Item | DT | Card | Conf | Description | Label |
---|
hl7:substanceAdministration
| | | R | | epSOtion |
@classCode
| cs | 1 … 1 | F | SBADM |
@moodCode
| cs | 1 … 1 | F | INT |
hl7:templateId
| II.EPSOS | 1 … 1 | M | CCD templateId | epSOtion |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.1.24 |
hl7:templateId
| II.EPSOS | 1 … 1 | M | epSOS templateId | epSOtion |
@root
| uid | 1 … 1 | F | 1.3.6.1.4.1.12559.11.10.1.3.1.3.2 |
hl7:templateId
| II.EPSOS | 1 … 1 | R | IHE PCC templateId Note: The usage of statusCode values different from “completed” makes this specification not formally compliant with the current IHE PCC specification of the Medication Item Entry Content Module. All the requirements of conformance assertion with these IHE PCC templates cannot therefore be applied until the revision – if any - of the referenced IHE PCC templates. | epSOtion |
@root
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.5.3.1.4.7 |
hl7:templateId
| II.EPSOS | 0 … 1 | R | A "normal" act that may not contain any subordinate acts | epSOtion |
@root
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.5.3.1.4.7.1 |
hl7:templateId
| II.EPSOS | 0 … 1 | R | A act that records combination medication component information in subordinate acts. | epSOtion |
@root
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.5.3.1.4.11 |
hl7:templateId
| II.EPSOS | 0 … 1 | R | A act that records split dose information in subordinate acts. | epSOtion |
@root
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.5.3.1.4.9 |
hl7:id
| II.EPSOS | 1 … 1 | M | Prescription ID. The following must be true:
- The prescription ID must be globally unique.
- The prescription ID can be used by the prescribing system or provider to identify the prescription to which it belongs. This provides the link from the dispensed medicine to the prescription. | epSOtion |
| Example | <id extension="23" root="1.2.246.556.12001.4.93.1.1"/> |
hl7:code
| CD.EPSOS | 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 are not known. | epSOtion |
| CONF | |
hl7:text
| ED | 0 … 1 | R | | epSOtion |
| Example | <text>...</text> |
hl7:reference
| | 0 … 1 | R | 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. | epSOtion |
| Example | <reference value="#eP_as_text"/> |
hl7:statusCode
| CS | 1 … 1 | M | The status of all <substanceAdministration> elements must be either "active" or "completed" and track the progress of the Act in its specified mood. For example, statusCode="completed" when moodCode is "RQO" doesn't mean that the substance has been administrated, but that the request (e.g. the prescription) has been completed. | epSOtion |
| CONF | @code shall be "active" | or | @code shall be "completed" |
|
| Example | <statusCode code="active"/> |
hl7:effectiveTime
| IVL_TS | 1 … * | R | 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. This is an additional constraint placed upon CDA Release 2.0 by this profile, and simplifies the exchange of start/stop and frequency information between EMR systems. 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.
| epSOtion |
| Example | <effectiveTime xsi:type="IVL_TS"> <low value="20130321"/> <high value="20140321"/></effectiveTime> |
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). |
| epSOtion |
hl7:routeCode
| CE.EPSOS | 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. | epSOtion |
| CONF | |
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, otherwise both <low> and <high> have the same value. If the dose is in countable units (tablets, caplets, "eaches"), then the unit should be valorized = ‘1’The unit attribute – when expresses measureable units - 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 shall be derived from the value set epSOSDoseForm, OID 1.3.6.1.4.1.12559.11.10.1.3.1.42.2.
Any <low> and <high> elements used for <doseQuantity> should contain a <translation> element that provides a <reference> to the <originalText> found in the narrative body of the document.
| epSOtion |
@unit
| cs | 1 … 1 | R | |
| CONF | |
| Example | <doseQuantity nullFlavor="UNK">...</doseQuantity> |
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 <rateQuantity> should contain a <translation> element that provides a <reference> to the <originalText> found in the narrative body of the document.
| epSOtion |
hl7:consumable
| | 1 … 1 | R | Contains 1.3.6.1.4.1.12559.11.10.1.3.1.3.1 epSOS CDA ManufacturedProduct (DYNAMIC) | epSOtion |
@typeCode
| cs | 1 … 1 | F | CSM |
Included | 0 … * | R | from 2.16.840.1.113883.3.1937.777.11.10.103 epSOS CDA author prescriber (DYNAMIC) In the unlikely case where the prescriber of a prescription item is different from the author of the prescription, the prescription item prescriber shall be represented by the element of the entry. When the Prescription Item Entry is part of a Dispensed Medicine Entry as a Related Prescription Item (see subsection 12.1.3.4.8), the author element shall be present, and shall contain the prescription item author (or author of the prescription if the prescription item has no separate author). See the 2.4.3.3 Prescriber description for the structure of the element. |
hl7:author
| | 0 … * | R | | epSOiber |
@typeCode
| cs | 0 … 1 | F | AUT |
@contextControlCode
| cs | 0 … 1 | F | OP |
hl7:functionCode
| CE.EPSOS | 1 … 1 | M | | R1.10.6 |
| CONF | |
hl7:time
| TS.EPSOS.TZ | 1 … 1 | R | The author/time element represents the start time of the author’s participation in the creation of the clinical document. The author/time element SHALL be present. | epSOiber |
hl7:assignedAuthor
| | 1 … 1 | R | | epSOiber |
@classCode
| cs | 0 … 1 | F | ASSIGNED |
| Schematron assert | role | error | |
| test | @nullFlavor or hl7:assignedPerson or hl7:assignedAuthoringDevice | |
| Message | If assignedAuthor has an associated representedOrganization with no assignedPerson or assignedAuthoringDevice, then the value for "ClinicalDocument/author/assignedAuthor/id/@NullFlavor" SHALL be "NA" "Not applicable" 2.16.840.1.113883.5.1008 NullFlavor STATIC. | |
hl7:id
| II.EPSOS | 1 … * | R | HP ID number | R1.10.5 |
@nullFlavor
| cs | 0 … 1 | F | NA |
hl7:code
| CE.EPSOS | 0 … 1 | R | HP Specialty | R1.10.7 |
hl7:addr
| AD.EPSOS | 1 … * | R | | IHE PCC |
hl7:telecom
| TEL.EPSOS | 1 … * | R | Attribute @value SHALL contain a URI if element telecom is used. The URI scheme SHALL be one of URLScheme | IHE PCC / R1.10.8 / R1.10.8.1 / R1.10.8.2 |
@use
| set_cs | 0 … 1 | | |
| CONF | |
hl7:assignedPerson
| | 1 … 1 | M | | epSOiber |
@classCode
| cs | 0 … 1 | F | PSN |
@determinerCode
| cs | 0 … 1 | F | INSTANCE |
hl7:name
| PN | 1 … 1 | R | HP Name | IHE PCC |
| Example | <name> <given>John</given> <family>Español Smith</family></name> |
hl7:family
| | 1 … * | R | HP Family Name/Surname | R1.10.1 |
hl7:given
| | 1 … * | R | HP Given Name | R1.10.2 |
hl7:prefix
| | 0 … * | R | HP Prefix | R1.10.3 |
hl7:suffix
| | 0 … * | R | HP Suffix | R1.10.4 |
hl7:representedOrganization
| | 1 … 1 | R | Contains 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization (DYNAMIC) | R1.10.9 |
Included | 0 … * | R | from 2.16.840.1.113883.3.1937.777.11.10.134 CDA Participant (Body) (DYNAMIC) The organization which provided the credentialing for the prescriber needs to be expressed via a <participant> structure, which is in addition to the <author> element specified earlier. The type code of the <participant> element shall be "AUT", and the class code of the <participantRole> element shall be "LIC".
The ID of the participation role is optional, and when present it shall be the prescriber ID as specified in the <author> structure at the section or entry level.
The credentialing organization (College) is represented by the <scopingEntity> element with a class code of "ORG". The name is represented by the <desc> element, and the credentialing organization (College) ID is represented by the <id> element of the scoping entity
|
hl7:participant
| | 0 … * | R | | CDAPBody |
@typeCode
| cs | 1 … 1 | R | |
| CONF | |
@contextControlCode
| cs | 1 … 1 | F | OP |
hl7:time
| IVL_TS | 0 … 1 | R | | CDAPBody |
hl7:awarenessCode
| CE.EPSOS | 0 … 1 | R | | CDAPBody |
| CONF | |
hl7:participantRole
| | 1 … 1 | R | | CDAPBody |
@classCode
| cs | 0 … 1 | F | ROL |
hl7:id
| II.EPSOS | 0 … * | R | | CDAPBody |
hl7:code
| CE.EPSOS | 0 … 1 | R | | CDAPBody |
@codeSystem
| CONF | 0 … 1 | F | 2.16.840.1.113883.5.111 |
hl7:addr
| AD | 0 … * | R | | CDAPBody |
hl7:telecom
| TEL | 0 … * | R | | CDAPBody |
Choice | 0 … 1 | | Elements to choose from: |
hl7:playingDevice
| | | R | Contains 2.16.840.1.113883.3.1937.777.11.10.129 CDA Device (DYNAMIC) | CDAPBody |
hl7:playingEntity
| | | R | Contains 2.16.840.1.113883.3.1937.777.11.10.128 CDA PlayingEntity (DYNAMIC) | CDAPBody |
hl7:scopingEntity
| | 0 … 1 | R | | CDAPBody |
@classCode
| cs | 0 … 1 | F | ENT |
@determinerCode
| cs | 0 … 1 | F | INSTANCE |
hl7:id
| II.EPSOS | 0 … * | R | | CDAPBody |
hl7:code
| CE.EPSOS | 0 … 1 | R | | CDAPBody |
| CONF | |
hl7:desc
| ED | 0 … 1 | R | | CDAPBody |
hl7:entryRelationship
| | 1 … 1 | R | Contains 1.3.6.1.4.1.12559.11.10.1.3.1.3.6 CDA Number of Packages (DYNAMIC) | epSOtion |
@typeCode
| cs | 1 … 1 | F | COMP |
hl7:entryRelationship
| | 0 … * | R | An entry relationship may be present to provide the fulfillment instructions. When present, this entry relationship shall contain a Medication Fulfillment Instructions entry content module. Again, a related statement is made about the medication or immunization. In CDA, this observation is recorded inside an <entryRelationship> element occurring at the end of the substance administration or supply entry. The containing <act> is the subject (typeCode='SUBJ') of this new observation, which is the inverse of the normal containment structure, thus inversionInd='true'. Contains 1.3.6.1.4.1.19376.1.5.3.1.4.3.1 Entry Medication FulFillment Instructions (DYNAMIC) | epSOtion |
@typeCode
| cs | 1 … 1 | F | SUBJ |
@inversionInd
| bl | 1 … 1 | F | true |
hl7:entryRelationship
| | 0 … 1 | R | An entry relationship may be present to provide the substitution instructions. When present, this entry relationship SHALL contain one and only one observation. This observation SHALL have : - the code element valorized with @code=‟SUBST' and @codeSystem='2.16.840.1.113883.5.6'
- the value element valorized with one of the value of the epSOSSubstitutionCode Value Set (Vaue Set OID 1.3.6.1.4.1.12559.11.10.1.3.1.42.7). Nullflavor is not allowed.
NOTE: Within the epSOS-I scope the “N” code shall be interpreted as No substitution allowed excepting for the Package Size. The presence of any other code that is not “N”, or the absence of the substitution instructions, means that also the brand name (as well as the Package Size) can be changed. | epSOtion |
@typeCode
| cs | 1 … 1 | F | SUBJ |
hl7:observation
| | | | | epSOtion |
@classCode
| cs | 0 … 1 | F | OBS |
@moodCode
| cs | 0 … 1 | F | EVN |
hl7:code
| | 1 … 1 | M | | epSOtion |
@code
| CONF | 1 … 1 | F | SUBST |
@codeSystem
| 1 … 1 | F | 2.16.840.1.113883.5.6 |
hl7:value
| | 1 … 1 | M | | epSOtion |
| CONF | |
hl7:entryRelationship
| | 0 … * | R | An entry relationship may be present to provide the patient medication instructions. When present, this entry relationship shall contain a Patient Medications Instructions entry content module. Again, a related statement is made about the medication or immunization. In CDA, this observation is recorded inside an <entryRelationship> element occurring at the end of the substance administration or supply entry. The containing <act> is the subject (typeCode='SUBJ') of this new observation, which is the inverse of the normal containment structure, thus inversionInd='true'. Contains 1.3.6.1.4.1.19376.1.5.3.1.4.3 epSOS Patient Medication Instructions (DYNAMIC) | epSOtion |
@typeCode
| cs | 1 … 1 | F | SUBJ |
@inversionInd
| bl | 1 … 1 | F | true |