Item | DT | Card | Conf | Description | Label |
---|
hl7:substanceAdministration
| | | R | The general model is to record each prescribed medication in a <substanceAdministration> intent (moodCode='INT'). To record medications which were taken in the past, the moodCode shall be set to 'EVN'. | MediHDSI |
@classCode
| cs | 1 … 1 | F | SBADM |
@moodCode
| cs | 1 … 1 | R | |
hl7:templateId
| II | 1 … 1 | M | | MediHDSI |
@root
| uid | 1 … 1 | F | 1.3.182.11.10.3.12 |
hl7:id
| | 1 … 1 | R | An UUID representing the line | MediHDSI |
@root
| uuid | 1 … 1 | R | |
@extension
| cs | 0 | NP | NP/not present |
hl7:code
| CD | 0 … 1 | R | The <code> element is used to supply a code that describes the <substanceAdminstration>act,not the medication being administered or prescribed. This may be a procedure code,such as those found in ICD-10, or may describe the method of medication administration such as by intravenous injection. The type of medication is coded in the consumable; do not supply the code for the medication in this element. This element is optional.
Note: One of the values from the Value Set epSOSCodeNoMedication shall be used in the<code> element to record that a patient is either not on medications, or that medications arenot known.
| MediHDSI |
hl7:text
| ED | 1 … 1 | M | | MediHDSI |
hl7:reference
| | 1 … 1 | M | The URI given in the value attribute of the 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 element points to an element in the narrative content that contains the complete text describing the medication. | MediHDSI |
@value
| cs | 1 … 1 | R | |
| Example | <reference value="#eP_as_text"/> |
hl7:statusCode
| CS | 1 … 1 | M | The status of all elements must be either "active" or"completed". Status of "active" indicates a currently valid prescription, status of completedi ndicates a previously taken medication. | MediHDSI |
| CONF | @code shall be "active" | or | @code shall be "completed" |
|
| Example | <statusCode code="active"/> |
hl7:effectiveTime
| IVL_TS | 1 … 1 | M | <low> represents the start date of the medication. <high> represents the end date of the medication, shall be set to nullFlavor = "UNK" if not known.
The first <effectiveTime> element encodes the start and stop time of the medication regimen. This an interval of time (xsi:type='IVL_TS'), and must be specified as shown. 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. 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 an un-refilled prescription 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.
| MediHDSI |
where [1] | |
| Example | <effectiveTime xsi:type="IVL_TS"> <low value="20130321"/> <high nullFlavor="UNK"/></effectiveTime> |
hl7:low
| TS.DATE | 1 … 1 | R | | MediHDSI |
@nullFlavor
| cs | 0 … 1 | F | UNK |
hl7:high
| TS.DATE | 1 … 1 | R | | MediHDSI |
@nullFlavor
| cs | 0 … 1 | F | UNK |
hl7:effectiveTime
| | 1 … * | R | The second <effectiveTime> element records the frequency of administration. This <effectiveTime> element must be intersected with the previous time specification (operator='A'), producing the bounded set containing only those time specifications that fall within the start and stop time of the medication regimen. Several common frequency expressions appear in the table below, along with their XML representations. This effectiveTime has a xsi:type of either TS, PIVL_TS, EIVL_TS, or SXPR_TS. Frequency | Description | XML Representation | b.i.d. | Twice a day | <effectiveTime xsi:type='PIVL_TS' institutionSpecified='true' operator='A'> <period value='12' unit='h' /></effectiveTime> | q12h | Every 12 hours | <effectiveTime xsi:type='PIVL_TS' institutionSpecified='false' operator='A'> <period value='12' unit='h' /></effectiveTime> | Once | Once, on 2005-09-01 at 1:18am. | <effectiveTime xsi:type='TS' value='200509010118'/> | t.i.d. | Three times a day, at times determined by the person administering the medication . | <effectiveTime xsi:type='PIVL_TS' institutionSpecified='true' operator='A'> <period value='8' unit='h' /></effectiveTime> | q8h | Every 8 hours | <effectiveTime xsi:type='PIVL_TS' institutionSpecified='false' operator='A'> <period value='8' unit='h' /></effectiveTime> | qam | In the morning | <effectiveTime xsi:type='EIVL' operator='A'> <event code='ACM'/></effectiveTime> | | Every day at 8 in the morning for 10 minutes | <effectiveTime xsi:type='PIVL_TS' operator='A'> <phase> <low value="198701010800" inclusive="true"/> <width value="10" unit="min"/> </phase> <period value='1' unit='d'/></effectiveTime> | q4-6h | Every 4 to 6 hours. | <effectiveTime xsi:type="PIVL_TS" institutionSpecified="false" operator="A"> <period xsi:type="PPD_PQ" value="5" unit="h"> <standardDeviation value="1" unit="h"/> </period></effectiveTime> |
The mean (average) of the low and high values is specified for the period. The mean of 4 and 6 is 5. The standard deviation is recorded as one half the differences between the high and low values, with an unspecified distribution. The type attribute of the <effectiveTime> element describes the kind of frequency specification it contains. More detail is given for each type in the table below.
xsi:type | Description | TS | An xsi:type of TS represents a single point in time, and is the simplest of all to represent. The value attribute of the <effectiveTime> element specifies the point in time in HL7 date-time format (CCYYMMDDHHMMSS) | PIVL_TS | An xsi:type of PIVL_TS is the most commonly used, representing a periodic interval of time. The <low> element of <phase> may be present. If so it specifies the starting point, and only the lower order components of this value are relevant with respect to the <period>. The <width> element represents the duration of the dose administration (e.g., for IV administration). The <period> indicates how often the dose is given. Legal values for the unit attribute of <period> are s, min, h, d, wk and mo representing seconds, minutes, hours, days, weeks, and months respectively. | EIVL_TS | An xsi:type of EIVL_TS represents an event based time interval, where the event is not a precise time, but is often used for timing purposes (e.g. with meals, between meals, before breakfast, before sleep). Refer to the HL7 TimingEvent vocabulary for the codes to use for the <event> element. This interval may specify an <offset> which provides information about the time offset from the specified event (e.g., <offset><low value='-1' unit='h'/><width value='10' unit='min'/></offset> means 1 hour before the event. In that same example, the <width> element indicates the duration for the dose to be given. | SXPR_TS | An xsi:type of SXPR_TS represents a parenthetical set of time expressions. This type is used when the frequency varies over time (e.g., for some cases of tapered dosing, or to handle split dosing). The <comp> elements of this <effectiveTime> element are themselves time expressions (using any of the types listed above). Each <comp> element may specify an operator (e.g. to intersect or form the union of two sets). |
| MediHDSI |
hl7:routeCode
| CE | 0 … 1 | R | The element specifies the route of administration using the EDQM route of administration vocabulary. A code must be specified if the route is known, and the displayName attribute should be specified. If the route is unknown, this element shall not be sent.
| MediHDSI |
hl7:doseQuantity
| IVL_PQ | 0 … 1 | R | The dose is specified in the <doseQuantity> element. If a dose range is given (e.g., 1-2 tablets, or 325-750mg), then the <low> and <high> bounds are specified in their respective elements... If the dose is in countable items (tablets, caplets, "eaches"), then the unit should be valorized = ‘1’. In this case it is allowed to used the UCUM annotations for describing the type of countable items (e.g. .{tablet}, {puff},..). The unit attribute – when expresses unit of measures- shall be derived from the Value Sets epSOSUnits, 1.3.6.1.4.1.12559.11.10.1.3.1.42.16 based on the UCUM code system. The countable units attribute is derived from the value set epSOSDoseForm, OID 1.3.6.1.4.1.12559.11.10.1.3.1.42.2 | MediHDSI |
hl7:rateQuantity
| IVL_PQ | 0 … 1 | R | The rate is specified in the <rateQuantity> element. The rate is given in units that have measure over time. In this case, the units should be specified as a string made up of a unit of measure (see doseQuantity above), followed by a slash (/), followed by a time unit (s, min, h or d). Again, if a range is given, then the <low> and <high> elements contain the lower and upper bound of the range, otherwise, they contain the same value. Any <low> and <high> elements used for <doseQuantity> or <rateQuantity> should contain a <translation> element that provides a <reference> to the <originalText> found in the narrative body of the document.
In a CDA document, any <low> and <high> elements used for <doseQuantity> or <rateQuantity> SHOULD contain a <translation> element that provides a <reference> to the <originalText> found in the narrative body of the document.
| MediHDSI |
hl7:consumable
| | 1 … 1 | M | The <consumable> element shall be present, and shall contain a <manufacturedProduct>element, conforming to the Medicine Entry Content module template
| MediHDSI |
hl7:manufacturedProduct
| | 1 … 1 | M | | MediHDSI |
@classCode
| cs | 1 … 1 | F | MANU |
hl7:manufacturedMaterial
| | 1 … 1 | M | | MediHDSI |
@classCode
| cs | 1 … 1 | F | MMAT |
@determinerCode
| cs | 0 … 1 | F | INSTANCE |
hl7:code
| CE.EPSOS | 1 … 1 | R | This element is generally used to identify a medicinal product. Containing Luxembourg medicinal product identifiers from ValueSet with OID 1.3.182.4.16.
In case where there is information "No information" or "Known absence" then the eSanté NullFlavorValues value set shall be used.
| MediHDSI |
| CONF | The value of @code shall be drawn from value set 1.3.182.10.63.1 eSante_NullValueRepresentation (DYNAMIC) | or | The value of @code shall be drawn from value set 1.3.182.10.68.1 eSante_Prescriptable_DrugItems (DYNAMIC) |
|
hl7:originalText
| ED | 0 … 1 | R | | MediHDSI |
hl7:name
| EN | 1 … 1 | R | This element is supposed to be valorized with the complete Medicinal Product Name as approved by the Medicines Regulatory Agency in a jurisdiction. | MediHDSI |
epsos:formCode
| CE | 1 … 1 | R | This code represents the form of the medication (e.g. tablet, capsule, liquid). The value of this code affects the units used in the substance administration quantity element – if the form is a tablet, for example, the unit is 1; if the form is a liquid, the unit will be part of UCUM. The value set is eSante_PharmaceuticalDoseForm, OID: 1.3.182.10.55.1
| MediHDSI |
| CONF | The value of @code shall be drawn from value set 1.3.182.10.55.1 eSante_PharmaceuticalDoseForm (DYNAMIC) |
|
epsos:asSpecializedKind
| | 0 … 1 | R | This module is used for representing the classification of the Substance according to the WHO Anatomical Therapeutic Chemical (ATC) Classification System.
The classCode of "GEN" identifies this structure as the representation of a generic equivalent of the medication described in the current Medicine entry.
The <epsos:code> element contains the ATC code, and the <epsos:name> element may be used for the plain text representation. | MediHDSI |
@classCode
| cs | 1 … 1 | F | GEN |
epsos:generalizedMedicineClass
| | | R | | MediHDSI |
@classCode
| cs | 1 … 1 | F | MMAT |
epsos:code
| CD | 1 … 1 | R | | MediHDSI |
epsos:name
| | 0 … 1 | | The element SHALL be skipped if the generalizedMedicineClass/code element is present and contains a valid value (not a nullFlavor).
If present, the element SHALL contain a textual description of the generic equivalent of the medication described in the current Medicine entry.
If the prescription is generic (based on one or more active ingredients), the element, if present, SHALL contain the INN or a similar description of the prescribed medicine. | MediHDSI |
epsos:ingredient
| | 0 … * | R | One or more active ingredients may be represented with this structure. The classCode of "ACTI" indicates that this is an active ingredient. The element contains the coded representation of the ingredient and the element may be used for the plain text representation.
| MediHDSI |
@classCode
| cs | 1 … 1 | F | ACTI |
epsos:quantity
| | 1 … 1 | R | The medication strength is represented as the ratio of the active ingredient(s) to a unit of medication. The element contains the numerator and denominator of the strength ratio.
The denominator element should contain an amount with its corresponding unit. Only when the numerator comes in a fractional form and cannot be separated into the numerator and denominator form, or is related to a unit of administration, a unit of '1' in the denominator is allowed.
The units used must come from the epSOSUnits Value Set.
The preferred way is to provide the medication strength in a coded form using the @numerator and @denominator attributes. If no coded information is available and even the use of UCUM annotations is not sufficient and more information is available within the national infrastructure, the originalText element can be used to add additional information:
<epsos:translation> <epsos:originalText>mg/dose</epsos:originalText> </epsos:translation> To improve understanding for the receiver, the additional information has to be provided in English.
| MediHDSI |
epsos:numerator
| ANY | 1 … 1 | R | | MediHDSI |
@unit
| cs | 0 … 1 | | |
@value
| | 0 … 1 | | |
| Constraint | @nullFlavor or (@unit and @value) |
epsos:denominator
| ANY | 1 … 1 | R | | MediHDSI |
@unit
| cs | 0 … 1 | | |
@value
| | 0 … 1 | | |
| Constraint | @nullFlavor or (@unit and @value)
|
epsos:ingredient
| | 1 … 1 | R | | MediHDSI |
@classCode
| cs | 1 … 1 | F | MMAT |
@determinerCode
| cs | 1 … 1 | F | KIND |
epsos:code
| CD | 1 … 1 | R | | MediHDSI |
| CONF | The value of @code shall be drawn from value set 1.3.182.10.56.1 eSante_ActiveIngredients (DYNAMIC) |
|
epsos:originalText
| ED | 0 … 1 | | | MediHDSI |
epsos:reference
| TEL | 0 … 1 | | | MediHDSI |
epsos:name
| ST | 0 … 1 | | | MediHDSI |
hl7:reference
| | 0 … 1 | | | MediHDSI |
@typeCode
| cs | 1 … 1 | F | REFR |
hl7:externalObservation
| | 1 … 1 | M | Reference which lead to Observation which caused this Medication being prescribed/dispensed for | MediHDSI |
hl7:id
| II | 1 … 1 | M | | MediHDSI |
@root
| uuid | 1 … 1 | R | |
@extension
| st | 0 | NP | NP/not present |
hl7:entryRelationship
| | 0 … 1 | | Contains 1.3.182.11.10.3.3 eHDSI Comment Entry (DYNAMIC) | MediHDSI |
@typeCode
| cs | 1 … 1 | F | SUBJ |
@inversionInd
| bl | 1 … 1 | F | true |