2.16.840.1.113883.10.21.4.7/static-2021-08-04T140915

Id	2.16.840.1.113883.10.21.4.7	Effective Date	2021‑08‑04 14:09:15 Other versions this id: UVMedicationstatement as of 2023‑01‑30 08:32:34 UVMedicationstatement as of 2017‑05‑01
Status	Under pre-publication review	Version Label	R1-STU2-ballot
Name	UVMedicationstatement	Display Name	UV Medication Statement
Description Universal Medication Statement: Recording a "medication statement" is an activity that can be performed by a variety of healthcare professionals, or the patient, or non-healthcare professionals. Examples of recording medication statements include taking a patient's medication history, recording reported use of medications where the source of the patient information is from a third party and not the patient e.g. a family member when the patient is unable to communicate their medication history.
Context	Parent nodes of template element with id 2.16.840.1.113883.10.21.4.7
Label	MedicationStatement
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Uses	Uses 11 templates Uses as Name Version 2.16.840.1.113883.10.21.9.1 Include UV Use Period (2023) DYNAMIC 2.16.840.1.113883.10.12.320 Containment CDA Subject (Body) DYNAMIC 2.16.840.1.113883.10.21.4.10 Containment UV Medication Information (simple) (R1-STU2-ballot) DYNAMIC 2.16.840.1.113883.10.21.4.11 Containment UV Medication Information (detail) (2023) DYNAMIC 2.16.840.1.113883.10.12.318 Containment CDA Author (Body) DYNAMIC 2.16.840.1.113883.10.12.153 Containment CDA AssignedEntity DYNAMIC 2.16.840.1.113883.10.12.316 Containment CDA RelatedEntity DYNAMIC 2.16.840.1.113883.10.12.321 Containment CDA Participant (Body) DYNAMIC 2.16.840.1.113883.10.21.4.6 Containment UV Subordinate Substance Administration (2023) DYNAMIC 2.16.840.1.113883.10.21.4.8 Containment UV Medication Order Reference (R1-STU2-ballot) DYNAMIC 2.16.840.1.113883.10.21.4.9 Containment UV Dispense Event Reference (R1-STU2-ballot) DYNAMIC
Relationship	Version: template 2.16.840.1.113883.10.21.4.7 UV Medication Statement (2017‑05‑01) Specialization: template 2.16.840.1.113883.10.12.308 CDA SubstanceAdministration (2005‑09‑07) ref ad1bbr-
Example	Example <substanceAdministration classCode="SBADM" moodCode="EVN">   <templateId root="2.16.840.1.113883.10.21.4.7"/>  <id root="1.2.3.99.99.99" extension="988437489739"/>  <code code="..." codeSystem="..."/>  <text>...</text>  <statusCode code="active"/>  <effectiveTime value="..."/>  <repeatNumber value="..."/>  <routeCode code="SOAK" codeSystem="2.16.840.1.113883.5.112" displayName="Immersion (soak)"/>  <approachSiteCode code="..." codeSystem="2.16.840.1.113883.5.1052"/>  <administrationUnitCode code="PUFF" displayName="Puff" codeSystem="2.16.840.1.113883.5.85"/>  <consumable typeCode="CSM">     <!-- Consumable -->   </consumable>  <participant typeCode="DEV">     <!-- Device -->   </participant>  <participant typeCode="LOC">     <!-- Location -->   </participant>  <entryRelationship typeCode="COMP">     <!-- Subordinate Substance Administrations -->   </entryRelationship>  <entryRelationship typeCode="COMP">     <!-- Annotations -->   </entryRelationship>  <precondition>     <!-- Precondition -->   </precondition></substanceAdministration>
Example	Example <substanceAdministration classCode="SBADM" moodCode="EVN">   <templateId root="2.16.840.1.113883.10.21.4.7"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="DRUG" displayName="Drug therapy" codeSystem="2.16.840.1.113883.5.4"/>  <text/>  <statusCode code="active"/>  <!-- include template 'UV Use Period' (dynamic) .. O -->   <repeatNumber/>  <routeCode code="SOAK" displayName="Immersion (soak)" codeSystem="2.16.840.1.113883.5.112"/>  <approachSiteCode code="--code--" codeSystem="2.16.840.1.113883.5.1052"/>  <administrationUnitCode code="APPFUL" displayName="Applicatorful" codeSystem="2.16.840.1.113883.5.85"/>  <subject>     <!-- template 'CDA Subject (Body)' (dynamic) -->   </subject>  <consumable typeCode="CSM">     <!-- template 2.16.840.1.113883.10.12.312 'CDA ManufacturedProduct' (dynamic) -->   </consumable>  <!-- choice: 1..1 element hl7:author element hl7:participant[@typeCode='AUT'] -->   <!-- choice: 0..1 element hl7:informant[exists(hl7:assignedEntity)] element hl7:participant[@typeCode='INF'] element hl7:informant[exists(hl7:relatedEntity)] -->   <participant typeCode="RCT">     <!-- template 2.16.840.1.113883.10.12.321 'CDA Participant (Body)' (dynamic) -->   </participant>  <participant typeCode="VRF">     <!-- template 2.16.840.1.113883.10.12.321 'CDA Participant (Body)' (dynamic) -->   </participant>  <entryRelationship typeCode="COMP">     <sequenceNumber value="1"/>    <!-- template 2.16.840.1.113883.10.21.4.6 'Subordinate Substance Administration' (dynamic) -->   </entryRelationship>  <entryRelationship typeCode="REFR">     <!-- template 2.16.840.1.113883.10.21.4.8 'UV Medication Order Reference' (dynamic) -->   </entryRelationship>  <entryRelationship typeCode="REFR">     <!-- template 2.16.840.1.113883.10.21.4.9 'UV Dispense Event Reference' (dynamic) -->   </entryRelationship></substanceAdministration>
Example	Example <substanceAdministration classCode="SBADM" moodCode="EVN">   <templateId root="2.16.840.1.113883.10.21.4.7"/>  <id root="1.2.3.99.99.99" extension="988437489739"/>  <code code="..." codeSystem="..."/>  <text>...</text>  <statusCode code="active"/>  <effectiveTime value="..."/>  <repeatNumber value="..."/>  <routeCode code="SOAK" codeSystem="2.16.840.1.113883.5.112" displayName="Immersion (soak)"/>  <approachSiteCode code="..." codeSystem="2.16.840.1.113883.5.1052"/>  <administrationUnitCode code="PUFF" displayName="Puff" codeSystem="2.16.840.1.113883.5.85"/>  <consumable typeCode="CSM">     <!-- Consumable -->   </consumable>  <participant typeCode="DEV">     <!-- Device -->   </participant>  <participant typeCode="LOC">     <!-- Location -->   </participant>  <entryRelationship typeCode="COMP">     <!-- Subordinate Substance Administrations -->   </entryRelationship>  <entryRelationship typeCode="COMP">     <!-- Annotations -->   </entryRelationship>  <precondition>     <!-- Precondition -->   </precondition></substanceAdministration>
Item DT Card Conf Description Label hl7:substanceAdministration Medi...ment @classCode cs 1 … 1 F SBADM @moodCode cs 1 … 1 R EVN will be used to record a medication statement where the patient is currently taking or has taken the medication in the past. INT will be used to record a medication statement where the patient plans to take the medication or be administered the medication in the future.   CONF @moodCode shall be "EVN" or @moodCode shall be "INT" hl7:templateId II 1 … 1 M Medi...ment @root uid 1 … 1 F 2.16.840.1.113883.10.21.4.7 hl7:id II 0 … * R Medi...ment hl7:code CD (preferred) 0 … 1 R The code element is valorized with the ACT code DRUG; FD or IMMUNIZ unless it is used for asserting the known absence of medication treatments or no information about them. Medi...ment   CONF The value of @code comes preferably from value set 2.16.840.1.113883.1.11.19708 ActSubstanceAdministrationCode (DYNAMIC) or The value of @code comes preferably from value set 2.16.840.1.113883.11.21.5 Unknown or absent medication (DYNAMIC) hl7:text ED 0 … 1 Medi...ment hl7:statusCode CS (required) 1 … 1 M Medi...ment   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19890 x_ActStatusActiveComplete (DYNAMIC) Included from 2.16.840.1.113883.10.21.9.1 UV Use Period (DYNAMIC) Choice 1 … 1 The effectiveTime element encodes the use period of the medication, it is always expressed as an interval of time. It may be expressed using the low and high OR with the width element. The first is used to indicate a specified interval (e.g. from march 15th, 2017); the latter for indicating a 'floating' period (e.g. 2 weeks). Elements to choose from: hl7:effectiveTime[hl7:low | hl7:high][not(hl7:width)] hl7:effectiveTime[hl7:width][not(hl7:low|hl7:high)] hl7:effectiveTime[hl7:low | hl7:width][not(hl7:high)] hl7:effectiveTime IVL_TS 0 … 1 C Case 1: specified interval The low and high values of the first effectiveTime element represent the start and stop times for the medication. The low value represents the start time, and the high value represents the stop time. If either the low or the high value is unknown, this shall be recorded by setting the nullFlavor attribute to UNK. In case of unbounded period (continuous therapy) the high element will be valued with the nullFlavor attribute to NA. The high value records the end of the medication regime according to the information provided in the prescription or order. For example, if the prescription is for enough medication to last 30 days, then the high value should contain a date that is 30 days later then the low value. The rationale is that a provider, seeing a prescription that has not been refilled would normally assume that the medication is no longer being taken, even if the intent of the treatment plan is to continue the medication indefinitely. Medi...ment where [hl7:low or [not(hl7:width)] @nullFlavor cs 0 … 1     Example Known Interval <effectiveTime type="IVL_TS">   <low value="20130321"/>  <high value="20140321"/></effectiveTime>   Example Information not available about the period <effectiveTime type="IVL_TS" nullFlavor="NI"/>   Example Unknown end date <effectiveTime type="IVL_TS">   <low value="20130321"/>  <high nullFlavor="UNK"/></effectiveTime>   Example continous therapy <effectiveTime type="IVL_TS">   <low value="20130321"/>  <high nullFlavor="NA"/></effectiveTime> hl7:low IVXB_TS 1 … 1 R Medi...ment hl7:high IVXB_TS 0 … 1 R Medi...ment hl7:effectiveTime IVL_TS 0 … 1 C Case 2: 'floating' period: The width element is used to specify a period of (actual or intended) administration that is not anchored to any specific date (e.g. a two weeks therapy) Medi...ment where [hl7:width] [not(hl7:lowor hl7:high)]   Example 2 week period <effectiveTime type="IVL_TS">   <width value="2" unit="w"/></effectiveTime> hl7:low NP Medi...ment hl7:high NP Medi...ment hl7:center NP Medi...ment hl7:width PQ 1 … 1 R Medi...ment @unit cs 1 … 1 R   CONF The value of @unit shall be drawn from value set 2.16.840.1.113883.11.21.1 Medication Time Units (UCUM) (DYNAMIC) hl7:effectiveTime IVL_TS 0 … 1 C Case 3: anchored period: The width element is used to specify a period of (actual or intended) administration anchored to a specific date (e.g. a two weeks therapy starting today) Medi...ment where [hl7:low or [not(hl7:high)]   Example 2 week period starting on 2013-03-21 <effectiveTime type="IVL_TS">   <low value="20130321"/>  <width value="2" unit="w"/></effectiveTime> hl7:low IVXB_TS 0 … 1 C Medi...ment hl7:width PQ 1 … 1 R Medi...ment @unit cs 1 … 1 R   CONF The value of @unit shall be drawn from value set 2.16.840.1.113883.11.21.1 Medication Time Units (UCUM) (DYNAMIC) hl7:repeatNumber IVL_INT 0 … 1 Medi...ment hl7:routeCode CE (example) 0 … 1 Medi...ment   CONF Examples of the value of @code are in the value set 2.16.840.1.113883.1.11.14581 RouteOfAdministration (DYNAMIC) hl7:approachSiteCode CD (example) 0 … * Medi...ment   CONF Examples of the value of @code are in the value set 2.16.840.1.113883.1.11.19724 HumanSubstanceAdministrationSite (DYNAMIC) hl7:doseQuantity IVL_PQ NP Medi...ment hl7:rateQuantity IVL_PQ NP Medi...ment hl7:maxDoseQuantity RTO_PQ_PQ 0 … 1 Medi...ment hl7:administrationUnitCode CE NP Medi...ment hl7:subject 0 … 1 C Patient: The patient that takes the medicine. Contains 2.16.840.1.113883.10.12.320 CDA Subject (Body) (DYNAMIC) Medi...ment   Constraint Condition: This can be omitted if the patient context that is provided in the CDA header is identical to the subject Choice 1 … 1 Elements to choose from: hl7:consumable containing template 2.16.840.1.113883.10.21.4.10 UV Medication Information (simple) (DYNAMIC) hl7:consumable containing template 2.16.840.1.113883.10.21.4.11 UV Medication Information (detail) (DYNAMIC) hl7:consumable 0 … 1 R Consumable: The medication that is administered (simple) Contains 2.16.840.1.113883.10.21.4.10 UV Medication Information (simple) (DYNAMIC) Medi...ment @typeCode cs 1 … 1 F CSM hl7:consumable 0 … 1 R Consumable: The medication that is administered (detail) Contains 2.16.840.1.113883.10.21.4.11 UV Medication Information (detail) (DYNAMIC) Medi...ment @typeCode cs 1 … 1 F CSM Choice 1 … 1 Required author of the medication statement: healthcare professional or patient Elements to choose from: hl7:author containing template 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC) hl7:participant[@typeCode='AUT'] hl7:author Use this if the author of the medication statement is a healthcare professional Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC) Medi...ment   Example Author of the medication statement is a healthcare professional <author>   <time value="20170221"/>  <assignedAuthor>     <id root="1.2.3.99.99.99" extension="75487435893498"/>    <assignedPerson>       <name>         <given qualifier="IN">Ampu</given>        <prefix qualifier="VV">L.</prefix>        <family>Lee</family>      </name>    </assignedPerson>  </assignedAuthor></author> hl7:participant Use this if the author of the medication statement is the patient Medi...ment where [@typeCode='AUT'] @typeCode cs 1 … 1 F AUT   Example Author of the medication statement is the patient <participant typeCode="AUT">   <time value="20170121091548"/>  <participantRole classCode="PAT"/></participant> hl7:time TS 1 … 1 R Medi...ment hl7:participantRole 1 … 1 M Medi...ment @classCode cs 1 … 1 F PAT Choice 0 … 1 Optional informants of the medication statement: healthcare professional or patient contact party (related party) Elements to choose from: hl7:informant[exists(hl7:assignedEntity)] hl7:participant[@typeCode='INF'] hl7:informant[exists(hl7:relatedEntity)] hl7:informant Use this if the informant of the medication statement is a healthcare professional Medi...ment where [exists(hl7:assignedEntity)] @typeCode cs 0 … 1 F INF @context​Control​Code cs 0 … 1 F OP   Example Informant of the medication statement is a healthcare professional <informant>   <assignedEntity>     <id root="1.2.3.99.99.99" extension="75487435893498"/>    <assignedPerson>       <name>         <given qualifier="IN">Ampu</given>        <prefix qualifier="VV">L.</prefix>        <family>Lee</family>      </name>    </assignedPerson>  </assignedEntity></informant> hl7:assignedEntity 1 … 1 Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) Medi...ment hl7:participant Use this if the informant of the medication statement is the patient Medi...ment where [@typeCode='INF'] @typeCode cs 1 … 1 F INF   Example Informant of the medication statement is the patient <participant typeCode="INF">   <time value="20170121091548"/>  <participantRole classCode="PAT"/></participant> hl7:time TS 1 … 1 R Medi...ment hl7:participantRole 1 … 1 M Medi...ment @classCode cs 1 … 1 F PAT hl7:informant Use this if the informant of the medication statement is a contact party (related party) Medi...ment where [exists(hl7:relatedEntity)] @typeCode cs 0 … 1 F INF @context​Control​Code cs 0 … 1 F OP   Example Informant of the medication statement is a contact party (related party) <informant>   <relatedEntity classCode="AGNT">     <relatedPerson classCode="PSN" determinerCode="INSTANCE">       <name>         <!-- .. -->       </name>    </relatedPerson>  </relatedEntity></informant> hl7:relatedEntity 1 … 1 Contains 2.16.840.1.113883.10.12.316 CDA RelatedEntity (DYNAMIC) Medi...ment hl7:participant 0 … 1 Record Target: indicates the person who's medical record holds the documentation of this medication statement. This element is only populated when the document is placed in a medical record of someone other than the patient (subject). Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC) Medi...ment where [@typeCode='RCT'] @typeCode cs 1 … 1 F RCT hl7:participant 0 … 1 Verifier: The person or organization that has primary responsibility for the medication statement. The responsible party is not necessarily present in an action, but is accountable for the action through the power to delegate. Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC) Medi...ment where [@typeCode='VRF'] @typeCode cs 1 … 1 F VRF hl7:entryRelationship 0 … * C Subordinate Substance Administration Statament as a component of the overall medication statement. At least one subordinated <substanceAdministration> has to be present to convey information about dosages (dose, frequency of intakes,..) unless medications are unknown or known absent. Subordinated <substanceAdministration> elements can be also used either to handle split dosing, or to support combination medications. Contains 2.16.840.1.113883.10.21.4.6 UV Subordinate Substance Administration (DYNAMIC) Medi...ment where [hl7:substanceAdministration] @typeCode cs 1 … 1 F COMP   Constraint At least one subordinate <substanceAdministration> element SHALL be present unless medications are unknown or known absent.</substanceAdministration>   Example <entryRelationship typeCode="COMP">   <!-- component: Subordinate Substance Administration Statement. -->   <substanceAdministration classCode="SBADM" moodCode="EVN">     <templateId root="2.16.840.1.113883.10.21.4.6"/>    <!-- .. -->   </substanceAdministration></entryRelationship> hl7:sequenceNumber INT 0 … 1 Sequence number of the Subordinate Substance Administration. Medi...ment hl7:entryRelationship 0 … * R Medication Order Reference. Contains 2.16.840.1.113883.10.21.4.8 UV Medication Order Reference (DYNAMIC) Medi...ment where [@typeCode='REFR'] [hl7:substanceAdministration] @typeCode cs 1 … 1 F REFR   Example <entryRelationship typeCode="REFR">   <substanceAdministration classCode="SBADM" moodCode="RQO">     <templateId root="2.16.840.1.113883.10.21.4.8"/>    <!-- .. -->   </substanceAdministration></entryRelationship> hl7:entryRelationship 0 … * R Dispense Event Reference. Contains 2.16.840.1.113883.10.21.4.9 UV Dispense Event Reference (DYNAMIC) Medi...ment where [@typeCode='REFR'] [ [hl7:supply] @typeCode cs 1 … 1 F REFR   Example <entryRelationship typeCode="REFR">   <supply classCode="SPLY" moodCode="EVN">     <templateId root="2.16.840.1.113883.10.21.4.9"/>    <!-- .. -->   </supply></entryRelationship>