goals and timing, new intervention and self-care activities are discussed and agreed to by the patient. The new/changed activities are scheduled and target dates agreed upon. The allied health care provider updates the clinical notes and the care plan with the assessment details, and any changes to the management plan including new advice to the patient. The date of next visit is also determined. Table X.4.2.1.1.2-1: Allied Health Professionals/Specialists Encounters – Activities and Outcomes Provider / Allied Health Provider Encounter Activities Outcomes Communications Diabetic Educator Review referral/patient progress assess learning needs and strategy discuss and finalize education plan Develop/update education plan Update clinical Generate progress notes New/updated education plan to patient Summary care plan and progress note shared with primary care provider and care providers, Dietitian/Nutritionist Review referral/patient progress Assess diet management needs and strategies Discuss and finalize diet management plan Develop/update diet plan Weight assessment; Exercise plan Diet management plan; Referral to educator and exercise therapy if necessary Update clinical notes Generate progress notes New/updated care plan to patient Summary care plan and progress note shared with primary care provider and other care providers, e.g., diabetic educator, exercise physiologist, etc. Exercise Physiologist Review referral/patient progress Assess exercise/activity needs and strategies Discuss and finalize exercise plan Develop/update exercise plan: Weight assessment; exercise plan Update clinical notes Generate progress New/updated exercise plan to patient Summary care plan and progress note shared with primary care provider and other care providers, e.g., diabetic educator, dietitian, etc.
Role: The Care Plan Service returns the requested CarePlan resource, or an error if the requested id does not exist. 3.Y2.3 Referenced Standards HL7 Fast Healthcare Information Resources (FHIR) DSTU 2.0 3.Y2.4 Interaction Diagram 3.Y2.4.1 Retrieve Care Plan The Care Plan Consumer retrieves a specific care plan from the Care Plan Service. 3.Y2.4.1.1 Trigger Events Any time a specific care plan needs to be retrieved, for the purposes of viewing or in conjunction with the preparation for an update to a care plan. 3.Y2.4.1.2 Message Semantics The message is a FHIR HTTP or HTTPS GET of a CarePlan resources where the parameter provided is the CarePlan.id with an option to ask for a specific version of the given CarePlan The URL for this operation is: [base]/CarePlan/[id] or, if this is an historical, version specific retrieval: [base]/CarePlan/[id]/_history/[vid] 3.Y2.4.1.3 Expected Actions The Care Plan Consumer initiates the retrieve request using HTTP or HTTPS GET, and the Care Plan Service responds according to the with the requested care plan or an error message. 3.Y2.5 Security Considerations No PHI are provided with this transaction so there are no additional HTTP or HTTPS GET concerns. 3.Y3 Subscribe to Care Plan Updates [PCC-Y3] 3.Y3.1 Scope This transaction is used to subscribe to updates made to a Care Plan. 3.Y3.2 Actor Roles Figure 3.Y3.2-1: Use Case Diagram