2.16.840.1.113883.10.22.3.1

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1 Template IPSMedicationSummarySection

1.1 Aktuelle Version

Id2.16.840.1.113883.10.22.3.1Gültigkeit ab2016‑11‑11
Status  Unter Revision vor der PublikationVersions-LabelSTU1
NameIPSMedicationSummarySectionBezeichnungIPS Medication Summary Section
Beschreibung
 
The medication summary section contains a description of the patient's medications relevant for the scope of the patient summary.
The actual content could depend on the jurisdiction, it could report:
  • the currently active medications; 
  • the current and past medications considered relevant by the authoring GP; 
  • the patient prescriptions or dispensations automatically extracted by a regional or a national EHR.
In all those cases however medications are documented in the Patient Summary as medication statements.

This section requires either an entry indicating the subject is known not to be on any medications; either an entry indicating that no information is available about medications; or entries summarizing the subject's medications.

The optional author and informant elements are used when necessary to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header.
KontextElternknoten des Template-Element mit Id 2.16.840.1.113883.10.22.3.1
KlassifikationCDA Section level template
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Assoziiert mit
Assoziiert mit 2 Konzepte
IdNameDatensatz
hl7ips-data​element-16  Medication Summary   CEN/TC 251 prEN 17269
hl7ips-data​element-61  List of medication   CEN/TC 251 prEN 17269
Benutzt
Benutzt 4 Templates
Benutzt als NameVersion
2.16.840.1.113883.10.22.4.14Inklusion  IPS Body Author (STU1)DYNAMIC
2.16.840.1.113883.10.12.319Containment  CDA Informant (Body)DYNAMIC
2.16.840.1.113883.10.22.4.4Containment  IPS Medication Statement (STU2)DYNAMIC
2.16.840.1.113883.10.22.3.15Containment  IPS Translation Section (2021)DYNAMIC
BeziehungAdaptation: Template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-

Adaptation: Template 2.16.840.1.113883.10.20.1.8 Medication section (DYNAMIC)
ref
ccd1-

Adaptation: Template 1.3.6.1.4.1.12559.11.10.1.3.1.2.3 Section Medication Summary (2013‑12‑20)
ref
epsos-
Beispiel
Beispiel
<section classCode="DOCSECT">
  <templateId root="2.16.840.1.113883.10.22.3.1"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="10160-0" codeSystem="2.16.840.1.113883.6.1" displayName="Terapie farmacologiche"/>  <title>Terapie farmacologiche</title>  <text>...</text>  <author>
    <!-- template 2.16.840.1.113883.10.22.4.14 'IPS Body Author' (dynamic) -->
  </author>
  <informant>
    <!-- template 2.16.840.1.113883.10.12.319 'CDA Informant (Body)' (dynamic) -->
  </informant>
  <entry typeCode="COMP" contextConductionInd="true">
    <!-- template 2.16.840.1.113883.10.22.4.4 'IPS Medication Entry' (dynamic) -->
  </entry>
  <component>
    <!-- template 2.16.840.1.113883.10.22.3.15 'IPS Translation Section' (dynamic) -->
  </component>
</section>
ItemDTKardKonfBeschreibungLabel
hl7:section
1 … 1M
 
 
hl7ips-data​element-16  Medication Summary   CEN/TC 251 prEN 17269
 @classCode
cs0 … 1FDOCSECT
 hl7:templateId
II1 … 1M
  @root
uid1 … 1F2.16.840.1.113883.10.22.3.1
 hl7:id
II0 … *
 hl7:code
CE.IPS1 … 1M  History of medication use
  @code
CONF1 … 1F10160-0
  @codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
 hl7:title
ST1 … 1M  Medication Summary
 hl7:text
SD.TEXT1 … 1M  Section text
Eingefügt0 … * von 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
 hl7:author
0 … *
  hl7:templateId
II1 … 1M
   @root
uid1 … 1F2.16.840.1.113883.10.22.4.14
  hl7:time
TS.IPS.TZ1 … 1R
  hl7:assignedAuthor
1 … 1M
   hl7:id
II1 … *R
   hl7:code
0 … 1R
Auswahl0 … 1Elemente in der Auswahl:
  • hl7:assigned​Person
  • hl7:assigned​Authoring​Device
    hl7:assigned​Person
0 … 1C
     @classCode
cs0 … 1FPSN
     @determiner​Code
cs0 … 1FINSTANCE
     hl7:name
PN1 … *R  Name of the person (e.g. the Healthcare Professional)  authoring this document
 Beispiel<name>
  <given>John</given>  <family>Español Smith</family></name>
      hl7:family
1 … *R
      hl7:given
1 … *R
    hl7:assigned​Authoring​Device
0 … 1C
 Beispiel<assignedAuthoringDevice classCode="DEV" determinerCode="INSTANCE">
  <softwareName displayName="Turriano"/></assignedAuthoringDevice>
Eingefügt von 2.16.840.1.113883.10.22.9.2 IPS CDA Device (DYNAMIC)
     @classCode
cs0 … 1FDEV
     @determiner​Code
cs0 … 1FINSTANCE
     hl7:code
CE0 … 1
     hl7:manufacturer​Model​Name
SC0 … 1
     hl7:softwareName
SC0 … 1
   hl7:represented​Organization
0 … 1
    hl7:id
II0 … *
    hl7:name
0 … *
    hl7:telecom
TEL0 … *
    hl7:addr
AD0 … *
 hl7:informant
0 … *Beinhaltet 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)
 hl7:entry
1 … *RBeinhaltet 2.16.840.1.113883.10.22.4.4 IPS Medication Statement (DYNAMIC)
 
 
hl7ips-data​element-61  List of medication   CEN/TC 251 prEN 17269
  @typeCode
cs1 … 1R
 CONF
Der Wert von @typeCode MUSS gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
  @context​Conduction​Ind
bl0 … 1Ftrue
 hl7:component
0 … *Beinhaltet 2.16.840.1.113883.10.22.3.15 IPS Translation Section (DYNAMIC)


1.2 Zusammenstellung aller Versionen dieses Templates