Consolidated CDA Release 2.1 StructureDefinition Publication
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Consolidated CDA Release 2.1 StructureDefinition Publication, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.1). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.1-sd/ and changes regularly. See the Directory of published versions

Logical Model: Medication Activity

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/MedicationActivity Version: 2.1
Draft as of 2023-09-29 Computable Name: MedicationActivity
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.16:2014-06-09

A Medication Activity describes substance administrations that have actually occurred (e.g., pills ingested or injections given) or are intended to occur (e.g., “take 2 tablets twice a day for the next 10 days”). Medication activities in “INT” mood are reflections of what a clinician intends a patient to be taking. For example, a clinician may intend that a patient be administered Lisinopril 20 mg PO for blood pressure control. If what was actually administered was Lisinopril 10 mg., then the Medication activities in the “EVN” mood would reflect actual use.

A moodCode of INT is allowed, but it is recommended that the Planned Medication Activity template be used for moodCodes other than EVN if the document type contains a section that includes Planned Medication Activity (for example a Care Plan document with Plan of Treatment, Intervention, or Goal sections).

At a minimum, a Medication Activity shall include an effectiveTime indicating the duration of the administration (or single-administration timestamp). Ambulatory medication lists generally provide a summary of use for a given medication over time - a medication activity in event mood with the duration reflecting when the medication started and stopped. Ongoing medications will not have a stop date (or will have a stop date with a suitable NULL value). Ambulatory medication lists will generally also have a frequency (e.g., a medication is being taken twice a day). Inpatient medications generally record each administration as a separate act.

The dose (doseQuantity) represents how many of the consumables are to be administered at each administration event. As a result, the dose is always relative to the consumable and the interval of administration. Thus, a patient consuming a single “metoprolol 25mg tablet “ per administration will have a doseQuantity of “1 “, whereas a patient consuming “metoprolol Oral Product “ (RxCUI 1163523) will have a dose of “25 mg “.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from CDAR2.SubstanceAdministration

NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration C1..1CDAR2.SubstanceAdministrationXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, repeatNumber, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode, consumable, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition
Base for all types and resources
1098-30800: Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800).
... classCode 1..1cs
... moodCode 1..1csBinding: MoodCodeEvnInt (required)
... Slices for templateId 1..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.16
..... extension 1..1stRequired Pattern: 2014-06-09
... code 0..1CDSubstanceAdministration.code is an optional field. Per HL7 Pharmacy Committee, "this is intended to further specify the nature of the substance administration act. To date the committee has made no use of this attribute". Because the type of substance administration is generally implicit in the routeCode, in the consumable participant, etc., the field is generally not used, and there is no defined value set.
... statusCode 1..1CS
.... code 1..1csThe substance administration effectiveTime field can repeat, in order to represent varying levels of complex dosing. effectiveTime can be used to represent the duration of administration (e.g., "10 days"), the frequency of administration (e.g., "every 8 hours"), and more. Here, we require that there SHALL be an effectiveTime documentation of the duration (or single-administration timestamp), and that there SHOULD be an effectiveTime documentation of the frequency. Other timing nuances, supported by the base CDA R2 standard, may also be included.
Binding: Medication Status (required)
... Slices for effectiveTime C1..*SXCM_TS, IVL_TS, EIVL_TS, PIVL_TS, SXPR_TSSlice: Unordered, Open by value:operator
1098-7513: SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499).
.... effectiveTime:duration C1..1IVL_TSThis effectiveTime represents either the medication duration (i.e., the time the medication was started and stopped) or the single-administration timestamp.
1098-32890: This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890).
..... value 0..1tsindicates a single-administration timestamp
..... low 0..1IVXB_TSindicates when medication started
..... high 0..1IVXB_TSindicates when medication stopped
.... effectiveTime:periodicFrequency 0..1EIVL_TSThis effectiveTime represents a periodic medication frequency (e.g., administration times per day).
..... operator 1..1csRequired Pattern: A
.... effectiveTime:eventFrequency 0..1PIVL_TSThis effectiveTime represents an event-based medication frequency (e.g., administration at bedtime).
..... operator 1..1csRequired Pattern: A
... repeatNumber 0..1IVL_INTIn "INT" (intent) mood, the repeatNumber defines the number of allowed administrations. For example, a repeatNumber of "3" means that the substance can be administered up to 3 times. In "EVN" (event) mood, the repeatNumber is the number of occurrences. For example, a repeatNumber of "3" in a substance administration event means that the current administration is the 3rd in a series.
... routeCode 0..1CEBinding: SPL Drug Route of Administration Terminology (required)
.... translation 0..*CDBinding: Medication Route (required)
... approachSiteCode 0..1CDBinding: Body Site Value Set (required)
... doseQuantity C1..1IVL_PQ1098-16879: Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is "simply metoprolol Oral Product" (RxCUI 1163523), then doseQuantity must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration (CONF:1098-16879).
1098-16878: Pre-coordinated consumable: If the consumable code is a pre-coordinated unit dose (e.g., "metoprolol 25mg tablet") then doseQuantity is a unitless number that indicates the number of products given per administration (e.g., "2", meaning 2 x "metoprolol 25mg tablet" per administration) (CONF:1098-16878).
.... unit 0..1csBinding: UnitsOfMeasureCaseSensitive (required)
... rateQuantity 0..1IVL_PQ
.... unit 1..1csBinding: UnitsOfMeasureCaseSensitive (required)
... maxDoseQuantity 0..1RTO_PQ_PQ
... administrationUnitCode 0..1CEadministrationUnitCode@code describes the units of medication administration for an item using a code that is pre-coordinated to include a physical unit form (ointment, powder, solution, etc.) which differs from the units used in administering the consumable (capful, spray, drop, etc.). For example when recording medication administrations, 'metric drop (C48491)'' would be appropriate to accompany the RxNorm code of 198283 (Timolol 0.25% Ophthalmic Solution) where the number of drops would be specified in doseQuantity@value.
Binding: AdministrationUnitDoseForm (required)
... consumable 1..1InfrastructureRoot
.... manufacturedProduct 1..1MedicationInformationBase for all types and resources
... performer 0..1Performer2
... author 0..*AuthorParticipationBase for all types and resources
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:participantRole, value:typeCode
.... participant:drugVehicle 0..*Participant2
..... typeCode 1..1csFixed Value: CSM
..... participantRole 1..1DrugVehicleBase for all types and resources
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by profile:substanceAdministration, profile:observation, profile:act, profile:supply
.... entryRelationship:indication 0..*EntryRelationship
..... typeCode 1..1csFixed Value: RSON
..... observation 1..1IndicationBase for all types and resources
.... entryRelationship:instruction 0..1EntryRelationship
..... typeCode 1..1csFixed Value: SUBJ
..... inversionInd 1..1blFixed Value: true
..... act 1..1InstructionBase for all types and resources
.... entryRelationship:supplyOrder 0..1EntryRelationship
..... typeCode 1..1csFixed Value: REFR
..... supply 1..1MedicationSupplyOrderBase for all types and resources
.... entryRelationship:medicationDispense 0..*EntryRelationship
..... typeCode 1..1csFixed Value: REFR
..... supply 1..1MedicationDispenseBase for all types and resources
.... entryRelationship:reaction 0..*EntryRelationship
..... typeCode 1..1csFixed Value: CAUS
..... observation 1..1ReactionObservationBase for all types and resources
.... entryRelationship:drugMonitoring 0..1EntryRelationship
..... typeCode 1..1csFixed Value: COMP
..... act 1..1DrugMonitoringActBase for all types and resources
.... entryRelationship:substanceAdministered 0..*EntryRelationshipThe following entryRelationship is used to indicate a given medication's order in a series. The nested Substance Administered Act identifies an administration in the series. The entryRelationship/sequenceNumber shows the order of this particular administration in that series.
..... typeCode 1..1csFixed Value: COMP
..... inversionInd 1..1blFixed Value: true
..... sequenceNumber 0..1INT
..... act 1..1SubstanceAdministeredActBase for all types and resources
.... entryRelationship:adherence 0..*EntryRelationshipThe following entryRelationship is used to indicate the patient's adherence to the medication order.
..... typeCode 1..1csFixed Value: COMP
..... observation 1..1MedicationAdherenceBase for all types and resources
.... entryRelationship:signature 0..*EntryRelationship
..... typeCode 1..1csFixed Value: COMP
..... substanceAdministration 1..1MedicationFreeTextSigBase for all types and resources
... precondition 0..*Precondition
.... typeCode 1..1csFixed Value: PRCN
.... criterion 1..1PreconditionforSubstanceAdministrationBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
SubstanceAdministration.moodCoderequiredMoodCodeEvnInt
SubstanceAdministration.statusCode.coderequiredMedication Status
SubstanceAdministration.routeCoderequiredSPL Drug Route of Administration Terminology
SubstanceAdministration.routeCode.translationrequiredMedication Route
SubstanceAdministration.approachSiteCoderequiredBody Site Value Set
SubstanceAdministration.doseQuantity.unitrequiredUnitsOfMeasureCaseSensitive (a valid code from UCUM)
SubstanceAdministration.rateQuantity.unitrequiredUnitsOfMeasureCaseSensitive (a valid code from UCUM)
SubstanceAdministration.administrationUnitCoderequiredAdministrationUnitDoseForm

Constraints

IdGradePath(s)DetailsRequirements
1098-7513errorSubstanceAdministration.effectiveTimeSHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499).
:
1098-16878warningSubstanceAdministration.doseQuantityPre-coordinated consumable: If the consumable code is a pre-coordinated unit dose (e.g., "metoprolol 25mg tablet") then doseQuantity is a unitless number that indicates the number of products given per administration (e.g., "2", meaning 2 x "metoprolol 25mg tablet" per administration) (CONF:1098-16878).
:
1098-16879warningSubstanceAdministration.doseQuantityNot pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is "simply metoprolol Oral Product" (RxCUI 1163523), then doseQuantity must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration (CONF:1098-16879).
:
1098-30800warningSubstanceAdministrationMedication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800).
:
1098-32890errorSubstanceAdministration.effectiveTime:durationThis effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890).
:
NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration C1..1CDAR2.SubstanceAdministrationXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, repeatNumber, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode, consumable, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition
Base for all types and resources
1098-30800: Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800).
... @classCode 1..1csBinding: ActClass (required)
Fixed Value: SBADM
... @moodCode 1..1csBinding: MoodCodeEvnInt (required)
... Slices for templateId 1..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.16
..... @extension 1..1stRequired Pattern: 2014-06-09
... code 0..1CDSubstanceAdministration.code is an optional field. Per HL7 Pharmacy Committee, "this is intended to further specify the nature of the substance administration act. To date the committee has made no use of this attribute". Because the type of substance administration is generally implicit in the routeCode, in the consumable participant, etc., the field is generally not used, and there is no defined value set.
Binding: ActSubstanceAdministrationCode (extensible)
... statusCode 1..1CSBinding: ActStatus (required)
.... @code 1..1csThe substance administration effectiveTime field can repeat, in order to represent varying levels of complex dosing. effectiveTime can be used to represent the duration of administration (e.g., "10 days"), the frequency of administration (e.g., "every 8 hours"), and more. Here, we require that there SHALL be an effectiveTime documentation of the duration (or single-administration timestamp), and that there SHOULD be an effectiveTime documentation of the frequency. Other timing nuances, supported by the base CDA R2 standard, may also be included.
Binding: Medication Status (required)
... Slices for effectiveTime C1..*Slice: Unordered, Open by value:operator
1098-7513: SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499).
.... effectiveTimeSXCM_TS
.... effectiveTimeIVL_TS
.... effectiveTimeEIVL_TS
.... effectiveTimePIVL_TS
.... effectiveTimeSXPR_TS
.... effectiveTime:duration C1..1IVL_TSThis effectiveTime represents either the medication duration (i.e., the time the medication was started and stopped) or the single-administration timestamp.
1098-32890: This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890).
..... @value 0..1tsindicates a single-administration timestamp
Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
..... low 0..1IVXB_TSindicates when medication started
..... high 0..1IVXB_TSindicates when medication stopped
.... effectiveTime:periodicFrequency 0..1EIVL_TSThis effectiveTime represents a periodic medication frequency (e.g., administration times per day).
..... @operator 1..1csBinding: SetOperator (required)
Required Pattern: A
.... effectiveTime:eventFrequency 0..1PIVL_TSThis effectiveTime represents an event-based medication frequency (e.g., administration at bedtime).
..... @operator 1..1csBinding: SetOperator (required)
Required Pattern: A
... repeatNumber 0..1IVL_INTIn "INT" (intent) mood, the repeatNumber defines the number of allowed administrations. For example, a repeatNumber of "3" means that the substance can be administered up to 3 times. In "EVN" (event) mood, the repeatNumber is the number of occurrences. For example, a repeatNumber of "3" in a substance administration event means that the current administration is the 3rd in a series.
... routeCode 0..1CEBinding: SPL Drug Route of Administration Terminology (required)
.... translation 0..*CDBinding: Medication Route (required)
... approachSiteCode 0..1CDBinding: Body Site Value Set (required)
... doseQuantity C1..1IVL_PQ1098-16879: Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is "simply metoprolol Oral Product" (RxCUI 1163523), then doseQuantity must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration (CONF:1098-16879).
1098-16878: Pre-coordinated consumable: If the consumable code is a pre-coordinated unit dose (e.g., "metoprolol 25mg tablet") then doseQuantity is a unitless number that indicates the number of products given per administration (e.g., "2", meaning 2 x "metoprolol 25mg tablet" per administration) (CONF:1098-16878).
.... @unit 0..1csBinding: UnitsOfMeasureCaseSensitive (required)
... rateQuantity 0..1IVL_PQ
.... @unit 1..1csBinding: UnitsOfMeasureCaseSensitive (required)
... maxDoseQuantity 0..1RTO_PQ_PQ
... administrationUnitCode 0..1CEadministrationUnitCode@code describes the units of medication administration for an item using a code that is pre-coordinated to include a physical unit form (ointment, powder, solution, etc.) which differs from the units used in administering the consumable (capful, spray, drop, etc.). For example when recording medication administrations, 'metric drop (C48491)'' would be appropriate to accompany the RxNorm code of 198283 (Timolol 0.25% Ophthalmic Solution) where the number of drops would be specified in doseQuantity@value.
Binding: AdministrationUnitDoseForm (required)
... consumable 1..1InfrastructureRoot
.... manufacturedProduct 1..1MedicationInformationBase for all types and resources
... performer 0..1Performer2
... author 0..*AuthorParticipationBase for all types and resources
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:participantRole, value:typeCode
.... participant:drugVehicle 0..*Participant2
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: CSM
..... participantRole 1..1DrugVehicleBase for all types and resources
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by profile:substanceAdministration, profile:observation, profile:act, profile:supply
.... entryRelationship:indication 0..*EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... observation 1..1IndicationBase for all types and resources
.... entryRelationship:instruction 0..1EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
..... @inversionInd 1..1blFixed Value: true
..... act 1..1InstructionBase for all types and resources
.... entryRelationship:supplyOrder 0..1EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... supply 1..1MedicationSupplyOrderBase for all types and resources
.... entryRelationship:medicationDispense 0..*EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... supply C1..1MedicationDispenseBase for all types and resources
.... entryRelationship:reaction 0..*EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: CAUS
..... observation 1..1ReactionObservationBase for all types and resources
.... entryRelationship:drugMonitoring 0..1EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... act 1..1DrugMonitoringActBase for all types and resources
.... entryRelationship:substanceAdministered 0..*EntryRelationshipThe following entryRelationship is used to indicate a given medication's order in a series. The nested Substance Administered Act identifies an administration in the series. The entryRelationship/sequenceNumber shows the order of this particular administration in that series.
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... @inversionInd 1..1blFixed Value: true
..... sequenceNumber 0..1INT
..... act 1..1SubstanceAdministeredActBase for all types and resources
.... entryRelationship:adherence 0..*EntryRelationshipThe following entryRelationship is used to indicate the patient's adherence to the medication order.
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... observation 1..1MedicationAdherenceBase for all types and resources
.... entryRelationship:signature 0..*EntryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... substanceAdministration 1..1MedicationFreeTextSigBase for all types and resources
... precondition 0..*Precondition
.... @typeCode 1..1csBinding: ActRelationshipType (required)
Fixed Value: PRCN
.... criterion 1..1PreconditionforSubstanceAdministrationBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
SubstanceAdministration.classCoderequiredFixed Value: SBADM
SubstanceAdministration.moodCoderequiredMoodCodeEvnInt
SubstanceAdministration.codeextensibleActSubstanceAdministrationCode
SubstanceAdministration.statusCoderequiredActStatus
SubstanceAdministration.statusCode.coderequiredMedication Status
SubstanceAdministration.effectiveTime:periodicFrequency.operatorrequiredPattern: A
SubstanceAdministration.effectiveTime:eventFrequency.operatorrequiredPattern: A
SubstanceAdministration.routeCoderequiredSPL Drug Route of Administration Terminology
SubstanceAdministration.routeCode.translationrequiredMedication Route
SubstanceAdministration.approachSiteCoderequiredBody Site Value Set
SubstanceAdministration.doseQuantity.unitrequiredUnitsOfMeasureCaseSensitive (a valid code from UCUM)
SubstanceAdministration.rateQuantity.unitrequiredUnitsOfMeasureCaseSensitive (a valid code from UCUM)
SubstanceAdministration.administrationUnitCoderequiredAdministrationUnitDoseForm
SubstanceAdministration.participant:drugVehicle.typeCoderequiredFixed Value: CSM
SubstanceAdministration.entryRelationship:indication.typeCoderequiredFixed Value: RSON
SubstanceAdministration.entryRelationship:instruction.typeCoderequiredFixed Value: SUBJ
SubstanceAdministration.entryRelationship:supplyOrder.typeCoderequiredFixed Value: REFR
SubstanceAdministration.entryRelationship:medicationDispense.typeCoderequiredFixed Value: REFR
SubstanceAdministration.entryRelationship:reaction.typeCoderequiredFixed Value: CAUS
SubstanceAdministration.entryRelationship:drugMonitoring.typeCoderequiredFixed Value: COMP
SubstanceAdministration.entryRelationship:substanceAdministered.typeCoderequiredFixed Value: COMP
SubstanceAdministration.entryRelationship:adherence.typeCoderequiredFixed Value: COMP
SubstanceAdministration.entryRelationship:signature.typeCoderequiredFixed Value: COMP
SubstanceAdministration.precondition.typeCoderequiredFixed Value: PRCN

Constraints

IdGradePath(s)DetailsRequirements
1098-7513errorSubstanceAdministration.effectiveTimeSHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499).
:
1098-16878warningSubstanceAdministration.doseQuantityPre-coordinated consumable: If the consumable code is a pre-coordinated unit dose (e.g., "metoprolol 25mg tablet") then doseQuantity is a unitless number that indicates the number of products given per administration (e.g., "2", meaning 2 x "metoprolol 25mg tablet" per administration) (CONF:1098-16878).
:
1098-16879warningSubstanceAdministration.doseQuantityNot pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is "simply metoprolol Oral Product" (RxCUI 1163523), then doseQuantity must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration (CONF:1098-16879).
:
1098-30800warningSubstanceAdministrationMedication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800).
:
1098-32890errorSubstanceAdministration.effectiveTime:durationThis effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890).
:
4537-9333errorSubstanceAdministration.entryRelationship:medicationDispense.supplyA supply act **SHALL** contain one product/Medication Information *OR* one product/Immunization Medication Information template (CONF:4537-9333).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration C1..1CDAR2.SubstanceAdministrationXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, repeatNumber, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode, consumable, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition
Base for all types and resources
1098-30800: Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800).
... @classCode 1..1csBinding: ActClass (required)
Fixed Value: SBADM
... @moodCode 1..1csBinding: MoodCodeEvnInt (required)
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 1..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.16
..... @extension 1..1stRequired Pattern: 2014-06-09
... id 1..*II
... code 0..1CDSubstanceAdministration.code is an optional field. Per HL7 Pharmacy Committee, "this is intended to further specify the nature of the substance administration act. To date the committee has made no use of this attribute". Because the type of substance administration is generally implicit in the routeCode, in the consumable participant, etc., the field is generally not used, and there is no defined value set.
Binding: ActSubstanceAdministrationCode (extensible)
... @negationInd 0..1bl
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csThe substance administration effectiveTime field can repeat, in order to represent varying levels of complex dosing. effectiveTime can be used to represent the duration of administration (e.g., "10 days"), the frequency of administration (e.g., "every 8 hours"), and more. Here, we require that there SHALL be an effectiveTime documentation of the duration (or single-administration timestamp), and that there SHOULD be an effectiveTime documentation of the frequency. Other timing nuances, supported by the base CDA R2 standard, may also be included.
Binding: Medication Status (required)
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... Slices for effectiveTime C1..*Slice: Unordered, Open by value:operator
1098-7513: SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499).
.... effectiveTimeSXCM_TS
.... effectiveTimeIVL_TS
.... effectiveTimeEIVL_TS
.... effectiveTimePIVL_TS
.... effectiveTimeSXPR_TS
.... effectiveTime:duration C1..1IVL_TSThis effectiveTime represents either the medication duration (i.e., the time the medication was started and stopped) or the single-administration timestamp.
1098-32890: This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890).
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @value 0..1tsindicates a single-administration timestamp
Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
..... @operator 0..1csBinding: SetOperator (required)
..... low 0..1IVXB_TSindicates when medication started
..... center 0..1TS
..... width 0..1PQ
..... high 0..1IVXB_TSindicates when medication stopped
.... effectiveTime:periodicFrequency 0..1EIVL_TSThis effectiveTime represents a periodic medication frequency (e.g., administration times per day).
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @operator 1..1csBinding: SetOperator (required)
Required Pattern: A
..... event 0..1CE
..... offset 0..1IVL_PQ
.... effectiveTime:eventFrequency 0..1PIVL_TSThis effectiveTime represents an event-based medication frequency (e.g., administration at bedtime).
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @operator 1..1csBinding: SetOperator (required)
Required Pattern: A
..... phase 0..1IVL_TS
..... period 0..1PQ
..... @alignment 0..1cs
..... @institutionSpecified 0..1bl
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INTIn "INT" (intent) mood, the repeatNumber defines the number of allowed administrations. For example, a repeatNumber of "3" means that the substance can be administered up to 3 times. In "EVN" (event) mood, the repeatNumber is the number of occurrences. For example, a repeatNumber of "3" in a substance administration event means that the current administration is the 3rd in a series.
... routeCode 0..1CEBinding: SPL Drug Route of Administration Terminology (required)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 0..1cs
.... @codeSystem 0..1oid, uuid, ruid
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CDBinding: Medication Route (required)
... approachSiteCode 0..1CDBinding: Body Site Value Set (required)
... doseQuantity C1..1IVL_PQ1098-16879: Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is "simply metoprolol Oral Product" (RxCUI 1163523), then doseQuantity must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration (CONF:1098-16879).
1098-16878: Pre-coordinated consumable: If the consumable code is a pre-coordinated unit dose (e.g., "metoprolol 25mg tablet") then doseQuantity is a unitless number that indicates the number of products given per administration (e.g., "2", meaning 2 x "metoprolol 25mg tablet" per administration) (CONF:1098-16878).
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @unit 0..1csBinding: UnitsOfMeasureCaseSensitive (required)
.... @value 0..1real
.... @operator 0..1csBinding: SetOperator (required)
.... low 0..1IVXB_PQ
.... center 0..1PQ
.... width 0..1PQ
.... high 0..1IVXB_PQ
... rateQuantity 0..1IVL_PQ
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @unit 1..1csBinding: UnitsOfMeasureCaseSensitive (required)
.... @value 0..1real
.... @operator 0..1csBinding: SetOperator (required)
.... low 0..1IVXB_PQ
.... center 0..1PQ
.... width 0..1PQ
.... high 0..1IVXB_PQ
... maxDoseQuantity 0..1RTO_PQ_PQ
... administrationUnitCode 0..1CEadministrationUnitCode@code describes the units of medication administration for an item using a code that is pre-coordinated to include a physical unit form (ointment, powder, solution, etc.) which differs from the units used in administering the consumable (capful, spray, drop, etc.). For example when recording medication administrations, 'metric drop (C48491)'' would be appropriate to accompany the RxNorm code of 198283 (Timolol 0.25% Ophthalmic Solution) where the number of drops would be specified in doseQuantity@value.
Binding: AdministrationUnitDoseForm (required)
... consumable 1..1InfrastructureRoot
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationTargetDirect (required)
Fixed Value: CSM
.... manufacturedProduct 1..1MedicationInformationBase for all types and resources
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..1Performer2
... author 0..*AuthorParticipationBase for all types and resources
... informant 0..*Informant
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:participantRole, value:typeCode
.... participant:drugVehicle 0..*Participant2
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: CSM
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... sdtcFunctionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
XML: functionCode (urn:hl7-org:sdtc)
..... time 0..1IVL_TS
..... awarenessCode 0..1CE
..... participantRole 1..1DrugVehicleBase for all types and resources
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by profile:substanceAdministration, profile:observation, profile:act, profile:supply
.... entryRelationship:indication 0..*EntryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 1..1IndicationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:instruction 0..1EntryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
..... @inversionInd 1..1blFixed Value: true
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 1..1InstructionBase for all types and resources
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:supplyOrder 0..1EntryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 1..1MedicationSupplyOrderBase for all types and resources
.... entryRelationship:medicationDispense 0..*EntryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply C1..1MedicationDispenseBase for all types and resources
.... entryRelationship:reaction 0..*EntryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: CAUS
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 1..1ReactionObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:drugMonitoring 0..1EntryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 1..1DrugMonitoringActBase for all types and resources
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:substanceAdministered 0..*EntryRelationshipThe following entryRelationship is used to indicate a given medication's order in a series. The nested Substance Administered Act identifies an administration in the series. The entryRelationship/sequenceNumber shows the order of this particular administration in that series.
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... @inversionInd 1..1blFixed Value: true
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 1..1SubstanceAdministeredActBase for all types and resources
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:adherence 0..*EntryRelationshipThe following entryRelationship is used to indicate the patient's adherence to the medication order.
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 1..1MedicationAdherenceBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:signature 0..*EntryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 1..1MedicationFreeTextSigBase for all types and resources
..... supply 0..1Supply
... reference 0..*Reference
... precondition 0..*Precondition
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @typeCode 1..1csBinding: ActRelationshipType (required)
Fixed Value: PRCN
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... criterion 1..1PreconditionforSubstanceAdministrationBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
SubstanceAdministration.classCoderequiredFixed Value: SBADM
SubstanceAdministration.moodCoderequiredMoodCodeEvnInt
SubstanceAdministration.templateId:primary.nullFlavorrequiredNullFlavor
SubstanceAdministration.codeextensibleActSubstanceAdministrationCode
SubstanceAdministration.statusCoderequiredActStatus
SubstanceAdministration.statusCode.nullFlavorrequiredNullFlavor
SubstanceAdministration.statusCode.coderequiredMedication Status
SubstanceAdministration.effectiveTime:duration.nullFlavorrequiredNullFlavor
SubstanceAdministration.effectiveTime:duration.operatorrequiredSetOperator
SubstanceAdministration.effectiveTime:periodicFrequency.nullFlavorrequiredNullFlavor
SubstanceAdministration.effectiveTime:periodicFrequency.operatorrequiredPattern: A
SubstanceAdministration.effectiveTime:eventFrequency.nullFlavorrequiredNullFlavor
SubstanceAdministration.effectiveTime:eventFrequency.operatorrequiredPattern: A
SubstanceAdministration.priorityCodeextensibleActPriority
SubstanceAdministration.routeCoderequiredSPL Drug Route of Administration Terminology
SubstanceAdministration.routeCode.nullFlavorrequiredNullFlavor
SubstanceAdministration.routeCode.translationrequiredMedication Route
SubstanceAdministration.approachSiteCoderequiredBody Site Value Set
SubstanceAdministration.doseQuantity.nullFlavorrequiredNullFlavor
SubstanceAdministration.doseQuantity.unitrequiredUnitsOfMeasureCaseSensitive (a valid code from UCUM)
SubstanceAdministration.doseQuantity.operatorrequiredSetOperator
SubstanceAdministration.rateQuantity.nullFlavorrequiredNullFlavor
SubstanceAdministration.rateQuantity.unitrequiredUnitsOfMeasureCaseSensitive (a valid code from UCUM)
SubstanceAdministration.rateQuantity.operatorrequiredSetOperator
SubstanceAdministration.administrationUnitCoderequiredAdministrationUnitDoseForm
SubstanceAdministration.consumable.nullFlavorrequiredNullFlavor
SubstanceAdministration.consumable.typeCoderequiredFixed Value: CSM
SubstanceAdministration.participant:drugVehicle.nullFlavorrequiredNullFlavor
SubstanceAdministration.participant:drugVehicle.typeCoderequiredFixed Value: CSM
SubstanceAdministration.participant:drugVehicle.contextControlCoderequiredFixed Value: OP
SubstanceAdministration.entryRelationship:indication.nullFlavorrequiredNullFlavor
SubstanceAdministration.entryRelationship:indication.typeCoderequiredFixed Value: RSON
SubstanceAdministration.entryRelationship:instruction.nullFlavorrequiredNullFlavor
SubstanceAdministration.entryRelationship:instruction.typeCoderequiredFixed Value: SUBJ
SubstanceAdministration.entryRelationship:supplyOrder.nullFlavorrequiredNullFlavor
SubstanceAdministration.entryRelationship:supplyOrder.typeCoderequiredFixed Value: REFR
SubstanceAdministration.entryRelationship:medicationDispense.nullFlavorrequiredNullFlavor
SubstanceAdministration.entryRelationship:medicationDispense.typeCoderequiredFixed Value: REFR
SubstanceAdministration.entryRelationship:reaction.nullFlavorrequiredNullFlavor
SubstanceAdministration.entryRelationship:reaction.typeCoderequiredFixed Value: CAUS
SubstanceAdministration.entryRelationship:drugMonitoring.nullFlavorrequiredNullFlavor
SubstanceAdministration.entryRelationship:drugMonitoring.typeCoderequiredFixed Value: COMP
SubstanceAdministration.entryRelationship:substanceAdministered.nullFlavorrequiredNullFlavor
SubstanceAdministration.entryRelationship:substanceAdministered.typeCoderequiredFixed Value: COMP
SubstanceAdministration.entryRelationship:adherence.nullFlavorrequiredNullFlavor
SubstanceAdministration.entryRelationship:adherence.typeCoderequiredFixed Value: COMP
SubstanceAdministration.entryRelationship:signature.nullFlavorrequiredNullFlavor
SubstanceAdministration.entryRelationship:signature.typeCoderequiredFixed Value: COMP
SubstanceAdministration.precondition.nullFlavorrequiredNullFlavor
SubstanceAdministration.precondition.typeCoderequiredFixed Value: PRCN

Constraints

IdGradePath(s)DetailsRequirements
1098-7513errorSubstanceAdministration.effectiveTimeSHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499).
:
1098-16878warningSubstanceAdministration.doseQuantityPre-coordinated consumable: If the consumable code is a pre-coordinated unit dose (e.g., "metoprolol 25mg tablet") then doseQuantity is a unitless number that indicates the number of products given per administration (e.g., "2", meaning 2 x "metoprolol 25mg tablet" per administration) (CONF:1098-16878).
:
1098-16879warningSubstanceAdministration.doseQuantityNot pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is "simply metoprolol Oral Product" (RxCUI 1163523), then doseQuantity must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration (CONF:1098-16879).
:
1098-30800warningSubstanceAdministrationMedication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800).
:
1098-32890errorSubstanceAdministration.effectiveTime:durationThis effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890).
:
4537-9333errorSubstanceAdministration.entryRelationship:medicationDispense.supplyA supply act **SHALL** contain one product/Medication Information *OR* one product/Immunization Medication Information template (CONF:4537-9333).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

This structure is derived from CDAR2.SubstanceAdministration

Summary

Mandatory: 10 elements (16 nested mandatory elements)
Fixed Value: 13 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element SubstanceAdministration.templateId is sliced based on the values of value:extension, value:root
  • The element SubstanceAdministration.effectiveTime is sliced based on the value of value:operator
  • The element SubstanceAdministration.participant is sliced based on the values of value:participantRole, value:typeCode
  • The element SubstanceAdministration.entryRelationship is sliced based on the values of profile:substanceAdministration, profile:observation, profile:act, profile:supply

Differential View

This structure is derived from CDAR2.SubstanceAdministration

NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration C1..1CDAR2.SubstanceAdministrationXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, repeatNumber, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode, consumable, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition
Base for all types and resources
1098-30800: Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800).
... classCode 1..1cs
... moodCode 1..1csBinding: MoodCodeEvnInt (required)
... Slices for templateId 1..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.16
..... extension 1..1stRequired Pattern: 2014-06-09
... code 0..1CDSubstanceAdministration.code is an optional field. Per HL7 Pharmacy Committee, "this is intended to further specify the nature of the substance administration act. To date the committee has made no use of this attribute". Because the type of substance administration is generally implicit in the routeCode, in the consumable participant, etc., the field is generally not used, and there is no defined value set.
... statusCode 1..1CS
.... code 1..1csThe substance administration effectiveTime field can repeat, in order to represent varying levels of complex dosing. effectiveTime can be used to represent the duration of administration (e.g., "10 days"), the frequency of administration (e.g., "every 8 hours"), and more. Here, we require that there SHALL be an effectiveTime documentation of the duration (or single-administration timestamp), and that there SHOULD be an effectiveTime documentation of the frequency. Other timing nuances, supported by the base CDA R2 standard, may also be included.
Binding: Medication Status (required)
... Slices for effectiveTime C1..*SXCM_TS, IVL_TS, EIVL_TS, PIVL_TS, SXPR_TSSlice: Unordered, Open by value:operator
1098-7513: SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499).
.... effectiveTime:duration C1..1IVL_TSThis effectiveTime represents either the medication duration (i.e., the time the medication was started and stopped) or the single-administration timestamp.
1098-32890: This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890).
..... value 0..1tsindicates a single-administration timestamp
..... low 0..1IVXB_TSindicates when medication started
..... high 0..1IVXB_TSindicates when medication stopped
.... effectiveTime:periodicFrequency 0..1EIVL_TSThis effectiveTime represents a periodic medication frequency (e.g., administration times per day).
..... operator 1..1csRequired Pattern: A
.... effectiveTime:eventFrequency 0..1PIVL_TSThis effectiveTime represents an event-based medication frequency (e.g., administration at bedtime).
..... operator 1..1csRequired Pattern: A
... repeatNumber 0..1IVL_INTIn "INT" (intent) mood, the repeatNumber defines the number of allowed administrations. For example, a repeatNumber of "3" means that the substance can be administered up to 3 times. In "EVN" (event) mood, the repeatNumber is the number of occurrences. For example, a repeatNumber of "3" in a substance administration event means that the current administration is the 3rd in a series.
... routeCode 0..1CEBinding: SPL Drug Route of Administration Terminology (required)
.... translation 0..*CDBinding: Medication Route (required)
... approachSiteCode 0..1CDBinding: Body Site Value Set (required)
... doseQuantity C1..1IVL_PQ1098-16879: Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is "simply metoprolol Oral Product" (RxCUI 1163523), then doseQuantity must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration (CONF:1098-16879).
1098-16878: Pre-coordinated consumable: If the consumable code is a pre-coordinated unit dose (e.g., "metoprolol 25mg tablet") then doseQuantity is a unitless number that indicates the number of products given per administration (e.g., "2", meaning 2 x "metoprolol 25mg tablet" per administration) (CONF:1098-16878).
.... unit 0..1csBinding: UnitsOfMeasureCaseSensitive (required)
... rateQuantity 0..1IVL_PQ
.... unit 1..1csBinding: UnitsOfMeasureCaseSensitive (required)
... maxDoseQuantity 0..1RTO_PQ_PQ
... administrationUnitCode 0..1CEadministrationUnitCode@code describes the units of medication administration for an item using a code that is pre-coordinated to include a physical unit form (ointment, powder, solution, etc.) which differs from the units used in administering the consumable (capful, spray, drop, etc.). For example when recording medication administrations, 'metric drop (C48491)'' would be appropriate to accompany the RxNorm code of 198283 (Timolol 0.25% Ophthalmic Solution) where the number of drops would be specified in doseQuantity@value.
Binding: AdministrationUnitDoseForm (required)
... consumable 1..1InfrastructureRoot
.... manufacturedProduct 1..1MedicationInformationBase for all types and resources
... performer 0..1Performer2
... author 0..*AuthorParticipationBase for all types and resources
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:participantRole, value:typeCode
.... participant:drugVehicle 0..*Participant2
..... typeCode 1..1csFixed Value: CSM
..... participantRole 1..1DrugVehicleBase for all types and resources
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by profile:substanceAdministration, profile:observation, profile:act, profile:supply
.... entryRelationship:indication 0..*EntryRelationship
..... typeCode 1..1csFixed Value: RSON
..... observation 1..1IndicationBase for all types and resources
.... entryRelationship:instruction 0..1EntryRelationship
..... typeCode 1..1csFixed Value: SUBJ
..... inversionInd 1..1blFixed Value: true
..... act 1..1InstructionBase for all types and resources
.... entryRelationship:supplyOrder 0..1EntryRelationship
..... typeCode 1..1csFixed Value: REFR
..... supply 1..1MedicationSupplyOrderBase for all types and resources
.... entryRelationship:medicationDispense 0..*EntryRelationship
..... typeCode 1..1csFixed Value: REFR
..... supply 1..1MedicationDispenseBase for all types and resources
.... entryRelationship:reaction 0..*EntryRelationship
..... typeCode 1..1csFixed Value: CAUS
..... observation 1..1ReactionObservationBase for all types and resources
.... entryRelationship:drugMonitoring 0..1EntryRelationship
..... typeCode 1..1csFixed Value: COMP
..... act 1..1DrugMonitoringActBase for all types and resources
.... entryRelationship:substanceAdministered 0..*EntryRelationshipThe following entryRelationship is used to indicate a given medication's order in a series. The nested Substance Administered Act identifies an administration in the series. The entryRelationship/sequenceNumber shows the order of this particular administration in that series.
..... typeCode 1..1csFixed Value: COMP
..... inversionInd 1..1blFixed Value: true
..... sequenceNumber 0..1INT
..... act 1..1SubstanceAdministeredActBase for all types and resources
.... entryRelationsh