Any medication may be the subject of further instructions to the pharmacist, for example
to indicate that it should be labeled in Spanish, et cetera. This structure is included
in the target substance administration or supply act using the <entryRelationship>
element defined in the CDA Schema. The figure below is an example of recording an
instruction for an <entry>, and is used as context for the sections to follow.
Context
Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.3.1
Classification
CDA Entry Level Template
Open/Closed
Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 8 templates, Uses 0 templates
epsos-issue-226: fix cardinality of status code (In Progress)
Item
DT
Card
Conf
Description
Label
hl7:act
(Ent…ons)
@classCode
cs
0 … 1
F
SPLY
@moodCode
cs
0 … 1
F
EVN
hl7:templateId
II.EPSOS
1 … 1
M
(CCD)
(Ent…ons)
@root
uid
1 … 1
F
2.16.840.1.113883.10.20.1.43
hl7:templateId
II.EPSOS
1 … 1
M
(IHE PCC)
(Ent…ons)
@root
uid
1 … 1
F
1.3.6.1.4.1.19376.1.5.3.1.4.3.1
hl7:code
CD.EPSOS
0 … 1
R
The <code> element indicates that this is a medication fulfilment instruction.
(Ent…ons)
@code
CONF
0 … 1
F
FINSTRUCT
@codeSystem
0 … 1
F
1.3.6.1.4.1.19376.1.5.3.2 (IHEActCode Vocabulary)
@codeSystemName
0 … 1
F
IHEActCode
hl7:text
ED
0 … 1
R
The <text> element contains a free text representation of the instruction. For CDA
this SHALL 1520 contain a <reference> element to the link text of the comment in the
narrative portion of the document. The comment itself is not the act being coded,
so it appears in the <text> of the <observation>, not as part of the <code>.
(Ent…ons)
hl7:reference
0 … 1
R
The URI given in the value attribute of the <reference> element points to an element
in the narrative content that contains the complete text describing the medication.
In a CDA document, the URI given in the value attribute of the <reference> element
points to an element in the narrative content that contains the complete text describing
the medication.
(Ent…ons)
Example
<referencevalue="#eP_as_text"/>
hl7:statusCode
CS
1 … 1
M
The code attribute of <statusCode> for all comments must be completed.