PHARM Templates Implementationguide

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This document contains: Implementation Guide Pharmacy Templates (0.90). The text materials belong to category cdapharm.

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HL7 CDA® R2 Implementation Guide: Pharmacy Templates, Release 1

Pharmacy Templates

Implementation Guide

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Co-Chair, Primary Editor	Melva Peters Jenaker Consulting melva@jenakerconsulting.com
Co-Chair, Primary Editor	John Hatem jnhatem@hotmail.com
Co-Chair	Scott Robertson PharmD scott.m.robertson@kp.org
Co-Chair	Jean Duteau jean@duteaudesign.com
Contributor	Dr Kai U. Heitmann Heitmann Consulting and Services, ART-DECOR Open Tools GmbH, HL7 Germany info@kheitmann.de
Contributor	Giorgio Cangioli, PhD Consultant, HL7 Italy giorgio.cangioli@gmail.com
Contributor	Tom de Jong VZVZ, HL7 The Netherlands tom@nova-pro.nl
Contributor	Dr Christof Geßner Gematik GmbH, HL7 Germany christof.gessner@gematik.de

Introduction

This Implementation Guide provides templates for Medication Order and Medication Statement that can be used by HL7 standards developers and external projects to develop models for pharmacy related content. The implementation guide is intended to provide consistency of pharmacy related models across all uses regardless of the method of transport by:

• creating a library of Universal pharmacy templates that can be used by other Work Groups to derive constrained versions.

Purpose

Background

Historically multiple HL7 Work Groups have developed specifications for pharmacy related content and as a result, there is inconsistency in the models that exist in HL7 V2, V3, CDA and FHIR. The Pharmacy Work Group often receives questions as to how to model pharmacy related content but in some cases, the use case cannot be met with the existing models.

This Implementation Guide provides a library of pharmacy templates that can be used by HL7 Work Groups or external projects to derive constrained versions of models for pharmacy related content.

Scope

The scope of the Implementation Guide is limited to Medication Order and Medication Statement. The content was developed by aligning and harmonizing the existing specifications for Consolidated CDA (C-CDA Release 2.1).

Future releases of the Implementation Guide will include Medication Dispense and Medication Administration.

Ballot Status of the Document

The Implementation Guide is being balloted as Informative with the intention to go to Standard for Trial Use (STU) and then to Normative.

Audience

• Clinical and Public Health laboratories
• Immunization Registries
• Pharmaceutical Vendors
• EHR/PHR vendors
• Clinical Decision Support Systems
• HIS Vendors
• Emergency Services Providers
• Healthcare Institutions
• Pharmacists
• Physicians and other Clinicians

Relationships with other projects and guides

• Consolidated CDA (C-CDA)
• HL7 Version 3 Pharmacy Models
• HL7 FHIR® Pharmacy Resources

Principles and background

Please Note

Nothing in here yet. Do we want to report about

• the new method to represent normal, split and tapered dose information in CDA Substance Administrations?
• do we want to tell people that we reduced the richness of the original Pharmacy V3 templates drastically to ease implementation?
• do we want to mention FHIR profile work that influenced heavily the development of the CDA templates?
• And/or more general other design principles?

Technical Background

What is a CDA

CDA R2 is "… a document markup standard that specifies the structure and semantics of clinical documents for the purpose of exchange” [CDA R2, Section 1.1]. Clinical documents, according to CDA, have the following characteristics:

• Persistence
• Stewardship
• Potential for authentication
• Context
• Wholeness
• Human readability

CDA defines a header for classification and management and a document body that carries the clinical record. While the header metadata are prescriptive and designed for consistency across all instances, the body is highly generic, leaving the designation of semantic requirements to implementation.

Templated CDA

CDA R2 can be constrained by mechanisms defined in the “Refinement and Localization” section of the HL7 Version 3 Interoperability Standards. The mechanism most commonly used to constrain CDA is referred to as “templated CDA”. This specification created a set of artifacts containing modular CDA templates (and associated value sets) for the purpose of the International Patient Summary, and the templates can be reused across any number of CDA document types.

There are different kinds of templates that might be created. Among them, the most common ones are:

• CDA Document Level Templates constrain fields in the Clinical Document Architecture (CDA) header, and define containment relationships to CDA sections.
  For example, a History-and-Physical document-level template might require that the patient’s name be present, and that the document contain a Physical Exam section.
• CDA Header Level Templates constrain fields for parts of the CDA header, like the patient (record target), the author, participations or the service event.
• CDA Section Level Templates constrain fields in the CDA section, and define containment relationships to CDA entries.
  For example, a Physical-exam section-level template might require that the section/code be fixed to a particular LOINC code, and that the section contain a Systolic Blood Pressure observation.
• CDA Entry Level Templates constrain the CDA clinical statement model in accordance with real world observations and acts.
  For example, a Systolic-blood-pressure entry-level template defines how the CDA Observation class is constrained (how to populate observation/code, how to populate observation/value, etc.) to represent the notion of a systolic blood pressure.

Open and Closed Templates

Open templates permit anything to be done in the underlying standard that is not explicitly prohibited. This allows templates to be built up over time that extend and go beyond the original use cases for which they were originally designed.

Closed templates only permit what has been defined in the template, and do not permit anything beyond that. There are good reasons to use closed templates, sometimes having to do with local policy. For example, in communicating information from a healthcare provider to an insurance company, some information may need to be omitted to ensure patient privacy laws are followed. Most templates developed for CDA are of the open sort.

Template versioning

Template versioning is needed to enable template designs to evolve over time.

Template versioning enables template designers to control and shape the conformance statements that make up a template’s design over time tailoring the design to fit the template’s intended purpose.

Each template version is associated with a particular template. The template – as a whole – has a mandatory globally unique, non-semantic, identifier. The identifier serves as the identifier of the original intent of the template and as the identifier of the set of versions that represent the template over time.

Template versions have a mandatory timestamp (date and optional time), called the “effective date”. The date can be seen as the point in time when the template version “came into being”, i.e. was recognized as existent by the governance group. Use of the template prior to this date would be considered an invalid use of the template.

For further information on Templates, Template Versions and related topics refer to the HL7 Templates Standard.

Identifiers for Templates and Value Sets

This specification specifies CDA Entry Level Templates only. They can be re-used in any appropriate context, such as an Entry of a medication section.

Two "root" Entry Templates are provided as entry points for the two described use cases:

• UV Medication Order (2.16.840.1.113883.10.21.4.1)
• UV Medication Statement (2.16.840.1.113883.10.21.4.7)

These templates use other Entry Level Templates that are all listed in a subsequent section of this document.

This specification uses the following OIDs for the artefacts that are registered at the HL7 OID registry.

• The root OID for templates is 2.16.840.1.113883.10.21
  • Entry Level templates are summarized under 2.16.840.1.113883.10.21.4, e.g. 2.16.840.1.113883.10.21.4.5 UV Substitution Permission
  • “other” assistance templates are summarized under 2.16.840.1.113883.10.21.9, e.g. 2.16.840.1.113883.10.22.9.1 UV Use Period
• The root OID for Value Sets is 2.16.840.1.113883.11

The sub branches for templates follow the recommendations of HL7 International and ISO 13582

How to read this document

All artifacts (templates, value sets etc.) listed with the status Draft or Pending are subject to ballot comments.

Artifacts with other status information, especially Final or Active are not (directly) part of the ballot and some artifacts actually even come from external sources. Reference artifacts are indicated by the symbol

ref

. These reference artifacts are also not subject to the ballot, as they might be balloted elsewhere already.

The PDF version contains a ruler on the left side of the pages. A ruler has the page number on top of it and allows locating a line at the page by simply specifying the number at the scale tick. This is more precise and allows also commenting on graphics and pictures.

For example if you have a comment on page 29 because of a typo (see figure), you simply specify the error with its location p0029-04.

Of course you can also refer by classical chapter and section numbers. The use of the ruler has the ballot team's preference, though.

To locate a typo on page 29 as a ballot comment, simply specify the location p0029-04.

Functional requirements and high-level use cases

The following use cases are relevant to the pharmacy domain for both community and institutional settings:

• Prescribing a medication (aka Prescription or Order or Request)
• Dispensing a medication
• Recording the administration of a medication
• Recording the use of a medication (in the past, current or future)

The following definitions are relevant to this Implementation Guide:

• “Prescribing” is an activity that can be performed by a variety of healthcare professionals and involves a variety of orderable items (see glossary entry). For the purposes of the following Implementation Guide, prescribing is defined as the act of prescribing a medication in either an ambulatory or an institutional setting. This could include initiating a new medication order or making all kinds of modifications to existing orders.
• “Dispensing” is an activity undertaken to fulfill the logistical requirements of a prescription. It supplies the materials needed to perform the prescribed actions by those who will perform them. Examples of dispensing include eyeglasses, contact lenses and medications. For the purposes of the following ballot material, dispensing is defined as supplying a medication in fulfillment of a prescription or medication order. While dispensing in these circumstances would usually be performed by a pharmacist, other health care providers such as nurses or physicians might also dispense medications.
• “Administration” is an activity undertaken to give medication to the patient. In the community, this process is usually not recorded, since the majority occurs in the patient's home; only administrations undertaken by a healthcare professional, such as vaccination, tend to be formally documented. Administration of medication in the institutional setting is usually recorded on a dose-by-dose basis, and may be messaged on that basis, or a summary of all the administrations occurring during an inpatient stay may be described.

Templates

Root Entry Level Templates

As mentioned before, this specification defines two "root" Entry Level Templates, one for each of the covered use cases.

UV Medication Order

The following graph gives an overview of the high-level template components of this template, followed by the actual definition.

Entry  UV Medication Order (2.16.840.1.113883.10.21.4.1) Entry  UV Use Period (2.16.840.1.113883.10.21.9.1) Entry  CDA Subject (Body) (2.16.840.1.113883.10.12.320) Entry  UV Medication Information (simple) (2.16.840.1.113883.10.21.4.10) *  CDA Organization (2.16.840.1.113883.10.12.151) Entry  UV Medication Information (detail) (2.16.840.1.113883.10.21.4.11) Entry  UV Content (2.16.840.1.113883.10.21.4.17) Entry  UV Generalized Medicine Class (2.16.840.1.113883.10.21.4.19) Entry  UV Content (2.16.840.1.113883.10.21.4.17) Entry  UV Generalized Medicine Class (2.16.840.1.113883.10.21.4.19) Entry  UV Content (2.16.840.1.113883.10.21.4.17) Entry  UV Generalized Medicine Class (2.16.840.1.113883.10.21.4.19) Entry  UV Content (2.16.840.1.113883.10.21.4.17) Entry  UV Generalized Medicine Class (2.16.840.1.113883.10.21.4.19) Entry  UV Ingredient (2.16.840.1.113883.10.21.4.18) Entry  UV Ingredient (2.16.840.1.113883.10.21.4.18) Entry  UV Ingredient (2.16.840.1.113883.10.21.4.18) Entry  UV Ingredient (2.16.840.1.113883.10.21.4.18) *  CDA Organization (2.16.840.1.113883.10.12.151) Entry  CDA Author (Body) (2.16.840.1.113883.10.12.318) *  CDA Person (2.16.840.1.113883.10.12.152) Entry  CDA Device (2.16.840.1.113883.10.12.315) *  CDA Organization (2.16.840.1.113883.10.12.151) Entry  CDA Participant (Body) (2.16.840.1.113883.10.12.321) Entry  CDA Device (2.16.840.1.113883.10.12.315) Entry  CDA PlayingEntity (2.16.840.1.113883.10.12.313) Entry  CDA Participant (Body) (2.16.840.1.113883.10.12.321) Entry  CDA Device (2.16.840.1.113883.10.12.315) Entry  CDA PlayingEntity (2.16.840.1.113883.10.12.313) Entry  UV Subordinate Substance Administration (2.16.840.1.113883.10.21.4.6) Entry  UV Dispense Request (2.16.840.1.113883.10.21.4.2) Entry  CDA Subject (Body) (2.16.840.1.113883.10.12.320) Entry  CDA ManufacturedProduct (2.16.840.1.113883.10.12.312) Entry  CDA LabeledDrug (2.16.840.1.113883.10.12.310) Entry  CDA Material (2.16.840.1.113883.10.12.311) *  CDA Organization (2.16.840.1.113883.10.12.151) Entry  CDA Performer (Body) (2.16.840.1.113883.10.12.323) *  CDA AssignedEntity (2.16.840.1.113883.10.12.153) *  CDA Person (2.16.840.1.113883.10.12.152) *  CDA Organization (2.16.840.1.113883.10.12.151) Entry  CDA Participant (Body) (2.16.840.1.113883.10.12.321) Entry  CDA Device (2.16.840.1.113883.10.12.315) Entry  CDA PlayingEntity (2.16.840.1.113883.10.12.313) Entry  CDA Participant (Body) (2.16.840.1.113883.10.12.321) Entry  CDA Device (2.16.840.1.113883.10.12.315) Entry  CDA PlayingEntity (2.16.840.1.113883.10.12.313) Entry  CDA Participant (Body) (2.16.840.1.113883.10.12.321) Entry  CDA Device (2.16.840.1.113883.10.12.315) Entry  CDA PlayingEntity (2.16.840.1.113883.10.12.313) Entry  CDA Participant (Body) (2.16.840.1.113883.10.12.321) Entry  CDA Device (2.16.840.1.113883.10.12.315) Entry  CDA PlayingEntity (2.16.840.1.113883.10.12.313) Entry  UV ClinicalStatement Observation (2.16.840.1.113883.10.21.4.3) Entry  CDA Subject (Body) (2.16.840.1.113883.10.12.320) Entry  CDA Specimen (2.16.840.1.113883.10.12.322) Entry  CDA Performer (Body) (2.16.840.1.113883.10.12.323) *  CDA AssignedEntity (2.16.840.1.113883.10.12.153) *  CDA Person (2.16.840.1.113883.10.12.152) *  CDA Organization (2.16.840.1.113883.10.12.151) Entry  CDA Author (Body) (2.16.840.1.113883.10.12.318) *  CDA Person (2.16.840.1.113883.10.12.152) Entry  CDA Device (2.16.840.1.113883.10.12.315) *  CDA Organization (2.16.840.1.113883.10.12.151) Entry  CDA Informant (Body) (2.16.840.1.113883.10.12.319) *  CDA AssignedEntity (2.16.840.1.113883.10.12.153) *  CDA Person (2.16.840.1.113883.10.12.152) *  CDA Organization (2.16.840.1.113883.10.12.151) Entry  CDA RelatedEntity (2.16.840.1.113883.10.12.316) *  CDA Person (2.16.840.1.113883.10.12.152) Entry  CDA Participant (Body) (2.16.840.1.113883.10.12.321) Entry  CDA Device (2.16.840.1.113883.10.12.315) Entry  CDA PlayingEntity (2.16.840.1.113883.10.12.313) Entry  CDA Reference (2.16.840.1.113883.10.12.324) Entry  CDA ExternalAct (2.16.840.1.113883.10.12.325) Entry  CDA ExternalObservation (2.16.840.1.113883.10.12.326) Entry  CDA ExternalProcedure (2.16.840.1.113883.10.12.327) Entry  CDA ExternalDocument (2.16.840.1.113883.10.12.328) Entry  CDA Precondition (2.16.840.1.113883.10.12.329) Entry  IPS Internal Reference (2.16.840.1.113883.10.22.4.31) Entry  UV ClinicalStatement Observation (2.16.840.1.113883.10.21.4.3) Entry  CDA Subject (Body) (2.16.840.1.113883.10.12.320) Entry  CDA Specimen (2.16.840.1.113883.10.12.322) Entry  CDA Performer (Body) (2.16.840.1.113883.10.12.323) *  CDA AssignedEntity (2.16.840.1.113883.10.12.153) *  CDA Person (2.16.840.1.113883.10.12.152) *  CDA Organization (2.16.840.1.113883.10.12.151) Entry  CDA Author (Body) (2.16.840.1.113883.10.12.318) *  CDA Person (2.16.840.1.113883.10.12.152) Entry  CDA Device (2.16.840.1.113883.10.12.315) *  CDA Organization (2.16.840.1.113883.10.12.151) Entry  CDA Informant (Body) (2.16.840.1.113883.10.12.319) *  CDA AssignedEntity (2.16.840.1.113883.10.12.153) *  CDA Person (2.16.840.1.113883.10.12.152) *  CDA Organization (2.16.840.1.113883.10.12.151) Entry  CDA RelatedEntity (2.16.840.1.113883.10.12.316) *  CDA Person (2.16.840.1.113883.10.12.152) Entry  CDA Participant (Body) (2.16.840.1.113883.10.12.321) Entry  CDA Device (2.16.840.1.113883.10.12.315) Entry  CDA PlayingEntity (2.16.840.1.113883.10.12.313) Entry  CDA Reference (2.16.840.1.113883.10.12.324) Entry  CDA ExternalAct (2.16.840.1.113883.10.12.325) Entry  CDA ExternalObservation (2.16.840.1.113883.10.12.326) Entry  CDA ExternalProcedure (2.16.840.1.113883.10.12.327) Entry  CDA ExternalDocument (2.16.840.1.113883.10.12.328) Entry  CDA Precondition (2.16.840.1.113883.10.12.329) Entry  UV Substitution Permission (2.16.840.1.113883.10.21.4.5) Entry  UV ClinicalStatement Encounter (2.16.840.1.113883.10.21.4.4) Entry  UV Comment Activity (2.16.840.1.113883.10.21.4.12) Entry  CDA Author (Body) (2.16.840.1.113883.10.12.318) *  CDA Person (2.16.840.1.113883.10.12.152) Entry  CDA Device (2.16.840.1.113883.10.12.315) *  CDA Organization (2.16.840.1.113883.10.12.151) Entry  CDA Precondition (2.16.840.1.113883.10.12.329)

Id	2.16.840.1.113883.10.21.4.1	Effective Date	2023‑01‑31 11:29:28 Other versions this id: UVSubstanceadministrationrequest as of 2023‑01‑31 10:52:39 UVSubstanceadministrationrequest as of 2023‑01‑30 08:30:30 UVSubstanceadministrationrequest as of 2021‑08‑04 17:03:38 UVSubstanceadministrationrequest as of 2015‑10‑07
Status	Draft	Version Label	2023
Name	UVSubstanceadministrationrequest	Display Name	UV Medication Order
Description	Universal Medication Order (Substance Administration Request)
Context	Parent nodes of template element with id 2.16.840.1.113883.10.21.4.1
Label	MedicationOrder
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Uses	Uses 14 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 2.16.840.1.113883.10.12.321 Containment CDA Participant (Body) DYNAMIC 2.16.840.1.113883.10.21.4.6 Containment UV Subordinate Substance Administration (2023) DYNAMIC 2.16.840.1.113883.10.21.4.2 Containment UV Dispense Request (R1-STU2-ballot) DYNAMIC 2.16.840.1.113883.10.21.4.3 Containment UV ClinicalStatement Observation (R1-STU2-ballot) DYNAMIC 2.16.840.1.113883.10.22.4.31 Containment IPS Internal Reference (STU1) DYNAMIC 2.16.840.1.113883.10.21.4.5 Containment UV Substitution Permission (R1-STU2-ballot) DYNAMIC 2.16.840.1.113883.10.21.4.4 Containment UV ClinicalStatement Encounter (R1-STU2-ballot) DYNAMIC 2.16.840.1.113883.10.21.4.12 Containment UV Comment Activity (R1-STU2-ballot) DYNAMIC 2.16.840.1.113883.10.12.329 Containment CDA Precondition DYNAMIC
Relationship	Version: template 2.16.840.1.113883.10.21.4.1 UV Medication Order (2015‑10‑07) Specialization: template 2.16.840.1.113883.10.12.308 CDA SubstanceAdministration (2005‑09‑07) ref ad1bbr-
Example	Example <substanceAdministration classCode="SBADM" moodCode="RQO">   <templateId root="2.16.840.1.113883.10.21.4.1"/>  <id root="1.2.3.99.99.99" extension="58768437489739"/>  <code code="..." codeSystem="..."/>  <text>...</text>  <statusCode code="active"/>  <effectiveTime value="..."/>  <repeatNumber value="..."/>  <routeCode code="IPINHL" codeSystem="2.16.840.1.113883.5.112" displayName="Inhalation, respiratory Inhalation, intrapulmonary Inhalation, oral"/>  <approachSiteCode code="..." codeSystem="2.16.840.1.113883.5.1052"/>  <administrationUnitCode code="PUFF" codeSystem="2.16.840.1.113883.5.85" displayName="Puff"/>  <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...rder @classCode cs 1 … 1 F SBADM @moodCode cs 1 … 1 F RQO hl7:templateId II 1 … 1 M Medi...rder @root uid 1 … 1 F 2.16.840.1.113883.10.21.4.1 hl7:id II 1 … * R Medi...rder hl7:code CD (extensible) 0 … 1 R Medi...rder   CONF The value of @code should be drawn from value set 2.16.840.1.113883.1.11.19708 ActSubstanceAdministrationCode (DYNAMIC) hl7:text ED 0 … 1 Medi...rder hl7:statusCode CS (required) 1 … 1 M Medi...rder   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.11.21.2 ActStatusActiveCompletedAbortedSuspended (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...rder 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...rder hl7:high IVXB_TS 0 … 1 R Medi...rder 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...rder 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...rder hl7:high NP Medi...rder hl7:center NP Medi...rder hl7:width PQ 1 … 1 R Medi...rder @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...rder 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...rder hl7:width PQ 1 … 1 R Medi...rder @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...rder hl7:routeCode CE (example) 0 … 1 Medi...rder   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...rder   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...rder hl7:rateQuantity IVL_PQ NP Medi...rder hl7:maxDoseQuantity RTO_PQ_PQ 0 … 1 Medi...rder hl7:administrationUnitCode CE NP Medi...rder hl7:subject 0 … 1 C The patient, subject to requested dispenses or subject to substances being administered to. Contains 2.16.840.1.113883.10.12.320 CDA Subject (Body) (DYNAMIC) Medi...rder   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...rder @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...rder @typeCode cs 1 … 1 F CSM hl7:author 0 … * Prescriber: A party that originates the order and therefore has responsibility for the information given in the order. Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC) Medi...rder 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...rder where [@typeCode='RCT'] @typeCode cs 1 … 1 F RCT hl7:participant 0 … 1 Verifier: The person or organization that has primary responsibility for the order. 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...rder where [@typeCode='VRF'] @typeCode cs 1 … 1 F VRF hl7:entryRelationship 0 … * C Subordinate Substance Administration Request as a component of the overall order. At least one subordinated Substance Administration should be present to convey information about dosages (dose, frequency of intakes,..) unless dosage is unknown. Subordinated Substance Administration 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...rder where [hl7:substanceAdministration] @typeCode cs 1 … 1 F COMP   Constraint At least one subordinate element SHALL be present.   Example <entryRelationship typeCode="COMP">   <!-- component: Subordinate Substance Administration Request. -->   <substanceAdministration classCode="SBADM" moodCode="RQO">     <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...rder hl7:entryRelationship 0 … 1 R Dispense Request as a component of the overall order. This element is used in the medication order when the dispense request information contains additional information to support a fully specified medication prescription. For example, to include the validity period of the dispense or the organization to dispense the medication. Contains 2.16.840.1.113883.10.21.4.2 UV Dispense Request (DYNAMIC) Medi...rder where [hl7:supply] @typeCode cs 1 … 1 F COMP   Example <entryRelationship typeCode="COMP">   <!-- component: The Dispense Request is a component of the overall order. -->   <supply classCode="SPLY" moodCode="RQO">     <templateId root="2.16.840.1.113883.10.21.4.2"/>    <!-- .. -->   </supply></entryRelationship> Choice 0 … * Elements to choose from: hl7:entryRelationship containing template 2.16.840.1.113883.10.21.4.3 UV ClinicalStatement Observation (DYNAMIC) hl7:entryRelationship containing template 2.16.840.1.113883.10.22.4.31 IPS Internal Reference (DYNAMIC) hl7:entryRelationship 0 … * R Reason: Specifies the reason (indication) for authoring the order. Contains 2.16.840.1.113883.10.21.4.3 UV ClinicalStatement Observation (DYNAMIC) Medi...rder @typeCode cs 1 … 1 F RSON   Example <hl7:entryRelationship typeCode="RSON">   <priorityNumber value="1"/>  <!-- template 2.16.840.1.113883.10.21.4.3 'UV ClinicalStatement Observation' (2016-05-01T00:00:00) --> </hl7:entryRelationship> pharm:priorityNumber INT.​NONNEG 0 … 1 R Indicates the priority of this reason for the order in relation to its sibling reasons. Medi...rder hl7:entryRelationship 0 … * R Reason: Specifies the reason (indication) for authoring the order. Contains 2.16.840.1.113883.10.22.4.31 IPS Internal Reference (DYNAMIC) Medi...rder @typeCode cs 1 … 1 F RSON   Example <entryRelationship typeCode="RSON">   <priorityNumber value="1"/>  <act>     <!-- Clinical Statement Minimal -->   </act></entryRelationship> pharm:priorityNumber INT.​NONNEG 0 … 1 R Indicates the priority of this reason for the order in relation to its sibling reasons. Medi...rder hl7:entryRelationship 0 … * R Pertinent Information: Specifies any pertinent information (observation) relevant to the order. Contains 2.16.840.1.113883.10.21.4.3 UV ClinicalStatement Observation (DYNAMIC) Medi...rder @typeCode cs 1 … 1 F PERT   Example <entryRelationship typeCode="PERT">   <observation>     <!-- Clinical Statement Observation -->   </observation></entryRelationship> hl7:entryRelationship 0 … 1 R Permission: The order can be the subject of the permissions related to substitution. Contains 2.16.840.1.113883.10.21.4.5 UV Substitution Permission (DYNAMIC) Medi...rder where [hl7:act] @typeCode cs 1 … 1 F COMP hl7:entryRelationship 0 … 1 R Encounter: Used to link an order to a specific encounter. Contains 2.16.840.1.113883.10.21.4.4 UV ClinicalStatement Encounter (DYNAMIC) Medi...rder where [hl7:encounter] @typeCode cs 1 … 1 F COMP   Example <encounter classCode="ENC" moodCode="EVN">   <id/>  <code code="..."/></encounter> hl7:entryRelationship 0 … * Annotations: The Medication Order can be the subject of annotations. Contains 2.16.840.1.113883.10.21.4.12 UV Comment Activity (DYNAMIC) Medi...rder @typeCode cs 1 … 1 F COMP hl7:precondition 0 … * Precondition: A requirement to be true before the SubstanceAdministration is performed. Contains 2.16.840.1.113883.10.12.329 CDA Precondition (DYNAMIC) Medi...rder

UV Medication Statement

The following graph gives an overview of the high-level template components of this template, followed by the actual definition.

Entry  UV Medication Statement (2.16.840.1.113883.10.21.4.7) Entry  UV Use Period (2.16.840.1.113883.10.21.9.1) Entry  CDA Subject (Body) (2.16.840.1.113883.10.12.320) Entry  UV Medication Information (simple) (2.16.840.1.113883.10.21.4.10) *  CDA Organization (2.16.840.1.113883.10.12.151) Entry  UV Medication Information (detail) (2.16.840.1.113883.10.21.4.11) Entry  UV Content (2.16.840.1.113883.10.21.4.17) Entry  UV Generalized Medicine Class (2.16.840.1.113883.10.21.4.19) Entry  UV Content (2.16.840.1.113883.10.21.4.17) Entry  UV Generalized Medicine Class (2.16.840.1.113883.10.21.4.19) Entry  UV Content (2.16.840.1.113883.10.21.4.17) Entry  UV Generalized Medicine Class (2.16.840.1.113883.10.21.4.19) Entry  UV Content (2.16.840.1.113883.10.21.4.17) Entry  UV Generalized Medicine Class (2.16.840.1.113883.10.21.4.19) Entry  UV Ingredient (2.16.840.1.113883.10.21.4.18) Entry  UV Ingredient (2.16.840.1.113883.10.21.4.18) Entry  UV Ingredient (2.16.840.1.113883.10.21.4.18) Entry  UV Ingredient (2.16.840.1.113883.10.21.4.18) *  CDA Organization (2.16.840.1.113883.10.12.151) Entry  CDA Author (Body) (2.16.840.1.113883.10.12.318) *  CDA Person (2.16.840.1.113883.10.12.152) Entry  CDA Device (2.16.840.1.113883.10.12.315) *  CDA Organization (2.16.840.1.113883.10.12.151) *  CDA AssignedEntity (2.16.840.1.113883.10.12.153) *  CDA Person (2.16.840.1.113883.10.12.152) *  CDA Organization (2.16.840.1.113883.10.12.151) Entry  CDA RelatedEntity (2.16.840.1.113883.10.12.316) *  CDA Person (2.16.840.1.113883.10.12.152) Entry  CDA Participant (Body) (2.16.840.1.113883.10.12.321) Entry  CDA Device (2.16.840.1.113883.10.12.315) Entry  CDA PlayingEntity (2.16.840.1.113883.10.12.313) Entry  CDA Participant (Body) (2.16.840.1.113883.10.12.321) Entry  CDA Device (2.16.840.1.113883.10.12.315) Entry  CDA PlayingEntity (2.16.840.1.113883.10.12.313) Entry  UV Subordinate Substance Administration (2.16.840.1.113883.10.21.4.6) Entry  UV Medication Order Reference (2.16.840.1.113883.10.21.4.8) Entry  CDA Author (Body) (2.16.840.1.113883.10.12.318) *  CDA Person (2.16.840.1.113883.10.12.152) Entry  CDA Device (2.16.840.1.113883.10.12.315) *  CDA Organization (2.16.840.1.113883.10.12.151) Entry  UV Dispense Event Reference (2.16.840.1.113883.10.21.4.9) Entry  UV ClinicalStatement Observation (2.16.840.1.113883.10.21.4.3) Entry  CDA Subject (Body) (2.16.840.1.113883.10.12.320) Entry  CDA Specimen (2.16.840.1.113883.10.12.322) Entry  CDA Performer (Body) (2.16.840.1.113883.10.12.323) *  CDA AssignedEntity (2.16.840.1.113883.10.12.153) *  CDA Person (2.16.840.1.113883.10.12.152) *  CDA Organization (2.16.840.1.113883.10.12.151) Entry  CDA Author (Body) (2.16.840.1.113883.10.12.318) *  CDA Person (2.16.840.1.113883.10.12.152) Entry  CDA Device (2.16.840.1.113883.10.12.315) *  CDA Organization (2.16.840.1.113883.10.12.151) Entry  CDA Informant (Body) (2.16.840.1.113883.10.12.319) *  CDA AssignedEntity (2.16.840.1.113883.10.12.153) *  CDA Person (2.16.840.1.113883.10.12.152) *  CDA Organization (2.16.840.1.113883.10.12.151) Entry  CDA RelatedEntity (2.16.840.1.113883.10.12.316) *  CDA Person (2.16.840.1.113883.10.12.152) Entry  CDA Participant (Body) (2.16.840.1.113883.10.12.321) Entry  CDA Device (2.16.840.1.113883.10.12.315) Entry  CDA PlayingEntity (2.16.840.1.113883.10.12.313) Entry  CDA Reference (2.16.840.1.113883.10.12.324) Entry  CDA ExternalAct (2.16.840.1.113883.10.12.325) Entry  CDA ExternalObservation (2.16.840.1.113883.10.12.326) Entry  CDA ExternalProcedure (2.16.840.1.113883.10.12.327) Entry  CDA ExternalDocument (2.16.840.1.113883.10.12.328) Entry  CDA Precondition (2.16.840.1.113883.10.12.329) Entry  IPS Internal Reference (2.16.840.1.113883.10.22.4.31)

Id	2.16.840.1.113883.10.21.4.7	Effective Date	2023‑01‑30 08:32:34 Other versions this id: UVMedicationstatement as of 2021‑08‑04 14:09:15 UVMedicationstatement as of 2017‑05‑01
Status	Draft	Version Label	2023
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 13 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 2.16.840.1.113883.10.21.4.3 Containment UV ClinicalStatement Observation (R1-STU2-ballot) DYNAMIC 2.16.840.1.113883.10.22.4.31 Containment IPS Internal Reference (STU1) DYNAMIC
Relationship	Version: template 2.16.840.1.113883.10.21.4.7 UV Medication Statement (2021‑08‑04 14:09:15) 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 2.16.840.1.113883.1.11.15933 ActStatus (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 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 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 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 [exists(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' and exists(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' and exists(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> Choice Elements to choose from: hl7:entryRelationship[@typeCode='RSON' and exists(hl7:observation)] containing template 2.16.840.1.113883.10.21.4.3 UV ClinicalStatement Observation (DYNAMIC) hl7:entryRelationship[@typeCode='RSON' and exists(hl7:act)] containing template 2.16.840.1.113883.10.22.4.31 IPS Internal Reference (DYNAMIC) hl7:entryRelationship 0 … * R Reason: Specifies the reason (indication) for authoring the order. Contains 2.16.840.1.113883.10.21.4.3 UV ClinicalStatement Observation (DYNAMIC) Medi...ment where [@typeCode='RSON' and exists(hl7:observation)] @typeCode cs 1 … 1 F RSON   Example <cda:entryRelationship typeCode="RSON">   <priorityNumber value="1"/>  <!-- template 2.16.840.1.113883.10.21.4.3 'UV ClinicalStatement Observation' (2016-05-01T00:00:00) --> </cda:entryRelationship> pharm:priorityNumber INT.​NONNEG 0 … 1 R Indicates the priority of this reason for the order in relation to its sibling reasons. Medi...ment hl7:entryRelationship 0 … * R Reason: Specifies the reason (indication) for authoring the order. Contains 2.16.840.1.113883.10.22.4.31 IPS Internal Reference (DYNAMIC) Medi...ment where [@typeCode='RSON' and exists(hl7:act)] @typeCode cs 1 … 1 F RSON   Example <entryRelationship typeCode="RSON">   <priorityNumber value="1"/>  <act>     <!-- Clinical Statement Minimal -->   </act></entryRelationship> pharm:priorityNumber INT.​NONNEG 0 … 1 R Indicates the priority of this reason for the order in relation to its sibling reasons. Medi...ment

Entry Level Templates

UV ClinicalStatement Encounter

Id	2.16.840.1.113883.10.21.4.4	Effective Date	2017‑01‑02
Status	Under pre-publication review	Version Label	R1-STU2-ballot
Name	UVClinicalStatementMinimalEncounter	Display Name	UV ClinicalStatement Encounter
Description	Universal Clinical Statement Minimal Encounter
Context	Parent nodes of template element with id 2.16.840.1.113883.10.21.4.4
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Relationship	Specialization: template 2.16.840.1.113883.10.12.302 CDA Encounter (2005‑09‑07) ref ad1bbr- Adaptation: template 2.16.840.1.113883.10.20.22.4.49 Encounter Activity (V3) (DYNAMIC) ref ccda-
Item DT Card Conf Description Label hl7:encounter (UVC...ter) @classCode cs 1 … 1 F ENC @moodCode cs 1 … 1 F EVN hl7:templateId II 1 … 1 R (UVC...ter) @root uid 1 … 1 F 2.16.840.1.113883.10.21.4.4 hl7:id II 0 … * (UVC...ter)

UV ClinicalStatement Observation

Id	2.16.840.1.113883.10.21.4.3	Effective Date	2016‑05‑01
Status	Under pre-publication review	Version Label	R1-STU2-ballot
Name	UVClinicalStatementMinimalObservation	Display Name	UV ClinicalStatement Observation
Description	Universal Clinical Statement Minimal Observation
Context	Parent nodes of template element with id 2.16.840.1.113883.10.21.4.3
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Uses	Uses 8 templates Uses as Name Version 2.16.840.1.113883.10.12.320 Containment CDA Subject (Body) DYNAMIC 2.16.840.1.113883.10.12.322 Containment CDA Specimen DYNAMIC 2.16.840.1.113883.10.12.323 Containment CDA Performer (Body) DYNAMIC 2.16.840.1.113883.10.12.318 Containment CDA Author (Body) DYNAMIC 2.16.840.1.113883.10.12.319 Containment CDA Informant (Body) DYNAMIC 2.16.840.1.113883.10.12.321 Containment CDA Participant (Body) DYNAMIC 2.16.840.1.113883.10.12.324 Containment CDA Reference DYNAMIC 2.16.840.1.113883.10.12.329 Containment CDA Precondition DYNAMIC
Relationship	Specialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07) ref ad1bbr-
Item DT Card Conf Description Label hl7:observation (UVC...ion) @classCode cs 1 … 1 F OBS @moodCode cs 1 … 1 F EVN @negationInd bl 0 … 1   hl7:templateId II 1 … 1 R (UVC...ion) @root uid 1 … 1 F 2.16.840.1.113883.10.21.4.3 hl7:id II 0 … * (UVC...ion) hl7:code CD 1 … 1 R This code (e.g. drawn from LOINC) specifies the type of observation, e.g. a lab value (creatinine) or a measurement of the body weight or a body surface. (UVC...ion)   CONF shall be drawn from concept domain "ObservationCode" hl7:derivationExpr ST 0 … 1 (UVC...ion) hl7:text ED 0 … 1 (UVC...ion) hl7:statusCode CS 0 … 1 (UVC...ion)   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC) hl7:effectiveTime IVL_TS 0 … 1 (UVC...ion) hl7:priorityCode CE 0 … 1 (UVC...ion)   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC) hl7:repeatNumber IVL_INT 0 … 1 (UVC...ion) hl7:language​Code CS 0 … 1 (UVC...ion)   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC) hl7:value ANY 0 … * (UVC...ion) hl7:interpretationCode CE 0 … * (UVC...ion)   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC) hl7:methodCode CE 0 … * (UVC...ion)   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14079 ObservationMethod (DYNAMIC) hl7:target​Site​Code CD 0 … * (UVC...ion)   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19724 HumanSubstanceAdministrationSite (DYNAMIC) hl7:subject 0 … 1 Contains 2.16.840.1.113883.10.12.320 CDA Subject (Body) (DYNAMIC) (UVC...ion) hl7:specimen 0 … * Contains 2.16.840.1.113883.10.12.322 CDA Specimen (DYNAMIC) (UVC...ion) hl7:performer 0 … * Contains 2.16.840.1.113883.10.12.323 CDA Performer (Body) (DYNAMIC) (UVC...ion) hl7:author 0 … * Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC) (UVC...ion) hl7:informant 0 … * Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC) (UVC...ion) hl7:participant 0 … * Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC) (UVC...ion) hl7:reference 0 … * Contains 2.16.840.1.113883.10.12.324 CDA Reference (DYNAMIC) (UVC...ion) hl7:precondition 0 … * Contains 2.16.840.1.113883.10.12.329 CDA Precondition (DYNAMIC) (UVC...ion) hl7:referenceRange 0 … * (UVC...ion) @typeCode cs 1 … 1 F REFV hl7:observationRange 1 … 1 R (UVC...ion) @classCode cs 0 … 1 F OBS @moodCode cs 0 … 1 F EVN.CRT hl7:code CD 0 … 1 (UVC...ion) @codeSystem CONF 0 … 1 F 2.16.840.1.113883.5.4 (Act Code) hl7:text ED 0 … 1 (UVC...ion) hl7:value ANY 0 … 1 (UVC...ion) hl7:interpretationCode CE 0 … 1 (UVC...ion)   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)

UV Dispense Request

Id	2.16.840.1.113883.10.21.4.2	Effective Date	2016‑05‑01
Status	Under pre-publication review	Version Label	R1-STU2-ballot
Name	UVDispenseRequest	Display Name	UV Dispense Request
Description	Universal Dispense Request (Supply Request)
Context	Parent nodes of template element with id 2.16.840.1.113883.10.21.4.2
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Uses	Uses 4 templates Uses as Name Version 2.16.840.1.113883.10.12.320 Containment CDA Subject (Body) DYNAMIC 2.16.840.1.113883.10.12.312 Containment CDA ManufacturedProduct DYNAMIC 2.16.840.1.113883.10.12.323 Containment CDA Performer (Body) DYNAMIC 2.16.840.1.113883.10.12.321 Containment CDA Participant (Body) DYNAMIC
Relationship	Specialization: template 2.16.840.1.113883.10.12.309 CDA Supply (2005‑09‑07) ref ad1bbr-
Example	Example <supply classCode="SPLY" moodCode="RQO">   <templateId root="2.16.840.1.113883.10.21.4.2"/>  <id root="..." extension="--example only--"/>  <code/>  <text/>  <statusCode code="active"/>  <effectiveTime xsi:type="IVL_TS">     <low value="20170601"/>    <high value="20170801"/>  </effectiveTime>  <repeatNumber/>  <independentInd value="false"/>  <quantity value="1"/>  <expectedUseTime>     <low value="20160511153724"/>  </expectedUseTime>  <subject>     <!-- template 'CDA Subject (Body)' (dynamic) -->   </subject>  <product typeCode="PRD">     <!-- template 'CDA ManufacturedProduct' (dynamic) -->   </product>  <performer>     <!-- template 'CDA Performer (Body)' (dynamic) -->   </performer>  <participant typeCode="ORG">     <!-- template 'CDA Participant (Body)' (dynamic) -->   </participant>  <participant typeCode="DST">     <!-- template 'CDA Participant (Body)' (dynamic) -->   </participant>  <participant typeCode="RCV">     <!-- template 'CDA Participant (Body)' (dynamic) -->   </participant>  <participant typeCode="LOC">     <!-- template 'CDA Participant (Body)' (dynamic) -->   </participant>  <entryRelationship typeCode="COMP">     <!-- template 'DispenseRequest' (dynamic) -->   </entryRelationship></supply>
Item DT Card Conf Description Label hl7:supply (UVD...est) @classCode cs 1 … 1 F SPLY @moodCode cs 1 … 1 F RQO hl7:templateId II 1 … 1 M (UVD...est) @root uid 1 … 1 F 2.16.840.1.113883.10.21.4.2 hl7:id II 0 … * (UVD...est) hl7:code CD (extensible) 0 … 1 (UVD...est)   CONF The value of @code should be drawn from value set 2.16.840.1.113883.1.11.16208 ActPharmacySupplyType (DYNAMIC) hl7:text ED 0 … 1 (UVD...est) hl7:statusCode CS 0 … 1 (UVD...est) @code CONF 0 … 1 F active hl7:effectiveTime IVL_TS 0 … 1 Validity period of the Dispense Request (UVD...est) hl7:repeatNumber IVL_INT 0 … 1 (UVD...est) hl7:independentInd BL 0 … 1 (UVD...est) hl7:quantity PQ 0 … 1 (UVD...est) hl7:expectedUseTime IVL_TS 0 … 1 (UVD...est) hl7:subject 0 … 1 Contains 2.16.840.1.113883.10.12.320 CDA Subject (Body) (DYNAMIC) (UVD...est) hl7:product 0 … 1 R Contains 2.16.840.1.113883.10.12.312 CDA ManufacturedProduct (DYNAMIC) (UVD...est) @typeCode cs 0 … 1 F PRD hl7:performer 0 … * Contains 2.16.840.1.113883.10.12.323 CDA Performer (Body) (DYNAMIC) (UVD...est) hl7:participant 0 … 1 Origin Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC) (UVD...est) @typeCode 1 … 1 F ORG hl7:participant 0 … 1 Destination Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC) (UVD...est) where [@typeCode='DST'] @typeCode 1 … 1 F DST hl7:participant 0 … * Receiver Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC) (UVD...est) where [@typeCode='RCV'] @typeCode 1 … 1 F RCV hl7:participant 0 … 1 Location Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC) (UVD...est) where [@typeCode='LOC'] @typeCode 1 … 1 F LOC

UV Dispense Event Reference

Id	2.16.840.1.113883.10.21.4.9	Effective Date	2017‑03‑30
Status	Under pre-publication review	Version Label	R1-STU2-ballot
Name	UVDispenseEventReference	Display Name	UV Dispense Event Reference
Description	This is a reference to a Dispense Event
Context	Parent nodes of template element with id 2.16.840.1.113883.10.21.4.9
Label	DispenseEventReference
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Relationship	Specialization: template 2.16.840.1.113883.10.12.309 CDA Supply (2005‑09‑07) ref ad1bbr-
Example	Example <supply classCode="SPLY" moodCode="EVN">   <templateId root="2.16.840.1.113883.10.21.4.9"/>  <id root="1.2.3.99.99.99" extension="978437489739"/></supply>
Item DT Card Conf Description Label hl7:supply Disp...ence @classCode cs 1 … 1 F SPLY @moodCode cs 1 … 1 F EVN hl7:templateId II 1 … 1 M Disp...ence @root uid 1 … 1 F 2.16.840.1.113883.10.21.4.9 hl7:id II 1 … 1 R Disp...ence

UV Medication Information (detail)

Id	2.16.840.1.113883.10.21.4.11	Effective Date	2023‑02‑03 13:03:38 Other versions this id: UVMedicationInformationdetail as of 2021‑08‑04 12:39:04 UVMedicationInformationdetail as of 2017‑05‑10
Status	Draft	Version Label	2023
Name	UVMedicationInformationdetail	Display Name	UV Medication Information (detail)
Description	Universal Medication Information (detail)
Context	Parent nodes of template element with id 2.16.840.1.113883.10.21.4.11
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Uses	Uses 4 templates Uses as Name Version 2.16.840.1.113883.10.21.4.17 Include UV Content (R1-STU2-ballot) DYNAMIC 2.16.840.1.113883.10.21.4.19 Include UV Generalized Medicine Class (2023) DYNAMIC 2.16.840.1.113883.10.21.4.18 Include UV Ingredient (R1-STU2-ballot) DYNAMIC 2.16.840.1.113883.10.12.151 Containment CDA Organization DYNAMIC
Relationship	Version: template 2.16.840.1.113883.10.21.4.11 UV Medication Information (detail) (2017‑05‑10) Specialization: template 2.16.840.1.113883.10.12.312 CDA ManufacturedProduct (2005‑09‑07) ref ad1bbr- Adaptation: template 1.3.6.1.4.1.19376.1.9.1.3.1 IHE MedicineEntryContentModule (DYNAMIC) ref ch-pharm-
Item DT Card Conf Description Label hl7:manufacturedProduct (UVM...ail) @classCode cs 1 … 1 F MANU hl7:templateId II 1 … 1 M (UVM...ail) @root uid 1 … 1 F 2.16.840.1.113883.10.21.4.11 hl7:manufactured​Material (UVM...ail) @classCode cs 0 … 1 F MMAT @determiner​Code cs 0 … 1 F KIND hl7:code CE 0 … 1 R The code describes the code of the medication. The medication may be either a brand/product or described as a generic/scientific name or a descriptor of a magistral preparation/compound medicine (UVM...ail) hl7:originalText ED 0 … 1 R The originalText shoud contain a reference whose URI value points to the name and strength of the medication in the corresponding section.text, or just the name alone if strength is not relevant. (UVM...ail) hl7:reference TEL 1 … 1 R (UVM...ail) hl7:translation CE 0 … * Product code(s) from any organizational or juristdictional system (UVM...ail)   CONF shall be drawn from concept domain "Product Code" hl7:name EN 0 … 1 R The element SHOULD contain the name of the medication (e.g., "Adol 500mg Caplet"). The medication may be either a brand/product or described as a generic/scientific name or a descriptor of a magistral preparation/compound medicine (UVM...ail) pharm:desc ED 0 … 1 (UVM...ail) pharm:formCode CE 0 … 1 This code represents the pharmaceutical dose form (e.g., tablet, capsule, liquid) and SHOULD be present, if not implied by the product. It MAY be present if implied by the product. The value of this code may affect the units used in the substance administration quantity element. (UVM...ail) hl7:lotNumberText ST 0 … 1 The lotNumberText element MAY be present and is a string representation of a lot number of this specific instance of the product. The provided lot number SHALL refer to the primary packaged item described in the Packaging element. (UVM...ail) pharm:expirationTime TS 0 … 1 The pharm:expirationTime element MAY be present and SHALL contain a value attribute containing the date (e.g., specific date, specific date including time) of expiration of this specific instance of the product. The value given in the pharm:expirationTime element SHALL refer to the primary packaged item described in the Medicine Packaging element. (UVM...ail) @value 1 … 1 R pharm:asContent 0 … * This structure describes the packaging of the medication. It represents the primary description of the packaging of the medicine (e.g., the medicine is packaged in ampoules of 50ml volume each) and may include additional packaging information of how many of the primary packaged items are within an outer package (e.g., 5 ampoules are packaged in a box). The primary description of the package should be consistent with the given pharmaceutical dose form (pharm:formCode of the medication). Example: a consistent pharmaceutical dose form to the package form “Ampoules” would be e.g., “Solution for injection”. In case the package describes a product, the pharm:code element provides the code for the product. In case the package describes a product, and the package has a brand name, it should be described in the pharm:name element (e.g., Xylocaine 1% with Adrenaline Inj, 5 injections package). The pharm:formCode element represents the form of the product/contaner (e.g., tablet container, bottle, ...). The <pharm:capacity​Quantity> element describes the capacity of the packaging, while the <pharm:quantity> the actual quantity of inner packaged items in the outer packaging container. The product might have a single (30 pills bottle) or multiple (5 vials 10 ml; box with 2 blisters of 20 tablets) layers of packaging. In the latter case, the most inner (nested) item represents the most outer package item. For example the case    \--Box    \-----2 blisters    \--------20 tablets  is described as "20 tablets" contained by "a blister"; "2 blisters" contained by one box. The most inner package represents the Packaged Medicinal Product. (UVM...ail) @classCode cs 1 … 1 F CONT   Example Packaged Medicinal Product with formCode <asContent classCode="CONT">   <containerPackagedProduct classCode="CONT" determinerCode="KIND">     <!-- Packaged Medicinal Product -->     <code codeSystem="1.999.999" code="PC_ID" displayName="Packaged Product Name"/>    <name>100 MIRACLE PILLS(TM)</name>    <formCode codeSystem="0.4.0.127.0.16.1.1.2.1" code="30009000" displayName="Box" CodeSystemName="EDQM"/>  </containerPackagedProduct></asContent>   Example General example <asContent classCode="CONT">   <quantity value=" " unit=" "/>  <containerPackagedProduct classCode="CONT" determinerCode="KIND">     <!-- Medicinal product code (package-level) -->     <code code=" " displayName=" " codeSystem=" " codeSystemName=" "/>    <!-- Brand name (package) -->     <name> . . . </name>    <formCode code=" " displayName=" " codeSystem=" " codeSystemName=" "/>    <capacityQuantity value=" " unit=" "/>    <asContent>       <containerPackagedProduct classCode="CONT" determinerCode="KIND">         <capacityQuantity value=" " unit=" "/>      </containerPackagedProduct>    </asContent>  </containerPackagedProduct></asContent>   Example Medicinal product with pharmaceutical dose form ”Tablets”, available as a “Tablet container” with 30 tablets <asContent classCode="CONT">   <!-- 30 tablets in the package -->   <quantity value="30" unit="{tablet}"/>  <containerPackagedProduct classCode="CONT" determinerCode="KIND">     <!-- .. -->     <formCode code=" " displayName="Tablet container" codeSystem=" " codeSystemName=" "/>  </containerPackagedProduct></asContent>   Example Medicinal product with pharmaceutical dose form 'Solution for injection', available as “Ampoules” with 50ml volume, packaged as 5 ampoules per box <asContent classCode="CONT">   <quantity value="50" unit="ml"/>  <!-- 50ml per ampoule -->   <containerPackagedProduct classCode="CONT" determinerCode="KIND">     <!-- .. -->     <formCode code=" " displayName="Ampoules" codeSystem=" " codeSystemName=" "/>    <asContent>       <!-- 5 ampoules in a box -->       <quantity value="5"/>      <containerPackagedProduct classCode="CONT" determinerCode="KIND">         <!-- .. -->       </containerPackagedProduct>    </asContent>  </containerPackagedProduct></asContent>   Example Packaged Medicinal Product with multiple layers packaging <asContent classCode="CONT">   <containerPackagedProduct>     <!-- Inner Package -->     <code codeSystem="..." code="..." displayName="..."/>    <asContent>       <containerPackagedProduct>         <!-- Intermediate Package -->         <asContent>           <containerPackagedProduct>             <!-- Outer Package / Packaged Medicinal Product -->           </containerPackagedProduct>        </asContent>      </containerPackagedProduct>    </asContent>  </containerPackagedProduct></asContent> Included from 2.16.840.1.113883.10.21.4.17 UV Content (DYNAMIC) pharm:quantity PQ 0 … 1 R The quantity which specified how many inner packaged content entities are in an outer packaging container entity. (UVM...ail) pharm:containerPackagedProduct 1 … 1 R (UVM...ail) @classCode cs 1 … 1 F CONT @determiner​Code cs 1 … 1 F KIND pharm:code CE 0 … 1 It represents the code of the Package Item or of the Packaged Medicinal Product. If this is also the most outer <pharm:containerPackagedProduct> than this element can be used to convey the Packaged Medicinal Product ID. (UVM...ail) pharm:name EN 0 … * It represents the Name of the Package Item or of the Packaged Medicinal Product. If this is also the most outer <pharm:containerPackagedProduct> than this element can be used for the brand name. (UVM...ail) pharm:formCode CE 0 … 1 This element encodes the type of the most inner package item or of the or the Packaged Medicinal Product. (UVM...ail) pharm:capacity​Quantity PQ 0 … 1 Captures the number of product units the package would contain if fully loaded. (UVM...ail) @value 1 … 1 R @unit cs 0 … 1   pharm:asContent 0 … * In case of multiple layers of packaging (5 vials 10 ml; box with 2 blisters of 20 tablets) this element can be used for describing the intermediate Packaged Medicinal Product Item or the Packaged Medicinal Product. For example in the case    \--Box    \-----2 blisters    \--------20 tablets  it describes the "2 blisters"  In the case of    \--Box    \-----5 vials it represents the Packaged Medicinal Product.  (UVM...ail) @classCode cs 1 … 1 F CONT pharm:quantity PQ 0 … 1 R The quantity which specified how many inner packaged content entities are in an outer packaging container entity. (UVM...ail) pharm:containerPackagedProduct 1 … 1 R It represents the intermediate Package Item or the Packaged Medicinal Product (UVM...ail) @classCode cs 1 … 1 F CONT @determiner​Code cs 1 … 1 F KIND pharm:code CD 0 … 1 It represents the code of the Package Item or of the Packaged Medicinal Product. If this is also the most outer <pharm:containerPackagedProduct> than this element can be used to convey the Packaged Medicinal Product ID. (UVM...ail) pharm:name ST 0 … 1 R It represents the Name of the Package Item or of the Packaged Medicinal Product. If this is also the most outer <pharm:containerPackagedProduct> than this element can be used for the brand name. (UVM...ail) pharm:formCode CE 1 … 1 R This element encodes the type of the intermediate package item or of the or the Packaged Medicinal Product. (UVM...ail) pharm:capacity​Quantity PQ 0 … 1 Captures the number of product units the package would contain if fully loaded. (UVM...ail) @value 1 … 1 R @unit cs 0 … 1   pharm:asContent 0 … * R In case of multiple layers of packaging (box with 2 blisters of 20 tablets) this element is used for describing the most outer Packaged Medicinal Product Item or the Packaged Medicinal Product. For example in the case    \--Box    \-----2 blisters    \--------20 tablets  it describes the Packaged Medicinal Product.  (UVM...ail) @classCode cs 1 … 1 F CONT pharm:quantity PQ 0 … 1 R (UVM...ail) pharm:containerPackagedProduct 1 … 1 R When present, it represents the Packaged Medicinal Product (UVM...ail) @classCode cs 1 … 1 F CONT @determiner​Code cs 1 … 1 F KIND pharm:code CD 0 … 1 When present, it can be used to convey the Packaged Medicinal Product ID. (UVM...ail) pharm:name ST 0 … 1 R (UVM...ail) pharm:formCode CE 1 … 1 R (UVM...ail) pharm:capacity​Quantity PQ 0 … 1 Captures the number of product units the package would contain if fully loaded. (UVM...ail) @value 1 … 1 R @unit cs 0 … 1   pharm:asSpecializedKind 0 … * R The Medicinal Product can be classified according to various classification systems, which may be jurisdictional or international as for example  the WHO ATC drug code, or the IDMP Pharmaceutical Product Identifier(s) (PhPID Set) when it will be available for use. The generalizedMaterialKind/code element is used to covey these codes. (UVM...ail) @classCode cs 1 … 1 F GRIC   Example <asSpecializedKind classCode="GRIC">   <generalizedMedicineClass classCode="MMAT">     <code code=" " displayName=" " codeSystem=" " codeSystemName=" "/>  </generalizedMedicineClass></asSpecializedKind> Included from 2.16.840.1.113883.10.21.4.19 UV Generalized Medicine Class (DYNAMIC) pharm:generalizedMedicineKind 0 … * (UVM...ail) @classCode cs 1 … 1 F MMAT @determiner​Code cs 1 … 1 F KIND pharm:code 1 … 1 R (UVM...ail) pharm:name 0 … * (UVM...ail) pharm:part 0 … * (UVM...ail) @classCode cs 1 … 1 F PART pharm:id II 0 … 1 (UVM...ail) pharm:quantity PQ 0 … 1 (UVM...ail) pharm:partProduct 1 … 1 (UVM...ail) pharm:code CE 0 … 1 (UVM...ail) pharm:name EN 0 … 1 (UVM...ail) pharm:desc ED 0 … 1 (UVM...ail) pharm:formCode CE 0 … 1 (UVM...ail) pharm:asContent 0 … * (UVM...ail) @classCode cs 1 … 1 F CONT Included from 2.16.840.1.113883.10.21.4.17 UV Content (DYNAMIC) pharm:quantity PQ 0 … 1 R The quantity which specified how many inner packaged content entities are in an outer packaging container entity. (UVM...ail) pharm:containerPackagedProduct 1 … 1 R (UVM...ail) @classCode cs 1 … 1 F CONT @determiner​Code cs 1 … 1 F KIND pharm:code CE 0 … 1 It represents the code of the Package Item or of the Packaged Medicinal Product. If this is also the most outer <pharm:containerPackagedProduct> than this element can be used to convey the Packaged Medicinal Product ID. (UVM...ail) pharm:name EN 0 … * It represents the Name of the Package Item or of the Packaged Medicinal Product. If this is also the most outer <pharm:containerPackagedProduct> than this element can be used for the brand name. (UVM...ail) pharm:formCode CE 0 … 1 This element encodes the type of the most inner package item or of the or the Packaged Medicinal Product. (UVM...ail) pharm:capacity​Quantity PQ 0 … 1 Captures the number of product units the package would contain if fully loaded. (UVM...ail) @value 1 … 1 R @unit cs 0 … 1   pharm:asContent 0 … * In case of multiple layers of packaging (5 vials 10 ml; box with 2 blisters of 20 tablets) this element can be used for describing the intermediate Packaged Medicinal Product Item or the Packaged Medicinal Product. For example in the case    \--Box    \-----2 blisters    \--------20 tablets  it describes the "2 blisters"  In the case of    \--Box    \-----5 vials it represents the Packaged Medicinal Product.  (UVM...ail) @classCode cs 1 … 1 F CONT pharm:quantity PQ 0 … 1 R The quantity which specified how many inner packaged content entities are in an outer packaging container entity. (UVM...ail) pharm:containerPackagedProduct 1 … 1 R It represents the intermediate Package Item or the Packaged Medicinal Product (UVM...ail) @classCode cs 1 … 1 F CONT @determiner​Code cs 1 … 1 F KIND pharm:code CD 0 … 1 It represents the code of the Package Item or of the Packaged Medicinal Product. If this is also the most outer <pharm:containerPackagedProduct> than this element can be used to convey the Packaged Medicinal Product ID. (UVM...ail) pharm:name ST 0 … 1 R It represents the Name of the Package Item or of the Packaged Medicinal Product. If this is also the most outer <pharm:containerPackagedProduct> than this element can be used for the brand name. (UVM...ail) pharm:formCode CE 1 … 1 R This element encodes the type of the intermediate package item or of the or the Packaged Medicinal Product. (UVM...ail) pharm:capacity​Quantity PQ 0 … 1 Captures the number of product units the package would contain if fully loaded. (UVM...ail) @value 1 … 1 R @unit cs 0 … 1   pharm:asContent 0 … * R In case of multiple layers of packaging (box with 2 blisters of 20 tablets) this element is used for describing the most outer Packaged Medicinal Product Item or the Packaged Medicinal Product. For example in the case    \--Box    \-----2 blisters    \--------20 tablets  it describes the Packaged Medicinal Product.  (UVM...ail) @classCode cs 1 … 1 F CONT pharm:quantity PQ 0 … 1 R (UVM...ail) pharm:containerPackagedProduct 1 … 1 R When present, it represents the Packaged Medicinal Product (UVM...ail) @classCode cs 1 … 1 F CONT @determiner​Code cs 1 … 1 F KIND pharm:code CD 0 … 1 When present, it can be used to convey the Packaged Medicinal Product ID. (UVM...ail) pharm:name ST 0 … 1 R (UVM...ail) pharm:formCode CE 1 … 1 R (UVM...ail) pharm:capacity​Quantity PQ 0 … 1 Captures the number of product units the package would contain if fully loaded. (UVM...ail) @value 1 … 1 R @unit cs 0 … 1   pharm:asSpecializedKind 0 … * (UVM...ail) @classCode cs 1 … 1 F GRIC Included from 2.16.840.1.113883.10.21.4.19 UV Generalized Medicine Class (DYNAMIC) pharm:generalizedMedicineKind 0 … * (UVM...ail) @classCode cs 1 … 1 F MMAT @determiner​Code cs 1 … 1 F KIND pharm:code 1 … 1 R (UVM...ail) pharm:name 0 … * (UVM...ail) pharm:part 0 … * (UVM...ail) @classCode cs 1 … 1 F PART pharm:id II 0 … 1 (UVM...ail) pharm:quantity PQ 0 … 1 (UVM...ail) pharm:partProduct 1 … 1 (UVM...ail) pharm:code CE 0 … 1 (UVM...ail) pharm:name EN 0 … 1 (UVM...ail) pharm:desc ED 0 … 1 (UVM...ail) pharm:formCode CE 0 … 1 (UVM...ail) pharm:asContent 0 … * (UVM...ail) @classCode cs 1 … 1 F CONT Included from 2.16.840.1.113883.10.21.4.17 UV Content (DYNAMIC) pharm:quantity PQ 0 … 1 R The quantity which specified how many inner packaged content entities are in an outer packaging container entity. (UVM...ail) pharm:containerPackagedProduct 1 … 1 R (UVM...ail) @classCode cs 1 … 1 F CONT @determiner​Code cs 1 … 1 F KIND pharm:code CE 0 … 1 It represents the code of the Package Item or of the Packaged Medicinal Product. If this is also the most outer <pharm:containerPackagedProduct> than this element can be used to convey the Packaged Medicinal Product ID. (UVM...ail) pharm:name EN 0 … * It represents the Name of the Package Item or of the Packaged Medicinal Product. If this is also the most outer <pharm:containerPackagedProduct> than this element can be used for the brand name. (UVM...ail) pharm:formCode CE 0 … 1 This element encodes the type of the most inner package item or of the or the Packaged Medicinal Product. (UVM...ail) pharm:capacity​Quantity PQ 0 … 1 Captures the number of product units the package would contain if fully loaded. (UVM...ail) @value 1 … 1 R @unit cs 0 … 1   pharm:asContent 0 … * In case of multiple layers of packaging (5 vials 10 ml; box with 2 blisters of 20 tablets) this element can be used for describing the intermediate Packaged Medicinal Product Item or the Packaged Medicinal Product. For example in the case    \--Box    \-----2 blisters    \--------20 tablets  it describes the "2 blisters"  In the case of    \--Box    \-----5 vials it represents the Packaged Medicinal Product.  (UVM...ail) @classCode cs 1 … 1 F CONT pharm:quantity PQ 0 … 1 R The quantity which specified how many inner packaged content entities are in an outer packaging container entity. (UVM...ail) pharm:containerPackagedProduct 1 … 1 R It represents the intermediate Package Item or the Packaged Medicinal Product (UVM...ail) @classCode cs 1 … 1 F CONT @determiner​Code cs 1 … 1 F KIND pharm:code CD 0 … 1 It represents the code of the Package Item or of the Packaged Medicinal Product. If this is also the most outer <pharm:containerPackagedProduct> than this element can be used to convey the Packaged Medicinal Product ID. (UVM...ail) pharm:name ST 0 … 1 R It represents the Name of the Package Item or of the Packaged Medicinal Product. If this is also the most outer <pharm:containerPackagedProduct> than this element can be used for the brand name. (UVM...ail) pharm:formCode CE 1 … 1 R This element encodes the type of the intermediate package item or of the or the Packaged Medicinal Product. (UVM...ail) pharm:capacity​Quantity PQ 0 … 1 Captures the number of product units the package would contain if fully loaded. (UVM...ail) @value 1 … 1 R @unit cs 0 … 1   pharm:asContent 0 … * R In case of multiple layers of packaging (box with 2 blisters of 20 tablets) this element is used for describing the most outer Packaged Medicinal Product Item or the Packaged Medicinal Product. For example in the case    \--Box    \-----2 blisters    \--------20 tablets  it describes the Packaged Medicinal Product.  (UVM...ail) @classCode cs 1 … 1 F CONT pharm:quantity PQ 0 … 1 R (UVM...ail) pharm:containerPackagedProduct 1 … 1 R When present, it represents the Packaged Medicinal Product (UVM...ail) @classCode cs 1 … 1 F CONT @determiner​Code cs 1 … 1 F KIND pharm:code CD 0 … 1 When present, it can be used to convey the Packaged Medicinal Product ID. (UVM...ail) pharm:name ST 0 … 1 R (UVM...ail) pharm:formCode CE 1 … 1 R (UVM...ail) pharm:capacity​Quantity PQ 0 … 1 Captures the number of product units the package would contain if fully loaded. (UVM...ail) @value 1 … 1 R @unit cs 0 … 1   pharm:asSpecializedKind 0 … * (UVM...ail) @classCode cs 1 … 1 F GRIC Included from 2.16.840.1.113883.10.21.4.19 UV Generalized Medicine Class (DYNAMIC) pharm:generalizedMedicineKind 0 … * (UVM...ail) @classCode cs 1 … 1 F MMAT @determiner​Code cs 1 … 1 F KIND pharm:code 1 … 1 R (UVM...ail) pharm:name 0 … * (UVM...ail) pharm:part 0 … * (UVM...ail) @classCode cs 1 … 1 F PART pharm:id II 0 … 1 (UVM...ail) pharm:quantity PQ 0 … 1 (UVM...ail) pharm:partProduct 1 … 1 (UVM...ail) pharm:code CE 0 … 1 (UVM...ail) pharm:name EN 0 … 1 (UVM...ail) pharm:desc ED 0 … 1 (UVM...ail) pharm:formCode CE 0 … 1 (UVM...ail) pharm:asContent 0 … * (UVM...ail) @classCode cs 1 … 1 F CONT Included from 2.16.840.1.113883.10.21.4.17 UV Content (DYNAMIC) pharm:quantity PQ 0 … 1 R The quantity which specified how many inner packaged content entities are in an outer packaging container entity. (UVM...ail) pharm:containerPackagedProduct 1 … 1 R (UVM...ail) @classCode cs 1 … 1 F CONT @determiner​Code cs 1 … 1 F KIND pharm:code CE 0 … 1 It represents the code of the Package Item or of the Packaged Medicinal Product. If this is also the most outer <pharm:containerPackagedProduct> than this element can be used to convey the Packaged Medicinal Product ID. (UVM...ail) pharm:name EN 0 … * It represents the Name of the Package Item or of the Packaged Medicinal Product. If this is also the most outer <pharm:containerPackagedProduct> than this element can be used for the brand name. (UVM...ail) pharm:formCode CE 0 … 1 This element encodes the type of the most inner package item or of the or the Packaged Medicinal Product. (UVM...ail) pharm:capacity​Quantity PQ 0 … 1 Captures the number of product units the package would contain if fully loaded. (UVM...ail) @value 1 … 1 R @unit cs 0 … 1   pharm:asContent 0 … * In case of multiple layers of packaging (5 vials 10 ml; box with 2 blisters of 20 tablets) this element can be used for describing the intermediate Packaged Medicinal Product Item or the Packaged Medicinal Product. For example in the case    \--Box    \-----2 blisters    \--------20 tablets  it describes the "2 blisters"  In the case of    \--Box    \-----5 vials it represents the Packaged Medicinal Product.  (UVM...ail) @classCode cs 1 … 1 F CONT pharm:quantity PQ 0 … 1 R The quantity which specified how many inner packaged content entities are in an outer packaging container entity. (UVM...ail) pharm:containerPackagedProduct 1 … 1 R It represents the intermediate Package Item or the Packaged Medicinal Product (UVM...ail) @classCode cs 1 … 1 F CONT @determiner​Code cs 1 … 1 F KIND pharm:code CD 0 … 1 It represents the code of the Package Item or of the Packaged Medicinal Product. If this is also the most outer <pharm:containerPackagedProduct> than this element can be used to convey the Packaged Medicinal Product ID. (UVM...ail) pharm:name ST 0 … 1 R It represents the Name of the Package Item or of the Packaged Medicinal Product. If this is also the most outer <pharm:containerPackagedProduct> than this element can be used for the brand name. (UVM...ail) pharm:formCode CE 1 … 1 R This element encodes the type of the intermediate package item or of the or the Packaged Medicinal Product. (UVM...ail) pharm:capacity​Quantity PQ 0 … 1 Captures the number of product units the package would contain if fully loaded. (UVM...ail) @value 1 … 1 R @unit cs 0 … 1   pharm:asContent 0 … * R In case of multiple layers of packaging (box with 2 blisters of 20 tablets) this element is used for describing the most outer Packaged Medicinal Product Item or the Packaged Medicinal Product. For example in the case    \--Box    \-----2 blisters    \--------20 tablets  it describes the Packaged Medicinal Product.  (UVM...ail) @classCode cs 1 … 1 F CONT pharm:quantity PQ 0 … 1 R (UVM...ail) pharm:containerPackagedProduct 1 … 1 R When present, it represents the Packaged Medicinal Product (UVM...ail) @classCode cs 1 … 1 F CONT @determiner​Code cs 1 … 1 F KIND pharm:code CD 0 … 1 When present, it can be used to convey the Packaged Medicinal Product ID. (UVM...ail) pharm:name ST 0 … 1 R (UVM...ail) pharm:formCode CE 1 … 1 R (UVM...ail) pharm:capacity​Quantity PQ 0 … 1 Captures the number of product units the package would contain if fully loaded. (UVM...ail) @value 1 … 1 R @unit cs 0 … 1   pharm:asSpecializedKind 0 … * (UVM...ail) @classCode cs 1 … 1 F GRIC Included from 2.16.840.1.113883.10.21.4.19 UV Generalized Medicine Class (DYNAMIC) pharm:generalizedMedicineKind 0 … * (UVM...ail) @classCode cs 1 … 1 F MMAT @determiner​Code cs 1 … 1 F KIND pharm:code 1 … 1 R (UVM...ail) pharm:name 0 … * (UVM...ail) pharm:part 0 … * (UVM...ail) @classCode cs 1 … 1 F PART pharm:ingredient 0 … * (UVM...ail) @classCode cs 1 … 1 R   CONF The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.10430 RoleClassIngredientEntity (DYNAMIC) Included from 2.16.840.1.113883.10.21.4.18 UV Ingredient (DYNAMIC) pharm:quantity RTO_PQ_PQ 0 … 1 (UVM...ail)   Example 10 mg of the ingredient per ml <pharm:quantity>   <cda:numerator xsi:type="PQ" value="10" unit="mg"/>  <cda:denominator xsi:type="PQ" value="1" unit="ml"/></pharm:quantity>   Example 2% of the ingredient <pharm:quantity>   <cda:numerator xsi:type="PQ" value="2" unit="%"/>  <cda:denominator xsi:type="PQ" value="1"/></pharm:quantity>   Example 5mg of the ingredient <pharm:quantity>   <cda:numerator xsi:type="PQ" value="5" unit="mg"/>  <cda:denominator xsi:type="PQ" value="1"/></pharm:quantity> cda:numerator PQ 0 … 1 (UVM...ail) cda:denominator PQ 0 … 1 (UVM...ail) pharm:ingredientSubstance 0 … 1 The substance used for this product plying the role indicated in the ingredient classCode. The <code> element contains the coded representation of the ingredient and the <name> element may be used for the plain text representation. (UVM...ail) @classCode cs 1 … 1 F MMAT @determiner​Code cs 1 … 1 F KIND pharm:code CD 0 … 1 C (UVM...ail) pharm:name EN 0 … 1 C (UVM...ail)   Schematron assert role  error     test pharm:code or pharm:name     Message Either the name or the code of the substance (or both) shall be provided   pharm:ingredient 0 … * (UVM...ail) @classCode cs 1 … 1 R   CONF The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.10430 RoleClassIngredientEntity (DYNAMIC) Included from 2.16.840.1.113883.10.21.4.18 UV Ingredient (DYNAMIC) pharm:quantity RTO_PQ_PQ 0 … 1 (UVM...ail)   Example 10 mg of the ingredient per ml <pharm:quantity>   <cda:numerator xsi:type="PQ" value="10" unit="mg"/>  <cda:denominator xsi:type="PQ" value="1" unit="ml"/></pharm:quantity>   Example 2% of the ingredient <pharm:quantity>   <cda:numerator xsi:type="PQ" value="2" unit="%"/>  <cda:denominator xsi:type="PQ" value="1"/></pharm:quantity>   Example 5mg of the ingredient <pharm:quantity>   <cda:numerator xsi:type="PQ" value="5" unit="mg"/>  <cda:denominator xsi:type="PQ" value="1"/></pharm:quantity> cda:numerator PQ 0 … 1 (UVM...ail) cda:denominator PQ 0 … 1 (UVM...ail) pharm:ingredientSubstance 0 … 1 The substance used for this product plying the role indicated in the ingredient classCode. The <code> element contains the coded representation of the ingredient and the <name> element may be used for the plain text representation. (UVM...ail) @classCode cs 1 … 1 F MMAT @determiner​Code cs 1 … 1 F KIND pharm:code CD 0 … 1 C (UVM...ail) pharm:name EN 0 … 1 C (UVM...ail)   Schematron assert role  error     test pharm:code or pharm:name     Message Either the name or the code of the substance (or both) shall be provided   pharm:ingredient 0 … * (UVM...ail) @classCode cs 1 … 1 R   CONF The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.10430 RoleClassIngredientEntity (DYNAMIC) Included from 2.16.840.1.113883.10.21.4.18 UV Ingredient (DYNAMIC) pharm:quantity RTO_PQ_PQ 0 … 1 (UVM...ail)   Example 10 mg of the ingredient per ml <pharm:quantity>   <cda:numerator xsi:type="PQ" value="10" unit="mg"/>  <cda:denominator xsi:type="PQ" value="1" unit="ml"/></pharm:quantity>   Example 2% of the ingredient <pharm:quantity>   <cda:numerator xsi:type="PQ" value="2" unit="%"/>  <cda:denominator xsi:type="PQ" value="1"/></pharm:quantity>   Example 5mg of the ingredient <pharm:quantity>   <cda:numerator xsi:type="PQ" value="5" unit="mg"/>  <cda:denominator xsi:type="PQ" value="1"/></pharm:quantity> cda:numerator PQ 0 … 1 (UVM...ail) cda:denominator PQ 0 … 1 (UVM...ail) pharm:ingredientSubstance 0 … 1 The substance used for this product plying the role indicated in the ingredient classCode. The <code> element contains the coded representation of the ingredient and the <name> element may be used for the plain text representation. (UVM...ail) @classCode cs 1 … 1 F MMAT @determiner​Code cs 1 … 1 F KIND pharm:code CD 0 … 1 C (UVM...ail) pharm:name EN 0 … 1 C (UVM...ail)   Schematron assert role  error     test pharm:code or pharm:name     Message Either the name or the code of the substance (or both) shall be provided   pharm:ingredient 0 … * This module provides the list of the ingredients (substances with a role) used for this product; one or more ingredients may be present. The classCode of "ACTI" indicates that this is an active ingredient. (UVM...ail) @classCode cs 1 … 1 R   CONF The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.10430 RoleClassIngredientEntity (DYNAMIC)   Example <pharm:ingredient classCode="ACTI">   <pharm:quantity>     <cda:numerator type="PQ" value=" " unit=" "/>    <cda:denominator type="PQ" value=" " unit=" "/>  </pharm:quantity>  <ingredientSubstance classCode="MMAT" determinerCode="KIND">     <code code=" " displayName=" " codeSystem="2.16.840.1.113883.6.73" codeSystemName="ATC WHO"/>  </ingredientSubstance></pharm:ingredient> Included from 2.16.840.1.113883.10.21.4.18 UV Ingredient (DYNAMIC) pharm:quantity RTO_PQ_PQ 0 … 1 (UVM...ail)   Example 10 mg of the ingredient per ml <pharm:quantity>   <cda:numerator xsi:type="PQ" value="10" unit="mg"/>  <cda:denominator xsi:type="PQ" value="1" unit="ml"/></pharm:quantity>   Example 2% of the ingredient <pharm:quantity>   <cda:numerator xsi:type="PQ" value="2" unit="%"/>  <cda:denominator xsi:type="PQ" value="1"/></pharm:quantity>   Example 5mg of the ingredient <pharm:quantity>   <cda:numerator xsi:type="PQ" value="5" unit="mg"/>  <cda:denominator xsi:type="PQ" value="1"/></pharm:quantity> cda:numerator PQ 0 … 1 (UVM...ail) cda:denominator PQ 0 … 1 (UVM...ail) pharm:ingredientSubstance 0 … 1 The substance used for this product plying the role indicated in the ingredient classCode. The <code> element contains the coded representation of the ingredient and the <name> element may be used for the plain text representation. (UVM...ail) @classCode cs 1 … 1 F MMAT @determiner​Code cs 1 … 1 F KIND pharm:code CD 0 … 1 C (UVM...ail) pharm:name EN 0 … 1 C (UVM...ail)   Schematron assert role  error     test pharm:code or pharm:name     Message Either the name or the code of the substance (or both) shall be provided   hl7:manufacturerOrganization 0 … 1 R Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) (UVM...ail)

UV Medication Information (simple)

Id	2.16.840.1.113883.10.21.4.10	Effective Date	2021‑09‑29 19:15:16 Other versions this id: UVMedicationInformationsimple as of 2021‑09‑29 19:15:02 UVMedicationInformationsimple as of 2017‑05‑10
Status	Under pre-publication review	Version Label	R1-STU2-ballot
Name	UVMedicationInformationsimple	Display Name	UV Medication Information (simple)
Description	Universal Medication Information (simple)
Context	Parent nodes of template element with id 2.16.840.1.113883.10.21.4.10
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Uses	Uses 1 template Uses as Name Version 2.16.840.1.113883.10.12.151 Containment CDA Organization DYNAMIC
Relationship	Version: template 2.16.840.1.113883.10.21.4.10 UV Medication Information (simple) (2017‑05‑10) Specialization: template 2.16.840.1.113883.10.12.312 CDA ManufacturedProduct (2005‑09‑07) ref ad1bbr- Adaptation: template 2.16.840.1.113883.10.20.22.4.54 Immunization Medication Information (V2) (2014‑06‑09) ref ccda-
Example	US RxNorm Code <hl7:manufacturedProduct classCode="MANU">   <hl7:templateId root="2.16.840.1.113883.10.21.4.10"/>  <hl7:manufacturedMaterial classCode="MMAT" determinerCode="KIND">     <hl7:code code="243670" codeSystem="2.16.840.1.113883.6.88" displayName="Aspirin 81 MG Oral Tablet"/>  </hl7:manufacturedMaterial></hl7:manufacturedProduct>
Example	Dutch G-Standaard Artikel Code <hl7:manufacturedProduct classCode="MANU">   <hl7:templateId root="2.16.840.1.113883.10.21.4.10"/>  <hl7:manufacturedMaterial classCode="MMAT" determinerCode="KIND">     <hl7:code code="14145839" codeSystem="2.16.840.1.113883.2.4.4.8" codeSystemName="G-Standaard Artikel" displayName="FUROSEMIDE CF 40MG TABLET"/>  </hl7:manufacturedMaterial></hl7:manufacturedProduct>
Example	German Pharmaceutical Product Code <hl7:manufacturedProduct classCode="MANU">   <hl7:templateId root="2.16.840.1.113883.10.21.4.10"/>  <hl7:manufacturedMaterial classCode="MMAT" determinerCode="KIND">     <hl7:code code="4213974" codeSystem="1.2.276.0.76.4.6" displayName="RAMIPRIL STADA 5 mg"/>    <hl7:lotNumberText>675-86574</hl7:lotNumberText>  </hl7:manufacturedMaterial>  <hl7:manufacturerOrganization>     <hl7:name>STADA GmbH</hl7:name>  </hl7:manufacturerOrganization></hl7:manufacturedProduct>
Item DT Card Conf Description Label hl7:manufacturedProduct (UVM...ple) @classCode cs 1 … 1 F MANU hl7:templateId II 1 … 1 M (UVM...ple) @root uid 1 … 1 F 2.16.840.1.113883.10.21.4.10 hl7:manufactured​Material 1 … 1 M (UVM...ple) @classCode cs 0 … 1 F MMAT @determiner​Code cs 0 … 1 F KIND hl7:code CD 1 … 1 R The code element describes the code of the medication. The medication may be either a brand/product or described as a generic/scientific name or a descriptor of a magistral preparation/compound medicine If the medicine has no code / is uncoded (e.g., magistral preparations, compound medicine, ...) nullFlavor="NA" SHALL be used. (UVM...ple) hl7:translation CE 0 … * (UVM...ple)   CONF shall be drawn from concept domain "Product Code" hl7:lotNumberText 0 … 1 (UVM...ple) hl7:manufacturerOrganization 0 … 1 R Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) (UVM...ple)

UV Medication Order Reference

Id	2.16.840.1.113883.10.21.4.8	Effective Date	2017‑03‑30
Status	Under pre-publication review	Version Label	R1-STU2-ballot
Name	UVMedicationOrderReference	Display Name	UV Medication Order Reference
Description	Universal Medication Medication Order Reference
Context	Parent nodes of template element with id 2.16.840.1.113883.10.21.4.8
Label	MedicationOrderReference
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Uses	Uses 1 template Uses as Name Version 2.16.840.1.113883.10.12.318 Containment CDA Author (Body) DYNAMIC
Relationship	Specialization: template 2.16.840.1.113883.10.12.308 CDA SubstanceAdministration (2005‑09‑07) ref ad1bbr-
Example	Example <substanceAdministration classCode="SBADM" moodCode="RQO">   <templateId root="2.16.840.1.113883.10.21.4.8"/>  <id root="1.2.3.99.99.99" extension="988437489739"/></substanceAdministration>
Item DT Card Conf Description Label hl7:substanceAdministration Medi...ence @classCode cs 1 … 1 F SBADM @moodCode cs 1 … 1 F RQO hl7:templateId II 1 … 1 M Medi...ence @root uid 1 … 1 F 2.16.840.1.113883.10.21.4.8 hl7:id II 1 … 1 R Medi...ence hl7:author 0 … * Prescriber: A party that originates the order and therefore has responsibility for the information given in the order. Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC) Medi...ence

UV Subordinate Substance Administration

Id	2.16.840.1.113883.10.21.4.6	Effective Date	2023‑01‑30 09:36:00 Other versions this id: UVSubordinateadministration as of 2017‑04‑30
Status	Draft	Version Label	2023
Name	UVSubordinateadministration	Display Name	UV Subordinate Substance Administration
Description	Universal Subordinate Substance Administration to convey information about dosages
Context	Parent nodes of template element with id 2.16.840.1.113883.10.21.4.6
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Relationship	Version: template 2.16.840.1.113883.10.21.4.6 UV Subordinate Substance Administration (2017‑04‑30) 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="2.16.840.1.113883.10.21.4.6"/>  <statusCode code="active"/>  <effectiveTime xsi:type="PIVL_TS" institutionSpecified="true">     <period value="12" unit="h"/>  </effectiveTime>  <doseQuantity xsi:type="IVL_PQ" value="2" unit="{puff}"/>  <consumable>     <manufacturedProduct>       <manufacturedMaterial nullFlavor="NA"/>    </manufacturedProduct>  </consumable></substanceAdministration>
Item DT Card Conf Description Label hl7:substanceAdministration 1 … 1 R (UVS...ion) @classCode cs 1 … 1 F SBADM @moodCode cs 1 … 1 R If the subordinate substance administration refers to Medication Order then a substance administration request (moodCode is 'RQO') is used. If it refers to a Medication Statement, the moodCode shall be set to event/intent (moodCode is 'EVN' or 'INT').   CONF The value of @moodCode shall be drawn from value set 2.16.840.1.113883.11.21.4 Mood Code Evn Int Rqo (DYNAMIC)   Constraint The moodCode of this subordinate substance administration SHALL be the same of the parent substance administration hl7:templateId II 1 … 1 M (UVS...ion) @root uid 1 … 1 F 2.16.840.1.113883.10.21.4.6 hl7:statusCode CS 1 … 1 M (UVS...ion)   Constraint The statusCode of this subordinate substance administration SHALL be the same of that of the parent substance administration.   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.11.21.2 ActStatusActiveCompletedAbortedSuspended (DYNAMIC) Choice 1 … 1 Elements to choose from: hl7:effectiveTime[@value or @nullFlavor] hl7:effectiveTime[@xsi:type='PIVL_TS'] hl7:effectiveTime[@xsi:type='EIVL_TS'] hl7:effectiveTime[@xsi:type='SXPR_TS'] hl7:effectiveTime TS 0 … 1 C This required element describes the frequency of intakes. If not known it shall be valued with the nullflavor "UNK" (UVS...ion) where [@value or @nullFlavor]   Example Once (known date) <effectiveTime value="20170404"/>   Example Unknown <effectiveTime nullFlavor="UNK"/> hl7:effectiveTime PIVL_TS 0 … 1 C Periodic Time Interval (UVS...ion) where [@xsi:type='PIVL_TS']   Example Every 4 hours <effectiveTime xsi:type="PIVL_TS" institutionSpecified="false">   <period value="4" unit="h"/></effectiveTime>   Example Twice a day <effectiveTime xsi:type="PIVL_TS" institutionSpecified="true">   <period value="12" unit="h"/></effectiveTime> hl7:effectiveTime EIVL_TS 0 … 1 C Event Related Time Interval (UVS...ion) where [@xsi:type='EIVL_TS']   Example After meal <effectiveTime xsi:type="EIVL_TS">   <event code="PC" codeSystem="2.16.840.1.113883.5.139"/></effectiveTime>   Example One hour before breakfast <effectiveTime xsi:type="EIVL_TS">   <event code="ACM" codeSystem="2.16.840.1.113883.5.139"/>  <offset>     <low value="1" unit="h"/>  </offset></effectiveTime> hl7:event EIVL.event 0 … 1 C (UVS...ion) @code cs 0 … 1     CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10706 TimingEvent (DYNAMIC) hl7:effectiveTime SXPR_TS 0 … 1 R Combined Time Interval (UVS...ion) where [@xsi:type='SXPR_TS'] hl7:doseQuantity IVL_PQ 0 … 1 R The doseQuantity describes the amount of the medication given (the dosage). If a dose range is given (e.g., 1-2 tablets, or 325-750mg), then the <low> and <high> bounds are specified in their respective elements; otherwise only one physical quantity is specified (e.g. 2 drops) The dose can be in some known and measurable unit, such as grams, milligrams,or described in "administration" units (unit of presentation, such as capsules). If the dose is in countable items (tablets, caplets, "eaches"), then the unit could be omitted or valorized using the UCUM annotations for describing the type of countable items (e.g. .{tablet}, {puff},..). The unit attribute – when expresses unit of measures- shall be derived from the UCUM code system. The used elements should contain a <translation> element that provides a reference to the originalText found in the narrative body of the document. (UVS...ion) @unit cs 0 … 1     Example Not pre-coordinated consumable <doseQuantity value="25" unit="mg"/>   Example Pre-coordinated consumable - Dose Range <doseQuantity>   <low value="1" unit="{tablet}"/>  <high value="2" unit="{tablet}"/></doseQuantity>   Example Pre-coordinated consumable <doseQuantity value="2" unit="{puff}"/>   Example Pre-coordinated consumable with text reference <doseQuantity value="2" unit="{puff}">   <translation nullFlavor="NI">     <originalText>       <reference value="#text-ref-1"/>    </originalText>  </translation></doseQuantity>   Example Textual dosage <doseQuantity nullFlavor="NI">   <translation nullFlavor="NI">     <originalText>       <reference value="#text-ref-1"/>    </originalText>  </translation></doseQuantity> hl7:rateQuantity IVL_PQ 0 … 1 (UVS...ion) hl7:maxDoseQuantity RTO_PQ_PQ 0 … 1 (UVS...ion) hl7:administrationUnitCode CE 0 … 1 (UVS...ion)   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14570 AdministrableDrugForm (DYNAMIC) hl7:consumable 1 … 1 R (UVS...ion) hl7:manufacturedProduct 1 … 1 R (UVS...ion) hl7:manufactured​Material 1 … 1 R (UVS...ion) @nullFlavor cs 1 … 1 F NA

UV Substitution Permission

Id	2.16.840.1.113883.10.21.4.5	Effective Date	2017‑01‑02
Status	Under pre-publication review	Version Label	R1-STU2-ballot
Name	UVSubstitutionPermission	Display Name	UV Substitution Permission
Description	Information about a substitution permission for this adminstration.
Context	Parent nodes of template element with id 2.16.840.1.113883.10.21.4.5
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Relationship	Specialization: template 2.16.840.1.113883.10.12.301 CDA Act (2005‑09‑07) ref ad1bbr-
Example	Example <act classCode="ACT" moodCode="DEF">   <templateId root="2.16.840.1.113883.10.21.4.5"/>  <code code="TE" codeSystem="2.16.840.1.113883.5.1070" displayName="therapeutic alternative"/>  <entryRelationship typeCode="RSON">     <act classCode="ACT" moodCode="EVN">       <!-- Reason no substitution -->     </act>  </entryRelationship></act>
Item DT Card Conf Description Label hl7:act 1 … 1 M (UVS...ion) @classCode cs 1 … 1 F ACT @moodCode cs 1 … 1 F DEF hl7:templateId II 1 … 1 M (UVS...ion) @root uid 1 … 1 F 2.16.840.1.113883.10.21.4.5 hl7:code CE (example) 1 … 1 The type of substitution that this permission relates to. (UVS...ion)   CONF Examples of the value of @code are in the value set 2.16.840.1.113883.1.11.16621 ActSubstanceAdminSubstitutionCode (DYNAMIC) hl7:entryRelationship 0 … 1 C Used when substitution is not allowed and may indicate the reason for why substitution is not allowed. (UVS...ion) @typeCode cs 1 … 1 F RSON   Example <entryRelationship typeCode="RSON">   <code code="PAT" codeSystem="2.16.840.1.113883.5.8" displayName="Patient request">     <originalText>Patient objects</originalText>  </code></entryRelationship> hl7:act 1 … 1 (UVS...ion) @classCode cs 1 … 1 F ACT @moodCode cs 1 … 1 F EVN hl7:code CD (example) 1 … 1 (UVS...ion)   CONF Examples of the value of @code are in the value set 2.16.840.1.113883.1.11.19719 SubstanceAdminSubstitutionNotAllowedReason (DYNAMIC)

UV Use Period

Id	2.16.840.1.113883.10.21.9.1	Effective Date	2023‑01‑30 09:55:27 Other versions this id: Useperiod as of 2017‑05‑02 Useperiod as of 2017‑01‑02
Status	Draft	Version Label	2023
Name	Useperiod	Display Name	UV Use Period
Description This element encodes the start and stop time of the medication regimen. This is an interval of time (xsi:type='IVL_TS'), and must be specified as shown. This is an additional constraint placed upon CDA Release 2.0 by this profile, and simplifies the exchange of start/stop and frequency information between EMR systems.
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Item DT Card Conf Description Label 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. (Use...iod) 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 (Use...iod) hl7:high IVXB_TS 0 … 1 R (Use...iod) 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) (Use...iod) 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 (Use...iod) hl7:high NP (Use...iod) hl7:center NP (Use...iod) hl7:width PQ 1 … 1 R (Use...iod) @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) (Use...iod) 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 (Use...iod) hl7:width PQ 1 … 1 R (Use...iod) @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)

Templates drawn from C-CDA (no ballot)

Comment Activity

Id	2.16.840.1.113883.10.20.22.4.64	Effective Date	valid from 2015‑08‑13 There are versions of templates with this id: CommentActivity as of 2015‑08‑13 CommentActivity as of 2013‑01‑31
Status	Under pre-publication review	Version Label	2.1
Name	CommentActivity	Display Name	Comment Activity
Description Comments are free text data that cannot otherwise be recorded using data elements already defined by this specification. They are not to be used to record information that can be recorded elsewhere. For example, a free text description of the severity of an allergic reaction would not be recorded in a comment.
Context	Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.64
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 0 transactions and 1 template, Uses 0 templates Used by as Name Version 2.16.840.1.113883.10.21.4.1 Containment UV Medication Order () 2015‑10‑07
Relationship	Specialization: template 2.16.840.1.113883.10.12.301 CDA Act (2005‑09‑07) ref (from repository: ad1bbr-)
Item DT Card Conf Description Label cda:act Comm...vity @classCode cs 1 … 1 F ACT CONF...9425   SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:81-9425). @moodCode cs 1 … 1 F EVN CONF...9426   SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:81-9426).   Constraint Data elements defined elsewhere in the specification SHALL NOT be recorded using the Comment Activity cda:templateId II 1 … 1 M SHALL contain exactly one [1..1] templateId (CONF:81-9427) such that it CONF...9427 @root uid 1 … 1 F 2.16.840.1.113883.10.20.22.4.64 CONF...0491   SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.64" (CONF:81-10491). cda:code CD 1 … 1 M SHALL contain exactly one [1..1] code (CONF:81-9428). CONF...9428 @code CONF 1 … 1 F 48767-8 @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) cda:text 1 … 1 M SHALL contain exactly one [1..1] text (CONF:81-9430). CONF...9430 cda:reference 1 … 1 M This text SHALL contain exactly one [1..1] reference (CONF:81-15967). CONF:81‑15967 / CONF:81‑9431 @value 1 … 1 R This reference SHALL contain exactly one [1..1] @value (CONF:81-15968). CONF...5968   Schematron assert role  error     test not(@value) or starts-with(@value, '#')     Message This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1)   cda:author 0 … 1 MAY contain zero or one [0..1] author (CONF:81-9433). CONF...9433 cda:time 1 … 1 R The author, if present, SHALL contain exactly one [1..1] time (CONF:81-9434). CONF...9434 cda:assignedAuthor 1 … 1 M The author, if present, SHALL contain exactly one [1..1] assignedAuthor (CONF:81-9435). SHALL include assignedPerson/name or representedOrganization/name CONF...9435 cda:id II 1 … 1 This assignedAuthor SHALL contain exactly one [1..1] id (CONF:81-9436). CONF...9436 cda:addr AD 1 … 1 M This assignedAuthor SHALL contain exactly one [1..1] addr (CONF:81-9437). CONF...9437   Schematron assert role  error     test cda:streetAddressLine and cda:city and ((not(cda:country) or cda:country!='US') or (cda:country='US' and cda:state and cda:postalCode))     Message The content of addr SHALL be a conformant US Realm Address (AD.US.FIELDED) (2.16.840.1.113883.10.20.22.5.2)   Choice 1 …  Elements to choose from: cda:assignedPerson cda:representedOrganization cda:assignedPerson CONF...9435 cda:name 1 … 1 M CONF...9435   Schematron assert role  error     test (cda:given and cda:family) or (not(*) and string-length(.)!=0)     Message An assignedPerson/name SHALL be a conformant US Realm Person Name (PN.US.FIELDED) (2.16.840.1.113883.10.20.22.5.1.1)   cda:representedOrganization CONF...9435 cda:name 1 … 1 R CONF...9435

Indication (V2)

Id	2.16.840.1.113883.10.20.22.4.19 ref ccda-	Effective Date	2014‑06‑09
Status	Draft	Version Label	2.1
Name	IndicationV2	Display Name	Indication (V2)
Description This template represents the rationale for an action such as an encounter, a medication administration, or a procedure. The id element can be used to reference a problem recorded elsewhere in the document, or can be used with a code and value to record the problem. Indications for treatment are not laboratory results; rather the problem associated with the laboratory result should be sited (e.g., hypokalemia instead of a laboratory result of Potassium 2.0 mEq/L). Use the Drug Monitoring Act [[]templateId 2.16.840.1.113883.10.20.22.4.123] to indicate if a particular drug needs special monitoring (e.g., anticoagulant therapy). Use Precondition for Substance Administration (V2) [[]templateId 2.16.840.1.113883.10.20.22.4.25.2] to represent that a medication is to be administered only when the associated criteria are met.
Context	Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.19
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Relationship	Specialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07) ref ad1bbr- Version: template 2.16.840.1.113883.10.20.22.4.19 Indication (2013‑01‑31) ref ccda-
Item DT Card Conf Description Label cda:observation (Ind...nV2) @classCode 1 … 1 F OBS CONF...7480   SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7480). @moodCode 1 … 1 F EVN CONF...7481   SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7481). cda:templateId II 1 … 1 M C-CDA R1.1 templateId root without an extension CONF...2936 @root uid 1 … 1 F 2.16.840.1.113883.10.20.22.4.19 cda:templateId II 1 … 1 M SHALL contain exactly one [1..1] templateId (CONF:1098-7482) such that it CONF...7482 @root 1 … 1 F 2.16.840.1.113883.10.20.22.4.19 CONF...0502   SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.19" (CONF:1098-10502). @extension 1 … 1 F 2014-06-09 CONF...2570   SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32570). cda:id II 1 … * SHALL contain at least one [1..*] id (CONF:1098-7483). CONF...7483 cda:code CD (preferred) 1 … 1 SHALL contain exactly one [1..1] code, which MAY be selected from ValueSet Problem Type urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 DYNAMIC 2014-09-02 (CONF:1098-31229). CONF...1229   CONF The value of @code comes preferably from value set 2.16.840.1.113883.3.88.12.3221.7.2 Problem Type (DYNAMIC) cda:statusCode CS 1 … 1 M SHALL contain exactly one [1..1] statusCode (CONF:1098-7487). CONF...7487 @code CONF 1 … 1 F completed cda:effectiveTime IVL_TS 0 … 1 R SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7488). CONF...7488 cda:value CD (preferred) 0 … 1 MAY contain zero or one [0..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Problem urn:oid:2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:1098-7489). CONF...7489   CONF The value of @code comes preferably from value set 2.16.840.1.113883.3.88.12.3221.7.4 Problem (DYNAMIC)

Appendix (Informative)

Acronyms and abbreviations

C-CDA	Consolidated CDA
CDA	Clinical Document Architecture
DSTU	Draft Standard for Trial Use
EDQM	European Directorate for the Quality of Medicines & Healthcare
EHR	Electronic Healthcare Record
HL7	Health Level Seven
HP	Healthcare Professional
IDMP	IDentification of Medicinal Products (ISO Standard)
IHE	Integrating the Healthcare Enterprise
ISO	International Organization for Standardization
JIC	Joint Initiative Council on SDO Global Health Informatics Standardization
LOINC	Logical Observation Identifiers Names & Codes
MPID	Medicinal Product Identifier
PCID	Medicinal Product Package Identifier
PhPID(s)	Pharmaceutical Product Identifier(s)
SDO	Standard Developing Organization
STU	Standard for Trial Use
UCUM	Unified Code for Units of Measure

Glossary

• Prescribing is an activity that can be performed by a variety of healthcare professionals and involves a variety of orderable items (see glossary entry). For the purposes of the following Implementation Guide, prescribing is defined as the act of prescribing a medication in either an ambulatory or an institutional setting. This could include initiating a new medication order or making all kinds of modifications to existing orders.
• Dispensing is an activity undertaken to fulfill the logistical requirements of a prescription. It supplies the materials needed to perform the prescribed actions by those who will perform them. Examples of dispensing include eyeglasses, contact lenses and medications. For the purposes of the following ballot material, dispensing is defined as supplying a medication in fulfillment of a prescription or medication order. While dispensing in these circumstances would usually be performed by a pharmacist, other health care providers such as nurses or physicians might also dispense medications.
• Administration is an activity undertaken to give medication to the patient. In the community, this process is usually not recorded, since the majority occurs in the patient's home; only administrations undertaken by a healthcare professional, such as vaccination, tend to be formally documented. Administration of medication in the institutional setting is usually recorded on a dose-by-dose basis, and may be messaged on that basis, or a summary of all the administrations occurring during an inpatient stay may be described.

Integrated examples

The Medication on CDA specification releases are published at Project Publication Page. The actual release has a link to the XML materials as which the W3C schemas are part of; it also includes example CDA document instances. A set of use cases have been defined and represented in Medication on CDA format.

It is likely that the publication site will move to hl7.org permanently, we will inform about that process.

Validation artifacts

You can test your implementation (instances) against the Medication on CDA specification. To download materials to your computer for local testing and validation consider...

• ...the W3C schemas (actually valid for any CDA specification) located at the Project Publication Page. The actual release has a link to the XML materials as which the W3C schemas are part of; it also includes example CDA document instances.
• ..the ISO schematron, automatically generated by the tool. These are files to do validation locally by associating IPS CDA instances with the main schematron using an XML editor or to use the derived XSLT conversions and apply the according XSLT derivation to your local IPS CDA instance.

For further information you can follow the documentation.

Operational information

• The original specification is hosted on the logical ART-DECOR main server art-decor.org under the Governance Group HL7 International, the project is reachable at the Live Project Landing Page.
• Any Medication on CDA specification release in HTML format resides at Project Publication Page. It is likely that the publication site will move to hl7.org permanently, we will inform about that process.

Licenses

Following is a non-exhaustive list of third-party terminologies that may require a separate license:

• SNOMED CT: SNOMED International (formerly know as International Healthcare Terminology Standards Development Organization IHTSDO) or info@ihtsdo.org
• Logical Observation Identifiers Names & Codes (LOINC): The Regenstrief Institute, Inc.
• Unified Code for Units of Measure (UCUM) : Regenstrief Institute, Inc. and the UCUM Organization
• EDQM Standard Terms  : European Directorate for the Quality of Medicines & Healthcare (EDQM)

List of all artifacts used in this guide

CDA Templates

• 2.16.840.1.113883.10.21.4.1 UV Medication Order
• 2.16.840.1.113883.10.21.4.2 UV Dispense Request
• 2.16.840.1.113883.10.21.4.3 UV ClinicalStatement Observation
• 2.16.840.1.113883.10.21.4.4 UV ClinicalStatement Encounter
• 2.16.840.1.113883.10.21.4.5 UV Substitution Permission
• 2.16.840.1.113883.10.21.4.6 UV Subordinate Substance Administration
• 2.16.840.1.113883.10.21.4.7 UV Medication Statement
• 2.16.840.1.113883.10.21.4.8 UV Medication Order Reference
• 2.16.840.1.113883.10.21.4.9 UV Dispense Event Reference
• 2.16.840.1.113883.10.21.4.10 UV Medication Information (simple)
• 2.16.840.1.113883.10.21.4.11 UV Medication Information (detail)
• 2.16.840.1.113883.10.21.9.1 UV Use Period

References (re-used) from current C-CDA

• 2.16.840.1.113883.10.20.22.4.64 Comment Activity
• 2.16.840.1.113883.10.20.22.4.19 Indication (V2)

Unconstrained Templates from the original CDA specification

• 2.16.840.1.113883.10.12.151 CDA Organization
• 2.16.840.1.113883.10.12.152 CDA Person
• 2.16.840.1.113883.10.12.153 CDA AssignedEntity
• 2.16.840.1.113883.10.12.310 CDA LabeledDrug
• 2.16.840.1.113883.10.12.311 CDA Material
• 2.16.840.1.113883.10.12.312 CDA ManufacturedProduct
• 2.16.840.1.113883.10.12.313 CDA PlayingEntity
• 2.16.840.1.113883.10.12.315 CDA Device
• 2.16.840.1.113883.10.12.316 CDA RelatedEntity
• 2.16.840.1.113883.10.12.318 CDA Author (Body)
• 2.16.840.1.113883.10.12.319 CDA Informant (Body)
• 2.16.840.1.113883.10.12.320 CDA Subject (Body)
• 2.16.840.1.113883.10.12.321 CDA Participant (Body)
• 2.16.840.1.113883.10.12.322 CDA Specimen
• 2.16.840.1.113883.10.12.323 CDA Performer (Body)
• 2.16.840.1.113883.10.12.324 CDA Reference
• 2.16.840.1.113883.10.12.325 CDA ExternalAct
• 2.16.840.1.113883.10.12.326 CDA ExternalObservation
• 2.16.840.1.113883.10.12.327 CDA ExternalProcedure
• 2.16.840.1.113883.10.12.328 CDA ExternalDocument
• 2.16.840.1.113883.10.12.329 CDA Precondition

Value Sets

• 2.16.840.1.113883.11.21.1 Medication Time Units (UCUM)
• 2.16.840.1.113883.11.21.2 ActStatusActiveCompletedAbortedSuspended

Referenced HL7 Version 3 Value Sets

• 2.16.840.1.113883.1.11.13955 ActEncounterCode
• 2.16.840.1.113883.1.11.16208 ActPharmacySupplyType
• 2.16.840.1.113883.1.11.16866 ActPriority
• 2.16.840.1.113883.1.11.15933 ActStatus
• 2.16.840.1.113883.1.11.19708 ActSubstanceAdministrationCode
• 2.16.840.1.113883.1.11.14570 AdministrableDrugForm
• 2.16.840.1.113883.1.11.11526 HumanLanguage
• 2.16.840.1.113883.11.20.9.18 MoodCodeEvnInt
• 2.16.840.1.113883.1.11.78 Observation Interpretation (HL7)
• 2.16.840.1.113883.1.11.14079 ObservationMethod
• 2.16.840.1.113883.1.11.14581 RouteOfAdministration
• 2.16.840.1.113883.1.11.19719 SubstanceAdminSubstitutionNotAllowedReason
• 2.16.840.1.113883.1.11.10706 TimingEvent
• 2.16.840.1.113883.1.11.19447 x_ActRelationshipEntryRelationship
• 2.16.840.1.113883.1.11.19890 x_ActStatusActiveComplete

References

Literature

• Keith W. Boone: The CDA TM Book. Springer 2011, ISBN 978-0-85729-336-7