Patient reported oral medication

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Example metadata last updated 2017-08-06 10:15:50.781000 UTC

Approval Status: Withdrawn (temporarily)

  • Approval Status: Withdrawn (temporarily)
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Comments:

  • Patients often report medications that they are taking, either self-prescribed or by another provider, and know the drug name but do not know any specific brand or dose. This is an example of how to record an herbal supplement (echinicea) that a patient has reported taking using the informant to denote that this is patient reported.

Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)

Full sample: Medications in empty CCD

Example: download example view on GitHub

<section>
    <templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>
    <templateId root="2.16.840.1.113883.10.20.22.2.1.1" extension="2014-06-09"/>
    <!-- Medication Section (entries required) -->
    <code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Medication Use"/>
    <title>MEDICATIONS</title>
    <text>
        <table border="1" width="100%">
            <thead>
                <tr>
                    <th>Medication</th>
                    <th>Instructions</th>
                    <th>Dosage</th>
                    <th>Effective Dates (start - stop)</th>
                    <th>Status</th>
                </tr>
            </thead>
            <tbody>
                <tr ID="Medication_8">
                    <td>
                        <content ID="MedicationName_8" xmlns="urn:hl7-org:v3">ECHINACEA ANGUSTIFOLIA Extract</content>
                    </td>
                    <td>
                        <content ID="MedicationSig_8" xmlns="urn:hl7-org:v3">Patient reports taking once daily</content>
                    </td>
                    <td>
                        <content ID="MedicationDosage_8" xmlns="urn:hl7-org:v3">unknown</content>
                    </td>
                    <td>Apr-09-2014 - </td>
                    <td>Active</td>
                </tr>
            </tbody>
        </table>
    </text>
    <entry typeCode="DRIV">
        <substanceAdministration classCode="SBADM" moodCode="EVN">
            <!-- This medication use case is a medication that the patient reports taking. If it has been already administered use moodCode = "EVN". -->
            <!-- If it is intended use "INT" or if ordered drug then use moodCode = "RQO" - Dependencies exist between moodCode, statusCode and effectiveTime  -->
            <templateId root="2.16.840.1.113883.10.20.22.4.16"/>
            <templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>
            <id root="2d359e3f-f2cb-437d-b004-9324d077be4e"/>
            <text>
                <!-- This reference refers to medication information in unstructured portion of section-->
                <reference value="#Medication_8"/>
            </text>
            <statusCode code="completed"/>
            <!-- This first effectiveTime shows that medication was added on April 9, 2014 which patient stopped taking on May 10-->
            <effectiveTime xsi:type="IVL_TS">
                <low value="20140409"/>
                <!-- The timing of last second of the day indicates the drug was taken on this day.-->
                <high value="20140510235959+0500"/>
            </effectiveTime>
            <!-- The second effectiveTime specifies dose frequency, which can be either a period (PIVL_TS) or event (EIVL_TS). -->
            <!-- InstituionSpecified = "false" is implied in ths omission of this attribute and means that it must be administered exactly once per day-->
            <!-- InstituionSpecified = "true" which is not default would mean that receiving institution has flexibility in dosing schedule-->
            <!-- Operator "A" means that this timing information is in addition to previous effectiveTime information provided-->
            <!-- The patient reports taking the medication once per day -->
            <effectiveTime xsi:type="PIVL_TS" operator="A">
                <period value="1" unit="d" />
            </effectiveTime>
            <routeCode code="C38288" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="Oral"/>
            <!-- The patient could not recall any specific dosage of this medication-->
            <!-- The nullFlavor of UNK is used since there is a dosage but it is unknown by C-CDA document author-->
            <doseQuantity nullFlavor="UNK"/>
            <consumable typeCode="CSM">
                <manufacturedProduct classCode="MANU">
                    <!-- ** Medication information ** -->
                    <templateId root="2.16.840.1.113883.10.20.22.4.23"/>
                    <templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/>
                    <manufacturedMaterial classCode="MMAT" determinerCode="KIND">
                        <!-- Medications should be specified at a level corresponding to prescription when possible -->
                        <!-- Since this is an over-the-counter supplement and the patient could not describe brand or dose, ingredient is shown-->
                        <code code="236121" codeSystem="2.16.840.1.113883.6.88" displayName="ECHINACEA ANGUSTIFOLIA Extract" codeSystemName="RxNorm">
                            <originalText>
                                <reference value="#MedicationName_8"/>
                            </originalText>
                        </code>
                    </manufacturedMaterial>
                </manufacturedProduct>
            </consumable>
            <author>
                <templateId root="2.16.840.1.113883.10.20.22.4.119"/>
                <!-- Time the author noted that patient is on no medications -->
                <time value="20140409"/>
                <assignedAuthor>
                    <id extension="66666" root="2.16.840.1.113883.4.6"/>
                    <code code="207RC0000X" codeSystem="2.16.840.1.113883.6.101"
                        codeSystemName="NUCC" displayName="Cardiovascular Disease"/>
                    <addr>
                        <streetAddressLine>6666 StreetName St.</streetAddressLine>
                        <city>Silver Spring</city>
                        <state>MD</state>
                        <postalCode>20901</postalCode>
                        <country>US</country>
                    </addr>
                    <telecom value="tel:+1(301)666-6666" use="WP"/>
                    <assignedPerson>
                        <name>
                            <given>Heartly</given>
                            <family>Sixer</family>
                            <suffix>MD</suffix>
                        </name>
                    </assignedPerson>
                </assignedAuthor>
            </author>
            <informant>
                <assignedEntity>
                    <!-- This is a fictional OID and identifier for the patient. This should be adapted to local implementation -->
                    <id root="2.16.840.1.113883.3.3208.101.2" extension="20130607100800-Patient1"/>
                    <addr use="HP">
                        <streetAddressLine>1111 StreetName St.</streetAddressLine>
                        <city>Silver Spring</city>
                        <state>MD</state>
                        <postalCode>20901</postalCode>
                        <country>US</country>
                    </addr>
                    <telecom value="tel:+1(301)111-1111" use="HP"/>
                    <assignedPerson>
                        <name>
                            <given>Patient</given>
                            <family>One</family>
                        </name>
                    </assignedPerson>
                </assignedEntity>
            </informant>
        </substanceAdministration>
    </entry>
</section>
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