1.3.6.1.4.1.19376.1.5.3.1.4.7.2

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Trial.gif Product Entry 1.3.6.1.4.1.19376.1.5.3.1.4.7.2

The product entry describes a medication or immunization used in a <substanceAdministration> or <supply> act. It adopts the constraints of the ASTM/HL7 Continuity of Care Document.


Uses

See Templates using Product Entry

Specification
Product Entry Example
<!-- Within a CDA Document -->
<manufacturedProduct>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.2'/>
  <templateId root='2.16.840.1.113883.10.20.1.53'/>
  <manufacturedMaterial>
    <code code='' displayName='' codeSystem='' codeSystemName=''>
      <originalText><reference value=''/></originalText>
    </code>
    <name></name>
  </manufacturedMaterial>
</manufacturedProduct>
<!-- Within a message -->
<administerableMaterial>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.2'/>
  <templateId root='2.16.840.1.113883.10.20.1.53'/>
  	<administerableMaterial>
    	<code></code>
		<desc></desc>
	</administerableMaterial>
</administerableMaterial>


<manufacturedProduct> -OR- <administerableMaterial>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.2'/>
 <templateId root='2.16.840.1.113883.10.20.1.53'/>
 <manufacturedMaterial> -OR- <administerableMaterial>

In a CDA document, the name and strength of the medication are specified in the elements under the <manufacturedMaterial> element. In a message, the are contained within the <administeredMaterial> element, inside another <administerableMaterial> element1. The templateId elements are required and identify this as a product entry.

1 This duplication of element names is an artifact of the standard.
<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '>
 <originalText><reference value=' '/></originalText>

The <code> element of the <manufacturedMaterial> describes the medication. This may be coded using a controlled vocabulary, such as RxNorm, First Databank, or other vocabulary system for medications, and should be the code that represents the generic medication name and strength (e.g., acetaminophen and oxycodone -5/325), or just the generic medication name alone if strength is not relevant (Acetaminophen).

In a CDA document, the <originalText> shall contain a <reference> whose URI value points to the generic name and strength of the medication, or just the generic name alone if strength is not relevant. Inside a message, the <originalText> may contain the actual text that describes the medication in similar fashion.


Note: When the text is supplied from the narrative, the implication is that if you supply the components of a combination medication in an entry, you must also display these in the narrative text, otherwise you would not be able to break the combination medication down into its component parts. This is entirely consistent with the CDA Release 2.0 requirements that the narrative supply the necessary and relevant human readable information content.

The <code> element is also used to support coding of the medication. If coded, it must provide a code and codeSystem attribute using a controlled vocabulary for medications. The displayName for the code and codeSystemName should be provided as well for diagnostic and human readability purposes, but are not required. The table below provides the codeSystem and codeSystemName for several controlled terminologies that may be used to encode medications and/or immunizations.

codeSystem codeSystemName Description
2.16.840.1.113883.6.88 RxNorm RxNorm
2.16.840.1.113883.6.69 NDC National Drug Codes
2.16.840.1.113883.6.63 FDDC First DataBank Drug Codes
2.16.840.1.113883.6.96 SNOMED-CT SNOMED Controlled Terminology
2.16.840.1.113883.6.59 CVX CDC Vaccine Codes
Example Medication and Immunization Vocabularies

The code used for an immunization may use code systems other than what might be used for other medications, such as the CDC maintained CVX codes. Code systems that describe vaccination procedures (such as CPT-4) shall not be used to describe the vaccine entry.

<name> -OR- <desc>

In a CDA document, the <name> element should contain the brand name of the medication (or active ingredient in the case of subordinate <substanceAdministration> elements used to record components of a medication). Within a message, this information shall be provided in the <desc> element.