| 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 | 0 … * | R | | Medi…rder |
| hl7:code
|
| CD CWE | 0 … 1 | R | | Medi…rder |
| | CONF | | The value of @code shall 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 CNE | 1 … 1 | M | | Medi…rder |
| | @code
|
| CONF | 1 … 1 | F | active |
| Included | | | from 2.16.840.1.113883.10.21.9.1 UV Use Period (DYNAMIC) |
| Choice | 1 … 1 | | The <effectiveTime> element encodes the period of administration 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 | R | 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 (continous terapy) 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 an un-refilled prescription 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] |
| |
| 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 | Continuous terapy <effectiveTime xsi: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 | R | 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> |
| PQ | 1 … 1 | R | | Medi…rder |
| cs | 1 … 1 | R | |
| | CONF | | The value of @unit shall be drawn from value set 2.16.840.1.113883.11.22.1 Medication Time Units (UCUM) (DYNAMIC) |
|
| hl7:repeatNumber
|
| IVL_INT | 0 … 1 | | | Medi…rder |
| hl7:routeCode
|
| CE | 0 … 1 | | | Medi…rder |
| | CONF | | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14581 RouteOfAdministration (DYNAMIC) |
|
| hl7:approachSiteCode
|
| CD | 0 … * | | | Medi…rder |
| | @codeSystem
|
| CONF | 1 … 1 | F | 2.16.840.1.113883.5.1052 (Act Site) |
| hl7:doseQuantity
|
| IVL_PQ | 0 … 1 | | | Medi…rder |
| hl7:rateQuantity
|
| IVL_PQ | 0 … 1 | | | Medi…rder |
| hl7:maxDoseQuantity
|
| RTO_PQ_PQ | 0 … 1 | | | Medi…rder |
| hl7:administrationUnitCode
|
| CE | 0 … 1 | | | Medi…rder |
| | CONF | | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14570 AdministrableDrugForm (DYNAMIC) |
|
| hl7:subject
|
| | 0 … 1 | C | Patient: The patient that the medicine is intended for dispenses or introduced into/applied to for substance administrations.
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 |
| 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)] |
| |
| | @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 |
| hl7:participant
|
| | 0 … 1 | | Record Target: indicates whose medical record holds the documentation of this order; Rationale: This is especially important when the subject of the order is not the patient him/herself.
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 <substanceAdministration> has to be present to convey information about dosages (dose, frequency of intakes,..).
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…rder |
| where [hl7:substanceAdministration] |
| |
| | @typeCode
|
| | 1 … 1 | F | COMP |
| | 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.
Contains 2.16.840.1.113883.10.21.4.2 UV Dispense Request (DYNAMIC) | Medi…rder |
| where [hl7:supply] |
| |
| | @typeCode
|
| | 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 … 1 | 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
|
| | 1 … 1 | F | RSON |
| | Example | <entryRelationship typeCode="RSON">
<priorityNumber value="1"/> <act>
<!-- Clinical Statement Minimal -->
</act></entryRelationship> |
| | pharm:priorityNumber
|
| INT.NONNEG | 0 … 1 | R | Indiciates the priority of this reason for the order in relation to its sibling reasons. | Medi…rder |
| hl7:entryRelationship
|
| | 0 … 1 | 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
|
| | 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
|
| | 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
|
| | 1 … 1 | F | COMP |
| | Example | <encounter classCode="ENC" moodCode="EVN">
<id/> <code code="..."/></encounter> |
| hl7:entryRelationship
|
| | 0 … * | | Annotations: The SubstanceAdministrationRequest can be the subject of annotations.
Contains 2.16.840.1.113883.10.20.22.4.64 Comment Activity (DYNAMIC) | Medi…rder |
| where [cda:act [cda: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 |
Draft
