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This content module describes the general structure for intravenous fluids. All intravenous fluid administration acts should be derived from this content module.
<substanceAdministration classCode='SBADM' moodCode='INT|EVN'> <templateId root='2.16.840.1.113822.214.171.124.24'/> <templateId root='126.96.36.199.4.1.193188.8.131.52.184.108.40.206.1'/> <templateId root=''/> <id root='' extension=''/> <code code='' codeSystem='' displayName='' codeSystemName=''/> <text><reference value='#med-1'/></text> <statusCode code='completed'/> <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='220.127.116.11.4.1.19318.104.22.168.22.214.171.124'/> <id root='' extension=''/> </act> </entryRelationship> <!-- An optional entry relationship that provides prescription activity --> <entryRelationship typeCode='REFR'> <templateId root='126.96.36.199.4.1.193188.8.131.52.184.108.40.206'/> : . </entryRelationship> <precondition> <criterion> <text><reference value=''></text> </criterion> </precondition> </substanceAdministation>
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, 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 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).|
|Dose||R2||<doseQuantity>||The amount of the medication given. This 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 relevant. In this case, only the unit count is specified , no units are specified. It may be a range.|
|Site||O||<approachSiteCode>||The site where the medication is administered, usually used with IV or topical drugs.|
|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.|
|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 name. This 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.|
|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 tablet. Another example is eye-drops, where the medication is in a solution of a particular strength, and the dose quantity is some number of drops. The originalText referenced by the <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.|
|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').
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='220.127.116.11.4.1.19318.104.22.168.1.4.7' />
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=' ' />
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.
|22.214.171.124.4.1.193126.96.36.199.188.8.131.52||A "normal" <substanceAdministration> act that may not contain any subordinate <substanceAdministration> acts.
<id root=' ' extension=' '/>
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.
<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '>
Do NOT code the medication here. This <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=' '/></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.
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.
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=' '/><high value=' '/>
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.
<routeCode code=' ' displayName=' ' 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.
<approachSiteCode code=' ' codeSystem=' '>