1.3.6.1.4.1.19376.1.5.3.1.4.13.7

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Trial.gif Advance Directive Observation 1.3.6.1.4.1.19376.1.5.3.1.4.13.7

An advance directive observation is a simple observation that uses a specific vocabulary, and inherits constraints from CCD.

Standards
CCD ASTM/HL7 Continuity of Care Document
Uses

See Templates using Advance Directive Observation

Specification
Advance Directive Observation Example

<observation typeCode='OBS' moodCode='EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='2.16.840.1.113883.10.20.1.17'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.7'/>
 <id root=' ' extension=' '/>
 <code code=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>
 <text><reference value='#xxx'/></text>
 <statusCode code='completed'/>
 <effectiveTime value=' '/>
 <repeatNumber value=' '/>
 <value xsi:type='BL' value='true|false'/>
 <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <reference typeCode='REFR'>
   <templateId root='2.16.840.1.113883.10.20.1.36'/>
   <externalDocument classCode='DOC' moodCode='EVN'>
     <id root=' ' extension=' '/>
     <text><reference value=' '/></text>
   </externalDocument>
 </reference>
</observation>


An advanced directive <observation> shall be represented as shown above. They shall not contain any <repeatNumber>, <interpretationCode>, <methodCode> or <targetSiteCode> elements.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
  <templateId root='2.16.840.1.113883.10.20.1.17'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13.7'/>

The <templateId> elements shown above shall be present, and indicated that this is an Advance Directive entry.

<code code=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>

The <code> element records the type of advance directive. It should use one of the following SNOMED codes in the table below.

Advance Directive Type Codes
Code Description Data Type
304251008 Resuscitation BL
52765003 Intubation
225204009 IV Fluid and Support
89666000 CPR
281789004 Antibiotics
78823007 Life Support
61420007 Tube Feedings
116859006 Transfusion of blood product
71388002 Other Directive <value> not permitted
<value xsi:type='BL' value='true|false'/>

The advance directive observation may include a <value> element using the Boolean (xsi:type='BL') data type to indicate simply whether the procedure described is permitted. Absence of the the <value> element indicates that an advance directive of the specified type has been recorded, and must be examined to determine what type of treatment should be performed. The value element is not permitted when the <code> element describes an Other directive.

<reference typeCode='REFR'>
  <templateId root='2.16.840.1.113883.10.20.1.36'/>
  <externalDocument classCode='DOC' moodCode='EVN'>
   <id root=' ' extension=' '/>
   <text><reference value=' '/></text>

The advanced directive observation may contain a single reference to an external document. That reference shall be recorded as shown above. The <id> element shall contain the appropriate root and extension attributes to identify the document. The <text> element may be present to provide a URL link to the document in the value attribute of the <reference> element. If the <reference> element is present, the Advance Directive in the narrative shall contain a <linkHTML> element to the same URL found in the value attribute.