Any medication may be the subject of further instructions to the patient, for example to indicate that it should be taken with food, etc.

This structure is included in the target supply act using the <entryRelationship> element defined in the CDA Schema. The example below shows the recording of patient medication instruction for an <entry>, and is used as context for the following section.

Act classCode

<act classCode='ACT' moodCode='INT'>

The related statement is the intent (moodCode='INT') on how the related entry is to be performed.

Template Id root

<templateId root='2.16.840.1.113883.10.20.1.49'/><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.3'/>

These <templateId> elements identify this <act> as a medication instruction, allowing for validation of the content.

Code

<code code='PINSTRUCT' codeSystem='1.3.6.1.4.1.19376.1.5.3.2' codeSystemName='IHEActCode' />

The <code> element indicates that this is a patient medication instruction. This element shall be recorded exactly as specified above.

Text-reference

<text><reference value='#comment'/></text>

The <text> element contains a free text representation of the instruction. This element SHALL contain a <reference>element to the link text of the comment in the narrative portion of the document. The comment itself is not the act being coded, so it appears in the <text> of the <observation>, not as part of the <code>.

Status Code

<statusCode code='completed' />

The code attribute of <statusCode> for all comments must be completed.