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Template MedikationC 2019‑02‑14 16:52:39

Id2.16.840.1.113883.3.1937.777.24.10.28Effective Date2019‑02‑14 16:52:39
Statusdraft DraftVersion Label
NameMedicationStatementCDisplay NameMedikationC
Descriptionde-DE Medikation
ContextParent nodes of template element with id 2.16.840.1.113883.3.1937.777.24.10.28
Labelmedspmp
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 9 templates
Uses as NameVersion
1.2.276.0.76.10.4023Containmentdraft Einzeldosierungen (mpp 2018)DYNAMIC
1.2.276.0.76.10.4024Containmentdraft Dosierung FreitextDYNAMIC
1.2.276.0.76.10.4026Containmentdraft PatienteninstruktionenDYNAMIC
1.2.276.0.76.10.4027Containmentdraft Grund für MedikationDYNAMIC
1.2.276.0.76.10.4028Containmentdraft Bezug zu Verordnung des MedikamentsDYNAMIC
1.2.276.0.76.10.4029Containmentdraft Bezug zu Abgabe des MedikamentsDYNAMIC
1.2.276.0.76.10.90020Includedraft RelatedEntity (Body)DYNAMIC
1.2.276.0.76.10.90023Includedraft EinnahmedauerDYNAMIC
1.2.276.0.76.10.90025Includedraft Author (Body)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.3.1937.777.24.10.13 MedikationB (2019‑01‑16 10:35:01)
Specialization: template 1.2.276.0.76.10.4083 Medikation (2016‑04‑01)
ref
aktin-

Specialization: template 2.16.840.1.113883.10.12.308 CDA SubstanceAdministration (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 1.2.276.0.76.10.4022 Medikation (2014‑11‑01)
ref
pmp-
Example
Example
<hl7:substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="false">
  <hl7:templateId root="2.16.840.1.113883.3.1937.777.24.10.13"/>  <hl7:templateId root="1.2.276.0.76.10.4083"/>  <hl7:id root="1.2.3.999" extension="--example only--"/>  <hl7:code code="DRUG" codeSystem="2.16.840.1.113883.5.4"/>  <hl7:text>
    <hl7:reference value="--TODO--"/>  </hl7:text>  <hl7:statusCode code="normal"/>  <!-- include template 1.2.276.0.76.10.90023 'Einnahmedauer' (2017-06-04T00:00:00) 0..1 R -->
  <__CHOICE__ min="0" max="1">
    <!--start choice particle-->
    <hl7:effectiveTime>
      <hl7:low value="20190125"/>      <hl7:high value="20190125"/>    </hl7:effectiveTime>    <!--end choice particle-->
    <!--start choice particle-->
    <hl7:effectiveTime>
      <hl7:width unit="a" value="1"/>    </hl7:effectiveTime>    <!--end choice particle-->
    <!--start choice particle-->
    <hl7:effectiveTime nullFlavor="NI" value="20190125103350"/>    <!--end choice particle-->
  </__CHOICE__>  <hl7:effectiveTime/>  <hl7:doseQuantity value="1"/>  <hl7:rateQuantity>
    <hl7:low value="1"/>  </hl7:rateQuantity>  <hl7:maxDoseQuantity/>  <hl7:routeCode code="AEO" codeSystem="2.16.840.1.113883.2.6.60.4.5.2" displayName="Öl"/>  <hl7:consumable/>  <hl7:consumable/>  <hl7:originalText/>  <hl7:originalText/>  <hl7:originalText/>  <hl7:originalText/>  <hl7:code code="#" codeSystem="2.16.840.1.113883.2.6.60.4.5.4" displayName="Messlöffel"/>  <hl7:id root="1.2.3.999" extension="--example only--"/>  <hl7:id root="1.2.3.999" extension="--example only--"/>  <__CHOICE__ min="0" max="1">
    <!--start choice particle-->
    <hl7:author>
      <!-- include template 1.2.276.0.76.10.90025 'Author (Body)' (2014-12-21T00:00:00) .. O -->
      <hl7:functionCode code="AUCG" codeSystem="2.16.840.1.113883.5.88" displayName="caregiver information receiver"/>      <hl7:time value="20190125103350"/>      <hl7:assignedAuthor classCode="ASSIGNED">
        <hl7:id root="1.2.3.999" extension="--example only--"/>        <hl7:code code="--code--" codeSystem="2.16.840.1.113883.5.111"/>        <hl7:addr>addr</hl7:addr>        <hl7:telecom value="tel:+1-12345678"/>        <hl7:assignedPerson>
          <!-- include template 1.2.276.0.76.10.90010 'CDA Person Elements' (2011-12-19T00:00:00) -->
          <hl7:name>name</hl7:name>        </hl7:assignedPerson>        <hl7:representedOrganization>
          <!-- include template 1.2.276.0.76.10.90011 'CDA Organization Elements' (2011-12-19T00:00:00) -->
          <hl7:id root="1.2.3.999" extension="--example only--"/>          <hl7:name>name</hl7:name>          <hl7:telecom value="tel:+1-12345678"/>          <hl7:addr>addr</hl7:addr>        </hl7:representedOrganization>      </hl7:assignedAuthor>    </hl7:author>    <!--end choice particle-->
    <!--start choice particle-->
    <hl7:participant typeCode="AUT">
      <hl7:time value="20190125103350"/>      <hl7:participantRole classCode="PAT"/>    </hl7:participant>    <!--end choice particle-->
  </__CHOICE__>  <hl7:informant typeCode="INF" contextControlCode="OP">
    <hl7:relatedEntity>
      <!-- include template 1.2.276.0.76.10.90020 'RelatedEntity (Body)' (2014-08-25T00:00:00) .. O -->
      <hl7:code code="FAMMEMB" codeSystem="2.16.840.1.113883.5.111" displayName="family member"/>      <hl7:addr>addr</hl7:addr>      <hl7:telecom value="tel:+1-12345678"/>      <hl7:effectiveTime>
        <hl7:low value="20190125103350"/>      </hl7:effectiveTime>      <hl7:relatedPerson>
        <!-- include template 1.2.276.0.76.10.90010 'CDA Person Elements' (2011-12-19T00:00:00) -->
        <hl7:name>name</hl7:name>      </hl7:relatedPerson>    </hl7:relatedEntity>  </hl7:informant>  <hl7:entryRelationship typeCode="COMP">
    <hl7:substanceAdministration classCode="SBADM" moodCode="EVN">
      <hl7:templateId root="1.2.276.0.76.10.4023"/>      <hl7:text>
        <hl7:reference value="--TODO--"/>      </hl7:text>      <__CHOICE__ max="1">
        <!--start choice particle-->
        <hl7:effectiveTime value="20190125103350"/>        <!--end choice particle-->
        <!--start choice particle-->
        <hl7:effectiveTime>
          <hl7:event code="cs"/>          <hl7:offset unit="a"/>        </hl7:effectiveTime>        <!--end choice particle-->
        <!--start choice particle-->
        <hl7:effectiveTime>
          <hl7:phase>
            <hl7:low value="20190125103350"/>          </hl7:phase>          <hl7:period unit="a" value="1"/>        </hl7:effectiveTime>        <!--end choice particle-->
        <!--start choice particle-->
        <hl7:effectiveTime>
          <hl7:comp>
            <hl7:phase>
              <hl7:low value="20190125103350"/>            </hl7:phase>            <hl7:period unit="a" value="1"/>          </hl7:comp>          <hl7:comp operator="A">
            <hl7:event code="cs"/>            <hl7:offset unit="a"/>          </hl7:comp>        </hl7:effectiveTime>        <!--end choice particle-->
      </__CHOICE__>      <hl7:doseQuantity>
        <hl7:translation code="#" codeSystem="2.16.840.1.113883.2.6.60.4.5.4" displayName="Messlöffel"/>      </hl7:doseQuantity>      <hl7:consumable>
        <hl7:manufacturedProduct>
          <hl7:manufacturedMaterial nullFlavor="NA"/>        </hl7:manufacturedProduct>      </hl7:consumable>      <!-- include template 1.2.276.0.76.10.90028 'Medikation Vorbedingung' (2017-06-04T00:00:00) 0..1 R -->
      <hl7:precondition typeCode="PRCN">
        <hl7:criterion classCode="OBS" moodCode="EVN.CRT">
          <hl7:code code="AF" codeSystem="1.2.276.0.76.5.478" displayName="bei Anfall">
            <hl7:originalText/>          </hl7:code>          <hl7:text>
            <hl7:reference value="--TODO--"/>          </hl7:text>        </hl7:criterion>      </hl7:precondition>    </hl7:substanceAdministration>    <!-- template 1.2.276.0.76.10.4023 'Einzeldosierungen' (2018-11-01T00:00:00) -->
  </hl7:entryRelationship>  <hl7:entryRelationship typeCode="COMP">
    <hl7:substanceAdministration classCode="SBADM" moodCode="EVN">
      <hl7:templateId root="1.2.276.0.76.10.4024"/>      <hl7:text>
        <hl7:reference value="--TODO--"/>      </hl7:text>      <hl7:consumable>
        <hl7:manufacturedProduct>
          <hl7:manufacturedMaterial nullFlavor="NA"/>        </hl7:manufacturedProduct>      </hl7:consumable>    </hl7:substanceAdministration>    <!-- template 1.2.276.0.76.10.4024 'Dosierung Freitext' (2014-11-01T00:00:00) -->
  </hl7:entryRelationship>  <hl7:entryRelationship typeCode="SUBJ" inversionInd="true">
    <hl7:act classCode="ACT" moodCode="INT">
      <hl7:templateId root="1.2.276.0.76.10.4026"/>      <hl7:code code="PINSTRUCT" codeSystem="1.3.6.1.4.1.19376.1.5.3.2"/>      <hl7:text>
        <hl7:reference value="--TODO--"/>      </hl7:text>      <hl7:statusCode code="completed"/>      <hl7:entryRelationship typeCode="SUBJ" inversionInd="true">
        <hl7:act classCode="INFRM" moodCode="RQO">
          <hl7:code code="A0" codeSystem="2.16.840.1.113883.2.6.60.4.5.5" displayName="Dünn auf die Haut auftragen!"/>        </hl7:act>      </hl7:entryRelationship>    </hl7:act>    <!-- template 1.2.276.0.76.10.4026 'Patienteninstruktionen' (2014-11-01T00:00:00) -->
  </hl7:entryRelationship>  <hl7:entryRelationship typeCode="RSON">
    <hl7:observation classCode="OBS" moodCode="EVN">
      <hl7:templateId root="1.2.276.0.76.10.4027"/>      <hl7:id/>      <hl7:code code="75326-9" codeSystem="2.16.840.1.113883.6.1"/>      <hl7:statusCode code="completed"/>      <hl7:value nullFlavor="OTH">
        <hl7:originalText>
          <hl7:reference value="--TODO--"/>        </hl7:originalText>      </hl7:value>    </hl7:observation>    <!-- template 1.2.276.0.76.10.4027 'Grund für Medikation' (2016-01-31T00:00:00) -->
  </hl7:entryRelationship>  <hl7:entryRelationship typeCode="REFR">
    <hl7:substanceAdministration classCode="SBADM" moodCode="INT">
      <hl7:templateId root="1.2.276.0.76.10.4028"/>      <hl7:id nullFlavor="NI" root="1.2.3.999" extension="--example only--"/>      <hl7:consumable>
        <hl7:manufacturedProduct>
          <hl7:manufacturedMaterial nullFlavor="NA"/>        </hl7:manufacturedProduct>      </hl7:consumable>      <hl7:author>
        <!-- include template 1.2.276.0.76.10.90025 'Author (Body)' (2014-12-21T00:00:00) -->
        <hl7:functionCode code="AUCG" codeSystem="2.16.840.1.113883.5.88" displayName="caregiver information receiver"/>        <hl7:time value="20190125103350"/>        <hl7:assignedAuthor classCode="ASSIGNED">
          <hl7:id root="1.2.3.999" extension="--example only--"/>          <hl7:code code="--code--" codeSystem="2.16.840.1.113883.5.111"/>          <hl7:addr>addr</hl7:addr>          <hl7:telecom value="tel:+1-12345678"/>          <hl7:assignedPerson>
            <!-- include template 1.2.276.0.76.10.90010 'CDA Person Elements' (2011-12-19T00:00:00) -->
            <hl7:name>name</hl7:name>          </hl7:assignedPerson>          <hl7:representedOrganization>
            <!-- include template 1.2.276.0.76.10.90011 'CDA Organization Elements' (2011-12-19T00:00:00) -->
            <hl7:id root="1.2.3.999" extension="--example only--"/>            <hl7:name>name</hl7:name>            <hl7:telecom value="tel:+1-12345678"/>            <hl7:addr>addr</hl7:addr>          </hl7:representedOrganization>        </hl7:assignedAuthor>      </hl7:author>    </hl7:substanceAdministration>    <!-- template 1.2.276.0.76.10.4028 'Bezug zu Verordnung des Medikaments' (2014-12-21T00:00:00) -->
  </hl7:entryRelationship>  <hl7:entryRelationship typeCode="REFR">
    <hl7:supply classCode="SPLY" moodCode="EVN">
      <hl7:templateId root="1.2.276.0.76.10.4029"/>      <hl7:id nullFlavor="NI" root="1.2.3.999" extension="--example only--"/>      <hl7:performer>
        <!-- include template 1.2.276.0.76.10.90014 'Performer (Body)' (2014-03-12T10:18:42) -->
        <hl7:time>
          <hl7:low value="20190125103350"/>        </hl7:time>        <hl7:assignedEntity>
          <!-- include template 1.2.276.0.76.10.90012 'CDA Assigned Entity Elements' (2011-12-19T00:00:00) -->
          <hl7:id root="1.2.3.999" extension="--example only--"/>          <hl7:addr>addr</hl7:addr>          <hl7:telecom value="tel:+1-12345678"/>          <hl7:assignedPerson>
            <!-- include template 1.2.276.0.76.10.90010 'CDA Person Elements' (2011-12-19T00:00:00) -->
            <hl7:name>name</hl7:name>          </hl7:assignedPerson>          <hl7:representedOrganization>
            <!-- include template 1.2.276.0.76.10.90011 'CDA Organization Elements' (2011-12-19T00:00:00) -->
            <hl7:id root="1.2.3.999" extension="--example only--"/>            <hl7:name>name</hl7:name>            <hl7:telecom value="tel:+1-12345678"/>            <hl7:addr>addr</hl7:addr>          </hl7:representedOrganization>        </hl7:assignedEntity>      </hl7:performer>    </hl7:supply>    <!-- template 1.2.276.0.76.10.4029 'Bezug zu Abgabe des Medikaments' (2014-12-21T00:00:00) -->
  </hl7:entryRelationship></hl7:substanceAdministration>
ItemDTCardConfDescriptionLabel
hl7:substanceAdministration
0 … *medspmp
@classCode
cs1 … 1FSBADM
@moodCode
cs1 … 1FEVN
@negationInd
bl0 … 1 
hl7:templateId
II1 … 1Mmedspmp
@root
uid1 … 1F2.16.840.1.113883.3.1937.777.24.10.28
hl7:templateId
II1 … 1Mmedspmp
@root
uid1 … 1F1.2.276.0.76.10.4083
hl7:id
II0 … *Rde-DE Identifikation
medspmp
hl7:text
EDde-DE Rezeptur
medspmp
@text
st0 … 1 de-DE Freitextzeile
hl7:code
CSde-DE Darreichungsform
medspmp
hl7:text
EDde-DE Dosierung 
medspmp
@text
st0 … 1 de-DE Dosierung im Freitext, wenn diese nicht strukturiert angegeben wird
hl7:effectiveTime
TSde-DE Datum des Eintrags
medspmp
hl7:statusCode
CS0 … 1medspmp
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC)
Included0 … 1R from 1.2.276.0.76.10.90023 Einnahmedauer (DYNAMIC)
Choice0 … 1Elements to choose from:
  • hl7:effectiveTime[hl7:low|hl7:high]
  • hl7:effectiveTime[hl7:width]
  • hl7:effectiveTime[@nullFlavor='NI']
hl7:effectiveTime
IVL_TS … 1Cde-DE Zeitelement zur Dokumentation der Einnahmedauer, hier spezifisches Interval von bisEinndotsauer
where [hl7:lowor
hl7:high]
@xsi:type
0 … 1FIVL_TS
 Example
Intervall bekannt
<effectiveTime xsi:type="IVL_TS">
  <low value="20130321"/>  <high value="20140321"/></effectiveTime>
 Example
unbekanntes Ende-Datum
<effectiveTime xsi:type="IVL_TS">
  <low value="20130321"/>  <high nullFlavor="UNK"/></effectiveTime>
 Example
Dauermedikation
<effectiveTime xsi:type="IVL_TS">
  <low value="20130321"/>  <high nullFlavor="NA"/></effectiveTime>
hl7:low
TS.DATE.MIN1 … 1REinndotsauer
hl7:high
TS.DATE.MIN0 … 1REinndotsauer
hl7:effectiveTime
IVL_TS … 1Cde-DE Zeitelement zur Dokumentation der Einnahmedauer, hier DauerEinndotsauer
where [hl7:width]
 Example
Einnahme für zwei Wochen
<effectiveTime xsi:type="IVL_TS">
  <width value="2" unit="wk"/></effectiveTime>
hl7:width
PQ1 … 1REinndotsauer
@unit
cs1 … 1R
 CONF
The value of @unit shall be drawn from value set 1.2.276.0.76.11.452 Zeiteinheiten (UCUM) (DYNAMIC)
hl7:effectiveTime
TS … 1CEinndotsauer
where [@nullFlavor='NI']
@nullFlavor
cs1 … 1FNI
 Example
Keine Informationen über die Einnahmedauer
<effectiveTime nullFlavor="NI"/>
hl7:effectiveTime
SXPR_TS0 … *Rde-DE
Startdatum der Einnahme und 
Enddatum der Einnahme, bis zu welchem Tag einschließlich das Medikament eingenommen werden soll
medspmp
where [hl7:comp]
hl7:doseQuantity
PQ1 … 1Rde-DE
Wirkstärke
medspmp
hl7:rateQuantity
IVL_PQ0 … 1medspmp
hl7:maxDoseQuantity
RTO_PQ_PQ0 … 1medspmp
hl7:routeCode
CE1 … 1Rde-DE Art der Anwendung der Arznei

medspmp
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.2.6.60.4.11.22 BMP Darreichungsform (DYNAMIC)
 Example<routeCode code="PO" codeSystem="2.16.840.1.113883.5.112" displayName="Swallow, oral"/>
Choice0 … 1
de-DE Autor, entweder:
  • Selbstmedikation (Quelle: Patient)
  • verschreibender Gesundheitsdienstleister
Elements to choose from:
  • hl7:author
  • hl7:participant[hl7:participantRole]
hl7:author
de-DE Autor dieser Information ist ein Gesundheitsdienstleistermedspmp
 Example
Autor der Information ist ein Gesundheitsdienstleister
<author>
  <time value="20131221"/>  <assignedAuthor>
    <id root="1.2.276.0.76.4.16" extension="123456701"/>    <assignedPerson>
      <name>
        <given qualifier="IN">Jan H.</given>        <family>Ausarz</family>      </name>    </assignedPerson>  </assignedAuthor></author>
Included from 1.2.276.0.76.10.90025 Author (Body) (DYNAMIC)
@typeCode
cs0 … 1FAUT
@contextControlCode
cs0 … 1FOP
hl7:functionCode
CE0 … 1AuthdotsBody
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)
hl7:time
TS1 … 1RAuthdotsBody
hl7:assignedAuthor
1 … 1RAuthdotsBody
@classCode
cs0 … 1FASSIGNED
hl7:id
II1 … *RAuthdotsBody
hl7:code
CE0 … 1AuthdotsBody
@codeSystem
CONF0 … 1F2.16.840.1.113883.5.111
hl7:addr
AD0 … *AuthdotsBody
hl7:telecom
TEL0 … *AuthdotsBody
hl7:assignedPerson
0 … 1AuthdotsBody
Included from 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC)
@classCode
cs0 … 1FPSN
@determinerCode
cs0 … 1FINSTANCE
hl7:name
PN1 … 1MPersdotsents
hl7:representedOrganization
0 … 1AuthdotsBody
Included from 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC)
@classCode
cs0 … 1FORG
@determinerCode
cs0 … 1FINSTANCE
hl7:id
II0 … *Orgadotsents
hl7:name
ON1 … 1MOrgadotsents
hl7:telecom
TEL0 … *Orgadotsents
hl7:addr
AD0 … 1Orgadotsents
hl7:participant
de-DE Autor dieser Information ist der Patientmedspmp
@typeCode
cs1 … 1FAUT
 Example
Autor der Information ist der Patient
<participant typeCode="AUT">
  <participantRole classCode="PAT"/></participant>
hl7:time
TS0 … 1Rmedspmp
hl7:participantRole
1 … 1Mmedspmp
@classCode
cs1 … 1FPAT
hl7:informant
0 … 1de-DE Informant dieser Information ist eine Kontaktperson/Angehöriger des Patientenmedspmp
@typeCode
cs0 … 1FINF
@contextControlCode
cs0 … 1FOP
 Example
Informant dieser Information ist eine Kontaktperson/Angehöriger des Patienten
<informant>
  <relatedEntity classCode="CON">
    <relatedPerson classCode="PSN" determinerCode="INSTANCE">
      <name> ... </name>    </relatedPerson>  </relatedEntity></informant>
hl7:relatedEntity
1 … 1Mmedspmp
Included from 1.2.276.0.76.10.90020 RelatedEntity (Body) (DYNAMIC)
@classCode
cs1 … 1R
 CONF
The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.19316 RoleClassMutualRelationship (DYNAMIC)
hl7:code
CE0 … 1ReladotsBody
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19563 PersonalRelationshipRoleType (DYNAMIC)
hl7:addr
AD0 … *ReladotsBody
hl7:telecom
TEL0 … *ReladotsBody
hl7:effectiveTime
IVL_TS0 … 1ReladotsBody
hl7:relatedPerson
0 … 1ReladotsBody
Included from 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC)
@classCode
cs0 … 1FPSN
@determinerCode
cs0 … 1FINSTANCE
hl7:name
PN1 … 1MPersdotsents
hl7:entryRelationship
0 … 5RSplit Dosing: a act that records split dose information in subordinate acts.
Contains 1.2.276.0.76.10.4023 Einzeldosierungen (DYNAMIC)		medspmp
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … 1Rde-DE Freitextliche Dosierinstruktionen
Contains 1.2.276.0.76.10.4024 Dosierung Freitext (DYNAMIC)		medspmp
@typeCode
cs1 … 1FCOMP
hl7:entryRelationship
0 … *Rde-DE Patienteninstruktionen
Contains 1.2.276.0.76.10.4026 Patienteninstruktionen (DYNAMIC)		medspmp
@typeCode
cs1 … 1FSUBJ
@inversionInd
bl1 … 1Ftrue
hl7:entryRelationship
0 … *Rde-DE Grund für die Medikation
Contains 1.2.276.0.76.10.4027 Grund für Medikation (DYNAMIC)		medspmp
@typeCode
cs1 … 1FRSON
hl7:entryRelationship
0 … *Rde-DE Bezug zu einer Verordnung
Contains 1.2.276.0.76.10.4028 Bezug zu Verordnung des Medikaments (DYNAMIC)		medspmp
@typeCode
cs1 … 1FREFR
hl7:entryRelationship
0 … *Rde-DE Bezug zu einer Abgabe
Contains 1.2.276.0.76.10.4029 Bezug zu Abgabe des Medikaments (DYNAMIC)		medspmp
@typeCode
cs1 … 1FREFR