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draft Template  Medikation

Id 1.2.276.0.76.3.1.261.1.10.4.6 Gültigkeit 2018‑02‑06 09:09:31
Status draft Entwurf Versions-Label
Name MedicationStatement Bezeichnung Medikation
Beschreibung Medikations-Eintrag (Medication Statement)
Kontext Elternknoten des Template-Element mit Id 1.2.276.0.76.3.1.261.1.10.4.6
Label medspmp
Klassifikation CDA Entry Level Template
Offen/Geschlossen Offen (auch andere als die definierten Elemente sind erlaubt)
Assoziiert mit
Assoziiert mit 2 Konzepte
Id Name Datensatz
dguvbbr-dataelement2-564 draft Arzneimittel/Wirkstoff/Rezeptur draft Stationärer Entlassungsbericht
dguvbbr-dataelement2-591 draft Art der Anwendung draft Stationärer Entlassungsbericht
Benutzt von / Benutzt
Benutzt von 1 Transaction und 2 Templates, Benutzt 4 Templates
Benutzt von als Name Version
dguvbbr-transaction-4 Transaktion draft Stationären Entlassungsbericht erzeugen 2018‑05‑25
1.2.276.0.76.3.1.261.1.10.3.3 Containment draft Aktuelle Medikation 2018‑02‑06 08:53:09
1.2.276.0.76.3.1.261.1.10.1.2 link draft Stationärer Entlassungsbericht 2018‑08‑24 09:48:53
Benutzt als Name Version
1.2.276.0.76.10.90023 Inklusion draft Einnahmedauer DYNAMIC
1.2.276.0.76.10.4025 Containment draft Medikament DYNAMIC
1.2.276.0.76.10.4023 Containment draft Einzeldosierungen (mpp 2018) DYNAMIC
1.2.276.0.76.10.4024 Containment draft Dosierung Freitext DYNAMIC
Beziehung Spezialisierung: Template 1.2.276.0.76.10.4022 Medikation (2017‑06‑04)
ref
pmp-

Spezialisierung: Template 2.16.840.1.113883.10.12.308 CDA SubstanceAdministration (2005‑09‑07)
ref
ad1bbr-
Beispiel
Beispiel
<hl7:substanceAdministration>
  <hl7:templateId root="1.2.276.0.76.3.1.261.1.10.4.6"/>  <hl7:id root="1.2.3.999" extension="--example only--"/>  <hl7:code code="DRUG" codeSystem="2.16.840.1.113883.5.4"/>  <hl7:text>
    <hl7:reference value="#med-1"/>  </hl7:text>  <hl7:statusCode code="active"/>  <hl7:routeCode code="20001000" codeSystem="0.4.0.127.0.16.1.1.2.1" displayName="Auricular use"/>  <hl7:consumable>
    <!-- template 1.2.276.0.76.3.1.261.1.10.4.7 'Medikament' (2018-02-06T08:59:15) -->
  </hl7:consumable>  <hl7:entryRelationship>
    <hl7:sequenceNumber value="1"/>    <!-- template 1.2.276.0.76.10.4023 'Einzeldosierungen' (2017-06-04T00:00:00) -->
  </hl7:entryRelationship>  <hl7:entryRelationship>
    <hl7:sequenceNumber value="1"/>    <!-- template 1.2.276.0.76.10.4024 'Dosierung Freitext' (2014-11-01T00:00:00) -->
  </hl7:entryRelationship></hl7:substanceAdministration>
Beispiel
Full example (auto-generated)
<hl7:substanceAdministration classCode="SBADM" moodCode="EVN">
  <hl7:templateId root="1.2.276.0.76.3.1.261.1.10.4.6"/>  <hl7:id root="1.2.3.999" extension="--example only--"/>  <hl7:code code="DRUG" codeSystem="2.16.840.1.113883.5.4"/>  <hl7:text>
    <hl7:reference value="--TODO--"/>  </hl7:text>  <hl7:statusCode code="completed"/>  <!-- include template 1.2.276.0.76.10.90023 'Einnahmedauer' (2017-06-04T00:00:00) 0..1 R -->
  <__CHOICE__ min="0" max="1">
    <!--start choice particle-->
    <hl7:effectiveTime xsi:type="IVL_TS">
      <hl7:low value="20210115"/>      <hl7:high value="20210115"/>    </hl7:effectiveTime>    <!--end choice particle-->
    <!--start choice particle-->
    <hl7:effectiveTime>
      <hl7:width unit="d" value="1"/>    </hl7:effectiveTime>    <!--end choice particle-->
    <!--start choice particle-->
    <hl7:effectiveTime nullFlavor="NI" value="20210115081149"/>    <!--end choice particle-->
  </__CHOICE__>  <hl7:routeCode code="20001000" codeSystem="0.4.0.127.0.16.1.1.2.1" displayName="Auricular use"/>  <hl7:consumable>
    <hl7:manufacturedProduct classCode="MANU">
      <hl7:templateId root="1.2.276.0.76.10.4025"/>      <!-- include template 1.2.276.0.76.10.90022 'Material' (2018-12-04T00:00:00) 1..1 M -->
      <hl7:manufacturedMaterial classCode="MMAT" determinerCode="KIND">
        <hl7:code nullFlavor="NA" code="--code--" codeSystem="1.2.276.0.76.4.6">
          <hl7:originalText>
            <hl7:reference value="--TODO--"/>          </hl7:originalText>          <hl7:translation/>        </hl7:code>        <hl7:name nullFlavor="NA">name</hl7:name>        <formCode code="10101000" codeSystem="0.4.0.127.0.16.1.1.2.1" displayName="Oral drops, solution">
          <hl7:translation code="AEO" codeSystem="1.2.276.0.76.3.1.1.5.2.40" displayName="Öl"/>        </formCode>        <asContent classCode="CONT">
          <containerPackagedProduct classCode="CONT" determinerCode="INSTANCE">
            <code code="--code--" codeSystem="1.2.276.0.76.4.6">
              <hl7:originalText/>            </code>            <name>name</name>            <formCode/>            <capacityQuantity value="1"/>          </containerPackagedProduct>        </asContent>        <asSpecializedKind classCode="GRIC">
          <generalizedMaterialKind classCode="MMAT">
            <hl7:code/>            <hl7:name>name</hl7:name>          </generalizedMaterialKind>        </asSpecializedKind>        <ingredient classCode="ACTI">
          <quantity>
            <hl7:numerator value="1">
              <hl7:translation code="#" codeSystem="1.2.276.0.76.3.1.1.5.2.41" displayName="Messlöffel"/>            </hl7:numerator>            <hl7:denominator value="1"/>          </quantity>          <ingredientSubstance>
            <code code="--code--" codeSystem="2.16.840.1.113883.6.73">
              <hl7:originalText/>              <hl7:translation/>            </code>            <name>name</name>          </ingredientSubstance>        </ingredient>      </hl7:manufacturedMaterial>    </hl7:manufacturedProduct>    <!-- template 1.2.276.0.76.10.4025 'Medikament' (2017-06-04T00:00:00) -->
  </hl7:consumable>  <hl7:entryRelationship typeCode="COMP">
    <hl7:sequenceNumber value="1"/>    <hl7:substanceAdministration classCode="SBADM" moodCode="EVN">
      <hl7:templateId root="1.2.276.0.76.10.4023"/>      <hl7:text>
        <hl7:reference value="--TODO--"/>      </hl7:text>      <__CHOICE__ max="1">
        <!--start choice particle-->
        <hl7:effectiveTime value="20210115081149"/>        <!--end choice particle-->
        <!--start choice particle-->
        <hl7:effectiveTime>
          <hl7:event code="AC"/>          <hl7:offset unit="d">
            <hl7:low value="1"/>          </hl7:offset>        </hl7:effectiveTime>        <!--end choice particle-->
        <!--start choice particle-->
        <hl7:effectiveTime>
          <hl7:phase>
            <hl7:low value="20210115081149"/>          </hl7:phase>          <hl7:period unit="d" value="1"/>        </hl7:effectiveTime>        <!--end choice particle-->
        <!--start choice particle-->
        <hl7:effectiveTime>
          <hl7:comp>
            <hl7:phase>
              <hl7:low value="20210115081149"/>            </hl7:phase>            <hl7:period unit="d" value="1"/>          </hl7:comp>          <hl7:comp operator="A">
            <hl7:event code="AC"/>            <hl7:offset unit="d">
              <hl7:low value="1"/>            </hl7:offset>          </hl7:comp>        </hl7:effectiveTime>        <!--end choice particle-->
        <!--start choice particle-->
        <hl7:effectiveTime>
          <hl7:comp>
            <hl7:low value="20210115081149"/>          </hl7:comp>          <hl7:comp operator="A">
            <hl7:event code="AC"/>            <hl7:offset unit="d">
              <hl7:low value="1"/>            </hl7:offset>          </hl7:comp>        </hl7:effectiveTime>        <!--end choice particle-->
      </__CHOICE__>      <hl7:doseQuantity>
        <hl7:translation code="#" codeSystem="2.16.840.1.113883.2.6.60.4.5.4" displayName="Messlöffel"/>      </hl7:doseQuantity>      <hl7:consumable>
        <hl7:manufacturedProduct>
          <hl7:manufacturedMaterial nullFlavor="NA"/>        </hl7:manufacturedProduct>      </hl7:consumable>      <!-- include template 1.2.276.0.76.10.90028 'Medikation Vorbedingung' (2017-06-04T00:00:00) 0..1 R -->
      <hl7:precondition typeCode="PRCN">
        <hl7:criterion classCode="OBS" moodCode="EVN.CRT">
          <hl7:code code="PRN" codeSystem="2.16.840.1.113883.5.4" displayName="bei Bedarf">
            <hl7:originalText/>          </hl7:code>          <hl7:text>
            <hl7:reference value="--TODO--"/>          </hl7:text>        </hl7:criterion>      </hl7:precondition>    </hl7:substanceAdministration>    <!-- template 1.2.276.0.76.10.4023 'Einzeldosierungen' (2018-11-01T00:00:00) -->
  </hl7:entryRelationship>  <hl7:entryRelationship typeCode="COMP">
    <hl7:sequenceNumber value="1"/>    <hl7:substanceAdministration classCode="SBADM" moodCode="EVN">
      <hl7:templateId root="1.2.276.0.76.10.4024"/>      <hl7:text>
        <hl7:reference value="--TODO--"/>      </hl7:text>      <hl7:consumable>
        <hl7:manufacturedProduct>
          <hl7:manufacturedMaterial nullFlavor="NA"/>        </hl7:manufacturedProduct>      </hl7:consumable>    </hl7:substanceAdministration>    <!-- template 1.2.276.0.76.10.4024 'Dosierung Freitext' (2014-11-01T00:00:00) -->
  </hl7:entryRelationship></hl7:substanceAdministration>
Beispiel
Beispiel
<hl7:substanceAdministration classCode="SBADM" moodCode="EVN">
  <hl7:templateId root="1.2.276.0.76.3.1.261.1.10.4.6"/>  <hl7:id root="1.2.3.999" extension="--example only--"/>  <hl7:code code="DRUG" codeSystem="2.16.840.1.113883.5.4"/>  <hl7:text>
    <hl7:reference value="--TODO--"/>  </hl7:text>  <hl7:statusCode code="completed"/>  <!-- include template 1.2.276.0.76.10.90023 'Einnahmedauer' (2017-06-04T00:00:00) 0..1 R -->
  <__CHOICE__ min="0" max="1">
    <!--start choice particle-->
    <hl7:effectiveTime xsi:type="IVL_TS">
      <hl7:low value="20210115"/>      <hl7:high value="20210115"/>    </hl7:effectiveTime>    <!--end choice particle-->
    <!--start choice particle-->
    <hl7:effectiveTime>
      <hl7:width unit="d" value="1"/>    </hl7:effectiveTime>    <!--end choice particle-->
    <!--start choice particle-->
    <hl7:effectiveTime nullFlavor="NI" value="20210115081003"/>    <!--end choice particle-->
  </__CHOICE__>  <hl7:routeCode code="20001000" codeSystem="0.4.0.127.0.16.1.1.2.1" displayName="Auricular use"/>  <hl7:consumable>
    <hl7:manufacturedProduct classCode="MANU">
      <hl7:templateId root="1.2.276.0.76.10.4025"/>      <!-- include template 1.2.276.0.76.10.90022 'Material' (2018-12-04T00:00:00) 1..1 M -->
      <hl7:manufacturedMaterial classCode="MMAT" determinerCode="KIND">
        <hl7:code nullFlavor="NA" code="--code--" codeSystem="1.2.276.0.76.4.6">
          <hl7:originalText>
            <hl7:reference value="--TODO--"/>          </hl7:originalText>          <hl7:translation/>        </hl7:code>        <hl7:name nullFlavor="NA">name</hl7:name>        <formCode code="10101000" codeSystem="0.4.0.127.0.16.1.1.2.1" displayName="Oral drops, solution">
          <hl7:translation code="AEO" codeSystem="1.2.276.0.76.3.1.1.5.2.40" displayName="Öl"/>        </formCode>        <asContent classCode="CONT">
          <containerPackagedProduct classCode="CONT" determinerCode="INSTANCE">
            <code code="--code--" codeSystem="1.2.276.0.76.4.6">
              <hl7:originalText/>            </code>            <name>name</name>            <formCode/>            <capacityQuantity value="1"/>          </containerPackagedProduct>        </asContent>        <asSpecializedKind classCode="GRIC">
          <generalizedMaterialKind classCode="MMAT">
            <hl7:code/>            <hl7:name>name</hl7:name>          </generalizedMaterialKind>        </asSpecializedKind>        <ingredient classCode="ACTI">
          <quantity>
            <hl7:numerator value="1">
              <hl7:translation code="#" codeSystem="1.2.276.0.76.3.1.1.5.2.41" displayName="Messlöffel"/>            </hl7:numerator>            <hl7:denominator value="1"/>          </quantity>          <ingredientSubstance>
            <code code="--code--" codeSystem="2.16.840.1.113883.6.73">
              <hl7:originalText/>              <hl7:translation/>            </code>            <name>name</name>          </ingredientSubstance>        </ingredient>      </hl7:manufacturedMaterial>    </hl7:manufacturedProduct>    <!-- template 1.2.276.0.76.10.4025 'Medikament' (2017-06-04T00:00:00) -->
  </hl7:consumable>  <hl7:entryRelationship typeCode="COMP">
    <hl7:sequenceNumber value="1"/>    <hl7:substanceAdministration classCode="SBADM" moodCode="EVN">
      <hl7:templateId root="1.2.276.0.76.10.4023"/>      <hl7:text>
        <hl7:reference value="--TODO--"/>      </hl7:text>      <__CHOICE__ max="1">
        <!--start choice particle-->
        <hl7:effectiveTime value="20210115081003"/>        <!--end choice particle-->
        <!--start choice particle-->
        <hl7:effectiveTime>
          <hl7:event code="AC"/>          <hl7:offset unit="d">
            <hl7:low value="1"/>          </hl7:offset>        </hl7:effectiveTime>        <!--end choice particle-->
        <!--start choice particle-->
        <hl7:effectiveTime>
          <hl7:phase>
            <hl7:low value="20210115081003"/>          </hl7:phase>          <hl7:period unit="d" value="1"/>        </hl7:effectiveTime>        <!--end choice particle-->
        <!--start choice particle-->
        <hl7:effectiveTime>
          <hl7:comp>
            <hl7:phase>
              <hl7:low value="20210115081003"/>            </hl7:phase>            <hl7:period unit="d" value="1"/>          </hl7:comp>          <hl7:comp operator="A">
            <hl7:event code="AC"/>            <hl7:offset unit="d">
              <hl7:low value="1"/>            </hl7:offset>          </hl7:comp>        </hl7:effectiveTime>        <!--end choice particle-->
        <!--start choice particle-->
        <hl7:effectiveTime>
          <hl7:comp>
            <hl7:low value="20210115081003"/>          </hl7:comp>          <hl7:comp operator="A">
            <hl7:event code="AC"/>            <hl7:offset unit="d">
              <hl7:low value="1"/>            </hl7:offset>          </hl7:comp>        </hl7:effectiveTime>        <!--end choice particle-->
      </__CHOICE__>      <hl7:doseQuantity>
        <hl7:translation code="#" codeSystem="2.16.840.1.113883.2.6.60.4.5.4" displayName="Messlöffel"/>      </hl7:doseQuantity>      <hl7:consumable>
        <hl7:manufacturedProduct>
          <hl7:manufacturedMaterial nullFlavor="NA"/>        </hl7:manufacturedProduct>      </hl7:consumable>      <!-- include template 1.2.276.0.76.10.90028 'Medikation Vorbedingung' (2017-06-04T00:00:00) 0..1 R -->
      <hl7:precondition typeCode="PRCN">
        <hl7:criterion classCode="OBS" moodCode="EVN.CRT">
          <hl7:code code="PRN" codeSystem="2.16.840.1.113883.5.4" displayName="bei Bedarf">
            <hl7:originalText/>          </hl7:code>          <hl7:text>
            <hl7:reference value="--TODO--"/>          </hl7:text>        </hl7:criterion>      </hl7:precondition>    </hl7:substanceAdministration>    <!-- template 1.2.276.0.76.10.4023 'Einzeldosierungen' (2018-11-01T00:00:00) -->
  </hl7:entryRelationship>  <hl7:entryRelationship typeCode="COMP">
    <hl7:sequenceNumber value="1"/>    <hl7:substanceAdministration classCode="SBADM" moodCode="EVN">
      <hl7:templateId root="1.2.276.0.76.10.4024"/>      <hl7:text>
        <hl7:reference value="--TODO--"/>      </hl7:text>      <hl7:consumable>
        <hl7:manufacturedProduct>
          <hl7:manufacturedMaterial nullFlavor="NA"/>        </hl7:manufacturedProduct>      </hl7:consumable>    </hl7:substanceAdministration>    <!-- template 1.2.276.0.76.10.4024 'Dosierung Freitext' (2014-11-01T00:00:00) -->
  </hl7:entryRelationship></hl7:substanceAdministration>
Item DT Kard Konf Beschreibung Label
hl7:substanceAdministration
 		0 … * medspmp
@classCode
 		cs 1 … 1 F SBADM
@moodCode
 		cs 1 … 1 F EVN
hl7:templateId
 		II 1 … 1 M medspmp
@root
 		uid 1 … 1 F 1.2.276.0.76.3.1.261.1.10.4.6
hl7:id
 		II 0 … * R medspmp
hl7:code
 		CV 1 … 1 M medspmp
@code
 		CONF 1 … 1 F DRUG
@codeSystem
 		1 … 1 F 2.16.840.1.113883.5.4 (Act Code)
hl7:text
 		ED 1 … 1 M medspmp
hl7:reference
 		TEL 1 … 1 M medspmp
@value
 		1 … 1 R #med-{generierteID}, z.B.: #med-1
hl7:statusCode
 		CS 1 … 1 R medspmp
  CONF
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.2.6.60.4.11.25 ActStatusActiveCompletedAbortedSuspended (DYNAMIC)
Eingefügt 0 … 1 R von 1.2.276.0.76.10.90023 Einnahmedauer (DYNAMIC)
Auswahl 0 … 1 Elemente in der Auswahl:
  • hl7:effectiveTime[hl7:low|hl7:high]
  • hl7:effectiveTime[hl7:width]
  • hl7:effectiveTime[@nullFlavor='NI']
hl7:effectiveTime
 		IVL_TS  … 1 C Zeitelement zur Dokumentation der Einnahmedauer, hier spezifisches Interval von bis medspmp
wo [hl7:lowoder
hl7:high]
@xsi:type
 		0 … 1 F IVL_TS
  Beispiel
Intervall bekannt
<effectiveTime xsi:type="IVL_TS">
  <low value="20130321"/>  <high value="20140321"/></effectiveTime>
  Beispiel
unbekanntes Ende-Datum
<effectiveTime xsi:type="IVL_TS">
  <low value="20130321"/>  <high nullFlavor="UNK"/></effectiveTime>
  Beispiel
Dauermedikation
<effectiveTime xsi:type="IVL_TS">
  <low value="20130321"/>  <high nullFlavor="NA"/></effectiveTime>
hl7:low
 		TS.DATE.MIN 1 … 1 R medspmp
 
target
dguvbbr-dataelement2-579 draft Startdatum Einnahme draft Stationärer Entlassungsbericht
hl7:high
 		TS.DATE.MIN 0 … 1 R medspmp
 
target
dguvbbr-dataelement2-580 draft Enddatum Einnahme draft Stationärer Entlassungsbericht
hl7:effectiveTime
 		IVL_TS  … 1 C Zeitelement zur Dokumentation der Einnahmedauer, hier Dauer medspmp
wo [hl7:width]
  Beispiel
Einnahme für zwei Wochen
<effectiveTime xsi:type="IVL_TS">
  <width value="2" unit="wk"/></effectiveTime>
hl7:width
 		PQ 1 … 1 R medspmp
 
target
dguvbbr-dataelement2-581 draft Dauer der Einnahme draft Stationärer Entlassungsbericht
@unit
 		cs 1 … 1 R
  CONF
Der Wert von @unit muss gewählt werden aus dem Value Set 1.2.276.0.76.11.452 Zeiteinheiten (UCUM) (DYNAMIC)
hl7:effectiveTime
 		TS  … 1 C medspmp
wo [@nullFlavor='NI']
@nullFlavor
 		cs 1 … 1 F NI
  Beispiel
Keine Informationen über die Einnahmedauer
<effectiveTime nullFlavor="NI"/>
hl7:routeCode
 		CE 0 … 1 R Art der Anwendung der Arznei medspmp
 
target
dguvbbr-dataelement2-591 draft Art der Anwendung draft Stationärer Entlassungsbericht
  CONF
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.2.6.60.4.11.26 EDQMRouteofAdministration (DYNAMIC)
hl7:consumable
 		1 … 1 M Arzneimittel/Wirkstoff/Rezeptur
Beinhaltet 1.2.276.0.76.10.4025 Medikament (DYNAMIC) 		medspmp
 
target
dguvbbr-dataelement2-564 draft Arzneimittel/Wirkstoff/Rezeptur draft Stationärer Entlassungsbericht
hl7:entryRelationship
 		0 … 5 R Einnahme: morgens, mittags, abends, zur Nacht
Beinhaltet 1.2.276.0.76.10.4023 Einzeldosierungen (DYNAMIC) 		medspmp
@typeCode
 		cs 1 … 1 F COMP
hl7:sequenceNumber
 		INT.POS 0 … 1 Reihenfolge in der Liste der Dosierungsangaben medspmp
hl7:entryRelationship
 		0 … 1 R Freitextliche Dosierinstruktionen
Beinhaltet 1.2.276.0.76.10.4024 Dosierung Freitext (DYNAMIC) 		medspmp
@typeCode
 		cs 1 … 1 F COMP
hl7:sequenceNumber
 		INT.POS 0 … 1 Reihenfolge in der Liste der Dosierungsangaben medspmp