Section Code |
LOINC: 42348-3 (ADVANCE DIRECTIVES) |
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Description |
Used to capture the current list of advance directives such as DNR orders or blood transfusions. The content of this section MAY be level 2 as identified by template id listed below as 2/IHE however SHOULD be level 3.
When this section is produced using Level 3 entries, the content is a series of Advance Directive observations with optional status observations describing the status of the advance directive. |
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CDA Level |
Level 2 or 3 (depends on the template ID used) |
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Template IDs |
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Level / Spec |
Template ID |
Standards Reference |
3 / CCD |
2.16.840.1.113883.10.20.1.1 |
HL7 CCD 3.2 |
2 / IHE |
1.3.6.1.4.1.19376.1.5.3.1.3.34 |
IHE PCC TF-2 : 6.3.3.6.5 |
3 / IHE |
1.3.6.1.4.1.19376.1.5.3.1.3.35 |
IHE PCC TF-2 : 6.3.3.6.6 |
Expected Entries / Sub-Sections |
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Entry |
Template ID |
Reference |
Advance Directive Observation |
2.16.840.1.113883.10.20.1.17 1.3.6.1.4.1.19376.1.5.3.1.4.13.7 |
3.4.2.1 |
OpenSHR Implementation Notes |
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Data Model |
Obs |
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Code File |
AdvanceDirectiveSectionProcessor.java |
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Additional Constraints |
- When template id 1.3.6.1.4.1.19376.1.5.3.1.3.35 is used, the content creator SHOULD include at least one advance directive observation.
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Notes |
An advance directive related to blood transfusion SHOULD be provided (as identified in the APS document template), however OpenSHR does not require this and will process an Advance Directive section without this advance directive. |
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Specification |
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<section classCode="DOCSECT" moodCode="EVN">
<!-- HL7 CCD Template ID -->
<templateId root="2.16.840.1.113883.10.20.1.1"/>
<!-- IHE Template ID Advance Directives (unstructured) -->
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.34"/>
<!-- IHE Template ID Advance Directives (coded) -->
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.35"/>
<!-- Advance Directives code -->
<code code="42348-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="ADVANCE DIRECTIVES"/>
<title>Advance Directives</title>
<!-- Text as described in general notes -->
<text mediaType="text/x-hl7-text+xml">
</text>
<!-- 1..n Advance Directive Observations (if coded) -->
<entry typeCode="DRIV" contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN" negationInd="true">
...
</observation>
</entry>
</section> |
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Example |
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The following example illustrates a patient who has refused blood transfusion, a directive which has been active since October 28, 2014. |
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<section classCode="DOCSECT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.1"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.34"/>
<id root="c295a96e-6226-4705-b028-eaee339da691"/>
<code code="42348-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="ADVANCE DIRECTIVES"/>
<title language="en-US">Advance Directives</title>
<text mediaType="text/x-hl7-text+xml">
<table>
<thead>
<tr>
<th>Observation</th>
<th>Date/Time</th>
<th>Observed Value</th>
<th>Author</th>
<th>Interpretation</th>
<th>Status</th>
<th>Notes</th>
</tr>
</thead>
<tbody>
<tr ID="obs317ef3a7">
<td>Blood Transfusion</td>
<td>Since Tue Oct 28 2014</td>
<td>
False
</td>
<td>
Author
</td>
<td></td>
<td ID="obs8a4b3b73">Current and Verified</td>
<td></td>
</tr>
</tbody>
</table>
</text>
<entry typeCode="DRIV" contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.7"/>
<templateId root="2.16.840.1.113883.10.20.1.17"/>
<id root="4dce8759-e246-4eaa-be61-255b4ed6d57a"/>
<code code="(xx-bld-transf-ok)" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Blood Transfusion"/>
<text representation="TXT" language="en-US">
<reference value="#obs317ef3a7"/>
</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20141028"/>
</effectiveTime>
<value xsi:type="BL" value="false"/>
<entryRelationship typeCode="REFR" contextConductionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.37"/>
<templateId root="2.16.840.1.113883.10.20.1.57"/>
<code code="33999-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Status"/>
<text representation="TXT" language="en-US">
<reference value="#obs8a4b3b73"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" code="425392003" codeSystem="2.16.840.1.113883.6.96" displayName="Current and Verified"/>
</observation>
</entryRelationship>
</observation>
</entry>
</section> |
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