Template 2.16.756.5.30.1.1.10.4.43 - PrescriptionItemEntryContentModule

Template Prescription Item Entry Content Module

2.16.756.5.30.1.1.10.4.43

ref

ch-pharm-

Effective Date

2016‑06‑25

Status Under pre-publication review Version Label 2017

Name PrescriptionItemEntryContentModule Display Name Prescription Item Entry Content Module

Description

A Prescription Item belongs to one prescription and represents one prescribed medication. It may be associated with one or more observations. Prescription Item is the atomic entity for logistics, distribution and billing. It contains the prescribed medicine and dosage information as well as other information to the prescribed item such as patient- and fulfillment instructions and substitution handling.

Context Parent nodes of template element with id 2.16.756.5.30.1.1.10.4.43

Classification CDA Entry Level Template

Open/Closed Closed (only defined elements are allowed)

Used by / Uses

Used by 0 transactions and 4 templates, Uses 12 templates

Used by	as	Name	Version
2.16.756.5.30.1.1.10.3.10	Containment	Prescription Section Content Module (2017)	2016‑06‑06
2.16.756.5.30.1.1.10.1.4		Medication Prescription document (2017)	2016‑05‑21
2.16.756.5.30.1.1.10.3.44	Containment	Medication List Section Content Module (2017)	2018‑01‑22 15:40:38
2.16.756.5.30.1.1.10.1.13		Medication List document (2017)	2018‑01‑22 15:17:26
Uses	as	Name	Version
2.16.756.5.30.1.1.10.4.35	Include	Dosage Instructions Start/Stop, Frequency, Dose (2017)	DYNAMIC
2.16.756.5.30.1.1.10.4.33	Include	Manufactured Material Entry Content Module (2017)	DYNAMIC
2.16.756.5.30.1.1.10.4.36	Include	Dosage Instructions Dosage Change (2017)	DYNAMIC
2.16.756.5.30.1.1.10.4.41	Containment	Treatment Reason Entry Content Module (2017)	DYNAMIC
2.16.756.5.30.1.1.10.4.45	Containment	MTP Reference Entry Content Module (2017)	DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.3	Containment	IHE Patient Medication Instructions (2014)	DYNAMIC
2.16.756.5.30.1.1.10.4.38	Containment	Prescribed Quantity Entry Content Module (2017)	DYNAMIC
1.3.6.1.4.1.19376.1.9.1.3.9.1	Containment	IHE Substitution Permission Content Module (2017)	DYNAMIC
1.3.6.1.4.1.19376.1.9.1.3.15	Containment	IHE Renewal Period Content Module (2017)	DYNAMIC
2.16.756.5.30.1.1.10.4.52	Containment	Dosage Instructions Non Structured Entry Content Module (2017)	DYNAMIC
2.16.756.5.30.1.1.10.4.37	Containment	Dosage Intake Mode Entry Content Module (2017)	DYNAMIC
2.16.756.5.30.1.1.10.4.2	Containment	Annotation Comments (2016)	DYNAMIC

Relationship Specialization: template 1.3.6.1.4.1.19376.1.9.1.3.2 (DYNAMIC)

Example

<substanceAdministration classCode="SBADM" moodCode="INT">  <templateId root="1.3.6.1.4.1.19376.1.9.1.3.2"/>  <templateId root="2.16.840.1.113883.10.20.1.24"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7"/>  <templateId root="2.16.756.5.30.1.1.10.4.43"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.1"/>  <id root="D41D72BA-2100-11E6-B67B-9E71128CAE77"/> <text> <reference value="#pre.1"/> </text> <statusCode code="completed"/> <effectiveTime xsi:type="IVL_TS"> <low value="20120204"/> </effectiveTime> <effectiveTime xsi:type="SXPR_TS" operator="A"> <comp xsi:type="EIVL_TS"> <event code="ACM"/> </comp> <comp xsi:type="EIVL_TS" operator="I"> <event code="ACV"/> </comp> </effectiveTime>  <repeatNumber value="2"/> <routeCode code="20053000" codeSystem="0.4.0.127.0.16.1.1.2.1" displayName="Oral use"/> <consumable> <manufacturedProduct classCode="MANU"> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.2"/> <templateId root="2.16.840.1.113883.10.20.1.53"/> <manufacturedMaterial classCode="MMAT" determinerCode="KIND"> <templateId root="2.16.756.5.30.1.1.10.4.33"/> <templateId root="1.3.6.1.4.1.19376.1.9.1.3.1"/> <code code="C08CA01" codeSystem="2.16.840.1.113883.6.73" codeSystemName="ATC WHO" displayName="amlodipine"> <originalText> <reference value="#pre.1.ingredient"/> </originalText> </code> <name>NORVASC Tabl 10 mg</name> <pharm:formCode code="10219000" codeSystem="0.4.0.127.0.16.1.1.2.1" displayName="Tablet"/> <pharm:asContent classCode="CONT"> <pharm:containerPackagedMedicine classCode="CONT" determinerCode="INSTANCE"> <pharm:code code="7680500440334" codeSystem="2.51.1.1" codeSystemName="GTIN" displayName="NORVASC Tabl 10 mg"/> <pharm:name>NORVASC Tabl 10 mg</pharm:name> <pharm:formCode code="10219000" codeSystem="0.4.0.127.0.16.1.1.2.1" displayName="Tablet"/> <pharm:capacityQuantity value="30"/> </pharm:containerPackagedMedicine> </pharm:asContent> <pharm:ingredient classCode="ACTI"> <pharm:quantity> <pharm:numerator unit="mg" value="10" xsi:type="pharm:PQ"/> <pharm:denominator value="1" xsi:type="pharm:PQ"/> </pharm:quantity> <pharm:ingredient classCode="MMAT" determinerCode="KIND"> <pharm:code code="C08CA01" codeSystem="2.16.840.1.113883.6.73" codeSystemName="ATC WHO" displayName="amlodipine"/> <pharm:name>amlodipine</pharm:name> </pharm:ingredient> </pharm:ingredient> </manufacturedMaterial> </manufacturedProduct> </consumable> <entryRelationship typeCode="RSON"> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.756.5.30.1.1.10.4.41"/> <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem" codeSystemName="LOINC"/> <text> <reference value="#pre.1.reason"/> </text> <statusCode code="completed"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <substanceAdministration moodCode="INT" classCode="SBADM"> <templateId root="2.16.756.5.30.1.1.10.4.37"/> <text> <reference value="#pre.1.dosageintakemode"/> </text> <consumable> <manufacturedProduct> <manufacturedMaterial nullFlavor="NA"/> </manufacturedProduct> </consumable> </substanceAdministration> </entryRelationship> <entryRelationship typeCode="COMP"> <supply moodCode="RQO" classCode="SPLY"> <templateId root="1.3.6.1.4.1.19376.1.9.1.3.8"/> <independentInd value="false"/> <quantity unit="1" value="1"/> </supply> </entryRelationship> <entryRelationship typeCode="REFR"> <substanceAdministration classCode="SBADM" moodCode="INT"> <templateId root="1.3.6.1.4.1.19376.1.9.1.3.10"/> <templateId root="2.16.756.5.30.1.1.10.4.45"/> <id root="5712FFFE-20C6-11E6-B67B-9E71128CAE77"/> <code code="MTPItem" codeSystem="1.3.6.1.4.1.19376.1.9.2.2" displayName="Medication Treatment Plan Item" codeSystemName="IHE Pharmacy Item Type List"/> <consumable> <manufacturedProduct> <manufacturedMaterial nullFlavor="NA"/> </manufacturedProduct> </consumable> <reference typeCode="XCRPT"> <externalDocument> <id root="5712FFFE-20C6-11E6-B67B-9E71128CAE77"/> </externalDocument> </reference> </substanceAdministration> </entryRelationship> <entryRelationship typeCode="COMP"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.756.5.30.1.1.10.4.2"/> <templateId root="2.16.840.1.113883.10.20.1.40"/> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.2"/> <code code="48767-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Annotation comment"/> <text> <reference value="#pre.1.note"/> </text> <statusCode code="completed"/> </act> </entryRelationship></substanceAdministration>

Item DT Card Conf Description Label

hl7:substanceAdministration Prescription Item Entry Additional Template ID 6.3..3.3

@classCode cs 1 … 1 F SBADM

@moodCode cs 1 … 1 F INT

hl7:templateId II 1 … 1 M CH-PHARM Prescription Item Entry Content Module 6.3..3.3

@root uid 1 … 1 F 2.16.756.5.30.1.1.10.4.43

hl7:templateId II 1 … 1 M Prescription Item Entry TemplateID 6.3..3.2

@root uid 1 … 1 F 1.3.6.1.4.1.19376.1.9.1.3.2

hl7:templateId II 1 … 1 M CCD 6.3..3.3

@root uid 1 … 1 F 2.16.840.1.113883.10.20.1.24

hl7:templateId II 1 … 1 M PCC Medication Entry Content Module 6.3..3.3

@root uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.7

Choice

1 …

Prescription Item Entry Additional Template ID

Elements to choose from:

hl7:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.4.7.1']
hl7:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.4.8']
hl7:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.4.9']

hl7:templateId II 0 … 1 A normal substanceAdministration act that may not contain any subordinate substanceAdministration acts. 6.3..3.3

where [@root='1.3.6.1.4.1.19376.1.5.3.1.4.7.1']

@root uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.7.1

hl7:templateId II 0 … 1 A substanceAdministration act that records tapered dose information in subordinate. 6.3..3.3

where [@root='1.3.6.1.4.1.19376.1.5.3.1.4.8']

@root uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.8

hl7:templateId II 0 … 1 A substanceAdministration act that records split dose information in subordinate substanceAdministration acts. 6.3..3.3

where [@root='1.3.6.1.4.1.19376.1.5.3.1.4.9']

@root uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.9

hl7:id 1 … 1 M This ID represents the Prescription Item ID and SHALL be present. 6.3..3.4

hl7:text 1 … 1 M Narrative Text 6.3..3.6

hl7:reference 1 … 1 M This element SHALL be present. 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 dispensed. 6.3..3.6

hl7:statusCode 1 … 1 M 6.3..3.7

@code 1 … 1 F completed

Included from 2.16.756.5.30.1.1.10.4.35 Dosage Instructions Start/Stop, Frequency, Dose (DYNAMIC)

hl7:effectiveTime IVL_TS 0 … 1 Dosage Instructions PCC 6.3.4.16.10 - Start and Stop 6.3..3.8

where [@xsi:type='IVL_TS']

hl7:low TS 0 … 1 Start of Treatment. If Start of Treatment is unknown this element SHALL be set to null flavor "UNK". 6.3..3.8

hl7:high TS 0 … 1 End of Treatment. If Start of Treatment is unknown this element SHALL be set to null flavor "UNK". 6.3..3.8

hl7:effectiveTime EIVL_TS 0 … 1 Dosage Instructions PCC 6.3.4.16.12 - Frequency: Event based time interval, where the event is not a precise time, but is used for timing purposes (e.g., with meals, between meals, before breakfast, before sleep). 6.3..3.8

where [@operator='A' and @xsi:type='EIVL_TS']

@operator cs 1 … 1 F A

hl7:event CS 1 … 1 M 6.3..3.8

@code cs 1 … 1 R

CONF

The value of @code shall be drawn from value set 2.16.756.5.30.1.127.77.4.11.2 TimingEvent (DYNAMIC)

hl7:effectiveTime SXPR_TS 0 … 1 Dosage Instructions PCC 6.3.4.16.12 - Frequency: Multiple events within a day with the same dosage 6.3..3.8

where [@operator='A' and @xsi:type='SXPR_TS']

@operator cs 1 … 1 F A

@xsi:type cs 1 … 1 F SXPR_TS

hl7:comp 1 … * M 6.3..3.8

where [@xsi:type='EIVL_TS']

@xsi:type cs 1 … 1 F EIVL_TS

hl7:event CS 1 … 1 M 6.3..3.8

@code cs 1 … 1 R

CONF

The value of @code shall be drawn from value set 2.16.756.5.30.1.127.77.4.11.2 TimingEvent (DYNAMIC)

hl7:comp 1 … * M 6.3..3.8

where [@operator='I' and @xsi:type='EIVL_TS']

@operator cs 1 … 1 F I

@xsi:type cs 1 … 1 F EIVL_TS

hl7:event CS 1 … 1 M 6.3..3.8

@code cs 1 … 1 R

CONF

The value of @code shall be drawn from value set 2.16.756.5.30.1.127.77.4.11.2 TimingEvent (DYNAMIC)

hl7:routeCode CD (required) 0 … 1 6.3..3.3

CONF

The value of @code shall be drawn from value set 2.16.756.5.30.1.1.11.2 RouteOfAdministration (EDQM) (DYNAMIC)

hl7:approachSiteCode CD 0 … * 6.3..3.3

hl7:doseQuantity IVL_PQ 0 … 1 6.3..3.3

hl7:rateQuantity IVL_PQ 0 … 1 6.3..3.3

hl7:repeatNumber 1 … 1 M Number of repeats/refills 6.3..3.9

hl7:consumable 1 … 1 6.3.3.10

hl7:manufacturedProduct 1 … 1 M 6.3.3.10

hl7:templateId II 1 … 1 M 6.3..3.1

where [@root='1.3.6.1.4.1.19376.1.5.3.1.4.7.2']

@root uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.7.2

hl7:templateId II 1 … 1 M 6.3..3.1

where [@root='2.16.840.1.113883.10.20.1.53']

@root uid 1 … 1 F 2.16.840.1.113883.10.20.1.53

Included 1 … 1 M from 2.16.756.5.30.1.1.10.4.33 Manufactured Material Entry Content Module (DYNAMIC)

hl7:manufacturedMaterial 1 … 1 M 6.3.3.10

@classCode cs 0 … 1 F MMAT

@determinerCode cs 0 … 1 F KIND

hl7:templateId II 1 … 1 M CH-PHARM Manufactured Material Content Module 6.3.3.10

@root uid 1 … 1 F 2.16.756.5.30.1.1.10.4.33

hl7:templateId II 1 … 1 M 6.3.3.10

@root uid 1 … 1 F 1.3.6.1.4.1.19376.1.9.1.3.1

hl7:code CE 1 … 1 R ATC Code of the medicine, if it as magistral preparation/compound medicin nullFlavor SHALL be NA 6.3.3.10

@codeSystem oid 0 … 1 F 2.16.840.1.113883.6.73

hl7:originalText ED 0 … 1 6.3.3.10

hl7:reference TEL 1 … 1 R 6.3.3.10

@nullFlavor cs 0 … 1 F NA

hl7:name EN 1 … 1 R The element SHALL contain the name of the medication. IHE PHARM PRE 6.3.4.1.3.4

@nullFlavor cs 0 … 1 F NA

pharm:formCode CE 0 … 1 This code represents the pharmaceutical dose form (e.g., tablet, capsule, liquid) and SHOULD be present, if not implied by the product. 6.3.3.10

CONF

The value of @code shall be drawn from value set 2.16.756.5.30.1.1.11.3 Pharmaceutical Dose Form (EDQM) (DYNAMIC)

hl7:lotNumberText ST 0 … 1 IHE PHARM PRE 6.3.4.1.3.6

pharm:expirationTime TS 0 … 1 IHE PHARM PRE 6.3.4.1.3.7

@value 1 … 1 R

pharm:asContent 0 … * IHE PHARM PRE 6.3.4.1.3.8

@classCode cs 1 … 1 F CONT

pharm:containerPackagedMedicine 1 … 1 M packaging of the medication IHE PHARM PRE 6.3.4.1.3.8

@classCode cs 1 … 1 F CONT

@determinerCode cs 1 … 1 F INSTANCE

pharm:code 0 … 1 In case the medicine describes a product, the GTIN code of the medication package SHOULD be specified. IHE PHARM PRE 6.3.4.1.3.8

pharm:name 0 … 1 In case the package describes a product, and the package has a brand name, it SHOULD be described. IHE PHARM PRE 6.3.4.1.3.8

pharm:formCode 0 … 1 IHE PHARM PRE 6.3.4.1.3.8

pharm:capacityQuantity PQ 1 … 1 R The element SHALL be present and describes the capacity of the packaging. IHE PHARM PRE 6.3.4.1.3.8

@unit cs 0 … 1

@value 1 … 1 R

pharm:ingredient 0 … * One or more active ingredients SHOULD be represented with this structure. 6.3.3.10

@classCode cs 1 … 1 F ACTI

pharm:quantity 0 … 1 The medication strength is represented as the ratio of the active ingredient(s) to a unit of medication 6.3.3.10

pharm:numerator 0 … 1 6.3.3.10

pharm:denominator 0 … 1 6.3.3.10

pharm:ingredient 0 … * 6.3.3.10

@classCode cs 1 … 1 F MMAT

@determinerCode cs 1 … 1 F KIND

pharm:code 0 … 1 6.3.3.10

pharm:name 1 … 1 R 6.3.3.10

hl7:author 0 … 1 Prescriber 6.3.3.11

hl7:time 1 … 1 M 6.3.3.11

hl7:author 0 … 1 Community Prescription document author 6.3.3.12

hl7:time 1 … 1 M 6.3.3.12

Included from 2.16.756.5.30.1.1.10.4.36 Dosage Instructions Dosage Change (DYNAMIC)

hl7:entryRelationship 0 … * Dosage Instructions PCC 6.3.4.16.12 - Dosage change IHE PCC 6.3.4.16.20

where [@typeCode='COMP' and hl7:substanceAdministration and (../hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.4.8'] or ../hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.4.10'] or ../hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.4.9'] or ../hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.4.11']) and not(hl7:substanceAdministration/hl7:templateId)]

@typeCode cs 1 … 1 F COMP

hl7:sequenceNumber INT 1 … 1 M IHE PCC 6.3.4.16.20

hl7:substanceAdministration 0 … 1 R IHE PCC 6.3.4.16.20

hl7:effectiveTime EIVL_TS 0 … 1 timing purpose IHE PCC 6.3.4.16.20

where [@xsi:type='EIVL_TS']

@xsi:type cs 1 … 1 F EIVL_TS

hl7:event CS 1 … 1 M IHE PCC 6.3.4.16.20

@code cs 1 … 1 R

CONF

The value of @code shall be drawn from value set 2.16.756.5.30.1.127.77.4.11.2 TimingEvent (DYNAMIC)

hl7:doseQuantity 0 … 1 IHE PCC 6.3.4.16.20

hl7:rateQuantity 0 … 1 IHE PCC 6.3.4.16.20

hl7:consumable 0 … 1 IHE PCC 6.3.4.16.20

hl7:manufacturedProduct 1 … 1 R IHE PCC 6.3.4.16.20

hl7:manufacturedMaterial 1 … 1 R IHE PCC 6.3.4.16.20

@nullFlavor cs 1 … 1 F NA

hl7:entryRelationship 0 … 1 Treatment Reason as text
Contains 2.16.756.5.30.1.1.10.4.41 Treatment Reason Entry Content Module (DYNAMIC) 6.3..3.3

where [hl7:observation]

@typeCode cs 1 … 1 F RSON

hl7:entryRelationship 0 … 1 Reference to Medication Treatment Plan Item. If the Prescription Item is related to a Medication Treatment Plan Item, the reference to it SHALL be present.
Contains 2.16.756.5.30.1.1.10.4.45 MTP Reference Entry Content Module (DYNAMIC) 6.3.3.14

where [@typeCode='REFR']

@typeCode cs 1 … 1 F REFR

hl7:entryRelationship 0 … 1 Patient Medication Instructions
Contains 1.3.6.1.4.1.19376.1.5.3.1.4.3 IHE Patient Medication Instructions (DYNAMIC) IHE PHARM PRE 6.3.4.2.3.16

where [hl7:act [hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.4.3']]]

@typeCode cs 1 … 1 F COMP

hl7:entryRelationship 0 … 1 Fulfillment Instructions 6.3.3.17

where [hl7:act [hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.4.3.1']]]

@typeCode 1 … 1 F SUBJ

@inversionInd 1 … 1 F true

hl7:act 6.3.3.17

hl7:templateId II 1 … 1 M 6.3.3.17

@root 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.3.1

hl7:entryRelationship 0 … 1 Amount of units of the consumable to dispense
Contains 2.16.756.5.30.1.1.10.4.38 Prescribed Quantity Entry Content Module (DYNAMIC) 6.3.3.18

where [hl7:supply [hl7:templateId [@root='1.3.6.1.4.1.19376.1.9.1.3.8']]]

@typeCode cs 1 … 1 F COMP

hl7:entryRelationship 0 … * Substitution permission
Contains 1.3.6.1.4.1.19376.1.9.1.3.9.1 IHE Substitution Permission Content Module (DYNAMIC) 6.3.3.19

where [hl7:observation [hl7:templateId [@root='1.3.6.1.4.1.19376.1.9.1.3.9.1']]]

@typeCode cs 1 … 1 F COMP

hl7:entryRelationship 0 … 1 Renewal Period
Contains 1.3.6.1.4.1.19376.1.9.1.3.15 IHE Renewal Period Content Module (DYNAMIC) 6.3.3.20

where [hl7:supply [hl7:templateId [@root='1.3.6.1.4.1.19376.1.9.1.3.15']]]

@typeCode cs 1 … 1 F COMP

hl7:entryRelationship 0 … 1 Contains 2.16.756.5.30.1.1.10.4.52 Dosage Instructions Non Structured Entry Content Module (DYNAMIC) 6.3..3.3

where [hl7:substanceAdministration [hl7:templateId [@root='2.16.756.5.30.1.1.10.4.52']]]

@typeCode cs 1 … 1 F COMP

hl7:entryRelationship 0 … 1 Contains 2.16.756.5.30.1.1.10.4.37 Dosage Intake Mode Entry Content Module (DYNAMIC) 6.3..3.3

where [hl7:substanceAdministration [hl7:templateId [@root='2.16.756.5.30.1.1.10.4.37']]]

@typeCode cs 1 … 1 F COMP

hl7:entryRelationship 0 … 1 Contains 2.16.756.5.30.1.1.10.4.2 Annotation Comments (DYNAMIC) 6.3..3.3

where [hl7:act [hl7:templateId [@root='2.16.756.5.30.1.1.10.4.2']]]

@typeCode cs 1 … 1 F COMP

hl7:reference 0 … * 6.3.3.21

@typeCode 1 … 1 F XCRPT

hl7:externalDocument 1 … 1 6.3.3.21

hl7:id 1 … * 6.3.3.21

hl7:precondition 0 … 1 Precondition Criterion 6.3.3.22

hl7:criterion 1 … 1 6.3.3.22

hl7:text 1 … 1 6.3.3.22

hl7:reference 1 … 1 6.3.3.22

@value 1 … 1 R

Template Prescription Item Entry Content Module