2.16.840.1.113883.10.21.4.1/static-2015-10-07T000000

Id	2.16.840.1.113883.10.21.4.1	Effective Date	2015‑10‑07
Status	Draft	Version Label
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 13 templates Uses as Name Version 2.16.840.1.113883.10.21.9.1 Include UV Use Period DYNAMIC 2.16.840.1.113883.10.12.320 Containment CDA Subject (Body) DYNAMIC 2.16.840.1.113883.10.21.4.11 Containment UV Medication Information (detail) 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 DYNAMIC 2.16.840.1.113883.10.21.4.2 Containment UV Dispense Request DYNAMIC 2.16.840.1.113883.10.20.22.4.19 Containment Indication (V2) (2.1) DYNAMIC 2.16.840.1.113883.10.21.4.3 Containment UV ClinicalStatement Observation DYNAMIC 2.16.840.1.113883.10.21.4.5 Containment UV Substitution Permission DYNAMIC 2.16.840.1.113883.10.21.4.4 Containment UV ClinicalStatement Encounter DYNAMIC 2.16.840.1.113883.10.21.4.12 Containment UV Comment Activity DYNAMIC 2.16.840.1.113883.10.12.329 Containment CDA Precondition 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="2.16.840.1.113883.10.21.4.1"/>  <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] hl7:effectiveTime[hl7:width] 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 hl7:high] @nullFlavor cs 0 … 1     Example Known Interval <effectiveTime xsi:type="IVL_TS">   <low value="20130321"/>  <high value="20140321"/></effectiveTime>   Example Information not available about the period <effectiveTime xsi:type="IVL_TS" nullFlavor="NI"/>   Example Unknown end date <effectiveTime xsi:type="IVL_TS">   <low value="20130321"/>  <high nullFlavor="UNK"/></effectiveTime>   Example continous therapy <effectiveTime xsi: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]   Example 2 week period <effectiveTime xsi:type="IVL_TS">   <width value="2" unit="w"/></effectiveTime> hl7:low 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: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 valuet 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 valuet 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 where [hl7:relatedSubject]   Constraint Condition: This can be omitted if the patient context that is provided in the CDA header is identical to the subject hl7:consumable 1 … 1 M Consumable: The medication that is being administered Contains 2.16.840.1.113883.10.21.4.11 UV Medication Information (detail) (DYNAMIC) Medi...rder where [not(@nullFlavor)] [hl7:manufacturedProduct] @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 where [hl7:assignedAuthor] 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> hl7:entryRelationship 0 … * R Reason: Specifies the reason (indication) for authoring the order. Contains 2.16.840.1.113883.10.20.22.4.19 Indication (V2) (DYNAMIC) Medi...rder where [cda:observation [cda:code [concat(@code, @codeSystem) = doc('include/voc-2.16.840.1.113883.3.88.12.3221.7.2-2014-09-02T000000.xml')//valueSet [1]/conceptList/concept/concat(@code, @codeSystem) or @nullFlavor]]] @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 where [hl7:observation] @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 where [hl7:act [hl7:code [(@code = '48767-8' and @codeSystem = '2.16.840.1.113883.6.1')]]] @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 where [hl7:criterion]