Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.13.3.2"
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<substanceAdministration classCode='SBADM' moodCode='INT|EVN'> | <substanceAdministration classCode='SBADM' moodCode='INT|EVN'> | ||
<templateId root='2.16.840.1.113883.10.20.1.24'/> | <templateId root='2.16.840.1.113883.10.20.1.24'/> | ||
− | <templateId root='1.3.6.1.4.1.19376.1.5.3.1. | + | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/> |
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.3.2'/> | <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.3.2'/> | ||
<templateId root=''/> | <templateId root=''/> | ||
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}} | }} | ||
− | This content module is derived from the Medication content module 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. | + | 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. |
====== Medication Fields ====== | ====== Medication Fields ====== | ||
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!Field!!Opt.!!CDA Tag!!Description | !Field!!Opt.!!CDA Tag!!Description | ||
|- | |- | ||
− | |Start and Stop Date||R2||<effectiveTime>||The date and time when the fluid regimen began and is expected to finish. | + | |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 | + | |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"). | |Site||O||<approachSiteCode>||The site where the fluid is administered (i.e. "Left Antecubital", or "Central Line"). | ||
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|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). | |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). | ||
|- | |- | ||
− | |Product||R||<consumable><br/> <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 (Plasmalyte)or a generic name. This information is required in all fluid entries. The name should not include packaging, strength or dosing information. | + | |Product||R||<consumable><br/> <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 (Plasmalyte®)or a generic name. This information is required in all fluid entries. The name should not include packaging, strength or dosing information. |
|- | |- | ||
|Code||R2||<consumable><br/> <code/><br/></consumable>||A code describing the product from a controlled vocabulary, such as RxNorm, First DataBank, et cetera. | |Code||R2||<consumable><br/> <code/><br/></consumable>||A code describing the product from a controlled vocabulary, such as RxNorm, First DataBank, et cetera. | ||
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=====<substanceAdministration classCode='SBADM' moodCode='INT|EVN'>===== | =====<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 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'). | ||
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=====<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' />===== | =====<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' />===== | ||
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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. | 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. | Subordinate <substanceAdministration> elements may, but need not be uniquely identified. | ||
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=====<span id='Medications_code'/><code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '>===== | =====<span id='Medications_code'/><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. | 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. | ||
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=====<text><reference value=' '/></text>===== | =====<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 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. | ||
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=====<statusCode code='completed'/>===== | =====<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. | 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. | ||
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=====<effectiveTime xsi:type='IVL_TS'>===== | =====<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. | 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=' '/>===== | =====<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 <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 | + | 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. |
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=====<span id='Medications_approachSiteCode'/><approachSiteCode code=' ' codeSystem=' '><br/> originalText><reference value=' '/></originalText><br/></approachSiteCode>===== | =====<span id='Medications_approachSiteCode'/><approachSiteCode code=' ' codeSystem=' '><br/> originalText><reference value=' '/></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). | 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=' ' unit=' '/><high value=' ' unit=' '/> </doseQuantity>===== | =====<span id='Medications_doseQuantity'/><doseQuantity> <low value=' ' unit=' '/><high value=' ' unit=' '/> </doseQuantity>===== | ||
− | The dose is specified if the <doseQuantity> element. If a dose range is given (e.g., | + | 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 >===== | =====<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 . | 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>===== | =====<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). | + | 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. | 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>===== | =====<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 | + | 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. |
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Revision as of 08:25, 4 June 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
Intravenous Fluids 1.3.6.1.4.1.19376.1.5.3.1.1.13.3.2
This content module describes the general structure for intravenous fluids. All intravenous fluid administration acts should be derived from this content module.
Uses
See Templates using Intravenous Fluids
Specification
<substanceAdministration classCode='SBADM' moodCode='INT|EVN'> <templateId root='2.16.840.1.113883.10.20.1.24'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.3.2'/> <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='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> |
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.
Medication Fields
Field | Opt. | CDA Tag | Description |
---|---|---|---|
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). |
Product | R | <consumable> <name> </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 (Plasmalyte®)or a generic name. This information is required in all fluid entries. The name should not include packaging, strength or dosing information. |
Code | R2 | <consumable> <code/> </consumable> |
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='2.16.840.1.113883.10.20.1.24'/>
<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=' ' />
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.
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=' ' 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. <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=' '/><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 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=' '>
|