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Intravenous Fluids 188.8.131.52.4.1.193184.108.40.206.220.127.116.11.2
This content module describes the general structure for intravenous fluids. All intravenous fluid administration acts should be derived from this content module.
See Templates using Intravenous Fluids
<substanceAdministration classCode='SBADM' moodCode='INT|EVN'> <templateId root='2.16.840.1.113818.104.22.168.24'/> <templateId root='22.214.171.124.4.1.193126.96.36.199.1.4.7'/> <templateId root='188.8.131.52.4.1.193184.108.40.206.220.127.116.11'/> <templateId root='18.104.22.168.4.1.19322.214.171.124.126.96.36.199.2'/> <id root='' extension=''/> <code code='' codeSystem='' displayName='' codeSystemName=''/> <text><reference value='#med-1'/></text> <statusCode code='completed|active'/> <effectiveTime xsi:type='IVL_TS'> <low value=''/> <high value=''/> </effectiveTime> <effectiveTime operator='A' xsi:type='TS|PIVL_TS|EIVL_TS|PIVL_PPD_TS|SXPR_TS'> : </effectiveTime> <routeCode code='' codeSystem='' displayName='' codeSystemName=''/> <doseQuantity value='' unit=''/> <approachSiteCode code='' codeSystem='' displayName='' codeSystemName=''/> <rateQuantity value='' unit=''/> <consumable> : . </consumable> <!-- 0..* entries describing the components --> <entryRelationship typeCode='COMP' > <sequenceNumber value=''/> </entryRelationship> <!-- An optional entry relationship that indicates the the reason for use --> <entryRelationship typeCode='RSON'> <act classCode='ACT' moodCode='EVN'> <templateId root='188.8.131.52.4.1.193184.108.40.206.220.127.116.11'/> <id root='' extension=''/> </act> </entryRelationship> <!-- An optional entry relationship that provides prescription activity --> <entryRelationship typeCode='REFR'> <templateId root='18.104.22.168.4.1.19322.214.171.124.126.96.36.199'/> : . </entryRelationship> <precondition> <criterion> <text><reference value=''/></text> </criterion> </precondition> </substanceAdministration>
This content module is derived from the Medication content module to specifically and more easily describe the necessary details of intravenous fluid administration. For the purpose of EDER and other profiles employing this content module, the table below identifies and describes the fields and constraints on whether or not they are required to be sent. The fields are listed in the order that they appear in the CDA XML content.
|Start and Stop Date||R2||<effectiveTime>||The date and time when the fluid regimen began and is expected to finish. The first component of the <effectiveTime> encodes the lower and upper bounds over which the <substanceAdministration> occurs, and the start time is determined from the lower bound. If the fluid has been known to be stopped, the high value must be present, but expressed as a flavor of null (e.g., Unknown).|
|Dose||R2||<doseQuantity>||The amount of fluid given. This should be in some known and measurable fluid unit, such as milliliters, or may be measured in "administration" units (such "units" of blood or "packs" of platelets).|
|Site||O||<approachSiteCode>||The site where the fluid is administered (i.e. "Left Antecubital", or "Central Line").|
|Rate||R2||<rateQuantity>||The rate is a measurement of how fast the fluid is given to the patient over time (e.g., .5 liter / 1 hr).|
|The name of the substance or product. This should be sufficient for a provider to identify the type of fluid. It may be a trade name (Plasmalyte®)or a generic name. This information is required in all fluid entries. The name should not include packaging, strength or dosing information.|
|A code describing the product from a controlled vocabulary, such as RxNorm, First DataBank, et cetera.|
<substanceAdministration classCode='SBADM' moodCode='INT|EVN'>
The general model is to record each fluid administered in a <substanceAdministration> intent (moodCode='INT'). Fluids that have been started but not completely administered should be recorded in a <substanceAdministration> intent (moodCode='INT'). Fluids that have been completed should be recorded as an event (moodCode='EVN').
<templateId root='188.8.131.52.4.1.193184.108.40.206.220.127.116.11' />
All intravenous fluid entries use the <templateId> elements specified above to indicate that they are IV fluid administration acts. This element is required.
<id root=' ' extension=' '/>
The <substanceAdministration> element must be uniquely identified. If there is no explicit identifier for this observation in the source EMR system, a GUID may be used for the root attribute, and the extension may be omitted. Although HL7 allows for multiple identifiers, this profile requires that one and only one be used.
<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '>
The <code> element is required, and is used to supply a code that describes the act of fluid administration, not the fluid being administered. This may be a procedure code, such as those found in CPT-4 (and often used for billing), or may describe the method of administration, such as by intravenous injection.
<text><reference value=' '/></text>
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 fluid administration.
The status of all <substanceAdministration> elements must be "completed" or "active". If "completed", then the administration has occurred, or the request or order has been placed. If "active", then at the time recorded, the fluid was still being administered.
The first <effectiveTime> element encodes the start and stop time of the administration. 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.
<low value=' '/><high value=' '/>
The <low> and <high> values of the first <effectiveTime> element represent the start and stop times for the fluid administration. 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 fluid administration according to the information provided in the initial fluid order or RN documentation. For example, if the fluid order is for one liter, and the fluid is to be delivered at 250 mL/hr, then the high value should contain a datetime that is 4 hours later then the <low> value. The rationale is that a provider, seeing a discontinued fluid could normally assume that the fluid has been stopped, even if the intent of the treatment plan is to continue the fluid continuously.
<approachSiteCode code=' ' codeSystem=' '>
originalText><reference value=' '/></originalText>
The <approachSiteCode> element contains a URI in the value attribute of the <reference> that points to the text in the narrative identifying the site. It may be coded to a controlled vocabulary that lists such sites (e.g., SNOMED-CT).
<doseQuantity><low value=' ' unit=' '/><high value=' ' unit=' '/> </doseQuantity>
The dose is specified if the <doseQuantity> element. If a dose range is given (e.g., 125-250 mL/hr [i.e. to replace fluid losses]), then the <low> and <high> bounds are specified in their respective elements, otherwise both <low> and <high> have the same value. The unit attribute should be derived from the HL7 UnitsOfMeasureCaseSensitive vocabulary .
<low|high value=' '> <translation> <originalText><reference value=' '/></originalText> </translation></low|high >
Any <low> and <high> elements used for <doseQuantity> or <rateQuantity> should contain a <translation> element that provides a <reference> to the <originalText> found in the narrative body of the document .
<rateQuantity><low value=' ' unit=' '/><high value=' ' unit=' '/></rateQuantity>
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) (i.e. mL/hr).
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.
The <consumable> element shall be present, and shall contain a <manufacturedProduct> entry conforming to the Product Entry template.