| Item | DT | Card | Conf | Description | Label |
|---|
hl7:substanceAdministration
|
| | | R | | (IPS...ent) |
| |  | | hl7ips-dataelement-104 |  Medication | CEN/TC 251 prEN 17269 |
|
 | @classCode
|
| cs | 1 … 1 | F | SBADM |
| @moodCode
|
| cs | 1 … 1 | R | If the statement refers to a prescribed medication then a <substanceAdministration> intent (moodCode='INT') is used; otherwise, to record medications which are stated to have taken, the moodCode shall be set to 'EVN'.</substanceAdministration> |
| | CONF | | The value of @moodCode shall be drawn from value set 2.16.840.1.113883.11.20.9.18 MoodCodeEvnInt (DYNAMIC) |
|
| hl7:templateId
|
| II | 1 … 1 | M | | (IPS...ent) |
 | | @root
|
| uid | 1 … 1 | F | 2.16.840.1.113883.10.22.4.4 |
| hl7:id
|
| II | 0 … * | R | | (IPS...ent) |
| hl7:code
|
| CD.IPS | 1 … 1 | R |
The <code> element is valorized with the Substance Administration ACT code "DRUG" unless it is used for asserting the known absence of medication treatments or no information about them.
| (IPS...ent) |
| | | | hl7ips-dataelement-220 | Medication Summary content status | CEN/TC 251 prEN 17269 |
|
| | CONF | | The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.14 DRUGActCode (DYNAMIC) | | or | | The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.15 Absent or Unknown Medication (DYNAMIC) |
|
| hl7:text
|
| ED | 0 … 1 | R |
The URI given in the value attribute of the <reference> 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 <reference> element points to an element in the narrative content that contains the complete text describing the medication.
| (IPS...ent) |
| | hl7:reference
|
| TEL | 1 … 1 | M | | (IPS...ent) |
| | 1 … 1 | R | Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1 |
| hl7:statusCode
|
| CS | 1 … 1 | M | | (IPS...ent) |
| | CONF | | The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.12 ActStatusActiveCompletedAbortedSuspended (DYNAMIC) |
|
| | Example | <statusCode code="active"/> |
| Included | 1 … 1 | R | from 2.16.840.1.113883.10.21.9.1 UV Use Period (DYNAMIC) |
| Choice | 1 … 1 | | The effectiveTime element encodes the use period of the medication, it is always expressed as an interval of time.
It may be expressed using the low and high OR with the width element.
The first is used to indicate a specified interval (e.g. from march 15th, 2017); the latter for indicating a 'floating' period (e.g. 2 weeks). Elements to choose from:- hl7:effectiveTime[hl7:low | hl7:high][not(hl7:width)]
- hl7:effectiveTime[hl7:width][not(hl7:low|hl7:high)]
- hl7:effectiveTime[hl7:low | hl7:width][not(hl7:high)]
|
| | hl7:effectiveTime
|
| IVL_TS | 0 … 1 | C | 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. If either the low or the high value is unknown, this shall be recorded by setting the nullFlavor attribute to UNK.
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 then the low value. The rationale is that a provider, seeing a prescription that has not been refilled 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. | (IPS...ent) |
where [hl7:low or
[not(hl7:width)] | |
| cs | 0 … 1 | | |
| | Example | Known Interval <effectiveTime type="IVL_TS">
<low value="20130321"/> <high value="20140321"/></effectiveTime> |
| | Example | Information not available about the period <effectiveTime type="IVL_TS" nullFlavor="NI"/> |
| | Example | Unknown end date <effectiveTime type="IVL_TS">
<low value="20130321"/> <high nullFlavor="UNK"/></effectiveTime> |
| | Example | continous therapy <effectiveTime type="IVL_TS">
<low value="20130321"/> <high nullFlavor="NA"/></effectiveTime> |
| IVXB_TS | 1 … 1 | R | | (IPS...ent) |
| IVXB_TS | 0 … 1 | R | | (IPS...ent) |
| | hl7:effectiveTime
|
| IVL_TS | 0 … 1 | C | Case 2: 'floating' period:
The width element is used to specify a period of (actual or intended) administration that is not anchored to any specific date (e.g. a two weeks therapy) | (IPS...ent) |
where [hl7:width] [not(hl7:lowor
hl7:high)] | |
| | Example | 2 week period <effectiveTime type="IVL_TS">
<width value="2" unit="w"/></effectiveTime> |
| | | NP | | (IPS...ent) |
| | | NP | | (IPS...ent) |
| | | NP | | (IPS...ent) |
| PQ | 1 … 1 | R | | (IPS...ent) |
| cs | 1 … 1 | R | |
| | CONF | | The value of @unit shall be drawn from value set 2.16.840.1.113883.11.21.1 Medication Time Units (UCUM) (DYNAMIC) |
|
| | hl7:effectiveTime
|
| IVL_TS | 0 … 1 | C | Case 3: anchored period:
The width element is used to specify a period of (actual or intended) administration anchored to a specific date (e.g. a two weeks therapy starting today) | (IPS...ent) |
where [hl7:low or
[not(hl7:high)] | |
| | Example | 2 week period starting on 2013-03-21 <effectiveTime type="IVL_TS">
<low value="20130321"/> <width value="2" unit="w"/></effectiveTime> |
| IVXB_TS | 0 … 1 | C | | (IPS...ent) |
| PQ | 1 … 1 | R | | (IPS...ent) |
| cs | 1 … 1 | R | |
| | CONF | | The value of @unit shall be drawn from value set 2.16.840.1.113883.11.21.1 Medication Time Units (UCUM) (DYNAMIC) |
|
| hl7:routeCode
|
| CE.IPS | 0 … 1 | R |
The <routeCode> element specifies the route of administration using the EDQM route of administration vocabulary.
A code must be specified if the route is known.
Since the EDQM Standards Terms, together with UCUM, is one of the IDMP terminologies actually available for usage, this code system has been selected as referecne terminology for representing Pharmaceutical Dose forms; Packages and Route of Administration.
It is known that also alternative jurisdictional and international terminologies are also used for this concept domain, as NCI or SNOMED CT.
Official NCI and EDQM maps for the route of administration are available from the EDQM site.
| (IPS...ent) |
| | | | hl7ips-dataelement-102 | Route of administration | CEN/TC 251 prEN 17269 |
|
| | CONF | | The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.33 IPS Medicine Route of Administration (DYNAMIC) |
|
| hl7:doseQuantity
|
| IVL_PQ | | NP | | (IPS...ent) |
| hl7:rateQuantity
|
| IVL_PQ | | NP | | (IPS...ent) |
| hl7:administrationUnitCode
|
| CE | | NP | | (IPS...ent) |
| hl7:consumable
|
| | 1 … 1 | M | Contains 2.16.840.1.113883.10.22.4.2 IPS Medication Information (detail) (DYNAMIC) | (IPS...ent) |
| | @typeCode
|
| cs | 1 … 1 | F | CSM |
| hl7:author
|
| | 0 … * | | Contains 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC) | (IPS...ent) |
| hl7:entryRelationship
|
| | 0 … * | C |
Subordinate Substance Administration Statement as a component of the overall medication statement.
Unless medications are unknown or known absent, at least one subordinated <substanceAdministration> has to be present to convey information about dosages (dose, frequency of intakes,..).
Subordinated <substanceAdministration> elements can be also used either to handle split dosing, or to support combination medications.
Contains 2.16.840.1.113883.10.21.4.6 UV Subordinate Substance Administration (DYNAMIC) | (IPS...ent) |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | Constraint | At least one subordinate <substanceAdministration> element SHALL be present unless medications are unknown or known absent. </substanceAdministration> |
| | Example | <cda:entryRelationship typeCode="COMP">
<!-- component: Subordinate Substance Administration Statement. -->
<hl7:substanceAdministration classCode="SBADM" moodCode="EVN">
<hl7:templateId root="2.16.840.1.113883.10.22.4.33"/> <!-- .. -->
</hl7:substanceAdministration> <cda:sequenceNumber value="1"/></cda:entryRelationship> |
| | hl7:sequenceNumber
|
| INT | 0 … 1 | | Sequence number of the Subordinate Substance Administration | (IPS...ent) |
Draft
