Med oral QID with PRN

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 1/9/2014

  • SDWG: 1/16/2014

  • SDWG C-CDA R2.1 Upgrade: 12/1/2016

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 which is QID and PRN (as needed) but with no precondition specified. It was generated based on SDWG list-serv discussion in December 2013. It also demonstrated a pre-coordinated generic medication coded at the SDC level (generic 600mg Oral Tablet) in RxNorm hierarchy.

Custodian

  • Brett Marquard

  • Keywords

  • medications

Permalink

Links

 

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_0">
                    <td>
                        <content ID="MedicationName_0" xmlns="urn:hl7-org:v3">Ibuprofen 600mg Oral Tablet</content>
                    </td>
                    <td>
                        <content>take 1 tablet QID PRN</content>
                    </td>
                    <td>
                        <content>600 MG</content>
                    </td>
                    <td>Dec-18-2013 - </td>
                    <td>Active</td>
                </tr>
            </tbody>
        </table>
    </text>
    <entry typeCode="DRIV">
        <substanceAdministration classCode="SBADM" moodCode="INT">
            <!-- This medication use case is a medication to be administered. If it has been already administered use moodCode = "EVN". If an 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="47d3e719-f688-459d-bcdc-47c6de0767a9"/>
            <text>
                <!-- This reference refers to medication information in unstructured portion of section-->
                <reference value="#Medication_0"/>
            </text>
            <statusCode code="active"/>
            <!-- This first effectiveTime shows that medication was added on December 18, 2013 (not known to have stopped)-->
            <effectiveTime xsi:type="IVL_TS">
                <low value="20131218"/>
                <high nullFlavor="NI"/>
            </effectiveTime>
            <!-- This second effectiveTime represents QID from medication sig. -->
            <!-- InstituionSpecified = "true" means that it can be given 4 times per day but need not be exactly timed to every 6 hours-->
            <!-- InstituionSpecified = "false" would mean that timing needs to be administered exactly as structured-->
            <!-- Operator "A" means that this timing information is in addition to previous effectiveTime information provided-->
            <effectiveTime xsi:type="PIVL_TS" institutionSpecified="true" operator="A">
                <period value="6" unit="h"/>
            </effectiveTime>
            <routeCode code="C38288" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="Oral Route of Administration"/>
            <!-- This relates directly to the code used for medication. Since it's a tablet, then only specified needed in dose is 1x per administration-->
            <doseQuantity value="1"/>
            <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-92b3-5d9815ff4ee8"/>
                    <manufacturedMaterial>
                        <!-- Medications should be specified at a level corresponding to prescription when possible, such as 600mg oral tablet (non-branded)-->
                        <code code="197806" displayName="ibuprofen 600 MG Oral Tablet" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm">
                            <originalText>
                                <reference value="#MedicationName_0"/>
                            </originalText>
                            <translation code="00603402221" codeSystem="2.16.840.1.113883.6.69"
                                codeSystemName="NDC" displayName="Ibuprofen 600mg Oral Tablet"/>
                        </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="20131218"/>
                <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="Allopathic &amp; Osteopathic Physicians; Internal Medicine, 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>
            <precondition typeCode="PRCN">
                <criterion>
                    <!-- ** Precondition for substance administration ** -->
                    <templateId root="2.16.840.1.113883.10.20.22.4.25"/>
                    <templateId root="2.16.840.1.113883.10.20.22.4.25" extension="2014-06-09"/>
                    <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"/>
                    <!-- If a precondition were specified in medication sig, you would include code here. Include nullFlavor="NI" when PRN specified but without precondition-->
                    <value xsi:type="CD" nullFlavor="NI"  />
                </criterion>
            </precondition>
        </substanceAdministration>
    </entry>
</section>

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