MHAD-Example-Smith-Johnson-Bundle3
type: Bundle
node role: treeRoot
resource.id:
  value: MHAD-Example-Smith-Johnson-Bundle3
resource.language:
  value: en
bundle.identifier:
  identifier.system:
    value: https://example.org/GoodHealth-Clinic
bundle.type:
  value: document
bundle.timestamp:
  value: 2024-03-29T14:25:34.001-05:00
bundle.entry:
  index: -1
  bundle.entry.full url:
    value: http://www.example.org/fhir/Composition/MHAD-Example-Smith-Johnson-Composition
  bundle.entry.resource: MHAD-Example-Smith-Johnson-Composition
bundle.entry:
  index: -1
  bundle.entry.full url:
    value: http://www.example.org/fhir/Organization/Example-Smith-Johnson-OrganizationCustodian1
  bundle.entry.resource: Example-Smith-Johnson-OrganizationCustodian1
bundle.entry:
  index: -1
  bundle.entry.full url:
    value: http://www.example.org/fhir/Patient/Example-Smith-Johnson-Patient1
  bundle.entry.resource: Example-Smith-Johnson-Patient1
bundle.entry:
  index: -1
  bundle.entry.full url:
    value: http://www.example.org/fhir/RelatedPerson/Example-Smith-Johnson-Notary2
  bundle.entry.resource: Example-Smith-Johnson-Notary2
bundle.entry:
  index: -1
  bundle.entry.full url:
    value: http://www.example.org/fhir/RelatedPerson/Example-Smith-Johnson-HealthcareAgent3
  bundle.entry.resource: Example-Smith-Johnson-HealthcareAgent3
bundle.entry:
  index: -1
  bundle.entry.full url:
    value: http://www.example.org/fhir/Consent/Example-Smith-Johnson-HealthcareAgentConsent2
  bundle.entry.resource: Example-Smith-Johnson-HealthcareAgentConsent2
bundle.entry:
  index: -1
  bundle.entry.full url:
    value: http://www.example.org/fhir/Binary/MHAD-Example-Smith-Johnson-Binary
  bundle.entry.resource: MHAD-Example-Smith-Johnson-Binary

MHAD-Example-Smith-Johnson-Composition
type: Composition
resource.id:
  value: MHAD-Example-Smith-Johnson-Composition
resource.meta:
  meta.profile:
    value: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PACPComposition
    index: -1
    link: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PACPComposition
resource.language:
  value: en
domain resource.text:
  narrative.status:
    value: extensions
  narrative.div: Generated Narrative: Composition MHAD-Example-Smith-Johnson-Composition Language: en-US Profile: ADI Person-Authored 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: Clinical note, 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
domain resource.extension:
  index: -1
  extension.url:
    value: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
  extension.value string:
    value: 2024-12-22T05:00:00+00:00
composition.identifier:
  identifier.system:
    value: https://example.org/standards/terminology/namingSystem/setId
composition.status:
  value: final
composition.type:
  codeable concept.coding: http://loinc.org/rdf#104144-1
    index: -1
    coding.system:
      value: http://loinc.org
    coding.code:
      value: 104144-1
    coding.display:
      value: Mental health Advance directives
composition.category:
  index: -1
  codeable concept.coding: http://loinc.org/rdf#107903-7
    index: -1
    coding.system:
      value: http://loinc.org
    coding.code:
      value: 107903-7
    coding.display:
      value: Clinical note
composition.category:
  index: -1
  codeable concept.coding: http://loinc.org/rdf#42348-3
    index: -1
    coding.system:
      value: http://loinc.org
    coding.code:
      value: 42348-3
    coding.display:
      value: Advance healthcare directives
composition.subject:
  link: http://hl7.org/fhir/us/pacio-adi/Patient/Example-Smith-Johnson-Patient1
  reference.reference:
    value: Patient/Example-Smith-Johnson-Patient1
composition.date:
  value: 2024-12-22T05:00:00+00:00
composition.author:
  index: -1
  link: http://hl7.org/fhir/us/pacio-adi/Patient/Example-Smith-Johnson-Patient1
  reference.reference:
    value: Patient/Example-Smith-Johnson-Patient1
  reference.display:
    value: Betsy Smith-Johnson
composition.title:
  value: Mental Health Directive (Maryland)
composition.attester:
  index: -1
  composition.attester.mode:
    value: personal
composition.custodian:
  link: http://hl7.org/fhir/us/pacio-adi/Organization/Example-Smith-Johnson-OrganizationCustodian1
  reference.reference:
    value: Organization/Example-Smith-Johnson-OrganizationCustodian1
composition.section:
  index: -1
  composition.section.title:
    value: MHAD Source Form for Betsy Smith-Johnson
  composition.section.code:
    codeable concept.coding:
      index: -1
      coding.system:
        value: http://hl7.org/fhir/us/pacio-adi/CodeSystem/adi-temp-cs
      coding.code:
        value: advance_directive_source_form
  composition.section.text:
    narrative.status:
      value: additional
    narrative.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.
  composition.section.entry:
    index: -1
    link: http://hl7.org/fhir/us/pacio-adi/Binary/MHAD-Example-Smith-Johnson-Binary
    reference.reference:
      value: Binary/MHAD-Example-Smith-Johnson-Binary
composition.section:
  index: -1
  composition.section.title:
    value: Appointment of a Primary Healthcare Agent and Alternate Healthcare Agents
  composition.section.code:
    codeable concept.coding: http://loinc.org/rdf#81335-2
      index: -1
      coding.system:
        value: http://loinc.org
      coding.code:
        value: 81335-2
      coding.display:
        value: Healthcare Agent
  composition.section.text:
    narrative.status:
      value: additional
    narrative.div: I am appointing my son, Charles Johnson, as my healthcare agent
  composition.section.entry:
    index: -1
    link: http://hl7.org/fhir/us/pacio-adi/RelatedPerson/Example-Smith-Johnson-Notary2
    reference.reference:
      value: RelatedPerson/Example-Smith-Johnson-Notary2
  composition.section.entry:
    index: -1
    link: http://hl7.org/fhir/us/pacio-adi/RelatedPerson/Example-Smith-Johnson-HealthcareAgent3
    reference.reference:
      value: RelatedPerson/Example-Smith-Johnson-HealthcareAgent3
  composition.section.entry:
    index: -1
    link: http://hl7.org/fhir/us/pacio-adi/Consent/Example-Smith-Johnson-HealthcareAgentConsent2
    reference.reference:
      value: Consent/Example-Smith-Johnson-HealthcareAgentConsent2

Example-Smith-Johnson-OrganizationCustodian1
type: Organization
resource.id:
  value: Example-Smith-Johnson-OrganizationCustodian1
resource.meta:
  meta.profile:
    value: http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization
    index: -1
    link: http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization
resource.language:
  value: en
domain resource.text:
  narrative.status:
    value: generated
  narrative.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
organization.identifier:
  index: -1
  identifier.system:
    value: http://hl7.org/fhir/sid/us-npi
  identifier.value:
    value: 1234567893
organization.active:
  value: true
organization.name:
  value: example.org
organization.telecom:
  index: -1
  contact point.system:
    value: phone
  contact point.value:
    value: +1(202)776-7700
  contact point.use:
    value: work
organization.address:
  index: -1
  address.type:
    value: physical
  address.line:
    value: 740 E. Campbell Rd. Suite 825
    index: -1
  address.city:
    value: Richardson
  address.state:
    value: TX
  address.postal code:
    value: 75081
  address.country:
    value: US

Example-Smith-Johnson-Patient1
type: Patient
resource.id:
  value: Example-Smith-Johnson-Patient1
resource.meta:
  meta.last updated:
    value: 2021-03-29T14:25:34.001-05:00
  meta.profile:
    value: http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient
    index: -1
    link: http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient
resource.language:
  value: en
domain resource.text:
  narrative.status:
    value: generated
  narrative.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 [Race & Ethnicity - CDC (CDCREC)](https://phinvads.cdc.gov/vads/ViewCodeSystem.action?id=2.16.840.1.113883.6.238) code system. Detailed 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
domain resource.extension:
  index: -1
  element.extension:
    index: -1
    extension.url:
      value: ombCategory
    extension.value coding:
      coding.system:
        value: urn:oid:2.16.840.1.113883.6.238
      coding.code:
        value: 2106-3
      coding.display:
        value: White
  element.extension:
    index: -1
    extension.url:
      value: text
    extension.value string:
      value: White
  extension.url:
    value: http://hl7.org/fhir/us/core/StructureDefinition/us-core-race
patient.identifier:
  index: -1
  identifier.use:
    value: usual
  identifier.type:
    codeable concept.coding:
      index: -1
      coding.system:
        value: http://terminology.hl7.org/CodeSystem/v2-0203
      coding.code:
        value: MR
      coding.display:
        value: Medical Record Number
    codeable concept.text:
      value: Medical Record Number
  identifier.system:
    value: http://example.org/GoodHealthHospital
  identifier.value:
    value: 1032702
patient.identifier:
  index: -1
  identifier.system:
    value: http://hl7.org/fhir/sid/us-medicare
  identifier.value:
    value: 1PA3D58WH16
patient.active:
  value: true
patient.name:
  index: -1
  human name.use:
    value: usual
  human name.text:
    value: Smith-Johnson, Betsy
  human name.family:
    value: Smith-Johnson
  human name.given:
    value: Betsy
    index: -1
patient.telecom:
  index: -1
  contact point.system:
    value: email
  contact point.use:
    value: home
patient.gender:
  value: female
patient.birth date:
  value: 1950-11-15
patient.address:
  index: -1
  address.use:
    value: home
  address.type:
    value: physical
  address.line:
    value: 111 Maple Court
    index: -1
  address.city:
    value: San Antonio
  address.state:
    value: TX
  address.postal code:
    value: 78212
  address.country:
    value: US
patient.marital status:
  codeable concept.coding:
    index: -1
    coding.system:
      value: http://terminology.hl7.org/CodeSystem/v3-NullFlavor
    coding.code:
      value: UNK
patient.contact:
  index: -1
  patient.contact.relationship:
    index: -1
    codeable concept.coding:
      index: -1
      coding.system:
        value: http://terminology.hl7.org/CodeSystem/v3-RoleCode
      coding.code:
        value: SONC
  patient.contact.name:
    human name.text:
      value: Charles Johnson
  patient.contact.telecom:
    index: -1
    contact point.system:
      value: phone
    contact point.value:
      value: (210) 222-3333
  patient.contact.address:
    address.text:
      value: 111 Maple Ct, Grand Rapids, MI 49503
patient.contact:
  index: -1
  patient.contact.relationship:
    index: -1
    codeable concept.coding:
      index: -1
      coding.system:
        value: http://terminology.hl7.org/CodeSystem/v3-RoleCode
      coding.code:
        value: DAUC
  patient.contact.name:
    human name.text:
      value: Debra Johnson
  patient.contact.telecom:
    index: -1
    contact point.system:
      value: phone
    contact point.value:
      value: (410) 444-5555
  patient.contact.address:
    address.text:
      value: 333 W. Camden St., Baltimore, MD 21201
patient.communication:
  index: -1
  patient.communication.language:
    codeable concept.coding:
      index: -1
      coding.system:
        value: urn:ietf:bcp:47
      coding.code:
        value: en
      coding.display:
        value: English
  patient.communication.preferred:
    value: true

Example-Smith-Johnson-Notary2
type: RelatedPerson
resource.id:
  value: Example-Smith-Johnson-Notary2
resource.meta:
  meta.profile:
    value: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-HealthcareAgentParticipant
    index: -1
    link: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-HealthcareAgentParticipant
resource.language:
  value: en
domain resource.text:
  narrative.status:
    value: additional
  narrative.div: Notary Charles Xavier
domain resource.extension:
  index: -1
  element.extension:
    index: -1
    extension.url:
      value: NotaryCommissionState
    extension.value codeable concept:
      codeable concept.coding:
        index: -1
  extension.url:
    value: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-notaryInformation-extension
related person.active:
  value: true
related person.patient:
  link: http://hl7.org/fhir/us/pacio-adi/Patient/Example-Smith-Johnson-Patient1
  reference.reference:
    value: Patient/Example-Smith-Johnson-Patient1
related person.relationship:
  index: -1
  codeable concept.coding:
    index: -1
    coding.system:
      value: http://terminology.hl7.org/CodeSystem/v3-RoleCode
    coding.code:
      value: SON
    coding.display:
      value: natural son
related person.name:
  index: -1
  human name.text:
    value: Johnson, Charles
  human name.family:
    value: Johnson
  human name.given:
    value: Charles
    index: -1
related person.telecom:
  index: -1
  contact point.system:
    value: email
  contact point.use:
    value: home

Example-Smith-Johnson-HealthcareAgent3
type: RelatedPerson
resource.id:
  value: Example-Smith-Johnson-HealthcareAgent3
resource.meta:
  meta.profile:
    value: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-HealthcareAgentParticipant
    index: -1
    link: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-HealthcareAgentParticipant
resource.language:
  value: en
domain resource.text:
  narrative.status:
    value: additional
  narrative.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]
related person.active:
  value: true
related person.patient:
  link: http://hl7.org/fhir/us/pacio-adi/Patient/Example-Smith-Johnson-Patient1
  reference.reference:
    value: Patient/Example-Smith-Johnson-Patient1
related person.relationship:
  index: -1
  codeable concept.coding:
    index: -1
    coding.system:
      value: http://terminology.hl7.org/CodeSystem/v3-RoleCode
    coding.code:
      value: SON
    coding.display:
      value: natural son
related person.name:
  index: -1
  human name.text:
    value: Johnson, Charles
  human name.family:
    value: Johnson
  human name.given:
    value: Charles
    index: -1
related person.telecom:
  index: -1
  contact point.system:
    value: email
  contact point.use:
    value: home

Example-Smith-Johnson-HealthcareAgentConsent2
type: Consent
resource.id:
  value: Example-Smith-Johnson-HealthcareAgentConsent2
resource.meta:
  meta.profile:
    value: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-HealthcareAgentConsentPermit
    index: -1
    link: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-HealthcareAgentConsentPermit
resource.language:
  value: en
domain resource.text:
  narrative.status:
    value: additional
  narrative.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
consent.status:
  value: active
consent.scope:
  codeable concept.coding: http://loinc.org/rdf#81377-4
    index: -1
    coding.system:
      value: http://loinc.org
    coding.code:
      value: 81377-4
    coding.display:
      value: Goals, preferences, and priorities regarding the appointment of healthcare agents Narrative - Reported
consent.category:
  index: -1
  codeable concept.coding:
    index: -1
    coding.system:
      value: http://terminology.hl7.org/CodeSystem/consentcategorycodes
    coding.version:
      value: 1.0.1
    coding.code:
      value: acd
    coding.display:
      value: Advance Directive
consent.patient:
  link: http://hl7.org/fhir/us/pacio-adi/Patient/Example-Smith-Johnson-Patient1
  reference.reference:
    value: Patient/Example-Smith-Johnson-Patient1
consent.date time:
  value: 2020-08-03
consent.policy:
  index: -1
  consent.policy.uri:
    value: http://example.org/healthcare-agent-policy
consent.provision:
  consent.provision.type:
    value: permit
  consent.provision.actor:
    index: -1
    consent.provision.actor.role:
      codeable concept.coding: http://loinc.org/rdf#75783-1
        index: -1
    consent.provision.actor.reference:
      link: http://hl7.org/fhir/us/pacio-adi/RelatedPerson/Example-Smith-Johnson-HealthcareAgent3
      reference.reference:
        value: RelatedPerson/Example-Smith-Johnson-HealthcareAgent3
  consent.provision.action:
    index: -1
    codeable concept.coding:
      index: -1
      coding.system:
        value: http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIHCADecisionsCS
      coding.code:
        value: intubation
      coding.display:
        value: Intubation
  consent.provision.action:
    index: -1
    codeable concept.coding:
      index: -1
      coding.system:
        value: http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIHCADecisionsCS
      coding.code:
        value: tube-feeding
      coding.display:
        value: Tube feeding
  consent.provision.action:
    index: -1
    codeable concept.coding:
      index: -1
      coding.system:
        value: http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIHCADecisionsCS
      coding.code:
        value: life-support
      coding.display:
        value: Life support
  consent.provision.action:
    index: -1
    codeable concept.coding:
      index: -1
      coding.system:
        value: http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIHCADecisionsCS
      coding.code:
        value: iv-fluid-and-support
      coding.display:
        value: IV fluid and support
  consent.provision.action:
    index: -1
    codeable concept.coding:
      index: -1
      coding.system:
        value: http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIHCADecisionsCS
      coding.code:
        value: antibiotics
      coding.display:
        value: Antibiotics
  consent.provision.action:
    index: -1
    codeable concept.coding:
      index: -1
      coding.system:
        value: http://hl7.org/fhir/us/pacio-adi/CodeSystem/ADIHCADecisionsCS
      coding.code:
        value: resuscitation-non-cpr
      coding.display:
        value: Non-CPR Resuscitation
  consent.provision.purpose:
    index: -1
    coding.system:
      value: http://terminology.hl7.org/CodeSystem/v3-ActReason
    coding.code:
      value: PWATRNY

MHAD-Example-Smith-Johnson-Binary
type: Binary
resource.id:
  value: MHAD-Example-Smith-Johnson-Binary
resource.meta:
  meta.profile:
    value: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-ADISourceFormInformation
    index: -1
    link: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-ADISourceFormInformation
resource.language:
  value: en
binary.content type:
  value: application/pdf

value: urn:iso:std:iso:3166:-2

value: US-MI

value: 75783-1

value: Primary healthcare agent [Reported]