Template

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Template Medication Free Text Sig 2015‑08‑13

Id2.16.840.1.113883.10.20.22.4.147
ref
ccda-
Gültigkeit ab2015‑08‑13
Statusdraft EntwurfVersions-Label2.1
NameMedicationFreeTextSigBezeichnungMedication Free Text Sig
Beschreibungen-US The template is available to explicitly identify the free text Sig within each medication. An example free text sig: Thyroxin 150 ug, take one tab by mouth every morning.
KontextElternknoten des Template-Element mit Id 2.16.840.1.113883.10.20.22.4.147
KlassifikationCDA Entry Level Template
Offen/GeschlossenGeschlossen (nur definierte Elemente sind erlaubt)
Benutzt von / Benutzt
Benutzt von 17 Transactions und 96 Templates, Benutzt 0 Templates
Benutzt von als NameVersion
2.16.840.1.113883.3.1937.99.3.4.29Transaktionfinal en-US Progress Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.4Transaktionfinal en-US Progress Note (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.21Transaktionfinal en-US Care Plan (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.3Transaktionfinal en-US Discharge Summary (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.2Transaktionfinal en-US Consultation Notes (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.28Transaktionfinal en-US Procedure Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.23Transaktionfinal en-US Continuity of Care Document (CCD) (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.30Transaktionfinal en-US Referral Note (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.6Transaktionfinal en-US Operative Note (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.7Transaktionfinal en-US History and Physical (H and P) (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.27Transaktionfinal en-US Operative Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.31Transaktionfinal en-US Transfer Summary (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.26Transaktionfinal en-US History and Physical (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.5Transaktionfinal en-US Procedure Note (US Realm – Release 1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.1Transaktionfinal en-US Continuity of Care Document (CCD) (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.25Transaktionfinal en-US Discharge Summary (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.22Transaktionfinal en-US Consultation Note (V3)2015‑08‑01
1.2.276.0.76.3.1.135.8.10.4linkdraft Medical Equipment Section (V2) (2.1)2015‑12‑02 12:50:20
1.2.276.0.76.10.3117linkdraft Medications Section (entries optional) (V2) (06) (2.1)2016‑09‑06 17:26:48
1.3.6.1.4.1.19376.1.4.1.4.41Containmentdraft Medication Activity - Cardiac (1.0)2017‑03‑24 00:35:10
2.16.840.1.113883.3.51.60.2.4linkpending BC CDA ClinicalDocumentDischargeSummary (V3) (2.1)2019‑03‑19 14:15:51
2.16.840.1.113883.3.1937.99.61.20.10.9linkdraft Medications Section (entries required) (V2) (2.1)2015‑11‑03 08:58:06
2.16.840.1.113883.3.1937.99.61.26.10.52linkdraft Procedure Activity Procedure (1.1)2019‑03‑06 11:55:46
2.16.840.1.113883.3.1937.99.61.26.10.54linkrejected Procedure Activity Procedure (V2) (2.1)2019‑03‑06 15:52:43
2.16.840.1.113883.3.1937.99.61.26.10.55linkdraft Allergy - Intolerance Observation (V2) (2.1)2019‑03‑08 04:36:16
2.16.840.1.113883.3.1937.99.61.26.10.61linkdraft Allergy Concern Act (V3) (2.1)2019‑03‑09 13:34:13
2.16.840.1.113883.3.1937.99.61.26.10.62linkrejected Allergies and Intolerances Section (entries optional) (V3) (2.1)2019‑03‑09 13:37:11
2.16.840.1.113883.3.1937.99.61.26.10.112linkrejected Adverse Events Section (entries optional) (V3) (2.1)2019‑03‑25 06:01:02
2.16.840.1.113883.3.1937.99.61.26.10.114Containmentrejected Medication Activity (V2) (2.1)2019‑03‑31 19:39:09
2.16.840.1.113883.3.1937.99.61.28.10.3linkdraft CDA de Consulta (1)2017‑04‑22 23:20:01
2.16.840.1.113883.3.1937.99.61.30.10.54linkcancelled Health Concern Act (harmonized) (0.1)2020‑10‑08 10:55:41
2.16.840.1.113883.3.1937.99.61.30.10.58linkdraft _Allergy - Intolerance Observation (harmonization)) (wip)2020‑10‑16 15:17:11
2.16.840.1.113883.3.1937.99.61.30.10.60linkdraft _Immunization (harmonized) (IAT)2021‑07‑06 09:55:32
2.16.840.1.113883.3.1937.99.61.41.10.4linkdraft Discharge Summary (1.1)2018‑02‑19 15:30:38
2.16.840.1.113883.3.1937.99.61.67.10.24linkcancelled XeH Alert Act2021‑04‑20 10:00:04
2.16.840.1.113883.3.1937.99.61.67.10.25linkcancelled XeH Risk Concern Act2021‑04‑20 10:06:56
2.16.840.1.113883.10.20.21.2.3linkdraft Interventions Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.2linkdraft Continuity of Care Document (CCD) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.2linkdraft Continuity of Care Document (CCD) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.3linkdraft History and Physical (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.3linkdraft History and Physical (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.4linkdraft Consultation Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.4linkdraft Consultation Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.6linkdraft Procedure Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.6linkdraft Procedure Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.7linkdraft Operative Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.7linkdraft Operative Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.8linkdraft Discharge Summary (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.8linkdraft Discharge Summary (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.9linkdraft Progress Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.9linkdraft Progress Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.13linkdraft Transfer Summary (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.14linkdraft Referral Note (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.15linkdraft Care Plan (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.1linkdraft Medications Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.1linkdraft Medications Section (entries optional) (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.1.1linkdraft Medications Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.1.1linkdraft Medications Section (entries required) (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.2linkdraft Immunizations Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.2linkdraft Immunizations Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.2.1linkdraft Immunizations Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.2.1linkdraft Immunizations Section (entries required) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.6linkdraft Allergies Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.6linkdraft Allergies and Intolerances Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.6.1linkdraft Allergies Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.6.1linkdraft Allergies and Intolerances Section (entries required) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.7linkdraft Procedures Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.7linkdraft Procedures Section (entries optional) (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.7linkpending Procedures Section (entries optional) (V2) (2.1)2019‑03‑16 21:12:43
2.16.840.1.113883.10.20.22.2.7.1linkdraft Procedures Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.7.1linkdraft Procedures Section (entries required) (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.11linkdraft Hospital Discharge Medications Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.11linkdraft Discharge Medications Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.11.1linkdraft Hospital Discharge Medications Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.11.1linkdraft Discharge Medications Section (entries required) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.23linkdraft Medical Equipment Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.25linkdraft Anesthesia Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.25linkdraft Anesthesia Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.38linkdraft Medications Administered Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.38linkdraft Medications Administered Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.44linkdraft Hospital Admission Medications Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.44linkdraft Admission Medications Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.58linkdraft Health Concerns Section (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.78Containmentdraft BC CDA Medication Activity (V2) (2.1)2019‑03‑15 14:29:33
2.16.840.1.113883.10.20.22.2.101linkdraft BC CDA Referral Note (V2) (2.1)2019‑04‑06 02:03:17
2.16.840.1.113883.10.20.22.4.7linkdraft Allergy - Intolerance Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.7linkdraft Allergy - Intolerance Observation (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.9linkdraft Reaction Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.9linkdraft Reaction Observation (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.12linkdraft Procedure Activity Act (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.12linkdraft Procedure Activity Act (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.13linkdraft Procedure Activity Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.13linkdraft Procedure Activity Observation (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.14linkdraft Procedure Activity Procedure (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.14linkdraft Procedure Activity Procedure (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.16linkdraft Medication Activity (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.16Containmentdraft Medication Activity (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.30linkdraft Allergy Problem Act (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.30linkdraft Allergy Concern Act (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.35linkdraft Discharge Medication (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.35linkcancelled Discharge Medication (V3) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.35linkdraft Discharge Medication (V3) (2.1)2016‑03‑01
2.16.840.1.113883.10.20.22.4.36linkdraft Admission Medication (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.36linkdraft Admission Medication (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.52linkdraft Immunization Activity (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.52linkdraft Immunization Activity (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.131linkdraft Intervention Act (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.132linkdraft Health Concern Act (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.135linkdraft Medical Equipment Organizer (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.136linkdraft Risk Concern Act (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.146linkdraft Planned Intervention Act (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.24.3.90linkdraft Substance or Device Allergy - Intolerance Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.24.3.90linkdraft Substance or Device Allergy - Intolerance Observation (V2) (2.1)2014‑06‑09
BeziehungSpezialisierung: Template 2.16.840.1.113883.10.12.308 CDA SubstanceAdministration (2005‑09‑07)
ref
ad1bbr-
ItemDTKardKonfBeschreibungLabel
cda:substanceAdministration
MedidotstSig
@classCode
cs1 … 1FSBADMCONFdots2770
 en-US SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1198-32770).
@moodCode
cs1 … 1Ren-US SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet MoodCodeEvnInt urn:oid:2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03 (CONF:1198-32771).CONFdots2771
 CONF
Der Wert von @moodCode muss gewählt werden aus dem Value Set 2.16.840.1.113883.11.20.9.18 MoodCodeEvnInt (DYNAMIC)
cda:templateId
II1 … 1Men-US SHALL contain exactly one [1..1] templateId (CONF:1198-32753) such that itCONFdots2753
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.147CONFdots2772
 en-US SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.147" (CONF:1198-32772).
cda:code
1 … 1Men-US SHALL contain exactly one [1..1] code (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1198-32775).

a. This code SHALL contain exactly one [1..1] @code="76662-6" Instructions Medication (CONF:1198-32780).
b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1 STATIC) (CONF:1198-32781).

CONFdots2775
@code
CONF1 … 1F76662-6
@codeSystem
1 … 1F2.16.840.1.113883.6.1
cda:text
1 … 1Men-US SHALL contain exactly one [1..1] text (CONF:1198-32754).CONFdots2754
cda:reference
1 … 1Men-US This text SHALL contain exactly one [1..1] reference (CONF:1198-32755).

Reference into the section/text to a tag that only contains free text sig.
CONFdots2755
@value
0 … 1 en-US This reference SHOULD contain zero or one [0..1] @value (CONF:1198-32756).CONFdots2756
 Schematron assertrolered error 
 testnot(@value) or starts-with(@value, '#') 
 MeldungThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) 
cda:consumable
1 … 1Men-US SHALL contain exactly one [1..1] consumable (CONF:1198-32776).CONFdots2776
cda:manufacturedProduct
1 … 1Men-US This consumable SHALL contain exactly one [1..1] manufacturedProduct (CONF:1198-32777).CONFdots2777
cda:manufacturedLabeledDrug
1 … 1en-US This manufacturedProduct SHALL contain exactly one [1..1] manufacturedLabeledDrug (CONF:1198-32778).CONFdots2778
@nullFlavor
cs1 … 1FNACONFdots2779
 en-US This manufacturedLabeledDrug SHALL contain exactly one [1..1] @nullFlavor="NA" Not Applicable (CONF:1198-32779).