Med oral with indications and instructions

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 12/15/2016
  • SDWG: 2/2/2017

C-CDA 2.1 Example:

  • 2.16.840.1.113883.10.20.22.2.1:2014-06-09

  • 2.16.840.1.113883.10.20.22.2.1.1:2014-06-09

  • 2.16.840.1.113883.10.20.22.4.16:2014-06-09

  • 2.16.840.1.113883.10.20.22.4.23:2014-06-09

  • 2.16.840.1.113883.10.20.22.4.119

    Reference to full CDA sample:

  • Medications in empty CCD

Validation location

Comments

  • This is an example of a medication administered orally with a PRN coded precondition, instructions (not PRN), and indications (not PRN).

Custodian

  • George Cole

    Keywords

  • medications

Permalink

Links

 

Example: download example view on GitHub 

<!-- These examples illustrate multiple ways that a medication can be prescribed for pain
     These examples are meant to illustrate for comparison purposes only!  
     DO NOT COPY as an example of a Medication Section. These would not appear together in one patient document.
     
     Summary of examples:
     
		1. PRN with a coded precondition  
   		Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours as needed for joint pain
   		
		2. Instructions; similar to above but NOT a PRN 
		Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours. Do not take on an empty stomach.
		
		3. Indication; again, NOT a PRN - 
		Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours for joint pain
-->
<section>
    <!-- Medication Section (entries required) (V2) -->
    <templateId root="2.16.840.1.113883.10.20.22.2.1.1" extension="2014-06-09"/>
    <templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>
    <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_PRN_222222">
                    <td>
                        <content ID="MedicationName_PRN_222222">Ibuprofen 600mg Oral Tablet</content>
                    </td>
                    <td>
                        <content ID="MedicationSig_PRN_222222">take 1 tablet Every 6 Hours PRN for joint pain</content>
                    </td>
                    <td>600 MG</td>
                    <td>Mar-10-2013 - </td>
                    <td>Active</td>
                </tr>			
                <tr ID="Medication_42424242">
                    <td>
                        <content ID="MedicationName_42424242">Ibuprofen 600mg Oral Tablet</content>
                    </td>
                    <td>
                        <content ID="MedicationSig_42424242">Take 1 tablet Every 6 Hours. <content ID="MedicationInstruction_42424242">Do not take on an empty stomach.</content></content>
                    </td>
                    <td>600 MG</td>
                    <td>Mar-10-2013 - </td>
                    <td>Active</td>
                </tr>
                <tr ID="Medication_84838281">
                    <td>
                        <content ID="MedicationName_84838281">Ibuprofen 600mg Oral Tablet</content>
                    </td>
                    <td>
                        <content ID="MedicationSig_84838281">take 1 tablet Every 6 Hours for <content ID="MedicationIndication_84838281">joint pain</content></content>
                    </td>
                    <td>600 MG</td>
                    <td>Mar-10-2013 - </td>
                    <td>Active</td>
                </tr>
            </tbody>
        </table>
    </text>
    
    <!-- 1. PRN with a coded precondition - Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours PRN for joint pain 
	compare to "Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours PRN"
	coded here as an precondition with a code
	note the following wording would be coded the same way, with a coded precondition:
 	Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours as needed for joint pain
	-->
    <entry>
        <substanceAdministration classCode="SBADM" moodCode="EVN">
            <!-- Medication Activity (V2) -->
            <templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>			
            <templateId root="2.16.840.1.113883.10.20.22.4.16"/>
            <id extension="300035" root="1.3.6.1.4.1.22812.3.99930.3.4.9"/>
            <id extension="300013" root="1.3.6.1.4.1.22812.3.99930.3.4.9"/>
            <text>
                <reference value="#Medication_PRN_222222"/>
            </text>
            <statusCode code="active"/>
            <effectiveTime xsi:type="IVL_TS">
                <low value="20130310"/>
                <high nullFlavor="NI"/>
            </effectiveTime>
            <!-- 
				institutionSpecified="true" for a PRN medication
				See http://hl7-c-cda-examples.herokuapp.com/examples/22 or https://docs.google.com/document/d/1Y0Z458o_MrR2aPnpx6EygO6hpI88Bl95esjRWZ0agtY/edit
			-->
            -->
            <effectiveTime xsi:type="PIVL_TS" institutionSpecified="true" operator="A">
                <period value="6" unit="h"/>
            </effectiveTime>
            <doseQuantity value="1"/>
            <consumable typeCode="CSM">
                <manufacturedProduct classCode="MANU">
                    <!-- Medication Information (V2) -->
                    <templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/>
                    <templateId root="2.16.840.1.113883.10.20.22.4.23"/>
                    <manufacturedMaterial>
                        <code code="197806" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="ibuprofen 600 MG Oral Tablet">
                            <originalText>
                                <reference value="#MedicationName_PRN_222222"/>
                            </originalText>
                            <translation code="00603402221" codeSystem="2.16.840.1.113883.6.69" codeSystemName="NDC" displayName="Ibuprofen 600mg Oral Tablet"/>
                        </code>
                        <name>Ibuprofen</name>
                    </manufacturedMaterial>
                </manufacturedProduct>
            </consumable>
            <entryRelationship typeCode="COMP">
                <!-- Medication Free Text SIG -->
                <substanceAdministration classCode="SBADM" moodCode="INT">
                    <templateId root="2.16.840.1.113883.10.20.22.4.147"/>
                    <code code="76662-6" codeSystem="2.16.840.1.113883.6.1"/>
                    <text>
                        <reference value="#MedicationSig_PRN_222222"/>
                    </text>
                    <consumable>
                        <manufacturedProduct>
                            <manufacturedLabeledDrug nullFlavor="NA"/>
                        </manufacturedProduct>
                    </consumable>
                </substanceAdministration>
            </entryRelationship>			
            <precondition typeCode="PRCN">
                <criterion>
                    <!-- ** Precondition for substance administration (V2) -->
                    <templateId root="2.16.840.1.113883.10.20.22.4.25" extension="2014-06-09"/>
                    <templateId root="2.16.840.1.113883.10.20.22.4.25"/>
                    <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
                    <!-- joint pain -->
                    <value xsi:type="CD" code="57676002" codeSystem="2.16.840.1.113883.6.96" displayName="Joint pain" />
                </criterion>
            </precondition>
        </substanceAdministration>
    </entry>
    
    <!-- Instructions; similar to above but NOT a PRN - Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours with food -->
    <entry>
        <substanceAdministration classCode="SBADM" moodCode="EVN">
            <templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>					
            <templateId root="2.16.840.1.113883.10.20.22.4.16"/>
            <id extension="200035" root="1.3.6.1.4.1.22812.3.99930.3.4.9"/>
            <id extension="200013" root="1.3.6.1.4.1.22812.3.99930.3.4.9"/>
            <text>
                <reference value="#Medication_42424242"/>
            </text>
            <statusCode code="active"/>
            <effectiveTime xsi:type="IVL_TS">
                <low value="20130310"/>
                <high nullFlavor="NI"/>
            </effectiveTime>
            <!-- for the frequency of every 6 hours, we omit the institutionSpecified="false" attribute as false is the default value 
				the reader is referred to the Frequency examples for more information.
			-->			
            <effectiveTime xsi:type="PIVL_TS" operator="A">
                <period value="6" unit="h"/>
            </effectiveTime>
            <doseQuantity value="1"/>
            <consumable typeCode="CSM">
                <manufacturedProduct classCode="MANU">
                    <templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/>
                    <templateId root="2.16.840.1.113883.10.20.22.4.23"/>
                    <manufacturedMaterial>
                        <code code="197806" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="ibuprofen 600 MG Oral Tablet">
                            <originalText>
                                <reference value="#MedicationName_42424242"/>
                            </originalText>
                            <translation code="00603402221" codeSystem="2.16.840.1.113883.6.69" codeSystemName="NDC" displayName="Ibuprofen 600mg Oral Tablet"/>
                        </code>
                        <name>Ibuprofen</name>
                    </manufacturedMaterial>
                </manufacturedProduct>
            </consumable>
            <entryRelationship typeCode="COMP">
                <!-- Medication Free Text SIG -->
                <substanceAdministration classCode="SBADM" moodCode="INT">
                    <templateId root="2.16.840.1.113883.10.20.22.4.147"/>
                    <code code="76662-6" codeSystem="2.16.840.1.113883.6.1"/>
                    <text>
                        <reference value="#MedicationSig_42424242"/>
                    </text>
                    <consumable>
                        <manufacturedProduct>
                            <manufacturedLabeledDrug nullFlavor="NA"/>
                        </manufacturedProduct>
                    </consumable>
                </substanceAdministration>
            </entryRelationship>						
            <!-- Instructions 
				Additional Note: careful consideration should be given as to whether or not an instruction is actually a precondition. Note also that including both a precondition and an instruction may be appropriate.
			-->
            <entryRelationship typeCode="SUBJ" inversionInd="true">
                <act classCode="ACT" moodCode="INT">
                    <!-- Instruction (V2) -->
                    <templateId root="2.16.840.1.113883.10.20.22.4.20" extension="2014-06-09"/>
                    <templateId root="2.16.840.1.113883.10.20.22.4.20"/>
                    <code code="422037009" displayName="Provider medication administration instructions" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
                    <text>
                        <reference value="#MedicationInstruction_42424242"/>
                    </text>
                    <statusCode code="completed"/>
                </act>
            </entryRelationship>
        </substanceAdministration>
    </entry>
    
    
    <!-- Indication; again, NOT a PRN - Ibuprofen 600mg Oral Tablet, 1 tablet Every 6 Hours for joint pain
				as if "for" was written as "because of", so coded with an indication, not precondition -->
    <entry>
        <substanceAdministration classCode="SBADM" moodCode="EVN">
            <templateId root="2.16.840.1.113883.10.20.22.4.16" extension="2014-06-09"/>			
            <templateId root="2.16.840.1.113883.10.20.22.4.16"/>
            <id extension="500035" root="1.3.6.1.4.1.22812.3.99930.3.4.9"/>
            <id extension="500013" root="1.3.6.1.4.1.22812.3.99930.3.4.9"/>
            <text>
                <reference value="#Medication_84838281"/>
            </text>
            <statusCode code="active"/>
            <effectiveTime xsi:type="IVL_TS">
                <low value="20130310"/>
                <high nullFlavor="NI"/>
            </effectiveTime>
            <!-- for the frequency of every 6 hours, we omit the institutionSpecified="false" attribute as false is the default value 
				the reader is referred to the Frequency examples for more information.
			-->
            <effectiveTime xsi:type="PIVL_TS" operator="A">
                <period value="6" unit="h"/>
            </effectiveTime>
            <doseQuantity value="1"/>
            <consumable typeCode="CSM">
                <manufacturedProduct classCode="MANU">
                    <templateId root="2.16.840.1.113883.10.20.22.4.23" extension="2014-06-09"/>
                    <templateId root="2.16.840.1.113883.10.20.22.4.23"/>
                    <manufacturedMaterial>
                        <code code="197806" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm" displayName="ibuprofen 600 MG Oral Tablet">
                            <originalText>
                                <reference value="#MedicationName_84838281"/>
                            </originalText>
                            <translation code="00603402221" codeSystem="2.16.840.1.113883.6.69" codeSystemName="NDC" displayName="Ibuprofen 600mg Oral Tablet"/>
                        </code>
                        <name>Ibuprofen</name>
                    </manufacturedMaterial>
                </manufacturedProduct>
            </consumable>
            <entryRelationship typeCode="COMP">
                <!-- Medication Free Text SIG -->
                <substanceAdministration classCode="SBADM" moodCode="INT">
                    <templateId root="2.16.840.1.113883.10.20.22.4.147"/>
                    <code code="76662-6" codeSystem="2.16.840.1.113883.6.1"/>
                    <text>
                        <reference value="#MedicationSig_84838281"/>
                    </text>
                    <consumable>
                        <manufacturedProduct>
                            <manufacturedLabeledDrug nullFlavor="NA"/>
                        </manufacturedProduct>
                    </consumable>
                </substanceAdministration>
            </entryRelationship>								
            <!-- a problem indication of joint pain -->
            <entryRelationship typeCode="RSON">
                <observation classCode="OBS" moodCode="EVN">
                    <!-- Indication (V2) -->
                    <templateId root="2.16.840.1.113883.10.20.22.4.19" extension="2014-06-09"/>
                    <templateId root="2.16.840.1.113883.10.20.22.4.19"/>					
                    <id extension="44" root="1.3.6.1.4.1.22812.3.99930.3.4.1.3"/>
                    <code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="404684003" displayName="Clinical finding"/>
                    <text>
                        <reference value="#MedicationIndication_84838281"/>
                    </text>
                    <statusCode code="completed"/>
                    <effectiveTime>
                        <low nullFlavor="NI"/>
                    </effectiveTime>
                    <value xsi:type="CD" code="57676002" codeSystem="2.16.840.1.113883.6.96" displayName="Joint pain" />
                </observation>
            </entryRelationship>
        </substanceAdministration>
    </entry>
</section>

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