2.16.840.1.113883.10.21.4.13/static-2019-02-17T000000

Id	2.16.840.1.113883.10.21.4.13	Effective Date	2019‑02‑17 Other versions this id: UVMedicationadministration as of 2023‑01‑30 08:31:37
Status	Under pre-publication review	Version Label	R1-STU2-ballot
Name	UVMedicationadministration	Display Name	UV Medication Administration
Description Universal Medication Administration: This includes information about an actual administration of a medication. Medication administrations include information about medication use where the medications have been prescribed or not prescribed. Medication administrations may include "negative" statements such as "the patient was not given medication ABC". Due to implementation experience, dosage information is always put into the subordinate substance administration entries.
Context	Parent nodes of template element with id 2.16.840.1.113883.10.21.4.13
Label	MedicationAdministration
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Uses	Uses 12 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 2.16.840.1.113883.10.21.4.14 Containment UV Substitution Event Adminstration (2023) DYNAMIC 2.16.840.1.113883.10.21.4.8 Containment UV Medication Order Reference (R1-STU2-ballot) DYNAMIC 2.16.840.1.113883.10.21.4.9 Containment UV Dispense Event Reference (R1-STU2-ballot) DYNAMIC
Relationship	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="2.16.840.1.113883.10.21.4.13"/>  <id root="1.2.3.99.99.99" extension="988437489739"/>  <code code="DRUG" codeSystem="2.16.840.1.113883.5.4"/>  <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="2.16.840.1.113883.10.21.4.13"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="DRUG" codeSystem="2.16.840.1.113883.5.4"/>  <text>...</text>  <statusCode code="active"/>  <!-- include template 'UV Use Period' (dynamic) .. O -->   <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'] -->   <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>
Item DT Card Conf Description Label hl7:substanceAdministration Medi...tion @classCode cs 1 … 1 F SBADM @moodCode cs 1 … 1 F EVN hl7:templateId II 1 … 1 M Medi...tion @root uid 1 … 1 F 2.16.840.1.113883.10.21.4.13 hl7:id II 0 … * R Medi...tion   Constraint If the use case requires updates on the order, the ID shall be made mandatory. hl7:code CD (extensible) 0 … 1 The code element is valorized with the ACT code from the indicated value set unless it is used for asserting the known absence of medication treatments or no information about them. Medi...tion   CONF The value of @code should be drawn from value set 2.16.840.1.113883.1.11.19708 ActSubstanceAdministrationCode (DYNAMIC) or The value of @code should be drawn from value set 2.16.840.1.113883.11.21.5 Unknown or absent medication (DYNAMIC) hl7:text ED 0 … 1 Medi...tion hl7:statusCode CS (required) 1 … 1 M Medi...tion   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19890 x_ActStatusActiveComplete (DYNAMIC) Included from 2.16.840.1.113883.10.21.9.1 UV Use Period (DYNAMIC) Choice 1 … 1 The effectiveTime element encodes the use period of the medication, it is always expressed as an interval of time. It may be expressed using the low and high OR with the width element. The first is used to indicate a specified interval (e.g. from march 15th, 2017); the latter for indicating a 'floating' period (e.g. 2 weeks). Elements to choose from: hl7:effectiveTime[hl7:low | hl7:high][not(hl7:width)] hl7:effectiveTime[hl7:width][not(hl7:low|hl7:high)] hl7:effectiveTime[hl7:low | hl7:width][not(hl7:high)] hl7:effectiveTime IVL_TS 0 … 1 C Case 1: specified interval The low and high values of the first effectiveTime element represent the start and stop times for the medication. The low value represents the start time, and the high value represents the stop time. If either the low or the high value is unknown, this shall be recorded by setting the nullFlavor attribute to UNK. In case of unbounded period (continuous therapy) the high element will be valued with the nullFlavor attribute to NA. The high value records the end of the medication regime according to the information provided in the prescription or order. For example, if the prescription is for enough medication to last 30 days, then the high value should contain a date that is 30 days later then the low value. The rationale is that a provider, seeing a prescription that has not been refilled would normally assume that the medication is no longer being taken, even if the intent of the treatment plan is to continue the medication indefinitely. Medi...tion 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...tion hl7:high IVXB_TS 0 … 1 R Medi...tion 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...tion 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...tion hl7:high NP Medi...tion hl7:center NP Medi...tion hl7:width PQ 1 … 1 R Medi...tion @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...tion 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...tion hl7:width PQ 1 … 1 R Medi...tion @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...tion hl7:routeCode CE (example) 0 … 1 Medi...tion   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...tion   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...tion hl7:rateQuantity IVL_PQ NP Medi...tion hl7:maxDoseQuantity RTO_PQ_PQ 0 … 1 Medi...tion hl7:administrationUnitCode CE NP Medi...tion 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...tion   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...tion @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...tion @typeCode cs 1 … 1 F CSM Choice 1 … 1 Required author of the medication administration: 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...tion   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 administration is the patient Medi...tion 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...tion hl7:participantRole 1 … 1 M Medi...tion @classCode cs 1 … 1 F PAT Choice 0 … 1 Optional informants of the medication administration: 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...tion 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...tion hl7:participant Use this if the informant of the medication statement is the patient Medi...tion 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...tion hl7:participantRole 1 … 1 M Medi...tion @classCode cs 1 … 1 F PAT hl7:informant Use this if the informant of the medication statement is a contact party (related party) Medi...tion 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...tion 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...tion 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...tion where [@typeCode='VRF'] @typeCode cs 1 … 1 F VRF hl7:participant 0 … 1 Location Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC) Medi...tion where [@typeCode='LOC'] @typeCode 1 … 1 F LOC 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...tion where [hl7:substanceAdministration] @typeCode cs 1 … 1 F COMP   Constraint At least one subordinate <substanceAdministration> element SHALL be present unless medications are unknown or known absent.   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...tion hl7:entryRelationship 0 … 1 R Information about any substitutions in medication that have been made. Contains 2.16.840.1.113883.10.21.4.14 UV Substitution Event Adminstration (DYNAMIC) Medi...tion where [@typeCode='COMP'] @typeCode cs 1 … 1 F COMP   Example <entryRelationship typeCode="COMP">   <act classCode="ACT" moodCode="EVN">     <!-- .. -->   </act></entryRelationship> hl7:entryRelationship 0 … * R Medication Order Reference. Contains 2.16.840.1.113883.10.21.4.8 UV Medication Order Reference (DYNAMIC) Medi...tion where [@typeCode='REFR'] [hl7:substanceAdministration] @typeCode cs 1 … 1 F REFR   Example <entryRelationship typeCode="REFR">   <substanceAdministration classCode="SBADM" moodCode="EVN">     <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...tion where [@typeCode='REFR'] [ [hl7:supply] @typeCode cs 1 … 1 F REFR   Example <entryRelationship typeCode="REFR">   <supply classCode="SPLY" moodCode="EVN">     <templateId root="2.16.840.1.113883.10.21.4.9"/>    <!-- .. -->   </supply></entryRelationship>