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Narrative

Note: links and images are rebased to the (stated) source

Source1

{
  "resourceType": "CarePlan",
  "id": "careplan-for-bundle",
  "meta": {
    "profile": [
      "http://hl7.org/fhir/us/mcc/StructureDefinition/mccCarePlan"
    ]
  },
  "text": {
    "status": "additional",
    "div": "<!-- snip (see above) -->"
  },
  "extension": [
    {
      "url": "http://hl7.org/fhir/us/mcc/StructureDefinition/custodian",
      "valueReference": {
        "reference": "Practitioner/practitionerMCC-3v",
        "display": "Dr. John Carlson"
      }
    }
  ],
  "status": "active",
  "intent": "plan",
  "category": [
    {
      "coding": [
        {
          "system": "http://snomed.info/sct",
          "code": "734163000",
          "display": "Care Plan"
        },
        {
          "system": "http://hl7.org/fhir/us/core/CodeSystem/careplan-category",
          "version": "6.1.0",
          "code": "assess-plan"
        }
      ]
    }
  ],
  "subject": {
    "reference": "Patient/cc-pat-pnoelle",
    "display": "Patricia Noelle"
  },
  "period": {
    "start": "2022-05-20"
  },
  "created": "2022-05-20",
  "contributor": [
    {
      "reference": "Practitioner/practitionerMCC-3v",
      "display": "Dr John Carlson, Primary Care Physician"
    },
    {
      "reference": "PractitionerRole/careCoordinator-1",
      "display": "Care-coordinator, served by Julie Smith"
    },
    {
      "reference": "Patient/cc-pat-pnoelle",
      "display": "Noelle"
    },
    {
      "reference": "PractitionerRole/dr-vince-jones",
      "display": "Nephrologist Role, served by Dr Vince Jones"
    },
    {
      "reference": "RelatedPerson/daughter1",
      "display": "Rose Noelle, Daughter"
    }
  ],
  "careTeam": [
    {
      "reference": "CareTeam/careteam-for-bundle",
      "display": "Long-COVID and CKD focused care team"
    }
  ],
  "addresses": [
    {
      "reference": "Condition/ConditionCKD",
      "display": "Chronic Kidney Disease"
    },
    {
      "reference": "Condition/encounter-diag-1",
      "display": "Long COVID"
    }
  ],
  "supportingInfo": [
    {
      "reference": "Observation/arterial-blood-gas-panel"
    },
    {
      "reference": "Observation/reduced-pain",
      "display": "Outcome example. Caregiver's observed thoughts on pain"
    },
    {
      "reference": "Condition/patient-health-concern-1",
      "display": "Patient Health Concern: Worry that Long Covid symptoms will effect CKD"
    },
    {
      "reference": "Condition/patient-health-concern-2",
      "display": "Patient Health Concern: Hard to exercise due to pain"
    },
    {
      "reference": "Condition/patient-health-concern-3",
      "display": "Patient Health Concern: Struggles to manage her diet and find affordable healthy food choices under her financial strain"
    },
    {
      "reference": "Condition/patient-health-concern-4",
      "display": "Patient Health Concern: Poor appetite for healthy CKD appropriate foods, likes cola, cake and chips"
    },
    {
      "reference": "Condition/careTeam-concerns-1",
      "display": "CareTeam Health Concern: Imbalanced Nutrition"
    },
    {
      "reference": "Condition/careTeam-concerns-2",
      "display": "CareTeam Health Concern: Dyspnea"
    },
    {
      "reference": "Condition/careTeam-concerns-3",
      "display": "CareTeam Health Concern: Pain in Legs"
    },
    {
      "reference": "Condition/careTeam-concerns-4",
      "display": "CareTeam Health Concern: Pain in Hands"
    },
    {
      "reference": "Condition/careTeam-concerns-5",
      "display": "CareTeam Health Concern: Pain in arms"
    },
    {
      "reference": "Condition/problem-list-1",
      "display": "Finding: Food aversion and cravings"
    },
    {
      "reference": "Condition/problem-list-2",
      "display": "Diagnosis: Metabolic acidosis"
    },
    {
      "reference": "Condition/chilblain-resolved",
      "display": "Long Covid related condition: Pustular chilblain resolved"
    },
    {
      "reference": "Observation/symptom2",
      "display": "Long Covid symptom: Dyspnea"
    },
    {
      "reference": "Observation/symptom3",
      "display": "Long Covid symptom: Pain in Legs"
    },
    {
      "reference": "Observation/symptom4",
      "display": "Long Covid symptom: Pain in hands"
    },
    {
      "reference": "Observation/symptom5",
      "display": "Long Covid symptom: Pain in arms"
    },
    {
      "reference": "Observation/symptom6",
      "display": "Long Covid symptom: Brain Fog - Intermittent confusion"
    },
    {
      "reference": "Observation/symptom7",
      "display": "Long Covid symptom: Brain Fog - Memory impairment"
    },
    {
      "reference": "Observation/symptom8",
      "display": "Long Covid symptom: Covid Toes - Toe swelling"
    },
    {
      "reference": "Observation/symptom9",
      "display": "Long Covid symptom: Covid Toes - Pustular chilblain"
    }
  ],
  "goal": [
    {
      "reference": "Goal/lower-pain-minimal-opioids",
      "display": "Lower pain with minimal opioids"
    },
    {
      "reference": "Goal/appetite-to-normal",
      "display": "Return appetite to normal"
    },
    {
      "reference": "Goal/electrolyte-protein-normal-range",
      "display": "Get Electrolyte and proteins back to normal"
    },
    {
      "reference": "Goal/bmi-normal-range",
      "display": "Get BMI into healthy range"
    },
    {
      "reference": "Goal/access-affordable-healthy-food",
      "display": "Improve access to affordable, healthy food"
    }
  ],
  "activity": [
    {
      "outcomeReference": [
        {
          "reference": "Procedure/dietitian-consult",
          "display": "Dietitian consult"
        },
        {
          "reference": "Observation/better-diet",
          "display": "Observation by caregiver (daughter) of improvement in diet"
        }
      ],
      "reference": {
        "reference": "ServiceRequest/dietitian-referral",
        "display": "Dietitian Referral"
      }
    },
    {
      "outcomeReference": [
        {
          "reference": "Procedure/dialysis-for-bundle"
        },
        {
          "reference": "Procedure/dialysis-for-bundle2"
        },
        {
          "reference": "Procedure/dialysis-for-bundle3"
        }
      ],
      "reference": {
        "reference": "ServiceRequest/dialysis-request"
      }
    },
    {
      "outcomeReference": [
        {
          "reference": "Procedure/ckd-app-education"
        }
      ]
    },
    {
      "outcomeReference": [
        {
          "reference": "MedicationRequest/med-for-chilblains",
          "display": "Treatment for chilblains"
        },
        {
          "reference": "Condition/chilblain-resolved"
        },
        {
          "reference": "ServiceRequest/pt-3x-wk",
          "display": "PT 3x per week"
        },
        {
          "reference": "ServiceRequest/counseling-1x-wk",
          "display": "Counseling 1x per week"
        },
        {
          "reference": "Task/meditation-7x-wk",
          "display": "Meditation 7x per week"
        },
        {
          "reference": "Observation/observation-moca",
          "display": "MOCA new result showing improvement"
        },
        {
          "reference": "Observation/observation-moca-original",
          "display": "MOCA initial result showing impairment"
        }
      ],
      "progress": [
        {
          "time": "2022-12-10",
          "text": "Long COVID symptoms improving"
        }
      ],
      "reference": {
        "reference": "ServiceRequest/long-covid-request",
        "display": "Long Covid Clinic Referral serviceRequest"
      }
    }
  ]
}