hl7:substanceAdministration
|
|
|
R |
|
(eHDion) |
@classCode
|
cs |
1 … 1 |
F |
SBADM |
@moodCode
|
cs |
1 … 1 |
F |
INT |
hl7:templateId
|
II.EPSOS |
1 … 1 |
M |
CCD templateId |
(eHDion) |
@root
|
uid |
1 … 1 |
F |
2.16.840.1.113883.10.20.1.24 |
hl7:templateId
|
II.EPSOS |
1 … 1 |
M |
epSOS templateId |
(eHDion) |
@root
|
uid |
1 … 1 |
F |
1.3.6.1.4.1.12559.11.10.1.3.1.3.2 |
hl7:templateId
|
II.EPSOS |
1 … 1 |
R |
IHE PCC templateId 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.
|
(eHDion) |
@root
|
uid |
1 … 1 |
F |
1.3.6.1.4.1.19376.1.5.3.1.4.7 |
hl7:templateId
|
II.EPSOS |
0 … 1 |
R |
A "normal"
act that may not contain any subordinate
acts
|
(eHDion) |
@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.
|
(eHDion) |
@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.
|
(eHDion) |
@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.
|
(eHDion) |
|
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.
|
(eHDion) |
|
CONF |
|
hl7:text
|
ED |
0 … 1 |
R |
|
(eHDion) |
|
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.
|
(eHDion) |
|
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.
|
(eHDion) |
|
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.
|
(eHDion) |
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.
|
(eHDion) |
hl7:width
|
PQ |
0 … 1 |
|
Length of the medication regimen.
|
(eHDion) |
hl7:high
|
IVXB_TS |
0 … 1 |
|
Stop of the medication regimen. If specified, must be complemented by the <low> or
the <width> value.
|
(eHDion) |
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)
|
(eHDion) |
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.
|
(eHDion) |
where [@xsi:type='PIVL_TS'] |
|
|
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.
|
(eHDion) |
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 |
|
(eHDion) |
@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).
|
(eHDion) |
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.
|
(eHDion) |
|
CONF |
|
hl7:doseQuantity
|
IVL_PQ |
0 … 1 |
R |
The dose is specified in the <doseQuantity> element. 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.
If the dose is in countable units (tablets, caplets, "eaches"), then the unit should
be valorized = ‘1’. The unit attribute – when expresses measureable units - shall
be derived from the Value Sets eHDSIUnit, 1.3.6.1.4.1.12559.11.10.1.3.1.42.16 based
on the UCUM code system. The
countable units attribute shall be derived from the value set eHDSIDoseForm, OID 1.3.6.1.4.1.12559.11.10.1.3.1.42.2.
Any <low> and <high> elements used for <doseQuantity> should contain a <translation>
element that provides a <reference> to the <originalText> found in the narrative body
of the document.
|
(eHDion) |
@unit
|
cs |
0 … 1 |
|
|
|
CONF |
|
|
Example |
Non pre-coordinated consumable - Dose Range <doseQuantity> <low value="25" unit="mg"/> <high value="50" unit="mg"/></doseQuantity> |
|
Example |
Pre-coordinated consumable - Dose Range <doseQuantity> <low value="1" unit="{tablet}"/> <high value="2" unit="{tablet}"/></doseQuantity> |
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.
|
(eHDion) |
hl7:consumable
|
|
1 … 1 |
R |
Contains 1.3.6.1.4.1.12559.11.10.1.3.1.3.1 eHDSI Manufactured Product (DYNAMIC)
|
(eHDion) |
@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 |
|
(eHDion) |
@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.
|
(eHDion) |
hl7:assignedAuthor
|
|
1 … 1 |
R |
|
(eHDion) |
@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 |
|
(eHDion) |
@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 |
|
(eHDion) |
@typeCode
|
cs |
1 … 1 |
R |
|
|
CONF |
|
@contextControlCode
|
cs |
1 … 1 |
F |
OP |
hl7:time
|
IVL_TS |
0 … 1 |
R |
|
(eHDion) |
hl7:awarenessCode
|
CE.EPSOS |
0 … 1 |
R |
|
(eHDion) |
|
CONF |
|
hl7:participantRole
|
|
1 … 1 |
R |
|
(eHDion) |
@classCode
|
cs |
0 … 1 |
|
|
|
CONF |
|
hl7:id
|
II.EPSOS |
0 … * |
R |
|
(eHDion) |
hl7:code
|
CE.EPSOS |
0 … 1 |
R |
|
(eHDion) |
@codeSystem
|
CONF |
0 … 1 |
F |
2.16.840.1.113883.5.111 (RoleCode) |
hl7:addr
|
AD |
0 … * |
R |
|
(eHDion) |
hl7:telecom
|
TEL |
0 … * |
R |
|
(eHDion) |
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)
|
(eHDion) |
hl7:playingEntity
|
|
|
R |
Contains 2.16.840.1.113883.3.1937.777.11.10.128 eHDSI Playing Entity (DYNAMIC)
|
(eHDion) |
hl7:scopingEntity
|
|
0 … 1 |
R |
|
(eHDion) |
@classCode
|
cs |
0 … 1 |
|
|
|
CONF |
|
@determinerCode
|
cs |
0 … 1 |
F |
INSTANCE |
hl7:id
|
II.EPSOS |
0 … * |
R |
|
(eHDion) |
hl7:code
|
CE.EPSOS |
0 … 1 |
R |
|
(eHDion) |
|
CONF |
|
hl7:desc
|
ED |
0 … 1 |
R |
|
(eHDion) |
hl7:entryRelationship
|
|
1 … 1 |
R |
An entry relationship is used to represent the number of packages in an ePrescription/eDispensation
document.
|
(eHDion) |
@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
|
|
|
|
|
(eHDion) |
@classCode
|
cs |
1 … 1 |
F |
SPLY |
@moodCode
|
cs |
1 … 1 |
F |
RQO |
hl7:independentInd
|
BL |
1 … 1 |
M |
|
(eHDion) |
@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 epsos:containerPackageMedicine/epsos:capacityQuantity
element. See its description for more information.
The unit attribute shall be present and equal UCUM unit 1.
|
(eHDion) |
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 1.3.6.1.4.1.19376.1.5.3.1.4.3.1 eHDSI Medication FulFillment Instructions (DYNAMIC)
|
(eHDion) |
where [hl7:act/hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.4.3.1'] |
|
@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.
|
(eHDion) |
where [hl7:observation/hl7:code/@code='SUBST'] |
|
@typeCode
|
cs |
1 … 1 |
F |
SUBJ |
hl7:observation
|
|
|
|
|
(eHDion) |
@classCode
|
cs |
0 … 1 |
F |
OBS |
@moodCode
|
cs |
0 … 1 |
F |
EVN |
hl7:code
|
|
1 … 1 |
M |
|
(eHDion) |
@code
|
CONF |
1 … 1 |
F |
SUBST |
@codeSystem
|
1 … 1 |
F |
2.16.840.1.113883.5.6 (ActClass) |
hl7:value
|
|
1 … 1 |
M |
|
(eHDion) |
|
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 1.3.6.1.4.1.19376.1.5.3.1.4.3 eHDSI Patient Medication Instructions (DYNAMIC)
|
(eHDion) |
where [hl7:act/hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.4.3'] |
|
@typeCode
|
cs |
1 … 1 |
F |
SUBJ |
@inversionInd
|
bl |
1 … 1 |
F |
true |