CarePlan
Overview
The DSTU2 CarePlan resource can be used to represent both care plans and care teams.
Care Plans
The CarePlan resource describes the intentions of how one or more practitioners plan to deliver care to a specific patient. Care plans are used in a variety of areas and scopes ranging from encounter or visit specific to cross-visits. Care plans are used to group activities, goals and/or practitioners to create context. Care plans are intended to be specific to the patient. It is possible for a planned activity to stand alone without a care plan such as a scheduled appointment.
The following fields are returned if valued:
- Id
- Subject (patient only)
- Status
- Context (patient encounter)
- Date/Time created
- Author
- Date/Time last modified
- Category (assess-plan)
- Care plan
Care Teams
For DSTU2 Resources, the CarePlan resource is used to represent care team members. Care team members or participants include practitioners (physicians, nurses, technicians, etc.), family members, friends, guardians, and the patient. The care team can be specific to an encounter or to the patient across all encounters (longitudinal).
If using R4 Resources, the R4 CareTeam resource is available.
The following fields are returned if valued:
- Id
- Subject (patient only)
- Status
- Context (patient encounter)
- Time period
- Last modified
- Category (careteam, longitudinal, or encounter)
- Participant
- Participant details (only applies to references to contained RelatedPerson)
- Participant Role
Terminology Bindings
| CarePlan.category |
|
Search
Search for CarePlans that meet supplied query parameters:
GET /CarePlan?:parameters
Implementation Notes
-
The CarePlan.activity element is not supported and will not be returned. This means that the CarePlan.activity.detail.status and CarePlan.activity.detail.prohibited modifier elements will not be returned.
-
The description of the CarePlan is included in the CarePlan.text.div element as ASCII text.
-
In DSTU2 CareTeam is not a stand alone resource. It is a CarePlan with participants. A CareTeam will be returned only if a CareTeam specific category code is supplied.
-
A CareTeam participant (CarePlan.participant) may have a reference to a contained RelatedPerson.
Authorization Types
Parameters
| Name | Required? | Type | Description |
|---|---|---|---|
_id |
See notes | token |
The logical resource id associated with the resource. |
date |
N | date |
Time period plan covers. Example: date=ge2016-08 or date=le2017-01-24T12:00:00.000Z
|
patient |
See notes | reference |
Who care plan is for. Example: patient=12345
|
subject |
See notes | reference |
Who care plan is for. Must represent a Patient resource. May use the :Patient modifier. Example: subject=Patient/12345 or subject:Patient=12345
|
_count |
N | number |
Number of results per page. |
category |
See notes | token |
The scope of care plan being searched for. Examples: category=assess-plan, category=http://argonaut.hl7.org|careteam, category=http://hl7.org/fhir/care-team-category|longitudinal, or category=careteam
|
context |
See notes | reference |
The encounter id of the care plan. Example: context=1138
|
Notes:
- The
_idparameter- May not be provided with the
category,context,date,patient, orsubjectparameters. - When provided,
_countis ignored.
- May not be provided with the
- The
dateparameter- May be provided up to two times, and must use the
georleprefixes.- When provided twice, the lower value must have the
geprefix and the higher value must have theleprefix.
- When provided twice, the lower value must have the
- Will be ignored if
categoryis set toencounter.
- May be provided up to two times, and must use the
- The
patientparameter- Unless the
subjectparameter is provided, this is required whencategoryis set tocareteam,assess-plan, orlongitudinal. - Cannot be provided with the
subjectparameter.
- Unless the
- The
subjectparameter- Unless the
patientparameter is provided, this is required whencategoryis set tocareteam,assess-plan, orlongitudinal. - Cannot be provided with the
patientparameter.
- Unless the
- The
categoryparameter- Must be provided when
_idis not provided. - Only supports the codes
careteam,assess-plan,longitudinal, andencounter.- The
careteamandassess-plancodes belong to the Argonaut system.longitudinalandencounterare defined by the CareTeam category system.
- The
- Must be provided when
- The
contextparameter- Must be set if the
categoryparameter is set toencounter. - Cannot be set if the
categoryparameter is set tocareteam,assess-plan, orlongitudinal.
- Must be set if the
Headers
Accept: application/json+fhir
Authorization: <OAuth2 Bearer Token>Example retrieve care plan
Request
GET https://fhir-open.cerner.com/dstu2/ec2458f2-1e24-41c8-b71b-0e701af7583d/CarePlan?patient=12724066&category=assess-plan
Response
Status: 200 OK{
"resourceType": "Bundle",
"id": "7ea66921-b1a3-4719-9e06-83b8ffd91e02",
"type": "searchset",
"link": [
{
"relation": "self",
"url": "https://fhir-open.cerner.com/dstu2/ec2458f2-1e24-41c8-b71b-0e701af7583d/CarePlan?patient=12724066&category=assess-plan&_count=10"
}
],
"entry": [
{
"fullUrl": "https://fhir-open.cerner.com/dstu2/ec2458f2-1e24-41c8-b71b-0e701af7583d/CarePlan/197286315",
"resource": {
"resourceType": "CarePlan",
"id": "197286315",
"meta": {
"versionId": "1",
"lastUpdated": "2020-04-04T23:00:46-05:00"
},
"text": {
"status": "additional",
"div": "<div><p><b>Care Plan</b></p><p><b>Patient</b>: SMART, NANCY</p><p><b>Status</b>: Completed</p><p><b>Description</b>:</p><pre>SMART, NANCY DOB: 08/11/1980	Age: 39 Years	MRN: 00000006930 -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Pregnancy Summary (Date of Report: 04/04/20) G 1 P 0 (0,0,0,0) Gestation: --	LMP (from pt. history): -- EDD: --	EDD/EGA Method: Date of Conception	EGA: -- -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Antepartum Note 	No antepartum notes have been documented -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Problems (Active Problems Only) Gestational diabetes mellitus, class A>1< (Related to Pregnant problem) (SNOMED CT: 124602011, Onset: 03/05/20) 	Comment: Problem added by Discern Expert (SYSTEM, SYSTEM Cerner on 03/05/20) Gestational hypertension (Related to Pregnant problem) (SNOMED CT: 495022012, Onset: 03/05/20) 	Comment: Problem added by Discern Expert (SYSTEM, SYSTEM Cerner on 03/05/20) Pregnant (SNOMED CT: 191073013, Onset: 06/12/19) -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Risk Factors and Genetic Screening Risk Factors (Current Pregnancy) Risk Factors: Diabetes, gestational, type A1, Gestational hypertension Risk Factors Comments: -- Ethnic Screening No ethnicities have been recorded. Genetic Disorders Screening No genetic disorders have been recorded. -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Gestational Age (EGA) and EDD * Note: EGA calculated as of 04/04/2020 EDD: 03/04/2020	EGA*: 44 weeks 3 days Type: Authoritative	Method Date: 06/12/2019 Method: Date of Conception (06/12/2019) Confirmation: Confirmed Description: Date Definite Comments: -- Entered by: Cerner Test, Women's Health - Nurse Cerner on 03/05/2020 Other EDD Calculations for this Pregnancy: No additional EDD calculations have been recorded for this pregnancy -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Measurements Pre-Pregnancy Weight:	-- Recent Weight Measured:	-- Height/Length Measured:	-- Body Mass Index Measured:	-- -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Prenatal Exam and Notes Date EGA FunHt PTL S/S Cervix BP Weight Urine Baby cm Dil Eff(%) Sta mmHg lbs | kg Gluc Prot FHR Fetal Activity Fet Pres 03/05/20 40w1d -- -- 4 -- -1 125/81 -- -- -- -- -- -- -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Physical Exams Physical Exam 	Respiratory 	SpO2: 98 % (03/05/20) -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Blood Types and Anti-D Immune Globulin Blood Type and Screen Mother ABO/Rh: -- Mother Antibody Screen: -- Father of Baby ABO/Rh: -- Father of Baby Antibody Screen: -- Anti-D Immune Globulin Rho(D) Initial Status: -- Rho(D) 28 Week Status: -- Rho(D) Dates Given: -- -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Prenatal Tests and Lab Results Results ending with 'TR' have been keyed in by the practice or interpreted manually. Result Date: Estimated weeks post pregnancy onset will display next to actual result date. Test Result Date Ref Range Cholesterol Total (H) 205 mg/dL 03/13/20 (41 weeks) <=200 LDL (H) 179 mg/dL 03/13/20 (41 weeks) <=100 Triglycerides (H) 172 mg/dL 03/13/20 (41 weeks) <=150 Chol/HDL 5 mg/dL 03/13/20 (41 weeks) 	<=5 HDL (L) 43 mg/dL 03/13/20 (41 weeks) >=50 -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Allergies (Active and Proposed Allergies Only) No Known Medication Allergies (Severity: Unknown severity, Onset: Unknown) -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Medications Prescriptions and Home Medications 	Currently Active or Taking 	No medications have been recorded 	Inactive or Suspended (Prescriptions and documented medications since 03/12/19) 	No medications have been recorded Medication Administrations In-Office/Hospital (All in-office/hospital administrated medications ordered since 03/12/19) 	No medications have been recorded -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Immunizations 	No immunizations have been administered or recorded as given -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Menstrual History Last Recorded Menstrual Period: -- Last Menstrual Period Description: -- Menarche Onset: -- Menarche Frequency: -- Menarche Length: -- Date of Menses Prior to LMP: -- On Hormonal Contracept within 2 months of LMP: -- Date of Home Pregnancy Test: -- Comments: -- -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Pregnancy History G1 P0(0,0,0,0) 	No previous pregnancies history have been recorded -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Medical History Past Medical History 	No active past medical history has been recorded Family History 	Father (Name not documented, Alive) 	Heart attack 	Hypertension Procedure or Surgical History 	No active procedures/surgeries have been recorded -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Social & Psychosocial History Social History 	Tobacco 	Smoking tobacco use: Former smoker, quit more than 30 days ago. 12 year(s). Psychosocial History 	No active psychosocial history has been recorded -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Infection History 	Infection history negative or not recorded -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Anesthesia and Transfusions Prior Anesthesia or Transfusion Received: -- Prior Anesthesia Reaction(s): -- Prior Transfusion Reaction(s): -- Blood Transfusion Acceptable to Patient: -- -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Birth Plan and Patient Requests Desired Delivery Location: -- Prenatal Education: -- Written Birth Plan: -- Written Birth Plan Location: -- Oral Intake OB: -- Support Person/Coach Relationship to Pt: -- Labor Preferences: -- Non-Medicinal Pain Relief: -- Anesthesia/Pain Medication During Labor: -- Delivery Plan: -- Infant Feeding: -- Circumcision: -- Patient Requests: -- Father of the Baby's Name: -- Pediatrician Selected: -- Planned Method of Delivery: -- Baby For Adoption: -- Surrogate Pregnancy: -- Support Person's Name: -- -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Education 1st Trimester Weight Gain		-- Alcohol Use		-- Blood Glucose Monitoring		-- Childbirth Classes		-- Domestic Violence		-- Drug Use		-- Environmental Hazards		-- Exercise		-- Expected Course of Prenatal Care		-- HIV Testing		-- Hospital Facilities		-- Hypertension in Pregnancy		-- Influenza Vaccine		-- Nutrition Counseling		-- Risk Factors Identified by History		-- Routine Prenatal Tests		-- Safety		-- Seat Belts		-- Sexual Activity		-- Signs and Symptoms of Preeclampsia		-- Smoking/Tobacco Use		-- Social Service		-- Special Diet Counseling		-- Toxoplasmosis Precautions		-- Travel		-- Ultrasound		-- Use of Any Medications		-- VBAC Counseling		-- Weight Management During Pregnancy		-- When to Call Health Care Provider		-- Work Hazards		-- 2nd Trimester Abnormal Lab Values		-- Blood Glucose Monitoring		-- Childbirth Classes		-- Choosing a Newborn Care Provider		-- Domestic Violence		-- Hypertension in Pregnancy		-- Influenza Vaccine		-- Postpartum Family Planning		-- Postpartum Tubal Sterilization		-- Premature Labor Signs and Symptoms		-- Safety		-- Signs and Symptoms of Preeclampsia		-- Smoking/Tobacco Use		-- Social Service		-- Weight Management During Pregnancy		-- 3rd Trimester Breast or Bottle Feeding		-- Analgesia Plans		-- Anesthesia Plans		-- Birth Plan		-- Blood Glucose Monitoring		-- Car Seat Safety		-- Childbirth Classes		-- Circumcision		-- Disability Forms		-- Domestic Violence		-- Family Medical Leave Forms		-- Fetal Movement Monitoring		-- Hypertension in Pregnancy		-- Influenza Vaccine		-- Labor Signs		-- Newborn Education		-- Postpartum Depression		-- Postterm Counseling		-- Safety		-- Signs and Symptoms of Preeclampsia		-- Ante Signs, Symptoms of PIH		-- Smoking/Tobacco Use		-- Social Service		-- VBAC Counseling		-- Verb Understanding Cervical Ripening		-- Weight Management During Pregnancy		-- Prenatal Educational Materials/Leaflets Provided 	No educational materials have been recorded as provided L&D Patient Education Activity Expectations		-- Activity Restrictions		-- Weight Gain		-- Analgesia Plans		-- Anesthesia Plans		-- Birth Plan		-- Blood Glucose Monitoring		-- Contractions		-- Diagnostic Results		-- Domestic Violence		-- Drug to Drug Interactions		-- Drug to Food Interactions		-- Epidural for Pain Management		-- Equipment/Devices		-- Fetal Monitoring		-- Fetal Monitoring Assessment		-- Fever During Pregnancy		-- Hypertension in Pregnancy		-- Infant Security		-- Med Generic/Brand Name,Purpose,Action		-- Med Preadministration Procedures		-- Medication Dosage, Route, Scheduling		-- Medication Instructions		-- Medication Precautions		-- Medication Side Effects		-- Nutrition Counseling		-- Pain Management		-- Plan of Care		-- Postoperative Instructions		-- Premature Labor Signs and Symptoms		-- Preoperative Instructions		-- Reportable Symptoms		-- Ruptured Membranes		-- Safety		-- Safety, Fall		-- Seat Belts		-- Sexual Activity Guideline/Restriction		-- Signs and Symptoms of Preeclampsia		-- Smoking Cessation		-- Surgery		-- Treatments/Procedures/Tests		-- Tubal Sterilization		-- Ultrasound		-- Unit Procedures		-- Vaccinations		-- Vaginal Bleeding		-- Verb Understanding Cervical Ripening		-- Weight Management During Pregnancy		-- Postpartum Patient Education Activity Expectations		-- Bladder/Bowel Function		-- Breast Care		-- Cardiac Disease		-- Contact Health Care Provider		-- Cramps		-- Diagnostic Results		-- Equipment/Devices		-- Hypertension in Pregnancy		-- Incision/Episiotomy Care		-- Infection		-- Lochia Changes		-- Med Generic/Brand Name,Purpose,Action		-- Medication Dosage, Route, Scheduling		-- Medication Precautions		-- Nutrition Counseling		-- Pain Management		-- Perineal Care		-- Plan of Care		-- Postoperative Instructions		-- Postpartum Depression		-- Preoperative Instructions		-- Pulmonary Embolism		-- Room Orientation		-- Safety		-- Safety, Fall		-- Sibling/Family Adjustment		-- Sitz Bath		-- Surgery		-- Treatments/Procedures/Tests		-- Unit Procedures		-- Venous Thromboembolism		-- Vaginal Discharge		-- -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Registration and Pregnancy Information 	Race: White		Ethnicity: Not Hispanic, Latino, or Spanish Origin 	Marital Status: Married 	Language(s): English 	Religious Preference(s): -- 	Occupation/Education: Address, Phone, and Health Plans 	Home Address: 12345 Main St, Kansas City, MO 64116 	Phone: (816)888-8887 (Home), --, -- 	Health Plans: 	1 -	Self Pay 	Member/Group: -- 	Deductible: $ --	Type: Self Pay 	Address: -- 	Phone: -- General Prenatal Information 	OB Provider(s) Information: Not explicitly recorded. May be noted in prenatal encounter section below. 	**See below for detailed information for all visits and information. 	Delivery Center/Hospital Information: -- 	Newborn Provider Information: -- 	Referring Provider Information: Cerner Test, Physician - Women's Health Cerner 	Primary Provider Information: Cerner Test, Physician - Hospitalist Cerner 	Husband/Partner Information: -- -- 	Support Person Information: -- 	Planned/Unplanned Pregnancy: -- 	Date Consent Signed for Tubal Ligation: -- 	Date Prenatal Record Sent to Hospital: -- -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Prenatal Visits and Encounters (Known encounters since 06/12/2019. May include lab encounters.) Date	Location	Provider	Type	Medical Service 03/04/2020	A	Cerner Test, Physician -	Inpatient	Maternity 03/04/2020	A	Carter, Kristin Cerner	Inpatient	Maternity 12/26/2019	MX Clinic 1	Cerner Test, Physician -	Outpatient	Cardiology 12/26/2019	A	Cerner Test, Physician -	Inpatient	Medicine-General -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Visit / Encounter Location Information **The following information represents known location and contact information for locations visited during pregnancy 	Model Hospital 	Address: 	No addresses found on file for location 	Phone: 	No phone numbers found on file for location 	Model Clinic 1 	Address: 	No addresses found on file for location 	Phone: 	No phone numbers found on file for location -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Prenatal Visit Diagnosis (Note: All diagnoses documented since 06/12/2019) 	No diagnoses have been recorded for prenatal visits -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Delivery Summary -------------------------------------------------------------------------------------------------------------------------------------------- Note: Items documented with '--' had no clinical data which qualified at time of report creation 	***** END OF REPORT *****</pre><p><b>Author</b>: SYSTEM, SYSTEM Cerner</p><p><b>Effective Date/Time</b>: Apr 5, 2020 4:00 A.M. UTC</p></div>"
},
"subject": {
"reference": "Patient/12724066",
"display": "SMART, NANCY"
},
"status": "completed",
"period": {
"start": "2020-04-04T23:00:45-05:00"
},
"author": [
{
"reference": "Practitioner/1",
"display": "SYSTEM, SYSTEM Cerner"
}
],
"modified": "2020-04-04T23:00:46-05:00",
"category": [
{
"coding": [
{
"system": "http://argonaut.hl7.org",
"code": "assess-plan",
"display": "Assess-Plan"
}
]
}
]
}
}
]
}Note: The examples provided here are non-normative and replaying them in the public sandbox is not guaranteed to yield the results shown on the site.
Example retrieve care teams
Request
GET https://fhir-open.cerner.com/dstu2/ec2458f2-1e24-41c8-b71b-0e701af7583d/CarePlan?patient=12724066&category=careteam
Response
Status: 200 OK{
"resourceType": "Bundle",
"id": "3f0248ed-05e3-4194-889e-f843a9a0d9a0",
"type": "searchset",
"total": 1,
"link": [
{
"relation": "self",
"url": "https://fhir-open.cerner.com/dstu2/ec2458f2-1e24-41c8-b71b-0e701af7583d/CarePlan?patient=12724066&category=careteam"
}
],
"entry": [
{
"fullUrl": "https://fhir-open.cerner.com/dstu2/ec2458f2-1e24-41c8-b71b-0e701af7583d/CarePlan/L12724066",
"resource": {
"resourceType": "CarePlan",
"id": "L12724066",
"meta": {
"versionId": "12724066",
"lastUpdated": "2019-12-26T15:41:55Z"
},
"text": {
"status": "generated",
"div": "<div><p><b>Care Team</b></p><p><b>Patient</b>: SMART, NANCY</p><p><b>Status</b>: Active</p><p><b>Category</b>: CareTeam</p><p><b>Participants</b>:</p><p><b>Name</b>: Cerner Test, Physician - Hospitalist Cerner</p><p><b>Role</b>: Primary Care Physician</p></div>"
},
"subject": {
"reference": "Patient/12724066",
"display": "SMART, NANCY"
},
"status": "active",
"modified": "2019-12-26T15:41:55Z",
"category": [
{
"coding": [
{
"system": "http://argonaut.hl7.org",
"code": "careteam",
"display": "CareTeam"
}
]
}
],
"participant": [
{
"member": {
"reference": "Practitioner/4122622",
"display": "Cerner Test, Physician - Hospitalist Cerner"
},
"role": {
"text": "Primary Care Physician"
}
}
]
}
}
]
}Note: The examples provided here are non-normative and replaying them in the public sandbox is not guaranteed to yield the results shown on the site.
Errors
The common errors and OperationOutcomes may be returned.
Retrieve by id
List an individual CarePlan by its id:
GET /CarePlan/:id
Authorization Types
Headers
Accept: application/json+fhir
Authorization: <OAuth2 Bearer Token>Example
Request
GET https://fhir-open.cerner.com/dstu2/ec2458f2-1e24-41c8-b71b-0e701af7583d/CarePlan/197286315
Response
Status: 200 OK{
"resourceType": "CarePlan",
"id": "197286315",
"meta": {
"versionId": "1",
"lastUpdated": "2020-04-04T23:00:46-05:00"
},
"text": {
"status": "additional",
"div": "<div><p><b>Care Plan</b></p><p><b>Patient</b>: SMART, NANCY</p><p><b>Status</b>: Completed</p><p><b>Description</b>:</p><pre>SMART, NANCY DOB: 08/11/1980	Age: 39 Years	MRN: 00000006930 -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Pregnancy Summary (Date of Report: 04/04/20) G 1 P 0 (0,0,0,0) Gestation: --	LMP (from pt. history): -- EDD: --	EDD/EGA Method: Date of Conception	EGA: -- -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Antepartum Note 	No antepartum notes have been documented -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Problems (Active Problems Only) Gestational diabetes mellitus, class A>1< (Related to Pregnant problem) (SNOMED CT: 124602011, Onset: 03/05/20) 	Comment: Problem added by Discern Expert (SYSTEM, SYSTEM Cerner on 03/05/20) Gestational hypertension (Related to Pregnant problem) (SNOMED CT: 495022012, Onset: 03/05/20) 	Comment: Problem added by Discern Expert (SYSTEM, SYSTEM Cerner on 03/05/20) Pregnant (SNOMED CT: 191073013, Onset: 06/12/19) -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Risk Factors and Genetic Screening Risk Factors (Current Pregnancy) Risk Factors: Diabetes, gestational, type A1, Gestational hypertension Risk Factors Comments: -- Ethnic Screening No ethnicities have been recorded. Genetic Disorders Screening No genetic disorders have been recorded. -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Gestational Age (EGA) and EDD * Note: EGA calculated as of 04/04/2020 EDD: 03/04/2020	EGA*: 44 weeks 3 days Type: Authoritative	Method Date: 06/12/2019 Method: Date of Conception (06/12/2019) Confirmation: Confirmed Description: Date Definite Comments: -- Entered by: Cerner Test, Women's Health - Nurse Cerner on 03/05/2020 Other EDD Calculations for this Pregnancy: No additional EDD calculations have been recorded for this pregnancy -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Measurements Pre-Pregnancy Weight:	-- Recent Weight Measured:	-- Height/Length Measured:	-- Body Mass Index Measured:	-- -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Prenatal Exam and Notes Date EGA FunHt PTL S/S Cervix BP Weight Urine Baby cm Dil Eff(%) Sta mmHg lbs | kg Gluc Prot FHR Fetal Activity Fet Pres 03/05/20 40w1d -- -- 4 -- -1 125/81 -- -- -- -- -- -- -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Physical Exams Physical Exam 	Respiratory 	SpO2: 98 % (03/05/20) -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Blood Types and Anti-D Immune Globulin Blood Type and Screen Mother ABO/Rh: -- Mother Antibody Screen: -- Father of Baby ABO/Rh: -- Father of Baby Antibody Screen: -- Anti-D Immune Globulin Rho(D) Initial Status: -- Rho(D) 28 Week Status: -- Rho(D) Dates Given: -- -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Prenatal Tests and Lab Results Results ending with 'TR' have been keyed in by the practice or interpreted manually. Result Date: Estimated weeks post pregnancy onset will display next to actual result date. Test Result Date Ref Range Cholesterol Total (H) 205 mg/dL 03/13/20 (41 weeks) <=200 LDL (H) 179 mg/dL 03/13/20 (41 weeks) <=100 Triglycerides (H) 172 mg/dL 03/13/20 (41 weeks) <=150 Chol/HDL 5 mg/dL 03/13/20 (41 weeks) 	<=5 HDL (L) 43 mg/dL 03/13/20 (41 weeks) >=50 -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Allergies (Active and Proposed Allergies Only) No Known Medication Allergies (Severity: Unknown severity, Onset: Unknown) -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Medications Prescriptions and Home Medications 	Currently Active or Taking 	No medications have been recorded 	Inactive or Suspended (Prescriptions and documented medications since 03/12/19) 	No medications have been recorded Medication Administrations In-Office/Hospital (All in-office/hospital administrated medications ordered since 03/12/19) 	No medications have been recorded -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Immunizations 	No immunizations have been administered or recorded as given -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Menstrual History Last Recorded Menstrual Period: -- Last Menstrual Period Description: -- Menarche Onset: -- Menarche Frequency: -- Menarche Length: -- Date of Menses Prior to LMP: -- On Hormonal Contracept within 2 months of LMP: -- Date of Home Pregnancy Test: -- Comments: -- -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Pregnancy History G1 P0(0,0,0,0) 	No previous pregnancies history have been recorded -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Medical History Past Medical History 	No active past medical history has been recorded Family History 	Father (Name not documented, Alive) 	Heart attack 	Hypertension Procedure or Surgical History 	No active procedures/surgeries have been recorded -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Social & Psychosocial History Social History 	Tobacco 	Smoking tobacco use: Former smoker, quit more than 30 days ago. 12 year(s). Psychosocial History 	No active psychosocial history has been recorded -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Infection History 	Infection history negative or not recorded -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Anesthesia and Transfusions Prior Anesthesia or Transfusion Received: -- Prior Anesthesia Reaction(s): -- Prior Transfusion Reaction(s): -- Blood Transfusion Acceptable to Patient: -- -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Birth Plan and Patient Requests Desired Delivery Location: -- Prenatal Education: -- Written Birth Plan: -- Written Birth Plan Location: -- Oral Intake OB: -- Support Person/Coach Relationship to Pt: -- Labor Preferences: -- Non-Medicinal Pain Relief: -- Anesthesia/Pain Medication During Labor: -- Delivery Plan: -- Infant Feeding: -- Circumcision: -- Patient Requests: -- Father of the Baby's Name: -- Pediatrician Selected: -- Planned Method of Delivery: -- Baby For Adoption: -- Surrogate Pregnancy: -- Support Person's Name: -- -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Education 1st Trimester Weight Gain		-- Alcohol Use		-- Blood Glucose Monitoring		-- Childbirth Classes		-- Domestic Violence		-- Drug Use		-- Environmental Hazards		-- Exercise		-- Expected Course of Prenatal Care		-- HIV Testing		-- Hospital Facilities		-- Hypertension in Pregnancy		-- Influenza Vaccine		-- Nutrition Counseling		-- Risk Factors Identified by History		-- Routine Prenatal Tests		-- Safety		-- Seat Belts		-- Sexual Activity		-- Signs and Symptoms of Preeclampsia		-- Smoking/Tobacco Use		-- Social Service		-- Special Diet Counseling		-- Toxoplasmosis Precautions		-- Travel		-- Ultrasound		-- Use of Any Medications		-- VBAC Counseling		-- Weight Management During Pregnancy		-- When to Call Health Care Provider		-- Work Hazards		-- 2nd Trimester Abnormal Lab Values		-- Blood Glucose Monitoring		-- Childbirth Classes		-- Choosing a Newborn Care Provider		-- Domestic Violence		-- Hypertension in Pregnancy		-- Influenza Vaccine		-- Postpartum Family Planning		-- Postpartum Tubal Sterilization		-- Premature Labor Signs and Symptoms		-- Safety		-- Signs and Symptoms of Preeclampsia		-- Smoking/Tobacco Use		-- Social Service		-- Weight Management During Pregnancy		-- 3rd Trimester Breast or Bottle Feeding		-- Analgesia Plans		-- Anesthesia Plans		-- Birth Plan		-- Blood Glucose Monitoring		-- Car Seat Safety		-- Childbirth Classes		-- Circumcision		-- Disability Forms		-- Domestic Violence		-- Family Medical Leave Forms		-- Fetal Movement Monitoring		-- Hypertension in Pregnancy		-- Influenza Vaccine		-- Labor Signs		-- Newborn Education		-- Postpartum Depression		-- Postterm Counseling		-- Safety		-- Signs and Symptoms of Preeclampsia		-- Ante Signs, Symptoms of PIH		-- Smoking/Tobacco Use		-- Social Service		-- VBAC Counseling		-- Verb Understanding Cervical Ripening		-- Weight Management During Pregnancy		-- Prenatal Educational Materials/Leaflets Provided 	No educational materials have been recorded as provided L&D Patient Education Activity Expectations		-- Activity Restrictions		-- Weight Gain		-- Analgesia Plans		-- Anesthesia Plans		-- Birth Plan		-- Blood Glucose Monitoring		-- Contractions		-- Diagnostic Results		-- Domestic Violence		-- Drug to Drug Interactions		-- Drug to Food Interactions		-- Epidural for Pain Management		-- Equipment/Devices		-- Fetal Monitoring		-- Fetal Monitoring Assessment		-- Fever During Pregnancy		-- Hypertension in Pregnancy		-- Infant Security		-- Med Generic/Brand Name,Purpose,Action		-- Med Preadministration Procedures		-- Medication Dosage, Route, Scheduling		-- Medication Instructions		-- Medication Precautions		-- Medication Side Effects		-- Nutrition Counseling		-- Pain Management		-- Plan of Care		-- Postoperative Instructions		-- Premature Labor Signs and Symptoms		-- Preoperative Instructions		-- Reportable Symptoms		-- Ruptured Membranes		-- Safety		-- Safety, Fall		-- Seat Belts		-- Sexual Activity Guideline/Restriction		-- Signs and Symptoms of Preeclampsia		-- Smoking Cessation		-- Surgery		-- Treatments/Procedures/Tests		-- Tubal Sterilization		-- Ultrasound		-- Unit Procedures		-- Vaccinations		-- Vaginal Bleeding		-- Verb Understanding Cervical Ripening		-- Weight Management During Pregnancy		-- Postpartum Patient Education Activity Expectations		-- Bladder/Bowel Function		-- Breast Care		-- Cardiac Disease		-- Contact Health Care Provider		-- Cramps		-- Diagnostic Results		-- Equipment/Devices		-- Hypertension in Pregnancy		-- Incision/Episiotomy Care		-- Infection		-- Lochia Changes		-- Med Generic/Brand Name,Purpose,Action		-- Medication Dosage, Route, Scheduling		-- Medication Precautions		-- Nutrition Counseling		-- Pain Management		-- Perineal Care		-- Plan of Care		-- Postoperative Instructions		-- Postpartum Depression		-- Preoperative Instructions		-- Pulmonary Embolism		-- Room Orientation		-- Safety		-- Safety, Fall		-- Sibling/Family Adjustment		-- Sitz Bath		-- Surgery		-- Treatments/Procedures/Tests		-- Unit Procedures		-- Venous Thromboembolism		-- Vaginal Discharge		-- -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Registration and Pregnancy Information 	Race: White		Ethnicity: Not Hispanic, Latino, or Spanish Origin 	Marital Status: Married 	Language(s): English 	Religious Preference(s): -- 	Occupation/Education: Address, Phone, and Health Plans 	Home Address: 12345 Main St, Kansas City, MO 64116 	Phone: (816)888-8887 (Home), --, -- 	Health Plans: 	1 -	Self Pay 	Member/Group: -- 	Deductible: $ --	Type: Self Pay 	Address: -- 	Phone: -- General Prenatal Information 	OB Provider(s) Information: Not explicitly recorded. May be noted in prenatal encounter section below. 	**See below for detailed information for all visits and information. 	Delivery Center/Hospital Information: -- 	Newborn Provider Information: -- 	Referring Provider Information: Cerner Test, Physician - Women's Health Cerner 	Primary Provider Information: Cerner Test, Physician - Hospitalist Cerner 	Husband/Partner Information: -- -- 	Support Person Information: -- 	Planned/Unplanned Pregnancy: -- 	Date Consent Signed for Tubal Ligation: -- 	Date Prenatal Record Sent to Hospital: -- -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Prenatal Visits and Encounters (Known encounters since 06/12/2019. May include lab encounters.) Date	Location	Provider	Type	Medical Service 03/04/2020	A	Cerner Test, Physician -	Inpatient	Maternity 03/04/2020	A	Carter, Kristin Cerner	Inpatient	Maternity 12/26/2019	MX Clinic 1	Cerner Test, Physician -	Outpatient	Cardiology 12/26/2019	A	Cerner Test, Physician -	Inpatient	Medicine-General -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Visit / Encounter Location Information **The following information represents known location and contact information for locations visited during pregnancy 	Model Hospital 	Address: 	No addresses found on file for location 	Phone: 	No phone numbers found on file for location 	Model Clinic 1 	Address: 	No addresses found on file for location 	Phone: 	No phone numbers found on file for location -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Prenatal Visit Diagnosis (Note: All diagnoses documented since 06/12/2019) 	No diagnoses have been recorded for prenatal visits -------------------------------------------------------------------------------------------------------------------------------------------- 				SMART, NANCY DOB: 08/11/80 Delivery Summary -------------------------------------------------------------------------------------------------------------------------------------------- Note: Items documented with '--' had no clinical data which qualified at time of report creation 	***** END OF REPORT *****</pre><p><b>Author</b>: SYSTEM, SYSTEM Cerner</p><p><b>Effective Date/Time</b>: Apr 5, 2020 4:00 A.M. UTC</p></div>"
},
"subject": {
"reference": "Patient/12724066",
"display": "SMART, NANCY"
},
"status": "completed",
"period": {
"start": "2020-04-04T23:00:45-05:00"
},
"author": [
{
"reference": "Practitioner/1",
"display": "SYSTEM, SYSTEM Cerner"
}
],
"modified": "2020-04-04T23:00:46-05:00",
"category": [
{
"coding": [
{
"system": "http://argonaut.hl7.org",
"code": "assess-plan",
"display": "Assess-Plan"
}
]
}
]
}Note: The examples provided here are non-normative and replaying them in the public sandbox is not guaranteed to yield the results shown on the site.
Errors
The common errors and OperationOutcomes may be returned.