| 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)] | |
| 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> |
| IVXB_TS | 1 … 1 | R | | Medi...rder |
| 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> |
| | | NP | | Medi...rder |
| | | NP | | Medi...rder |
| | | NP | | Medi...rder |
| PQ | 1 … 1 | R | | Medi...rder |
| 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> |
| IVXB_TS | 0 … 1 | C | | Medi...rder |
| PQ | 1 … 1 | R | | Medi...rder |
| 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 |
| 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 |
| 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 |
| 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> |
| 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 |
| cs | 1 … 1 | F | RSON |
| | Example | <entryRelationship typeCode="RSON">
<priorityNumber value="1"/> <act>
<!-- Clinical Statement Minimal -->
</act></entryRelationship> |
| 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 |
Draft
