TEMPLATE Consumer Entered Notes (545b62ec-7891-4d0e-bb37-998154901efa)

TEMPLATE ID545b62ec-7891-4d0e-bb37-998154901efa
ConceptConsumer Entered Notes
DescriptionThe aim of Consumer Entered Notes is to record healthcare narratives about a subject of care withinthe PCEHR system (as described in the PCEHR Concept of Operations document). These narrativesare entered by the subject of care or a non-clinical agent who is allowed to act on their behalf.
UseConsumer Entered Notes is provided as a memory aid for the subject of care and their authorised non-clinical agent. The Consumer Entered Notes are not visible to the healthcare providers within the PCEHRsystem.
MisuseUsing to record clinician notes.
PurposeThe aim of Consumer Entered Notes is to record healthcare narratives about a subject of care withinthe PCEHR system (as described in the PCEHR Concept of Operations document). These narrativesare entered by the subject of care or a non-clinical agent who is allowed to act on their behalf.
References
AuthorsOrganisation: Nehta; Authored date: 2011-12-19
Other Details LanguageOrganisation: Nehta; Authored date: 2011-12-19
OtherDetails Language Independent{Publication Version=Publication Version, Publication ID=Publication ID, MetaDataSet:NEHTA=MetaDataSet:NEHTA}
Language useden
Citeable Identifier1013.26.558
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.consumer_entered_notes.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1], code=at0000, itemType=COMPOSITION, level=0, text=Consumer Entered Notes, description=Narratives about the subject of care's healthcare information recorded by the subject of care or their authorised representative within the PCEHR system. This helps the subject of care or their authorised representative to keep track of the subject of care health information within the system. (PCEHR Concept of Operations document)., comment=null, uncommonOntologyItems={detail_docref=structured_documents/NEHTA-16681-Consumer_Entered_Notes-Structured_Document.xml, dc_id=16681, spec_id=151}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=COMPOSITION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=null, code=null, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=1, text=Other Context, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.participation.v3 and name/value='Subject of Care'], code=at0000, itemType=CLUSTER, level=2, text=Subject of Care, description=Identifies and describes an entity and the role it plays while partaking in a healthcare event., comment=The primary purpose of a participation within a NEHTA specification is to provide sufficient information to enable a recipient of a document to identify the participant within their own systems and not to exchange information about that participant. Nonetheless, it is recognised that it is often necessary to send information about participants, in particular, contact details, and since much of this information is often also used in the identification of participants, this model is the natural place to include it., uncommonOntologyItems={detail_docref=data_groups/NEHTA-10296-Participation-Data_Group.xml, dc_id=10296, spec_id=28}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.participation.v3 and name/value='Subject of Care']/items[at0001], code=at0001, itemType=ELEMENT, level=3, text=Participation Type, description=The categorisation of the nature of the participant's involvement in the healthcare event described by this participation., comment=It is preferred that this item be coded from the Participation Type Values Value Domain. Examples: 1. Author Originator 2. Authenticator 3. Physical Performer 4. Receiver 5. Responsible Party, uncommonOntologyItems={detail_docref=data_elements/NEHTA-10297-Participation_Type-Data_Element.xml, dc_id=10297, coding_preferred=true, value_domain_name=Participation Type Values, value_domain_dc_id=10299}, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.participation.v3 and name/value='Subject of Care']/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Role, description=The involvement or role of the participant in the related action from a healthcare perspective rather than the specific participation perspective., comment=It is preferred that this item be coded from the Role Values Value Domain. A participant is linked to an action by a participation instance, however the professional credentials of the participant may be quite different from the role the participant is playing. A common example is interns and residents performing anesthesia or surgeries under (more or less) supervision of attending specialists. In this case, this data element (Role) should have a value of Intern , say, and the would be used to specify the nature of the participation. Examples: (In each of the following Role examples, the Participation Type could be "Recipient":) 1. Attending physician 2. Carer 3. Clinical nurse specialist 4. Dietician 5. General practitioner 6. Performing pathologist 7. Prescriber 8. Senior surgical registrar 9. Subject of care (patient), uncommonOntologyItems={detail_docref=data_elements/NEHTA-10342-Role-Data_Element.xml, dc_id=10342, coding_preferred=true, value_domain_name=Role Values, value_domain_dc_id=16269}, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.participation.v3 and name/value='Subject of Care']/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Participation Period, description=The time interval during which the participation in the health care event occurred., comment=A participation period is needed when the participant's involvement in the healthcare event spans only part of the event's period. This means that the participation period indicates the time period during which certain common sub-activities occur that may not be worth recording explicitly, but which are implicitly modelled by the participation type. Although this data element is optional, in most contexts, it will be further constrained to either be disallowed or essential. For example, in a Discharge Summary: Some typical contexts where Participation Period is essential are: The period of time during which a doctor was responsible for a patient during a healthcare event. The end of the participation period of a Document Author participation is the time associated with the completion of editing the content of a document. Some typical contexts where participation period is disallowed are: For a Document Recipient participation. For a Facility participation. For a Nominated Primary Healthcare Provider participation. Examples: (See:), uncommonOntologyItems={detail_docref=data_elements/NEHTA-10300-Participation_Period-Data_Element.xml, dc_id=10300}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_INTERVAL, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.participation.v3 and name/value='Subject of Care']/items[at0005], code=at0005, itemType=CLUSTER, level=3, text=Location of Participation, description=Specifies the geographic site (building, room, etc) where the participation of a healthcare event occurs., comment=LOCATION OF PARTICIPATION is not required where it is the same as the location at which the healthcare event has taken place. The location of participation may be distinctly different from the registered address/location of the Healthcare Provider Individual or Organisation. A healthcare event participation may occur in a single location (as in the cases of face-to-face healthcare consultation, ED encounter, inpatient event), or may occur over multiple locations (as in the case of telemedicine)., uncommonOntologyItems={detail_docref=data_groups/NEHTA-10343-Location_of_Participation-Data_Group.xml, dc_id=10343}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.participation.v3 and name/value='Subject of Care']/items[at0005]/items[at0006], code=at0006, itemType=ELEMENT, level=4, text=Location of Participation Type, description=Specifies the type of location where the participation in the healthcare event occurred., comment=It is preferred that this item be coded from the Location of Participation Type Values Value Domain. Examples: 1. Subject of care (patient) residence 2. Site of accident (e.g. in the event of a natural disaster, ambulance calls) 3. Healthcare facility responsible for treating the subject of care (patient) 4. Remote teleconsultation setting, uncommonOntologyItems={detail_docref=data_elements/NEHTA-10344-Location_of_Participation_Type-Data_Element.xml, dc_id=10344, coding_preferred=true, value_domain_name=Location of Participation Type Values, value_domain_dc_id=10344}, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.participation.v3 and name/value='Document Author'], code=at0000, itemType=CLUSTER, level=2, text=Document Author, description=Identifies and describes an entity and the role it plays while partaking in a healthcare event., comment=The primary purpose of a participation within a NEHTA specification is to provide sufficient information to enable a recipient of a document to identify the participant within their own systems and not to exchange information about that participant. Nonetheless, it is recognised that it is often necessary to send information about participants, in particular, contact details, and since much of this information is often also used in the identification of participants, this model is the natural place to include it., uncommonOntologyItems={detail_docref=data_groups/NEHTA-10296-Participation-Data_Group.xml, dc_id=10296, spec_id=28}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.participation.v3 and name/value='Document Author']/items[at0001], code=at0001, itemType=ELEMENT, level=3, text=Participation Type, description=The categorisation of the nature of the participant's involvement in the healthcare event described by this participation., comment=It is preferred that this item be coded from the Participation Type Values Value Domain. Examples: 1. Author Originator 2. Authenticator 3. Physical Performer 4. Receiver 5. Responsible Party, uncommonOntologyItems={detail_docref=data_elements/NEHTA-10297-Participation_Type-Data_Element.xml, dc_id=10297, coding_preferred=true, value_domain_name=Participation Type Values, value_domain_dc_id=10299}, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.participation.v3 and name/value='Document Author']/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Role, description=The involvement or role of the participant in the related action from a healthcare perspective rather than the specific participation perspective., comment=It is preferred that this item be coded from the Role Values Value Domain. A participant is linked to an action by a participation instance, however the professional credentials of the participant may be quite different from the role the participant is playing. A common example is interns and residents performing anesthesia or surgeries under (more or less) supervision of attending specialists. In this case, this data element (Role) should have a value of Intern , say, and the would be used to specify the nature of the participation. Examples: (In each of the following Role examples, the Participation Type could be "Recipient":) 1. Attending physician 2. Carer 3. Clinical nurse specialist 4. Dietician 5. General practitioner 6. Performing pathologist 7. Prescriber 8. Senior surgical registrar 9. Subject of care (patient), uncommonOntologyItems={detail_docref=data_elements/NEHTA-10342-Role-Data_Element.xml, dc_id=10342, coding_preferred=true, value_domain_name=Role Values, value_domain_dc_id=16269}, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.participation.v3 and name/value='Document Author']/items[at0003], code=at0003, itemType=ELEMENT, level=3, text=Participation Period, description=The time interval during which the participation in the health care event occurred., comment=A participation period is needed when the participant's involvement in the healthcare event spans only part of the event's period. This means that the participation period indicates the time period during which certain common sub-activities occur that may not be worth recording explicitly, but which are implicitly modelled by the participation type. Although this data element is optional, in most contexts, it will be further constrained to either be disallowed or essential. For example, in a Discharge Summary: Some typical contexts where Participation Period is essential are: The period of time during which a doctor was responsible for a patient during a healthcare event. The end of the participation period of a Document Author participation is the time associated with the completion of editing the content of a document. Some typical contexts where participation period is disallowed are: For a Document Recipient participation. For a Facility participation. For a Nominated Primary Healthcare Provider participation. Examples: (See:), uncommonOntologyItems={detail_docref=data_elements/NEHTA-10300-Participation_Period-Data_Element.xml, dc_id=10300}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_INTERVAL, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.participation.v3 and name/value='Document Author']/items[at0005], code=at0005, itemType=CLUSTER, level=3, text=Location of Participation, description=Specifies the geographic site (building, room, etc) where the participation of a healthcare event occurs., comment=LOCATION OF PARTICIPATION is not required where it is the same as the location at which the healthcare event has taken place. The location of participation may be distinctly different from the registered address/location of the Healthcare Provider Individual or Organisation. A healthcare event participation may occur in a single location (as in the cases of face-to-face healthcare consultation, ED encounter, inpatient event), or may occur over multiple locations (as in the case of telemedicine)., uncommonOntologyItems={detail_docref=data_groups/NEHTA-10343-Location_of_Participation-Data_Group.xml, dc_id=10343}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.participation.v3 and name/value='Document Author']/items[at0005]/items[at0006], code=at0006, itemType=ELEMENT, level=4, text=Location of Participation Type, description=Specifies the type of location where the participation in the healthcare event occurred., comment=It is preferred that this item be coded from the Location of Participation Type Values Value Domain. Examples: 1. Subject of care (patient) residence 2. Site of accident (e.g. in the event of a natural disaster, ambulance calls) 3. Healthcare facility responsible for treating the subject of care (patient) 4. Remote teleconsultation setting, uncommonOntologyItems={detail_docref=data_elements/NEHTA-10344-Location_of_Participation_Type-Data_Element.xml, dc_id=10344, coding_preferred=true, value_domain_name=Location of Participation Type Values, value_domain_dc_id=10344}, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/context/other_context[at0001]/items[at0008], code=at0008, itemType=ELEMENT, level=2, text=DateTime Authored, description=The date or date and time that authoring of the Consumer Entered Notes by thesubject of care or their authorised representative is completed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/content[openEHR-EHR-SECTION.clinical_synposes.v1], code=at0000, itemType=SECTION, level=1, text=Note, description=A section that captures one or more narratives about a subject of care health and related matters as entered by the subject of care or their authorised representative., comment=null, uncommonOntologyItems={detail_docref=sections/NEHTA-16684-Clinical_Synopses-Section.xml, dc_id=16684, spec_id=152}, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/content[openEHR-EHR-SECTION.clinical_synposes.v1]/items[openEHR-EHR-EVALUATION.clinical_synopsis.v4], code=at0000, itemType=EVALUATION, level=2, text=Consumer Entered Note, description=The clinical synopsis contains summary information or comments about the clinical management of the patient, and the prognosis of diagnoses/ problems identified during the healthcare encounter. It may also include health-related information pertinent to the patient, and a clinical interpretation of relevant investigations and observations performed on the patient (including pathology and diagnostic imaging)., comment=Narrative information is captured or entered here by a healthcare provider from the focus of a healthcare provider, carer, subject of care and/or others unrelated to the subject of care., uncommonOntologyItems={detail_docref=data_groups/NEHTA-15513-Clinical_Synopsis-Data_Group.xml, spec_id=10}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/content[openEHR-EHR-SECTION.clinical_synposes.v1]/items[openEHR-EHR-EVALUATION.clinical_synopsis.v4]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/content[openEHR-EHR-SECTION.clinical_synposes.v1]/items[openEHR-EHR-EVALUATION.clinical_synopsis.v4]/data[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Consumer Note Title, description=The clinical synopsis title/topic, written in free text., comment=Topic of the clinical description about the subject of care and the health care event/encounter. The topic enables to organise the healthcare provider's description or the subject of care's interpretation of the health event/encounter. The title may be a free text intended to allow a summary title to the description of the issues/problems, management strategies, outcomes/progress and possible prognosis. Examples: 1. My Diabetes: 2. Diagnosis: 3. My Blood Pressure:, uncommonOntologyItems={detail_docref=data_elements/NEHTA-16673-Clinical_Synopsis_Topic-Data_Element.xml, dc_id=16673}, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/content[openEHR-EHR-SECTION.clinical_synposes.v1]/items[openEHR-EHR-EVALUATION.clinical_synopsis.v4]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Consumer Note Description, description=The clinical synopsis, written in free text., comment=Provides concise narrative about the subject of care and the health care event/encounter. It may include the healthcare provider's interpretation (meta-observation) and the subject of care's understanding of the health care event that complements other structured or unstructured information contents captured or communicated about the health event/encounter. The description may include a summary of the issues/problems, management strategies, outcomes/progress and possible prognosis. Examples: 1. Admitted for elective bronchoscopy for assessment of left lingular and bibasal pneumonia. No focal endobronchial pathology identified. No evidence of malignancy and no pathogens isolated on bronchial brushings and washings. 2. 3/52 ago involved in a rear end motor vehicle accident, mid-velocity impact- complaining of neck pain, dizziness, nausea and difficulties concentrating. Disturbed sleep. No spinal cord signs., uncommonOntologyItems={detail_docref=data_elements/NEHTA-15582-Clinical_Synopsis_Description-Data_Element.xml, dc_id=15582}, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/content[openEHR-EHR-SECTION.clinical_synposes.v1]/items[openEHR-EHR-ACTION.medication.v3], code=at0000, itemType=ACTION, level=2, text=Medication Action, description=Details of use, administration, dispensing or other care step relating to a medicine, vaccine or other therapeutic good which may arise from an instruction from a clinician., comment=The specification of each constituent data element is the same whether it is being used in the context of prescribed, dispensed, administered or reviewed. There may be seperate data instances for each of these contexts., uncommonOntologyItems={detail_docref=data_groups/NEHTA-16210-Medication_Action-Data_Group.xml, spec_id=97}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/content[openEHR-EHR-SECTION.clinical_synposes.v1]/items[openEHR-EHR-ACTION.medication.v3]/description[at0017], code=at0017, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Description, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/content[openEHR-EHR-SECTION.clinical_synposes.v1]/items[openEHR-EHR-ACTION.medication.v3]/description[at0017]/items[at0020], code=at0020, itemType=ELEMENT, level=4, text=Medicine, description=The medicine, vaccine or other therapeutic good which was the focus of the action., comment=It is preferred that this item be coded from the Medicines Terminology Value Domain. This includes medications and medical devices. It includes drugs, appliances, dressings and reagents. Identifies a therapeutic good, which is broadly defined as a good which is represented in any way to be, or is likely to be taken to be, for therapeutic use (unless specifically excluded or included under Section 7 of the Therapeutic Goods Act 1989). Therapeutic use means use in or in connection with: preventing, diagnosing, curing or alleviating a disease, ailment, defect or injury; influencing, inhibiting or modifying a physiological process; testing the susceptibility of persons to a disease or ailment; influencing, controlling or preventing conception; testing for pregnancy; or replacement or modification of parts of the anatomy. From . The formal definition of a therapeutic good (from the Therapeutic Goods Act 1989) can be found at: . Examples: (Some examples of AMT ConceptID and their AMT Preferred Term are:) 1. 293049011000036110, paracetamol 500 mg + codeine phosphate 30 mg tablet 2. 327004011000036118, paracetamol 500 mg + codeine phosphate 30 mg tablet, 20 3. 234184011000036115, Panadeine Forte tablet: uncoated, 20 tablets 4. 192727011000036112, Panadeine Forte (paracetamol 500 mg + codeine phosphate 30 mg) tablet: uncoated, 1 tablet 5. 278453011000036118, Panadeine Forte tablet: uncoated, 20 tablets, blister pack 6. 315236011000036113, bandage compression 10 cm x 3.5 m bandage: high stretch, 1 bandage 7. 186324011000036116, Eloflex (2480) (bandage compression 10 cm x 3.5 m) bandage: high stretch, 1 bandage 8. 73875011000036101, Je-Vax (Japanese encephalitis virus inactivated vaccine) injection: powder for, vial, uncommonOntologyItems={fsn=Therapeutic Good Identification, detail_docref=data_elements/NEHTA-10194-Therapeutic_Good_Identification-Data_Element.xml, coding_preferred=true, value_domain_name=Medicines Terminology, value_domain_dc_id=16115}, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/content[openEHR-EHR-SECTION.clinical_synposes.v1]/items[openEHR-EHR-ACTION.medication.v3]/description[at0017]/items[at0033], code=at0033, itemType=ELEMENT, level=4, text=Instructions to Subject of Care or Carer, description=Any instructions given to the subject of care or carer at the time of the action., comment=null, uncommonOntologyItems={fsn=Medication Action Instructions, detail_docref=data_elements/NEHTA-16491-Medication_Action_Instructions-Data_Element.xml}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/content[openEHR-EHR-SECTION.clinical_synposes.v1]/items[openEHR-EHR-ACTION.medication.v3]/description[at0017]/items[at0021], code=at0021, itemType=ELEMENT, level=4, text=Reason, description=The reason(s) the specific action or step was carried out., comment=It is preferred that this item be coded from the Reason for Action Values Value Domain. This is not the reason for the medication instruction, rather the specific reason e.g. for administration or for ceasing the medication., uncommonOntologyItems={fsn=Reason for Action, detail_docref=data_elements/NEHTA-16492-Reason_for_Action-Data_Element.xml, coding_preferred=true, value_domain_name=Reason for Action Values, value_domain_dc_id=16492}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/content[openEHR-EHR-SECTION.clinical_synposes.v1]/items[openEHR-EHR-ACTION.medication.v3]/description[at0017]/items[at0024], code=at0024, itemType=ELEMENT, level=4, text=Comment, description=A comment on the action taken., comment=null, uncommonOntologyItems={fsn=Medication Action Comment, detail_docref=data_elements/NEHTA-16181-Medication_Action_Comment-Data_Element.xml}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/content[openEHR-EHR-SECTION.clinical_synposes.v1]/items[openEHR-EHR-ACTION.medication.v3]/description[at0017]/items[at0025], code=at0025, itemType=ELEMENT, level=4, text=Sequence Number, description=The sequence number specific to the action being recorded., comment=Used to specify the sequence number of the dispensing (in prescription with repeats) or medication administration action., uncommonOntologyItems={detail_docref=data_elements/NEHTA-16424-Sequence_Number-Data_Element.xml}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/content[openEHR-EHR-SECTION.clinical_synposes.v1]/items[openEHR-EHR-ACTION.medication.v3]/description[at0017]/items[at0036], code=at0036, itemType=ELEMENT, level=4, text=Brand Substituted, description=A different brand of the same medicine, vaccine or other therapeutic good was substituted for the one nominated in the order., comment=For dispense records for medicines. Examples: (See: .), uncommonOntologyItems={fsn=Brand Substitution Occurred, detail_docref=data_elements/NEHTA-16064-Brand_Substitution_Occurred-Data_Element.xml}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/content[openEHR-EHR-SECTION.clinical_synposes.v1]/items[openEHR-EHR-ACTION.medication.v3]/protocol[at0030], code=at0030, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/content[openEHR-EHR-SECTION.clinical_synposes.v1]/items[openEHR-EHR-ACTION.medication.v3]/protocol[at0030]/items[at0026], code=at0026, itemType=ELEMENT, level=4, text=Batchid, description=Assigned by the manufacturer to identify the manufacturing batch of the item., comment=null, uncommonOntologyItems={fsn=Batch Identifier, detail_docref=data_elements/NEHTA-16273-Batch_Identifier-Data_Element.xml}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/content[openEHR-EHR-SECTION.clinical_synposes.v1]/items[openEHR-EHR-ACTION.medication.v3]/protocol[at0030]/items[at0040], code=at0040, itemType=ELEMENT, level=4, text=Date of Expiry, description=The expiry date as documented by the manufacturer., comment=null, uncommonOntologyItems={fsn=Expiry Date, detail_docref=data_elements/NEHTA-16425-Expiry_Date-Data_Element.xml}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/content[openEHR-EHR-SECTION.clinical_synposes.v1]/items[openEHR-EHR-ACTION.medication.v3]/protocol[at0030]/items[at0032], code=at0032, itemType=ELEMENT, level=4, text=Remaining Repeats, description=The number of times the medicine, vaccine or other therapeutic good may still be dispensed without re-issue of a prescription or order., comment=This is the information required by the subject of care and prescriber., uncommonOntologyItems={detail_docref=data_elements/NEHTA-16427-Remaining_Repeats-Data_Element.xml}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.consumer_entered_notes.v1]/content[openEHR-EHR-SECTION.clinical_synposes.v1]/items[openEHR-EHR-ACTION.medication.v3]/protocol[at0030]/items[at0038], code=at0038, itemType=ELEMENT, level=4, text=Claim Category, description=The category of reimbursement or subsidy sought for the item., comment=It is preferred that this item be coded from the Therapeutic Good Claim Category Reference Set Value Domain. Applicable to dispense records. The primary purpose of this data element is to enable the determination of the source of any applicable financial subsidy for the item. Not to be confused with Concession Benefit. Examples: 1. General PBS benefit 2. Safety Net Concession benefit 3. Safety Net Entitlement Card benefit, uncommonOntologyItems={detail_docref=data_elements/NEHTA-16060-Claim_Category-Data_Element.xml, coding_preferred=true, value_domain_name=Therapeutic Good Claim Category Reference Set, value_domain_dc_id=16060}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], templateType=normal]