{"resourceType":"PlanDefinition","id":"RPMHeartFailureCarePlanTemplate","language":"en-NZ","url":"https://build.fhir.org/ig/tewhatuora/cinc-fhir-ig/PlanDefinition/RemoteMonitoringHeartFailureCarePlanTemplate","identifier":[{"use":"official","value":"RemoteMonitoringHeartFailureCarePlanTemplate"}],"version":"0.1.6","name":"RemoteMonitoringHeartFailureCarePlanTemplate","title":"Template for Remote Monitoring Heart Failure Care Plan","subtitle":"Care in the Community plans to handle heart failure patients remotely in an ongoing capacity","type":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/plan-definition-type","code":"order-set","display":"Order Set"}],"text":"Order Set"},"status":"active","experimental":true,"subjectCodeableConcept":{"coding":[{"system":"http://hl7.org/fhir/resource-types","code":"Patient","display":"Patient"}],"text":"Patient"},"date":"2023-07-25","publisher":"Te Whatu Ora","contact":[{"name":"Te Whatu Ora","telecom":[{"system":"url","value":"https://www.tewhatuora.govt.nz/"}]},{"name":"Te Whatu Ora Integration Team","telecom":[{"system":"email","value":"integration@tewhatuora.govt.nz","use":"work"}]}],"description":"This careplan designed to support ongoing monitoring of long term conditions (heart failure) in primary care.","jurisdiction":[{"coding":[{"system":"urn:iso:std:iso:3166","code":"NZ","display":"New Zealand"}]}],"purpose":"This careplan designed to support ongoing monitoring of long term conditions (heart failure) in primary care","usage":"Allows monitoring and tracking of progress of a self serve remote Heart failure patient.","lastReviewDate":"2022-08-04","effectivePeriod":{"start":"2022-08-04","end":"2023-08-04"},"topic":[{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/definition-topic","code":"treatment","display":"Treatment"}],"text":"Treatment"}],"author":[{"name":"HNZ RPM Project"}],"editor":[{"name":"HNZ RPM Project"}],"reviewer":[{"name":"HNZ RPM Project"}],"endorser":[{"name":"Alastair Kenworthy","telecom":[{"system":"other","value":"CinC Fit for Future Project"}]}],"goal":[{"id":"heart-failure-monitoring","category":{"text":"Heart Failure Monitoring"},"description":{"text":"Activities in the Remote Monitoring Careplan for Cardiac Heart Failure are intended to support the person and whanau managing their heart failure through capturing and sharing information relating to their needs and experience, symptoms and observations. These activities are in alignment with the NZ Health pathways base heart failure pathway."},"priority":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/goal-priority","code":"medium-priority","display":"Medium Priority"}],"text":"Medium Priority"},"start":{"text":"Assessed as suitable"}}],"action":[{"id":"1","prefix":"1.","title":"Daily Symptom Survey","description":"Daily Symptom Survey","textEquivalent":"Daily Survey to gather any symptoms experianced by a patient","priority":"routine","goalId":["heart-failure-monitoring"],"subjectCodeableConcept":{"coding":[{"system":"http://hl7.org/fhir/resource-types","code":"Patient","display":"Patient"}],"text":"Patient"},"type":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/action-type","code":"create","display":"Create"}],"text":"Create"},"requiredBehavior":"must","precheckBehavior":"yes","cardinalityBehavior":"multiple","definitionCanonical":"{{API_URL}}/Questionnaire?identifier=RemoteMonitoringHeartFailureSymptomSurveyQuestionnaire"},{"id":"2","prefix":"2.","title":"Weekly Feedback Survey","description":"Weekly Feedback Survey","textEquivalent":"A weekly survey giving an opportunity for patients to provide feedback towards their experiance with the program","priority":"routine","goalId":["heart-failure-monitoring"],"subjectCodeableConcept":{"coding":[{"system":"http://hl7.org/fhir/resource-types","code":"Patient","display":"Patient"}],"text":"Patient"},"type":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/action-type","code":"create","display":"Create"}],"text":"Create"},"requiredBehavior":"must","precheckBehavior":"yes","cardinalityBehavior":"multiple","definitionCanonical":"{{API_URL}}/Questionnaire?identifier=RemoteMonitoringFeedbackSurveyQuestionnaire"},{"id":"3","prefix":"3.","title":"Observation Activity","description":"Take an obervation","priority":"routine","goalId":["heart-failure-monitoring"],"subjectCodeableConcept":{"coding":[{"system":"http://hl7.org/fhir/resource-types","code":"Patient","display":"Patient"}],"text":"Patient"},"type":{"coding":[{"system":"http://terminology.hl7.org/CodeSystem/action-type","code":"create","display":"Create"}],"text":"Create"},"requiredBehavior":"must","precheckBehavior":"yes","cardinalityBehavior":"multiple","definitionCanonical":"https://build.fhir.org/ig/tewhatuora/cinc-fhir-ig/ActivityDefinition/RemoteMonitoringObservationRequest"}]}