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: Medication Free Text Sig

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.147 Version: 2.2
Active as of 2022-05-13 Computable Name: MedicationFreeTextSig
Other Identifiers: : urn:oid:2.16.840.1.113883.10.20.22.4.147

The template is available to explicitly identify the free text Sig within each medication.

An example free text sig: Thyroxin 150 ug, take one tab by mouth every morning.

Usage:

Formal Views of Profile Content

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

This structure is derived from CDAR2.SubstanceAdministration

Summary

Mandatory: 13 elements

Slices

This structure defines the following Slices:

  • The element SubstanceAdministration.templateId is sliced based on the value of value:root (Closed)

This structure is derived from CDAR2.SubstanceAdministration

NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration 1..1CDAR2.SubstanceAdministration
... classCode 1..1code
... moodCode 1..1codemoodCode must match the parent substanceAdministration EVN or INT
Binding: MoodCodeEvnInt (required)
... Slices for templateId 0..*IISlice: Unordered, Closed by value:root
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.147
.... code 1..1stringRequired Pattern: 76662-6
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1ED
.... reference 1..1TELReference into the section/text to a tag that only contains free text sig.
..... value I0..1uri81-32774: 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).
... consumable 1..1Element
.... manufacturedProduct 1..1ManufacturedProduct
..... manufacturedLabeledDrug 1..1LabeledDrug
...... nullFlavor 1..1codeRequired Pattern: NA

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration 1..1CDAR2.SubstanceAdministration
... classCode 1..1codeBinding: ActClass (required)
Fixed Value: SBADM
... moodCode 1..1codemoodCode must match the parent substanceAdministration EVN or INT
Binding: MoodCodeEvnInt (required)
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 0..*IISlice: Unordered, Closed by value:root
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.147
..... extension 0..1string
... id 0..*II
... code 1..1CD​Binding: http://terminology.hl7.org/ValueSet/v3-SubstanceAdministrationActCode (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 76662-6
.... 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
.... qualifier 0..*CR
.... translation 0..*CD
... negationInd 0..1boolean
... text 1..1ED
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... charset 0..1code
.... compression 0..1codeBinding: CompressionAlgorithm (required)
.... integrityCheck 0..1base64Binary
.... integrityCheckAlgorithm 0..1codeBinding: IntegrityCheckAlgorithm (required)
.... language 0..1code
.... mediaType 0..1code
.... representation 0..1code
.... data[x] 0..1
..... dataStringstring
..... dataBase64Binarybase64Binary
.... reference 1..1TELReference into the section/text to a tag that only contains free text sig.
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... value I0..1uri81-32774: 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).
..... useablePeriod 0..*
...... useablePeriodIVL_TS
...... useablePeriodEIVL_TS
...... useablePeriodPIVL_TS
...... useablePeriodSXPR_TS
..... use 0..*codeBinding: AddressUse (required)
.... thumbnail 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..*
.... effectiveTimeSXCM_TS
.... effectiveTimeIVL_TS
.... effectiveTimeEIVL_TS
.... effectiveTimePIVL_TS
.... effectiveTimeSXPR_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... routeCode 0..1CEBinding: RouteOfAdministration (extensible)
... approachSiteCode 0..*CDBinding: v3 Code System ActSite (extensible)
... doseQuantity 0..1IVL_PQ
... rateQuantity 0..1IVL_PQ
... maxDoseQuantity 0..1RTO_PQ_PQ
... administrationUnitCode 0..1CEBinding: AdministrableDrugForm (extensible)
... consumable 1..1Element
.... typeCode 1..1codeBinding: ParticipationTargetDirect (required)
Fixed Value: CSM
.... manufacturedProduct 1..1ManufacturedProduct
..... classCode 1..1codeBinding: RoleClassManufacturedProduct (required)
Fixed Value: MANU
..... templateId 0..*II
..... id 0..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
..... manufacturedLabeledDrug 1..1LabeledDrug
...... nullFlavor 1..1codeBinding: NullFlavor (required)
Required Pattern: NA
...... classCode 1..1codeBinding: EntityClassManufacturedMaterial (required)
Fixed Value: MMAT
...... determinerCode 1..1codeBinding: EntityDeterminerDetermined (required)
Fixed Value: KIND
...... templateId 0..*II
...... code 0..1CE​Binding: http://terminology.hl7.org/ValueSet/v3-DrugEntity (extensible)
...... name 0..1EN
..... manufacturedMaterial 0..1Material
..... manufacturerOrganization 0..1Organization
... 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
... specimen 0..*Specimen
... performer 0..*Performer2
... 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
... participant 0..*Participant2
... entryRelationship I0..*Element
.... typeCode 1..1code
.... inversionInd 0..1boolean
.... contextConductionInd 1..1boolean
.... sequenceNumber 0..1INT
.... negationInd 0..1boolean
.... seperatableInd 0..1BL
.... (Choice of one) 1..1
..... observation 0..1Observation
..... regionOfInterest 0..1RegionOfInterest
..... observationMedia 0..1ObservationMedia
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
..... procedure 0..1Procedure
..... encounter 0..1Encounter
..... organizer 0..1Organizer
..... act 0..1Act
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition

doco Documentation for this format

This structure is derived from CDAR2.SubstanceAdministration

Summary

Mandatory: 13 elements

Slices

This structure defines the following Slices:

  • The element SubstanceAdministration.templateId is sliced based on the value of value:root (Closed)

Differential View

This structure is derived from CDAR2.SubstanceAdministration

NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration 1..1CDAR2.SubstanceAdministration
... classCode 1..1code
... moodCode 1..1codemoodCode must match the parent substanceAdministration EVN or INT
Binding: MoodCodeEvnInt (required)
... Slices for templateId 0..*IISlice: Unordered, Closed by value:root
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.147
.... code 1..1stringRequired Pattern: 76662-6
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1ED
.... reference 1..1TELReference into the section/text to a tag that only contains free text sig.
..... value I0..1uri81-32774: 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).
... consumable 1..1Element
.... manufacturedProduct 1..1ManufacturedProduct
..... manufacturedLabeledDrug 1..1LabeledDrug
...... nullFlavor 1..1codeRequired Pattern: NA

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration 1..1CDAR2.SubstanceAdministration
... classCode 1..1codeBinding: ActClass (required)
Fixed Value: SBADM
... moodCode 1..1codemoodCode must match the parent substanceAdministration EVN or INT
Binding: MoodCodeEvnInt (required)
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 0..*IISlice: Unordered, Closed by value:root
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.147
..... extension 0..1string
... id 0..*II
... code 1..1CD​Binding: http://terminology.hl7.org/ValueSet/v3-SubstanceAdministrationActCode (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 76662-6
.... 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
.... qualifier 0..*CR
.... translation 0..*CD
... negationInd 0..1boolean
... text 1..1ED
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... charset 0..1code
.... compression 0..1codeBinding: CompressionAlgorithm (required)
.... integrityCheck 0..1base64Binary
.... integrityCheckAlgorithm 0..1codeBinding: IntegrityCheckAlgorithm (required)
.... language 0..1code
.... mediaType 0..1code
.... representation 0..1code
.... data[x] 0..1
..... dataStringstring
..... dataBase64Binarybase64Binary
.... reference 1..1TELReference into the section/text to a tag that only contains free text sig.
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... value I0..1uri81-32774: 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).
..... useablePeriod 0..*
...... useablePeriodIVL_TS
...... useablePeriodEIVL_TS
...... useablePeriodPIVL_TS
...... useablePeriodSXPR_TS
..... use 0..*codeBinding: AddressUse (required)
.... thumbnail 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..*
.... effectiveTimeSXCM_TS
.... effectiveTimeIVL_TS
.... effectiveTimeEIVL_TS
.... effectiveTimePIVL_TS
.... effectiveTimeSXPR_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... routeCode 0..1CEBinding: RouteOfAdministration (extensible)
... approachSiteCode 0..*CDBinding: v3 Code System ActSite (extensible)
... doseQuantity 0..1IVL_PQ
... rateQuantity 0..1IVL_PQ
... maxDoseQuantity 0..1RTO_PQ_PQ
... administrationUnitCode 0..1CEBinding: AdministrableDrugForm (extensible)
... consumable 1..1Element
.... typeCode 1..1codeBinding: ParticipationTargetDirect (required)
Fixed Value: CSM
.... manufacturedProduct 1..1ManufacturedProduct
..... classCode 1..1codeBinding: RoleClassManufacturedProduct (required)
Fixed Value: MANU
..... templateId 0..*II
..... id 0..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML: identifiedBy (urn:hl7-org:sdtc)
..... manufacturedLabeledDrug 1..1LabeledDrug
...... nullFlavor 1..1codeBinding: NullFlavor (required)
Required Pattern: NA
...... classCode 1..1codeBinding: EntityClassManufacturedMaterial (required)
Fixed Value: MMAT
...... determinerCode 1..1codeBinding: EntityDeterminerDetermined (required)
Fixed Value: KIND
...... templateId 0..*II
...... code 0..1CE​Binding: http://terminology.hl7.org/ValueSet/v3-DrugEntity (extensible)
...... name 0..1EN
..... manufacturedMaterial 0..1Material
..... manufacturerOrganization 0..1Organization
... 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
... specimen 0..*Specimen
... performer 0..*Performer2
... 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
... participant 0..*Participant2
... entryRelationship I0..*Element
.... typeCode 1..1code
.... inversionInd 0..1boolean
.... contextConductionInd 1..1boolean
.... sequenceNumber 0..1INT
.... negationInd 0..1boolean
.... seperatableInd 0..1BL
.... (Choice of one) 1..1
..... observation 0..1Observation
..... regionOfInterest 0..1RegionOfInterest
..... observationMedia 0..1ObservationMedia
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
..... procedure 0..1Procedure
..... encounter 0..1Encounter
..... organizer 0..1Organizer
..... act 0..1Act
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / Code
SubstanceAdministration.classCoderequiredFixed Value: SBADM
SubstanceAdministration.moodCoderequiredMoodCodeEvnInt
SubstanceAdministration.templateId:primary.nullFlavorrequiredNullFlavor
SubstanceAdministration.codeextensible​http://terminology.hl7.org/ValueSet/v3-SubstanceAdministrationActCode
SubstanceAdministration.code.nullFlavorrequiredNullFlavor
SubstanceAdministration.text.nullFlavorrequiredNullFlavor
SubstanceAdministration.text.compressionrequiredCompressionAlgorithm
SubstanceAdministration.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
SubstanceAdministration.text.reference.nullFlavorrequiredNullFlavor
SubstanceAdministration.text.reference.userequiredAddressUse
SubstanceAdministration.statusCoderequiredActStatus
SubstanceAdministration.priorityCodeextensibleActPriority
SubstanceAdministration.routeCodeextensibleRouteOfAdministration
SubstanceAdministration.approachSiteCodeextensiblev3.ActSite
SubstanceAdministration.administrationUnitCodeextensibleAdministrableDrugForm
SubstanceAdministration.consumable.typeCoderequiredFixed Value: CSM
SubstanceAdministration.consumable.manufacturedProduct.classCoderequiredFixed Value: MANU
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.nullFlavorrequiredPattern: NA
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.classCoderequiredFixed Value: MMAT
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.determinerCoderequiredFixed Value: KIND
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.codeextensible​http://terminology.hl7.org/ValueSet/v3-DrugEntity
SubstanceAdministration.subject.typeCoderequiredFixed Value: SBJ
SubstanceAdministration.subject.contextControlCoderequiredFixed Value: OP
SubstanceAdministration.subject.awarenessCodeextensibleTargetAwareness
SubstanceAdministration.informant.typeCoderequiredFixed Value: INF
SubstanceAdministration.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePathDetailsRequirements
81-32774errorSubstanceAdministration.text.reference.valueThis 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).
:
subst-er-1errorSubstanceAdministration.entryRelationshipOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1