PACIO Advance Healthcare Directive Interoperability Implementation Guide
2.0.0 - STU 2 – Ballot United States of America flag

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 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-pacio-adi/ and changes regularly. See the Directory of published versions

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

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:trueMarital Status:unknown
Other Id:Medical Record Number/1032702 (use: usual)
Contact Detail
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:

Document Content

Example Source Form - Betsy Smith-Johnson

I understand the purpose and effect of this Advance Directive, I agree with everything that is written in this form, and I have made this advance directive knowingly, willingly and after careful deliberation.

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:trueMarital Status:unknown
Other Id:Medical Record Number/1032702 (use: usual)
Contact Detail
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:

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

Resource PractitionerRole:

Kyle Anydoc (http://hl7.org/fhir/sid/us-npi#United States National Provider Identifier#1818345971)

Practitioner:Kyle Anydoc (http://hl7.org/fhir/sid/us-npi#United States National Provider Identifier#1818345971)
Contact Detail

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

Resource Practitioner:

Kyle Anydoc (http://hl7.org/fhir/sid/us-npi#United States National Provider Identifier#1818345971)

Gender:Male
Contact Detail
Qualification:Doctor of Medicine

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

Resource Organization:

example.org (http://hl7.org/fhir/sid/us-npi#United States National Provider Identifier#1234567893)

Active:true
Contact Detail

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

Resource 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: Kyle Anydoc (http://hl7.org/fhir/sid/us-npi#United States National Provider Identifier#1818345971)

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:

Margaret A. Reynolds: primary performer at Example Organization

Active:true
Practitioner:Margaret A. Reynolds
Organization:Example Organization
Role:primary performer
Specialty:Clinical Social Worker
Endpoint:Good Health Clinic Endpoint (HL7 FHIR (Endpoint Connection Type#hl7-fhir-rest)): https://example.org/address

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

Resource Practitioner:

Margaret Q. Reynolds (http://example.org/fhir/MI-state-license#86420)

Active:trueGender:Female
Contact Detail
  • ph: (555) 391-9414
  • 18051 Mack Ave, Detroit, MI 48224

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

Resource Endpoint:

Good Health Clinic Endpoint (HL7 FHIR): https://example.org/address

Status:Active
Address:https://example.org/address
Connection Type:HL7 FHIR
Payload:
  • Payload Type: For documents following C-CDA constraints using a structured body

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:

Provenance for Composition Portable Medical Order

Summary

Recorded2021-03-29 14:25:34-0500

Agents

Typewho
AssemblerGoodHealth Clinic (http://example.org/GoodHealthClinic/id#12c5dcee5089494ca1ca0cb428ed3fff)

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

Resource Organization:

GoodHealth Clinic (http://example.org/GoodHealthClinic/id#12c5dcee5089494ca1ca0cb428ed3fff)

Active:true
Contact Detail

Entry 16 - fullUrl = http://www.example.org/fhir/Binary/Example-Stub-SourceForm-Smith-Johnson-Binary

Resource Binary:

contentType: application/pdf

data: JVBERi0xLjMKJcTl8uXrp/Og0MTGCjMg... (base64 data - 14,712 base64 chars)