Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.13.3.1"

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{{HL7V3|Intravenous Fluids|1.3.6.1.4.1.19376.1.5.3.1.4.7|Comment|
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{{HL7V3|Acuity|1.3.6.1.4.1.19376.1.5.3.1.1.13.3.1|Trial|
This content module describes the general structure for intravenous fluids. All intravenous fluid administration acts should be derived from this content module.
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A acuity entry indicates the triage acuity entry and the triage time of the patient.
|Example=
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|Example=<pre>
<pre>
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<entry>
<substanceAdministration classCode='SBADM' moodCode='INT|EVN'>
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  <!-- Acuity Event  -->
  <templateId root='2.16.840.1.113883.10.20.1.24'/>
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  <observation classCode='OBS' moodCode='EVN'>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.3.1'/>
+
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.3.1'/>
  <templateId root=''/>
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    <id root='&nbsp;' extension='&nbsp;'/>
  <id root='' extension=''/>
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    &lt;code code='&nbsp;' displayName='&nbsp;'
  &lt;code code='' codeSystem='' displayName='' codeSystemName=''/>
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          <code code='273887006' displayName='Triage index'
  <text><reference value='#med-1'/></text>
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          codeSystem='2.16.840.1.113883.6.96'
  <statusCode code='completed'/>
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          codeSystemName='SNOMED CT'/> <!-- Triage index (assessment scale) FullySpecifiedName -->  
  <effectiveTime xsi:type='IVL_TS'>
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       <originalText><reference value='#(ID of text coded)/></orginalText>
       <low value=''/>
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     </code>
      <high value=''/>
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    <text><reference value='#text/></text>
  </effectiveTime>
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     <!-- effectiveTime
  <effectiveTime operator='A' xsi:type='TS|PIVL_TS|EIVL_TS|PIVL_PPD_TS|SXPR_TS'>
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    <effectiveTime>
     :
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       <low value=''/> <!-- start of triage, may be sent -->
  </effectiveTime>
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       <high value=''/><!-- end of triage should be sent -->
  <routeCode code='' codeSystem='' displayName='' codeSystemName=''>
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     </effectiveTime>
  <doseQuantity value='' unit=''/>
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   </observation>
  <approachSiteCode code='' codeSystem='' displayName='' codeSystemName=''>
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</entry>
  <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='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/>
 
      <id root='' extension=''/>
 
    </act>
 
  </entryRelationship>
 
  <!-- An optional entry relationship that provides prescription activity -->
 
  <entryRelationship typeCode='REFR'>
 
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.3'/>
 
      :
 
      .
 
  </entryRelationship>
 
  <precondition>
 
    <criterion>
 
      <text><reference value=''></text>
 
     </criterion>
 
   </precondition>
 
</substanceAdministation>
 
 
</pre>
 
</pre>
 
}}
 
}}
This section makes use of the linking, severity and instruction entries.
 
  
This content module is derived from the Medication content module and is employed to specifically describe the necessary details of intravenous fluid administration. For the purpose of EDER and other profiles employing this content module, this profile identifies the following relevant fields.  
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=====<observation classCode='OBS' moodCode='EVN'>=====
 +
This element indicates that the entry is an observation regarding the event of triage assessment. This entry records the observation and the time of the observation.
  
The table below identifies and describes these fields, and indicates the 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.
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=====<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.3.1'/>=====
====== Medication Fields ======
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The <templateId> element identifies this <act> as about Acuity Assessment of the patient.  The templateId must have root='1.3.6.1.4.1.19376.1.5.3.1.1.13.3.1'.
{|border=1
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=====<id root='&nbsp;' extension='&nbsp;'/>=====
|+Medication Fields
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The entry must have an identifier.
|-bgcolor='#D9D9D9'
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=====&lt;code code='&nbsp;' displayName='&nbsp;'<br/>&nbsp;codeSystem='2.16.840.1.113883.6.96' &nbsp;codeSystemName='SNOMED CT'>=====
!Field!!Opt.!!CDA Tag!!Description
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The code describes the triage acuity scaleIHE recommends the use the Emergency Severity Index (ESI).  However, the vocabulary used within an affinity domain may be determined by a policy agreement within the domain.
|-
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=====<originalText><reference value='#xxx'/><orginalText>=====
|Start and Stop Date||R2||<effectiveTime>||The date (and time if available) when the medication 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 medication has been known to be stopped, the high value must be present, but expressed as a flavor of null (e.g., Unknown).
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This is a reference to the narrative text within the section that describes the acuity description.
|-
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=====<text><reference value='#text/></text>=====
|Dose||R2||<doseQuantity>||The amount of the medication givenThis should be in some known and measurable unit, such as grams, milligrams, et cetera.  It may be measured in "administration" units (such as tablets or each), for medications where the strength is relevantIn this case, only the unit count is specified , no units are specified.  It may be a range.
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This is a reference to the narrative text corresponding to the Observation act.
|-
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=====<effectiveTime>=====
|Site||O||<approachSiteCode>||The site where the medication is administered, usually used with IV or topical drugs.
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The effectiveTime element shall be sentIt records the interval of time over which triage occurs.  The use case for this information requires that the ending time of triage be recorded. However, the <low value='&nbsp;'> element may be sent by systems that capture the beginning and end of the triage process. 
|-
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=====<high value='&nbsp;'/>=====
|Rate||R2||<rateQuantity>||The rate is a measurement of how fast the dose is given to the patient over time (e.g., .5 liter / 1 hr), and is often used with IV drugs.
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This element records the time of completion of triage, and is required. If unknown, it must be recorded using a flavor of nullThis element may be sent using the TS data type, as shown aboveIf there is uncertainty about the time of completion of triage, the sender may record the time using the IVL_TS data type, as shown below.  
|-
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{|
|Product||R||<consumable><br/>&nbsp;<name><br/></consumable>||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 or a generic nameThis information is required in all fluid entries.  If the name of the medication is unknown, the type, purpose or other description may be supplied.  The name should not include packaging, strength or dosing information.Note: Due to restrictions of the CDA schema, there is no way to explicitly link the name to the narrative text.
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|+Triage as a Time Range
|-
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|<pre>
|Strength||R2||<consumable><br/>&nbsp;&lt;code><br/>&nbsp;&nbsp;<originalText/><br/>&nbsp;</code><br/></consumable>||The name and strength of the medication.  This information is only relevant for some medications, as the dose of the medication is often sufficient to indicate how much medication the patient receives. For example, the medication Percocet comes in a variety of strengths, which indicate specific amounts of two different medications being received in single tabletAnother example is eye-drops, where the medication is in a solution of a particular strength, and the dose quantity is some number of dropsThe originalText referenced by the &lt;code> element in the consumable should refer to the name and strength of the medication in the narrative text.Note: Due to restrictions of the CDA schema, there is no way to separately record the strength.
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<high xsi:type='IVL_TS'>
|-
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  <low value=''/>
|Code||R2||<consumable><br/>&nbsp;&lt;code/><br/></consumable>||A code describing the product from a controlled vocabulary, such as RxNorm, First DataBank, et cetera.
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  <high value=''/>
 +
</high>
 +
</pre>
 
|}
 
|}
 
=====<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').
 
 
The <substanceAdministration> element may contain subordinate <substanceAdministration> elements in a related component entry to deal with special cases (see the section below on Special Cases). These cases include split, tapered, or conditional dosing, or combination medications. The use of subordinate <substanceAdministration> elements to deal with these cases is optional.  The comment field should always be used in these cases to provide the same information as free text in the top level <substanceAdministration> element.
 
 
=====<templateId root='2.16.840.1.113883.10.20.1.24'/><br/><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7' />=====
 
All intravenous fluid entries use the <templateId> elements specified above to indicate that they are IV fluid administration acts.  This element is required.  In addition, a fluid entry shall further identify itself using one of the template identifiers detailed in the next section.
 
=====<templateId root='&nbsp;' />=====
 
The <templateId> element identifies this <entry> as a particular type of intravenous fluid event, allowing for validation of the content.  As a side effect, readers of the CDA can quickly locate and identify IV fluid events. The templateId must use one of the values in the table below for the root attribute.
 
{|border=1
 
|+Extension values for <templateId> in <substanceAdministration>
 
|-bgcolor='#D9D9D9'
 
!root!!Description
 
|-
 
|1.3.6.1.4.1.19376.1.5.3.1.4.7.1||A "normal" <substanceAdministration> act that may not contain any subordinate <substanceAdministration> acts.
 
}
 
=====<id root='&nbsp;' extension='&nbsp;'/>=====
 
A top level <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.
 
Subordinate <substanceAdministration> elements may, but need not be uniquely identified.
 
=====<span id='Medications_code'/>&lt;code code='&nbsp;' displayName='&nbsp;' codeSystem='&nbsp;' codeSystemName='&nbsp;'>=====
 
Do NOT code the medication here.  This &lt;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 CPT-4 (and often used for billing), or may describe the method of medication administration, such as by  intravenous injection.  This element is optional.
 
=====<text><reference value='&nbsp;'/></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 medication.
 
=====<statusCode code='completed'/>=====
 
The status of all <substanceAdministration> elements must be "completed".  The act has either occurred, or the request or order has been placed.  Unlike the condition observation, this attribute does not indicate whether or not the patient is still under the medication regime.
 
=====<effectiveTime xsi:type='IVL_TS'>=====
 
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.
 
=====<low value='&nbsp;'/><high value='&nbsp;'/>=====
 
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.
 
 
 
=====<span id='Medications_routeCode'/><routeCode code='&nbsp;' displayName='&nbsp;' codeSystem='2.16.840.1.113883.5.112' codeSystemName='RouteOfAdministration'>=====
 
The <routeCode> element specifies the route of administration using the HL7 RouteOfAdministration 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.
 
=====<span id='Medications_approachSiteCode'/><approachSiteCode code='&nbsp;' codeSystem='&nbsp;'><br/>&nbsp;originalText><reference value='&nbsp;'/></originalText><br/></approachSiteCode>=====
 
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).
 
=====<span id='Medications_doseQuantity'/><doseQuantity> <low value='&nbsp;' unit='&nbsp;'/><high value='&nbsp;' unit='&nbsp;'/> </doseQuantity>=====
 
The dose is specified if 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 attribute is not sent.  Otherwise the units are sent.  The unit attribute should be derived from the HL7 UnitsOfMeasureCaseSensitive vocabulary .
 
=====<low|high value='&nbsp;'> <translation> <originalText><reference value='&nbsp;'/></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='&nbsp;' unit='&nbsp;'/><high value='&nbsp;' unit='&nbsp;'/></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).
 
 
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.
 
=====<span id='Medications_consumable'/><consumable>=====
 
The <consumable> element shall be present, and shall contain a <manufacturedProduct> entry conforming to the {{ILink|1.3.6.1.4.1.19376.1.5.3.1.4.7|1.3.6.1.4.1.19376.1.5.3.1.4.7.2|Product Entry}} template
 
=====<entryRelationship typeCode='REFR'><br/>&nsbp;<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7.3'/>=====
 
The top level <substanceAdministration> element may contain a reference (typeCode='REFR') to related prescription activity as described in section 5.4.4.16.
 
=====<entryRelationship typeCode='COMP'><br/>&nbsp;<sequenceNumber value='&nbsp;'>=====
 
A top level <substanceAdministration> element may contain one or more related components, either to handle split, tapered or conditional dosing, or to support combination medications.
 
 
In the first three cases, the subordinate components shall specify only the changed <frequency> and/or <doseAmount> elements.  For conditional dosing, each subordinate component shall have a <precondition> element that specifies the <observation> that must be obtained before administration of the dose.
 
The value of the <sequenceNumber> shall be an ordinal number, starting at 1 for the first component, and increasing by 1 for each subsequent component.  Components shall be sent in <sequenceNumber> order.
 
=====<entryRelationship typeCode='SUBJ' inversionInd='true'/>=====
 
At most one instruction may be provided for each <substanceAdministration> entry.  If provided, it shall conform to the requirements listed above under section 5.4.4.6 on medication instructions.  The instructions shall contain any special case dosing instructions (e.g., split, tapered, or conditional dosing), and may contain other information (take with food, et cetera).
 
=====<entryRelationship typeCode='RSON'><br/>&nbsp;<act classCode='ACT' moodCode='EVN'><br/>&nbsp;&nbsp;<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/><br/>&nbsp;&nbsp;<id root='&nbsp;' extension='&nbsp;'/><br/>&nbsp;</act><br/></entryRelationship>=====
 
A <substanceAdministration> event may indicate one or more reasons for the use of the medication. These reasons identify the concern that was the reason for use via the Internal Reference entry content module specified in section 5.4.4.8.2.
 
 
The extension and root of each observation present must match the identifier of a concern entry contained elsewhere within the CDA document.
 
 
A consumer of the Medical Summary is encouraged, but not required to maintain these links on import.
 
=====<precondition><criterion><br/>&nbsp;<text><reference value='&nbsp;'></text><br/></criterion></precondition>=====
 

Latest revision as of 10:17, 7 December 2007

Development Only

The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at http://www.ihe.net/Technical_Framework/index.cfm#PCC

Trial.gif Acuity 1.3.6.1.4.1.19376.1.5.3.1.1.13.3.1

A acuity entry indicates the triage acuity entry and the triage time of the patient.


Uses

See Templates using Acuity

Specification
Acuity Example
<entry>
  <!-- Acuity Event  -->
  <observation classCode='OBS' moodCode='EVN'>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.3.1'/>
    <id root=' ' extension=' '/>
    <code code=' ' displayName=' '
          <code code='273887006' displayName='Triage index'
           codeSystem='2.16.840.1.113883.6.96'
           codeSystemName='SNOMED CT'/> <!-- Triage index (assessment scale) FullySpecifiedName --> 
      <originalText><reference value='#(ID of text coded)/></orginalText>
    </code>
    <text><reference value='#text/></text>
    <!-- effectiveTime 
    <effectiveTime>
      <low value=''/> <!-- start of triage, may be sent -->
      <high value=''/><!-- end of triage should be sent -->
    </effectiveTime>
  </observation>
</entry>


<observation classCode='OBS' moodCode='EVN'>

This element indicates that the entry is an observation regarding the event of triage assessment. This entry records the observation and the time of the observation.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.3.1'/>

The <templateId> element identifies this <act> as about Acuity Assessment of the patient. The templateId must have root='1.3.6.1.4.1.19376.1.5.3.1.1.13.3.1'.

<id root=' ' extension=' '/>

The entry must have an identifier.

<code code=' ' displayName=' '
 codeSystem='2.16.840.1.113883.6.96'  codeSystemName='SNOMED CT'>

The code describes the triage acuity scale. IHE recommends the use the Emergency Severity Index (ESI). However, the vocabulary used within an affinity domain may be determined by a policy agreement within the domain.

<originalText><reference value='#xxx'/><orginalText>

This is a reference to the narrative text within the section that describes the acuity description.

<text><reference value='#text/></text>

This is a reference to the narrative text corresponding to the Observation act.

<effectiveTime>

The effectiveTime element shall be sent. It records the interval of time over which triage occurs. The use case for this information requires that the ending time of triage be recorded. However, the <low value=' '> element may be sent by systems that capture the beginning and end of the triage process.

<high value=' '/>

This element records the time of completion of triage, and is required. If unknown, it must be recorded using a flavor of null. This element may be sent using the TS data type, as shown above. If there is uncertainty about the time of completion of triage, the sender may record the time using the IVL_TS data type, as shown below.

Triage as a Time Range
<high xsi:type='IVL_TS'>
  <low value=''/>
  <high value=''/>
</high>