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 Activity

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.16 Version: 2.2
Active as of 2022-05-13 Computable Name: MedicationActivity
Other Identifiers: : 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 (V2) template be used for moodCodes other than EVN if the document type contains a section that includes Planned Medication Activity (V2) (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” 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

Summary

Mandatory: 12 elements (24 nested mandatory 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

This structure is derived from CDAR2.SubstanceAdministration

NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration I1..1CDAR2.SubstanceAdministration1098-30800: Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800).
... classCode 1..1code
... moodCode 1..1codeBinding: MoodCodeEvnInt (required)
... Slices for templateId 0..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.16
..... extension 1..1stringRequired 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..1stringBinding: Medication Status (required)
... Slices for effectiveTime 0..*SXCM_TS, IVL_TS, EIVL_TS, PIVL_TS, SXPR_TSSlice: Unordered, Open by value:operator
.... effectiveTime:duration I1..1IVL_TSThis effectiveTime represents either the medication duration (i.e., the time the medication was started and stopped) or the single-administration timestamp. undefined
1098-32890: This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890).
..... value 0..1dateTimeindicates a single-administration timestamp
..... low 0..1TSindicates when medication started
..... high 0..1TSindicates when medication stopped
.... effectiveTime:frequency I0..1SXCM_TS, IVL_TS, EIVL_TS, PIVL_TS, SXPR_TSThis effectiveTime represents the medication frequency (e.g., administration times per day).
1098-28499: **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499).
​..... operator 1..1Required 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 I1..1IVL_PQ1098-16879: Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is simply "metoprolol"), 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..1codeBinding: UnitsOfMeasureCaseSensitive (required)
... rateQuantity 0..1IVL_PQ
.... unit 1..1codeBinding: 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..1Element
.... manufacturedProduct 1..1MedicationInformation
... performer 0..1Performer2
... author 0..*AuthorParticipation
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:participantRole, value:typeCode
.... participant:drugVehicle 0..*Participant2
..... typeCode 1..1codeRequired Pattern: CSM
..... participantRole 1..1DrugVehicle
... Slices for entryRelationship 0..*ElementSlice: Unordered, Open by profile:substanceAdministration, profile:observation, profile:act, profile:supply
.... entryRelationship:indication 0..*Element
..... typeCode 1..1codeRequired Pattern: RSON
..... observation 1..1Indication
.... entryRelationship:instruction 0..1Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... act 1..1Instruction
.... entryRelationship:supplyOrder 0..1Element
..... typeCode 1..1codeRequired Pattern: REFR
..... supply 1..1MedicationSupplyOrder
.... entryRelationship:medicationDispense 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... supply 1..1MedicationDispense
.... entryRelationship:reaction 0..*Element
..... typeCode 1..1codeRequired Pattern: CAUS
..... observation 1..1ReactionObservation
.... entryRelationship:drugMonitoring 0..1Element
..... typeCode 1..1codeRequired Pattern: COMP
..... act 1..1DrugMonitoringAct
.... entryRelationship:substanceAdministered 0..*ElementThe 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..1codeRequired Pattern: COMP
..... inversionInd 1..1booleanRequired Pattern: true
..... sequenceNumber 0..1INT
..... act 1..1SubstanceAdministeredAct
.... entryRelationship:signature 0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... substanceAdministration 1..1MedicationFreeTextSig
... precondition 0..*Precondition
.... typeCode 1..1codeRequired Pattern: PRCN
.... criterion 1..1PreconditionforSubstanceAdministration

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration I1..1CDAR2.SubstanceAdministration1098-30800: Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800).
... classCode 1..1codeBinding: ActClass (required)
Fixed Value: SBADM
... moodCode 1..1codeBinding: MoodCodeEvnInt (required)
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 0..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.16
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..*II
... code 0..1CD​SubstanceAdministration.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: http://terminology.hl7.org/ValueSet/v3-SubstanceAdministrationActCode (extensible)
... negationInd 0..1boolean
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringBinding: Medication Status (required)
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
... Slices for effectiveTime 0..*Slice: Unordered, Open by value:operator
.... effectiveTimeSXCM_TS
.... effectiveTimeIVL_TS
.... effectiveTimeEIVL_TS
.... effectiveTimePIVL_TS
.... effectiveTimeSXPR_TS
.... effectiveTime:duration I1..1IVL_TSThis effectiveTime represents either the medication duration (i.e., the time the medication was started and stopped) or the single-administration timestamp. undefined
1098-32890: This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890).
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... value 0..1dateTimeindicates a single-administration timestamp
..... inclusive 0..1boolean
..... operator 0..1code
..... low 0..1TSindicates when medication started
..... high 0..1TSindicates when medication stopped
..... width 0..1PQ
..... center 0..1TS
.... effectiveTime:frequency I0..1This effectiveTime represents the medication frequency (e.g., administration times per day).
1098-28499: **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499).
..... effectiveTime:frequency:All Types Content/Rules for all Types
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... effectiveTimeSXCM_TS
..... effectiveTimeIVL_TS
..... effectiveTimeEIVL_TS
..... effectiveTimePIVL_TS
..... effectiveTimeSXPR_TS
... 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..1codeBinding: NullFlavor (required)
.... code 0..1string
.... codeSystem 0..1string
.... 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..*CDBinding: Medication Route (required)
... approachSiteCode 0..1CDBinding: Body Site Value Set (required)
... doseQuantity I1..1IVL_PQ1098-16879: Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is simply "metoprolol"), 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..1codeBinding: NullFlavor (required)
.... unit 0..1codeBinding: UnitsOfMeasureCaseSensitive (required)
.... value 0..1decimal
.... low 0..1PQ
.... high 0..1PQ
.... width 0..1PQ
.... center 0..1PQ
... rateQuantity 0..1IVL_PQ
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... unit 1..1codeBinding: UnitsOfMeasureCaseSensitive (required)
.... value 0..1decimal
.... low 0..1PQ
.... high 0..1PQ
.... width 0..1PQ
.... center 0..1PQ
... 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..1Element
.... typeCode 1..1codeBinding: ParticipationTargetDirect (required)
Fixed Value: CSM
.... manufacturedProduct 1..1MedicationInformation
... 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..1Performer2
... author 0..*AuthorParticipation
... 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 participant 0..*Participant2Slice: Unordered, Open by value:participantRole, value:typeCode
.... participant:drugVehicle 0..*Participant2
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 1..1codeBinding: ParticipationType (required)
Required Pattern: CSM
..... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... sdtcFunctionCode 0..1CEXML: functionCode (urn:hl7-org:sdtc)
..... time 0..1IVL_TS
..... awarenessCode 0..1CE
..... participantRole 1..1DrugVehicle
... Slices for entryRelationship I0..*ElementSlice: Unordered, Open by profile:substanceAdministration, profile:observation, profile:act, profile:supply
.... entryRelationship:All Slices Content/Rules for all slices
..... 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
.... entryRelationship:indication I0..*Element
..... typeCode 1..1codeRequired Pattern: RSON
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1Indication
.... entryRelationship:instruction I0..1Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1Instruction
.... entryRelationship:supplyOrder I0..1Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... supply 1..1MedicationSupplyOrder
.... entryRelationship:medicationDispense I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... supply I1..1MedicationDispense
.... entryRelationship:reaction I0..*Element
..... typeCode 1..1codeRequired Pattern: CAUS
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1ReactionObservation
.... entryRelationship:drugMonitoring I0..1Element
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1DrugMonitoringAct
.... entryRelationship:substanceAdministered I0..*ElementThe 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..1codeRequired Pattern: COMP
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1SubstanceAdministeredAct
.... entryRelationship:signature I0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... substanceAdministration 1..1MedicationFreeTextSig
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 1..1codeBinding: ActRelationshipType (required)
Required Pattern: PRCN
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... criterion 1..1PreconditionforSubstanceAdministration

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration I1..1CDAR2.SubstanceAdministration1098-30800: Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800).

doco Documentation for this format

This structure is derived from CDAR2.SubstanceAdministration

Summary

Mandatory: 12 elements (24 nested mandatory 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 I1..1CDAR2.SubstanceAdministration1098-30800: Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800).
... classCode 1..1code
... moodCode 1..1codeBinding: MoodCodeEvnInt (required)
... Slices for templateId 0..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.16
..... extension 1..1stringRequired 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..1stringBinding: Medication Status (required)
... Slices for effectiveTime 0..*SXCM_TS, IVL_TS, EIVL_TS, PIVL_TS, SXPR_TSSlice: Unordered, Open by value:operator
.... effectiveTime:duration I1..1IVL_TSThis effectiveTime represents either the medication duration (i.e., the time the medication was started and stopped) or the single-administration timestamp. undefined
1098-32890: This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890).
..... value 0..1dateTimeindicates a single-administration timestamp
..... low 0..1TSindicates when medication started
..... high 0..1TSindicates when medication stopped
.... effectiveTime:frequency I0..1SXCM_TS, IVL_TS, EIVL_TS, PIVL_TS, SXPR_TSThis effectiveTime represents the medication frequency (e.g., administration times per day).
1098-28499: **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499).
​..... operator 1..1Required 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 I1..1IVL_PQ1098-16879: Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is simply "metoprolol"), 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..1codeBinding: UnitsOfMeasureCaseSensitive (required)
... rateQuantity 0..1IVL_PQ
.... unit 1..1codeBinding: 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..1Element
.... manufacturedProduct 1..1MedicationInformation
... performer 0..1Performer2
... author 0..*AuthorParticipation
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:participantRole, value:typeCode
.... participant:drugVehicle 0..*Participant2
..... typeCode 1..1codeRequired Pattern: CSM
..... participantRole 1..1DrugVehicle
... Slices for entryRelationship 0..*ElementSlice: Unordered, Open by profile:substanceAdministration, profile:observation, profile:act, profile:supply
.... entryRelationship:indication 0..*Element
..... typeCode 1..1codeRequired Pattern: RSON
..... observation 1..1Indication
.... entryRelationship:instruction 0..1Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... act 1..1Instruction
.... entryRelationship:supplyOrder 0..1Element
..... typeCode 1..1codeRequired Pattern: REFR
..... supply 1..1MedicationSupplyOrder
.... entryRelationship:medicationDispense 0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... supply 1..1MedicationDispense
.... entryRelationship:reaction 0..*Element
..... typeCode 1..1codeRequired Pattern: CAUS
..... observation 1..1ReactionObservation
.... entryRelationship:drugMonitoring 0..1Element
..... typeCode 1..1codeRequired Pattern: COMP
..... act 1..1DrugMonitoringAct
.... entryRelationship:substanceAdministered 0..*ElementThe 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..1codeRequired Pattern: COMP
..... inversionInd 1..1booleanRequired Pattern: true
..... sequenceNumber 0..1INT
..... act 1..1SubstanceAdministeredAct
.... entryRelationship:signature 0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... substanceAdministration 1..1MedicationFreeTextSig
... precondition 0..*Precondition
.... typeCode 1..1codeRequired Pattern: PRCN
.... criterion 1..1PreconditionforSubstanceAdministration

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration I1..1CDAR2.SubstanceAdministration1098-30800: Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800).
... classCode 1..1codeBinding: ActClass (required)
Fixed Value: SBADM
... moodCode 1..1codeBinding: MoodCodeEvnInt (required)
... realmCode 0..*CS
... typeId 0..1II
... Slices for templateId 0..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.16
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..*II
... code 0..1CD​SubstanceAdministration.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: http://terminology.hl7.org/ValueSet/v3-SubstanceAdministrationActCode (extensible)
... negationInd 0..1boolean
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringBinding: Medication Status (required)
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
... Slices for effectiveTime 0..*Slice: Unordered, Open by value:operator
.... effectiveTimeSXCM_TS
.... effectiveTimeIVL_TS
.... effectiveTimeEIVL_TS
.... effectiveTimePIVL_TS
.... effectiveTimeSXPR_TS
.... effectiveTime:duration I1..1IVL_TSThis effectiveTime represents either the medication duration (i.e., the time the medication was started and stopped) or the single-administration timestamp. undefined
1098-32890: This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890).
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... value 0..1dateTimeindicates a single-administration timestamp
..... inclusive 0..1boolean
..... operator 0..1code
..... low 0..1TSindicates when medication started
..... high 0..1TSindicates when medication stopped
..... width 0..1PQ
..... center 0..1TS
.... effectiveTime:frequency I0..1This effectiveTime represents the medication frequency (e.g., administration times per day).
1098-28499: **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499).
..... effectiveTime:frequency:All Types Content/Rules for all Types
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... effectiveTimeSXCM_TS
..... effectiveTimeIVL_TS
..... effectiveTimeEIVL_TS
..... effectiveTimePIVL_TS
..... effectiveTimeSXPR_TS
... 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..1codeBinding: NullFlavor (required)
.... code 0..1string
.... codeSystem 0..1string
.... 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..*CDBinding: Medication Route (required)
... approachSiteCode 0..1CDBinding: Body Site Value Set (required)
... doseQuantity I1..1IVL_PQ1098-16879: Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is simply "metoprolol"), 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..1codeBinding: NullFlavor (required)
.... unit 0..1codeBinding: UnitsOfMeasureCaseSensitive (required)
.... value 0..1decimal
.... low 0..1PQ
.... high 0..1PQ
.... width 0..1PQ
.... center 0..1PQ
... rateQuantity 0..1IVL_PQ
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... unit 1..1codeBinding: UnitsOfMeasureCaseSensitive (required)
.... value 0..1decimal
.... low 0..1PQ
.... high 0..1PQ
.... width 0..1PQ
.... center 0..1PQ
... 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..1Element
.... typeCode 1..1codeBinding: ParticipationTargetDirect (required)
Fixed Value: CSM
.... manufacturedProduct 1..1MedicationInformation
... 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..1Performer2
... author 0..*AuthorParticipation
... 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 participant 0..*Participant2Slice: Unordered, Open by value:participantRole, value:typeCode
.... participant:drugVehicle 0..*Participant2
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... typeCode 1..1codeBinding: ParticipationType (required)
Required Pattern: CSM
..... contextControlCode 0..1codeBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... sdtcFunctionCode 0..1CEXML: functionCode (urn:hl7-org:sdtc)
..... time 0..1IVL_TS
..... awarenessCode 0..1CE
..... participantRole 1..1DrugVehicle
... Slices for entryRelationship I0..*ElementSlice: Unordered, Open by profile:substanceAdministration, profile:observation, profile:act, profile:supply
.... entryRelationship:All Slices Content/Rules for all slices
..... 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
.... entryRelationship:indication I0..*Element
..... typeCode 1..1codeRequired Pattern: RSON
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1Indication
.... entryRelationship:instruction I0..1Element
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1Instruction
.... entryRelationship:supplyOrder I0..1Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... supply 1..1MedicationSupplyOrder
.... entryRelationship:medicationDispense I0..*Element
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... supply I1..1MedicationDispense
.... entryRelationship:reaction I0..*Element
..... typeCode 1..1codeRequired Pattern: CAUS
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1ReactionObservation
.... entryRelationship:drugMonitoring I0..1Element
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1DrugMonitoringAct
.... entryRelationship:substanceAdministered I0..*ElementThe 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..1codeRequired Pattern: COMP
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1SubstanceAdministeredAct
.... entryRelationship:signature I0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... substanceAdministration 1..1MedicationFreeTextSig
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... typeCode 1..1codeBinding: ActRelationshipType (required)
Required Pattern: PRCN
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... criterion 1..1PreconditionforSubstanceAdministration

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.statusCoderequiredActStatus
SubstanceAdministration.statusCode.nullFlavorrequiredNullFlavor
SubstanceAdministration.statusCode.coderequiredMedication Status
SubstanceAdministration.effectiveTime:duration.nullFlavorrequiredNullFlavor
SubstanceAdministration.priorityCodeextensibleActPriority
SubstanceAdministration.routeCoderequiredSPL Drug Route of Administration Terminology
SubstanceAdministration.routeCode.nullFlavorrequiredNullFlavor
SubstanceAdministration.routeCode.translationrequiredMedicationRoute
SubstanceAdministration.approachSiteCoderequiredBodySiteValueSet
SubstanceAdministration.doseQuantity.nullFlavorrequiredNullFlavor
SubstanceAdministration.doseQuantity.unitrequiredUnitsOfMeasureCaseSensitive
SubstanceAdministration.rateQuantity.nullFlavorrequiredNullFlavor
SubstanceAdministration.rateQuantity.unitrequiredUnitsOfMeasureCaseSensitive
SubstanceAdministration.administrationUnitCoderequiredAdministrationUnitDoseForm
SubstanceAdministration.consumable.typeCoderequiredFixed Value: CSM
SubstanceAdministration.subject.typeCoderequiredFixed Value: SBJ
SubstanceAdministration.subject.contextControlCoderequiredFixed Value: OP
SubstanceAdministration.subject.awarenessCodeextensibleTargetAwareness
SubstanceAdministration.informant.typeCoderequiredFixed Value: INF
SubstanceAdministration.informant.contextControlCoderequiredFixed Value: OP
SubstanceAdministration.participant:drugVehicle.nullFlavorrequiredNullFlavor
SubstanceAdministration.participant:drugVehicle.typeCoderequiredPattern: CSM
SubstanceAdministration.participant:drugVehicle.contextControlCoderequiredFixed Value: OP
SubstanceAdministration.precondition.nullFlavorrequiredNullFlavor
SubstanceAdministration.precondition.typeCoderequiredPattern: PRCN

Constraints

IdGradePathDetailsRequirements
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).
:
1098-28499errorSubstanceAdministration.effectiveTime:frequency**SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499).
:
ele-1errorSubstanceAdministration.effectiveTime:frequency.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorSubstanceAdministration.effectiveTime:frequency.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
1098-16879warningSubstanceAdministration.doseQuantityNot pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is simply "metoprolol"), 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).
:
1098-16878warningSubstanceAdministration.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).
:
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
subst-er-1errorSubstanceAdministration.entryRelationship:indicationOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
subst-er-1errorSubstanceAdministration.entryRelationship:instructionOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
subst-er-1errorSubstanceAdministration.entryRelationship:supplyOrderOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
subst-er-1errorSubstanceAdministration.entryRelationship:medicationDispenseOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
1098-9333errorSubstanceAdministration.entryRelationship:medicationDispense.supplyA supply act **SHALL** contain one product/Medication Information *OR* one product/Immunization Medication Information template (CONF:1098-9333).
:
subst-er-1errorSubstanceAdministration.entryRelationship:reactionOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
subst-er-1errorSubstanceAdministration.entryRelationship:drugMonitoringOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
subst-er-1errorSubstanceAdministration.entryRelationship:substanceAdministeredOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
subst-er-1errorSubstanceAdministration.entryRelationship:signatureOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1