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pending Template  IPS Medication Statement

Id 2.16.840.1.113883.10.22.4.4 Effective Date 2016‑11‑11
Status pending Under pre-publication review Version Label STU1
Name IPSMedicationStatement Display Name IPS Medication Statement
Description
An IPS Medication entry describes a medication statement, that is a substance administration that has 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.
The source of this information can be the patient, significant other (such as a family member or spouse), or a clinician. A common scenario where this information is captured is during the history taking process during a patient visit or stay, but it could be derived from the medications information recorded into a GP's EHR-system, in form of prescribed medication, or administration statements.
The medication information may come from sources such as the patient's memory, from a prescription bottle, or from a list of medications the patient, clinician or other party maintains.
A medication statement is usually less specific than an a prescription or a medication administration record.  
This entry is composed by a main substanceAdministration act and a subordinate substanceAdministration act, unless it is asserted that there are no medications data. 
The first conveys information as the product, the period of administration and the route of administration; the latter is used to provide dosage information as the frequency of intakes or the amount of the medication given.
Context Parent nodes of template element with id 2.16.840.1.113883.10.22.4.4
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Associated with
Associated with 3 concepts
Id Name Data Set
hl7ips-dataelement-102 draft Route of administration draft CEN/TC 251 prEN 17269
hl7ips-dataelement-220 draft Medication Summary content status draft CEN/TC 251 prEN 17269
hl7ips-dataelement-104 draft Medication draft CEN/TC 251 prEN 17269
Used by / Uses
Used by 1 transaction and 3 templates, Uses 4 templates
Used by as Name Version
hl7ips-transaction-2 Transaction draft IPS Created 2017‑04‑07 11:10:54
2.16.840.1.113883.10.22.3.1 Containment pending IPS Medication Summary Section (STU1) 2016‑11‑11
2.16.840.1.113883.10.22.1.1 link draft International Patient Summary 2020‑05‑08 12:30:59
2.16.840.1.113883.10.22.1.1 link pending International Patient Summary (STU1) 2017‑04‑11
Uses as Name Version
2.16.840.1.113883.10.21.9.1 Include draft UV Use Period DYNAMIC
2.16.840.1.113883.10.22.4.2 Containment pending IPS Medication Information (detail) (STU1) DYNAMIC
2.16.840.1.113883.10.22.4.14 Containment pending IPS Body Author (STU1) DYNAMIC
2.16.840.1.113883.10.22.4.33 Containment pending IPS Subordinate SubstanceAdministration (STU1) DYNAMIC
Relationship Adaptation: template 1.3.6.1.4.1.12559.11.10.1.3.1.3.4 Medication Item (2013‑12‑20)
ref
epsos-

Specialization: template 2.16.840.1.113883.10.21.4.7 UV Medication Statement (DYNAMIC)
ref
pharmcda-
Example
Example
<substanceAdministration classCode="SBADM" moodCode="INT">
  <templateId root="2.16.840.1.113883.10.22.4.4"/>  <code code="DRUG" codeSystem="2.16.840.1.113883.5.4" displayName="Drug"/>  <statusCode code="active"/>  <effectiveTime>
    <width value="2" unit="wk"/>  </effectiveTime>  <consumable typeCode="CSM">
    <!-- template 'IPS ManufacturedProduct' (dynamic) -->
  </consumable>  <entryRelationship typeCode="COMP">
    <substanceAdministration classCode="SBADM" moodCode="EVN">
      <statusCode code="active"/>      <effectiveTime xsi:type="PIVL_TS" institutionSpecified="true">
        <period value="12" unit="h"/>      </effectiveTime>      <doseQuantity value="2" unit="{puff}"/>      <consumable>
        <manufacturedProduct>
          <manufacturedMaterial nullFlavor="NA"/>        </manufacturedProduct>      </consumable>    </substanceAdministration>  </entryRelationship></substanceAdministration>
Example
No medication infos
<substanceAdministration classCode="SBADM" moodCode="INT">
  <templateId root="2.16.840.1.113883.10.22.4.4"/>  <code code="no-medication-info" codeSystem="2.16.840.1.113883.5.1150.1" displayName="No information about medications"/>  <statusCode code="completed"/>  <effectiveTime nullFlavor="NA" xsi:type="IVL_TS"/>  <consumable>
    <manufacturedProduct>
      <manufacturedMaterial nullFlavor="NA"/>    </manufacturedProduct>  </consumable></substanceAdministration>
notice There are open issues with this item:
Item DT Card Conf Description Label
hl7:substanceAdministration
 		R (IPSdotsent)
 
target
hl7ips-dataelement-104 draft Medication draft CEN/TC 251 prEN 17269
@classCode
 		cs 1 … 1 F SBADM
@moodCode
 		cs 1 … 1 R If 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)
hl7:templateId
 		II 1 … 1 M (IPSdotsent)
@root
 		uid 1 … 1 F 2.16.840.1.113883.10.22.4.4
hl7:id
 		II 0 … * R (IPSdotsent)
hl7:code
 		CD.IPS 1 … 1 R
The <code> element is valorized with the Substance Administration ACT code "DRUG" unless it is used for asserting the  known absence of medication treatments or no information about them.
(IPSdotsent)
 
target
hl7ips-dataelement-220 draft Medication Summary content status draft CEN/TC 251 prEN 17269
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.14 DRUGActCode (DYNAMIC)
or
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.15 Absent or Unknown Medication (DYNAMIC)
hl7:text
 		ED 0 … 1 R
The URI given in the value attribute of the <reference> 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 <reference> element points to an element in the narrative content that contains the complete text describing the medication.
(IPSdotsent)
hl7:reference
 		TEL 1 … 1 M (IPSdotsent)
@value
 		1 … 1 R Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
hl7:statusCode
 		CS 1 … 1 M (IPSdotsent)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.12 ActStatusActiveCompletedAbortedSuspended (DYNAMIC)
  Example <statusCode code="active"/>
Included 1 … 1 R from 2.16.840.1.113883.10.21.9.1 UV Use Period (DYNAMIC)
Choice 1 … 1
The effectiveTime element encodes the use period of the medication, it is always expressed as an interval of time.
It may be expressed using the low and high OR with the width element.
The first is used to indicate a specified interval (e.g. from march 15th, 2017); the latter for indicating a 'floating' period (e.g. 2 weeks).
Elements to choose from:
  • hl7:effectiveTime[hl7:low | hl7:high]
  • hl7:effectiveTime[hl7:width]
hl7:effectiveTime
 		IVL_TS 0 … 1 C Case 1: specified interval
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.

In case of unbounded period (continuous therapy) the high element will be valued with the nullFlavor attribute to NA.

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 a prescription that has not been refilled 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. 		(IPSdotsent)
where [hl7:low or
hl7:high]
 
target
hl7ips-dataelement-103 draft Period of Medication Use draft CEN/TC 251 prEN 17269
@nullFlavor
 		cs 0 … 1  
  Example
Known Interval
<effectiveTime xsi:type="IVL_TS">
  <low value="20130321"/>  <high value="20140321"/></effectiveTime>
  Example
Information not available about the period
<effectiveTime xsi:type="IVL_TS" nullFlavor="NI"/>
  Example
Unknown end date
<effectiveTime xsi:type="IVL_TS">
  <low value="20130321"/>  <high nullFlavor="UNK"/></effectiveTime>
  Example
continous therapy
<effectiveTime xsi:type="IVL_TS">
  <low value="20130321"/>  <high nullFlavor="NA"/></effectiveTime>
hl7:low
 		IVXB_TS 1 … 1 R (IPSdotsent)
hl7:high
 		IVXB_TS 0 … 1 R (IPSdotsent)
hl7:effectiveTime
 		IVL_TS 0 … 1 C Case 2: 'floating' period:
The width element is used to specify a period of (actual or intended) administration that is not anchored to any specific date (e.g. a two weeks therapy) 		(IPSdotsent)
where [hl7:width]
 
target
hl7ips-dataelement-103 draft Period of Medication Use draft CEN/TC 251 prEN 17269
  Example
2 week period
<effectiveTime xsi:type="IVL_TS">
  <width value="2" unit="w"/></effectiveTime>
hl7:low
 		NP (IPSdotsent)
hl7:width
 		PQ 1 … 1 R (IPSdotsent)
@unit
 		cs 1 … 1 R
  CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.21.1 Medication Time Units (UCUM) (DYNAMIC)
hl7:routeCode
 		CE.IPS 0 … 1 R
The <routeCode> element specifies the route of administration using the EDQM route of administration vocabulary.
A code must be specified if the route is known. 
Since the EDQM Standards Terms, together with UCUM, is one of the IDMP terminologies actually available for usage, this code system has been selected  as referecne terminology for representing Pharmaceutical Dose forms; Packages and Route of Administration.
It is known that also alternative jurisdictional and international terminologies are also used for this concept domain, as NCI or SNOMED CT.
Official NCI and EDQM maps for the route of administration are available from the EDQM site.
(IPSdotsent)
 
target
hl7ips-dataelement-102 draft Route of administration draft CEN/TC 251 prEN 17269
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.33 Medicine Route of Administration (DYNAMIC)
hl7:doseQuantity
 		IVL_PQ NP (IPSdotsent)
hl7:rateQuantity
 		IVL_PQ NP (IPSdotsent)
hl7:administrationUnitCode
 		CE NP (IPSdotsent)
hl7:consumable
 		1 … 1 M Contains 2.16.840.1.113883.10.22.4.2 IPS Medication Information (detail) (DYNAMIC) (IPSdotsent)
@typeCode
 		cs 1 … 1 F CSM
hl7:author
 		0 … * Contains 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC) (IPSdotsent)
hl7:entryRelationship
 		0 … * C
Subordinate Substance Administration Statement as a component of the overall medication statement.
Unless 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.

Contains 2.16.840.1.113883.10.22.4.33 IPS Subordinate SubstanceAdministration (DYNAMIC) 		(IPSdotsent)
@typeCode
 		cs 1 … 1 F COMP
  Constraint At least one subordinate <substanceAdministration> element SHALL be present unless medications are unknown or known absent.
  Example <cda:entryRelationship typeCode="COMP">
  <!-- component: Subordinate Substance Administration Statement. -->
  <cda:substanceAdministration classCode="SBADM" moodCode="EVN">
    <cda:templateId root="2.16.840.1.113883.10.22.4.33"/>    <!-- .. -->
  </cda:substanceAdministration>  <cda:sequenceNumber value="1"/></cda:entryRelationship>
hl7:sequenceNumber
 		INT 0 … 1 Sequence number of the Subordinate Substance Administration (IPSdotsent)