hl7:substanceAdministration
|
|
|
R |
The general model is to record each prescribed medication in a <substanceAdministration>
intent (moodCode='INT'). To record medications which were taken in the past, the moodCode
shall be set to 'EVN'. The <substanceAdministration> element may contain subordinate
<substanceAdministration> elements in a related component entry to deal with special
cases (see the following sections below on Special Cases). These cases include split, tapered, or conditional dosing, or combination medications.
The use of subordinate
<substanceAdministration> elements to deal with these cases is optional. The comment
field should always be used in these cases to provide the same information as free
text in the top level <substanceAdministration> element. There are a variety of special
cases for dosing that need to be accounted for. These are described below. Most of
these special cases involve changing the dosage or frequency over time, or based on
some measurement. When the dosage changes, then additional entries are required for
each differing dosage. The last case deals with combination medications.
For the purposes of WP3.5 only the normal, the split dosing and the combination medications
are addressed.
-
Normal Dosing 1.3.6.1.4.1.19376.1.5.3.1.4.7.1
This template identifier is used to identify medication administration events that
do not require any special processing. The parent template is 1.3.6.1.4.1.19376.1.5.3.1.4.7.
Medications that use this template identifier shall not use subordinate <substanceAdministation>
acts.
-
Combination Medications 1.3.6.1.4.1.19376.1.5.3.1.4.11
This template identifier is used to identify medication administration events that
require special processing to handle combination medications. The parent template
is 1.3.6.1.4.1.19376.1.5.3.1.4.7. A combination medication is made up of two or more
other medications. These may be prepackaged, such as Percocet, which is a combination
of Acetaminophen and oxycodone in predefined ratios, or prepared by a pharmacist,
such as a GI cocktail.
In the case of the prepackaged combination, it is sufficient to supply the name of
the combination drug product, and its strength designation in a single <substanceAdministation>
entry. The dosing information should then be recorded as simply a count of administration
units.
In the latter case of a prepared mixture, the description of the mixture should be
provided as the product name (e.g., "GI Cocktail"), in the <substanceAdministration>
entry. That entry may, but is not required, to have subordinate <substanceAdministration>
entries included beneath it to record the components of the mixture.
-
Split Dosing 1.3.6.1.4.1.19376.1.5.3.1.4.9
This template identifier is used to identify medication administration events that
require special processing to handle split dosing. The parent template is 1.3.6.1.4.1.19376.1.5.3.1.4.7.
A split dose is often used when different dosages are given at different times (e.g.,
at different times of day, or on different days). This may be to account for different
metabolism rates at different times of day, or to simply address drug packaging deficiencies
(e.g., and order for Coumadin 2mg on even days, 2.5mg on odd days is used because
Coumadin does not come in a
2.25mg dose form). In this case a subordinate <substanceAdministration> entry is required for each separate
dosage.
Other template IDs exist for the tapered doses, split dosing, conditional dosing,
and combination medications. The reader is pointed to the PCC-TF:2 section 6.1.4.16.5.
For the epSOS purposes, only the normal, the combination and the split dosing are
described.
|
(Medtem) |
@classCode
|
cs |
1 … 1 |
F |
SBADM |
@moodCode
|
cs |
1 … 1 |
R |
|
|
CONF |
@moodCode shall be "INT" |
or |
@moodCode shall be "EVN" |
|
hl7:templateId
|
II.EPSOS |
0 … 1 |
R |
(CCD) |
(Medtem) |
@root
|
uid |
1 … 1 |
F |
2.16.840.1.113883.10.20.1.24 |
hl7:templateId
|
II.EPSOS |
0 … 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.
|
(Medtem) |
@root
|
uid |
1 … 1 |
F |
1.3.6.1.4.1.19376.1.5.3.1.4.7 |
hl7:templateId
|
II.EPSOS |
1 … 1 |
R |
(epSOS) |
(Medtem) |
@root
|
uid |
1 … 1 |
F |
1.3.6.1.4.1.12559.11.10.1.3.1.3.4 |
hl7:templateId
|
II.EPSOS |
0 … 1 |
R |
A "normal"
act that may not contain any subordinate
acts
|
(Medtem) |
@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.
|
(Medtem) |
@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.
|
(Medtem) |
@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 |
A top level
element must be uniquely identified. This can be the prescription item ID if appropriate.
Although HL7 allows for multiple identifiers, one and only one shall be used.
|
(Medtem) |
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.
Note: One of the concepts from the Value Set eHDSI-AbsentOrUnknownMedication shall be
used in the <code> element to record that a patient is either not on medications,
or that medications are not known.
|
(Medtem) |
|
CONF |
|
hl7:text
|
ED |
0 … 1 |
R |
|
(Medtem) |
|
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.
|
(Medtem) |
|
Example |
<reference value="#eP_as_text"/> |
hl7:statusCode
|
CS |
1 … 1 |
M |
The status of all
elements must be either "active" or "completed". Status of "active" indicates a currently
valid prescription, status of completed indicates a previously taken medication.
|
(Medtem) |
|
CONF |
@code shall be "active" |
or |
@code shall be "completed" |
|
|
Example |
<statusCode code="active"/> |
Choice |
2 … 2 |
|
Elements to choose from:
- hl7:effectiveTime[@xsi:type='IVL_TS']
- 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
|
IVL_TS |
1 … 1 |
R |
The first <effectiveTime> element encodes the start and stop time 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 and frequency information between EMR systems.
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. If either the <low> or the <high> value is
unknown, this shall be recorded by setting the nullFlavor attribute to UNK.
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 then 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.
|
(Medtem) |
where [@xsi:type='IVL_TS'] |
|
|
|
|
Example |
<effectiveTime type="IVL_TS"> <low value="20130321"/> <high value="20140321"/></effectiveTime> |
hl7:effectiveTime
|
TS |
0 … 1 |
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)
|
(Medtem) |
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 … 1 |
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.
|
(Medtem) |
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 … 1 |
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 epSOSTimingEvent 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.
|
(Medtem) |
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 |
|
(Medtem) |
@code
|
cs |
0 … 1 |
|
|
|
CONF |
|
hl7:effectiveTime
|
SXPR_TS |
0 … 1 |
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).
|
(Medtem) |
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.
|
(Medtem) |
|
|
|
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...
If the dose is in countable items (tablets, caplets, "eaches"), then the unit should
be valorized = ‘1’. In this case it is allowed to used the UCUM annotations for describing
the type of countable items (e.g. .{tablet}, {puff},..).
The unit attribute – when expresses unit of measures- shall be derived from the Value
Sets epSOSUnits, 1.3.6.1.4.1.12559.11.10.1.3.1.42.16 based on the UCUM code system.
The countable units attribute is derived from the value set epSOSDoseForm, OID 1.3.6.1.4.1.12559.11.10.1.3.1.42.2
|
(Medtem) |
|
|
|
Example |
<doseQuantity nullFlavor="UNK">...</doseQuantity> |
|
Example |
<doseQuantity value="2" unit="{tablet}"/> |
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 <doseQuantity> or
<rateQuantity> should contain a <translation> element that provides a <reference>
to the <originalText> found in the narrative body of the document.
In a CDA document, any <low> and <high> elements used for <doseQuantity> or <rateQuantity>
SHOULD contain a <translation> element that provides a <reference> to the <originalText>
found in the narrative body of the document.
|
(Medtem) |
hl7:consumable
|
|
1 … 1 |
R |
The
element shall be present, and shall contain a
element, conforming to the Medicine Entry Content module template.
Contains 1.3.6.1.4.1.12559.11.10.1.3.1.3.1 eHDSI Manufactured Product (DYNAMIC)
|
(Medtem) |
@typeCode
|
cs |
0 … 1 |
F |
CSM |
Included |
0 … * |
R |
from 2.16.840.1.113883.3.1937.777.11.10.103 eHDSI Author Prescriber (DYNAMIC) In the case where there is a prescriber of a medication, the prescriber is represented
by the
element of the entry. See the Prescriber description for the structure of the
element.
|
hl7:author
|
|
0 … * |
R |
|
(Medtem) |
@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.
|
(Medtem) |
hl7:assignedAuthor
|
|
1 … 1 |
R |
|
(Medtem) |
@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 |
|
(Medtem) |
@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 |
|
|
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 administra- tion 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)
|
(Medtem) |
@typeCode
|
cs |
1 … 1 |
F |
SUBJ |
@inversionInd
|
bl |
1 … 1 |
R |
|
hl7:entryRelationship
|
|
0 … * |
R |
A top level <substanceAdministration> element may contain one or more related components,
either to handle split dosing, or to support combination medications. In the first case, the subordinate components shall specify only the changed <effectiveTime>
and/or <doseQuantity> elements. The value of the <sequenceNumber> shall be an ordinal
number, starting at 1 for the first component, and increasing by 1 for each subsequent
component. Components shall be sent in <sequenceNumber> order.
This information is given for
informative purposes as only normal or combination medications are administered in
epSOS.
|
(Medtem) |
@typeCode
|
cs |
1 … 1 |
F |
COMP |
hl7:sequenceNumber
|
INT |
1 … 1 |
M |
|
(Medtem) |