Generated Narrative: Composition PMO-Example-Smith-Johnson-PMOComposition1 Language: en-US Profile: ADI PMO Composition Composition Version Number: 2024-03-29T14:25:34-05:00 Data Enterer: Smith-Johnson, Betsy Female, DoB: 1950-11-15 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#1PA3D58WH16) Participant: PractitionerRole: telecom = kanydoc@example.org(Work) ADI Expiration Date: 2024-03-29 14:25:34-0500 Performer: PractitionerRole: telecom = kanydoc@example.org(Work) Informant: RelatedPerson Johnson, Charles Revoke Status: deprecated Clause Clause: Example Clause Statement identifier: http://example.org/GoodHealthClinic/id/0-87f37989294a408897aacd1fc5d8fd16 status: Final type: Portable medical order form category: Clinical note, Advance healthcare directives date: 2023-03-29 14:25:34-0500 author: PractitionerRole: telecom = kanydoc@example.org(Work) title: Portable Medical Order Attesters - Mode Party * Legal PractitionerRole: telecom = kanydoc@example.org(Work) custodian: Organization example.org event detail: PractitionerRole primary performer Example-Smith-Johnson-HealthcareAgentConsent-Permit Example-Smith-Johnson-HealthcareAgentConsent-Deny
Example Clause Statement
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.
PMO Medical Orders Order Exists: available here
PMOLST Order Observation Order Exists: available here
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:
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
Generated Narrative: PractitionerRole Example-Kyle-Anydoc-PractitionerRole1 Profile: US Core PractitionerRole Profile practitioner: Practitioner Kyle Anydoc telecom: kanydoc@example.org
Generated Narrative: Practitioner Example-Kyle-Anydoc-Practitioner Profile: US Core Practitioner Profile identifier: United States National Provider Identifier/1818345971 name: Kyle Anydoc telecom: kanydoc@example.org address: 567 Healthcare Drive Anytown MA 12345 US (home) gender: Male Qualifications - Code * Doctor of Medicine
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: ServiceRequest Example-Smith-Johnson-CPR-ServiceRequest1 Profile: ADI PMO Cardiopulmonary Resuscitation ServiceRequest status: Active intent: Directive category: Cardiopulmonary resuscitation orders doNotPerform: true code: Yes CPR orderDetail: Yes CPR 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
Generated Narrative: PractitionerRole ADI-Facilitator-MSW-MargaretReynolds 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
Generated Narrative: Practitioner Practitioner-MargaretReynolds identifier: http://example.org/fhir/MI-state-license/86420 active: true name: Margaret Q. Reynolds telecom: ph: (555) 391-9414 address: 18051 Mack Ave, Detroit, MI 48224 gender: Female
Generated Narrative: Endpoint Example-Smith-Johnson-Endpoint2 identifier: https://example.org/GoodHealth-Clinic/PatientCorrection status: Active connectionType: Endpoint Connection Type: hl7-fhir-rest (HL7 FHIR) name: Good Health Clinic Endpoint payloadType: For documents following C-CDA constraints using a structured body address: https://example.org/address
For documents following C-CDA constraints using a structured body
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.
Goals, preferences, and priorities regarding the appointment of healthcare agents Narrative - Reported
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.
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]
Generated Narrative: Provenance Example-Smith-Johnson-PMOProvenance1 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
Generated Narrative: Organization Example-Smith-Johnson-OrganizationAssembler1 Profile: US Core Organization Profile identifier: http://example.org/GoodHealthClinic/id/12c5dcee5089494ca1ca0cb428ed3fff active: true name: GoodHealth Clinic telecom: +1(202)776-7700 address: 740 E. Campbell Rd. Suite 825 Richardson TX 75081 US