2.16.840.1.113883.10.21.4.7/static-2017-05-01T000000

Id	2.16.840.1.113883.10.21.4.7	Effective Date	valid from 2017‑05‑01
Status	Draft	Version Label
Name	UVMedicationstatement	Display Name	UV 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.
Context	Parent nodes of template element with id 2.16.840.1.113883.10.21.4.7
Label	MedicationStatement
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 0 transactions and 0 templates, Uses 10 templates Uses as Name Version 2.16.840.1.113883.10.21.9.1 Include UV Use Period DYNAMIC 2.16.840.1.113883.10.12.320 Containment CDA Subject (Body) DYNAMIC 2.16.840.1.113883.10.21.4.10 Containment UV Medication Information (simple) DYNAMIC 2.16.840.1.113883.10.12.318 Include CDA Author (Body) DYNAMIC 2.16.840.1.113883.10.12.153 Containment CDA AssignedEntity DYNAMIC 2.16.840.1.113883.10.12.316 Containment CDA RelatedEntity DYNAMIC 2.16.840.1.113883.10.12.321 Containment CDA Participant (Body) DYNAMIC 2.16.840.1.113883.10.21.4.6 Containment UV Subordinate Substance Administration DYNAMIC 2.16.840.1.113883.10.21.4.8 Containment UV Medication Order Reference DYNAMIC 2.16.840.1.113883.10.21.4.9 Containment UV Dispense Event Reference DYNAMIC
Relationship	Specialization: template 2.16.840.1.113883.10.12.308 (2005‑09‑07)
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="ASSERTION" displayName="Assertion" 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>
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 (preferred) 0 … 1 R Medi...ment @code CONF 0 … 1 F ASSERTION @codeSystem 0 … 1 F 2.16.840.1.113883.5.4 (Act Code) 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 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 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] @nullFlavor 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 continous therapy <effectiveTime xsi:type="IVL_TS">   <low value="20130321"/>  <high nullFlavor="NA"/></effectiveTime> hl7:low IVXB_TS 1 … 1 R Medi...ment hl7:high 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> hl7:width PQ 1 … 1 R Medi...ment @unit 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 Required 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) @typeCode 0 … 1 F AUT @context​Control​Code 0 … 1 F OP hl7:functionCode 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) hl7:time TS 1 … 1 R Medi...ment hl7:assignedAuthor 1 … 1 Medi...ment @classCode 0 … 1 F ASSIGNED hl7:id II 1 … * R Medi...ment hl7:code CE 0 … 1 Medi...ment @codeSystem CONF 0 … 1 F 2.16.840.1.113883.5.111 (Role Code) hl7:addr AD 0 … * Medi...ment hl7:telecom TEL 0 … * Medi...ment Choice 0 … 1 Elements to choose from: hl7:assigned​Person containing template 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC) hl7:assigned​Authoring​Device containing template 2.16.840.1.113883.10.12.315 CDA Device (DYNAMIC) hl7:assigned​Person Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC) Medi...ment hl7:assigned​Authoring​Device Contains 2.16.840.1.113883.10.12.315 CDA Device (DYNAMIC) Medi...ment hl7:represented​Organization 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'] @typeCode cs 1 … 1 F AUT   Example Author of the medication statement is the patient <participant typeCode="AUT">   <time value="20170121091548"/>  <participantRole classCode="PAT"/></participant> hl7:time TS 1 … 1 R Medi...ment hl7:participantRole 1 … 1 M Medi...ment @classCode 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)] @typeCode cs 0 … 1 F INF @context​Control​Code 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> hl7:assignedEntity 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'] @typeCode cs 1 … 1 F INF   Example Informant of the medication statement is the patient <participant typeCode="INF">   <time value="20170121091548"/>  <participantRole classCode="PAT"/></participant> hl7:time TS 1 … 1 R Medi...ment hl7:participantRole 1 … 1 M Medi...ment @classCode 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)] @typeCode cs 0 … 1 F INF @context​Control​Code 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> hl7:relatedEntity 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>