Pharmacy Templates

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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


© 2016-2017 Health Level Seven International ® ALL RIGHTS RESERVED.
The reproduction of this material in any form is strictly forbidden without the written permission of the publisher. HL7 and Health Level Seven are register



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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[1].

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[2]

How to read this document

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

Artifacts with other status information, especially Kgreen.png 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.

IPS ballotruler.jpg

IPS ballotruler.jpg

[Figure 1] 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 over the high-level template components of this template, followed by the actual definition. {{:2.16.840.1.113883.10.21.4.1/hgraph

Id2.16.840.1.113883.10.21.4.1Effective Date2023‑01‑31 11:29:28
Other versions this id:
  • Kblank.png UVSubstanceadministrationrequest as of 2023‑01‑31 10:52:39
  • Kblank.png UVSubstanceadministrationrequest as of 2023‑01‑30 08:30:30
  • Kblank.png UVSubstanceadministrationrequest as of 2021‑08‑04 17:03:38
  • Kblank.png UVSubstanceadministrationrequest as of 2015‑10‑07
StatusKyellow.png DraftVersion Label2023
NameUVSubstanceadministrationrequestDisplay NameUV Medication Order
DescriptionUniversal Medication Order (Substance Administration Request)
ContextParent nodes of template element with id 2.16.840.1.113883.10.21.4.1
LabelMedicationOrder
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 14 templates
Uses as NameVersion
2.16.840.1.113883.10.21.9.1IncludeKyellow.png UV Use Period (2023)DYNAMIC
2.16.840.1.113883.10.12.320ContainmentKgreen.png CDA Subject (Body)DYNAMIC
2.16.840.1.113883.10.21.4.10ContainmentKorange.png UV Medication Information (simple) (R1-STU2-ballot)DYNAMIC
2.16.840.1.113883.10.21.4.11ContainmentKyellow.png UV Medication Information (detail) (2023)DYNAMIC
2.16.840.1.113883.10.12.318ContainmentKgreen.png CDA Author (Body)DYNAMIC
2.16.840.1.113883.10.12.321ContainmentKgreen.png CDA Participant (Body)DYNAMIC
2.16.840.1.113883.10.21.4.6ContainmentKyellow.png UV Subordinate Substance Administration (2023)DYNAMIC
2.16.840.1.113883.10.21.4.2ContainmentKorange.png UV Dispense Request (R1-STU2-ballot)DYNAMIC
2.16.840.1.113883.10.21.4.3ContainmentKorange.png UV ClinicalStatement Observation (R1-STU2-ballot)DYNAMIC
2.16.840.1.113883.10.22.4.31ContainmentKorange.png IPS Internal Reference (STU1)DYNAMIC
2.16.840.1.113883.10.21.4.5ContainmentKorange.png UV Substitution Permission (R1-STU2-ballot)DYNAMIC
2.16.840.1.113883.10.21.4.4ContainmentKorange.png UV ClinicalStatement Encounter (R1-STU2-ballot)DYNAMIC
2.16.840.1.113883.10.21.4.12ContainmentKorange.png UV Comment Activity (R1-STU2-ballot)DYNAMIC
2.16.840.1.113883.10.12.329ContainmentKgreen.png CDA PreconditionDYNAMIC
RelationshipVersion: 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>
ItemDTCardConfDescriptionLabel
hl7:substanceAdministration
Medi...rder
Treetree.png@classCode
cs1 … 1FSBADM
Treetree.png@moodCode
cs1 … 1FRQO
Treetree.pnghl7:templateId
II1 … 1MMedi...rder
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.21.4.1
Treetree.pnghl7:id
II1 … *RMedi...rder
Treetree.pnghl7:code
CD (extensible)0 … 1RMedi...rder
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.1.11.19708 ActSubstanceAdministrationCode (DYNAMIC)
Treetree.pnghl7:text
ED0 … 1Medi...rder
Treetree.pnghl7:statusCode
CS (required)1 … 1MMedi...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)
Choice1 … 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)]
Treeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1CCase 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)]
Treeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 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>
Treeblank.pngTreeblank.pngTreetree.pnghl7:low
IVXB_TS1 … 1RMedi...rder
Treeblank.pngTreeblank.pngTreetree.pnghl7:high
IVXB_TS0 … 1RMedi...rder
Treeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1CCase 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>
Treeblank.pngTreeblank.pngTreetree.pnghl7:low
NPMedi...rder
Treeblank.pngTreeblank.pngTreetree.pnghl7:high
NPMedi...rder
Treeblank.pngTreeblank.pngTreetree.pnghl7:center
NPMedi...rder
Treeblank.pngTreeblank.pngTreetree.pnghl7:width
PQ1 … 1RMedi...rder
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs1 … 1R
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.21.1 Medication Time Units (UCUM) (DYNAMIC)
Treeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1CCase 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>
Treeblank.pngTreeblank.pngTreetree.pnghl7:low
IVXB_TS0 … 1CMedi...rder
Treeblank.pngTreeblank.pngTreetree.pnghl7:width
PQ1 … 1RMedi...rder
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs1 … 1R
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.21.1 Medication Time Units (UCUM) (DYNAMIC)
Treetree.pnghl7:repeatNumber
IVL_INT0 … 1Medi...rder
Treetree.pnghl7:routeCode
CE (example)0 … 1Medi...rder
 CONF
Examples of the value of @code are in the value set 2.16.840.1.113883.1.11.14581 RouteOfAdministration (DYNAMIC)
Treetree.pnghl7: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)
Treetree.pnghl7:doseQuantity
IVL_PQNPMedi...rder
Treetree.pnghl7:rateQuantity
IVL_PQNPMedi...rder
Treetree.pnghl7:maxDoseQuantity
RTO_PQ_PQ0 … 1Medi...rder
Treetree.pnghl7:administrationUnitCode
CENPMedi...rder
Treetree.pnghl7:subject
0 … 1CThe 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
 ConstraintCondition: This can be omitted if the patient context that is provided in the CDA header is identical to the subject
Choice1 … 1Elements 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)
Treeblank.pngTreetree.pnghl7:consumable
0 … 1RConsumable: The medication that is administered (simple)
Contains 2.16.840.1.113883.10.21.4.10 UV Medication Information (simple) (DYNAMIC)		Medi...rder
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FCSM
Treeblank.pngTreetree.pnghl7:consumable
0 … 1RConsumable: The medication that is administered (detail)
Contains 2.16.840.1.113883.10.21.4.11 UV Medication Information (detail) (DYNAMIC)		Medi...rder
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FCSM
Treetree.pnghl7: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
Treetree.pnghl7:participant
0 … 1Record 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']
Treeblank.pngTreetree.png@typeCode
cs1 … 1FRCT
Treetree.pnghl7:participant
0 … 1Verifier: 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']
Treeblank.pngTreetree.png@typeCode
cs1 … 1FVRF
Treetree.pnghl7:entryRelationship
0 … *CSubordinate 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]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
 ConstraintAt 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>
Treeblank.pngTreetree.pnghl7:sequenceNumber
INT0 … 1Sequence number of the Subordinate Substance Administration.Medi...rder
Treetree.pnghl7:entryRelationship
0 … 1RDispense 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]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
 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>
Choice0 … *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)
Treeblank.pngTreetree.pnghl7:entryRelationship
0 … *RReason: Specifies the reason (indication) for authoring the order.
Contains 2.16.840.1.113883.10.21.4.3 UV ClinicalStatement Observation (DYNAMIC)		Medi...rder
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FRSON
 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>
Treeblank.pngTreeblank.pngTreetree.pngpharm:priorityNumber
INT.​NONNEG0 … 1RIndicates the priority of this reason for the order in relation to its sibling reasons.Medi...rder
Treeblank.pngTreetree.pnghl7:entryRelationship
0 … *RReason: Specifies the reason (indication) for authoring the order.
Contains 2.16.840.1.113883.10.22.4.31 IPS Internal Reference (DYNAMIC)		Medi...rder
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FRSON
 Example<entryRelationship typeCode="RSON">
  <priorityNumber value="1"/>  <act>
    <!-- Clinical Statement Minimal -->
  </act></entryRelationship>
Treeblank.pngTreeblank.pngTreetree.pngpharm:priorityNumber
INT.​NONNEG0 … 1RIndicates the priority of this reason for the order in relation to its sibling reasons.Medi...rder
Treetree.pnghl7:entryRelationship
0 … *RPertinent 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
Treeblank.pngTreetree.png@typeCode
cs1 … 1FPERT
 Example<entryRelationship typeCode="PERT">
  <observation>
    <!-- Clinical Statement Observation -->
  </observation></entryRelationship>
Treetree.pnghl7:entryRelationship
0 … 1RPermission: 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]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treetree.pnghl7:entryRelationship
0 … 1REncounter: 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]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
 Example<encounter classCode="ENC" moodCode="EVN">
  <id/>  <code code="..."/></encounter>
Treetree.pnghl7: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
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treetree.pnghl7: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 over the high-level template components of this template, followed by the actual definition. {{:2.16.840.1.113883.10.21.4.7/hgraph

Id2.16.840.1.113883.10.21.4.7Effective Date2023‑01‑30 08:32:34
Other versions this id:
  • Kblank.png UVMedicationstatement as of 2021‑08‑04 14:09:15
  • Kblank.png UVMedicationstatement as of 2017‑05‑01
StatusKyellow.png DraftVersion Label2023
NameUVMedicationstatementDisplay NameUV 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.
ContextParent nodes of template element with id 2.16.840.1.113883.10.21.4.7
LabelMedicationStatement
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 13 templates
Uses as NameVersion
2.16.840.1.113883.10.21.9.1IncludeKyellow.png UV Use Period (2023)DYNAMIC
2.16.840.1.113883.10.12.320ContainmentKgreen.png CDA Subject (Body)DYNAMIC
2.16.840.1.113883.10.21.4.10ContainmentKorange.png UV Medication Information (simple) (R1-STU2-ballot)DYNAMIC
2.16.840.1.113883.10.21.4.11ContainmentKyellow.png UV Medication Information (detail) (2023)DYNAMIC
2.16.840.1.113883.10.12.318ContainmentKgreen.png CDA Author (Body)DYNAMIC
2.16.840.1.113883.10.12.153ContainmentKgreen.png CDA AssignedEntityDYNAMIC
2.16.840.1.113883.10.12.316ContainmentKgreen.png CDA RelatedEntityDYNAMIC
2.16.840.1.113883.10.12.321ContainmentKgreen.png CDA Participant (Body)DYNAMIC
2.16.840.1.113883.10.21.4.6ContainmentKyellow.png UV Subordinate Substance Administration (2023)DYNAMIC
2.16.840.1.113883.10.21.4.8ContainmentKorange.png UV Medication Order Reference (R1-STU2-ballot)DYNAMIC
2.16.840.1.113883.10.21.4.9ContainmentKorange.png UV Dispense Event Reference (R1-STU2-ballot)DYNAMIC
2.16.840.1.113883.10.21.4.3ContainmentKorange.png UV ClinicalStatement Observation (R1-STU2-ballot)DYNAMIC
2.16.840.1.113883.10.22.4.31ContainmentKorange.png IPS Internal Reference (STU1)DYNAMIC
RelationshipVersion: 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>
ItemDTCardConfDescriptionLabel
hl7:substanceAdministration
Medi...ment
Treetree.png@classCode
cs1 … 1FSBADM
Treetree.png@moodCode
cs1 … 1REVN 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"
Treetree.pnghl7:templateId
II1 … 1MMedi...ment
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.21.4.7
Treetree.pnghl7:id
II0 … *RMedi...ment
Treetree.pnghl7:code
CD (preferred)0 … 1RThe 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)
Treetree.pnghl7:text
ED0 … 1Medi...ment
Treetree.pnghl7:statusCode
CS (required)1 … 1MMedi...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)
Choice1 … 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)]
Treeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1CCase 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)]
Treeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 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>
Treeblank.pngTreeblank.pngTreetree.pnghl7:low
IVXB_TS1 … 1RMedi...ment
Treeblank.pngTreeblank.pngTreetree.pnghl7:high
IVXB_TS0 … 1RMedi...ment
Treeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1CCase 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>
Treeblank.pngTreeblank.pngTreetree.pnghl7:low
NPMedi...ment
Treeblank.pngTreeblank.pngTreetree.pnghl7:high
NPMedi...ment
Treeblank.pngTreeblank.pngTreetree.pnghl7:center
NPMedi...ment
Treeblank.pngTreeblank.pngTreetree.pnghl7:width
PQ1 … 1RMedi...ment
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs1 … 1R
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.21.1 Medication Time Units (UCUM) (DYNAMIC)
Treeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1CCase 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>
Treeblank.pngTreeblank.pngTreetree.pnghl7:low
IVXB_TS0 … 1CMedi...ment
Treeblank.pngTreeblank.pngTreetree.pnghl7:width
PQ1 … 1RMedi...ment
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs1 … 1R
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.21.1 Medication Time Units (UCUM) (DYNAMIC)
Treetree.pnghl7:repeatNumber
IVL_INT0 … 1Medi...ment
Treetree.pnghl7:routeCode
CE (example)0 … 1Medi...ment
 CONF
Examples of the value of @code are in the value set 2.16.840.1.113883.1.11.14581 RouteOfAdministration (DYNAMIC)
Treetree.pnghl7: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)
Treetree.pnghl7:doseQuantity
IVL_PQNPMedi...ment
Treetree.pnghl7:rateQuantity
IVL_PQNPMedi...ment
Treetree.pnghl7:maxDoseQuantity
RTO_PQ_PQ0 … 1Medi...ment
Treetree.pnghl7:administrationUnitCode
CENPMedi...ment
Treetree.pnghl7:subject
0 … 1CPatient: The patient that takes the medicine.
Contains 2.16.840.1.113883.10.12.320 CDA Subject (Body) (DYNAMIC)		Medi...ment
 ConstraintCondition: This can be omitted if the patient context that is provided in the CDA header is identical to the subject
ChoiceElements 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)
Treeblank.pngTreetree.pnghl7:consumable
0 … 1RConsumable: The medication that is administered (simple)
Contains 2.16.840.1.113883.10.21.4.10 UV Medication Information (simple) (DYNAMIC)		Medi...ment
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FCSM
Treeblank.pngTreetree.pnghl7:consumable
0 … 1RConsumable: The medication that is administered (detail)
Contains 2.16.840.1.113883.10.21.4.11 UV Medication Information (detail) (DYNAMIC)		Medi...ment
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FCSM
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']
Treeblank.pngTreetree.pnghl7: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>
Treeblank.pngTreetree.pnghl7:participant
Use this if the author of the medication statement is the patientMedi...ment
where [@typeCode='AUT']
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FAUT
 Example
Author of the medication statement is the patient
<participant typeCode="AUT">
  <time value="20170121091548"/>  <participantRole classCode="PAT"/></participant>
Treeblank.pngTreeblank.pngTreetree.pnghl7:time
TS1 … 1RMedi...ment
Treeblank.pngTreeblank.pngTreetree.pnghl7:participantRole
1 … 1MMedi...ment
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FPAT
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)]
Treeblank.pngTreetree.pnghl7:informant
Use this if the informant of the medication statement is a healthcare professionalMedi...ment
where [exists(hl7:assignedEntity)]
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs0 … 1FINF
Treeblank.pngTreeblank.pngTreetree.png@context​Control​Code
cs0 … 1FOP
 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>
Treeblank.pngTreeblank.pngTreetree.pnghl7:assignedEntity
1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)Medi...ment
Treeblank.pngTreetree.pnghl7:participant
Use this if the informant of the medication statement is the patientMedi...ment
where [@typeCode='INF']
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FINF
 Example
Informant of the medication statement is the patient
<participant typeCode="INF">
  <time value="20170121091548"/>  <participantRole classCode="PAT"/></participant>
Treeblank.pngTreeblank.pngTreetree.pnghl7:time
TS1 … 1RMedi...ment
Treeblank.pngTreeblank.pngTreetree.pnghl7:participantRole
1 … 1MMedi...ment
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FPAT
Treeblank.pngTreetree.pnghl7:informant
Use this if the informant of the medication statement is a contact party (related party)Medi...ment
where [exists(hl7:relatedEntity)]
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs0 … 1FINF
Treeblank.pngTreeblank.pngTreetree.png@context​Control​Code
cs0 … 1FOP
 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>
Treeblank.pngTreeblank.pngTreetree.pnghl7:relatedEntity
1 … 1Contains 2.16.840.1.113883.10.12.316 CDA RelatedEntity (DYNAMIC)Medi...ment
Treetree.pnghl7:participant
0 … 1Record 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']
Treeblank.pngTreetree.png@typeCode
cs1 … 1FRCT
Treetree.pnghl7:participant
0 … 1Verifier: 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']
Treeblank.pngTreetree.png@typeCode
cs1 … 1FVRF
Treetree.pnghl7:entryRelationship
0 … *CSubordinate 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)]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
 ConstraintAt 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>
Treeblank.pngTreetree.pnghl7:sequenceNumber
INT0 … 1Sequence number of the Subordinate Substance Administration.Medi...ment
Treetree.pnghl7:entryRelationship
0 … *RMedication 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)]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREFR
 Example<entryRelationship typeCode="REFR">
  <substanceAdministration classCode="SBADM" moodCode="RQO">
    <templateId root="2.16.840.1.113883.10.21.4.8"/>    <!-- .. -->
  </substanceAdministration></entryRelationship>
Treetree.pnghl7:entryRelationship
0 … *RDispense 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)]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREFR
 Example<entryRelationship typeCode="REFR">
  <supply classCode="SPLY" moodCode="EVN">
    <templateId root="2.16.840.1.113883.10.21.4.9"/>    <!-- .. -->
  </supply></entryRelationship>
ChoiceElements 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)
Treeblank.pngTreetree.pnghl7:entryRelationship
0 … *RReason: 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)]
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FRSON
 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>
Treeblank.pngTreeblank.pngTreetree.pngpharm:priorityNumber
INT.​NONNEG0 … 1RIndicates the priority of this reason for the order in relation to its sibling reasons.Medi...ment
Treeblank.pngTreetree.pnghl7:entryRelationship
0 … *RReason: 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)]
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FRSON
 Example<entryRelationship typeCode="RSON">
  <priorityNumber value="1"/>  <act>
    <!-- Clinical Statement Minimal -->
  </act></entryRelationship>
Treeblank.pngTreeblank.pngTreetree.pngpharm:priorityNumber
INT.​NONNEG0 … 1RIndicates the priority of this reason for the order in relation to its sibling reasons.Medi...ment


Entry Level Templates

Id2.16.840.1.113883.10.21.4.5Effective Date2017‑01‑02
StatusKorange.png Under pre-publication reviewVersion LabelR1-STU2-ballot
NameUVSubstitutionPermissionDisplay NameUV Substitution Permission
DescriptionInformation about a substitution permission for this adminstration.
ContextParent nodes of template element with id 2.16.840.1.113883.10.21.4.5
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
RelationshipSpecialization: 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>
ItemDTCardConfDescriptionLabel
hl7:act
1 … 1M(UVS...ion)
Treetree.png@classCode
cs1 … 1FACT
Treetree.png@moodCode
cs1 … 1FDEF
Treetree.pnghl7:templateId
II1 … 1M(UVS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.21.4.5
Treetree.pnghl7:code
CE (example)1 … 1The 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)
Treetree.pnghl7:entryRelationship
0 … 1CUsed when substitution is not allowed and may indicate the reason for why substitution is not allowed.(UVS...ion)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FRSON
 Example<entryRelationship typeCode="RSON">
  <code code="PAT" codeSystem="2.16.840.1.113883.5.8" displayName="Patient request">
    <originalText>Patient objects</originalText>  </code></entryRelationship>
Treeblank.pngTreetree.pnghl7:act
1 … 1(UVS...ion)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FACT
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs1 … 1FEVN
Treeblank.pngTreeblank.pngTreetree.pnghl7: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)

Appendix (Informative)

Acronyms and abbreviations

C-CDAConsolidated CDA
CDAClinical Document Architecture
DSTUDraft Standard for Trial Use
EDQMEuropean Directorate for the Quality of Medicines & Healthcare
EHRElectronic Healthcare Record
HL7Health Level Seven
HPHealthcare Professional
IDMPIDentification of Medicinal Products (ISO Standard)
IHEIntegrating the Healthcare Enterprise
ISOInternational Organization for Standardization
JICJoint Initiative Council on SDO Global Health Informatics Standardization
LOINCLogical Observation Identifiers Names & Codes
MPIDMedicinal Product Identifier
PCID Medicinal Product Package Identifier
PhPID(s)Pharmaceutical Product Identifier(s)
SDOStandard Developing Organization
STUStandard for Trial Use
UCUMUnified 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)[3] 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) [4]

List of all artifacts used in this guide

CDA Templates

Unconstrained Templates from the original CDA specification

Value Sets

System OIDs / IDs

Code systems

Datatypes

References

Literature

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

Links

  1. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named teits
  2. ↑ ISO/TS 13582:2013 Health informatics -- Sharing of OID registry information
  3. ↑ Get SNOMED CT http://www.ihtsdo.org/snomed-ct/get-snomed-ct
  4. ↑ EDQM Standard Terms https://standardterms.edqm.eu

Figures

  1. ↑ Locating ballot comments
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