MHAD-Example-Smith-Johnson-Bundle3
type: Bundle
node role: treeRoot
id:
  v: MHAD-Example-Smith-Johnson-Bundle3
identifier:
  system:
    v: https://example.org/GoodHealth-Clinic
type:
  v: document
timestamp:
  v: 2024-03-29T14:25:34.001-05:00
entry:
  full url:
    v: http://www.example.org/fhir/Composition/MHAD-Example-Smith-Johnson-Composition
  resource: MHAD-Example-Smith-Johnson-Composition
entry:
  full url:
    v: http://www.example.org/fhir/Organization/Example-Smith-Johnson-OrganizationCustodian1
  resource: Example-Smith-Johnson-OrganizationCustodian1
entry:
  full url:
    v: http://www.example.org/fhir/Patient/Example-Smith-Johnson-Patient1
  resource: Example-Smith-Johnson-Patient1
entry:
  full url:
    v: http://www.example.org/fhir/RelatedPerson/Example-Smith-Johnson-Notary2
  resource: Example-Smith-Johnson-Notary2
entry:
  full url:
    v: http://www.example.org/fhir/RelatedPerson/Example-Smith-Johnson-HealthcareAgent3
  resource: Example-Smith-Johnson-HealthcareAgent3
entry:
  full url:
    v: http://www.example.org/fhir/Consent/Example-Smith-Johnson-HealthcareAgentConsent2
  resource: Example-Smith-Johnson-HealthcareAgentConsent2
entry:
  full url:
    v: http://www.example.org/fhir/Binary/MHAD-Example-Smith-Johnson-Binary
  resource: MHAD-Example-Smith-Johnson-Binary

MHAD-Example-Smith-Johnson-Composition
type: Composition
id:
  v: MHAD-Example-Smith-Johnson-Composition
meta:
  profile:
    v: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PACPComposition
    link: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PACPComposition
language:
  v: en-US
text:
  status:
    v: extensions
  div: Generated Narrative: Composition MHAD-Example-Smith-Johnson-Composition Language: en-US Profile: ADI PtAuthored Composition Composition Version Number: 2024-12-22T05:00:00+00:00 identifier: https://example.org/standards/terminology/namingSystem/setId/2.16.840.1.113883.15.15.200.1:11220-d580858d0d83427381cd9d2237580048 status: Final type: Mental health Advance directives category: Advance healthcare directives date: 2024-12-22 05:00:00+0000 author: Betsy Smith-Johnson title: Mental Health Directive (Maryland) Attesters - Mode * Personal custodian: Organization example.org
extension:
  url:
    v: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
  value: string
    v: 2024-12-22T05:00:00+00:00
identifier:
  system:
    v: https://example.org/standards/terminology/namingSystem/setId
status:
  v: final
type:
  coding: https://loinc.org/rdf/104144-1
    system:
      v: http://loinc.org
    code:
      v: 104144-1
    display:
      v: Mental health Advance directives
category:
  coding: https://loinc.org/rdf/42348-3
    system:
      v: http://loinc.org
    code:
      v: 42348-3
    display:
      v: Advance healthcare directives
subject:
  link: http://hl7.org/fhir/us/pacio-adi/Patient/Example-Smith-Johnson-Patient1
  reference:
    v: Patient/Example-Smith-Johnson-Patient1
date:
  v: 2024-12-22T05:00:00+00:00
author:
  link: http://hl7.org/fhir/us/pacio-adi/Patient/Example-Smith-Johnson-Patient1
  reference:
    v: Patient/Example-Smith-Johnson-Patient1
  display:
    v: Betsy Smith-Johnson
title:
  v: Mental Health Directive (Maryland)
attester:
  mode:
    v: personal
custodian:
  link: http://hl7.org/fhir/us/pacio-adi/Organization/Example-Smith-Johnson-OrganizationCustodian1
  reference:
    v: Organization/Example-Smith-Johnson-OrganizationCustodian1
section:
  title:
    v: Appointment of a Primary Healthcare Agent and Alternate Healthcare Agents
  code:
    coding: https://loinc.org/rdf/81335-2
      system:
        v: http://loinc.org
      code:
        v: 81335-2
      display:
        v: Healthcare Agent
  text:
    status:
      v: additional
    div: I am appointing my son, Charles Johnson, as my healthcare agent
  entry:
    link: http://hl7.org/fhir/us/pacio-adi/RelatedPerson/Example-Smith-Johnson-Notary2
    reference:
      v: RelatedPerson/Example-Smith-Johnson-Notary2
  entry:
    link: http://hl7.org/fhir/us/pacio-adi/RelatedPerson/Example-Smith-Johnson-HealthcareAgent3
    reference:
      v: RelatedPerson/Example-Smith-Johnson-HealthcareAgent3
  entry:
    link: http://hl7.org/fhir/us/pacio-adi/Consent/Example-Smith-Johnson-HealthcareAgentConsent2
    reference:
      v: Consent/Example-Smith-Johnson-HealthcareAgentConsent2
section:
  title:
    v: MHAD Minimal Source Form for Betsy Smith-Johnson
  code:
    coding:
      system:
        v: http://hl7.org/fhir/us/pacio-adi/CodeSystem/adi-temp-cs
      code:
        v: minimal_source_form
  text:
    status:
      v: additional
    div: I am emotionally and mentally competent to make this Mental Health Advance Directive (MHAD). I understand the purpose and effect of this MHAD, I agree with everything that is written in this uADD, and I have made this MHAD knowingly, willingly and after careful deliberation.
  entry:
    link: http://hl7.org/fhir/us/pacio-adi/Binary/MHAD-Example-Smith-Johnson-Binary
    reference:
      v: Binary/MHAD-Example-Smith-Johnson-Binary

Example-Smith-Johnson-OrganizationCustodian1
type: Organization
id:
  v: Example-Smith-Johnson-OrganizationCustodian1
meta:
  profile:
    v: http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization
    link: http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization
text:
  status:
    v: generated
  div: Generated Narrative: Organization Example-Smith-Johnson-OrganizationCustodian1 Profile: US Core Organization Profile identifier: United States National Provider Identifier/1234567893 active: true name: example.org telecom: +1(202)776-7700 address: 740 E. Campbell Rd. Suite 825 Richardson TX 75081 US
identifier:
  system:
    v: http://hl7.org/fhir/sid/us-npi
  value:
    v: 1234567893
active:
  v: true
name:
  v: example.org
telecom:
  system:
    v: phone
  value:
    v: +1(202)776-7700
  use:
    v: work
address:
  type:
    v: physical
  line:
    v: 740 E. Campbell Rd. Suite 825
  city:
    v: Richardson
  state:
    v: TX
  postal code:
    v: 75081
  country:
    v: US

Example-Smith-Johnson-Patient1
type: Patient
id:
  v: Example-Smith-Johnson-Patient1
meta:
  last updated:
    v: 2021-03-29T14:25:34.001-05:00
  profile:
    v: http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient
    link: http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient
language:
  v: en-US
text:
  status:
    v: generated
  div: Generated Narrative: Patient Example-Smith-Johnson-Patient1 Last updated: 2021-03-29 14:25:34-0500; Language: en-US Profile: US Core Patient Profile Smith-Johnson, Betsy Female, DoB: 1950-11-15 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1PA3D58WH16) Active: true Marital Status: unknown Other Id: Medical Record Number/1032702 (use: usual, ) Contact Detail BetsySJ@example.com 111 Maple Court San Antonio TX 78212 US (home) Language: English (preferred) son: Charles Johnson 111 Maple Ct, Grand Rapids, MI 49503 ph: (210) 222-3333 daughter: Debra Johnson 333 W. Camden St., Baltimore, MD 21201 ph: (410) 444-5555 <td style="background-color: #f3f5da" title="Concepts classifying the person into a named category of humans sharing common history, traits, geographical origin or nationality. The race codes used to represent these concepts are based upon the [CDC Race and Ethnicity Code Set Version 1.0](http://www.cdc.gov/phin/resources/vocabulary/index.html#3) which includes over 900 concepts for representing race and ethnicity of which 921 reference race. The race concepts are grouped by and pre-mapped to the 5 OMB race categories:#xA;#xA; - American Indian or Alaska Native#xA; - Asian#xA; - Black or African American#xA; - Native Hawaiian or Other Pacific Islander#xA; - White.">US Core Race Extension: ombCategory: CDC Race and Ethnicity 2106-3: White text: White
extension:
  extension:
    url:
      v: ombCategory
    value: Coding
      system:
        v: urn:oid:2.16.840.1.113883.6.238
      code:
        v: 2106-3
      display:
        v: White
  extension:
    url:
      v: text
    value: string
      v: White
  url:
    v: http://hl7.org/fhir/us/core/StructureDefinition/us-core-race
identifier:
  use:
    v: usual
  type:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/v2-0203
      code:
        v: MR
      display:
        v: Medical Record Number
    text:
      v: Medical Record Number
  system:
    v: http://example.org/GoodHealthHospital
  value:
    v: 1032702
identifier:
  system:
    v: http://hl7.org/fhir/sid/us-medicare
  value:
    v: 1PA3D58WH16
active:
  v: true
name:
  use:
    v: usual
  text:
    v: Smith-Johnson, Betsy
  family:
    v: Smith-Johnson
  given:
    v: Betsy
telecom:
  system:
    v: email
  use:
    v: home
gender:
  v: female
birth date:
  v: 1950-11-15
address:
  use:
    v: home
  type:
    v: physical
  line:
    v: 111 Maple Court
  city:
    v: San Antonio
  state:
    v: TX
  postal code:
    v: 78212
  country:
    v: US
marital status:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/v3-NullFlavor
    code:
      v: UNK
contact:
  relationship:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/v3-RoleCode
      code:
        v: SONC
  name:
    text:
      v: Charles Johnson
  telecom:
    system:
      v: phone
    value:
      v: (210) 222-3333
  address:
    text:
      v: 111 Maple Ct, Grand Rapids, MI 49503
contact:
  relationship:
    coding:
      system:
        v: http://terminology.hl7.org/CodeSystem/v3-RoleCode
      code:
        v: DAUC
  name:
    text:
      v: Debra Johnson
  telecom:
    system:
      v: phone
    value:
      v: (410) 444-5555
  address:
    text:
      v: 333 W. Camden St., Baltimore, MD 21201
communication:
  language:
    coding:
      system:
        v: urn:ietf:bcp:47
      code:
        v: en
      display:
        v: English
  preferred:
    v: true

Example-Smith-Johnson-Notary2
type: RelatedPerson
id:
  v: Example-Smith-Johnson-Notary2
meta:
  profile:
    v: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-HealthcareAgentParticipant
    link: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-HealthcareAgentParticipant
text:
  status:
    v: additional
  div: Notary Charles Xavier
patient:
  link: http://hl7.org/fhir/us/pacio-adi/Patient/Example-Smith-Johnson-Patient1
  reference:
    v: Patient/Example-Smith-Johnson-Patient1
relationship:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/v3-RoleCode
    code:
      v: SON
    display:
      v: natural son
name:
  text:
    v: Johnson, Charles
  family:
    v: Johnson
  given:
    v: Charles
telecom:
  system:
    v: email
  use:
    v: home

Example-Smith-Johnson-HealthcareAgent3
type: RelatedPerson
id:
  v: Example-Smith-Johnson-HealthcareAgent3
meta:
  profile:
    v: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-HealthcareAgentParticipant
    link: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-HealthcareAgentParticipant
text:
  status:
    v: additional
  div: Primary Healthcare Agent The person I choose as my Primary Healthcare Agent is: Charles Johnson (Son) CharlesSJ@example.com [SELECTED to act as a healthcare agent on 3/29/2021, at 2:25 PM CDT] [ACCEPTED to act as a healthcare agent on 4/1/2021, at 3:39 PM CDT]
patient:
  link: http://hl7.org/fhir/us/pacio-adi/Patient/Example-Smith-Johnson-Patient1
  reference:
    v: Patient/Example-Smith-Johnson-Patient1
relationship:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/v3-RoleCode
    code:
      v: SON
    display:
      v: natural son
name:
  text:
    v: Johnson, Charles
  family:
    v: Johnson
  given:
    v: Charles
telecom:
  system:
    v: email
  use:
    v: home

Example-Smith-Johnson-HealthcareAgentConsent2
type: Consent
id:
  v: Example-Smith-Johnson-HealthcareAgentConsent2
meta:
  profile:
    v: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-ADIConsentPermit
    link: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-ADIConsentPermit
text:
  status:
    v: additional
  div: status: active scope: Powers granted to healthcare agent - Reported category: Advance Directive patient: Betsy Smith-Johnson ; BetsySJ@example.com; gender: female; birthDate: 1950-11-15 dateTime: 2020-08-03 Policies - Authority Uri * https://www.michigan.gov/ http://www.legislature.mi.gov/(S(tpnclc1ofteerx2x2dppcmdz))/mileg.aspx?page=GetObject&objectname=mcl-386-1998-V-5 provision type: permit actor role: Primary healthcare agent - Reported reference: natural son; Charles Johnson ; CharlesSJ@example.com actor role: First alternate healthcare agent - Reported reference: First alternate healthcare agent - Reported, natural daughter; Debra Johnson ; DebraSJ@example.com action: Advance directive - request for intubation, Advance directive - request for tube feeding, Advance directive - request for life support, Advance directive - request for IV fluid and support, Advance directive - request for antibiotics, Advance directive - request for resuscitation that differs from cardiopulmonary resuscitation purpose: power of attorney
status:
  v: active
scope:
  coding: https://loinc.org/rdf/81377-4
    system:
      v: http://loinc.org
    code:
      v: 81377-4
    display:
      v: Goals, preferences, and priorities regarding the appointment of healthcare agents Narrative - Reported
category:
  coding:
    system:
      v: http://terminology.hl7.org/CodeSystem/consentcategorycodes
    version:
      v: 1.0.0
    code:
      v: acd
    display:
      v: Advance Directive
patient:
  link: http://hl7.org/fhir/us/pacio-adi/Patient/Example-Smith-Johnson-Patient1
  reference:
    v: Patient/Example-Smith-Johnson-Patient1
date time:
  v: 2020-08-03
policy:
  uri:
    v: http://example.org/healthcare-agent-policy
provision:
  type:
    v: permit
  actor:
    role:
      coding: https://loinc.org/rdf/75783-1
    reference:
      link: http://hl7.org/fhir/us/pacio-adi/RelatedPerson/Example-Smith-Johnson-HealthcareAgent3
      reference:
        v: RelatedPerson/Example-Smith-Johnson-HealthcareAgent3
  action:
    coding:
      system:
        v: http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIHCADecisionsCS
      code:
        v: intubation
      display:
        v: Intubation
  action:
    coding:
      system:
        v: http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIHCADecisionsCS
      code:
        v: tube-feeding
      display:
        v: Tube feeding
  action:
    coding:
      system:
        v: http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIHCADecisionsCS
      code:
        v: life-support
      display:
        v: Life support
  action:
    coding:
      system:
        v: http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIHCADecisionsCS
      code:
        v: iv-fluid-and-support
      display:
        v: IV fluid and support
  action:
    coding:
      system:
        v: http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIHCADecisionsCS
      code:
        v: antibiotics
      display:
        v: Antibiotics
  action:
    coding:
      system:
        v: http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIHCADecisionsCS
      code:
        v: resuscitation-non-cpr
      display:
        v: Non-CPR Resuscitation
  purpose:
    system:
      v: http://terminology.hl7.org/CodeSystem/v3-ActReason
    code:
      v: PWATRNY

MHAD-Example-Smith-Johnson-Binary
type: Binary
id:
  v: MHAD-Example-Smith-Johnson-Binary
meta:
  profile:
    v: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-ADIMinimalSourceFormInformation
    link: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-ADIMinimalSourceFormInformation
content type:
  v: application/pdf

v: 75783-1

v: Primary healthcare agent [Reported]