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: MedicationFreeTextSig - Detailed Descriptions

Active as of 2022-05-13

Definitions for the 2.16.840.1.113883.10.20.22.4.147 resource profile.

1. SubstanceAdministration
Control1..1
2. SubstanceAdministration.classCode
Control1..1
BindingThe codes SHALL be taken from ActClass
Typecode
Requirements

SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:81-32770).

Default ValueSBADM
Fixed ValueSBADM
3. SubstanceAdministration.moodCode
Control1..1
BindingThe codes SHALL be taken from MoodCodeEvnInt
Typecode
Requirements

SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet MoodCodeEvnInt urn:oid:2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03 (CONF:81-32771).

4. SubstanceAdministration.realmCode
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/CS
5. SubstanceAdministration.typeId
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/II
6. SubstanceAdministration.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/II
SlicingThis element introduces a set of slices on SubstanceAdministration.templateId. The slices are unordered and Closed, and can be differentiated using the following discriminators:
  • value @ root
7. SubstanceAdministration.templateId:primary
SliceNameprimary
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/II
Requirements

SHALL contain exactly one [1..1] templateId (CONF:81-32753) such that it

8. SubstanceAdministration.templateId:primary.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from NullFlavor
Typecode
9. SubstanceAdministration.templateId:primary.assigningAuthorityName
Definition

A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.

Control0..1
Typestring
10. SubstanceAdministration.templateId:primary.displayable
Definition

Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).

Control0..1
Typeboolean
11. SubstanceAdministration.templateId:primary.root
Definition

A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier.

Control1..1
Typestring
Requirements

SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.147" (CONF:81-32772).

Pattern Value2.16.840.1.113883.10.20.22.4.147
12. SubstanceAdministration.templateId:primary.extension
Definition

A character string as a unique identifier within the scope of the identifier root.

Control0..1
Typestring
13. SubstanceAdministration.id
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/II
14. SubstanceAdministration.code
Control1..1
BindingThe codes SHALL be taken from http://terminology.hl7.org/ValueSet/v3-SubstanceAdministrationActCode; other codes may be used where these codes are not suitable
Typehttp://hl7.org/fhir/cda/StructureDefinition/CD
Requirements

SHALL contain exactly one [1..1] code (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:81-32775).

15. SubstanceAdministration.code.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from NullFlavor
Typecode
16. SubstanceAdministration.code.code
Definition

The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.

Control1..1
Typestring
Requirements

This code SHALL contain exactly one [1..1] @code="76662-6" Instructions Medication (CONF:81-32780).

Pattern Value76662-6
17. SubstanceAdministration.code.codeSystem
Definition

Specifies the code system that defines the code.

Control1..1
Typestring
Requirements

This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1 STATIC) (CONF:81-32781).

Pattern Value2.16.840.1.113883.6.1
18. SubstanceAdministration.code.codeSystemName
Definition

The common name of the coding system.

Control0..1
Typestring
19. SubstanceAdministration.code.codeSystemVersion
Definition

If applicable, a version descriptor defined specifically for the given code system.

Control0..1
Typestring
20. SubstanceAdministration.code.displayName
Definition

A name or title for the code, under which the sending system shows the code value to its users.

Control0..1
Typestring
21. SubstanceAdministration.code.sdtcValueSet
Definition

The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept.

Control0..1
Typestring
22. SubstanceAdministration.code.sdtcValueSetVersion
Definition

The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept.

Control0..1
Typestring
23. SubstanceAdministration.code.originalText
Definition

The text or phrase used as the basis for the coding.

Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ED
24. SubstanceAdministration.code.qualifier
Definition

Specifies additional codes that increase the specificity of the the primary code.

Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/CR
25. SubstanceAdministration.code.translation
Definition

A set of other concept descriptors that translate this concept descriptor into other code systems.

Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/CD
26. SubstanceAdministration.negationInd
Control0..1
Typeboolean
27. SubstanceAdministration.text
Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ED
Requirements

SHALL contain exactly one [1..1] text (CONF:81-32754).

28. SubstanceAdministration.text.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from NullFlavor
Typecode
29. SubstanceAdministration.text.charset
Definition

For character-based encoding types, this property specifies the character set and character encoding used. The charset shall be identified by an Internet Assigned Numbers Authority (IANA) Charset Registration [] in accordance with RFC 2978 [].

Control0..1
Typecode
30. SubstanceAdministration.text.compression
Definition

Indicates whether the raw byte data is compressed, and what compression algorithm was used.

Control0..1
BindingThe codes SHALL be taken from CompressionAlgorithm
Typecode
31. SubstanceAdministration.text.integrityCheck
Definition

The integrity check is a short binary value representing a cryptographically strong checksum that is calculated over the binary data. The purpose of this property, when communicated with a reference is for anyone to validate later whether the reference still resolved to the same data that the reference resolved to when the encapsulated data value with reference was created.

Control0..1
Typebase64Binary
32. SubstanceAdministration.text.integrityCheckAlgorithm
Definition

Specifies the algorithm used to compute the integrityCheck value. The cryptographically strong checksum algorithm Secure Hash Algorithm-1 (SHA-1) is currently the industry standard. It has superseded the MD5 algorithm only a couple of years ago, when certain flaws in the security of MD5 were discovered. Currently the SHA-1 hash algorithm is the default choice for the integrity check algorithm. Note that SHA-256 is also entering widespread usage.

Control0..1
BindingThe codes SHALL be taken from IntegrityCheckAlgorithm
Typecode
33. SubstanceAdministration.text.language
Definition

For character based information the language property specifies the human language of the text.

Control0..1
Typecode
34. SubstanceAdministration.text.mediaType
Definition

Identifies the type of the encapsulated data and identifies a method to interpret or render the data.

Control0..1
Typecode
35. SubstanceAdministration.text.representation
Control0..1
Typecode
36. SubstanceAdministration.text.data[x]
Definition

Data that is primarily intended for human interpretation or for further machine processing is outside the scope of HL7. This includes unformatted or formatted written language, multimedia data, or structured information as defined by a different standard (e.g., XML-signatures.)

Control0..1
TypeChoice of: string, base64Binary
[x] NoteSee Choice of Data Types for further information about how to use [x]
37. SubstanceAdministration.text.reference
Definition

A telecommunication address (TEL), such as a URL for HTTP or FTP, which will resolve to precisely the same binary data that could as well have been provided as inline data.

Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/TEL
Requirements

This text SHALL contain exactly one [1..1] reference (CONF:81-32755).

38. SubstanceAdministration.text.reference.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from NullFlavor
Typecode
39. SubstanceAdministration.text.reference.value
Control0..1
Typeuri
Requirements

This reference SHOULD contain zero or one [0..1] @value (CONF:81-32756).

InvariantsDefined on this element
81-32774: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:81-32774). (: )
40. SubstanceAdministration.text.reference.useablePeriod
Definition

Specifies the periods of time during which the telecommunication address can be used. For a telephone number, this can indicate the time of day in which the party can be reached on that telephone. For a web address, it may specify a time range in which the web content is promised to be available under the given address.

Control0..*
TypeChoice of: http://hl7.org/fhir/cda/StructureDefinition/IVL-TS, http://hl7.org/fhir/cda/StructureDefinition/EIVL-TS, http://hl7.org/fhir/cda/StructureDefinition/PIVL-TS, http://hl7.org/fhir/cda/StructureDefinition/SXPR-TS
41. SubstanceAdministration.text.reference.use
Definition

One or more codes advising a system or user which telecommunication address in a set of like addresses to select for a given telecommunication need.

Control0..*
BindingThe codes SHALL be taken from AddressUse
Typecode
42. SubstanceAdministration.text.thumbnail
Definition

An abbreviated rendition of the full data. A thumbnail requires significantly fewer resources than the full data, while still maintaining some distinctive similarity with the full data. A thumbnail is typically used with by-reference encapsulated data. It allows a user to select data more efficiently before actually downloading through the reference.

Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ED
43. SubstanceAdministration.statusCode
Control0..1
BindingThe codes SHALL be taken from ActStatus
Typehttp://hl7.org/fhir/cda/StructureDefinition/CS
44. SubstanceAdministration.effectiveTime
Control0..*
TypeChoice of: http://hl7.org/fhir/cda/StructureDefinition/SXCM-TS, http://hl7.org/fhir/cda/StructureDefinition/IVL-TS, http://hl7.org/fhir/cda/StructureDefinition/EIVL-TS, http://hl7.org/fhir/cda/StructureDefinition/PIVL-TS, http://hl7.org/fhir/cda/StructureDefinition/SXPR-TS
45. SubstanceAdministration.priorityCode
Control0..1
BindingThe codes SHALL be taken from ActPriority; other codes may be used where these codes are not suitable
Typehttp://hl7.org/fhir/cda/StructureDefinition/CE
46. SubstanceAdministration.repeatNumber
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/IVL-INT
47. SubstanceAdministration.routeCode
Control0..1
BindingThe codes SHALL be taken from RouteOfAdministration; other codes may be used where these codes are not suitable
Typehttp://hl7.org/fhir/cda/StructureDefinition/CE
48. SubstanceAdministration.approachSiteCode
Control0..*
BindingThe codes SHALL be taken from v3 Code System ActSite; other codes may be used where these codes are not suitable
Typehttp://hl7.org/fhir/cda/StructureDefinition/CD
49. SubstanceAdministration.doseQuantity
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/IVL-PQ
50. SubstanceAdministration.rateQuantity
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/IVL-PQ
51. SubstanceAdministration.maxDoseQuantity
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/RTO-PQ-PQ
52. SubstanceAdministration.administrationUnitCode
Control0..1
BindingThe codes SHALL be taken from AdministrableDrugForm; other codes may be used where these codes are not suitable
Typehttp://hl7.org/fhir/cda/StructureDefinition/CE
53. SubstanceAdministration.consumable
Control1..1
TypeElement
Requirements

SHALL contain exactly one [1..1] consumable (CONF:81-32776).

54. SubstanceAdministration.consumable.typeCode
Control1..1
BindingThe codes SHALL be taken from ParticipationTargetDirect
Typecode
Default ValueCSM
Fixed ValueCSM
55. SubstanceAdministration.consumable.manufacturedProduct
Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ManufacturedProduct
Requirements

This consumable SHALL contain exactly one [1..1] manufacturedProduct (CONF:81-32777).

56. SubstanceAdministration.consumable.manufacturedProduct.classCode
Control1..1
BindingThe codes SHALL be taken from RoleClassManufacturedProduct
Typecode
Default ValueMANU
Fixed ValueMANU
57. SubstanceAdministration.consumable.manufacturedProduct.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/II
58. SubstanceAdministration.consumable.manufacturedProduct.id
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/II
59. SubstanceAdministration.consumable.manufacturedProduct.sdtcIdentifiedBy
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/IdentifiedBy
60. SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug
Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/LabeledDrug
Requirements

This manufacturedProduct SHALL contain exactly one [1..1] manufacturedLabeledDrug (CONF:81-32778).

61. SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.nullFlavor
Control1..1
BindingThe codes SHALL be taken from NullFlavor
Typecode
Requirements

This manufacturedLabeledDrug SHALL contain exactly one [1..1] @nullFlavor="NA" Not Applicable (CONF:81-32779).

Pattern ValueNA
62. SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.classCode
Control1..1
BindingThe codes SHALL be taken from EntityClassManufacturedMaterial
Typecode
Default ValueMMAT
Fixed ValueMMAT
63. SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.determinerCode
Control1..1
BindingThe codes SHALL be taken from EntityDeterminerDetermined
Typecode
Default ValueKIND
Fixed ValueKIND
64. SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/II
65. SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.code
Control0..1
BindingThe codes SHALL be taken from http://terminology.hl7.org/ValueSet/v3-DrugEntity; other codes may be used where these codes are not suitable
Typehttp://hl7.org/fhir/cda/StructureDefinition/CE
66. SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.name
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/EN
67. SubstanceAdministration.consumable.manufacturedProduct.manufacturedMaterial
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Material
68. SubstanceAdministration.consumable.manufacturedProduct.manufacturerOrganization
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Organization
69. SubstanceAdministration.subject
Control0..1
TypeElement
70. SubstanceAdministration.subject.typeCode
Control1..1
BindingThe codes SHALL be taken from ParticipationTargetSubject
Typecode
Default ValueSBJ
Fixed ValueSBJ
71. SubstanceAdministration.subject.contextControlCode
Control1..1
BindingThe codes SHALL be taken from ContextControl
Typecode
Default ValueOP
Fixed ValueOP
72. SubstanceAdministration.subject.awarenessCode
Control0..1
BindingThe codes SHALL be taken from TargetAwareness; other codes may be used where these codes are not suitable
Typehttp://hl7.org/fhir/cda/StructureDefinition/CE
73. SubstanceAdministration.subject.relatedSubject
Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/RelatedSubject
74. SubstanceAdministration.specimen
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Specimen
75. SubstanceAdministration.performer
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Performer2
76. SubstanceAdministration.author
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Author
77. SubstanceAdministration.informant
Control0..*
TypeElement
78. SubstanceAdministration.informant.typeCode
Control1..1
BindingThe codes SHALL be taken from ParticipationInformationGenerator
Typecode
Default ValueINF
Fixed ValueINF
79. SubstanceAdministration.informant.contextControlCode
Control1..1
BindingThe codes SHALL be taken from ContextControl
Typecode
Default ValueOP
Fixed ValueOP
80. SubstanceAdministration.informant.assignedEntity
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/AssignedEntity
81. SubstanceAdministration.informant.relatedEntity
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/RelatedEntity
82. SubstanceAdministration.participant
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Participant2
83. SubstanceAdministration.entryRelationship
Control0..*
TypeElement
InvariantsDefined on this element
subst-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act (: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1)
84. SubstanceAdministration.entryRelationship.typeCode
Control1..1
Typecode
85. SubstanceAdministration.entryRelationship.inversionInd
Control0..1
Typeboolean
86. SubstanceAdministration.entryRelationship.contextConductionInd
Control1..1
Typeboolean
Default Valuetrue
87. SubstanceAdministration.entryRelationship.sequenceNumber
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/INT
88. SubstanceAdministration.entryRelationship.negationInd
Control0..1
Typeboolean
89. SubstanceAdministration.entryRelationship.seperatableInd
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/BL
90. SubstanceAdministration.entryRelationship.observation
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Observation
91. SubstanceAdministration.entryRelationship.regionOfInterest
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/RegionOfInterest
92. SubstanceAdministration.entryRelationship.observationMedia
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ObservationMedia
93. SubstanceAdministration.entryRelationship.substanceAdministration
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/SubstanceAdministration
94. SubstanceAdministration.entryRelationship.supply
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Supply
95. SubstanceAdministration.entryRelationship.procedure
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Procedure
96. SubstanceAdministration.entryRelationship.encounter
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Encounter
97. SubstanceAdministration.entryRelationship.organizer
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Organizer
98. SubstanceAdministration.entryRelationship.act
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Act
99. SubstanceAdministration.reference
Control0..*
TypeElement
100. SubstanceAdministration.reference.typeCode
Control1..1
Typecode
101. SubstanceAdministration.reference.seperatableInd
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/BL
102. SubstanceAdministration.reference.externalAct
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ExternalAct
103. SubstanceAdministration.reference.externalObservation
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ExternalObservation
104. SubstanceAdministration.reference.externalProcedure
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ExternalProcedure
105. SubstanceAdministration.reference.externalDocument
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ExternalDocument
106. SubstanceAdministration.precondition
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Precondition