PACIO Advance Healthcare Directive Interoperability Implementation Guide
2.0.0-ballot - STU 2 – Ballot

PACIO Advance Healthcare Directive Interoperability Implementation Guide, published by HL7 International / Patient Empowerment. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/pacio-adi/ and changes regularly. See the Directory of published versions

## Example Bundle: PMO-Example-Smith-Johnson-Bundle2

Document Details

Profile: ADI Bundle

Final Document at 2023-03-29 14:25:34-0500 by PractitionerRole: telecom = kanydoc@example.org(Work) for Smith-Johnson, Betsy Female, DoB: 1950-11-15 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1PA3D58WH16)

Document Subject

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
US Core Race Extension: | ombCategory: CDC Race and Ethnicity 2106-3: White text: White

Document Content

## Portable Medical Orders

PMO Medical Orders

Order Exists: available here

## Additional Documentation

PMOLST Order Observation

Order Exists: available here

## Witnesses and Notary

I am emotionally and mentally competent to make this uADD. I understand the purpose and effect of this uADD, I agree with everything that is written in this uADD, and I have made this uADD knowingly, willingly and after careful deliberation.

Signature: | Betsy Smith-Johnson
Date: | 3/29/2024

Statement of Witnesses

I declare that the person who signed this uADD, or who asked another to sign this uADD on his/her behalf, is the individual identified in the document, and he/she did so in my presence or otherwise provided satisfactory proof to me of his/her identity. I believe him/her to be of sound mind and at least 18 years of age. I personally witnessed him/her sign this document or ask the person indicated to do so, or I received proof of his/her identity that I believe is adequate, and I believe that he/she did so voluntarily. By signing this document as a witness, I certify that I am:

- At least 18 years of age.
- Not related to the person signing this document by blood, marriage or adoption.
- Not a healthcare agent appointed by the person signing this document.
- Not directly financially responsible for that person’s healthcare.
- Not a healthcare provider directly serving the person at this time.
- Not an employee (other than a social worker or chaplain), officer, director, or partner of a healthcare provider (or any parent organization of such healthcare provider) directly serving the person at this time.
- Not aware that I am entitled to or have a claim against the person’s estate.

Witness Number: |
Signature: |
Date: |

## Additional Resources Included in Document

Entry 2 - fullUrl = http://www.example.org/fhir/Patient/Example-Smith-Johnson-Patient1

Resource Patient:

> 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
> US Core Race Extension: | ombCategory: CDC Race and Ethnicity 2106-3: White text: White

Entry 3 - fullUrl = http://www.example.org/fhir/PractitionerRole/Example-Kyle-Anydoc-PractitionerRole1

Resource PractitionerRole:

> Profile: US Core PractitionerRole Profile

> practitioner: Practitioner Kyle Anydoc

Entry 4 - fullUrl = http://www.example.org/fhir/Practitioner/Example-Kyle-Anydoc-Practitioner

Resource Practitioner:

> Profile: US Core Practitioner Profile

> identifier: United States National Provider Identifier/1818345971

> name: Kyle Anydoc

> telecom: kanydoc@example.org

> gender: Male

> address: 567 Healthcare Drive Anytown MA 12345 US (home)

> ### Qualifications

> - | Code
> * | Doctor of Medicine

Entry 5 - fullUrl = http://www.example.org/fhir/Organization/Example-Smith-Johnson-OrganizationCustodian1

Resource Organization:

> Profile: US Core Organization Profile

> identifier: United States National Provider Identifier/1234567893

> active: true

> name: example.org

> ### Contacts

> - | Telecom | Address
> * | +1(202)776-7700 | 740 E. Campbell Rd. Suite 825 Richardson TX 75081 US

Entry 6 - fullUrl = http://www.example.org/fhir/ServiceRequest/Example-Smith-Johnson-CPR-ServiceRequest1

Resource ServiceRequest:

> Profile: ADI PMO Cardiopulmonary Resuscitation ServiceRequest

> status: Active

> intent: Directive

> category: Cardiopulmonary resuscitation orders

> doNotPerform: true

> code: No display for ServiceRequest.code (concept: Yes CPR)

> orderDetail: No display for ServiceRequest.orderDetail ()

> subject: Smith-Johnson, Betsy Female, DoB: 1950-11-15 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1PA3D58WH16)

> requester: Practitioner Kyle Anydoc

Entry 7 - fullUrl = http://www.example.org/fhir/Observation/Example-Smith-Johnson-DocumentationObservation2

Resource Observation:

> PMOLST Order Observation

> Order Exists: available here

Entry 8 - fullUrl = http://www.example.org/fhir/PractitionerRole/ADI-Facilitator-MSW-MargaretReynolds

Resource PractitionerRole:

> Profile: ADI Facilitator

> active: true

> practitioner: Margaret A. Reynolds

> organization: Example Organization

> code: primary performer

> specialty: Clinical Social Worker

> endpoint: Endpoint Good Health Clinic Endpoint

Entry 9 - fullUrl = http://www.example.org/fhir/Practitioner/Practitioner-MargaretReynolds

Resource Practitioner:

> identifier: `http://example.org/fhir/MI-state-license`/86420

> active: true

> name: Margaret Q. Reynolds

> telecom: ph: (555) 391-9414

> gender: Female

> address: 18051 Mack Ave, Detroit, MI 48224

Entry 10 - fullUrl = http://www.example.org/fhir/Endpoint/Example-Smith-Johnson-Endpoint2

Resource Endpoint:

> identifier: `https://example.org/GoodHealth-Clinic`/PatientCorrection

> status: Active

> connectionType: HL7 FHIR

> name: Good Health Clinic Endpoint

> address: https://example.org/address

Entry 11 - fullUrl = http://www.example.org/fhir/Consent/Example-Smith-Johnson-HealthcareAgentConsent-Permit

Resource Consent:

> I am consenting for my son Charles to be my authorized personal representative (primary healthcare agent) and I am permitting him to make decisions on my behalf about intubation.

Entry 12 - fullUrl = http://www.example.org/fhir/Consent/Example-Smith-Johnson-HealthcareAgentConsent-Deny

Resource Consent:

> I am consenting for my son Charles to be my primary healthcare agent and I am denying him to make decisions on my behalf about nutrition.

Entry 13 - fullUrl = http://www.example.org/fhir/RelatedPerson/Example-Smith-Johnson-HealthcareAgent1

Resource RelatedPerson:

> 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]

Entry 14 - fullUrl = http://www.example.org/fhir/Provenance/Example-Smith-Johnson-PMOProvenance1

Resource Provenance:

> Profile: ADI Provenance

> Provenance for Composition Portable Medical Order

> Summary

> Recorded | 2021-03-29 14:25:34-0500

> Agents

> Type | who
> Assembler | Organization GoodHealth Clinic

Entry 15 - fullUrl = http://www.example.org/fhir/Organization/Example-Smith-Johnson-OrganizationAssembler1

Resource Organization:

> Profile: US Core Organization Profile

> identifier: `http://example.org/GoodHealthClinic/id`/12c5dcee5089494ca1ca0cb428ed3fff

> active: true

> name: GoodHealth Clinic

> ### Contacts

> - | Telecom | Address
> * | +1(202)776-7700 | 740 E. Campbell Rd. Suite 825 Richardson TX 75081 US