Item | DT | Card | Conf | Description | Label |
---|
hl7:substanceAdministration
| | | R | | eHDS tion |
@classCode
| cs | 1 … 1 | F | SBADM |
@moodCode
| cs | 1 … 1 | F | INT |
hl7:templateId
| II.EPSOS | 1 … 1 | M | eHDSI Substance Administration | eHDS tion |
@root
| uid | 1 … 1 | F | 1.3.6.1.4.1.12559.11.10.1.3.1.3.2 |
hl7:templateId
| II.EPSOS | 0 … 1 | R | IHE Medications Entry (IHE PCC) Note: The usage of statusCode values different from “completed” makes this specification not formally compliant with the current IHE PCC specification of the Medication Item Entry Content Module. All the requirements of conformance assertion with these IHE PCC templates cannot therefore be applied until the revision – if any - of the referenced IHE PCC templates. | eHDS tion |
@root
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.5.3.1.4.7 |
hl7:templateId
| II.EPSOS | 1 … 1 | M | Medication activity (CCD) | eHDS tion |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.1.24 |
hl7:templateId
| II.EPSOS | 0 … 1 | R | A "normal" act that may not contain any subordinate acts | eHDS tion |
@root
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.5.3.1.4.7.1 |
hl7:templateId
| II.EPSOS | 0 … 1 | R | A act that records combination medication component information in subordinate acts. | eHDS tion |
@root
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.5.3.1.4.11 |
hl7:templateId
| II.EPSOS | 0 … 1 | R | A act that records split dose information in subordinate acts. | eHDS tion |
@root
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.5.3.1.4.9 |
hl7:id
| II.EPSOS | 1 … 1 | M | Prescription ID. The following must be true: - The prescription ID must be globally unique.
- The prescription ID can be used by the prescribing system or provider to identify the prescription to which it belongs. This provides the link from the dispensed medicine to the prescription.
| eHDS tion |
| |
| Example | <id extension="23" root="1.2.246.556.12001.4.93.1.1"/> |
hl7:code
| CD.EPSOS | 0 … 1 | R | The <code> element is used to supply a code that describes the <substanceAdminstration> act, not the medication being administered or prescribed. This may be a procedure code, such as those found in ICD-10, or may describe the method of medication administration, such as by intravenous injection. The type of medication is coded in the consumable; do not supply the code for the medication in this element. This element is optional.
| eHDS tion |
| CONF | |
hl7:text
| ED | 0 … 1 | R | | eHDS tion |
| |
| Example | <text>...</text> |
hl7:reference
| | 0 … 1 | R | The URI given in the value attribute of the element points to an element in the narrative content that contains the complete text describing the medication. In a CDA document, the URI given in the value attribute of the element points to an element in the narrative content that contains the complete text describing the medication. | eHDS tion |
| Example | <reference value="#eP_as_text"/> |
hl7:statusCode
| CS | 1 … 1 | M | The status of all <substanceAdministration> elements must be either "active" or "completed" and track the progress of the Act in its specified mood. For example, statusCode="completed" when moodCode is "RQO" doesn't mean that the substance has been administrated, but that the request (e.g. the prescription) has been completed. | eHDS tion |
| CONF | @code shall be "active" | or | @code shall be "completed" |
|
| Example | <statusCode code="active"/> |
hl7:effectiveTime
| IVL_TS | 1 … * | R | The first <effectiveTime> element encodes the start and stop time of the medication regimen or the length of the medication regimen. This an interval of time (xsi:type='IVL_TS'), and must be specified as shown. This is an additional constraint placed upon CDA Release 2.0 by this profile, and simplifies the exchange of start/stop/length and frequency information between EMR systems. If no information is available for the dosage period, a nullFlavor attribute has to be provided with the value 'UNK'.
Case 1: specified interval The <low> and <high> values of the first <effectiveTime> element represent the start and stop times for the medication. The <low> value represents the start time, and the <high> value represents the stop time.
In case of unbounded period (continuous therapy) the <high> element will be valued with the nullFlavor attribute to NA.
The <high> value records the end of the medication regime according to the information provided in the prescription or order. For example, if the prescription is for enough medication to last 30 days, then the high value should contain a date that is 30 days later than the <low> value. The rationale is that a provider, seeing an un-refilled prescription would normally assume that the medication is no longer being taken, even if the intent of the treatment plan is to continue the medication indefinitely.
Case 2: 'floating' period If the start and/or stop time is unknown, but the length of the medication regimen is known, it shall be indicated in the <width> value.
| eHDS tion |
where [@xsi:type='IVL_TS'] | |
| |
@nullFlavor
| cs | 0 … 1 | F | UNK |
| Example | Known Interval <effectiveTime type="IVL_TS"> <low value="20200415"/> <high value="20210415"/></effectiveTime> |
| Example | Information not available about the period <effectiveTime type="IVL_TS" nullFlavor="UNK"/> |
| Example | Unknown end date <effectiveTime type="IVL_TS"> <low value="20200415"/> <high nullFlavor="UNK"/></effectiveTime> |
| Example | Continuous therapy <effectiveTime type="IVL_TS"> <low value="20200415"/> <high nullFlavor="NA"/></effectiveTime> |
| Example | 2 week period <effectiveTime type="IVL_TS"> <width value="2" unit="wk"/></effectiveTime> |
| Example | 7 day period starting 15/04/2020 <effectiveTime type="IVL_TS"> <low value="20200415"/> <width value="7" unit="d"/></effectiveTime> |
| Example | 7 day period ending 15/04/2020 <effectiveTime type="IVL_TS"> <width value="7" unit="d"/> <high value="20200415"/></effectiveTime> |
hl7:low
| IVXB_TS | 0 … 1 | | Start of the medication regimen. If specified, must be complemented by the <high> or the <width> value.
| eHDS tion |
hl7:width
| PQ | 0 … 1 | | Length of the medication regimen.
| eHDS tion |
hl7:high
| IVXB_TS | 0 … 1 | | Stop of the medication regimen. If specified, must be complemented by the <low> or the <width> value.
| eHDS tion |
Choice | 1 … * | | Elements to choose from:- hl7:effectiveTime[(@value or @nullFlavor) and not(@xsi:type='IVL_TS' or @xsi:type='PIVL_TS' or @xsi:type='EIVL_TS' or @xsi:type='SXPR_TS')]
- hl7:effectiveTime[@xsi:type='PIVL_TS']
- hl7:effectiveTime[@xsi:type='EIVL_TS']
- hl7:effectiveTime[@xsi:type='SXPR_TS']
|
hl7:effectiveTime
| TS | 0 … * | C | This required element describes the frequency of intakes. If not known it shall be valued with the nullflavor "UNK".
An xsi:type of TS represents a single point in time, and is the simplest of all to represent. The value attribute of the <effectiveTime> element specifies the point in time in HL7 date-time format (CCYYMMDDHHMMSS)
| eHDS tion |
where [(@value or @nullFlavor) and not(@xsi:type='IVL_TS' or @xsi:type='PIVL_TS' or @xsi:type='EIVL_TS' or @xsi:type='SXPR_TS')] | |
| |
| Example | Once (known date) <effectiveTime value="20191203"/> |
| Example | Unknown <effectiveTime nullFlavor="UNK"/> |
hl7:effectiveTime
| PIVL_TS | 0 … * | C | An xsi:type of PIVL_TS is the most commonly used, representing a periodic interval of time. The <low> element of <phase> may be present. If so it specifies the starting point, and only the lower order components of this value are relevant with respect to the <period>. The <width> element represents the duration of the dose administration (e.g., for IV administration). The <period> indicates how often the dose is given. Legal values for the unit attribute of <period> are s, min, h, d, wk and mo representing seconds, minutes, hours, days, weeks, and months respectively.
| eHDS tion |
where [@xsi:type='PIVL_TS'] | |
| |
@institutionSpecified
| bl | 0 … 1 | | Indicates whether the exact timing is up to the party executing the schedule (e.g., to distinguish "every 8 hours" from "3 times a day".) |
| Example | Every 4 hours <effectiveTime type="PIVL_TS" institutionSpecified="false"> <period value="4" unit="h"/></effectiveTime> |
| Example | Twice a day <effectiveTime type="PIVL_TS" institutionSpecified="true"> <period value="12" unit="h"/></effectiveTime> |
| Example | Every day at 8 in the morning for 10 minutes <effectiveTime type="PIVL_TS"> <phase> <low value="202001010800" inclusive="true"/> <width value="10" unit="min"/> </phase> <period value="1" unit="d"/></effectiveTime> |
| Example | Every 4 to 6 hours <effectiveTime type="PIVL_TS" institutionSpecified="false"> <period type="PPD_PQ" value="5" unit="h"> <standardDeviation value="1" unit="h"/> </period></effectiveTime> |
hl7:effectiveTime
| EIVL_TS | 0 … * | C | An xsi:type of EIVL_TS represents an event based time interval, where the event is not a precise time, but is often used for timing purposes (e.g. with meals, between meals, before breakfast, before sleep). Refer to the eHDSITimingEvent value set for the codes to use for the <event> element. This interval may specify an <offset> which provides information about the time offset from the specified event (e.g., <offset><low value='-1' unit='h'/><width value='10' unit='min'/></offset> means 1 hour before the event. In that same example, the <width> element indicates the duration for the dose to be given.
| eHDS tion |
where [@xsi:type='EIVL_TS'] | |
| |
| Example | After meal <effectiveTime type="EIVL_TS"> <event code="PC" codeSystem="2.16.840.1.113883.5.139"/></effectiveTime> |
| Example | One hour before breakfast <effectiveTime type="EIVL_TS"> <event code="ACM" codeSystem="2.16.840.1.113883.5.139"/> <offset> <low value="-1" unit="h"/> </offset></effectiveTime> |
hl7:event
| EIVL.event | 0 … 1 | C | | eHDS tion |
| |
@code
| cs | 0 … 1 | | |
| CONF | |
hl7:effectiveTime
| SXPR_TS | 0 … * | C | An xsi:type of SXPR_TS represents a parenthetical set of time expressions. This type is used when the frequency varies over time (e.g., for some cases of tapered dosing, or to handle split dosing). The <comp> elements of this <effectiveTime> element are themselves time expressions (using any of the types listed above). Each <comp> element may specify an operator (e.g. to intersect or form the union of two sets).
| eHDS tion |
where [@xsi:type='SXPR_TS'] | |
| |
hl7:routeCode
| CE.EPSOS | 0 … 1 | R | The element specifies the route of administration using the EDQM route of administration vocabulary. A code must be specified if the route is known, and the displayName attribute should be specified. If the route is unknown, this element shall not be sent. | eHDS tion |
| |
| CONF | |
hl7:doseQuantity
| IVL_PQ | 0 … 1 | R | The doseQuantity element specifies the amount of medication (i.e. dose) for each intake. The dose could be for example "2 tablets". If the dose quantity is unknown, it must be nullFlavored (nullFlavor="UNK"). If a dose range is given (e.g., 1-2 tablets, or 325-750mg), then the <low> and <high> bounds are specified in their respective elements, otherwise both <low> and <high> have the same value.
| eHDS tion |
| |
| Example | Dose quantity is unknown <doseQuantity nullFlavor="UNK"/> |
| Example | Non pre-coordinated consumable - Dose Range <doseQuantity> <low value="25" unit="mg"/> <high value="50" unit="mg"/></doseQuantity> |
| Example | Pre-coordinated consumable using UCUM annotations - Dose Range <doseQuantity> <low value="1" unit="{tablet}"/> <high value="2" unit="{tablet}"/></doseQuantity> |
| Example | Pre-coordinated consumable - Dose Range <doseQuantity> <low value="2" unit="1"> <translation> <originalText>tablet</originalText> </translation> </low> <high value="2" unit="1"> <translation> <originalText>tablet</originalText> </translation> </high></doseQuantity> |
hl7:low
| IVXB_PQ | 1 … 1 | R | indicates the minimum amount of intake for every dose. If the value of low is 0, this means that the medication should be taken if needed. | eHDS tion |
@unit
| cs | 1 … 1 | R | must specify the unit of the dose. Units must be taken from UCUM code system. If the dose is in countable units (tablets, drops, pieces), then the unit must equal "1". The exact type of the countable unit may be specified as text in the underlying translation element with a concept from the eHDSIQuantityUnit Value Set. For the sake of understandability the text needs to be presented in English. |
@value
| | 1 … 1 | R | must be a positive integer or decimal representing the number of units in the dose. |
hl7:high
| IVXB_PQ | 1 … 1 | R | indicates the maximum amount of intake for every dose. | eHDS tion |
@unit
| cs | 1 … 1 | R | must specify the unit of the dose. Units must be taken from UCUM code system. If the dose is in countable units (tablets, drops, pieces), then the unit must equal "1". The exact type of the countable unit may be specified as text in the underlying translation element with a concept from the eHDSIQuantityUnit Value Set. For the sake of understandability the text needs to be presented in English. |
@value
| | 1 … 1 | R | must be a positive integer or decimal representing the number of units in the dose. |
hl7:rateQuantity
| IVL_PQ | 0 … 1 | R | The rate is specified in the <rateQuantity> element. The rate is given in units that have measure over time. In this case, the units should be specified as a string made up of a unit of measure (see doseQuantity above), followed by a slash (/), followed by a time unit (s, min, h or d). Again, if a range is given, then the <low> and <high> elements contain the lower and upper bound of the range, otherwise, they contain the same value.
Any <low> and <high> elements used for <rateQuantity> should contain a <translation> element that provides a <reference> to the <originalText> found in the narrative body of the document.
| eHDS tion |
hl7:consumable
| | 1 … 1 | R | Contains 1.3.6.1.4.1.12559.11.10.1.3.1.3.29 eHDSI eP/eD Medication Information (DYNAMIC) | eHDS tion |
@typeCode
| cs | 1 … 1 | F | CSM |
Included | 0 … * | R | from 2.16.840.1.113883.3.1937.777.11.10.103 eHDSI Author Prescriber (DYNAMIC) In the unlikely case where the prescriber of a prescription item is different from the author of the prescription, the prescription item prescriber shall be represented by the element of the entry. When the Prescription Item Entry is part of a Dispensed Medicine Entry as a Related Prescription Item (see subsection 12.1.3.4.8), the author element shall be present, and shall contain the prescription item author (or author of the prescription if the prescription item has no separate author). See the 2.4.3.3 Prescriber description for the structure of the element. |
hl7:author
| | 0 … * | R | | eHDS iber |
@typeCode
| cs | 0 … 1 | F | AUT |
@contextControlCode
| cs | 0 … 1 | F | OP |
hl7:functionCode
| CE.EPSOS | 1 … 1 | M | | R1.10.6 |
| |
| CONF | |
hl7:time
| TS.EPSOS.TZ | 1 … 1 | R | The author/time element represents the start time of the author’s participation in the creation of the clinical document. The author/time element SHALL be present. | eHDS iber |
hl7:assignedAuthor
| | 1 … 1 | R | | eHDS iber |
@classCode
| cs | 0 … 1 | F | ASSIGNED |
| Schematron assert | role | error | |
| test | @nullFlavor or hl7:assignedPerson or hl7:assignedAuthoringDevice | |
| Message | At least an assignedPerson or an assignedAuthoringDevice has to be provided, otherwise a nullFlavor shall be present. | |
hl7:id
| II.EPSOS | 1 … * | R | Identification of the Healthcare Practitioner that is the author of this document.
| R1.10.5 |
| |
@nullFlavor
| cs | 0 … 1 | F | NA |
hl7:code
| CE.EPSOS | 0 … 1 | R | HP Specialty | R1.10.7 |
| |
hl7:addr
| AD.EPSOS | 1 … * | R | | IHE PCC |
| |
hl7:telecom
| TEL.EPSOS | 1 … * | R | This telephone or e-mail <telecom> element is required.
If there is no information, the nullFlavor attribute shall have a value of 'NI' and the "value" and "use" attributes shall be omitted, otherwise the nullFlavor attribute shall not be present, and the "value" and "use" attributes shall be present.
Attribute @value SHALL contain a URI if element telecom is used. The URI scheme SHALL be one of URLScheme. | IHE PCC / R1.10.8 / R1.10.8.1 / R1.10.8.2 |
| |
@use
| set_cs | 0 … 1 | | |
| CONF | |
hl7:assignedPerson
| | 1 … 1 | M | | eHDS iber |
@classCode
| cs | 0 … 1 | F | PSN |
@determinerCode
| cs | 0 … 1 | F | INSTANCE |
hl7:name
| PN | 1 … 1 | R | HP Name | IHE PCC |
| Example | <name> <given>John</given> <family>Español Smith</family></name> |
hl7:family
| | 1 … * | R | HP Family Name/Surname | R1.10.1 |
| |
hl7:given
| | 1 … * | R | HP Given Name | R1.10.2 |
| |
hl7:prefix
| | 0 … * | R | HP Prefix | R1.10.3 |
hl7:suffix
| | 0 … * | R | HP Suffix | R1.10.4 |
hl7:representedOrganization
| | 1 … 1 | R | Contains 2.16.840.1.113883.3.1937.777.11.10.111 eHDSI Organization (DYNAMIC) | R1.10.9 |
| |
Included | 0 … * | R | from 2.16.840.1.113883.3.1937.777.11.10.134 eHDSI Participant (Body) (DYNAMIC) The organization which provided the credentialing for the prescriber needs to be expressed via a <participant> structure, which is in addition to the <author> element specified earlier. The type code of the <participant> element shall be "AUT", and the class code of the <participantRole> element shall be "LIC".
The ID of the participation role is optional, and when present it shall be the prescriber ID as specified in the <author> structure at the section or entry level.
The credentialing organization (College) is represented by the <scopingEntity> element with a class code of "ORG". The name is represented by the <desc> element, and the credentialing organization (College) ID is represented by the <id> element of the scoping entity
|
hl7:participant
| | 0 … * | R | | eHDS Body |
@typeCode
| cs | 1 … 1 | R | |
| CONF | |
@contextControlCode
| cs | 1 … 1 | F | OP |
hl7:time
| IVL_TS | 0 … 1 | R | | eHDS Body |
hl7:awarenessCode
| CE.EPSOS | 0 … 1 | R | | eHDS Body |
| CONF | |
hl7:participantRole
| | 1 … 1 | R | | eHDS Body |
@classCode
| cs | 0 … 1 | | |
| CONF | |
hl7:id
| II.EPSOS | 0 … * | R | | eHDS Body |
hl7:code
| CE.EPSOS | 0 … 1 | R | | eHDS Body |
@codeSystem
| CONF | 0 … 1 | F | 2.16.840.1.113883.5.111 |
hl7:addr
| AD | 0 … * | R | | eHDS Body |
hl7:telecom
| TEL | 0 … * | R | | eHDS Body |
Choice | 0 … 1 | | Elements to choose from: |
hl7:playingDevice
| | | R | Contains 2.16.840.1.113883.3.1937.777.11.10.129 eHDSI Device (DYNAMIC) | eHDS Body |
hl7:playingEntity
| | | R | Contains 2.16.840.1.113883.3.1937.777.11.10.128 eHDSI Playing Entity (DYNAMIC) | eHDS Body |
hl7:scopingEntity
| | 0 … 1 | R | | eHDS Body |
@classCode
| cs | 0 … 1 | | |
| CONF | |
@determinerCode
| cs | 0 … 1 | F | INSTANCE |
hl7:id
| II.EPSOS | 0 … * | R | | eHDS Body |
hl7:code
| CE.EPSOS | 0 … 1 | R | | eHDS Body |
| CONF | |
hl7:desc
| ED | 0 … 1 | R | | eHDS Body |
hl7:entryRelationship
| | 1 … 1 | R | An entry relationship is used to represent the number of packages in an ePrescription/eDispensation document. | eHDS tion |
@typeCode
| cs | 1 … 1 | F | COMP |
| Example | <entryRelationship typeCode="COMP"> <supply classCode="SPLY" moodCode="RQO"> <independentInd value="false"/> <quantity unit="1" value="4"/> </supply></entryRelationship> |
hl7:supply
| | | | | eHDS tion |
@classCode
| cs | 1 … 1 | F | SPLY |
@moodCode
| cs | 1 … 1 | F | RQO |
hl7:independentInd
| BL | 1 … 1 | M | | eHDS tion |
@value
| bl | 1 … 1 | F | false |
hl7:quantity
| PQ | 1 … 1 | M | The supply entry shall indicate the number of packages available for dispensation on the prescription.
The value attribute shall be present and indicate the number of packages. In prescriptions for overall amount (such as 400 tablets), the value attribute must equal 1, and the overall amount shall be placed in pharm:containerPackagedProduct/pharm:quantity element. See its description for more information.
The unit attribute shall be present and equal UCUM unit 1. | eHDS tion |
| |
@unit
| cs | 1 … 1 | F | 1 |
hl7:entryRelationship
| | 0 … * | R | An entry relationship may be present to provide the fulfillment instructions. When present, this entry relationship shall contain a Medication Fulfillment Instructions entry content module. Again, a related statement is made about the medication or immunization. In CDA, this observation is recorded inside an <entryRelationship> element occurring at the end of the substance administration or supply entry. The containing <act> is the subject (typeCode='SUBJ') of this new observation, which is the inverse of the normal containment structure, thus inversionInd='true'. Contains 1.3.6.1.4.1.12559.11.10.1.3.1.3.13 eHDSI Medication FulFillment Instructions (DYNAMIC) | eHDS tion |
where [hl7:act/hl7:templateId/@root='1.3.6.1.4.1.12559.11.10.1.3.1.3.13'] | |
@typeCode
| cs | 1 … 1 | F | SUBJ |
@inversionInd
| bl | 1 … 1 | F | true |
hl7:entryRelationship
| | 0 … 1 | R | An entry relationship may be present to provide the substitution instructions. When present, this entry relationship SHALL contain one and only one observation. This observation SHALL have : - the code element valorized with @code=‟SUBST' and @codeSystem='2.16.840.1.113883.5.6'
- the value element valorized with one of the value of the eHDSISubstitutionCode Value Set (Value Set OID 1.3.6.1.4.1.12559.11.10.1.3.1.42.7). Nullflavor is not allowed.
NOTE: Within the epSOS-I scope the “N” code shall be interpreted as No substitution allowed excepting for the Package Size. The presence of any other code that is not “N”, or the absence of the substitution instructions, means that also the brand name (as well as the Package Size) can be changed. | eHDS tion |
where [hl7:observation/hl7:code/@code='SUBST'] | |
| |
@typeCode
| cs | 1 … 1 | F | SUBJ |
hl7:observation
| | | | | eHDS tion |
@classCode
| cs | 0 … 1 | F | OBS |
@moodCode
| cs | 0 … 1 | F | EVN |
hl7:code
| | 1 … 1 | M | | eHDS tion |
@code
| CONF | 1 … 1 | F | SUBST |
@codeSystem
| 1 … 1 | F | 2.16.840.1.113883.5.6 |
hl7:value
| | 1 … 1 | M | | eHDS tion |
| CONF | |
hl7:entryRelationship
| | 0 … * | R | An entry relationship may be present to provide the patient medication instructions. When present, this entry relationship shall contain a Patient Medications Instructions entry content module. Again, a related statement is made about the medication or immunization. In CDA, this observation is recorded inside an <entryRelationship> element occurring at the end of the substance administration or supply entry. The containing <act> is the subject (typeCode='SUBJ') of this new observation, which is the inverse of the normal containment structure, thus inversionInd='true'. Contains 1.3.6.1.4.1.12559.11.10.1.3.1.3.12 eHDSI Patient Medication Instructions (DYNAMIC) | eHDS tion |
where [hl7:act/hl7:templateId/@root='1.3.6.1.4.1.12559.11.10.1.3.1.3.12'] | |
@typeCode
| cs | 1 … 1 | F | SUBJ |
@inversionInd
| bl | 1 … 1 | F | true |