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

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

- Kind Code Status Performer Description

* MedicationRequest Medication Therapy In Progress John Michael Smith Continue Amlodipine 5mg once daily for blood pressure control

activity

Details

- Kind Code Status Scheduled[x] Description

* Task Lifestyle Modifications In Progress 5 per 1 week Maintain low-sodium diet (less than 2000mg/day), regular aerobic exercise 30 minutes 5 days per week, maintain healthy weight

activity

Details

- Kind Code Status Scheduled[x] Description

* Task Home Blood Pressure Monitoring In Progress 2 per 1 day Monitor 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

- Kind Code Status Scheduled[x] Performer Description

* Appointment Follow-up Visit Scheduled 2024-03-18 10:00:00+0000 --> 2024-03-18 10:30:00+0000 Dr. Sarah Johnson Three-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.