2.16.840.1.113883.10.21.4.7/static-2017-05-01T000000

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Id2.16.840.1.113883.10.21.4.7Effective Date valid from 2017‑05‑01
StatusKyellow.png DraftVersion Label
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)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 10 templates
Uses as NameVersion
2.16.840.1.113883.10.21.9.1IncludeKyellow.png UV Use PeriodDYNAMIC
2.16.840.1.113883.10.12.320ContainmentKgreen.png CDA Subject (Body)DYNAMIC
2.16.840.1.113883.10.21.4.10ContainmentKyellow.png UV Medication Information (simple)DYNAMIC
2.16.840.1.113883.10.12.318IncludeKgreen.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 AdministrationDYNAMIC
2.16.840.1.113883.10.21.4.8ContainmentKyellow.png UV Medication Order ReferenceDYNAMIC
2.16.840.1.113883.10.21.4.9ContainmentKyellow.png UV Dispense Event ReferenceDYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.308 xxx (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>
ItemDTCardConfDescriptionLabel
hl7:substanceAdministration
Medi...ment
Treetree.png@classCode
cs1 … 1FSBADM
Treetree.png@moodCode
cs1 … 1FEVN
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 … 1RMedi...ment
Treeblank.pngTreetree.png@code
CONF0 … 1FASSERTION
Treeblank.pngTreetree.png@codeSystem
0 … 1F2.16.840.1.113883.5.4 (Act Code)
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 2.16.840.1.113883.1.11.19890 x_ActStatusActiveComplete (DYNAMIC)
Included from 2.16.840.1.113883.10.21.9.1 UV Use Period (DYNAMIC)
Choice1 … 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]
Treeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1RCase 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
Treeblank.pngTreeblank.png where [hl7:low or
hl7:high]
Treeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 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>
Treeblank.pngTreeblank.pngTreetree.pnghl7:low
IVXB_TS1 … 1RMedi...ment
Treeblank.pngTreeblank.pngTreetree.pnghl7:high
IVXB_TS0 … 1RMedi...ment
Treeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1RCase 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
Treeblank.pngTreeblank.png where [hl7:width]
 Example
2 week period
<effectiveTime xsi:type="IVL_TS">
  <width value="2" unit="w"/></effectiveTime>
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
CE0 … 1Medi...ment
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14581 RouteOfAdministration (DYNAMIC)
Treetree.pnghl7:approachSiteCode
CD0 … *Medi...ment
 CONF
The value of @code shall be drawn from 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
Treetree.pnghl7:consumable
1 … 1MConsumable: The medication that is administered
Contains 2.16.840.1.113883.10.21.4.10 UV Medication Information (simple) (DYNAMIC)
Medi...ment
Treeblank.png where [@typeCode='CSM'] [hl7:manufacturedProduct [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.21.4.10']]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCSM
Choice1 … 1
Required author of the medication statement: healthcare professional or patient
Elements to choose from:
  • hl7:author
  • hl7:participant[@typeCode='AUT']
Treeblank.pngTreetree.pnghl7:author
Use this if the author of the medication statement is a healthcare professionalMedi...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)
Treeblank.pngTreeblank.pngTreetree.png@typeCode
0 … 1FAUT
Treeblank.pngTreeblank.pngTreetree.png@context​Control​Code
0 … 1FOP
Treeblank.pngTreeblank.pngTreetree.pnghl7:functionCode
CE0 … 1Medi...ment
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)
Treeblank.pngTreeblank.pngTreetree.pnghl7:time
TS1 … 1RMedi...ment
Treeblank.pngTreeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1Medi...ment
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … *RMedi...ment
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:code
CE0 … 1Medi...ment
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF0 … 1F2.16.840.1.113883.5.111 (Role Code)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … *Medi...ment
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *Medi...ment
Choice0 … 1Elements 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)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC)Medi...ment
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Authoring​Device
Contains 2.16.840.1.113883.10.12.315 CDA Device (DYNAMIC)Medi...ment
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)Medi...ment
Treeblank.pngTreetree.pnghl7:participant
Use this if the author of the medication statement is the patientMedi...ment
Treeblank.pngTreeblank.png 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
Choice0 … 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)]
Treeblank.pngTreetree.pnghl7:informant
Use this if the informant of the medication statement is a healthcare professionalMedi...ment
Treeblank.pngTreeblank.png 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
Treeblank.pngTreeblank.png 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
Treeblank.pngTreeblank.png 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 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
Treeblank.png 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
Treeblank.png 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,..).
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
Treeblank.png where [hl7:substanceAdministration]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
 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>
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
Treeblank.png where [@typeCode='REFR'] [hl7:substanceAdministration]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREFR
 Example<entryRelationship typeCode="REFR">
  <substanceAdministration classCode="SBADM" moodCode="EVN">
    <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
Treeblank.png where [@typeCode='REFR'] [ [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>