| Item | DT | Card | Conf | Description | Label |
|---|
hl7:substanceAdministration
|
| | | | | Medi...ment |
 | @classCode
|
| cs | 1 … 1 | F | SBADM |
| @moodCode
|
| cs | 1 … 1 | F | EVN |
| 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 (extensible) | 0 … 1 | R | | Medi...ment |
| | 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...ment |
| hl7:statusCode
|
| CS (required) | 1 … 1 | M | | Medi...ment |
| | CONF | | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19890 x_ActStatusActiveComplete (DYNAMIC) |
|
| 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...ment |
| | 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...ment |
| IVXB_TS | 0 … 1 | R | | Medi...ment |
| | 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...ment |
| | where [hl7:width] |
| |
| | Example | 2 week period <effectiveTime xsi:type="IVL_TS">
<width value="2" unit="w"/></effectiveTime> |
| 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 | 0 … 1 | | | Medi...ment |
| | 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...ment |
| | CONF | | The value of @code shall be drawn from value 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 |
| hl7:consumable
|
| | 1 … 1 | M | Consumable: The medication that is administered
Contains 2.16.840.1.113883.10.21.4.10 UV Medication Information (simple) (DYNAMIC) | Medi...ment |
| where [@typeCode='CSM'] [hl7:manufacturedProduct [hl7:templateId [@root='2.16.840.1.113883.10.21.4.10']]] |
| |
| | @typeCode
|
| cs | 1 … 1 | F | CSM |
| Choice | 1 … 1 | | Reuqired author of the medication statement: healthcare professional or patient Elements to choose from:- hl7:author
- hl7:participant[@typeCode='AUT']
|
| | hl7:author
|
| | | | Use this if the author of the medication statement is a healthcare professional | 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> |
| Included | | | from 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC) |
| | 0 … 1 | F | AUT |
| | 0 … 1 | F | OP |
| CE | 0 … 1 | | | Medi...ment |
| | CONF | | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC) |
|
| TS | 1 … 1 | R | | Medi...ment |
| | 1 … 1 | | | Medi...ment |
| | 0 … 1 | F | ASSIGNED |
| II | 1 … * | R | | Medi...ment |
| CE | 0 … 1 | | | Medi...ment |
| CONF | 0 … 1 | F | 2.16.840.1.113883.5.111 (Role Code) |
| AD | 0 … * | | | Medi...ment |
| TEL | 0 … * | | | Medi...ment |
| Choice | 0 … 1 | | Elements to choose from:- hl7:assignedPerson containing template 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC)
- hl7:assignedAuthoringDevice containing template 2.16.840.1.113883.10.12.315 CDA Device (DYNAMIC)
|
| | | | Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC) | Medi...ment |
| | | | | hl7:assignedAuthoringDevice
|
| | | | Contains 2.16.840.1.113883.10.12.315 CDA Device (DYNAMIC) | Medi...ment |
| | | | hl7:representedOrganization
|
| | 0 … 1 | | Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) | Medi...ment |
| | 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 | 0 … 1 | | 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 whose medical record holds the documentation of this medication statement; Rationale: This is especially important when the subject of the medication statement is not the patient him/herself.
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,..).
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 [hl7:substanceAdministration] |
| |
| | @typeCode
|
| cs | 1 … 1 | F | COMP |
| | Example | <entryRelationship typeCode="COMP">
<!-- component: Subordinate Substance Administration Statement. -->
<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...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'] [hl7:substanceAdministration] |
| |
| | @typeCode
|
| cs | 1 … 1 | F | REFR |
| | Example | <entryRelationship typeCode="REFR">
<substanceAdministration classCode="SBADM" moodCode="EVN">
<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'] [ [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> |
Draft
