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Because the data can be structured or represented by a text, information can be duplicated and there are no guidelines on how to reconcile that. The dosage instructions can appear three times in a CDA-CH-EMED document: as a structured data, in the non-structured entry and in the original representation.
Propositions:
1. Templates Medication Treatment Plan Item Entry Content Module , Prescription Item Entry Content Module , Dispense Item Entry Content Module : when the dosage instructions are given in structured form, the entryRelationship element for the Dosage Instructions Non Structured Entry Content Module is forbidden. Else, the latter is mandatory.
2. If the structured data and the original representation (StrucDocText or PDF) differ, the source of truth is the former because the original representation can always be regenerated by a machine. A human could change the structured data to match the narrative if needed, by replacing the document or issuing a PADV CHANGE.
Drafted by HUG and CARA.