PACIO Advance Directive Interoperability Implementation Guide
0.1.0 - STU 1 Ballot

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## ValueSet: Documentation Types

Summary

Defining URL: | http://hl7.org/fhir/us/pacio-adi/ValueSet/PADIDocumentationTypeVS
Version: | 0.1.0
Name: | PADIDocumentationTypeVS
Title: | Documentation Types
Status: | Active as of 12/6/21 8:50 PM
Definition: | Types of Documents
Publisher: | HL7 Patient Empowerment Working Group
Copyright: | This material contains content from LOINC (http://loinc.org). LOINC is copyright © 1995-2020, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and is available at no cost under the license at http://loinc.org/license. LOINC® is a registered United States trademark of Regenstrief Institute, Inc This value set includes content from SNOMED CT, which is copyright © 2002+ International Health Terminology Standards Development Organisation (IHTSDO), and distributed by agreement between IHTSDO and HL7. Implementer use of SNOMED CT is not covered by this agreement
Source Resource: | XML / JSON / Turtle

References

- ADI Documentation Observation

### Logical Definition (CLD)

This value set includes codes based on the following rules:

- Include these codes as defined in `http://loinc.org`

  Code | Display
  81352-7 | Medical Order for Life-Sustaining Treatment, Physician Order for Life-Sustaining Treatment, or a similar medical order is in place [Reported]
  81351-9 | Do Not Resuscitate, Do Not Attempt Resuscitation, or Allow Natural Death order is in place [Reported]
  75320-2 | Advance directive

- Include these codes as defined in `http://snomed.info/sct`

  Code | Display
  304253006 | Not for resuscitation
  714748000 | Has advance care plan

- Include codes from `http://snomed.info/sct` where concept is-a 425392003 (Active advance directive (finding))
- Include codes from `http://snomed.info/sct` where concept is-a 423876004 (Clinical document (record artifact))

### Expansion

This value set contains 187 concepts

Expansion based on:

- Loinc v2.71
- SNOMED CT United States edition 01-Sep 2021

Code | System | Display | Definition
81352-7 | http://loinc.org | Medical Order for Life-Sustaining Treatment, Physician Order for Life-Sustaining Treatment, or a similar medical order is in place [Reported] |
81351-9 | http://loinc.org | Do Not Resuscitate, Do Not Attempt Resuscitation, or Allow Natural Death order is in place [Reported] |
75320-2 | http://loinc.org | Advance directive |
304253006 | http://snomed.info/sct | Not for resuscitation |
714748000 | http://snomed.info/sct | Has advance care plan (finding) |
425392003 | http://snomed.info/sct | Active advance directive (finding) |
310305009 | http://snomed.info/sct | Active advance directive (copy within chart) (finding) |
425393008 | http://snomed.info/sct | Active Durable Power of Attorney for Healthcare (finding) |
425394002 | http://snomed.info/sct | Active healthcare will (finding) |
425395001 | http://snomed.info/sct | Active living will (finding) |
425396000 | http://snomed.info/sct | Active advance directive with verification by family (finding) |
425397009 | http://snomed.info/sct | Active advance directive with verification by healthcare professional (finding) |
3011000175104 | http://snomed.info/sct | Active limitation of emergency treatment (finding) |
3021000175108 | http://snomed.info/sct | Active heathcare surrogate (finding) |
3041000175100 | http://snomed.info/sct | Active five wishes (finding) |
4921000175109 | http://snomed.info/sct | Active mental health treatment preference declaration (finding) |
423876004 | http://snomed.info/sct | Clinical document (record artifact) |
270107007 | http://snomed.info/sct | Coroner's postmortem report |
270116006 | http://snomed.info/sct | Postmortem report |
308376004 | http://snomed.info/sct | Police surgeon postmortem report |
371525003 | http://snomed.info/sct | Clinical procedure report |
371526002 | http://snomed.info/sct | Operative report |
371527006 | http://snomed.info/sct | Radiology report |
371528001 | http://snomed.info/sct | Pathology report |
371529009 | http://snomed.info/sct | History and physical report |
371530004 | http://snomed.info/sct | Clinical consultation report |
371531000 | http://snomed.info/sct | Encounter report |
371532007 | http://snomed.info/sct | Progress report |
371535009 | http://snomed.info/sct | Transfer summary report |
371537001 | http://snomed.info/sct | Consent report |
371538006 | http://snomed.info/sct | Advance directive report |
371539003 | http://snomed.info/sct | Conference report |
371540001 | http://snomed.info/sct | Supervising physician report |
371541002 | http://snomed.info/sct | Provider comment report |
371542009 | http://snomed.info/sct | Admission history and physical report |
371543004 | http://snomed.info/sct | Comprehensive history and physical report |
371544005 | http://snomed.info/sct | Targeted history and physical report |
371545006 | http://snomed.info/sct | Confirmatory consultation report |
371546007 | http://snomed.info/sct | Educational visit report |
373942005 | http://snomed.info/sct | Discharge summary |
399345000 | http://snomed.info/sct | Adult echocardiography procedure report |
406018008 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Adrenal gland: Resection |
406019000 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Ampulla of Vater: Ampullectomy |
406020006 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Ampulla of Vater: Pancreaticoduodenectomy |
406021005 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Anus: Excisional Biopsy |
406022003 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Anus: Local Excision (Transanal Disk Excision) |
406023008 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Anus: Resection |
406024002 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Urinary bladder, Ureter, Renal Pelvis: Biopsy |
406025001 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Urinary bladder: Cystectomy, Partial, Total, or Radical; Anterior Exenteration |
406026000 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Renal pelvis: Resection/Nephroureterectomy, Partial or Complete |
406027009 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Ureter: Resection |
406028004 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Bone Marrow: Blood Film, Aspirate, Cell Block, Trephine Biopsy, Touch Imprint |
406029007 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Brain/Spinal Cord: Biopsy/Resection |
406030002 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Breast: Excision Less Than Total Mastectomy (Includes Wire-Guided Localization Excisions); Total Mastectomy, Modified Radical Mastectomy, Radical Mastectomy |
406031003 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Colon and Rectum: Excisional Biopsy (Polypectomy) |
406032005 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Rectum: Local Excision (Transanal Disk Excision) |
406033000 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Colon and Rectum: Resection |
406034006 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Endometrium: Biopsy |
406035007 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Endometrium: Hysterectomy, With or Without Other Organs or Tissues |
406036008 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Esophagus: Biopsy |
406037004 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Esophagus: Resection |
406038009 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Extrahepatic Bile Ducts: Resection |
406039001 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Uveal Melanoma: Resection |
406040004 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Vulva: Excisional Biopsy/Resection |
406041000 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Vagina: Biopsy |
406042007 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Vagina: Excisional Biopsy, Resection |
406043002 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Uterine Cervix: Cone Biopsy |
406044008 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Uterine Cervix: Colpectomy, Hysterectomy, Pelvic Exenteration |
406045009 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Upper Aerodigestive Tract and Minor Salivary Glands: Incisional and Excisional Biopsy/Resection |
406046005 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Major Salivary Glands: Resection |
406047001 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Trophoblast: Dilation and Curettage/Resection |
406048006 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Thyroid: Resection |
406049003 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Thymoma and Thymic Carcinoma: Biopsy |
406050003 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Thymoma and Thymic Carcinoma: Thymectomy, Other Procedure |
406051004 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Pleura/Pericardium: Resection |
406052006 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Pleura/Pericardium: Biopsy |
406053001 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Testis: Radical Orchiectomy |
406054007 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Testis: Retroperitoneal Lymphadenectomy |
406055008 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Stomach: Biopsy |
406056009 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Stomach: Resection |
406057000 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Small Intestine: Polypectomy, Segmental Resection, Pancreaticoduodenectomy, Partial or Complete, With or Without Partial Gastrectomy (Whipple Resection) |
406058005 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Melanoma of the Skin: Excision; Re-Excision |
406059002 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Fallopian Tube: Unilateral Salpingectomy, Salpingo-oophorectomy, or Hysterectomy with Salpingo-oophorectomy |
406060007 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Gallbladder: Resection/Cholecystectomy |
406061006 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Gastrointestinal Lymphoma: Resection |
406062004 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Heart: Resection |
406063009 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Hodgkin Lymphoma: Biopsy/Staging Procedure |
406064003 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Kidney: Biopsy |
406065002 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Kidney: Nephrectomy, Partial or Radical |
406066001 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Liver: Resection |
406067005 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Lung: Biopsy |
406068000 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Lung: Resection |
406069008 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Non-Hodgkin Lymphoma: Biopsy, Resection |
406070009 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Ovary: Oophorectomy, Salpingo-oophorectomy, Subtotal Oophorectomy or Removal of Tumor in Fragments, Hysterectomy with Salpingo-oophorectomy |
406073006 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Pancreas (Endocrine): Excisional Biopsy (Enucleation), Resection |
406074000 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Pancreas (Exocrine): Resection |
406075004 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Peritoneum: Resection |
406076003 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Prostate Gland: Needle Biopsy, Transurethral Prostatic Resection (TUR), Enucleation Specimen |
406077007 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Prostate Gland: Radical Prostatectomy |
406078002 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Retinoblastoma: Enucleation, Partial or Complete Exenteration |
406079005 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Carcinoma of the Skin: Resection |
406080008 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Rhabdomyosarcoma and Related Neoplasms: Excision, Local or Wide; Compartmentectomy; Excision, Radical; Amputation; Other |
406081007 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Kidney: Resection for Wilms Tumor |
409713006 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Neuroblastoma: Resection |
409740006 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Primitive Neuroectodermal Tumor / Ewing Sarcoma: Resection |
416700005 | http://snomed.info/sct | Written operative report |
417185000 | http://snomed.info/sct | Dictated operative report |
421411003 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Prostate Gland: Needle Biopsy (record artifact) |
421714007 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Prostate Gland:Transurethral Prostatic Resection (TUR), Enucleation Specimen |
421870003 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Appendix: Resection (record artifact) |
422735006 | http://snomed.info/sct | Summary clinical document (record artifact) |
422817006 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Soft Tissue: Biopsy (record artifact) |
423000007 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Soft Tissue: Resection (record artifact) |
423183009 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Bone: Biopsy (record artifact) |
423372007 | http://snomed.info/sct | College of American Pathologists Cancer Checklist; Bone: Resection (record artifact) |
444754002 | http://snomed.info/sct | Hospital inpatient progress report (record artifact) |
444804000 | http://snomed.info/sct | Multidisciplinary care conference report (record artifact) |
445042000 | http://snomed.info/sct | Hospital outpatient progress report (record artifact) |
697978002 | http://snomed.info/sct | Provider orders for life-sustaining treatment |
714335001 | http://snomed.info/sct | Lower gastrointestinal tract endoscopy report (record artifact) |
714337009 | http://snomed.info/sct | Upper gastrointestinal tract endoscopy report (record artifact) |
714340009 | http://snomed.info/sct | Implanted device maintenance report |
720449003 | http://snomed.info/sct | Pulmonary function report (record artifact) |
721599005 | http://snomed.info/sct | Wound care management note (record artifact) |
721631001 | http://snomed.info/sct | Bone marrow pathology biopsy report (record artifact) |
721913004 | http://snomed.info/sct | Privacy policy acknowledgment of electronic data usage (record artifact) |
721914005 | http://snomed.info/sct | Patient consent document (record artifact) |
721915006 | http://snomed.info/sct | Admission request document (record artifact) |
721916007 | http://snomed.info/sct | Physician consulting initial evaluation note (record artifact) |
721917003 | http://snomed.info/sct | Physician discharge concise summary (record artifact) |
721919000 | http://snomed.info/sct | Nurse discharge summary (record artifact) |
721921005 | http://snomed.info/sct | Nurse discharge concise summary (record artifact) |
721923008 | http://snomed.info/sct | Obstetrics and gynecology discharge summary (record artifact) |
721924002 | http://snomed.info/sct | Overall plan of care (record artifact) |
721967005 | http://snomed.info/sct | Tissue pathology biopsy report (record artifact) |
721968000 | http://snomed.info/sct | Cardiac catheterization report (record artifact) |
721981007 | http://snomed.info/sct | Diagnostic studies report (record artifact) |
722014005 | http://snomed.info/sct | Cardiology hospital progress note (record artifact) |
722015006 | http://snomed.info/sct | Intensive care unit progress note (record artifact) |
722052006 | http://snomed.info/sct | Physical therapy consult note (record artifact) |
722091001 | http://snomed.info/sct | Conclusion interpretation document (record artifact) |
722124004 | http://snomed.info/sct | Radiology studies report (record artifact) |
722143004 | http://snomed.info/sct | Infectious disease diagnostic study note (record artifact) |
723394009 | http://snomed.info/sct | Photographic image record (record artifact) |
725869001 | http://snomed.info/sct | Record of implantation of cardiac electronic device (record artifact) |
725870000 | http://snomed.info/sct | Diagnostic coronary angiography report (record artifact) |
725956001 | http://snomed.info/sct | Ambulatory blood pressure monitoring report (record artifact) |
726566009 | http://snomed.info/sct | Pathology biopsy report (record artifact) |
770572002 | http://snomed.info/sct | Endoscopic ultrasound report (record artifact) |
770573007 | http://snomed.info/sct | Airway endoscopy report (record artifact) |
770574001 | http://snomed.info/sct | Endoscopic retrograde cholangiopancreatography report |
770575000 | http://snomed.info/sct | Endobronchial ultrasound report (record artifact) |
782659005 | http://snomed.info/sct | Cystoscopy report (record artifact) |
782660000 | http://snomed.info/sct | Combined upper and lower gastrointestinal tract endoscopy report |
787607005 | http://snomed.info/sct | Photographic image with lips closed (record artifact) |
787610003 | http://snomed.info/sct | Mirrored visible image corrected |
787611004 | http://snomed.info/sct | Photographic image extraoral with mandible postured forward (record artifact) |
787612006 | http://snomed.info/sct | Photographic image extraoral with 45 degree view |
789130005 | http://snomed.info/sct | Photographic image with mouth partially opened position and teeth apart (record artifact) |
789131009 | http://snomed.info/sct | Close up photographic view of teeth with no set magnification or distance |
789132002 | http://snomed.info/sct | Mirrored visible image uncorrected flipped horizontally and vertically |
789133007 | http://snomed.info/sct | Mirrored visible image uncorrected flipped vertically |
789134001 | http://snomed.info/sct | Mirrored visible image uncorrected flipped horizontally (record artifact) |
789135000 | http://snomed.info/sct | Mirrored visible image uncorrected (record artifact) |
789310004 | http://snomed.info/sct | Mirrored photographic image of teeth corrected flipped horizontally (record artifact) |
789311000 | http://snomed.info/sct | Mirrored photographic image of teeth corrected flipped vertically |
789312007 | http://snomed.info/sct | Mirrored photographic image of teeth corrected flipped vertically and horizontally |
789313002 | http://snomed.info/sct | Photographic image of anterior teeth |
789314008 | http://snomed.info/sct | Photographic image of face with lips in relaxed position (record artifact) |
551000220107 | http://snomed.info/sct | Gynecology discharge summary (record artifact) |
601000220109 | http://snomed.info/sct | Newborn discharge summary (record artifact) |
4201000179104 | http://snomed.info/sct | Imaging report (record artifact) |
4211000179102 | http://snomed.info/sct | Bone density scan report (record artifact) |
4221000179107 | http://snomed.info/sct | Ultrasound imaging report (record artifact) |
4231000179109 | http://snomed.info/sct | Mammography report (record artifact) |
4241000179101 | http://snomed.info/sct | Laboratory report (record artifact) |
4251000179103 | http://snomed.info/sct | Magnetic resonance imaging report (record artifact) |
4261000179100 | http://snomed.info/sct | Computed tomography imaging report (record artifact) |
4271000179106 | http://snomed.info/sct | Nuclear medicine report (record artifact) |
4311000179106 | http://snomed.info/sct | Chemical pathology report (record artifact) |
4321000179101 | http://snomed.info/sct | Hematology report (record artifact) |
4331000179104 | http://snomed.info/sct | Clinical immunology report (record artifact) |
4341000179107 | http://snomed.info/sct | Microbiology report (record artifact) |
4351000179105 | http://snomed.info/sct | Radioisotope laboratory report (record artifact) |
5481000179108 | http://snomed.info/sct | Home visit medical report (record artifact) |
21151000175105 | http://snomed.info/sct | Cervical papanicolaou smear and human papillomavirus deoxyribonucleic acid detection cotesting report (record artifact) |
432551000124102 | http://snomed.info/sct | Medication summary (record artifact) |

Explanation of the columns that may appear on this page:

Level | A few code lists that FHIR defines are hierarchical - each code is assigned a level. In this scheme, some codes are under other codes, and imply that the code they are under also applies
Source | The source of the definition of the code (when the value set draws in codes defined elsewhere)
Code | The code (used as the code in the resource instance)
Display | The display (used in the display element of a Coding). If there is no display, implementers should not simply display the code, but map the concept into their application
Definition | An explanation of the meaning of the concept
Comments | Additional notes about how to use the code