Universal Medication Statement: Recording a "medication statement" is an activity that can be performed by a variety of healthcare professionals, or the patient, or non-healthcare professionals. Examples of recording medication statements include taking a patient's medication history, recording reported use of medications where the source of the patient information is from a third party and not the patient e.g. a family member when the patient is unable to communicate their medication history.
Kontext
Elternknoten des Template-Element mit Id 1.2.276.0.76.3.1.195.10.67
Klassifikation
CDA Entry Level Template
Offen/Geschlossen
Offen (auch andere als die definierten Elemente sind erlaubt)
EVN will be used to record a medication statement where the patient is currently taking or has taken the medication in the past. INT will be used to record a medication statement where the patient plans to take the medication or be administered the medication in the future.
CONF
@moodCode muss "EVN" sein
oder
@moodCode muss "INT" sein
hl7:templateId
II
1 … 1
M
(Med...ion)
@root
uid
1 … 1
F
1.2.276.0.76.3.1.195.10.67
hl7:id
II
0 … *
R
(Med...ion)
hl7:code
CD
1 … 1
R
(Med...ion)
@code
CONF
0 … 1
F
DRUG
@codeSystem
0 … 1
F
2.16.840.1.113883.5.4 (Act Code)
hl7:text
ED
1 … 1
M
(Med...ion)
hl7:reference
TEL
1 … 1
M
(Med...ion)
@value
1 … 1
R
#med-{generierteID}, z.B.: #med-1
hl7:statusCode
CS
0 … 1
(Med...ion)
CONF
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC)
hl7:effectiveTime
NP
(Med...ion)
hl7:routeCode
CE (Beispiel)
0 … 1
(Med...ion)
CONF
Beispiele von der Wert von @code stehen in den Value Set 2.16.840.1.113883.1.11.14581 RouteOfAdministration (DYNAMIC)
hl7:approachSiteCode
CD (Beispiel)
0 … *
(Med...ion)
CONF
Beispiele von der Wert von @code stehen in den Value Set 2.16.840.1.113883.1.11.19724 HumanSubstanceAdministrationSite (DYNAMIC)
hl7:doseQuantity
IVL_PQ
NP
(Med...ion)
hl7:rateQuantity
IVL_PQ
NP
(Med...ion)
hl7:maxDoseQuantity
RTO_PQ_PQ
0 … 1
(Med...ion)
hl7:administrationUnitCode
CE
NP
(Med...ion)
hl7:consumable
0 … 1
R
Consumable: The medication that is administered (simple) Beinhaltet
Fehler: Kann das Template "2.16.840.1.113883.10.21.4.10" (DYNAMIC) nicht finden
(Med...ion)
@typeCode
cs
1 … 1
F
CSM
hl7:entryRelationship
0 … *
C
Subordinate Substance Administration Statament as a component of the overall medication statement. At least one subordinated <substanceAdministration> has to be present to convey information about dosages (dose, frequency of intakes,..) unless medications are unknown or known absent. Subordinated <substanceAdministration> elements can be also used either to handle split dosing, or to support combination medications. Beinhaltet 2.16.840.1.113883.10.21.4.6 UV Subordinate Substance Administration (DYNAMIC)
(Med...ion)
wo [exists(hl7:substanceAdministration)]
@typeCode
cs
1 … 1
F
COMP
Constraint
At least one subordinate <substanceAdministration> element SHALL be present unless medications are unknown or known absent.</substanceAdministration>
hl7:sequenceNumber
INT
0 … 1
Sequence number of the Subordinate Substance Administration.