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Template MedicationStatement

Medikations-Eintrag (Medication Statement)

Aktuelle Version

Id	1.2.276.0.76.3.1.261.1.10.4.6	Gültigkeit	2018‑02‑06 09:09:31
Status	Entwurf	Versions-Label
Name	MedicationStatement	Bezeichnung	Medikation
Beschreibung	Medikations-Eintrag (Medication Statement)
Kontext	Elternknoten des Template-Element mit Id 1.2.276.0.76.3.1.261.1.10.4.6
Label	medspmp
Klassifikation	CDA Entry Level Template
Offen/Geschlossen	Offen (auch andere als die definierten Elemente sind erlaubt)
Assoziiert mit	Assoziiert mit 2 Konzepte Id Name Datensatz dguvbbr-data​element2-564  Arzneimittel/Wirkstoff/Rezeptur  Stationärer Entlassungsbericht dguvbbr-data​element2-591  Art der Anwendung  Stationärer Entlassungsbericht
Benutzt	Benutzt 4 Templates Benutzt als Name Version 1.2.276.0.76.10.90023 Inklusion Einnahmedauer DYNAMIC 1.2.276.0.76.10.4025 Containment Medikament DYNAMIC 1.2.276.0.76.10.4023 Containment Einzeldosierungen (mpp 2018) DYNAMIC 1.2.276.0.76.10.4024 Containment Dosierung Freitext DYNAMIC
Beziehung	Spezialisierung: Template 1.2.276.0.76.10.4022 Medikation (2017‑06‑04) ref pmp- Spezialisierung: Template 2.16.840.1.113883.10.12.308 CDA SubstanceAdministration (2005‑09‑07) ref ad1bbr-
Beispiel	Beispiel <hl7:substanceAdministration>   <hl7:templateId root="1.2.276.0.76.3.1.261.1.10.4.6"/>  <hl7:id root="1.2.3.999" extension="--example only--"/>  <hl7:code code="DRUG" codeSystem="2.16.840.1.113883.5.4"/>  <hl7:text>     <hl7:reference value="#med-1"/>  </hl7:text>  <hl7:statusCode code="active"/>  <hl7:routeCode code="20001000" codeSystem="0.4.0.127.0.16.1.1.2.1" displayName="Auricular use"/>  <hl7:consumable>     <!-- template 1.2.276.0.76.3.1.261.1.10.4.7 'Medikament' (2018-02-06T08:59:15) -->   </hl7:consumable>  <hl7:entryRelationship>     <hl7:sequenceNumber value="1"/>    <!-- template 1.2.276.0.76.10.4023 'Einzeldosierungen' (2017-06-04T00:00:00) -->   </hl7:entryRelationship>  <hl7:entryRelationship>     <hl7:sequenceNumber value="1"/>    <!-- template 1.2.276.0.76.10.4024 'Dosierung Freitext' (2014-11-01T00:00:00) -->   </hl7:entryRelationship></hl7:substanceAdministration>
Beispiel	Full example (auto-generated) <hl7:substanceAdministration classCode="SBADM" moodCode="EVN">   <hl7:templateId root="1.2.276.0.76.3.1.261.1.10.4.6"/>  <hl7:id root="1.2.3.999" extension="--example only--"/>  <hl7:code code="DRUG" codeSystem="2.16.840.1.113883.5.4"/>  <hl7:text>     <hl7:reference value="--TODO--"/>  </hl7:text>  <hl7:statusCode code="completed"/>  <!-- include template 1.2.276.0.76.10.90023 'Einnahmedauer' (2017-06-04T00:00:00) 0..1 R -->   <__CHOICE__ min="0" max="1">     <!--start choice particle-->     <hl7:effectiveTime xsi:type="IVL_TS">       <hl7:low value="20210115"/>      <hl7:high value="20210115"/>    </hl7:effectiveTime>    <!--end choice particle-->     <!--start choice particle-->     <hl7:effectiveTime>       <hl7:width unit="d" value="1"/>    </hl7:effectiveTime>    <!--end choice particle-->     <!--start choice particle-->     <hl7:effectiveTime nullFlavor="NI" value="20210115081149"/>    <!--end choice particle-->   </__CHOICE__>  <hl7:routeCode code="20001000" codeSystem="0.4.0.127.0.16.1.1.2.1" displayName="Auricular use"/>  <hl7:consumable>     <hl7:manufacturedProduct classCode="MANU">       <hl7:templateId root="1.2.276.0.76.10.4025"/>      <!-- include template 1.2.276.0.76.10.90022 'Material' (2018-12-04T00:00:00) 1..1 M -->       <hl7:manufacturedMaterial classCode="MMAT" determinerCode="KIND">         <hl7:code nullFlavor="NA" code="--code--" codeSystem="1.2.276.0.76.4.6">           <hl7:originalText>             <hl7:reference value="--TODO--"/>          </hl7:originalText>          <hl7:translation/>        </hl7:code>        <hl7:name nullFlavor="NA">name</hl7:name>        <formCode code="10101000" codeSystem="0.4.0.127.0.16.1.1.2.1" displayName="Oral drops, solution">           <hl7:translation code="AEO" codeSystem="1.2.276.0.76.3.1.1.5.2.40" displayName="Öl"/>        </formCode>        <asContent classCode="CONT">           <containerPackagedProduct classCode="CONT" determinerCode="INSTANCE">             <code code="--code--" codeSystem="1.2.276.0.76.4.6">               <hl7:originalText/>            </code>            <name>name</name>            <formCode/>            <capacityQuantity value="1"/>          </containerPackagedProduct>        </asContent>        <asSpecializedKind classCode="GRIC">           <generalizedMaterialKind classCode="MMAT">             <hl7:code/>            <hl7:name>name</hl7:name>          </generalizedMaterialKind>        </asSpecializedKind>        <ingredient classCode="ACTI">           <quantity>             <hl7:numerator value="1">               <hl7:translation code="#" codeSystem="1.2.276.0.76.3.1.1.5.2.41" displayName="Messlöffel"/>            </hl7:numerator>            <hl7:denominator value="1"/>          </quantity>          <ingredientSubstance>             <code code="--code--" codeSystem="2.16.840.1.113883.6.73">               <hl7:originalText/>              <hl7:translation/>            </code>            <name>name</name>          </ingredientSubstance>        </ingredient>      </hl7:manufacturedMaterial>    </hl7:manufacturedProduct>    <!-- template 1.2.276.0.76.10.4025 'Medikament' (2017-06-04T00:00:00) -->   </hl7:consumable>  <hl7:entryRelationship typeCode="COMP">     <hl7:sequenceNumber value="1"/>    <hl7:substanceAdministration classCode="SBADM" moodCode="EVN">       <hl7:templateId root="1.2.276.0.76.10.4023"/>      <hl7:text>         <hl7:reference value="--TODO--"/>      </hl7:text>      <__CHOICE__ max="1">         <!--start choice particle-->         <hl7:effectiveTime value="20210115081149"/>        <!--end choice particle-->         <!--start choice particle-->         <hl7:effectiveTime>           <hl7:event code="AC"/>          <hl7:offset unit="d">             <hl7:low value="1"/>          </hl7:offset>        </hl7:effectiveTime>        <!--end choice particle-->         <!--start choice particle-->         <hl7:effectiveTime>           <hl7:phase>             <hl7:low value="20210115081149"/>          </hl7:phase>          <hl7:period unit="d" value="1"/>        </hl7:effectiveTime>        <!--end choice particle-->         <!--start choice particle-->         <hl7:effectiveTime>           <hl7:comp>             <hl7:phase>               <hl7:low value="20210115081149"/>            </hl7:phase>            <hl7:period unit="d" value="1"/>          </hl7:comp>          <hl7:comp operator="A">             <hl7:event code="AC"/>            <hl7:offset unit="d">               <hl7:low value="1"/>            </hl7:offset>          </hl7:comp>        </hl7:effectiveTime>        <!--end choice particle-->         <!--start choice particle-->         <hl7:effectiveTime>           <hl7:comp>             <hl7:low value="20210115081149"/>          </hl7:comp>          <hl7:comp operator="A">             <hl7:event code="AC"/>            <hl7:offset unit="d">               <hl7:low value="1"/>            </hl7:offset>          </hl7:comp>        </hl7:effectiveTime>        <!--end choice particle-->       </__CHOICE__>      <hl7:doseQuantity>         <hl7:translation code="#" codeSystem="2.16.840.1.113883.2.6.60.4.5.4" displayName="Messlöffel"/>      </hl7:doseQuantity>      <hl7:consumable>         <hl7:manufacturedProduct>           <hl7:manufacturedMaterial nullFlavor="NA"/>        </hl7:manufacturedProduct>      </hl7:consumable>      <!-- include template 1.2.276.0.76.10.90028 'Medikation Vorbedingung' (2017-06-04T00:00:00) 0..1 R -->       <hl7:precondition typeCode="PRCN">         <hl7:criterion classCode="OBS" moodCode="EVN.CRT">           <hl7:code code="PRN" codeSystem="2.16.840.1.113883.5.4" displayName="bei Bedarf">             <hl7:originalText/>          </hl7:code>          <hl7:text>             <hl7:reference value="--TODO--"/>          </hl7:text>        </hl7:criterion>      </hl7:precondition>    </hl7:substanceAdministration>    <!-- template 1.2.276.0.76.10.4023 'Einzeldosierungen' (2018-11-01T00:00:00) -->   </hl7:entryRelationship>  <hl7:entryRelationship typeCode="COMP">     <hl7:sequenceNumber value="1"/>    <hl7:substanceAdministration classCode="SBADM" moodCode="EVN">       <hl7:templateId root="1.2.276.0.76.10.4024"/>      <hl7:text>         <hl7:reference value="--TODO--"/>      </hl7:text>      <hl7:consumable>         <hl7:manufacturedProduct>           <hl7:manufacturedMaterial nullFlavor="NA"/>        </hl7:manufacturedProduct>      </hl7:consumable>    </hl7:substanceAdministration>    <!-- template 1.2.276.0.76.10.4024 'Dosierung Freitext' (2014-11-01T00:00:00) -->   </hl7:entryRelationship></hl7:substanceAdministration>
Beispiel	Beispiel <hl7:substanceAdministration classCode="SBADM" moodCode="EVN">   <hl7:templateId root="1.2.276.0.76.3.1.261.1.10.4.6"/>  <hl7:id root="1.2.3.999" extension="--example only--"/>  <hl7:code code="DRUG" codeSystem="2.16.840.1.113883.5.4"/>  <hl7:text>     <hl7:reference value="--TODO--"/>  </hl7:text>  <hl7:statusCode code="completed"/>  <!-- include template 1.2.276.0.76.10.90023 'Einnahmedauer' (2017-06-04T00:00:00) 0..1 R -->   <__CHOICE__ min="0" max="1">     <!--start choice particle-->     <hl7:effectiveTime xsi:type="IVL_TS">       <hl7:low value="20210115"/>      <hl7:high value="20210115"/>    </hl7:effectiveTime>    <!--end choice particle-->     <!--start choice particle-->     <hl7:effectiveTime>       <hl7:width unit="d" value="1"/>    </hl7:effectiveTime>    <!--end choice particle-->     <!--start choice particle-->     <hl7:effectiveTime nullFlavor="NI" value="20210115081003"/>    <!--end choice particle-->   </__CHOICE__>  <hl7:routeCode code="20001000" codeSystem="0.4.0.127.0.16.1.1.2.1" displayName="Auricular use"/>  <hl7:consumable>     <hl7:manufacturedProduct classCode="MANU">       <hl7:templateId root="1.2.276.0.76.10.4025"/>      <!-- include template 1.2.276.0.76.10.90022 'Material' (2018-12-04T00:00:00) 1..1 M -->       <hl7:manufacturedMaterial classCode="MMAT" determinerCode="KIND">         <hl7:code nullFlavor="NA" code="--code--" codeSystem="1.2.276.0.76.4.6">           <hl7:originalText>             <hl7:reference value="--TODO--"/>          </hl7:originalText>          <hl7:translation/>        </hl7:code>        <hl7:name nullFlavor="NA">name</hl7:name>        <formCode code="10101000" codeSystem="0.4.0.127.0.16.1.1.2.1" displayName="Oral drops, solution">           <hl7:translation code="AEO" codeSystem="1.2.276.0.76.3.1.1.5.2.40" displayName="Öl"/>        </formCode>        <asContent classCode="CONT">           <containerPackagedProduct classCode="CONT" determinerCode="INSTANCE">             <code code="--code--" codeSystem="1.2.276.0.76.4.6">               <hl7:originalText/>            </code>            <name>name</name>            <formCode/>            <capacityQuantity value="1"/>          </containerPackagedProduct>        </asContent>        <asSpecializedKind classCode="GRIC">           <generalizedMaterialKind classCode="MMAT">             <hl7:code/>            <hl7:name>name</hl7:name>          </generalizedMaterialKind>        </asSpecializedKind>        <ingredient classCode="ACTI">           <quantity>             <hl7:numerator value="1">               <hl7:translation code="#" codeSystem="1.2.276.0.76.3.1.1.5.2.41" displayName="Messlöffel"/>            </hl7:numerator>            <hl7:denominator value="1"/>          </quantity>          <ingredientSubstance>             <code code="--code--" codeSystem="2.16.840.1.113883.6.73">               <hl7:originalText/>              <hl7:translation/>            </code>            <name>name</name>          </ingredientSubstance>        </ingredient>      </hl7:manufacturedMaterial>    </hl7:manufacturedProduct>    <!-- template 1.2.276.0.76.10.4025 'Medikament' (2017-06-04T00:00:00) -->   </hl7:consumable>  <hl7:entryRelationship typeCode="COMP">     <hl7:sequenceNumber value="1"/>    <hl7:substanceAdministration classCode="SBADM" moodCode="EVN">       <hl7:templateId root="1.2.276.0.76.10.4023"/>      <hl7:text>         <hl7:reference value="--TODO--"/>      </hl7:text>      <__CHOICE__ max="1">         <!--start choice particle-->         <hl7:effectiveTime value="20210115081003"/>        <!--end choice particle-->         <!--start choice particle-->         <hl7:effectiveTime>           <hl7:event code="AC"/>          <hl7:offset unit="d">             <hl7:low value="1"/>          </hl7:offset>        </hl7:effectiveTime>        <!--end choice particle-->         <!--start choice particle-->         <hl7:effectiveTime>           <hl7:phase>             <hl7:low value="20210115081003"/>          </hl7:phase>          <hl7:period unit="d" value="1"/>        </hl7:effectiveTime>        <!--end choice particle-->         <!--start choice particle-->         <hl7:effectiveTime>           <hl7:comp>             <hl7:phase>               <hl7:low value="20210115081003"/>            </hl7:phase>            <hl7:period unit="d" value="1"/>          </hl7:comp>          <hl7:comp operator="A">             <hl7:event code="AC"/>            <hl7:offset unit="d">               <hl7:low value="1"/>            </hl7:offset>          </hl7:comp>        </hl7:effectiveTime>        <!--end choice particle-->         <!--start choice particle-->         <hl7:effectiveTime>           <hl7:comp>             <hl7:low value="20210115081003"/>          </hl7:comp>          <hl7:comp operator="A">             <hl7:event code="AC"/>            <hl7:offset unit="d">               <hl7:low value="1"/>            </hl7:offset>          </hl7:comp>        </hl7:effectiveTime>        <!--end choice particle-->       </__CHOICE__>      <hl7:doseQuantity>         <hl7:translation code="#" codeSystem="2.16.840.1.113883.2.6.60.4.5.4" displayName="Messlöffel"/>      </hl7:doseQuantity>      <hl7:consumable>         <hl7:manufacturedProduct>           <hl7:manufacturedMaterial nullFlavor="NA"/>        </hl7:manufacturedProduct>      </hl7:consumable>      <!-- include template 1.2.276.0.76.10.90028 'Medikation Vorbedingung' (2017-06-04T00:00:00) 0..1 R -->       <hl7:precondition typeCode="PRCN">         <hl7:criterion classCode="OBS" moodCode="EVN.CRT">           <hl7:code code="PRN" codeSystem="2.16.840.1.113883.5.4" displayName="bei Bedarf">             <hl7:originalText/>          </hl7:code>          <hl7:text>             <hl7:reference value="--TODO--"/>          </hl7:text>        </hl7:criterion>      </hl7:precondition>    </hl7:substanceAdministration>    <!-- template 1.2.276.0.76.10.4023 'Einzeldosierungen' (2018-11-01T00:00:00) -->   </hl7:entryRelationship>  <hl7:entryRelationship typeCode="COMP">     <hl7:sequenceNumber value="1"/>    <hl7:substanceAdministration classCode="SBADM" moodCode="EVN">       <hl7:templateId root="1.2.276.0.76.10.4024"/>      <hl7:text>         <hl7:reference value="--TODO--"/>      </hl7:text>      <hl7:consumable>         <hl7:manufacturedProduct>           <hl7:manufacturedMaterial nullFlavor="NA"/>        </hl7:manufacturedProduct>      </hl7:consumable>    </hl7:substanceAdministration>    <!-- template 1.2.276.0.76.10.4024 'Dosierung Freitext' (2014-11-01T00:00:00) -->   </hl7:entryRelationship></hl7:substanceAdministration>
Item DT Kard Konf Beschreibung Label hl7:substanceAdministration 0 … * medspmp @classCode cs 1 … 1 F SBADM @moodCode cs 1 … 1 F EVN hl7:templateId II 1 … 1 M medspmp @root uid 1 … 1 F 1.2.276.0.76.3.1.261.1.10.4.6 hl7:id II 0 … * R medspmp hl7:code CV 1 … 1 M medspmp @code CONF 1 … 1 F DRUG @codeSystem 1 … 1 F 2.16.840.1.113883.5.4 (Act Code) hl7:text ED 1 … 1 M medspmp hl7:reference TEL 1 … 1 M medspmp @value 1 … 1 R #med-{generierteID}, z.B.: #med-1 hl7:statusCode CS 1 … 1 R medspmp   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.2.6.60.4.11.25 ActStatusActiveCompletedAbortedSuspended (DYNAMIC) Eingefügt 0 … 1 R von 1.2.276.0.76.10.90023 Einnahmedauer (DYNAMIC) Auswahl 0 … 1 Elemente in der Auswahl: hl7:effectiveTime[hl7:low|hl7:high] hl7:effectiveTime[hl7:width] hl7:effectiveTime[@nullFlavor='NI'] hl7:effectiveTime IVL_TS  … 1 C Zeitelement zur Dokumentation der Einnahmedauer, hier spezifisches Interval von bis medspmp wo [hl7:lowoder hl7:high] @xsi:type 0 … 1 F IVL_TS   Beispiel Intervall bekannt <effectiveTime xsi:type="IVL_TS">   <low value="20130321"/>  <high value="20140321"/></effectiveTime>   Beispiel unbekanntes Ende-Datum <effectiveTime xsi:type="IVL_TS">   <low value="20130321"/>  <high nullFlavor="UNK"/></effectiveTime>   Beispiel Dauermedikation <effectiveTime xsi:type="IVL_TS">   <low value="20130321"/>  <high nullFlavor="NA"/></effectiveTime> hl7:low TS.​DATE.​MIN 1 … 1 R medspmp   dguvbbr-data​element2-579  Startdatum Einnahme  Stationärer Entlassungsbericht hl7:high TS.​DATE.​MIN 0 … 1 R medspmp   dguvbbr-data​element2-580  Enddatum Einnahme  Stationärer Entlassungsbericht hl7:effectiveTime IVL_TS  … 1 C Zeitelement zur Dokumentation der Einnahmedauer, hier Dauer medspmp wo [hl7:width]   Beispiel Einnahme für zwei Wochen <effectiveTime xsi:type="IVL_TS">   <width value="2" unit="wk"/></effectiveTime> hl7:width PQ 1 … 1 R medspmp   dguvbbr-data​element2-581  Dauer der Einnahme  Stationärer Entlassungsbericht @unit cs 1 … 1 R   CONF Der Wert von @unit muss gewählt werden aus dem Value Set 1.2.276.0.76.11.452 Zeiteinheiten (UCUM) (DYNAMIC) hl7:effectiveTime TS  … 1 C medspmp wo [@nullFlavor='NI'] @nullFlavor cs 1 … 1 F NI   Beispiel Keine Informationen über die Einnahmedauer <effectiveTime nullFlavor="NI"/> hl7:routeCode CE 0 … 1 R Art der Anwendung der Arznei medspmp   dguvbbr-data​element2-591  Art der Anwendung  Stationärer Entlassungsbericht   CONF Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.2.6.60.4.11.26 EDQMRouteofAdministration (DYNAMIC) hl7:consumable 1 … 1 M Arzneimittel/Wirkstoff/Rezeptur Beinhaltet 1.2.276.0.76.10.4025 Medikament (DYNAMIC) medspmp   dguvbbr-data​element2-564  Arzneimittel/Wirkstoff/Rezeptur  Stationärer Entlassungsbericht hl7:entryRelationship 0 … 5 R Einnahme: morgens, mittags, abends, zur Nacht Beinhaltet 1.2.276.0.76.10.4023 Einzeldosierungen (DYNAMIC) medspmp @typeCode cs 1 … 1 F COMP hl7:sequenceNumber INT.POS 0 … 1 Reihenfolge in der Liste der Dosierungsangaben medspmp hl7:entryRelationship 0 … 1 R Freitextliche Dosierinstruktionen Beinhaltet 1.2.276.0.76.10.4024 Dosierung Freitext (DYNAMIC) medspmp @typeCode cs 1 … 1 F COMP hl7:sequenceNumber INT.POS 0 … 1 Reihenfolge in der Liste der Dosierungsangaben medspmp

Zusammenstellung aller Versionen dieses Templates

• 2018-02-06 09:09:31 (In Entwicklung)