Care Coordination and 360 Referrals (Proof of Concept)
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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

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

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<CarePlan xmlns="http://hl7.org/fhir">
  <id value="CommunitySupportPlan"/>
  <meta>
    <profile
             value="https://fhir.acmeexample.org.uk/PatientCareCoordination/StructureDefinition/PatientCarePlan"/>
  </meta>
  <language value="en"/>
  <text>
    <status value="generated"/>
    <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>
  </text>
  <status value="active"/>
  <intent value="plan"/>
  <category>
    <text value="Community care and support plan"/>
  </category>
  <title value="Care and support after the virtual ward"/>
  <subject>🔗 
    <reference value="Patient/Patient-Manchester"/>
  </subject>
  <period>
    <start value="2026-10-13"/>
  </period>
  <author>🔗 
    <reference value="Organization/R0A"/>
  </author>
  <addresses>🔗 
    <reference value="Condition/ConditionCOPDExacerbation"/>
  </addresses>
  <supportingInfo>🔗 
    <reference value="QuestionnaireResponse/CareAssessmentResponse"/>
  </supportingInfo>
  <activity>
    <detail>
      <status value="scheduled"/>
      <description
                   value="Home care: help with washing and dressing each morning for 2 weeks (local authority reablement)."/>
    </detail>
  </activity>
  <activity>
    <detail>
      <status value="not-started"/>
      <description value="Referral to pulmonary rehabilitation."/>
    </detail>
  </activity>
  <activity>
    <detail>
      <status value="scheduled"/>
      <description
                   value="GP review in 2 weeks, including inhaler technique."/>
    </detail>
  </activity>
</CarePlan>