| Item | DT | Card | Conf | Description | Label |
|---|
hl7:substanceAdministration
|
| | | | | Medi...ment |
 | @classCode
|
| cs | 1 … 1 | F | SBADM |
| @moodCode
|
| cs | 1 … 1 | R | EVN will be used to record a medication statement where the patient is currently taking or has taken the medication in the past.
INT will be used to record a medication statement where the patient plans to take the medication or be administered the medication in the future. |
| | CONF | | @moodCode shall be "EVN" | | or | | @moodCode shall be "INT" |
|
| hl7:templateId
|
| II | 1 … 1 | M | | Medi...ment |
 | | @root
|
| uid | 1 … 1 | F | 2.16.840.1.113883.10.21.4.7 |
| hl7:id
|
| II | 0 … * | R | | Medi...ment |
| hl7:code
|
| CD (preferred) | 0 … 1 | R | The code element is valorized with the ACT code DRUG; FD or IMMUNIZ unless it is used for asserting the known absence of medication treatments or no information about them. | Medi...ment |
| | CONF | | The value of @code comes preferably from value set 2.16.840.1.113883.1.11.19708 ActSubstanceAdministrationCode (DYNAMIC) | | or | | The value of @code comes preferably from value set 2.16.840.1.113883.11.21.5 Unknown or absent medication (DYNAMIC) |
|
| hl7:text
|
| ED | 0 … 1 | | | Medi...ment |
| hl7:statusCode
|
| CS (required) | 1 … 1 | M | | Medi...ment |
| | CONF | | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC) |
|
| Included | | | from 2.16.840.1.113883.10.21.9.1 UV Use Period (DYNAMIC) |
| Choice | 1 … 1 | | The effectiveTime element encodes the use period of the medication, it is always expressed as an interval of time.
It may be expressed using the low and high OR with the width element.
The first is used to indicate a specified interval (e.g. from march 15th, 2017); the latter for indicating a 'floating' period (e.g. 2 weeks). Elements to choose from:- hl7:effectiveTime[hl7:low | hl7:high][not(hl7:width)]
- hl7:effectiveTime[hl7:width][not(hl7:low|hl7:high)]
- hl7:effectiveTime[hl7:low | hl7:width][not(hl7:high)]
|
| | hl7:effectiveTime
|
| IVL_TS | 0 … 1 | C | Case 1: specified interval
The low and high values of the first effectiveTime element represent the start and stop times for the medication. The low value represents the start time, and the high value represents the stop time. If either the low or the high value is unknown, this shall be recorded by setting the nullFlavor attribute to UNK.
In case of unbounded period (continuous therapy) the high element will be valued with the nullFlavor attribute to NA.
The high value records the end of the medication regime according to the information provided in the prescription or order. For example, if the prescription is for enough medication to last 30 days, then the high value should contain a date that is 30 days later then the low value. The rationale is that a provider, seeing a prescription that has not been refilled would normally assume that the medication is no longer being taken, even if the intent of the treatment plan is to continue the medication indefinitely. | Medi...ment |
where [hl7:low or
[not(hl7:width)] | |
| 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...ment |
| IVXB_TS | 0 … 1 | R | | Medi...ment |
| | hl7:effectiveTime
|
| IVL_TS | 0 … 1 | C | Case 2: 'floating' period:
The width element is used to specify a period of (actual or intended) administration that is not anchored to any specific date (e.g. a two weeks therapy) | Medi...ment |
where [hl7:width] [not(hl7:lowor
hl7:high)] | |
| | Example | 2 week period <effectiveTime type="IVL_TS">
<width value="2" unit="w"/></effectiveTime> |
| | | NP | | Medi...ment |
| | | NP | | Medi...ment |
| | | NP | | Medi...ment |
| PQ | 1 … 1 | R | | Medi...ment |
| cs | 1 … 1 | R | |
| | CONF | | The value of @unit shall be drawn from value set 2.16.840.1.113883.11.21.1 Medication Time Units (UCUM) (DYNAMIC) |
|
| | hl7:effectiveTime
|
| IVL_TS | 0 … 1 | C | Case 3: anchored period:
The width element is used to specify a period of (actual or intended) administration anchored to a specific date (e.g. a two weeks therapy starting today) | Medi...ment |
where [hl7:low or
[not(hl7:high)] | |
| | Example | 2 week period starting on 2013-03-21 <effectiveTime type="IVL_TS">
<low value="20130321"/> <width value="2" unit="w"/></effectiveTime> |
| IVXB_TS | 0 … 1 | C | | Medi...ment |
| PQ | 1 … 1 | R | | Medi...ment |
| cs | 1 … 1 | R | |
| | CONF | | The value of @unit shall be drawn from value set 2.16.840.1.113883.11.21.1 Medication Time Units (UCUM) (DYNAMIC) |
|
| hl7:repeatNumber
|
| IVL_INT | 0 … 1 | | | Medi...ment |
| hl7:routeCode
|
| CE (example) | 0 … 1 | | | Medi...ment |
| | CONF | | Examples of the value of @code are in the valuet set 2.16.840.1.113883.1.11.14581 RouteOfAdministration (DYNAMIC) |
|
| hl7:approachSiteCode
|
| CD (example) | 0 … * | | | Medi...ment |
| | CONF | | Examples of the value of @code are in the valuet set 2.16.840.1.113883.1.11.19724 HumanSubstanceAdministrationSite (DYNAMIC) |
|
| hl7:doseQuantity
|
| IVL_PQ | | NP | | Medi...ment |
| hl7:rateQuantity
|
| IVL_PQ | | NP | | Medi...ment |
| hl7:maxDoseQuantity
|
| RTO_PQ_PQ | 0 … 1 | | | Medi...ment |
| hl7:administrationUnitCode
|
| CE | | NP | | Medi...ment |
| hl7:subject
|
| | 0 … 1 | C | Patient: The patient that takes the medicine.
Contains 2.16.840.1.113883.10.12.320 CDA Subject (Body) (DYNAMIC) | Medi...ment |
| | Constraint | Condition: This can be omitted if the patient context that is provided in the CDA header is identical to the subject |
| Choice | | | Elements to choose from:- hl7:consumable containing template 2.16.840.1.113883.10.21.4.10 UV Medication Information (simple) (DYNAMIC)
- hl7:consumable containing template 2.16.840.1.113883.10.21.4.11 UV Medication Information (detail) (DYNAMIC)
|
| | hl7:consumable
|
| | 0 … 1 | R | Consumable: The medication that is administered (simple)
Contains 2.16.840.1.113883.10.21.4.10 UV Medication Information (simple) (DYNAMIC) | Medi...ment |
| cs | 1 … 1 | F | CSM |
| | hl7:consumable
|
| | 0 … 1 | R | Consumable: The medication that is administered (detail)
Contains 2.16.840.1.113883.10.21.4.11 UV Medication Information (detail) (DYNAMIC) | Medi...ment |
| cs | 1 … 1 | F | CSM |
| Choice | | | Required author of the medication statement: healthcare professional or patient Elements to choose from:- hl7:author containing template 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC)
- hl7:participant[@typeCode='AUT']
|
| | hl7:author
|
| | | | Use this if the author of the medication statement is a healthcare professional
Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC) | Medi...ment |
| | Example | Author of the medication statement is a healthcare professional <author>
<time value="20170221"/> <assignedAuthor>
<id root="1.2.3.99.99.99" extension="75487435893498"/> <assignedPerson>
<name>
<given qualifier="IN">Ampu</given> <prefix qualifier="VV">L.</prefix> <family>Lee</family> </name> </assignedPerson> </assignedAuthor></author> |
| | hl7:participant
|
| | | | Use this if the author of the medication statement is the patient | Medi...ment |
| where [@typeCode='AUT'] | |
| cs | 1 … 1 | F | AUT |
| | Example | Author of the medication statement is the patient <participant typeCode="AUT">
<time value="20170121091548"/> <participantRole classCode="PAT"/></participant> |
| TS | 1 … 1 | R | | Medi...ment |
| | 1 … 1 | M | | Medi...ment |
| cs | 1 … 1 | F | PAT |
| Choice | | | Optional informants of the medication statement: healthcare professional or patient contact party (related party) Elements to choose from:- hl7:informant[exists(hl7:assignedEntity)]
- hl7:participant[@typeCode='INF']
- hl7:informant[exists(hl7:relatedEntity)]
|
| | hl7:informant
|
| | | | Use this if the informant of the medication statement is a healthcare professional | Medi...ment |
| where [exists(hl7:assignedEntity)] | |
| cs | 0 … 1 | F | INF |
| 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> |
| | 1 … 1 | | Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) | Medi...ment |
| | hl7:participant
|
| | | | Use this if the informant of the medication statement is the patient | Medi...ment |
| where [@typeCode='INF'] | |
| cs | 1 … 1 | F | INF |
| | Example | Informant of the medication statement is the patient <participant typeCode="INF">
<time value="20170121091548"/> <participantRole classCode="PAT"/></participant> |
| TS | 1 … 1 | R | | Medi...ment |
| | 1 … 1 | M | | Medi...ment |
| cs | 1 … 1 | F | PAT |
| | hl7:informant
|
| | | | Use this if the informant of the medication statement is a contact party (related party) | Medi...ment |
| where [exists(hl7:relatedEntity)] | |
| cs | 0 … 1 | F | INF |
| 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> |
| | 1 … 1 | | Contains 2.16.840.1.113883.10.12.316 CDA RelatedEntity (DYNAMIC) | Medi...ment |
| hl7:participant
|
| | 0 … 1 | | Record Target: indicates the person who's medical record holds the documentation of this medication statement. This element is only populated when the document is placed in a medical record of someone other than the patient (subject).
Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC) | Medi...ment |
| where [@typeCode='RCT'] | |
| | @typeCode
|
| cs | 1 … 1 | F | RCT |
| hl7:participant
|
| | 0 … 1 | | Verifier: The person or organization that has primary responsibility for the medication statement. The responsible party is not necessarily present in an action, but is accountable for the action through the power to delegate.
Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC) | Medi...ment |
| where [@typeCode='VRF'] | |
| | @typeCode
|
| cs | 1 … 1 | F | VRF |
| hl7:entryRelationship
|
| | 0 … * | C | Subordinate Substance Administration Statament as a component of the overall medication statement.
At least one subordinated <substanceAdministration> has to be present to convey information about dosages (dose, frequency of intakes,..) unless medications are unknown or known absent.
Subordinated <substanceAdministration> elements can be also used either to handle split dosing, or to support combination medications.
Contains 2.16.840.1.113883.10.21.4.6 UV Subordinate Substance Administration (DYNAMIC) | Medi...ment |
| where [exists(hl7:substanceAdministration)] | |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | Constraint | At least one subordinate <substanceAdministration> element SHALL be present unless medications are unknown or known absent.</substanceAdministration>
|
| | Example | <entryRelationship typeCode="COMP">
<!-- component: Subordinate Substance Administration Statement. -->
<substanceAdministration classCode="SBADM" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.21.4.6"/> <!-- .. -->
</substanceAdministration></entryRelationship> |
| | hl7:sequenceNumber
|
| INT | 0 … 1 | | Sequence number of the Subordinate Substance Administration. | Medi...ment |
| hl7:entryRelationship
|
| | 0 … * | R | Medication Order Reference.
Contains 2.16.840.1.113883.10.21.4.8 UV Medication Order Reference (DYNAMIC) | Medi...ment |
| where [@typeCode='REFR' and exists(hl7:substanceAdministration)] | |
| | @typeCode
|
| cs | 1 … 1 | F | REFR |
| | Example | <entryRelationship typeCode="REFR">
<substanceAdministration classCode="SBADM" moodCode="RQO">
<templateId root="2.16.840.1.113883.10.21.4.8"/> <!-- .. -->
</substanceAdministration></entryRelationship> |
| hl7:entryRelationship
|
| | 0 … * | R | Dispense Event Reference.
Contains 2.16.840.1.113883.10.21.4.9 UV Dispense Event Reference (DYNAMIC) | Medi...ment |
| where [@typeCode='REFR' and exists(hl7:supply)] | |
| | @typeCode
|
| cs | 1 … 1 | F | REFR |
| | Example | <entryRelationship typeCode="REFR">
<supply classCode="SPLY" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.21.4.9"/> <!-- .. -->
</supply></entryRelationship> |
| Choice | | | Elements to choose from:- hl7:entryRelationship[@typeCode='RSON' and exists(hl7:observation)] containing template 2.16.840.1.113883.10.21.4.3 UV ClinicalStatement Observation (DYNAMIC)
- hl7:entryRelationship[@typeCode='RSON' and exists(hl7:act)] containing template 2.16.840.1.113883.10.22.4.31 IPS Internal Reference (DYNAMIC)
|
| | hl7:entryRelationship
|
| | 0 … * | R | Reason: Specifies the reason (indication) for authoring the order.
Contains 2.16.840.1.113883.10.21.4.3 UV ClinicalStatement Observation (DYNAMIC) | Medi...ment |
| where [@typeCode='RSON' and exists(hl7:observation)] | |
| cs | 1 … 1 | F | RSON |
| | Example | <cda:entryRelationship typeCode="RSON">
<priorityNumber value="1"/> <!-- template 2.16.840.1.113883.10.21.4.3 'UV ClinicalStatement Observation' (2016-05-01T00:00:00) -->
</cda:entryRelationship> |
| INT.NONNEG | 0 … 1 | R | Indicates the priority of this reason for the order in relation to its sibling reasons. | Medi...ment |
| | hl7:entryRelationship
|
| | 0 … * | R | Reason: Specifies the reason (indication) for authoring the order.
Contains 2.16.840.1.113883.10.22.4.31 IPS Internal Reference (DYNAMIC) | Medi...ment |
| where [@typeCode='RSON' and exists(hl7:act)] | |
| 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...ment |
Draft
