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Template VPS Terapie Farmacologiche (SBADM) 2017‑05‑20 17:09:55

Id2.16.840.1.113883.2.9.10.1.6.52Effective Date2017‑05‑20 17:09:55
Statusdraft DraftVersion Label
NameHL7ITVPSMedicationActivityDisplay NameVPS Terapie Farmacologiche (SBADM)
Description
A Medication Activity describes substance administrations that have actually occurred (e.g., pills ingested or injections given) or are intended to occur (e.g., "take 2 tablets twice a day for the next 10 days"). Medication activities in "INT" mood are reflections of what a clinician intends a patient to be taking. For example, a clinician may intend that a patient to be administered Lisinopril 20 mg PO for blood pressure control. If what was actually administered was Lisinopril 10 mg., then the Medication activities in the "EVN" mood would reflect actual use. A moodCode of INT is allowed, but it is recommended that the Planned Medication Activity (V2) template be used for moodCodes other than EVN if the document type contains a section that includes Planned Medication Activity (V2) (for example a Care Plan document with Plan of Treatment, Intervention, or Goal sections). At a minimum, a Medication Activity shall include an effectiveTime indicating the duration of the administration (or single-administration timestamp). Ambulatory medication lists generally provide a summary of use for a given medication over time - a medication activity in event mood with the duration reflecting when the medication started and stopped. Ongoing medications will not have a stop date (or will have a stop date with a suitable NULL value). Ambulatory medication lists will generally also have a frequency (e.g., a medication is being taken twice a day). Inpatient medications generally record each administration as a separate act. The dose (doseQuantity) represents how many of the consumables are to be administered at each administration event. As a result, the dose is always relative to the consumable and the interval of administration. Thus, a patient consuming a single "metoprolol 25mg tablet" per administration will have a doseQuantity of "1", whereas a patient consuming "metoprolol" will have a dose of "25 mg".
ContextParent nodes of template element with id 2.16.840.1.113883.2.9.10.1.6.52
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 8 concepts
IdNameData Set
vpsee-dataelement-623draft  draft Emergency Encounter report
vpsee-dataelement-321draft Healthcare Provider infos draft Emergency Encounter report
vpsee-dataelement-233draft  draft Emergency Encounter report
vpsee-dataelement-624draft  draft Emergency Encounter report
vpsee-dataelement-625draft  draft Emergency Encounter report
vpsee-dataelement-626draft  draft Emergency Encounter report
vpsee-dataelement-655draft Healthcare Provider infos draft Emergency Encounter report
vpsee-dataelement-329draft Healthcare Provider infos draft Emergency Encounter report
Used by / Uses
Used by 0 transactions and 3 templates, Uses 3 templates
Used by as NameVersion
2.16.840.1.113883.2.9.10.1.6.29Containmentdraft VPS Terapie Farmacologiche in PS2017‑04‑20 14:48:44
2.16.840.1.113883.2.9.10.1.6.57Containmentdraft VPS Storia Terapie Farmacologiche2017‑05‑22 16:35:10
2.16.840.1.113883.2.9.10.1.6.74Containmentdraft VPS Sezione Terapie Farmacologiche alla dimissione2017‑05‑27 07:59:28
Uses as NameVersion
2.16.840.1.113883.2.9.10.1.6.44Containmentdraft CDA Performer (Body)DYNAMIC
2.16.840.1.113883.2.9.10.1.6.53Containmentdraft VPS Informazioni FarmaciDYNAMIC
2.16.840.1.113883.10.12.318Containmentactive CDA Author (Body)DYNAMIC
RelationshipAdaptation: template 2.16.840.1.113883.10.12.308 CDA SubstanceAdministration (2005‑09‑07)
ref
ad1bbr-
ItemDTCardConfDescriptionLabel
cda:substanceAdministration
HL7Idotsvity
@classCode
cs1 … 1FSBADM
@moodCode
cs1 … 1R
 CONF
@moodCode shall be "ENV"
or
@moodCode shall be "INT"
hl7:templateId
II1 … 1MHL7Idotsvity
@root
uid1 … 1F2.16.840.1.113883.2.9.10.1.6.52
cda:id
II1 … *RHL7Idotsvity
cda:code
0 … 1HL7Idotsvity
cda:statusCode
CS1 … 1MHL7Idotsvity
cda:effectiveTime
IVL_TS1 … 1RHL7Idotsvity
where [not(@operator='A')]
 
target
vpsee-dataelement-233draft  draft Emergency Encounter report
cda:low
0 … 1RHL7Idotsvity
cda:high
0 … 1HL7Idotsvity
cda:repeatNumber
0 … 1HL7Idotsvity
cda:routeCode
0 … 1RHL7Idotsvity
 
target
vpsee-dataelement-623draft  draft Emergency Encounter report
cda:approachSiteCode
CD0 … 1HL7Idotsvity
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.3221.8.9 Body Site (DYNAMIC)
cda:doseQuantity
NPHL7Idotsvity
cda:rateQuantity
NPHL7Idotsvity
cda:maxDoseQuantity
RTO_PQ_PQ0 … 1HL7Idotsvity
cda:administrationUnitCode
CE0 … 1

administrationUnitCode@code describes the units of medication administration for an item using a code that is pre-coordinated to include a physical unit form (ointment, powder, solution, etc.) which differs from the units used in administering the consumable (capful, spray, drop, etc.). For example when recording medication administrations, “metric drop (C48491)” would be appropriate to accompany the RxNorm code of 198283 (Timolol 0.25% Ophthalmic Solution) where the number of drops would be specified in doseQuantity@value.

HL7Idotsvity
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113762.1.4.1021.30 Administration Unit Dose Form (DYNAMIC)
cda:consumable
1 … 1MContains 2.16.840.1.113883.2.9.10.1.6.53 VPS Informazioni Farmaci (DYNAMIC)HL7Idotsvity
cda:performer
0 … 1Contains 2.16.840.1.113883.2.9.10.1.6.44 CDA Performer (Body) (DYNAMIC)HL7Idotsvity
 
target
vpsee-dataelement-321draft Healthcare Provider infos draft Emergency Encounter report
cda:author
0 … *RContains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC)HL7Idotsvity
 
target
vpsee-dataelement-655draft Healthcare Provider infos draft Emergency Encounter report
hl7:entryRelationship
0 … *CUnless medications are unknown or known absent, at least one subordinated <substanceAdministration> has to be present to convey information about dosages (dose, frequency of intakes,..).
Subordinated <substanceAdministration> elements can be also used either to handle split dosing, or to support combination medications.
HL7Idotsvity
@typeCode
cs1 … 1FCOMP
 ConstraintAt least one subordinate <substanceAdministration> element SHALL be present unless medications are unknown or known absent.
hl7:sequenceNumber
INT0 … 1HL7Idotsvity
hl7:substanceAdministration
1 … 1RHL7Idotsvity
@classCode
cs1 … 1FSBADM
@moodCode
cs1 … 1RIf the statement refers to a prescribed medication then a <substanceAdministration> intent (moodCode='INT') is used; otherwise, to record medications which are stated to have taken, the moodCode shall be set to 'EVN'.
 CONF
The value of @moodCode shall be drawn from value set 2.16.840.1.113883.11.20.9.18 MoodCodeEvnInt (DYNAMIC)
 ConstraintThe moodCode of this subordinate <substanceAdministration> SHALL be the same of the parent <substanceAdministration> .
hl7:statusCode
CS1 … 1MHL7Idotsvity
 ConstraintThe statusCode of this subordinate <substanceAdministration> SHALL be the same of that of the parent <substanceAdministration>.
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.1937.777.13.11.12 (DYNAMIC)
 Example<statusCode code="active"/>
hl7:effectiveTime
1 … 1RThis required element describes the frequency of intakes. If not known it shall be valued with the nullflavor "UNK"
HL7Idotsvity
 
target
vpsee-dataelement-626draft  draft Emergency Encounter report
 Example
Once (known date)
<effectiveTime value="20170404"/>
 Example
Unknown
<effectiveTime nullFlavor="UNK"/>
 Example
Every 4 hours
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="false">
  <period value="4" unit="h"/></effectiveTime>
 Example
Twice a day
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true">
  <period value="12" unit="h"/></effectiveTime>
 Example
After meal
<effectiveTime xsi:type="EIVL_TS">
  <event code="PC" codeSystem="2.16.840.1.113883.5.139"/></effectiveTime>
 Example
One hour before breakfast
<effectiveTime xsi:type="EIVL_TS">
  <event code="ACM" codeSystem="2.16.840.1.113883.5.139"/>  <offset>
    <low value="1" unit="h"/>  </offset>
</effectiveTime>
Choice0 … 1Elements to choose from:
  • hl7:doseQuantity
  • hl7:rateQuantity
hl7:doseQuantity
IVL_PQ0 … 1RThe <doseQuantity> describes the amount of the medication given (the dosage).

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; otherwise only one physical quantity is specified (e.g. 2 drops)

The dose can be in some known and measurable unit, such as grams, milligrams,or described in "administration" units (unit of presentation, such as capsules).

If the dose is in countable items (tablets, caplets, "eaches"), then the unit could be omitted or valorized using 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 UCUM code system.

The used elements should contain a <translation> element that provides a <reference> to the <originalText> found in the narrative body of the document.

HL7Idotsvity
 
target
vpsee-dataelement-624draft  draft Emergency Encounter report
@unit
cs0 … 1 
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.1.11.12839 UnitsOfMeasureCaseSensitive (DYNAMIC)
 Example
Not pre-coordinated consumable
<doseQuantity value="25" unit="mg"/>
 Example
Pre-coordinated consumable - Dose Range
<doseQuantity>
  <low value="1" unit="{tablet}"/>  <high value="2" unit="{tablet}"/></doseQuantity>
 Example
Pre-coordinated consumable
<doseQuantity value="2" unit="{puff}"/>
 Example
Pre-coordinated consumable with text reference
<!-- TO BE CHECKED -->
<doseQuantity value="2" unit="{puff}">
  <translation>
    <originalText>
      <reference value="#text-ref-1"/>    </originalText>
  </translation>
</doseQuantity>
 Example
Textual dosage
<!-- TO BE CHECKED -->
<doseQuantity>
  <translation>
    <originalText>
      <reference value="#text-ref-1"/>    </originalText>
  </translation>
</doseQuantity>
hl7:rateQuantity
IVL_PQ0 … 1RHL7Idotsvity
 
target
vpsee-dataelement-625draft  draft Emergency Encounter report
@unit
cs0 … 1 
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.1.11.12839 UnitsOfMeasureCaseSensitive (DYNAMIC)
hl7:maxDoseQuantity
RTO_PQ_PQ0 … 1HL7Idotsvity
hl7:consumable
1 … 1RHL7Idotsvity
hl7:manufacturedProduct
1 … 1RHL7Idotsvity
hl7:manufacturedMaterial
1 … 1RHL7Idotsvity
@nullFlavor
cs1 … 1FNA
cda:entryRelationship
0 … *(it-IT) Prescrizione a cui questa somministrazione fa riferimentoHL7Idotsvity
@typeCode
cs1 … 1FREFR
 Constraint(it-IT) Presente solo se il moodCode="EVN"
cda:substanceAdministration
HL7Idotsvity
@classCode
cs1 … 1FSBADM
@moodCode
cs1 … 1R
 CONF
@moodCode shall be "INT"
cda:id
II1 … *RHL7Idotsvity
cda:statusCode
CS0 … 1RHL7Idotsvity
cda:effectiveTime
IVL_TS0 … 1RHL7Idotsvity
cda:low
0 … 1RHL7Idotsvity
cda:high
0 … 1HL7Idotsvity
cda:consumable
1 … 1MContains 2.16.840.1.113883.2.9.10.1.6.53 VPS Informazioni Farmaci (DYNAMIC)HL7Idotsvity
cda:author
0 … *RContains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC)HL7Idotsvity
 
target
vpsee-dataelement-329draft Healthcare Provider infos draft Emergency Encounter report