Medication Refused

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Approval Status

  • Approval Status: Pending
  • Example Task Force: 5/3/2018
  • SDWG:

Templates

  • 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

Validation location:

TBD

Reference to full CDA sample: TBD

Comments

  • This is an example of a patient refusing to take a medication at a point in time due to a reason of patient objection (QRDA template used)

Custodian

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

Keywords

  • medication, negation

 

Example: download example view on GitHub

<!-- This is an example of a medication being refused by a patient --> 
<!-- This example illustrates hhow such documentation may represent an exclusion criterion for a quality measure -->
<!-- This example uses a QRDA tempalte to document reason with a coded concept --> 
<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>Dosage</th>
                    <th>Effective Dates (start - stop)</th>
                    <th>Comments</th>
                </tr>
            </thead>
            <tbody>
                <tr ID="Medication_0">
                    <td>
                        Patient refused: 
                        <content ID="MedicationName_0" xmlns="urn:hl7-org:v3">Lisinopril 10mg Oral Tablet</content>
                    </td>
                    <td>NA</td>
                    <td>March 15, 2018</td>
                    <td ID="Medication_0_comment">Patient refused</td>
                </tr>
            </tbody>
        </table>
    </text>
    <entry typeCode="DRIV">
        <!-- Since the negation has occurred, the moodCode is set to "EVN" with negationInd to "true" -->
        <substanceAdministration classCode="SBADM" moodCode="EVN" negationInd="true">
            <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="47d3e719-f688-459d-bcdc-47c6de0767b9"/>
            <text>
                <!-- This reference refers to medication information in unstructured portion of section-->
                <reference value="#Medication_0"/>
            </text>
            <statusCode code="completed"/>
            <!-- This effectiveTime is a point in time -->
            <effectiveTime value="20180315112305-0500"/>
            <routeCode nullFlavor="NA"/>
            <doseQuantity nullFlavor="NA"/>
            <consumable>
                <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"/>
                    <id root="2a620155-9d11-439e-92b3-5d9815ff4eb8"/>
                    <manufacturedMaterial>
                        <!-- Medications should be specified at a level corresponding to prescription when possible, such as 600mg oral tablet (non-branded)-->
                        <code code="314076" displayName="Lisninopril 10mg Oral Tablet" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm">
                            <originalText>
                                <reference value="#MedicationName_0"/>
                            </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="20180315112305-0500"/>
                <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>
            <!-- Comment activity --> 
            <entryRelationship>
                <act classCode="ACT" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.22.4.64"/>
                    <code code="48767-8" displayName="Annotation Comment" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>
                    <text>
                        <reference value="#Medication_0_comment"/>
                    </text>
                </act>
            </entryRelationship>
            <!-- This is the QRDA template --> 
            <entryRelationship>
                <observation classCode="OBS" moodCode="EVN">
                    <!-- Reason (V2) -->
                    <templateId root="2.16.840.1.113883.10.20.24.3.88" extension="2014-12-01" />
                    <id root="5750a5bb-6a01-4b99-9b1c-cda56b1dce0c" />
                    <code code="77301-0" codeSystem="2.16.840.1.113883.6.1" displayName="Reason care action performed or not" codeSystemName="LOINC" />
                    <statusCode code="completed" />
                    <effectiveTime>
                        <low value="20180315112305-0500"/>
                    </effectiveTime>
                    <!-- sdtc:valueset extension is required in many QRDA templates. It's allowed in C-CDA. -->
                    <value xsi:type="CD" code="105480006" codeSystem="2.16.840.1.113883.6.96"  codeSystemName="SNOMED CT" displayName="Refusal of treatment by patient" sdtc:valueSet="2.16.840.1.113883.3.526.3.1008" />
                </observation>
            </entryRelationship>
        </substanceAdministration>
    </entry>
</section>
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