Care Coordination and 360 Referrals (Proof of Concept) - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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: Care Plan - community care and support (from the care assessment)

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

<http://hl7.org/fhir/CarePlan/CommunitySupportPlan> a fhir:CarePlan ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:Resource.id [ fhir:value "CommunitySupportPlan"] ;
  fhir:Resource.meta [
     fhir:Meta.profile [
       fhir:value "https://fhir.acmeexample.org.uk/PatientCareCoordination/StructureDefinition/PatientCarePlan" ;
       fhir:index -1 ;
       fhir:link <https://fhir.acmeexample.org.uk/PatientCareCoordination/StructureDefinition/PatientCarePlan>
     ]
  ] ;
  fhir:Resource.language [ fhir:value "en"] ;
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ] ;
     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: CarePlan CommunitySupportPlan</b></p><a name=\"CommunitySupportPlan\"> </a><a name=\"hcCommunitySupportPlan\"> </a><div style=\"display: inline-block; background-color: #fbffeb; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-PatientCarePlan.html\">Care Plan</a></p></div><p><b>status</b>: Active</p><p><b>intent</b>: Plan</p><p><b>category</b>: <span title=\"Codes:\">Community care and support plan</span></p><p><b>title</b>: Care and support after the virtual ward</p><p><b>subject</b>: <a href=\"Patient-Patient-Manchester.html\">Sansa MANCHESTER  Female, DoB: 1972-09-21 ( National Health Plan Identifier: NHS Number#9737383192)</a></p><p><b>period</b>: 2026-10-13 --&gt; (ongoing)</p><p><b>author</b>: <a href=\"Organization-R0A.html\">Manchester University NHS Foundation Trust (https://fhir.nhs.uk/Id/ods-organization-code#ODS Organisation Code#R0A)</a></p><p><b>addresses</b>: <a href=\"Condition-ConditionCOPDExacerbation.html\">Condition Acute exacerbation of chronic obstructive airways disease</a></p><p><b>supportingInfo</b>: <a href=\"QuestionnaireResponse-CareAssessmentResponse.html\">Response to Questionnaire '-&gt;Care Assessment' about '-&gt;Sansa MANCHESTER  Female, DoB: 1972-09-21 ( National Health Plan Identifier: NHS Number#9737383192)'</a></p><blockquote><p><b>activity</b></p><h3>Details</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Status</b></td><td><b>Description</b></td></tr><tr><td style=\"display: none\">*</td><td>Scheduled</td><td>Home care: help with washing and dressing each morning for 2 weeks (local authority reablement).</td></tr></table></blockquote><blockquote><p><b>activity</b></p><h3>Details</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Status</b></td><td><b>Description</b></td></tr><tr><td style=\"display: none\">*</td><td>Not Started</td><td>Referral to pulmonary rehabilitation.</td></tr></table></blockquote><blockquote><p><b>activity</b></p><h3>Details</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Status</b></td><td><b>Description</b></td></tr><tr><td style=\"display: none\">*</td><td>Scheduled</td><td>GP review in 2 weeks, including inhaler technique.</td></tr></table></blockquote></div>"
  ] ;
  fhir:CarePlan.status [ fhir:value "active"] ;
  fhir:CarePlan.intent [ fhir:value "plan"] ;
  fhir:CarePlan.category [
     fhir:index -1 ;
     fhir:CodeableConcept.text [ fhir:value "Community care and support plan" ]
  ] ;
  fhir:CarePlan.title [ fhir:value "Care and support after the virtual ward"] ;
  fhir:CarePlan.subject [
     fhir:link <http://hl7.org/fhir/Patient/Patient-Manchester> ;
     fhir:Reference.reference [ fhir:value "Patient/Patient-Manchester" ]
  ] ;
  fhir:CarePlan.period [
     fhir:Period.start [ fhir:value "2026-10-13"^^xsd:date ]
  ] ;
  fhir:CarePlan.author [
     fhir:link <http://hl7.org/fhir/Organization/R0A> ;
     fhir:Reference.reference [ fhir:value "Organization/R0A" ]
  ] ;
  fhir:CarePlan.addresses [
     fhir:index -1 ;
     fhir:link <http://hl7.org/fhir/Condition/ConditionCOPDExacerbation> ;
     fhir:Reference.reference [ fhir:value "Condition/ConditionCOPDExacerbation" ]
  ] ;
  fhir:CarePlan.supportingInfo [
     fhir:index -1 ;
     fhir:link <http://hl7.org/fhir/QuestionnaireResponse/CareAssessmentResponse> ;
     fhir:Reference.reference [ fhir:value "QuestionnaireResponse/CareAssessmentResponse" ]
  ] ;
  fhir:CarePlan.activity [
     fhir:index -1 ;
     fhir:CarePlan.activity.detail [
       fhir:CarePlan.activity.detail.status [ fhir:value "scheduled" ] ;
       fhir:CarePlan.activity.detail.description [ fhir:value "Home care: help with washing and dressing each morning for 2 weeks (local authority reablement)." ]
     ]
  ], [
     fhir:index -1 ;
     fhir:CarePlan.activity.detail [
       fhir:CarePlan.activity.detail.status [ fhir:value "not-started" ] ;
       fhir:CarePlan.activity.detail.description [ fhir:value "Referral to pulmonary rehabilitation." ]
     ]
  ], [
     fhir:index -1 ;
     fhir:CarePlan.activity.detail [
       fhir:CarePlan.activity.detail.status [ fhir:value "scheduled" ] ;
       fhir:CarePlan.activity.detail.description [ fhir:value "GP review in 2 weeks, including inhaler technique." ]
     ]
  ] .

<http://hl7.org/fhir/Patient/Patient-Manchester> a fhir:Patient .

<http://hl7.org/fhir/Organization/R0A> a fhir:Organization .

<http://hl7.org/fhir/Condition/ConditionCOPDExacerbation> a fhir:Condition .

<http://hl7.org/fhir/QuestionnaireResponse/CareAssessmentResponse> a fhir:QuestionnaireResponse .

# - ontology header ------------------------------------------------------------

<http://hl7.org/fhir/CarePlan/CommunitySupportPlan.ttl> a owl:Ontology ;
  owl:imports fhir:fhir.ttl ;
  owl:versionIRI <http://build.fhir.org/CarePlan/CommunitySupportPlan.ttl> .