Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02

The content of this release is not comprehensive and is not fully validated and must not be used in live system implementations.

ELEMENT Domain Model: MedicationTag

An ELEMENT to represent the tags or labels that can be assigned to a medication. These components do not convey clinical meanings such as findings or procedures. Their primary use is to categorise record components into common headings to enable reuse and retrieval. E.g. a branch of models concerned with a specific medication activity can be categorised as an activity involving the prescription, supply, consumption, or administration of a new, continued, changed, or recommended drug/medication. The meaning of the medication activity and its associated medicinal product, dosage details, etc. will remain unchanged irrespective of the medication tag used. However, the context in which the information is to be consumed may change depending on the medication tag used to label the medication activity.

Attributes

Name Data type Occurs Description Value Constraints
name SC 1..1 The name, expressed as a coded value or as plain text, specifies the clinical or administrative concept to which this EHR node corresponds, as labelled in the EHR system in which it was first committed.

value
Literal value(s): RECORD_ARTEFACT_ELEMENT
rc_id II 1..1 The globally-unique identifier by which this node in the EHR hierarchy is referenced in the EHR system to which the data were first committed. This identifier shall be retained by the EHR Recipient and re-used whenever this RECORD_COMPONENT is subsequently included in another EHR_EXTRACT.
meaning CD.CV.SCT 1..1 The standardised clinical or administrative concept to which the name attribute has been mapped. In archetyped systems it will correspond to the archetype node name. In non-archetyped systems it might be a coded term from an appropriate terminology system.

code
Semantic expression constraint
synthesised BL 1..1 This attribute value shall be TRUE if this RECORD_COMPONENT has been created in order to comply with this standard , but this point in the EHR hierarchy has no corresponding node in the EHR from which it was extracted.

value
Default value: false
obs_time IVL_TS 0..1 The date and time, or interval, at which the ITEM actually occurred or was true, if different from the session time of the COMPOSITION.
value ANY 1..1 An ELEMENT has a single DATA_VALUE containing the value, unless this is indicated as absent by a null_flavour attribute.

nullFlavor
Literal value(s): NA


COMPONENT RELATIONSHIPS

Object of relationships

Name Subject of relationship Occurs Dependency
HasRecordRole ProductOrSubstanceRelatedActivity 0..* INDEPENDENT

Item of ENTRY Domain Models

ProductOrSubstanceRelatedActivity

Reference Model Type

RECORD_ARTEFACT_ELEMENT