Consolidated CDA Release 2.2
2.2 - CI Build United States of America flag

Consolidated CDA Release 2.2, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.2). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.2/ and changes regularly. See the Directory of published versions

Resource Profile: Medications Section (entries required)

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.1.1 Version: 2.2
Active as of 2022-05-13 Computable Name: MedicationsSectionEntriesRequired
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.2.1.1:2014-06-09

The Medications Section contains a patient’s current medications and pertinent medication history. At a minimum, the currently active medications are listed. An entire medication history is an option. The section can describe a patient’s prescription and dispense history and information about intended drug monitoring.

This section requires either an entry indicating the subject is not known to be on any medications or entries summarizing the subject’s medications.

Usage:

Formal Views of Profile Content

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

This structure is derived from MedicationsSectionEntriesOptional

Summary

Mandatory: 10 elements

Slices

This structure defines the following Slices:

  • The element Section.templateId is sliced based on the values of value:root, value:extension
  • The element Section.entry is sliced based on the value of value:substanceAdministration

This structure is derived from MedicationsSectionEntriesOptional

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1MedicationsSectionEntriesOptional
... nullFlavor 0..1codeRequired Pattern: NI
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:secondary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.1.1
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CE
.... code 1..1stringRequired Pattern: 10160-0
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... Slices for entry 1..*ElementIf section/@nullFlavor is not present:
Slice: Unordered, Open by value:substanceAdministration
.... entry:medActivity 1..*Element

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1MedicationsSectionEntriesOptional
... ID 0..1string
... nullFlavor 0..1codeBinding: NullFlavor (required)
Required Pattern: NI
... classCode 1..1code​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.1
..... extension 1..1stringRequired Pattern: 2014-06-09
.... templateId:secondary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.1.1
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 10160-0
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ED
... text S1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... Slices for entry I1..*ElementIf section/@nullFlavor is not present:
Slice: Unordered, Open by value:substanceAdministration
.... entry:medActivity I1..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... substanceAdministration I1..1MedicationActivity
... component 0..*Element
.... typeCode 1..1codeFixed Value: COMP
.... contextConductionInd 1..1boolean
.... section 1..1Section

doco Documentation for this format

This structure is derived from MedicationsSectionEntriesOptional

Summary

Mandatory: 10 elements

Slices

This structure defines the following Slices:

  • The element Section.templateId is sliced based on the values of value:root, value:extension
  • The element Section.entry is sliced based on the value of value:substanceAdministration

Differential View

This structure is derived from MedicationsSectionEntriesOptional

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1MedicationsSectionEntriesOptional
... nullFlavor 0..1codeRequired Pattern: NI
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:secondary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.1.1
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CE
.... code 1..1stringRequired Pattern: 10160-0
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... Slices for entry 1..*ElementIf section/@nullFlavor is not present:
Slice: Unordered, Open by value:substanceAdministration
.... entry:medActivity 1..*Element

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1MedicationsSectionEntriesOptional
... ID 0..1string
... nullFlavor 0..1codeBinding: NullFlavor (required)
Required Pattern: NI
... classCode 1..1code​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.1
..... extension 1..1stringRequired Pattern: 2014-06-09
.... templateId:secondary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.1.1
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 10160-0
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ED
... text S1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... Slices for entry I1..*ElementIf section/@nullFlavor is not present:
Slice: Unordered, Open by value:substanceAdministration
.... entry:medActivity I1..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... substanceAdministration I1..1MedicationActivity
... component 0..*Element
.... typeCode 1..1codeFixed Value: COMP
.... contextConductionInd 1..1boolean
.... section 1..1Section

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredPattern: NI
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.templateId:primary.nullFlavorrequiredNullFlavor
Section.templateId:secondary.nullFlavorrequiredNullFlavor
Section.codeextensibleDocumentSectionType
Section.code.nullFlavorrequiredNullFlavor
Section.languageCoderequiredHumanLanguage
Section.subject.typeCoderequiredFixed Value: SBJ
Section.subject.contextControlCoderequiredFixed Value: OP
Section.subject.awarenessCodeextensibleTargetAwareness
Section.informant.typeCoderequiredFixed Value: INF
Section.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePathDetailsRequirements
only-one-statementerrorSection.entrySHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
only-one-statementerrorSection.entry:medActivitySHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
1098-30800warningSection.entry:medActivity.substanceAdministrationMedication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800).
: