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
MHAD Source Form for Betsy Smith-Johnson
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.
Appointment of a Primary Healthcare Agent and Alternate Healthcare Agents
I am appointing my son, Charles Johnson, as my healthcare agent
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
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
Notary Charles Xavier
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]
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
Goals, preferences, and priorities regarding the appointment of healthcare agents Narrative - Reported