12 -hold until \"less busy\"</td>\n </tr>\n </tbody>\n </table>\n </div>"
  },
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      "resourceType" : "Condition",
      "id" : "p1",
      "clinicalStatus" : {
        "coding" : [
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            "system" : "http://terminology.hl7.org/CodeSystem/condition-clinical",
            "code" : "active"
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      "verificationStatus" : {
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      "code" : {
        "text" : "GERDS"
      },
      "subject" : {
        "reference" : "Patient/1",
        "display" : "Eve Everywoman"
      }
    },
    {
      "resourceType" : "Condition",
      "id" : "p2",
      "clinicalStatus" : {
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      "verificationStatus" : {
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      },
      "code" : {
        "text" : "Obesity"
      },
      "subject" : {
        "reference" : "Patient/1",
        "display" : "Eve Everywoman"
      }
    },
    {
      "resourceType" : "Condition",
      "id" : "p3",
      "clinicalStatus" : {
        "coding" : [
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            "system" : "http://terminology.hl7.org/CodeSystem/condition-clinical",
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      },
      "verificationStatus" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/condition-ver-status",
            "code" : "confirmed"
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        ]
      },
      "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"
    }
  ],
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      "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"
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        "goal" : [
          {
            "reference" : "#g1"
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        "status" : "not-started",
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        "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" : {
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            "url" : "http://example.org/fhir/StructureDefinition/RevisionDate",
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        ],
        "goal" : [
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            "reference" : "#g2"
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        "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"
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        ],
        "goal" : [
          {
            "reference" : "#g3"
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        ],
        "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"
        }
      ],
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            "url" : "http://example.org/fhir/StructureDefinition/RevisionDate",
            "valueDate" : "2012-09-10"
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        "goal" : [
          {
            "reference" : "#g3"
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        "status" : "in-progress",
        "doNotPerform" : false,
        "scheduledPeriod" : {
          "start" : "2012-07-23"
        },
        "description" : "Eve will walk 3 blocks to her parents house twice a week"
      }
    },
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      "detail" : {
        "extension" : [
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            "url" : "http://example.org/fhir/StructureDefinition/RevisionDate",
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        ],
        "goal" : [
          {
            "reference" : "#g4"
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        "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"
        }
      ],
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            "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"
    }
  ]
}