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ref Template  epSOS Patient Medication Instructions

Id 1.3.6.1.4.1.19376.1.5.3.1.4.3 ref (aus Repository: epsos-) Gültigkeit gültig ab 2013‑12‑20
Status draft Draft Versions-Label
Name epsosPatientMedicationInstructions Anzeigename epSOS Patient Medication Instructions
Beschreibung en-US

Any medication may be the subject of further instructions to the patient, for example to indicate that it should be taken with food, etc.

This structure is included in the target supply act using the <entryRelationship> element defined in the CDA Schema. The example below shows the recording of patient medication instruction for an <entry>, and is used as context for the following section.

Act classCode

<act classCode='ACT' moodCode='INT'>

The related statement is the intent (moodCode='INT') on how the related entry is to be performed.

Template Id root

<templateId root='2.16.840.1.113883.10.20.1.49'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.3'/>

These <templateId> elements identify this <act> as a medication instruction, allowing for validation of the content.

Code

<code code='PINSTRUCT' codeSystem='1.3.6.1.4.1.19376.1.5.3.2' codeSy s temName='IHEActCode' />

The <code> element indicates that this is a patient medication instruction. This element shall be recorded exactly as specified above.

Text-reference

<text><reference value='#comment'/></text>

The <text> element contains a free text representation of the instruction. This element SHALL contain a <reference>element to the link text of the comment in the narrative portion of the document. The comment itself is not the act being coded, so it appears in the <text> of the <observation>, not as part of the <code>.

Status Code

<statusCode code='completed' />

The code attribute of <statusCode> for all comments must be completed.
Kontext Elternknoten des Template-Element mit Id 1.3.6.1.4.1.19376.1.5.3.1.4.3
Klassifikation CDA Entry Level Template
Offen/Geschlossen Offen (auch andere als die definierten Elemente sind erlaubt)
Assoziiert mit
Assoziiert mit 1 Konzept
Id Name Datensatz
cdachemed-dataelement-54 Anwendungsinstruktion Parameter eMedikation B8
Benutzt von / Benutzt
Benutzt von 12 Templates, Benutzt 0 Templates
Benutzt von Template-Id als Name Version
2.16.756.5.30.1.1.1.1.3.10.2.10.1.10.4.1 Containment Medication Treatment Plan Item Entry Content Module 2016‑06‑13 14:23:13
2.16.756.5.30.1.1.1.1.3.10.2.10.1.10.3.1 link eCurrentMedication Section Content Module 2016‑05‑21 23:12:35
2.16.756.5.30.1.1.1.1.3.10.1 link eCurrentMedication V1 2016‑05‑13 22:09:17
2.16.756.5.30.1.1.1.1.3.10.2.10.2.10.4.1 link Prescription Item Entry Content Module 2016‑06‑25 12:22:37
2.16.756.5.30.1.1.1.1.3.10.2.10.2.10.3.1 link Prescription Section Content Module 2016‑06‑06 15:45:17
2.16.756.5.30.1.1.1.1.3.10.2 link eRezept V1 2016‑05‑21 10:48:21
2.16.756.5.30.1.1.1.1.3.10.2.10.4.10.4.1 link Pharmaceutical Advice Item Entry Content Module 2016‑06‑25 13:03:02
2.16.756.5.30.1.1.1.1.3.10.2.10.4.10.3.1 link Pharmaceutical Advice Section Content Module 2016‑06‑06 16:43:15
2.16.756.5.30.1.1.1.1.3.10.4 link eMedicationComment V1 2016‑05‑21 10:50:30
2.16.756.5.30.1.1.1.1.3.10.2.10.3.10.4.1 link Dispense Item Entry Content Module 2016‑06‑17 23:36:35
2.16.756.5.30.1.1.1.1.3.10.2.10.3.10.3.1 link Dispense Section Content Module 2016‑06‑06 15:58:22
2.16.756.5.30.1.1.1.1.3.10.3 link eAbgabeAnwendungsDokument V1 2016‑05‑21 10:49:53
Beziehung Specialization: Template 2.16.840.1.113883.10.12.301 (2005‑09‑07)
Beispiel
Beispiel
<entry>
  <supply classCode="SPLY" moodCode="EVN">
    <!-- ... -->
    <entryRelationship typeCode="SUBJ" inversionInd="true">
      <act classCode="ACT" moodCode="INT">
        <templateId root="2.16.840.1.113883.10.20.1.49"/>
        <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.3"/>
        <code code="PINSTRUCT" codeSystem="1.3.6.1.4.1.19376.1.5.3.2" codeSystemName="IHEActCode"/>
        <text>
          <reference value="#comment-2"/>
        </text>        <statusCode code="completed"/>
      </act>    </entryRelationship>    <!-- ... -->
  </supply></entry>
Item DT Kard Konf Beschreibung Label
hl7:act
0 … * R (epsosPatientMedicationInstructions)
treetree @classCode
1 … 1 F ACT
treetree @moodCode
1 … 1 F INT
treetree hl7:templateId
II.EPSOS 1 … 1 R (epsosPatientMedicationInstructions)
treeblank treetree @root
1 … 1 F 2.16.840.1.113883.10.20.1.49
treetree hl7:templateId
1 … 1 M (epsosPatientMedicationInstructions)
treeblank treetree @root
1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.3
treetree hl7:code
CD.EPSOS 1 … 1 R (epsosPatientMedicationInstructions)
treeblank treetree @code
1 … 1 F PINSTRUCT
treeblank treetree @codeSystem
1 … 1 F 1.3.6.1.4.1.19376.1.5.3.2 (IHEActCode Vocabulary)
treetree hl7:text
ED 0 … 1 R (epsosPatientMedicationInstructions)
treeblank treetree hl7:reference
TEL 1 … 1 M (epsosPatientMedicationInstructions)
treeblank treeblank treetree @value
1 … 1 R en-US Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
  target Ziel der Konzept Id(s):
cdachemed-dataelement-54 Anwendungsinstruktion Parameter eMedikation B8
treetree hl7:statusCode
CS 0 … 1 R (epsosPatientMedicationInstructions)
treeblank treetree @code
1 … 1 F completed