{ "resourceType": "CarePlan", "id": "ma-ma-schema-1-CarePlan-14001", "meta": { "lastUpdated": "2023-12-18T23:07:47Z", "source": "urn:telus:emr:ma:ma-schema-1", "security": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-Confidentiality", "code": "N", "display": "normal" } ] }, "text": { "status": "generated", "div": "

Generated Narrative: CarePlan ma-ma-schema-1-CarePlan-14001

Last updated: 2023-12-18 23:07:47+0000;

Information Source: urn:telus:emr:ma:ma-schema-1

Security Label: normal (Details: Confidentiality code N = 'normal')

identifier: urn:telus:emr:ma:ma-schema-1:CarePlan/14001 (use: official, )

status: Active

intent: Plan

category: Assessment and Plan of Treatment

title: Hypertension Management Care Plan

description: Comprehensive care plan for managing essential hypertension including lifestyle modifications, medication management, and regular monitoring.

subject: John Michael Smith

encounter: Encounter: identifier = urn:telus:emr:ma:ma-schema-1:Encounter#2001 (use: official, ); status = finished; class = ambulatory (ActCode#AMB); type = Patient encounter procedure; serviceType = General practice service; priority = routine; period = 2023-12-18 10:00:00+0000 --> 2023-12-18 10:45:00+0000; reasonCode = Follow-up encounter

period: 2023-12-18 --> 2024-12-18

created: 2023-12-18 10:40:00+0000

author: Dr. Sarah Johnson

careTeam: CareTeam Hypertension Management Care Team

addresses: Essential Hypertension

supportingInfo: Blood Pressure Reading

goal: Goal: identifier = urn:telus:emr:ma:ma-schema-1:Goal#14003 (use: official, ); lifecycleStatus = active; achievementStatus = In Progress; category = Physiotherapy; priority = High Priority; description = Blood pressure control; start[x] = 2023-12-18; statusDate = 2023-12-18; statusReason = Patient actively working toward goal with medication and lifestyle modifications; note = Patient understands importance of blood pressure control. Motivated to achieve target through medication adherence and lifestyle changes including diet and exercise.; outcomeCode = Patient's condition improved

activity

outcomeReference: MedicationRequest: identifier = urn:telus:emr:ma:ma-schema-1:MedicationRequest#8002 (use: official, ); status = active; intent = order; priority = routine; medication[x] = ->Amlodipine 5 mg Tablet; authoredOn = 2023-12-18 10:35:00+0000; note = Take once daily in the morning. Monitor blood pressure regularly.

Details

-KindCodeStatusPerformerDescription
*MedicationRequestMedication TherapyIn ProgressJohn Michael SmithContinue Amlodipine 5mg once daily for blood pressure control

activity

Details

-KindCodeStatusScheduled[x]Description
*TaskLifestyle ModificationsIn Progress5 per 1 weekMaintain low-sodium diet (less than 2000mg/day), regular aerobic exercise 30 minutes 5 days per week, maintain healthy weight

activity

Details

-KindCodeStatusScheduled[x]Description
*TaskHome Blood Pressure MonitoringIn Progress2 per 1 dayMonitor blood pressure at home twice daily (morning and evening). Record readings in log. Bring to follow-up appointments.

activity

outcomeReference: Appointment: identifier = urn:telus:emr:ma:ma-schema-1:Appointment#10001 (use: official, ); status = booked; serviceCategory = General Practice; serviceType = General practice service; specialty = Family practice; appointmentType = Follow-up; reasonCode = Follow-up encounter; priority = 5; description = Three-month follow-up appointment for hypertension monitoring. Review blood pressure logs and medication effectiveness.; start = 2024-03-18 10:00:00+0000; end = 2024-03-18 10:30:00+0000; minutesDuration = 30; created = 2023-12-18 10:40:00+0000; comment = Patient requested morning appointment. Bring current medication list and blood pressure log.; patientInstruction = Please bring your blood pressure log and current medication list. Arrive 10 minutes early to complete any necessary paperwork.; requestedPeriod = 2024-03-18 09:00:00+0000 --> 2024-03-18 12:00:00+0000

Details

-KindCodeStatusScheduled[x]PerformerDescription
*AppointmentFollow-up VisitScheduled2024-03-18 10:00:00+0000 --> 2024-03-18 10:30:00+0000Dr. Sarah JohnsonThree-month follow-up appointment to assess blood pressure control and medication effectiveness

note:

Patient motivated and engaged in care. Good understanding of hypertension management. Continue current approach with regular monitoring.

\n
" }, "identifier": [ { "use": "official", "system": "urn:telus:emr:ma:ma-schema-1:CarePlan", "value": "14001" } ], "status": "active", "intent": "plan", "category": [ { "coding": [ { "system": "http://hl7.org/fhir/us/core/CodeSystem/careplan-category", "code": "assess-plan", "display": "Assessment and Plan of Treatment" } ] } ], "title": "Hypertension Management Care Plan", "description": "Comprehensive care plan for managing essential hypertension including lifestyle modifications, medication management, and regular monitoring.", "subject": { "reference": "Patient/ma-ma-schema-1-Patient-12345", "type": "Patient", "display": "John Michael Smith" }, "encounter": { "reference": "Encounter/ma-ma-schema-1-Encounter-2001", "type": "Encounter" }, "period": { "start": "2023-12-18", "end": "2024-12-18" }, "created": "2023-12-18T10:40:00Z", "author": { "reference": "Practitioner/ma-ma-schema-1-Practitioner-789", "type": "Practitioner", "display": "Dr. Sarah Johnson" }, "careTeam": [ { "reference": "CareTeam/ma-ma-schema-1-CareTeam-14002", "type": "CareTeam" } ], "addresses": [ { "reference": "Condition/ma-ma-schema-1-Condition-problem-list-3001", "type": "Condition", "display": "Essential Hypertension" } ], "supportingInfo": [ { "reference": "Observation/ma-ma-schema-1-Observation-vitals-bp-5001", "type": "Observation", "display": "Blood Pressure Reading" } ], "goal": [ { "reference": "Goal/ma-ma-schema-1-Goal-14003", "type": "Goal" } ], "activity": [ { "outcomeReference": [ { "reference": "MedicationRequest/ma-ma-schema-1-MedicationRequest-8002", "type": "MedicationRequest" } ], "detail": { "kind": "MedicationRequest", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "182904002", "display": "Drug therapy" } ], "text": "Medication Therapy" }, "status": "in-progress", "performer": [ { "reference": "Patient/ma-ma-schema-1-Patient-12345", "type": "Patient", "display": "John Michael Smith" } ], "description": "Continue Amlodipine 5mg once daily for blood pressure control" } }, { "detail": { "kind": "Task", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "386463000", "display": "Prescribed activity/exercise education" } ], "text": "Lifestyle Modifications" }, "status": "in-progress", "scheduledTiming": { "repeat": { "frequency": 5, "period": 1, "periodUnit": "wk" } }, "description": "Maintain low-sodium diet (less than 2000mg/day), regular aerobic exercise 30 minutes 5 days per week, maintain healthy weight" } }, { "detail": { "kind": "Task", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "413153004", "display": "Blood pressure monitoring" } ], "text": "Home Blood Pressure Monitoring" }, "status": "in-progress", "scheduledTiming": { "repeat": { "frequency": 2, "period": 1, "periodUnit": "d" } }, "description": "Monitor blood pressure at home twice daily (morning and evening). Record readings in log. Bring to follow-up appointments." } }, { "outcomeReference": [ { "reference": "Appointment/ma-ma-schema-1-Appointment-10001", "type": "Appointment" } ], "detail": { "kind": "Appointment", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "390906007", "display": "Follow-up encounter" } ], "text": "Follow-up Visit" }, "status": "scheduled", "scheduledPeriod": { "start": "2024-03-18T10:00:00Z", "end": "2024-03-18T10:30:00Z" }, "performer": [ { "reference": "Practitioner/ma-ma-schema-1-Practitioner-789", "type": "Practitioner", "display": "Dr. Sarah Johnson" } ], "description": "Three-month follow-up appointment to assess blood pressure control and medication effectiveness" } } ], "note": [ { "text": "Patient motivated and engaged in care. Good understanding of hypertension management. Continue current approach with regular monitoring." } ] }