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Medications Section

[Section: templateId 1.3.6.1.4.1.19376.1.5.3.1.3.19]

The medications section shall contain a description of the relevant medications for the patient, e.g. an ambulatory prescription list. It shall include entries for medications as described in the Entry Content Module.

  1. SHALL conform to CCD Medications Section template (templateId: 2.16.840.1.113883.10.20.1.8)
  2. SHALL contain at least one [1..*] entry, such that
    1. Contains exactly one [1..1] Medication (templateId: 1.3.6.1.4.1.19376.1.5.3.1.4.7)
  3. SHALL satisfy: Contains one dosing template to identify this as a particular type of medication event. Possible dosing templates: 1.3.6.1.4.1.19376.1.5.3.1.4.7.1 Normal Dosing, 1.3.6.1.4.1.19376.1.5.3.1.4.8, Tapered Dosing, 1.3.6.1.4.1.19376.1.5.3.1.4.9 Split Dosing, 1.3.6.1.4.1.19376.1.5.3.1.4.10 Conditional Dosing, 1.3.6.1.4.1.19376.1.5.3.1.4.11 Combination Dosing.
    • There are a variety of special cases for dosing that need to be accounted for. Most of these special cases involve changing the dosage or frequency over time, or based on some measurement. When the dosage changes, then additional entries are required for each differing dosage.
  4. MAY satisfy: contains one or more related components (<entryRelationship typeCode='COMP'>, either to handle split, tapered or conditional dosing, or to support combination medications.
    • n the first three cases, the subordinate components shall specify only the changed <frequency> and/or <doseAmount> elements. For conditional dosing, each subordinate component shall have a <precondition> element that specifies the <observation> that must be obtained before administration of the dose. The value of the <sequenceNumber> shall be an ordinal number, starting at 1 for the first component, and increasing by 1 for each subsequent component. Components shall be sent in <sequenceNumber> order.

Medications Section example

<?xml version="1.0" encoding="UTF-8"?>
<section xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3" xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd">
  <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"/>
  <id root="1683089960"/>
  <code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of medication use"/>
  <title/>
  <text/>
</section>