1.3.6.1.4.1.19376.1.5.3.1.4.3
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Patient Medication Instructions 1.3.6.1.4.1.19376.1.5.3.1.4.3
Any medication may be the subject of further instructions to the patient, for example to indicate that it should be taken with food, et cetera.
This structure is included in the target substance administration or supply act using the <entryRelationship> element defined in the CDA Schema. The example below shows the recording of patient medication instruction for an <entry>, and is used as context for the following section.
Standards
| Pharmacy | HL7 Pharmacy Domain (Normative) |
Uses
See Templates using Patient Medication Instructions
Specification
<entry>
<substanceAdministration classCode='SBADM' moodCode='EVN'>
∶
<entryRelationship typeCode='SUBJ' inversionInd='true'>
<act classCode='ACT' moodCode='INT'>
<templateId root='2.16.840.1.113883.10.20.1.49'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.3'/>
<code code='PINSTRUCT' codeSystem='1.3.6.1.4.1.19376.1.5.3.2'
codeSystemName='IHEActCode' />
<text><reference value='#comment-2'/></text>
<statusCode code='completed' />
</act>
</entryRelationship>
∶
</substanceAdministration>
</entry>
|
<entryRelationship typeCode='SUBJ' inversionInd='true'>
Again, a related statement is made about the medication or immunization. This observation is recorded inside an <entryRelationship> element occurring at the end of the substance administration or supply entry. The containing <entry> is the subject (typeCode='SUBJ') of this new observation, which is the inverse of the normal containment structure, thus inversionInd='true'.
<act classCode='ACT' moodCode='INT'>
The related statement is the intent (moodCode='INT') on how the related entry is to be performed. .
<templateId root='2.16.840.1.113883.10.20.1.49'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.3'/>
These <templateId> elements identify this <act> as a medication instruction, allowing for validation of the content. As a side effect, readers of the CDA can quickly locate and identify medication instructions.
<code code='PINSTRUCT' codeSystem='1.3.6.1.4.1.19376.1.5.3.2' codeSystemName='IHEActCode' />
The <code> element indicates that this is a patient medication instruction. This element shall be recorded exactly as specified above.
| Note: | These values will be sent to HL7 for harmonization with the HL7 Act Vocabulary. |
<text><reference value='#comment-2'/></text>
The <text> element indicates the text of the comment. For CDA, this SHALL be represented as a <reference> element that points at the narrative portion of the document. The comment itself is not the act being coded, so it appears in the <text> of the <observation>, not as part of the <code>. For HL7 Version 3 Messages, the full text SHALL be represented here.
<statusCode code='completed' />
The code attribute of <statusCode> for all comments must be completed.