HL7 Implementation Guide for CDA Release 2

CDAR2_IG_PACP_R1_DSTU1.0_2015NOV_ Vol2_Introductory_Material Project Insight: 1204

HL7 Implementation Guide for CDA® Release 2: Personal Advance Care Plan Document (US Realm) Draft Standard for Trial Use Release 1.0 Volume 2 — Templates and Supporting Material November 2015

Publication of this draft standard for trial use and comment has been approved by Health Level Seven International (HL7). This draft standard is not an accredited American National Standard. The comment period for use of this draft standard shall end 24 months from the date of publication. Suggestions for revision should be submitted at http://www.hl7.org/dstucomments/index.cfm. Following this 24 month evaluation period, this draft standard, revised as necessary, will be submitted to a normative ballot in preparation for approval by ANSI as an American National Standard. Implementations of this draft standard shall be viable throughout the normative ballot process and for up to six months after publication of the relevant normative standard.

Sponsored by: Structured Documents Work Group Patient Care Work Group

HL7 CDA R2 IG: Personal Advance Care Plan (US Realm), DSTU R1.0—Vol. 2: Templates and Supporting Material Page 1 Nov 2015 © 2015 Health Level Seven, Inc. All rights reserved. Copyright © 2015 Health Level Seven International ® ALL RIGHTS RESERVED. The reproduction of this material in any form is strictly forbidden without the written permission of the publisher. HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. Pat & TM Off. Use of this material is governed by HL7's IP Compliance Policy.

Personal Advance Care Plan November 16 Page 2 Table of Contents

Table of Figures

Table of Tables

Personal Advance Care Plan Document - Draft [ClinicalDocument: identifier urn:hl7ii:2.16.840.1.113883.4.823.1.1.1:2015- 10-13 (open)]

Table 1: Personal Advance Care Plan Document Contexts

Contained By: Contains: Personal Advance Directives Section

This template can be used to create a patient generated document which is authored by the subject of the document (the recordTarget). It expresses the person's goals, preferences, and priorities (GPPs) for care and treatment under certain future conditions.The content of this document may include appointment of Health Care Agents (a.k.a. durable power of attorney for health care) and other instructions for Health Care Agents or statements related to execution of the advance care plan. It may include GPPs for care and treatment at end of life, GPPs upon or following death, and other personal GPPs that can be considered when planning the care experience.

Table 2: Personal Advance Care Plan Document Constraints Overview

XPath Card. Verb Data CONF# Value Type ClinicalDocument (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.1.1:2015-10-13) templateId 1..1 SHALL 2211- 32944 @root 1..1 SHALL 2211- 2.16.840.1.113883.4.823.1.1.1 32945 @extension 1..1 SHALL 2211- 2015-10-13 32946 templateId 1..1 SHALL 2211- 32947 @root 1..1 SHALL 2211- 2.16.840.1.113883.4.823.1.2.1 32948 @extension 1..1 SHALL 2211- 2015-10-13 32949 component 1..1 SHALL 2211- 32995 structuredBody 1..1 SHALL 2211- 32996 component 1..* SHALL 2211- 32997 section 1..1 SHALL 2211- Personal Advance Directives Section 32998 (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1. 3.1:2015-10-13

Personal Advance Care Plan November 16 Page 4 1. SHALL contain exactly one [1..1] templateId (CONF:2211-32944) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.823.1.1.1" (CONF:2211-32945). b. SHALL contain exactly one [1..1] @extension="2015-10-13" (CONF:2211-32946). 2. SHALL contain exactly one [1..1] templateId (CONF:2211-32947) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.823.1.2.1" (CONF:2211-32948). b. SHALL contain exactly one [1..1] @extension="2015-10-13" (CONF:2211-32949). 3. SHALL contain exactly one [1..1] component (CONF:2211-32995). a. This component SHALL contain exactly one [1..1] structuredBody (CONF:2211-32996). a.i. This structuredBody SHALL contain at least one [1..*] component (CONF:2211-32997). a.i.1. Such components SHALL contain exactly one [1..1] Personal Advance Directives Section (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.3.1:2015-10-13) (CONF:2211-32998).

Personal Advance Care Plan Header - Draft [ClinicalDocument: identifier urn:hl7ii:2.16.840.1.113883.4.823.1.2.1:2015- 10-13 (open)] This template is further constraint of the US Realm Patient Generated Document Header (V2) which in turn further constrains the US Realm Header (V3). The Personal Advance Care Plan Header further constrains the Patient Generated Document Header to address specific information exchange requirements for a document containing a person's advance care plan directives.

Table 3: Personal Advance Care Plan Header Constraints Overview

XPath Card. Verb Data CONF# Value Type ClinicalDocument (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.2.1:2015-10-13) templateId 1..1 SHALL 2211- 28458 @root 1..1 SHALL 2211- 2.16.840.1.113883.4.823.1.2.1 28459 @extension 1..1 SHALL 2211- 2015-10-13 32917 templateId 1..1 SHALL 2211- 33009 @root 1..1 SHALL 2211- 2.16.840.1.113883.10.20.29.1 33010 @extension 1..1 SHALL 2211- 2015-08-01 33011 recordTarget 1..1 SHALL 2211- 28460 patientRole 1..1 SHALL 2211- 28461 id 1..* SHALL 2211-

HL7 CDA R2 IG: Personal Advance Care Plan (US Realm), DSTU R1.0—Vol. 2: Templates and Supporting Material Page 5 Nov 2015 © 2015 Health Level Seven, Inc. All rights reserved. 28462 patient 1..1 SHALL 2211- 28465 guardian 0..* MAY 2211- 28469 id 0..* SHOUL 2211- D 28470 code 0..1 SHOUL 2211- urn:oid:2.16.840.1.113883.11.20.12.1 D 28473 (Personal And Legal Relationship Role Type) languageCommunication 0..* SHOUL 2211- D 28474 preferenceInd 0..1 MAY 2211- 28475 providerOrganization 0..1 MAY 2211- 28476 author 1..* SHALL 2211- 28477 assignedAuthor 1..1 SHALL 2211- 28478 id 1..* SHALL 2211- 28479 code 0..1 SHOUL 2211- D 28481 @code 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.11.20.12.1 28676 (Personal And Legal Relationship Role Type) assignedAuthoringDevice 0..0 SHALL 2211- NOT 33108 dataEnterer 0..1 MAY 2211- 28678 assignedEntity 1..1 SHALL 2211- 28679 code 0..1 MAY 2211- urn:oid:2.16.840.1.113883.11.20.12.1 28680 (Personal And Legal Relationship Role Type) custodian 1..1 SHALL 2211- 28685 assignedCustodian 1..1 SHALL 2211- 28686 representedCustodianOrganization 1..1 SHALL 2211- 28687 id 1..* SHALL 2211- 28688 informationRecipient 0..* MAY 2211- 28690 intendedRecipient 1..1 SHALL 2211- 28691

Personal Advance Care Plan November 16 Page 6 id 0..* SHOUL 2211- D 28692 @root 0..1 SHOUL 2211- D 28693 legalAuthenticator 0..1 MAY 2211- 28694 assignedEntity 1..1 SHALL 2211- 28695 id 1..* SHALL 2211- 28696 code 0..1 MAY 2211- 28697 @code 0..1 MAY 2211- urn:oid:2.16.840.1.113883.11.20.12.1 28698 (Personal And Legal Relationship Role Type) authenticator 0..* MAY 2211- 28699 assignedEntity 1..1 SHALL 2211- 28700 id 1..* SHALL 2211- 28701 code 0..1 SHOUL 2211- urn:oid:2.16.840.1.113883.11.20.12.1 D 28702 (Personal And Legal Relationship Role Type) participant 0..* MAY 2211- 28703 @typeCode 1..1 SHALL 2211- 28704 associatedEntity 1..1 SHALL 2211- 28705 code 0..1 SHOUL 2211- urn:oid:2.16.840.1.113883.11.20.12.1 D 28706 (Personal And Legal Relationship Role Type) inFulfillmentOf 0..* MAY 2211- 28707 order 1..1 SHALL 2211- 28708 id 1..* SHALL 2211- 28709 relatedDocument 0..* MAY 2211- 33012 parentDocument 1..1 SHALL 2211- 33013 id 1..* SHALL 2211- 33014 setId 1..1 SHALL 2211- 33015 versionNumber 1..1 SHALL 2211-

1. SHALL contain exactly one [1..1] templateId (CONF:2211-28458) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.823.1.2.1" (CONF:2211-28459). b. SHALL contain exactly one [1..1] @extension="2015-10-13" (CONF:2211-32917). 2. SHALL contain exactly one [1..1] templateId (CONF:2211-33009) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.29.1" (CONF:2211- 33010). b. SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:2211-33011). The recordTarget records the patient whose advance care plan directives are described by the clinical document. each recordTarget must contain at least one patientRole element. HL7 Vocabulary simply describes guardian as a relationship to a ward. This need not be a formal legal relationship. When a guardian relationship exists for the patient, it can be represented, regardless of who is present at the time the document is generated. This need not be a formal legal relationship. A child’s parent can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "mother" for the child’s mom or "father" for the child’s dad. An elderly person's child can be represented in the guardian role. In this case, the guardian/code element would encode the personal relationship of "daughter" or "son", or if a legal relationship existed, the relationship of "legal guardian" could be encoded.

3. SHALL contain exactly one [1..1] recordTarget (CONF:2211-28460). a. This recordTarget SHALL contain exactly one [1..1] patientRole (CONF:2211-28461). a.i. This patientRole SHALL contain at least one [1..*] id (CONF:2211-28462). a.ii. This patientRole SHALL contain exactly one [1..1] patient (CONF:2211-28465). a.ii.1. This patient MAY contain zero or more [0..*] guardian (CONF:2211-28469). a.ii.1.a. The guardian, if present, SHOULD contain zero or more [0..*] id (CONF:2211-28470). a.ii.1.b. The guardian, if present, SHOULD contain zero or one [0..1] code, which SHALL be selected from ValueSet Personal And Legal Relationship Role Type urn:oid:2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:2211-28473). a.ii.2. This patient SHOULD contain zero or more [0..*] languageCommunication (CONF:2211-28474). a.ii.2.a. The languageCommunication, if present, MAY contain zero or one [0..1] preferenceInd (CONF:2211-28475). Note: Indicates a preference for information about care delivery and treatments be communicated (or translated if needed) into this language.

If more than one languageCommunication is present, only one languageCommunication element SHALL have a preferenceInd with a value of 1.

If present, this organization represents the provider organization where the person is claiming to be a patient.

Personal Advance Care Plan November 16 Page 8 a.iii.This patientRole MAY contain zero or one [0..1] providerOrganization (CONF:2211- 28476). Note: If present, this organization represents the provider organization where the person is claiming to be a patient. The author element represents the creator of the clinical document. In this case of a Personal Advance Care Plan, the subject of the document (the recordTarget) is always the author as well.

4. SHALL contain at least one [1..*] author (CONF:2211-28477). a. Such authors SHALL contain exactly one [1..1] assignedAuthor (CONF:2211-28478). a.i. This assignedAuthor SHALL contain at least one [1..*] id (CONF:2211-28479). When the author is a person who is not acting in the role of a clinician, this code encodes the personal or legal relationship between author and the patient.

a.ii. This assignedAuthor SHOULD contain zero or one [0..1] code (CONF:2211-28481). a.ii.1. The code, if present, SHALL contain exactly one [1..1] @code, which SHOULD be selected from ValueSet Personal And Legal Relationship Role Type urn:oid:2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:2211- 28676). To indicate the name of the system used to assemble the person's original advance care planning information into a document for exchange, use a participant with typeCode DEV and assignedEntity classCode of ASSEMBLER. No personal advance care plan information is "generated" by a device. The information in a Personal Advance Care Plan document represents the person's own thoughts only.

a.iii.This assignedAuthor SHALL NOT contain [0..0] assignedAuthoringDevice (CONF:2211-33108). The dataEnterer element represents the person who transferred the content, of the person's directives (written or spoken) into the system used to create the document. The guiding rule of thumb is that an author provides the content found within the header or body of the document, subject to their own interpretation, and the dataEnterer adds that information to the electronic system. In other words, a dataEnterer records information provided by the author. If the dataEnterer is missing, this role is assumed to be played by the author.

5. MAY contain zero or one [0..1] dataEnterer (CONF:2211-28678). a. The dataEnterer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:2211- 28679). a.i. This assignedEntity MAY contain zero or one [0..1] code, which SHOULD be selected from ValueSet Personal And Legal Relationship Role Type urn:oid:2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:2211-28680). The custodian element represents the organization or person that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the "original" source document. Every CDA document has exactly one custodian. The custodian participation satisfies the CDA definition of Stewardship. Because CDA is an exchange standard and may not represent the original form of the authenticated document (e.g., CDA could include scanned copy of original), the custodian represents the steward of the original source document. The custodian may be the document originator, a health information exchange, or other responsible party. Also, the custodian may be the patient or an organization acting on behalf of the patient, such as a PHR organization.

6. SHALL contain exactly one [1..1] custodian (CONF:2211-28685). a. This custodian SHALL contain exactly one [1..1] assignedCustodian (CONF:2211-28686).

HL7 CDA R2 IG: Personal Advance Care Plan (US Realm), DSTU R1.0—Vol. 2: Templates and Supporting Material Page 9 Nov 2015 © 2015 Health Level Seven, Inc. All rights reserved. The representedCustodianOrganization may be the person when the document is not maintained by an organization.

a.i. This assignedCustodian SHALL contain exactly one [1..1] representedCustodianOrganization (CONF:2211-28687). The combined @root and @extension attributes record the custodian organization’s identity in a secure, trusted, and unique way.

a.i.1. This representedCustodianOrganization SHALL contain at least one [1..*] id (CONF:2211-28688). The informationRecipient element records the intended recipient of the information at the time the document is created.

7. MAY contain zero or more [0..*] informationRecipient (CONF:2211-28690). a. The informationRecipient, if present, SHALL contain exactly one [1..1] intendedRecipient (CONF:2211-28691). The combined @root and @extension attributes to record the information recipient’s identity in a secure, trusted, and unique way.

a.i. This intendedRecipient SHOULD contain zero or more [0..*] id (CONF:2211-28692). For a provider, the id/@root ="2.16.840.1.113883.4.6" indicates the National Provider Identifier where id/@extension is the NPI number for the provider. The ids MAY reference the id of a person or organization entity specified elsewhere in the document.

a.i.1. The id, if present, SHOULD contain zero or one [0..1] @root (CONF:2211- 28693). In a patient authored document, the legalAuthenticator identifies the single person legally responsible for the document and must be present if the document has been legally authenticated. (Note that per the following section, there may also be one or more document authenticators.) A Notary Public may serve a the legal authenticator of an advance directive. Based on local practice, patient authored documents may be provided without legal authentication. This implies that a patient authored document that does not contain this element has not been legally authenticated. The act of legal authentication requires a certain privilege be granted to the legal authenticator depending upon local policy. All patient documents have the potential for legal authentication, given the appropriate legal authority. Local policies MAY choose to delegate the function of legal authentication to a device or system that generates the document. In these cases, the legal authenticator is the person accepting responsibility for the document, not the generating device or system. Note that the legal authenticator, if present, must be a person.

8. MAY contain zero or one [0..1] legalAuthenticator (CONF:2211-28694). a. The legalAuthenticator, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:2211-28695). The combined @root and @extension attributes to record the information recipient’s identity in a secure, trusted, and unique way.

a.i. This assignedEntity SHALL contain at least one [1..*] id (CONF:2211-28696). a.ii. This assignedEntity MAY contain zero or one [0..1] code (CONF:2211-28697).

Personal Advance Care Plan November 16 Page 10 a.ii.1. The code, if present, MAY contain zero or one [0..1] @code, which SHOULD be selected from ValueSet Personal And Legal Relationship Role Type urn:oid:2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:2211- 28698). Individuals who witness the Advance Care Plan Directives play the role of authenticator.

9. MAY contain zero or more [0..*] authenticator (CONF:2211-28699). a. The authenticator, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:2211- 28700). The combined @root and @extension attributes to record the authenticator’s identity in a secure, trusted, and unique way.

a.i. This assignedEntity SHALL contain at least one [1..*] id (CONF:2211-28701). a.ii. This assignedEntity SHOULD contain zero or one [0..1] code, which SHOULD be selected from ValueSet Personal And Legal Relationship Role Type urn:oid:2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:2211-28702). The participant element identifies other supporting participants, including parents, relatives, next of kin, caregivers, insurance policyholders, guarantors, and other participants related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin)

10. MAY contain zero or more [0..*] participant (CONF:2211-28703). Unless otherwise specified by the document specific header constraints, when participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30

a. The participant, if present, SHALL contain exactly one [1..1] @typeCode (CONF:2211-28704). b. The participant, if present, SHALL contain exactly one [1..1] associatedEntity (CONF:2211- 28705). b.i. This associatedEntity SHOULD contain zero or one [0..1] code, which SHOULD be selected from ValueSet Personal And Legal Relationship Role Type urn:oid:2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:2211-28706). If the Advance Care Plan Directive was requested to be created by a specific request from a person or organization, then the requester and the requester's information may be included in the inFulfillmentOf element.

11. MAY contain zero or more [0..*] inFulfillmentOf (CONF:2211-28707). a. The inFulfillmentOf, if present, SHALL contain exactly one [1..1] order (CONF:2211-28708). A scheduled appointment or service event in a practice management system may be represented using this id element.

a.i. This order SHALL contain at least one [1..*] id (CONF:2211-28709). 12. MAY contain zero or more [0..*] relatedDocument (CONF:2211-33012). a. The relatedDocument, if present, SHALL contain exactly one [1..1] parentDocument (CONF:2211- 33013) such that it id shall reference a previously created Advance Care Plan Directives Document.

HL7 CDA R2 IG: Personal Advance Care Plan (US Realm), DSTU R1.0—Vol. 2: Templates and Supporting Material Page 11 Nov 2015 © 2015 Health Level Seven, Inc. All rights reserved. a.i. SHALL contain at least one [1..*] id (CONF:2211-33014). The setId shall include the prior document's setId.

a.ii. SHALL contain exactly one [1..1] setId (CONF:2211-33015). The versionNumber shall include the prior document's versionNumber.

a.iii.SHALL contain exactly one [1..1] versionNumber (CONF:2211-33016).

Personal Advance Care Plan November 16 Page 12 2 S E C T I O N

GPP for End-of-Life or Severely Dibilitating Condition - Draft [section: identifier urn:hl7ii:2.16.840.1.113883.4.823.1.3.4:2015-10-13 (open)]

Table 4: GPP for End-of-Life or Severely Dibilitating Condition Contexts

Contained By: Contains: Personal Advance Directives Section (optional) Advance Care Planning Priorities Organizer Care Experience Consideration Personal Health Goal Personal Treatment Preference

This section records a person's goals, priorities, and preferences for interventions at the end of life or when faced with a severely debilitating condition.

Table 5: GPP for End-of-Life or Severely Dibilitating Condition Constraints Overview

XPath Card. Verb Data CONF# Value Type section (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.3.4:2015-10-13) @nullFlavor 0..1 MAY 2211- urn:oid:2.16.840.1.113883.5.1008 32961 (HL7NullFlavor) = NI templateId 1..1 SHALL 2211- 32959 @root 1..1 SHALL 2211- 2.16.840.1.113883.4.823.1.3.4 32962 @extension 1..1 SHALL 2211- 2015-10-13 32963 code 0..1 MAY 2211- 32960 @code 1..1 SHALL 2211- TMP-LOINC-PACP2 32964 @codeSystem 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.6.1 (LOINC) 32965 = 2.16.840.1.113883.6.1 title 1..1 SHALL 2211- 32966 text 1..1 SHALL 2211- 32967 entry 0..* SHOUL 2211- D 33092 observation 1..1 SHALL 2211- Personal Health Goal (identifier: 33095 urn:hl7ii:2.16.840.1.113883.4.823.1. 4.6:2015-11-15

HL7 CDA R2 IG: Personal Advance Care Plan (US Realm), DSTU R1.0—Vol. 2: Templates and Supporting Material Page 13 Nov 2015 © 2015 Health Level Seven, Inc. All rights reserved. entry 0..* SHOUL 2211- D 33093 act 1..1 SHALL 2211- Personal Treatment Preference 33096 (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1. 4.5:2015-11-15 entry 0..* MAY 2211- 33094 observation 1..1 SHALL 2211- Care Experience Consideration 33097 (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1. 4.10:2015-11-15 entry 0..* MAY 2211- 33098 organizer 1..1 SHALL 2211- Advance Care Planning Priorities 33099 Organizer (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1. 4.7:2015-11-15

1. MAY contain zero or one [0..1] @nullFlavor="NI" No Information (CodeSystem: HL7NullFlavor urn:oid:2.16.840.1.113883.5.1008) (CONF:2211-32961). 2. SHALL contain exactly one [1..1] templateId (CONF:2211-32959) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.823.1.3.4" (CONF:2211-32962). b. SHALL contain exactly one [1..1] @extension="2015-10-13" (CONF:2211-32963). 3. MAY contain zero or one [0..1] code (CONF:2211-32960). a. The code, if present, SHALL contain exactly one [1..1] @code="TMP-LOINC-PACP2" GPP at EOL or Severly Dibilitating Condition (CONF:2211-32964). b. The code, if present, SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2211-32965). 4. SHALL contain exactly one [1..1] title (CONF:2211-32966). 5. SHALL contain exactly one [1..1] text (CONF:2211-32967). 6. SHOULD contain zero or more [0..*] entry (CONF:2211-33092) such that it a. SHALL contain exactly one [1..1] Personal Health Goal (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.4.6:2015-11-15) (CONF:2211-33095). 7. SHOULD contain zero or more [0..*] entry (CONF:2211-33093) such that it a. SHALL contain exactly one [1..1] Personal Treatment Preference (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.4.5:2015-11-15) (CONF:2211-33096). 8. MAY contain zero or more [0..*] entry (CONF:2211-33094) such that it a. SHALL contain exactly one [1..1] Care Experience Consideration (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.4.10:2015-11-15) (CONF:2211-33097). 9. MAY contain zero or more [0..*] entry (CONF:2211-33098) such that it a. SHALL contain exactly one [1..1] Advance Care Planning Priorities Organizer (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.4.7:2015-11-15) (CONF:2211-33099).

Personal Advance Care Plan November 16 Page 14 GPP upon Death - Draft [section: identifier urn:hl7ii:2.16.840.1.113883.4.823.1.3.5:2015-10-13 (open)]

Table 6: GPP upon Death Contexts

Contained By: Contains: Personal Advance Directives Section (optional) Advance Care Planning Priorities Organizer Care Experience Consideration Personal Health Goal Personal Treatment Preference

This section records a person's goals, priorities, and preferences for decisions that are made upon or following death.

Table 7: GPP upon Death Constraints Overview

XPath Card. Verb Data CONF# Value Type section (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.3.5:2015-10-13) @nullFlavor 0..1 MAY 2211- urn:oid:2.16.840.1.113883.5.1008 32974 (HL7NullFlavor) = NI templateId 1..1 SHALL 2211- 32968 @root 1..1 SHALL 2211- 2.16.840.1.113883.4.823.1.3.5 32970 @extension 1..1 SHALL 2211- 2015-10-13 32971 code 0..1 MAY 2211- 32969 @code 1..1 SHALL 2211- TMP-LOINC-PACP3 32972 @codeSystem 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.6.1 (LOINC) 32973 = 2.16.840.1.113883.6.1 title 1..1 SHALL 2211- 32975 text 1..1 SHALL 2211- 32976 entry 0..* SHOUL 2211- D 33100 observation 1..1 SHALL 2211- Personal Health Goal (identifier: 33104 urn:hl7ii:2.16.840.1.113883.4.823.1. 4.6:2015-11-15 entry 0..* SHOUL 2211- D 33101 act 1..1 SHALL 2211- Personal Treatment Preference 33105 (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1. 4.5:2015-11-15

HL7 CDA R2 IG: Personal Advance Care Plan (US Realm), DSTU R1.0—Vol. 2: Templates and Supporting Material Page 15 Nov 2015 © 2015 Health Level Seven, Inc. All rights reserved. entry 0..* MAY 2211- 33102 organizer 1..1 SHALL 2211- Advance Care Planning Priorities 33106 Organizer (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1. 4.7:2015-11-15 entry 0..* MAY 2211- 33103 observation 1..1 SHALL 2211- Care Experience Consideration 33107 (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1. 4.10:2015-11-15

1. MAY contain zero or one [0..1] @nullFlavor="NI" No Information (CodeSystem: HL7NullFlavor urn:oid:2.16.840.1.113883.5.1008) (CONF:2211-32974). 2. SHALL contain exactly one [1..1] templateId (CONF:2211-32968) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.823.1.3.5" (CONF:2211-32970). b. SHALL contain exactly one [1..1] @extension="2015-10-13" (CONF:2211-32971). 3. MAY contain zero or one [0..1] code (CONF:2211-32969). a. The code, if present, SHALL contain exactly one [1..1] @code="TMP-LOINC-PACP3" GPP upon Death (CONF:2211-32972). b. The code, if present, SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2211-32973). 4. SHALL contain exactly one [1..1] title (CONF:2211-32975). 5. SHALL contain exactly one [1..1] text (CONF:2211-32976). 6. SHOULD contain zero or more [0..*] entry (CONF:2211-33100) such that it a. SHALL contain exactly one [1..1] Personal Health Goal (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.4.6:2015-11-15) (CONF:2211-33104). 7. SHOULD contain zero or more [0..*] entry (CONF:2211-33101) such that it a. SHALL contain exactly one [1..1] Personal Treatment Preference (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.4.5:2015-11-15) (CONF:2211-33105). 8. MAY contain zero or more [0..*] entry (CONF:2211-33102) such that it a. SHALL contain exactly one [1..1] Advance Care Planning Priorities Organizer (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.4.7:2015-11-15) (CONF:2211-33106). 9. MAY contain zero or more [0..*] entry (CONF:2211-33103) such that it a. SHALL contain exactly one [1..1] Care Experience Consideration (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.4.10:2015-11-15) (CONF:2211-33107).

Personal Advance Care Plan November 16 Page 16 Health Care Agent Appointment - Draft [section: identifier urn:hl7ii:2.16.840.1.113883.4.823.1.3.3:2015-10-13 (open)]

Table 8: Health Care Agent Appointment Contexts

Contained By: Contains: Personal Advance Directives Section (optional)

This section records the appointment of health care agents. It include a primary agent, an alternate agent, and a second alternate. It may include other information relating to specific powers granted to or limitations placed upon the health care agents.

Table 9: Health Care Agent Appointment Constraints Overview

XPath Card. Verb Data CONF# Value Type section (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.3.3:2015-10-13) @nullFlavor 0..1 MAY 2211- urn:oid:2.16.840.1.113883.5.1008 32950 (HL7NullFlavor) = NI templateId 1..1 SHALL 2211- 32951 @root 1..1 SHALL 2211- 2.16.840.1.113883.4.823.1.3.3 32953 @extension 1..1 SHALL 2211- 2015-10-13 32954 code 0..1 MAY 2211- 32952 @code 1..1 SHALL 2211- TMP-LOINC-PACP1 32955 @codeSystem 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.6.1 (LOINC) 32956 = 2.16.840.1.113883.6.1 title 1..1 SHALL 2211- 32957 text 1..1 SHALL 2211- 32958

1. MAY contain zero or one [0..1] @nullFlavor="NI" No Information (CodeSystem: HL7NullFlavor urn:oid:2.16.840.1.113883.5.1008) (CONF:2211-32950). 2. SHALL contain exactly one [1..1] templateId (CONF:2211-32951) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.823.1.3.3" (CONF:2211-32953). b. SHALL contain exactly one [1..1] @extension="2015-10-13" (CONF:2211-32954). 3. MAY contain zero or one [0..1] code (CONF:2211-32952). a. The code, if present, SHALL contain exactly one [1..1] @code="TMP-LOINC-PACP1" Health Care Agents (CONF:2211-32955).

HL7 CDA R2 IG: Personal Advance Care Plan (US Realm), DSTU R1.0—Vol. 2: Templates and Supporting Material Page 17 Nov 2015 © 2015 Health Level Seven, Inc. All rights reserved. b. The code, if present, SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2211-32956). 4. SHALL contain exactly one [1..1] title (CONF:2211-32957). 5. SHALL contain exactly one [1..1] text (CONF:2211-32958).

Other Care Experience Considerations - Draft [section: identifier urn:hl7ii:2.16.840.1.113883.4.823.1.3.6:2015-10-13 (open)]

Table 10: Other Care Experience Considerations Contexts

Contained By: Contains: Personal Advance Directives Section (optional) Care Experience Consideration

This section records additional personal observations about things that can be considered when planning the care experience.

Table 11: Other Care Experience Considerations Constraints Overview

XPath Card. Verb Data CONF# Value Type section (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.3.6:2015-10-13) @nullFlavor 0..1 MAY 2211- urn:oid:2.16.840.1.113883.5.1008 32983 (HL7NullFlavor) = NI templateId 1..1 SHALL 2211- 32977 @root 1..1 SHALL 2211- 2.16.840.1.113883.4.823.1.3.6 32979 @extension 1..1 SHALL 2211- 2015-10-13 32980 code 0..1 MAY 2211- 32978 @code 1..1 SHALL 2211- TMP-LOINC-PACP4 32981 @codeSystem 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.6.1 (LOINC) 32982 = 2.16.840.1.113883.6.1 title 1..1 SHALL 2211- 32984 text 1..1 SHALL 2211- 32985 entry 0..* SHOUL 2211- D 33090 observation 1..1 SHALL 2211- Care Experience Consideration 33091 (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1. 4.10:2015-11-15

Personal Advance Care Plan November 16 Page 18 1. MAY contain zero or one [0..1] @nullFlavor="NI" No Information (CodeSystem: HL7NullFlavor urn:oid:2.16.840.1.113883.5.1008) (CONF:2211-32983). 2. SHALL contain exactly one [1..1] templateId (CONF:2211-32977) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.823.1.3.6" (CONF:2211-32979). b. SHALL contain exactly one [1..1] @extension="2015-10-13" (CONF:2211-32980). 3. MAY contain zero or one [0..1] code (CONF:2211-32978). a. The code, if present, SHALL contain exactly one [1..1] @code="TMP-LOINC-PACP4" Care Experience Considerations (CONF:2211-32981). b. The code, if present, SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2211-32982). 4. SHALL contain exactly one [1..1] title (CONF:2211-32984). 5. SHALL contain exactly one [1..1] text (CONF:2211-32985). 6. SHOULD contain zero or more [0..*] entry (CONF:2211-33090) such that it a. SHALL contain exactly one [1..1] Care Experience Consideration (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.4.10:2015-11-15) (CONF:2211-33091).

Personal Advance Directives Section - Draft [section: identifier urn:hl7ii:2.16.840.1.113883.4.823.1.3.1:2015-10-13 (open)]

Table 12: Personal Advance Directives Section Contexts

Contained By: Contains: Personal Advance Care Plan Document (required) GPP for End-of-Life or Severely Dibilitating Condition GPP upon Death Health Care Agent Appointment Other Care Experience Considerations Witnesses and Notary

This section contains data describing the patient’s advance directives. It includes references to any supporting documentation, It includes: appointment of healthcare proxies, goals, priorities, and preferences for care and treatment at the end of life or when there is a severely debilitating injury or illness, instructions for choices that follow death, other types of information that may be relevant to providing a positive care experience, and other instructions that may effect the powers and limitations of the healthcare proxy. It includes any other personal advance care plan directives not covered by the previously mentioned topics. If the referenced documents are available, they may be included in the exchange package. The most recent directives are required, if known, and should be listed in as much detail as possible. The Personal Advance Directives Section represents the actual information in a person's "advance directive document". The Advance Directives Section used in a Continuity of Care document, Consultation Note, Referral Summary, or Transfer of Care document contains information about a person's directives and does not contain the actual directives contained herein.The Advance Directives Section used in a clinical summary document

HL7 CDA R2 IG: Personal Advance Care Plan (US Realm), DSTU R1.0—Vol. 2: Templates and Supporting Material Page 19 Nov 2015 © 2015 Health Level Seven, Inc. All rights reserved. summarizes the type of directives present in the person's advance care plan and provides a reference to the actual document which was verified by a care provider.

Table 13: Personal Advance Directives Section Constraints Overview

XPath Card. Verb Data CONF# Value Type section (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.3.1:2015-10-13) @nullFlavor 0..1 MAY 2211- urn:oid:2.16.840.1.113883.5.1008 32800 (HL7NullFlavor) = NI templateId 1..1 SHALL 2211- 30227 @root 1..1 SHALL 2211- 2.16.840.1.113883.4.823.1.3.1 30228 @extension 1..1 SHALL 2211- 2015-10-13 32512 code 1..1 SHALL 2211- 32929 @code 1..1 SHALL 2211- 42348-3 32930 @codeSystem 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.6.1 (LOINC) 32931 = 2.16.840.1.113883.6.1 title 1..1 SHALL 2211- 32932 text 1..1 SHALL 2211- 32933 component 0..* SHOUL 2211- D 32999 section 1..1 SHALL 2211- Health Care Agent Appointment 33000 (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1. 3.3:2015-10-13 component 0..* MAY 2211- 33001 section 1..1 SHALL 2211- GPP for End-of-Life or Severely 33002 Dibilitating Condition (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1. 3.4:2015-10-13 component 0..* MAY 2211- 33003 section 1..1 SHALL 2211- GPP upon Death (identifier: 33004 urn:hl7ii:2.16.840.1.113883.4.823.1. 3.5:2015-10-13 component 0..* MAY 2211- 33005 section 1..1 SHALL 2211- Other Care Experience 33006 Considerations (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1. 3.6:2015-10-13

Personal Advance Care Plan November 16 Page 20 component 0..* SHOUL 2211- D 33007 section 1..1 SHALL 2211- Witnesses and Notary (identifier: 33008 urn:hl7ii:2.16.840.1.113883.4.823.1. 3.7:2015-10-13

1. MAY contain zero or one [0..1] @nullFlavor="NI" No information (CodeSystem: HL7NullFlavor urn:oid:2.16.840.1.113883.5.1008) (CONF:2211-32800). 2. SHALL contain exactly one [1..1] templateId (CONF:2211-30227) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.823.1.3.1" (CONF:2211-30228). b. SHALL contain exactly one [1..1] @extension="2015-10-13" (CONF:2211-32512). 3. SHALL contain exactly one [1..1] code (CONF:2211-32929). a. This code SHALL contain exactly one [1..1] @code="42348-3" Advance Directives (CONF:2211- 32930). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2211-32931). 4. SHALL contain exactly one [1..1] title (CONF:2211-32932). 5. SHALL contain exactly one [1..1] text (CONF:2211-32933). 6. SHOULD contain zero or more [0..*] component (CONF:2211-32999) such that it a. SHALL contain exactly one [1..1] Health Care Agent Appointment (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.3.3:2015-10-13) (CONF:2211-33000). 7. MAY contain zero or more [0..*] component (CONF:2211-33001) such that it a. SHALL contain exactly one [1..1] GPP for End-of-Life or Severely Dibilitating Condition (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.3.4:2015-10-13) (CONF:2211-33002). 8. MAY contain zero or more [0..*] component (CONF:2211-33003) such that it a. SHALL contain exactly one [1..1] GPP upon Death (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.3.5:2015-10-13) (CONF:2211-33004). 9. MAY contain zero or more [0..*] component (CONF:2211-33005) such that it a. SHALL contain exactly one [1..1] Other Care Experience Considerations (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.3.6:2015-10-13) (CONF:2211-33006). 10. SHOULD contain zero or more [0..*] component (CONF:2211-33007) such that it a. SHALL contain exactly one [1..1] Witnesses and Notary (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.3.7:2015-10-13) (CONF:2211-33008).

Witnesses and Notary - Draft [section: identifier urn:hl7ii:2.16.840.1.113883.4.823.1.3.7:2015-10-13 (open)]

Table 14: Witnesses and Notary Contexts

Contained By: Contains: Personal Advance Directives Section (optional)

HL7 CDA R2 IG: Personal Advance Care Plan (US Realm), DSTU R1.0—Vol. 2: Templates and Supporting Material Page 21 Nov 2015 © 2015 Health Level Seven, Inc. All rights reserved. This section records information about the people who witnessed and notarized the advance care plan directives.

Table 15: Witnesses and Notary Constraints Overview

XPath Card. Verb Data CONF# Value Type section (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.3.7:2015-10-13) @nullFlavor 0..1 MAY 2211- urn:oid:2.16.840.1.113883.5.1008 32992 (HL7NullFlavor) = NI templateId 1..1 SHALL 2211- 32986 @root 1..1 SHALL 2211- 2.16.840.1.113883.4.823.1.3.7 32988 @extension 1..1 SHALL 2211- 2015-10-13 32989 code 0..1 MAY 2211- 32987 @code 1..1 SHALL 2211- TMP-LOINC-PACP5 32990 @codeSystem 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.6.1 (LOINC) 32991 = 2.16.840.1.113883.6.1 title 1..1 SHALL 2211- 32993 text 1..1 SHALL 2211- 32994

1. MAY contain zero or one [0..1] @nullFlavor="NI" No Information (CodeSystem: HL7NullFlavor urn:oid:2.16.840.1.113883.5.1008) (CONF:2211-32992). 2. SHALL contain exactly one [1..1] templateId (CONF:2211-32986) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.823.1.3.7" (CONF:2211-32988). b. SHALL contain exactly one [1..1] @extension="2015-10-13" (CONF:2211-32989). 3. MAY contain zero or one [0..1] code (CONF:2211-32987). a. The code, if present, SHALL contain exactly one [1..1] @code="TMP-LOINC-PACP5" Witnesses (CONF:2211-32990). b. The code, if present, SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:2211-32991). 4. SHALL contain exactly one [1..1] title (CONF:2211-32993). 5. SHALL contain exactly one [1..1] text (CONF:2211-32994).

Personal Advance Care Plan November 16 Page 22 3 E N T RY

Advance Care Planning Priorities Organizer - Draft [organizer: identifier urn:hl7ii:2.16.840.1.113883.4.823.1.4.7:2015-11-15 (open)]

Table 16: Advance Care Planning Priorities Organizer Contexts

Contained By: Contains: GPP for End-of-Life or Severely Dibilitating Condition Personal Health Goal (optional) Personal Treatment Preference GPP upon Death (optional)

This clinical statement groups and orders a set of advance care planning priorities. The list of priorities may include personal goals and/or treatment preferences. Goals and preferences with a lower sequence number have a higher priority for the person authoring the priorities list.

Table 17: Advance Care Planning Priorities Organizer Constraints Overview

XPath Card. Verb Data CONF# Value Type organizer (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.4.7:2015-11-15) @classCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.6 33029 (HL7ActClass) = CLUSTER @moodCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.1001 33030 (ActMood) = EVN templateId 1..1 SHALL 2211- 33025 @root 1..1 SHALL 2211- 2.16.840.1.113883.4.823.1.4.7 33031 @extension 1..1 SHALL 2211- 2015-11-15 33037 id 1..* SHALL 2211- 33032 code 1..1 SHALL 2211- 33026 @code 1..1 SHALL 2211- TMP-LOINC-PACP6 33033 @codeSystem 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.6.1 (LOINC) 33034 = 2.16.840.1.113883.6.1 statusCode 1..1 SHALL 2211- 33027 @code 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.14 33035 (ActStatus) = completed author 0..* SHOUL 2211- Author Participation (identifier: D 33036 urn:oid:2.16.840.1.113883.10.20.22.4.11

HL7 CDA R2 IG: Personal Advance Care Plan (US Realm), DSTU R1.0—Vol. 2: Templates and Supporting Material Page 23 Nov 2015 © 2015 Health Level Seven, Inc. All rights reserved. 9 component 0..* SHOUL 2211- D 33024 observation 1..1 SHALL 2211- Personal Health Goal (identifier: 33028 urn:hl7ii:2.16.840.1.113883.4.823.1. 4.6:2015-11-15 component 0..* SHOUL 2211- D 33038 act 1..1 SHALL 2211- Personal Treatment Preference 33039 (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1. 4.5:2015-11-15

1. SHALL contain exactly one [1..1] @classCode="CLUSTER" Cluster (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:2211-33029). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:2211-33030). 3. SHALL contain exactly one [1..1] templateId (CONF:2211-33025) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.823.1.4.7" (CONF:2211-33031). b. SHALL contain exactly one [1..1] @extension="2015-11-15" (CONF:2211-33037). 4. SHALL contain at least one [1..*] id (CONF:2211-33032). 5. SHALL contain exactly one [1..1] code (CONF:2211-33026). a. This code SHALL contain exactly one [1..1] @code="TMP-LOINC-PACP6" Advance Care Planning Priorities (CONF:2211-33033). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1 STATIC) (CONF:2211-33034). 6. SHALL contain exactly one [1..1] statusCode (CONF:2211-33027). a. This statusCode SHALL contain exactly one [1..1] @code="completed" (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:2211-33035). The author represents the person whose priorities are represented in the goals and preferences on the list and the assigned sequence order.

7. SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:2211-33036). 8. SHOULD contain zero or more [0..*] component (CONF:2211-33024) such that it a. SHALL contain exactly one [1..1] Personal Health Goal (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.4.6:2015-11-15) (CONF:2211-33028). 9. SHOULD contain zero or more [0..*] component (CONF:2211-33038) such that it a. SHALL contain exactly one [1..1] Personal Treatment Preference (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.4.5:2015-11-15) (CONF:2211-33039).

Personal Advance Care Plan November 16 Page 24 Care Experience Consideration - Draft [observation: identifier urn:hl7ii:2.16.840.1.113883.4.823.1.4.10:2015-11-15 (open)]

Table 18: Care Experience Consideration Contexts

Contained By: Contains: GPP for End-of-Life or Severely Dibilitating Condition (optional) GPP upon Death (optional) Other Care Experience Considerations (optional)

This clinical statement represents a personal thought about something the person authoring the statement feels is relevant to his or her care experience and may be pertinent when planning his or her care.

Table 19: Care Experience Consideration Constraints Overview

XPath Card. Verb Data CONF# Value Type observation (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.4.10:2015-11-15) @classCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.6 33085 (HL7ActClass) = OBS @moodCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.1001 33086 (ActMood) = EVN templateId 1..1 SHALL 2211- 33040 @root 1..1 SHALL 2211- 2.16.840.1.113883.4.823.1.4.10 33060 @extension 1..1 SHALL 2211- 2015-11-15 33061 id 1..* SHALL 2211- 33087 code 1..1 SHALL 2211- urn:oid:2.16.840.1.113762.1.4.1046.38 33089 (Personal Goal Preference and Priority Choices) statusCode 1..1 SHALL 2211- 33043 @code 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.14 33064 (ActStatus) = completed effectiveTime 1..1 SHALL 2211- 33044 low 1..1 SHALL 2211- 33066 high 1..1 SHALL 2211- 33045 value 1..1 SHALL 2211- 33058 author 0..* SHOUL 2211- Author Participation (identifier:

HL7 CDA R2 IG: Personal Advance Care Plan (US Realm), DSTU R1.0—Vol. 2: Templates and Supporting Material Page 25 Nov 2015 © 2015 Health Level Seven, Inc. All rights reserved. D 33088 urn:oid:2.16.840.1.113883.10.20.22.4.11 9 participant 0..* SHOUL 2211- D 33046 @typeCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.90 33071 (HL7ParticipationType) = VRF templateId 1..1 SHALL 2211- 33050 @root 1..1 SHALL 2211- 2.16.840.1.113883.10.20.1.58 33072 time 0..1 SHOUL 2211- D 33047 participantRole 1..1 SHALL 2211- 33048 code 0..1 SHOUL 2211- urn:oid:2.16.840.1.114222.4.11.1066 D 33069 (Healthcare Provider Taxonomy (HIPAA)) addr 0..* MAY 2211- US Realm Address (AD.US.FIELDED) 33070 (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2 playingEntity 0..1 MAY 2211- 33049 code 0..1 SHOUL 2211- urn:oid:2.16.840.1.113883.11.20.9.51 D 33068 (Healthcare Agent Qualifier) name 0..* MAY 2211- US Realm Person Name 33059 (PN.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.1.1 participant 0..* SHOUL 2211- D 33051 @typeCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.90 33079 (HL7ParticipationType) = CST participantRole 1..1 SHALL 2211- 33052 @classCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.110 33075 (RoleClass) = AGNT code 0..1 SHOUL 2211- urn:oid:2.16.840.1.113883.11.20.12.1 D 33078 (Personal And Legal Relationship Role Type) addr 0..1 SHOUL 2211- US Realm Address (AD.US.FIELDED) D 33076 (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2 telecom 0..* SHOUL 2211- D 33077 playingEntity 1..1 SHALL 2211- 33053 code 0..1 SHOUL 2211- urn:oid:2.16.840.1.113883.11.20.9.51 D 33074 (Healthcare Agent Qualifier) name 1..1 SHALL 2211-

Personal Advance Care Plan November 16 Page 26 33073 reference 1..* SHOUL 2211- D 33054 @typeCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.1002 33083 (HL7ActRelationshipType) = REFR externalDocument 1..1 SHALL 2211- 33055 id 1..* SHALL 2211- 33082 text 0..1 MAY 2211- 33056 reference 0..1 MAY 2211- 33057

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:2211-33085). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:2211-33086). 3. SHALL contain exactly one [1..1] templateId (CONF:2211-33040) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.4.823.1.4.10" (CONF:2211-33060). b. SHALL contain exactly one [1..1] @extension="2015-11-15" (CONF:2211-33061). 4. SHALL contain at least one [1..*] id (CONF:2211-33087). 5. SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet Personal Goal Preference and Priority Choices urn:oid:2.16.840.1.113762.1.4.1046.38 (CONF:2211-33089). 6. SHALL contain exactly one [1..1] statusCode (CONF:2211-33043). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:2211-33064). 7. SHALL contain exactly one [1..1] effectiveTime (CONF:2211-33044). a. This effectiveTime SHALL contain exactly one [1..1] low (CONF:2211-33066). b. This effectiveTime SHALL contain exactly one [1..1] high (CONF:2211-33045). b.i. If the Advance Directive does not have a specified ending time, the element SHALL have the nullFlavor attribute set to NA (CONF:2211-33065).

8. SHALL contain exactly one [1..1] value (CONF:2211-33058) such that it a. If type CD, then value will be SNOMED-CT 2.16.840.1.113883.6.96 (CONF:2211-33084). The author is the person whose personal care experience consideration are represented in the clinical statement.

9. SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:2211-33088). The participant "VRF" represents the clinician(s) who verified the patient advance directive observation.

10. SHOULD contain zero or more [0..*] participant (CONF:2211-33046) such that it a. SHALL contain exactly one [1..1] @typeCode="VRF" Verifier (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:2211- 33071).

HL7 CDA R2 IG: Personal Advance Care Plan (US Realm), DSTU R1.0—Vol. 2: Templates and Supporting Material Page 27 Nov 2015 © 2015 Health Level Seven, Inc. All rights reserved. b. SHALL contain exactly one [1..1] templateId (CONF:2211-33050) such that it b.i. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.1.58" (CONF:2211-33072). c. SHOULD contain zero or one [0..1] time (CONF:2211-33047). c.i. The data type of Observation/participant/time in a verification SHALL be TS (time stamp) (CONF:2211-33067).

d. SHALL contain exactly one [1..1] participantRole (CONF:2211-33048). d.i. This participantRole SHOULD contain zero or one [0..1] code, which SHOULD be selected from ValueSet Healthcare Provider Taxonomy (HIPAA) urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:2211-33069). d.ii. This participantRole MAY contain zero or more [0..*] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:2211- 33070). d.iii. This participantRole MAY contain zero or one [0..1] playingEntity (CONF:2211- 33049). d.iii.1.The playingEntity, if present, SHOULD contain zero or one [0..1] code, which SHOULD be selected from ValueSet Healthcare Agent Qualifier urn:oid:2.16.840.1.113883.11.20.9.51 DYNAMIC (CONF:2211- 33068). d.iii.2.The playingEntity, if present, MAY contain zero or more [0..*] US Realm Person Name (PN.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:2211-33059). This custodian (CST) participant identifies a legal representative for the patient's advance directive. Examples of such individuals are called health care agents, substitute decision makers and/or health care proxies. If there is more than one legal representative, a qualifier may be used to designate the legal representative as primary or secondary.

11. SHOULD contain zero or more [0..*] participant (CONF:2211-33051) such that it a. SHALL contain exactly one [1..1] @typeCode="CST" Custodian (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:2211- 33079). b. SHALL contain exactly one [1..1] participantRole (CONF:2211-33052). b.i. This participantRole SHALL contain exactly one [1..1] @classCode="AGNT" Agent (CodeSystem: RoleClass urn:oid:2.16.840.1.113883.5.110 STATIC) (CONF:2211-33075). b.ii. This participantRole SHOULD contain zero or one [0..1] code, which SHOULD be selected from ValueSet Personal And Legal Relationship Role Type urn:oid:2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:2211-33078). b.iii. This participantRole SHOULD contain zero or one [0..1] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:2211-33076). b.iv.This participantRole SHOULD contain zero or more [0..*] telecom (CONF:2211-33077). b.v. This participantRole SHALL contain exactly one [1..1] playingEntity (CONF:2211- 33053).

Personal Advance Care Plan November 16 Page 28 b.v.1. This playingEntity SHOULD contain zero or one [0..1] code, which SHOULD be selected from ValueSet Healthcare Agent Qualifier urn:oid:2.16.840.1.113883.11.20.9.51 DYNAMIC (CONF:2211- 33074). Record the name of the agent who can provide a copy of the Advance Directive in the name element.

b.v.2. This playingEntity SHALL contain exactly one [1..1] name (CONF:2211-33073). 12. SHOULD contain at least one [1..*] reference (CONF:2211-33054) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:2211-33083). b. SHALL contain exactly one [1..1] externalDocument (CONF:2211-33055). b.i. This externalDocument SHALL contain at least one [1..*] id (CONF:2211-33082). b.ii. This externalDocument MAY contain zero or one [0..1] text (CONF:2211-33056). b.ii.1. The text, if present, MAY contain zero or one [0..1] reference (CONF:2211- 33057). b.ii.1.a. The URL of a referenced advance directive document MAY be present, and SHALL be represented in Observation/reference/ExternalDocument/text/reference (CONF:2211- 33080). b.ii.1.b. If a URL is referenced, then it SHOULD have a corresponding linkHTML element in narrative block (CONF:2211-33081).

Medical Order for Life Sustaining Treatment - Draft [observation: identifier urn:hl7ii:2.16.840.1.113883.4.823.1.4.8:2015-11-15 (open)] This observation indicates if a person has a medical order or physician order for life sustaining treatment (MOLST or POLST) which limits the type of treatment that can be performed to sustain the person's life. The MOLST or POLST is not a patient generated document. It is authored by a physician and is recognized in certain states. This observation indicates if the person has a life sustaining treatment order in place or not. If the person does have a MOLST or POLST a reference is included to link or point to the actual order.

Table 20: Medical Order for Life Sustaining Treatment Constraints Overview

XPath Card. Verb Data CONF# Value Type observation (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.4.8:2015-11-15) @classCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.6 33154 (HL7ActClass) = OBS @moodCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.1001 33155 (ActMood) = EVN templateId 1..1 SHALL 2211- 33109 @root 1..1 SHALL 2211- 2.16.840.1.113883.10.20.22.4.48

HL7 CDA R2 IG: Personal Advance Care Plan (US Realm), DSTU R1.0—Vol. 2: Templates and Supporting Material Page 29 Nov 2015 © 2015 Health Level Seven, Inc. All rights reserved. 33129 @extension 1..1 SHALL 2211- 2015-08-01 33130 id 1..* SHALL 2211- 33156 code 1..1 SHALL 2211- 33110 @code 1..1 SHALL 2211- TMP-LOINC-PACP7 33158 @codeSystem 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.11.16492 33159 (LogicalObservationIdentifierNamesAnd Codes) = 2.16.840.1.113883.6.1 statusCode 1..1 SHALL 2211- 33112 @code 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.14 33133 (ActStatus) = completed effectiveTime 1..1 SHALL 2211- 33113 low 1..1 SHALL 2211- 33135 high 1..1 SHALL 2211- 33114 value 1..1 SHALL 2211- 33127 author 0..* SHOUL 2211- Author Participation (identifier: D 33157 urn:oid:2.16.840.1.113883.10.20.22.4.11 9 participant 0..* SHOUL 2211- D 33115 @typeCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.90 33140 (HL7ParticipationType) = VRF templateId 1..1 SHALL 2211- 33119 @root 1..1 SHALL 2211- 2.16.840.1.113883.10.20.1.58 33141 time 0..1 SHOUL 2211- D 33116 participantRole 1..1 SHALL 2211- 33117 code 0..1 SHOUL 2211- urn:oid:2.16.840.1.114222.4.11.1066 D 33138 (Healthcare Provider Taxonomy (HIPAA)) addr 0..* MAY 2211- US Realm Address (AD.US.FIELDED) 33139 (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2 playingEntity 0..1 MAY 2211- 33118 code 0..1 SHOUL 2211- urn:oid:2.16.840.1.113883.11.20.9.51

Personal Advance Care Plan November 16 Page 30 D 33137 (Healthcare Agent Qualifier) name 0..* MAY 2211- US Realm Person Name 33128 (PN.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.1.1 participant 0..* SHOUL 2211- D 33120 @typeCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.90 33148 (HL7ParticipationType) = CST participantRole 1..1 SHALL 2211- 33121 @classCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.110 33144 (RoleClass) = AGNT code 0..1 SHOUL 2211- urn:oid:2.16.840.1.113883.11.20.12.1 D 33147 (Personal And Legal Relationship Role Type) addr 0..1 SHOUL 2211- US Realm Address (AD.US.FIELDED) D 33145 (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2 telecom 0..* SHOUL 2211- D 33146 playingEntity 1..1 SHALL 2211- 33122 code 0..1 SHOUL 2211- urn:oid:2.16.840.1.113883.11.20.9.51 D 33143 (Healthcare Agent Qualifier) name 1..1 SHALL 2211- 33142 reference 1..* SHOUL 2211- D 33123 @typeCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.1002 33152 (HL7ActRelationshipType) = REFR externalDocument 1..1 SHALL 2211- 33124 id 1..* SHALL 2211- 33151 text 0..1 MAY 2211- 33125 reference 0..1 MAY 2211- 33126

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:2211-33154). 2. SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:2211-33155). 3. SHALL contain exactly one [1..1] templateId (CONF:2211-33109) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.48" (CONF:2211-33129). b. SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:2211-33130).

HL7 CDA R2 IG: Personal Advance Care Plan (US Realm), DSTU R1.0—Vol. 2: Templates and Supporting Material Page 31 Nov 2015 © 2015 Health Level Seven, Inc. All rights reserved. 4. SHALL contain at least one [1..*] id (CONF:2211-33156). 5. SHALL contain exactly one [1..1] code (CONF:2211-33110) such that it a. SHALL contain exactly one [1..1] @code="TMP-LOINC-PACP7" Life Sustaining Treatment Order (CONF:2211-33158). b. SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LogicalObservationIdentifierNamesAndCodes urn:oid:2.16.840.1.113883.11.16492 STATIC) (CONF:2211-33159). 6. SHALL contain exactly one [1..1] statusCode (CONF:2211-33112). a. This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:2211-33133). 7. SHALL contain exactly one [1..1] effectiveTime (CONF:2211-33113). a. This effectiveTime SHALL contain exactly one [1..1] low (CONF:2211-33135). b. This effectiveTime SHALL contain exactly one [1..1] high (CONF:2211-33114). b.i. If the Advance Directive does not have a specified ending time, the element SHALL have the nullFlavor attribute set to NA (CONF:2211-33134).

8. SHALL contain exactly one [1..1] value (CONF:2211-33127) such that it a. SHALL be type Boolean where true means the person does have an order regarding life sustaining treatment and false means the person does not have an order regarding life sustaining treatment (CONF:2211-33153).

9. SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:2211-33157). The participant "VRF" represents the clinician(s) who verified the patient advance directive observation.

10. SHOULD contain zero or more [0..*] participant (CONF:2211-33115) such that it a. SHALL contain exactly one [1..1] @typeCode="VRF" Verifier (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:2211- 33140). b. SHALL contain exactly one [1..1] templateId (CONF:2211-33119) such that it b.i. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.1.58" (CONF:2211-33141). c. SHOULD contain zero or one [0..1] time (CONF:2211-33116). c.i. The data type of Observation/participant/time in a verification SHALL be TS (time stamp) (CONF:2211-33136).

d. SHALL contain exactly one [1..1] participantRole (CONF:2211-33117). d.i. This participantRole SHOULD contain zero or one [0..1] code, which SHOULD be selected from ValueSet Healthcare Provider Taxonomy (HIPAA) urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:2211-33138). d.ii. This participantRole MAY contain zero or more [0..*] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:2211- 33139). d.iii. This participantRole MAY contain zero or one [0..1] playingEntity (CONF:2211- 33118). d.iii.1.The playingEntity, if present, SHOULD contain zero or one [0..1] code, which SHOULD be selected from ValueSet Healthcare Agent Qualifier

Personal Advance Care Plan November 16 Page 32 urn:oid:2.16.840.1.113883.11.20.9.51 DYNAMIC (CONF:2211- 33137). d.iii.2.The playingEntity, if present, MAY contain zero or more [0..*] US Realm Person Name (PN.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:2211-33128). This custodian (CST) participant identifies a legal representative for the patient's advance directive. Examples of such individuals are called health care agents, substitute decision makers and/or health care proxies. If there is more than one legal representative, a qualifier may be used to designate the legal representative as primary or secondary.

11. SHOULD contain zero or more [0..*] participant (CONF:2211-33120) such that it a. SHALL contain exactly one [1..1] @typeCode="CST" Custodian (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:2211- 33148). b. SHALL contain exactly one [1..1] participantRole (CONF:2211-33121). b.i. This participantRole SHALL contain exactly one [1..1] @classCode="AGNT" Agent (CodeSystem: RoleClass urn:oid:2.16.840.1.113883.5.110 STATIC) (CONF:2211-33144). b.ii. This participantRole SHOULD contain zero or one [0..1] code, which SHOULD be selected from ValueSet Personal And Legal Relationship Role Type urn:oid:2.16.840.1.113883.11.20.12.1 DYNAMIC (CONF:2211-33147). b.iii. This participantRole SHOULD contain zero or one [0..1] US Realm Address (AD.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.2) (CONF:2211-33145). b.iv.This participantRole SHOULD contain zero or more [0..*] telecom (CONF:2211-33146). b.v. This participantRole SHALL contain exactly one [1..1] playingEntity (CONF:2211- 33122). b.v.1. This playingEntity SHOULD contain zero or one [0..1] code, which SHOULD be selected from ValueSet Healthcare Agent Qualifier urn:oid:2.16.840.1.113883.11.20.9.51 DYNAMIC (CONF:2211- 33143). Record the name of the agent who can provide a copy of the Advance Directive in the name element.

b.v.2. This playingEntity SHALL contain exactly one [1..1] name (CONF:2211-33142). 12. SHOULD contain at least one [1..*] reference (CONF:2211-33123) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:2211-33152). b. SHALL contain exactly one [1..1] externalDocument (CONF:2211-33124). b.i. This externalDocument SHALL contain at least one [1..*] id (CONF:2211-33151). b.ii. This externalDocument MAY contain zero or one [0..1] text (CONF:2211-33125). b.ii.1. The text, if present, MAY contain zero or one [0..1] reference (CONF:2211- 33126). b.ii.1.a. The URL of a referenced advance directive document MAY be present, and SHALL be represented in

HL7 CDA R2 IG: Personal Advance Care Plan (US Realm), DSTU R1.0—Vol. 2: Templates and Supporting Material Page 33 Nov 2015 © 2015 Health Level Seven, Inc. All rights reserved. Observation/reference/ExternalDocument/text/reference (CONF:2211- 33149). b.ii.1.b. If a URL is referenced, then it SHOULD have a corresponding linkHTML element in narrative block (CONF:2211-33150).

Personal Health Goal - Draft [observation: identifier urn:hl7ii:2.16.840.1.113883.4.823.1.4.6:2015-11-15 (open)]

Table 21: Personal Health Goal Contexts

Contained By: Contains: GPP for End-of-Life or Severely Dibilitating Condition (optional) GPP upon Death (optional) Advance Care Planning Priorities Organizer (optional)

This template represents a personal health goal. A Goal Observation template may have related components that are acts, encounters, observations, procedures, substance administrations, or supplies. A personal health goal observation is the person' health goal. The author is set to the recordTarget (patient). A goal may have components consisting of other goals (milestones). These milestones are related to the overall goal through entryRelationships. SHALL assert conformance to the Goal entry defined for C-CDA. 2.16.840.1.113883.10.20.22.4.121: (The version extension for this template was 2014-06-09, but was not included in the template identification.)

Table 22: Personal Health Goal Constraints Overview

XPath Card. Verb Data CONF# Value Type observation (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.4.6:2015-11-15) @classCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.6 30418 (HL7ActClass) = OBS @moodCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.1001 30419 (ActMood) = GOL templateId 1..1 SHALL 2211- 8583 @root 1..1 SHALL 2211- 2.16.840.1.113883.10.20.22.4.121 10512 @extension 1..1 SHALL 2211- 2015-11-15 33018 templateId 1..1 SHALL 2211- 33017 @root 1..1 SHALL 2211- 2.16.840.1.113883.10.20.22.4.121 33019 id 1..* SHALL 2211- 32332

Personal Advance Care Plan November 16 Page 34 code 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.6.1 (LOINC) 30784 statusCode 1..1 SHALL 2211- 32333 @code 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.14 32334 (ActStatus) = active effectiveTime 0..1 SHOUL 2211- D 32335 value 0..1 MAY 2211- 32743 author 1..* SHALL 2211- Author Participation (identifier: 30995 urn:oid:2.16.840.1.113883.10.20.22.4.11 9 entryRelationship 0..* MAY 2211- 30701 @typeCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.1002 30702 (HL7ActRelationshipType) = REFR act 1..1 SHALL 2211- Entry Reference (identifier: 30703 urn:oid:2.16.840.1.113883.10.20.22.4.12 2 entryRelationship 0..* MAY 2211- 30704 @typeCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.1002 30705 (HL7ActRelationshipType) = COMP act 1..1 SHALL 2211- Entry Reference (identifier: 32879 urn:oid:2.16.840.1.113883.10.20.22.4.12 2 entryRelationship 0..1 SHOUL 2211- D 30785 @typeCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.1002 30786 (HL7ActRelationshipType) = REFR observation 1..1 SHALL 2211- Priority Preference (identifier: 30787 urn:oid:2.16.840.1.113883.10.20.22.4.14 3 entryRelationship 0..* MAY 2211- 31448 @typeCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.1002 31449 (HL7ActRelationshipType) = COMP observation 1..1 SHALL 2211- Goal Observation (identifier: 32880 urn:oid:2.16.840.1.113883.10.20.22.4.12 1 entryRelationship 0..* MAY 2211- 31559 @typeCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.1002 31560 (HL7ActRelationshipType) = REFR act 1..1 SHALL 2211- Entry Reference (identifier: 31588 urn:oid:2.16.840.1.113883.10.20.22.4.12 2

HL7 CDA R2 IG: Personal Advance Care Plan (US Realm), DSTU R1.0—Vol. 2: Templates and Supporting Material Page 35 Nov 2015 © 2015 Health Level Seven, Inc. All rights reserved. reference 0..* MAY 2211- 32754 @typeCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.1002 32755 (HL7ActRelationshipType) = REFR externalDocument 1..1 SHALL 2211- External Document Reference (identifier: 32756 urn:hl7ii:2.16.840.1.113883.10.20.22.4.1 15:2014-06-09

1. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:2211-30418). 2. SHALL contain exactly one [1..1] @moodCode="GOL" Goal (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:2211-30419). 3. SHALL contain exactly one [1..1] templateId (CONF:2211-8583) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.121" (CONF:2211-10512). b. SHALL contain exactly one [1..1] @extension="2015-11-15" (CONF:2211-33018). 4. SHALL contain exactly one [1..1] templateId (CONF:2211-33017) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.121" (CONF:2211-33019). 5. SHALL contain at least one [1..*] id (CONF:2211-32332). 6. SHALL contain exactly one [1..1] code, which SHOULD be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:2211-30784). 7. SHALL contain exactly one [1..1] statusCode (CONF:2211-32333). a. This statusCode SHALL contain exactly one [1..1] @code="active" (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:2211-32334). 8. SHOULD contain zero or one [0..1] effectiveTime (CONF:2211-32335). 9. MAY contain zero or one [0..1] value (CONF:2211-32743). The author is set to be the person stating this is his or her goal.

10. SHALL contain at least one [1..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:2211-30995). The following entryRelationship represents the relationship between a Goal Observation and a Health Concern Act (Goal Observation REFERS TO Health Concern Act). As Health Concern Act is already defined in Health Concerns Section, rather than clone the whole Health Concern Act template, an Entry Reference may be used in entryRelationship to refer the template.

11. MAY contain zero or more [0..*] entryRelationship (CONF:2211-30701) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:2211- 30702). b. SHALL contain exactly one [1..1] Entry Reference (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.122) (CONF:2211-30703). The following entryRelationship represents a planned component of the goal such as Planned Encounter (V2), Planned Observation (V2), Planned Procedure (V2), Planned Medication Activity (V2), Planned Supply (V2), Planned Act (V2) or Planned Immunization Activity. Because these entries are already described in the

Personal Advance Care Plan November 16 Page 36 Interventions Section of the CDA document instance, rather than repeating the full content of the entries, the Entry Reference template may be used to reference the entries.

12. MAY contain zero or more [0..*] entryRelationship (CONF:2211-30704) such that it a. SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:2211- 30705). b. SHALL contain exactly one [1..1] Entry Reference (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.122) (CONF:2211-32879). The following entryRelationship represents the priority that the patient or a provider puts on the goal.

13. SHOULD contain zero or one [0..1] entryRelationship (CONF:2211-30785) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:2211- 30786). b. SHALL contain exactly one [1..1] Priority Preference (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.143) (CONF:2211-30787). The following entryRelationship represents the relationship between two Goal Observations where the target is a component of the source (Goal Observation HAS COMPONENT Goal Observation). The component goal (target) is a Milestone.

14. MAY contain zero or more [0..*] entryRelationship (CONF:2211-31448) such that it a. SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:2211- 31449). b. SHALL contain exactly one [1..1] Goal Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.121) (CONF:2211-32880). Where a Goal Observation needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry.

15. MAY contain zero or more [0..*] entryRelationship (CONF:2211-31559) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:2211- 31560). b. SHALL contain exactly one [1..1] Entry Reference (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.122) (CONF:2211-31588). Where it is necessary to reference an external clinical document such a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument.

16. MAY contain zero or more [0..*] reference (CONF:2211-32754). a. The reference, if present, SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:2211-32755). b. The reference, if present, SHALL contain exactly one [1..1] External Document Reference (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.115:2014-06-09) (CONF:2211-32756).

HL7 CDA R2 IG: Personal Advance Care Plan (US Realm), DSTU R1.0—Vol. 2: Templates and Supporting Material Page 37 Nov 2015 © 2015 Health Level Seven, Inc. All rights reserved. Personal Treatment Preference - Draft [act: identifier urn:hl7ii:2.16.840.1.113883.4.823.1.4.5:2015-11-15 (open)]

Table 23: Personal Treatment Preference Contexts

Contained By: Contains: GPP for End-of-Life or Severely Dibilitating Condition (optional) GPP upon Death (optional) Advance Care Planning Priorities Organizer (optional)

This template represents a personal preference for a type of medication treatment (intervention). It uses negationInd TRUE to represent a person's preference for the medical treatment NOT to be performed. The coding for the medical treatment may include pre-coordinated semantics to incorporation the conditions under which the person prefers for the medical treatment to be or not to be performed. It is a wrapper for planned intervention-type activities considered to be parts of the same intervention. For example, an activity such as "elevate head of bed" combined with "provide humidified O2 per nasal cannula" may be the interventions planned for a health concern of "respiratory insufficiency" in order to attempt to achieve a goal of "pulse oximetry greater than 92%". These intervention activities may be newly described or derived from a variety of sources within an EHR. Interventions are actions taken to increase the likelihood of achieving the patient's or providers' goals. An Intervention Act MAY contain a reference to a Goal Observation representing the reason for the intervention. Preferences are statements about interventions that have not yet occurred. They are a future oriented statement and have a moodCode of INT to indicate that the statement represents the person's intention. The author of a Personal Treatment Preference is the person indicating his or her preference.

Table 24: Personal Treatment Preference Constraints Overview

XPath Card. Verb Data CONF# Value Type act (identifier: urn:hl7ii:2.16.840.1.113883.4.823.1.4.5:2015-11-15) @classCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.6 32678 (HL7ActClass) = ACT @moodCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.1001 32679 (ActMood) = INT @negationInd 0..1 MAY 2211- 33023 templateId 1..1 SHALL 2211- 32653 @root 1..1 SHALL 2211- 2.16.840.1.113883.10.20.22.4.146 32680 @extension 1..1 SHALL 2211- 2015-08-01 32912 templateId 1..1 SHALL 2211- 33020 @root 1..1 SHALL 2211- 2.16.840.1.113883.10.20.22.4.131

Personal Advance Care Plan November 16 Page 38 33021 @extension 1..1 SHALL 2211- 2015-08-01 33022 id 1..* SHALL 2211- 32681 code 1..1 SHALL 2211- 32654 @code 1..1 SHALL 2211- 362956003 32682 @codeSystem 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.6.96 32683 (SNOMED CT) = 2.16.840.1.113883.6.96 statusCode 1..1 SHALL 2211- 32655 @code 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.14 32684 (ActStatus) = active effectiveTime 0..1 SHOUL 2211- D 32723 author 0..* SHOUL 2211- Author Participation (identifier: D 32719 urn:oid:2.16.840.1.113883.10.20.22.4.11 9 entryRelationship 0..* MAY 2211- 32656 @typeCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.1002 32686 (HL7ActRelationshipType) = REFR substanceAdministration 1..1 SHALL 2211- Immunization Activity (V3) (identifier: 32687 urn:hl7ii:2.16.840.1.113883.10.20.22.4.5 2:2015-08-01 entryRelationship 0..* MAY 2211- 32657 @typeCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.1002 32688 (HL7ActRelationshipType) = REFR substanceAdministration 1..1 SHALL 2211- Medication Activity (V2) (identifier: 32689 urn:hl7ii:2.16.840.1.113883.10.20.22.4.1 6:2014-06-09 entryRelationship 0..* MAY 2211- 32658 @typeCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.1002 32690 (HL7ActRelationshipType) = REFR act 1..1 SHALL 2211- Procedure Activity Act (V2) (identifier: 32691 urn:hl7ii:2.16.840.1.113883.10.20.22.4.1 2:2014-06-09 entryRelationship 0..* MAY 2211- 32661 @typeCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.1002 32696 (HL7ActRelationshipType) = REFR procedure 1..1 SHALL 2211- Procedure Activity Procedure (V2) 32697 (identifier:

HL7 CDA R2 IG: Personal Advance Care Plan (US Realm), DSTU R1.0—Vol. 2: Templates and Supporting Material Page 39 Nov 2015 © 2015 Health Level Seven, Inc. All rights reserved. urn:hl7ii:2.16.840.1.113883.10.20.22.4.1 4:2014-06-09 entryRelationship 0..* MAY 2211- 32662 @typeCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.1002 32698 (HL7ActRelationshipType) = REFR encounter 1..1 SHALL 2211- Encounter Activity (V3) (identifier: 32699 urn:hl7ii:2.16.840.1.113883.10.20.22.4.4 9:2015-08-01 entryRelationship 0..* MAY 2211- 32664 @typeCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.1002 32702 (HL7ActRelationshipType) = REFR supply 1..1 SHALL 2211- Non-Medicinal Supply Activity (V2) 32703 (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.5 0:2014-06-09 entryRelationship 0..* MAY 2211- 32671 procedure 1..1 SHALL 2211- Nutrition Recommendation (identifier: 32716 urn:oid:2.16.840.1.113883.10.20.22.4.13 0 entryRelationship 0..* MAY 2211- 32672 @typeCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.1002 32717 (HL7ActRelationshipType) = REFR act 1..1 SHALL 2211- Entry Reference (identifier: 32718 urn:oid:2.16.840.1.113883.10.20.22.4.12 2 entryRelationship 1..1 SHALL 2211- 32673 @typeCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.1002 32720 (HL7ActRelationshipType) = RSON act 1..1 SHALL 2211- Entry Reference (identifier: 32721 urn:oid:2.16.840.1.113883.10.20.22.4.12 2 reference 0..* MAY 2211- 32766 @typeCode 1..1 SHALL 2211- urn:oid:2.16.840.1.113883.5.1002 32767 (HL7ActRelationshipType) = REFR externalDocument 1..1 SHALL 2211- External Document Reference (identifier: 32768 urn:hl7ii:2.16.840.1.113883.10.20.22.4.1 15:2014-06-09

1. SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:2211-32678). 2. SHALL contain exactly one [1..1] @moodCode="INT" Intent (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:2211-32679).

Personal Advance Care Plan November 16 Page 40 When negationInd is set to true, it indicates an intervention the person does not want to have performed. Negation does not change the meaning of any pre-coordinated conditions.

3. MAY contain zero or one [0..1] @negationInd (CONF:2211-33023). 4. SHALL contain exactly one [1..1] templateId (CONF:2211-32653) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.146" (CONF:2211-32680). b. SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:2211-32912). 5. SHALL contain exactly one [1..1] templateId (CONF:2211-33020) such that it a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.131" (CONF:2211-33021). b. SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:2211-33022). 6. SHALL contain at least one [1..*] id (CONF:2211-32681). 7. SHALL contain exactly one [1..1] code (CONF:2211-32654). a. This code SHALL contain exactly one [1..1] @code="362956003" procedure / intervention (navigational concept) (CONF:2211-32682). b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.96" (CodeSystem: SNOMED CT urn:oid:2.16.840.1.113883.6.96) (CONF:2211-32683). 8. SHALL contain exactly one [1..1] statusCode (CONF:2211-32655). a. This statusCode SHALL contain exactly one [1..1] @code="active" Active (CodeSystem: ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:2211-32684). 9. SHOULD contain zero or one [0..1] effectiveTime (CONF:2211-32723). The author is set to be the person stating this is his or her preference.

10. SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:2211-32719). 11. MAY contain zero or more [0..*] entryRelationship (CONF:2211-32656) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:2211- 32686). b. SHALL contain exactly one [1..1] Immunization Activity (V3) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.52:2015-08-01) (CONF:2211-32687). 12. MAY contain zero or more [0..*] entryRelationship (CONF:2211-32657) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:2211- 32688). b. SHALL contain exactly one [1..1] Medication Activity (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.16:2014-06-09) (CONF:2211-32689). 13. MAY contain zero or more [0..*] entryRelationship (CONF:2211-32658) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:2211- 32690). b. SHALL contain exactly one [1..1] Procedure Activity Act (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.12:2014-06-09) (CONF:2211-32691). 14. MAY contain zero or more [0..*] entryRelationship (CONF:2211-32661) such that it

HL7 CDA R2 IG: Personal Advance Care Plan (US Realm), DSTU R1.0—Vol. 2: Templates and Supporting Material Page 41 Nov 2015 © 2015 Health Level Seven, Inc. All rights reserved. a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:2211- 32696). b. SHALL contain exactly one [1..1] Procedure Activity Procedure (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.14:2014-06-09) (CONF:2211-32697). 15. MAY contain zero or more [0..*] entryRelationship (CONF:2211-32662) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:2211- 32698). b. SHALL contain exactly one [1..1] Encounter Activity (V3) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01) (CONF:2211-32699). 16. MAY contain zero or more [0..*] entryRelationship (CONF:2211-32664) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:2211- 32702). b. SHALL contain exactly one [1..1] Non-Medicinal Supply Activity (V2) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.50:2014-06-09) (CONF:2211-32703). 17. MAY contain zero or more [0..*] entryRelationship (CONF:2211-32671) such that it a. SHALL contain exactly one [1..1] Nutrition Recommendation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.130) (CONF:2211-32716). Where an Intervention needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry.

18. MAY contain zero or more [0..*] entryRelationship (CONF:2211-32672) such that it a. SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:2211- 32717). b. SHALL contain exactly one [1..1] Entry Reference (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.122) (CONF:2211-32718). An Intervention Act SHALL reference a Goal Observation. Because the Goal Observation is already described in the CDA document instance's Goals section, rather than repeating the full content of the Goal Observation, the Entry Reference template can be used to reference this entry. The following entryRelationship represents an Entry Reference to Goal Observation.

19. SHALL contain exactly one [1..1] entryRelationship (CONF:2211-32673) such that it a. SHALL contain exactly one [1..1] @typeCode="RSON" Has reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:2211- 32720). b. SHALL contain exactly one [1..1] Entry Reference (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.122) (CONF:2211-32721). c. This entryReference template SHALL reference an instance of a Goal Observation template (CONF:2211-32722).

20. MAY contain zero or more [0..*] reference (CONF:2211-32766). a. The reference, if present, SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:2211-32767).

Personal Advance Care Plan November 16 Page 42 b. The reference, if present, SHALL contain exactly one [1..1] External Document Reference (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.115:2014-06-09) (CONF:2211-32768).

HL7 CDA R2 IG: Personal Advance Care Plan (US Realm), DSTU R1.0—Vol. 2: Templates and Supporting Material Page 43 Nov 2015 © 2015 Health Level Seven, Inc. All rights reserved. 4 T E M P L AT E I D S I N T H I S G U I D E

Table 25: Template List

Template Title Template Type templateId Personal Advance Care Plan document urn:hl7ii:2.16.840.1.113883.4.823.1.1.1:20 Document 15-10-13 Personal Advance Care Plan Header document urn:hl7ii:2.16.840.1.113883.4.823.1.2.1:20 15-10-13 GPP for End-of-Life or Severely section urn:hl7ii:2.16.840.1.113883.4.823.1.3.4:20 Dibilitating Condition 15-10-13 GPP upon Death section urn:hl7ii:2.16.840.1.113883.4.823.1.3.5:20 15-10-13 Health Care Agent Appointment section urn:hl7ii:2.16.840.1.113883.4.823.1.3.3:20 15-10-13 Other Care Experience Considerations section urn:hl7ii:2.16.840.1.113883.4.823.1.3.6:20 15-10-13 Personal Advance Directives Section section urn:hl7ii:2.16.840.1.113883.4.823.1.3.1:20 15-10-13 Witnesses and Notary section urn:hl7ii:2.16.840.1.113883.4.823.1.3.7:20 15-10-13 Advance Care Planning Priorities entry urn:hl7ii:2.16.840.1.113883.4.823.1.4.7:20 Organizer 15-11-15 Care Experience Consideration entry urn:hl7ii:2.16.840.1.113883.4.823.1.4.10:2 015-11-15 Medical Order for Life Sustaining entry urn:hl7ii:2.16.840.1.113883.4.823.1.4.8:20 Treatment 15-11-15 Personal Health Goal entry urn:hl7ii:2.16.840.1.113883.4.823.1.4.6:20 15-11-15 Personal Treatment Preference entry urn:hl7ii:2.16.840.1.113883.4.823.1.4.5:20 15-11-15

Table 26: Template Containments

Template Title Template Type templateId Personal Advance Care Plan document urn:hl7ii:2.16.840.1.113883.4.823.1.1.1:20 Document 15-10-13 Personal Advance Directives Section section urn:hl7ii:2.16.840.1.113883.4.823.1.3.1:20 15-10-13 GPP for End-of-Life or Severely section urn:hl7ii:2.16.840.1.113883.4.823.1.3.4:20 Dibilitating Condition 15-10-13 Advance Care Planning Priorities entry urn:hl7ii:2.16.840.1.113883.4.823.1.4.7:20 Organizer 15-11-15 Personal Health Goal entry urn:hl7ii:2.16.840.1.113883.4.823.1.4.6:20 15-11-15

Personal Advance Care Plan November 16 Page 44 Template Title Template Type templateId Personal Treatment Preference entry urn:hl7ii:2.16.840.1.113883.4.823.1.4.5:20 15-11-15 Care Experience Consideration entry urn:hl7ii:2.16.840.1.113883.4.823.1.4.10:2 015-11-15 Personal Health Goal entry urn:hl7ii:2.16.840.1.113883.4.823.1.4.6:20 15-11-15 Personal Treatment Preference entry urn:hl7ii:2.16.840.1.113883.4.823.1.4.5:20 15-11-15 GPP upon Death section urn:hl7ii:2.16.840.1.113883.4.823.1.3.5:20 15-10-13 Advance Care Planning Priorities entry urn:hl7ii:2.16.840.1.113883.4.823.1.4.7:20 Organizer 15-11-15 Personal Health Goal entry urn:hl7ii:2.16.840.1.113883.4.823.1.4.6:20 15-11-15 Personal Treatment Preference entry urn:hl7ii:2.16.840.1.113883.4.823.1.4.5:20 15-11-15 Care Experience Consideration entry urn:hl7ii:2.16.840.1.113883.4.823.1.4.10:2 015-11-15 Personal Health Goal entry urn:hl7ii:2.16.840.1.113883.4.823.1.4.6:20 15-11-15 Personal Treatment Preference entry urn:hl7ii:2.16.840.1.113883.4.823.1.4.5:20 15-11-15 Health Care Agent Appointment section urn:hl7ii:2.16.840.1.113883.4.823.1.3.3:20 15-10-13 Other Care Experience section urn:hl7ii:2.16.840.1.113883.4.823.1.3.6:20 Considerations 15-10-13 Care Experience Consideration entry urn:hl7ii:2.16.840.1.113883.4.823.1.4.10:2 015-11-15 Witnesses and Notary section urn:hl7ii:2.16.840.1.113883.4.823.1.3.7:20 15-10-13 Personal Advance Care Plan Header document urn:hl7ii:2.16.840.1.113883.4.823.1.2.1:20 15-10-13 Medical Order for Life Sustaining entry urn:hl7ii:2.16.840.1.113883.4.823.1.4.8:20 Treatment 15-11-15

HL7 CDA R2 IG: Personal Advance Care Plan (US Realm), DSTU R1.0—Vol. 2: Templates and Supporting Material Page 45 Nov 2015 © 2015 Health Level Seven, Inc. All rights reserved. 5 VAL U E S E T S I N T H I S G U I D E

Table 27: Personal And Legal Relationship Role Type

Value Set: Personal And Legal Relationship Role Type urn:oid:2.16.840.1.113883.11.20.12.1 A personal or legal relationship records the role of a person in relation to another person, or a person to himself or herself. This value set is to be used when recording relationships based on personal or family ties or through legal assignment of responsibility. Value Set Source: http://www.hl7.org/documentcenter/public/standards/vocabulary/vocabulary_tables/infrastructure/vocabulary/voc abulary.html Code Code System Code System OID Print Name SELF RoleCode urn:oid:2.16.840.1.113883.5.11 self 1 MTH RoleCode urn:oid:2.16.840.1.113883.5.11 mother 1 FTH RoleCode urn:oid:2.16.840.1.113883.5.11 father 1 DAU RoleCode urn:oid:2.16.840.1.113883.5.11 natural daughter 1 SON RoleCode urn:oid:2.16.840.1.113883.5.11 natural son 1 DAUINLAW RoleCode urn:oid:2.16.840.1.113883.5.11 daughter in-law 1 SONINLAW RoleCode urn:oid:2.16.840.1.113883.5.11 son in-law 1 GUARD RoleCode urn:oid:2.16.840.1.113883.5.11 guardian 1 HPOWATT RoleCode urn:oid:2.16.840.1.113883.5.11 healthcare power of attorney 1 ...

Table 28: Healthcare Agent Qualifier

Value Set: Healthcare Agent Qualifier urn:oid:2.16.840.1.113883.11.20.9.51 A value set SNOMED-CT qualifier codes for representing principal and secondary. Value Set Source: https://vsac.nlm.nih.gov Code Code System Code System OID Print Name 63161005 SNOMED CT urn:oid:2.16.840.1.113883.6.96 Principal 2603003 SNOMED CT urn:oid:2.16.840.1.113883.6.96 Secondary

Personal Advance Care Plan November 16 Page 46 Table 29: Healthcare Provider Taxonomy (HIPAA)

Value Set: Healthcare Provider Taxonomy (HIPAA) urn:oid:2.16.840.1.114222.4.11.1066 The Health Care Provider Taxonomy value set is a collection of unique alphanumeric codes, ten characters in length. The code set is structured into three distinct Levels including Provider Type, Classification, and Area of Specialization. The Health Care Provider Taxonomy code set allows a single provider (individual, group, or institution) to identify their specialty category. Providers may have one or more than one value associated to them. When determining what value or values to associate with a provider, the user needs to review the requirements of the trading partner with which the value(s) are being used. Value Set Source: http://www.nucc.org/index.php?option=com_content&view=article&id=14&Itemid=125 Code Code System Code System OID Print Name 171100000X Healthcare Provider Taxonomy urn:oid:2.16.840.1.113883.6.10 Acupuncturist (HIPAA) 1 363LA2100X Healthcare Provider Taxonomy urn:oid:2.16.840.1.113883.6.10 Nurse Practitioner - Acute Care (HIPAA) 1 364SA2100X Healthcare Provider Taxonomy urn:oid:2.16.840.1.113883.6.10 Clinical Nurse Specialist - (HIPAA) 1 Acute Care 101YA0400X Healthcare Provider Taxonomy urn:oid:2.16.840.1.113883.6.10 Counselor - Addiction (HIPAA) 1 (Substance Use Disorder) 103TA0400X Healthcare Provider Taxonomy urn:oid:2.16.840.1.113883.6.10 Psychologist - Addiction (HIPAA) 1 (Substance Use Disorder) 163WA0400X Healthcare Provider Taxonomy urn:oid:2.16.840.1.113883.6.10 Registered Nurse - Addiction (HIPAA) 1 (Substance Use Disorder) 207LA0401X Healthcare Provider Taxonomy urn:oid:2.16.840.1.113883.6.10 Anesthesiology - Addiction (HIPAA) 1 Medicine 207QA0401X Healthcare Provider Taxonomy urn:oid:2.16.840.1.113883.6.10 Family Medicine - Addiction (HIPAA) 1 Medicine 207RA0401X Healthcare Provider Taxonomy urn:oid:2.16.840.1.113883.6.10 Internal Medicine - Addiction (HIPAA) 1 Medicine 2084A0401X Healthcare Provider Taxonomy urn:oid:2.16.840.1.113883.6.10 Psychiatry & Neurology - (HIPAA) 1 Addiction Medicine ...

Table 30: Personal Goal Preference and Priority Choices

Value Set: Personal Goal Preference and Priority Choices urn:oid:2.16.840.1.113762.1.4.1046.38 A set of coded questions which permit personal answers to be provided for the standardized questions. Code Code System Code System OID Print Name 75773-2 LOINC urn:oid:2.16.840.1.113883.6.1 What are your goals, preferences and priorities for your medical treatment? 75775-7 LOINC urn:oid:2.16.840.1.113883.6.1 Do you want your doctors and nurses to know about the role religion, faith, or spirituality play in your life? 75776-5 LOINC urn:oid:2.16.840.1.113883.6.1 If you are having significant pain or suffering, would you like your doctors to consult a Supportive and Palliative Care

HL7 CDA R2 IG: Personal Advance Care Plan (US Realm), DSTU R1.0—Vol. 2: Templates and Supporting Material Page 47 Nov 2015 © 2015 Health Level Seven, Inc. All rights reserved. Value Set: Personal Goal Preference and Priority Choices urn:oid:2.16.840.1.113762.1.4.1046.38 A set of coded questions which permit personal answers to be provided for the standardized questions. Team to help treat your physical, emotional, and spiritual discomfort, and to support your family? 75777-3 LOINC urn:oid:2.16.840.1.113883.6.1 If your health ever deteriorates due to a terminal illness, and your doctors believe you will not be able to interact meaningfully with your family, friends, or surroundings, what would you like to tell your doctors? 75780-7 LOINC urn:oid:2.16.840.1.113883.6.1 If it were possible to choose, where would you like to spend your final days? ...

Personal Advance Care Plan November 16 Page 48 6 C O D E S Y S T E M S I N T H I S G U I D E

Table 31: Code Systems

Name OID ActMood urn:oid:2.16.840.1.113883.5.1001 ActStatus urn:oid:2.16.840.1.113883.5.14 Healthcare Provider Taxonomy (HIPAA) urn:oid:2.16.840.1.113883.6.101 HL7ActClass urn:oid:2.16.840.1.113883.5.6 HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 HL7NullFlavor urn:oid:2.16.840.1.113883.5.1008 HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 LogicalObservationIdentifierNamesAndCodes urn:oid:2.16.840.1.113883.11.16492 LOINC urn:oid:2.16.840.1.113883.6.1 RoleClass urn:oid:2.16.840.1.113883.5.110 RoleCode urn:oid:2.16.840.1.113883.5.111 SNOMED CT urn:oid:2.16.840.1.113883.6.96