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

This page is part of the PACIO Advance Directive Information Implementation Guide (v2.0.0-ballot: STU 2 Ballot) based on FHIR (HL7® FHIR® Standard) R4. This version is a pre-release. The current official version is 1.0.0. For a full list of available versions, 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:
  • 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: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:
  • 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:

practitioner: Practitioner Kyle Anydoc

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

Resource Practitioner:

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:

identifier: United States National Provider Identifier/1234567893

active: true

name: example.org

Contacts

-TelecomAddress
*+1(202)776-7700740 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:

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:

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:

Provenance for Composition Portable Medical Order

Summary

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

Agents

Typewho
AssemblerOrganization GoodHealth Clinic

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

Resource Organization:

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

active: true

name: GoodHealth Clinic

Contacts

-TelecomAddress
*+1(202)776-7700740 E. Campbell Rd. Suite 825 Richardson TX 75081 US