Difference between revisions of "2.16.840.1.113883.10.22.3.1/static-2016-11-11T000000"

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<div>The medication summary section contains a description of the patient's medications relevant for the scope of the patient summary.<br />The actual content could depend on the jurisdiction, it could report:<div><ul><li>the currently active medications; <br /></li><li>the current and past medications considered relevant by the authoring GP; <br /></li><li>the patient prescriptions or dispensations automatically extracted by a regional or a national EHR.</li></ul>In all those cases however medications are documented in the Patient Summary as medication statements.<br /><br />This section requires either an entry indicating the subject is known not to be on any medications; either an entry indicating that no information is available about medications; or entries summarizing the subject's medications.<br /><br />The optional author and informant elements are used when necessary to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header.</div></div>
 
<div>The medication summary section contains a description of the patient's medications relevant for the scope of the patient summary.<br />The actual content could depend on the jurisdiction, it could report:<div><ul><li>the currently active medications; <br /></li><li>the current and past medications considered relevant by the authoring GP; <br /></li><li>the patient prescriptions or dispensations automatically extracted by a regional or a national EHR.</li></ul>In all those cases however medications are documented in the Patient Summary as medication statements.<br /><br />This section requires either an entry indicating the subject is known not to be on any medications; either an entry indicating that no information is available about medications; or entries summarizing the subject's medications.<br /><br />The optional author and informant elements are used when necessary to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header.</div></div>
 
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Latest revision as of 05:11, 7 August 2024

Id2.16.840.1.113883.10.22.3.1Effective Date2016‑11‑11
StatusKorange.png Under pre-publication reviewVersion LabelSTU1
NameIPSMedicationSummarySectionDisplay NameIPS Medication Summary Section
Description
The medication summary section contains a description of the patient's medications relevant for the scope of the patient summary.
The actual content could depend on the jurisdiction, it could report:
  • the currently active medications; 
  • the current and past medications considered relevant by the authoring GP; 
  • the patient prescriptions or dispensations automatically extracted by a regional or a national EHR.
In all those cases however medications are documented in the Patient Summary as medication statements.

This section requires either an entry indicating the subject is known not to be on any medications; either an entry indicating that no information is available about medications; or entries summarizing the subject's medications.

The optional author and informant elements are used when necessary to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header.
ContextParent nodes of template element with id 2.16.840.1.113883.10.22.3.1
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 2 concepts
IdNameData Set
hl7ips-data​element-16Kyellow.png Medication Summary Kyellow.png CEN/TC 251 prEN 17269
hl7ips-data​element-61Kyellow.png List of medication Kyellow.png CEN/TC 251 prEN 17269
Uses
Uses 4 templates
Uses as NameVersion
2.16.840.1.113883.10.22.4.14IncludeKorange.png IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.12.319ContainmentKgreen.png CDA Informant (Body)DYNAMIC
2.16.840.1.113883.10.22.4.4ContainmentKyellow.png IPS Medication Statement (STU2)DYNAMIC
2.16.840.1.113883.10.22.3.15ContainmentKyellow.png IPS Translation Section (2021)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 2.16.840.1.113883.10.20.1.8 Medication section (DYNAMIC)
ref
ccd1-

Adaptation: template 1.3.6.1.4.1.12559.11.10.1.3.1.2.3 Section Medication Summary (2013‑12‑20)
ref
epsos-
Example
Example
<section classCode="DOCSECT">
  <templateId root="2.16.840.1.113883.10.22.3.1"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="10160-0" codeSystem="2.16.840.1.113883.6.1" displayName="Terapie farmacologiche"/>  <title>Terapie farmacologiche</title>  <text>...</text>  <author>
    <!-- template 2.16.840.1.113883.10.22.4.14 'IPS Body Author' (dynamic) -->
  </author>
  <informant>
    <!-- template 2.16.840.1.113883.10.12.319 'CDA Informant (Body)' (dynamic) -->
  </informant>
  <entry typeCode="COMP" contextConductionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.4 'IPS Medication Entry' (dynamic) -->
  </entry>
  <component>
    <!-- template 2.16.840.1.113883.10.22.3.15 'IPS Translation Section' (dynamic) -->
  </component>
</section>
ItemDTCardConfDescriptionLabel
hl7:section
1 … 1M(IPS...ion)
 
Target.png
hl7ips-data​element-16Kyellow.png Medication Summary Kyellow.png CEN/TC 251 prEN 17269
Treetree.png@classCode
cs0 … 1FDOCSECT
Treetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.3.1
Treetree.pnghl7:id
II0 … *(IPS...ion)
Treetree.pnghl7:code
CE.IPS1 … 1MHistory of medication use(IPS...ion)
Treeblank.pngTreetree.png@code
CONF1 … 1F10160-0
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:title
ST1 … 1MMedication Summary (IPS...ion)
Treetree.pnghl7:text
SD.TEXT1 … 1MSection text(IPS...ion)
Included0 … * from 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
Treetree.pnghl7:author
0 … *(IPS...ion)
Treeblank.pngTreetree.pnghl7:templateId
II1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.14
Treeblank.pngTreetree.pnghl7:time
TS.IPS.TZ1 … 1R(IPS...ion)
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1M(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
0 … 1R(IPS...ion)
Choice0 … 1Elements to choose from:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1C(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *RName of the person (e.g. the Healthcare Professional)  authoring this document(IPS...ion)
 Example<name>
  <given>John</given>  <family>Español Smith</family></name>
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
1 … *R(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
0 … 1C(IPS...ion)
 Example<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Included from 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FDEV
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:manufacturer​Model​Name
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:softwareName
SC0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *(IPS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *(IPS...ion)
Treetree.pnghl7:informant
0 … *Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)(IPS...ion)
Treetree.pnghl7:entry
1 … *RContains 2.16.840.1.113883.10.22.4.4 IPS Medication Statement (DYNAMIC)(IPS...ion)
 
Target.png
hl7ips-data​element-61Kyellow.png List of medication Kyellow.png CEN/TC 251 prEN 17269
Treeblank.pngTreetree.png@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
Treeblank.pngTreetree.png@context​Conduction​Ind
bl0 … 1Ftrue
Treetree.pnghl7:component
0 … *Contains 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)(IPS...ion)