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
Table of Contents
1 document 3
1.1 Personal Advance Care Plan Document - Draft 3
1.2 Personal Advance Care Plan Header - Draft 5
2 section 16
2.1 GPP for End-of-Life or Severely Dibilitating Condition - Draft 16
2.2 GPP upon Death - Draft 17
2.3 Health Care Agent Appointment - Draft 18
2.4 Other Care Experience Considerations - Draft 19
2.5 Personal Advance Directives Section - Draft 20
2.6 Witnesses and Notary - Draft 23
3 entry 25
3.1 Advance Care Planning Priorities Organizer - Draft 25
3.2 Care Experience Consideration - Draft 26
3.2.1 Autopsy Directive - Draft 27
3.2.2 Organ Donation Directive - Draft 28
3.3 Health Care Agent Selection - Draft 30
3.4 Medical Order for Life Sustaining Treatment - Draft 34
3.5 Personal Health Goal - Draft 37
3.6 Personal Treatment Preference - Draft 40
4 Template Ids in This Guide 44
5 Value Sets In This Guide 47
6 Code Systems in This Guide 50
Table of Figures
Figure 1: Personal Advance Care Plan Document Example 5
Figure 2: Personal Advance Care Plan Header - 1- Record Target 11
Figure 3: Personal Advance Care Plan Header - 2 - Author 12
Figure 4: Personal Advance Care Plan Header - 3 - Custodian 12
Figure 5: Personal Advance Care Plan Header - 4 - Authenticator 13
Figure 6: Personal Advance Care Plan Header - 5 - Legal Authenticator 13
Figure 7: Personal Advance Care Plan Header - 6 - Data Enterer 14
Figure 8: Personal Advance Care Plan Header - 7 - Health Care Agent 14
Figure 9: Personal Advance Care Plan Header - 8 - Software Used to Assemble Information for Exchange 15
Figure 10: Personal Advance Care Plan Header - 9 - Person who provide assistance in creatin the Advance Care plan 16
Figure 11: GPP for End-of-Life or Severely Dibilitating Condition Example 18
Figure 12: GPP upon Death Example 19
Figure 13: Health Care Agent Appointment 20
Figure 14: Other Care Experience Considerations 21
Figure 15: Personal Advance Directives Section Example 23
Figure 16: Witness and Notary Example 25
Figure 17: Health Care Agent Selection Example 34
Table of Tables
Table 1: Personal Advance Care Plan Document Contexts 4
Table 2: GPP for End-of-Life or Severely Dibilitating Condition Contexts 17
Table 3: GPP upon Death Contexts 18
Table 4: Health Care Agent Appointment Contexts 19
Table 5: Other Care Experience Considerations Contexts 20
Table 6: Personal Advance Directives Section Contexts 21
Table 7: Witnesses and Notary Contexts 24
Table 8: Advance Care Planning Priorities Organizer Contexts 26
Table 9: Care Experience Consideration Contexts 27
Table 10: Personal Health Goal Contexts 38
Table 11: Personal Treatment Preference Contexts 41
Table 12: Template List 45
Table 13: Template Containments 46
Table 14: Personal And Legal Relationship Role Type 48
Table 15: Personal Goal Preference and Priority Choices 49
Table 16: Healthcare Agent Qualifier 50
Table 17: Healthcare Provider Taxonomy (HIPAA) 50
Table 18: Code Systems 51
1 document
1.1 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 person 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.
The design of this template considers the design of the Advance Directives section template and the clinical statement templates for expressing goals and interventions in Consolidated CDA (C-CDA) R2.1.
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).
The template for the header elements for this Personal Advance Care Plan type of document.
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).
i. This structuredBody SHALL contain at least one [1..*] component (CONF:2211-32997).
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).
Figure 1: Personal Advance Care Plan Document Example
<ClinicalDocument
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xsi:schemaLocation="urn:hl7-org:v3 file:/C:/Users/lisa.nelson/Documents/05%20Professional/01%20HL7/000%20CDA%20R2%20Extensions/20150602%20CDA_SDTC/CDA_SDTC/infrastructure/cda/CDA_SDTC.xsd"
xmlns="urn:hl7-org:v3"
xmlns:cda="urn:hl7-org:v3"
xmlns:sdtc="urn:hl7-org:sdtc">
<realmCode code="US"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<templateId root="2.16.840.1.113883.4.823.1.1.1" extension="2015-10-13"/>
<!-- C-CDA Header -->
<templateId root="2.16.840.1.113883.4.823.1.2.1" extension="2015-10-13"/>
<!-- uADD Document -->
<id root="2.16.840.1.113883.3.3208.101.1" extension="20130607100315-CCDA-CCD"/>
<code code="45473-6" displayName="Advance directive - living will" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<title>Universal Advance Digital Directive (uADD)TM</title>
<effectiveTime value="20140731172200-0600"/>
<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="en-US"/>
<!-- **IMPORTANT** The SetID of the document maps to the "version number" of the advance care plan in the custodian system. -->
<setId root="2.16.840.1.113883.4.823.1.12345" extension="123"/>
<!-- **IMPORTANT** this is not the Version number of the advance care plan as managed by the system used to created and maintain a person's advance care plan.
This version number is unique to the information recipient getting a copy of the advance care plan.
The SetID of the document maps to the "version number" of the advance care plan in the custodian system. -->
<versionNumber value="16"/>
...
<!-- CDA Body -->
<component>
<structuredBody>
<!-- Advance Directives Section -->
<component>
<!-- nullFlavor of NI indicates No Information.-->
<section>
<templateId root="2.16.840.1.113883.4.823.1.3.1" extension="2015-10-13"/>
<!-- Personal Advance Directives section -->
<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="42348-3" displayName="Advance Directives (narrative)"/>
<title>Personal Advance Care Plan</title>
...
<!-- Nested sub-sections go in here. -->
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>
1.2 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 a further constraint of the US Realm Patient Generated Document Header (V2) which in turn further constrains the US Realm Header (V3). The additional constraints address specific information exchange requirements for a document containing a person's advance care plan directives.
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).
US Realm Header for Patient Generated Document (V2) from C-CDA R2.1
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).
US Realm Header (V3) from C-CDA R2.1
3. SHALL contain exactly one [1..1] templateId (CONF:2211-33160) such that it
a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.1" (CONF:2211-33161).
b. SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:2211-33162).
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.
4. SHALL contain exactly one [1..1] recordTarget (CONF:2211-28460).
a. This recordTarget SHALL contain exactly one [1..1] patientRole (CONF:2211-28461).
i. This patientRole SHALL contain at least one [1..*] id (CONF:2211-28462).
ii. This patientRole SHALL contain exactly one [1..1] patient (CONF:2211-28465).
1. This patient MAY contain zero or more [0..*] guardian (CONF:2211-28469).
a. The guardian, if present, SHOULD contain zero or more [0..*] id (CONF:2211-28470).
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).
2. This patient SHOULD contain zero or more [0..*] languageCommunication (CONF:2211-28474).
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.
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.
5. SHALL contain at least one [1..*] author (CONF:2211-28477).
a. Such authors SHALL contain exactly one [1..1] assignedAuthor (CONF:2211-28478).
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.
ii. This assignedAuthor SHOULD contain zero or one [0..1] code (CONF:2211-28481).
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.
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.
6. 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).
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.
7. SHALL contain exactly one [1..1] custodian (CONF:2211-28685).
a. This custodian SHALL contain exactly one [1..1] assignedCustodian (CONF:2211-28686).
The representedCustodianOrganization may be the person when the document is not maintained by an organization.
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.
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.
8. 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 @extensionattributes to record the information recipient’s identity in a secure, trusted, and unique way.
i. This intendedRecipient SHOULD contain zero or more [0..*] id (CONF:2211-28692).