Free Text Medication SIG

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Approval Status

  • Approval Status: Pending
  • Example Task Force: 11/1/2018
  • SDWG:

C-CDA 2.1 Example:

  • Medications Section: 2.16.840.1.113883.10.20.22.2.1.1:2014-06-09
  • Medication Activity: 2.16.840.1.113883.10.20.22.4.16:2014-06-09
  • Medication Information: 2.16.840.1.113883.10.20.22.4.23:2014-06-09

Reference to full CDA sample:

  • Medications in empty CCD

Validation location

Comments

  • This is an example of having a medication with only a free text SIG when you have no other coded information.

Custodian

  • Brett Marquard

Keywords

  • free text SIG

 

Example: download example view on GitHub

<section>
    <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>Date</th>
                    <th>Status</th>
                </tr>
            </thead>
            <tbody>
                <tr ID="Medication_1">
                     <td><!-- This shouldn't be used if a medication substance can be coded -->
                        <content ID="MedicationSIG">Experimental '150 cure-all drug', take one tab by mouth every morning</content>
                    </td>
                    <td>Jan 10 2018</td>
                    <td>Active</td> 
                </tr>
            </tbody>
        </table>
    </text>
    <entry typeCode="DRIV">
        <substanceAdministration classCode="SBADM" moodCode="EVN">
            <templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>
            <id root="1310a2d3-f888-4722-b4c4-a3c5911ac7f9"/>
            <text>
                <!-- This reference refers to medication information in unstructured portion of section-->
                <reference value="#Medication_1"/>
            </text>
            <statusCode code="active"/>
            <!-- This first effectiveTime shows that medication was added on January 10, 2018 (not known to have stopped)-->
            <effectiveTime xsi:type="IVL_TS">
                <low value="20180110"/>
                <high nullFlavor="NI"/>
            </effectiveTime>
           <doseQuantity nullFlavor="UNK"/>
            <consumable typeCode="CSM">
                <manufacturedProduct classCode="MANU">
                    <!-- ** Medication information ** -->
                    <templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/>
                    <manufacturedMaterial>
                        <!-- Medications should be specified at a level corresponding to prescription when possible - coded information isn't available -->
                        <code nullFlavor="UNK"/>                      
                    </manufacturedMaterial>
                </manufacturedProduct>
            </consumable>
            <entryRelationship typeCode="COMP">
                <substanceAdministration classCode="SBADM" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.22.4.147"/>
                    <code code="76662-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Medication Instructions"/>
                    <text>
                        <!-- Reference into the section.text to a tag that ONLY contains free text SIG -->
                        <reference value="#MedicationSIG"/>
                    </text>
                    <consumable>
                        <manufacturedProduct>
                            <manufacturedLabeledDrug nullFlavor="NA"/>
                        </manufacturedProduct>
                    </consumable>
                </substanceAdministration>
            </entryRelationship>
        </substanceAdministration>
    </entry>
</section>
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