Section Code |
LOINC: 10160-0 (HISTORY OF MEDICATION USE) |
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Description |
The medications section is intended to capture the current and past medication regimen that the patient is on. It contains a narrative description of the regimen as well as structured substanceAdministrations containing the individual medications, frequency of use, start/stop time, dosage, etc. |
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CDA Level |
Level 3 Only |
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Template IDs |
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Level / Spec |
Template ID |
Standards Reference |
3 / CCD |
2.16.840.1.113883.10.20.1.8 |
CCD 3.9 |
3 / IHE |
1.3.6.1.4.1.19376.1.5.3.1.3.19 |
IHE PCC TF-2: 6.3.3.3.1 |
Expected Entries / Sub-Sections |
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Entry |
Template ID |
Reference |
Medications Entry |
2.16.840.1.113883.10.20.1.24
1.3.6.1.4.1.19376.1.5.3.1.4.7 |
3.4.2.11 |
OpenSHR Implementation Notes |
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Data Model |
Obs |
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Code File |
MedicationsSectionProcessor.java |
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Additional Constraints |
- Solicitors should use the IHE PCC template identifier when submitting a medications section. Sections with only the CCD template identifier will not be processed by the CDA import module.
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Notes |
The medications being taken or that were historically taken should be identified with appropriate substanceAdministration entries. If the patient's medication history is unknown solicitors may choose to send, and OpenSHR will send, a single substanceAdministration entry with SNOMED code 182904002 (Drug Treatment Unknown) |
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Specification |
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<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<!-- HL7 CCD Template Identifier - Medications-->
<templateId root="2.16.840.1.113883.10.20.1.8"/>
<!-- IHE PCC Template Identifier - History of Medication Use -->
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.19"/>
<!-- 1..1 Section Code-->
<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF MEDICATION USE"/>
<!-- 1..1 Title -->
<title language="en-US">...</title>
<!-- 1..1 Text (See general implementation notes for guidance) -->
<text mediaType="text/x-hl7-text+xml">
...
</text>
<!-- 0..n Substance Administration entries representing medications given -->
<entry typeCode="DRIV" contextConductionInd="true">
<substanceAdministration classCode="SBADM" moodCode="EVN">
</substanceAdministration>
</entry>
</section>
</component> |
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Example |
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This example illustrates a patient currently taking 2 puffs of Albuterol 4 times a day since July 2005, and is taking Plavix 75mg once daily. |
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<component typeCode="COMP" contextConductionInd="true">
<section classCode="DOCSECT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.8"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.19"/>
<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF MEDICATION USE"/>
<title language="en-US">History of Medication Use</title>
<text mediaType="text/x-hl7-text+xml">
...
</text>
<!-- Substance Administration for Albuterol medication-->
<entry typeCode="DRIV" contextConductionInd="true">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.24"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7"/>
<id root="1.2.3.4.5.3" extension="166"/>
<text>
<reference value="#obsc9fa5d60"/>
</text>
<statusCode code="completed"/>
<!-- Has been taken since July 2005 -->
<effectiveTime xsi:type="IVL_TS">
<low value="200507"/>
</effectiveTime>
<!-- Taken every 6 h -->
<effectiveTime xsi:type="PIVL_TS" operator="A">
<period unit="h" value="6"/>
</effectiveTime>
<!-- Route of administration - Oral -->
<routeCode code="ORNEB" codeSystem="2.16.840.1.113883.5.112" codeSystemName="2.16.840.1.113883.5.112" displayName="inhalation, nebulization, oral">
<originalText representation="TXT">inhalation, nebulization, oral</originalText>
</routeCode>
<!-- 2 Puffs per dose -->
<doseQuantity unit="puffs" value="2"/>
<!-- Identifies the manner in which the medication is administered -->
<administrationUnitCode code="421759004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Metered dose aerosol inhaler">
<originalText representation="TXT" language="en-US">
<reference value="#txt69b35fd1"/>
</originalText>
</administrationUnitCode>
<!-- Consumable representing the medication drug -->
<consumable typeCode="CSM">
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.1.53"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.2"/>
<manufacturedMaterial classCode="MMAT">
<!-- RxNORM Code representing the drug, note this may include a dose -->
<code code="307782" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNORM" displayName="Albuterol 0.09 MG/ACTUAT inhalant solution">
<originalText representation="TXT" language="en-US">
<reference value="#txt4e51a937"/>
</originalText>
</code>
<name>Albuterol 0.09 MG/ACTUAT inhalant solution</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
<!-- Another drug in the patient's regimen -->
<entry typeCode="DRIV" contextConductionInd="true">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.1.24"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7"/>
<id root="1.2.3.4.5.3" extension="173"/>
<text>
<reference value="#obs0c86d295"/>
</text>
<statusCode code="completed"/>
<!-- Still being taken, unknown start time-->
<effectiveTime xsi:type="IVL_TS">
<low nullFlavor="UNK"/>
<high nullFlavor="UNK"/>
</effectiveTime>
<!-- Once per day -->
<effectiveTime xsi:type="PIVL_TS" operator="A">
<period unit="h" value="24"/>
</effectiveTime>
<!-- Orally -->
<routeCode code="PO" codeSystem="2.16.840.1.113883.5.112" codeSystemName="2.16.840.1.113883.5.112" displayName="Oral">
<originalText representation="TXT">Oral</originalText>
</routeCode>
<!-- 75 mg dose -->
<doseQuantity unit="mg" value="75"/>
<administrationUnitCode code="421026006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Tablet dose form">
<originalText representation="TXT" language="en-US">
<reference value="#txt38ea94ec"/>
</originalText>
</administrationUnitCode>
<consumable typeCode="CSM">
<manufacturedProduct classCode="MANU">
<templateId root="2.16.840.1.113883.10.20.1.53"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.2"/>
<manufacturedMaterial classCode="MMAT">
<code code="309362" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNORM" displayName="Clopidogrel 75 MG oral tablet">
<originalText representation="TXT" language="en-US">
<reference value="#txta9fdeeb1"/>
</originalText>
<translation code="174742" codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNORM" displayName="Plavix"/>
</code>
<name>Plavix</name>
</manufacturedMaterial>
</manufacturedProduct>
</consumable>
</substanceAdministration>
</entry>
</section>
</component> |
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