Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build
Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build
Consolidated CDA Release 2.1 StructureDefinition Publication, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.1). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.1-sd/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/MedicationActivity | Version: 2.1 | |||
| Draft as of 2023-09-29 | Computable Name: MedicationActivity | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.16:2014-06-09 | ||||
A Medication Activity describes substance administrations that have actually occurred (e.g., pills ingested or injections given) or are intended to occur (e.g., “take 2 tablets twice a day for the next 10 days”). Medication activities in “INT” mood are reflections of what a clinician intends a patient to be taking. For example, a clinician may intend that a patient be administered Lisinopril 20 mg PO for blood pressure control. If what was actually administered was Lisinopril 10 mg., then the Medication activities in the “EVN” mood would reflect actual use.
A moodCode of INT is allowed, but it is recommended that the Planned Medication Activity template be used for moodCodes other than EVN if the document type contains a section that includes Planned Medication Activity (for example a Care Plan document with Plan of Treatment, Intervention, or Goal sections).
At a minimum, a Medication Activity shall include an effectiveTime indicating the duration of the administration (or single-administration timestamp). Ambulatory medication lists generally provide a summary of use for a given medication over time - a medication activity in event mood with the duration reflecting when the medication started and stopped. Ongoing medications will not have a stop date (or will have a stop date with a suitable NULL value). Ambulatory medication lists will generally also have a frequency (e.g., a medication is being taken twice a day). Inpatient medications generally record each administration as a separate act.
The dose (doseQuantity) represents how many of the consumables are to be administered at each administration event. As a result, the dose is always relative to the consumable and the interval of administration. Thus, a patient consuming a single “metoprolol 25mg tablet “ per administration will have a doseQuantity of “1 “, whereas a patient consuming “metoprolol Oral Product “ (RxCUI 1163523) will have a dose of “25 mg “.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.SubstanceAdministration
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  SubstanceAdministration | C | 1..1 | CDAR2.SubstanceAdministration | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, repeatNumber, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode, consumable, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition Base for all types and resources 1098-30800: Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800). |
 classCode | 1..1 | cs | ||
| moodCode | 1..1 | cs | Binding: MoodCodeEvnInt (required) | |
  Slices for templateId | 1..* | II | Slice: Unordered, Open by value:extension, value:root | |
   templateId:primary | 1..1 | II | ||
  root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.16 | |
  extension | 1..1 | st | Required Pattern: 2014-06-09 | |
| id | 1..* | II | ||
| code | 0..1 | CD | 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. | |
| statusCode | 1..1 | CS | ||
 code | 1..1 | cs | The substance administration effectiveTime field can repeat, in order to represent varying levels of complex dosing. effectiveTime can be used to represent the duration of administration (e.g., "10 days"), the frequency of administration (e.g., "every 8 hours"), and more. Here, we require that there SHALL be an effectiveTime documentation of the duration (or single-administration timestamp), and that there SHOULD be an effectiveTime documentation of the frequency. Other timing nuances, supported by the base CDA R2 standard, may also be included. Binding: Medication Status (required) | |
| Slices for effectiveTime | C | 1..* | SXCM_TS, IVL_TS, EIVL_TS, PIVL_TS, SXPR_TS | Slice: Unordered, Open by value:operator 1098-7513: SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499). |
 effectiveTime:duration | C | 1..1 | IVL_TS | This effectiveTime represents either the medication duration (i.e., the time the medication was started and stopped) or the single-administration timestamp. 1098-32890: This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890). |
 value | 0..1 | ts | indicates a single-administration timestamp | |
| low | 0..1 | IVXB_TS | indicates when medication started | |
| high | 0..1 | IVXB_TS | indicates when medication stopped | |
| effectiveTime:periodicFrequency | 0..1 | EIVL_TS | This effectiveTime represents a periodic medication frequency (e.g., administration times per day). | |
| operator | 1..1 | cs | Required Pattern: A | |
| effectiveTime:eventFrequency | 0..1 | PIVL_TS | This effectiveTime represents an event-based medication frequency (e.g., administration at bedtime). | |
| operator | 1..1 | cs | Required Pattern: A | |
| repeatNumber | 0..1 | IVL_INT | In "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..1 | CE | Binding: SPL Drug Route of Administration Terminology (required) | |
| translation | 0..* | CD | Binding: Medication Route (required) | |
| approachSiteCode | 0..1 | CD | Binding: Body Site Value Set (required) | |
| doseQuantity | C | 1..1 | IVL_PQ | 1098-16879: Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is "simply metoprolol Oral Product" (RxCUI 1163523), then doseQuantity must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration (CONF:1098-16879). 1098-16878: Pre-coordinated consumable: If the consumable code is a pre-coordinated unit dose (e.g., "metoprolol 25mg tablet") then doseQuantity is a unitless number that indicates the number of products given per administration (e.g., "2", meaning 2 x "metoprolol 25mg tablet" per administration) (CONF:1098-16878). |
| unit | 0..1 | cs | Binding: UnitsOfMeasureCaseSensitive (required) | |
| rateQuantity | 0..1 | IVL_PQ | ||
| unit | 1..1 | cs | Binding: UnitsOfMeasureCaseSensitive (required) | |
| maxDoseQuantity | 0..1 | RTO_PQ_PQ | ||
| administrationUnitCode | 0..1 | CE | administrationUnitCode@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..1 | InfrastructureRoot | ||
 manufacturedProduct | 1..1 | MedicationInformation | Base for all types and resources | |
| performer | 0..1 | Performer2 | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for participant | 0..* | Participant2 | Slice: Unordered, Open by value:participantRole, value:typeCode | |
| participant:drugVehicle | 0..* | Participant2 | ||
| typeCode | 1..1 | cs | Fixed Value: CSM | |
| participantRole | 1..1 | DrugVehicle | Base for all types and resources | |
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:substanceAdministration, profile:observation, profile:act, profile:supply | |
| entryRelationship:indication | 0..* | EntryRelationship | ||
| typeCode | 1..1 | cs | Fixed Value: RSON | |
| observation | 1..1 | Indication | Base for all types and resources | |
| entryRelationship:instruction | 0..1 | EntryRelationship | ||
| typeCode | 1..1 | cs | Fixed Value: SUBJ | |
| inversionInd | 1..1 | bl | Fixed Value: true | |
| act | 1..1 | Instruction | Base for all types and resources | |
| entryRelationship:supplyOrder | 0..1 | EntryRelationship | ||
| typeCode | 1..1 | cs | Fixed Value: REFR | |
| supply | 1..1 | MedicationSupplyOrder | Base for all types and resources | |
| entryRelationship:medicationDispense | 0..* | EntryRelationship | ||
| typeCode | 1..1 | cs | Fixed Value: REFR | |
| supply | 1..1 | MedicationDispense | Base for all types and resources | |
| entryRelationship:reaction | 0..* | EntryRelationship | ||
| typeCode | 1..1 | cs | Fixed Value: CAUS | |
| observation | 1..1 | ReactionObservation | Base for all types and resources | |
| entryRelationship:drugMonitoring | 0..1 | EntryRelationship | ||
| typeCode | 1..1 | cs | Fixed Value: COMP | |
| act | 1..1 | DrugMonitoringAct | Base for all types and resources | |
| entryRelationship:substanceAdministered | 0..* | EntryRelationship | The 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..1 | cs | Fixed Value: COMP | |
| inversionInd | 1..1 | bl | Fixed Value: true | |
| sequenceNumber | 0..1 | INT | ||
| act | 1..1 | SubstanceAdministeredAct | Base for all types and resources | |
| entryRelationship:adherence | 0..* | EntryRelationship | The following entryRelationship is used to indicate the patient's adherence to the medication order. | |
| typeCode | 1..1 | cs | Fixed Value: COMP | |
| observation | 1..1 | MedicationAdherence | Base for all types and resources | |
| entryRelationship:signature | 0..* | EntryRelationship | ||
| typeCode | 1..1 | cs | Fixed Value: COMP | |
| substanceAdministration | 1..1 | MedicationFreeTextSig | Base for all types and resources | |
 precondition | 0..* | Precondition | ||
| typeCode | 1..1 | cs | Fixed Value: PRCN | |
| criterion | 1..1 | PreconditionforSubstanceAdministration | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| SubstanceAdministration.moodCode | required | MoodCodeEvnInt |
| SubstanceAdministration.statusCode.code | required | Medication Status |
| SubstanceAdministration.routeCode | required | SPL Drug Route of Administration Terminology |
| SubstanceAdministration.routeCode.translation | required | Medication Route |
| SubstanceAdministration.approachSiteCode | required | Body Site Value Set |
| SubstanceAdministration.doseQuantity.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM) |
| SubstanceAdministration.rateQuantity.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM) |
| SubstanceAdministration.administrationUnitCode | required | AdministrationUnitDoseForm |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-7513 | error | SubstanceAdministration.effectiveTime | SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499). : | |
| 1098-16878 | warning | SubstanceAdministration.doseQuantity | 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). : | |
| 1098-16879 | warning | SubstanceAdministration.doseQuantity | Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is "simply metoprolol Oral Product" (RxCUI 1163523), then doseQuantity must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration (CONF:1098-16879). : | |
| 1098-30800 | warning | SubstanceAdministration | Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800). : | |
| 1098-32890 | error | SubstanceAdministration.effectiveTime:duration | This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890). : |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| SubstanceAdministration | C | 1..1 | CDAR2.SubstanceAdministration | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, repeatNumber, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode, consumable, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition Base for all types and resources 1098-30800: Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800). |
 @classCode | 1..1 | cs | Binding: ActClass (required) Fixed Value: SBADM | |
| @moodCode | 1..1 | cs | Binding: MoodCodeEvnInt (required) | |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:extension, value:root | |
| templateId:primary | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.16 | |
| @extension | 1..1 | st | Required Pattern: 2014-06-09 | |
| id | 1..* | II | ||
| code | 0..1 | CD | 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: ActSubstanceAdministrationCode (extensible) | |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| @code | 1..1 | cs | The substance administration effectiveTime field can repeat, in order to represent varying levels of complex dosing. effectiveTime can be used to represent the duration of administration (e.g., "10 days"), the frequency of administration (e.g., "every 8 hours"), and more. Here, we require that there SHALL be an effectiveTime documentation of the duration (or single-administration timestamp), and that there SHOULD be an effectiveTime documentation of the frequency. Other timing nuances, supported by the base CDA R2 standard, may also be included. Binding: Medication Status (required) | |
| Slices for effectiveTime | C | 1..* | Slice: Unordered, Open by value:operator 1098-7513: SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499). | |
  effectiveTime | SXCM_TS | |||
| effectiveTime | IVL_TS | |||
| effectiveTime | EIVL_TS | |||
| effectiveTime | PIVL_TS | |||
| effectiveTime | SXPR_TS | |||
| effectiveTime:duration | C | 1..1 | IVL_TS | This effectiveTime represents either the medication duration (i.e., the time the medication was started and stopped) or the single-administration timestamp. 1098-32890: This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890). |
| @value | 0..1 | ts | indicates a single-administration timestamp Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| low | 0..1 | IVXB_TS | indicates when medication started | |
| high | 0..1 | IVXB_TS | indicates when medication stopped | |
| effectiveTime:periodicFrequency | 0..1 | EIVL_TS | This effectiveTime represents a periodic medication frequency (e.g., administration times per day). | |
| @operator | 1..1 | cs | Binding: SetOperator (required) Required Pattern: A | |
| effectiveTime:eventFrequency | 0..1 | PIVL_TS | This effectiveTime represents an event-based medication frequency (e.g., administration at bedtime). | |
| @operator | 1..1 | cs | Binding: SetOperator (required) Required Pattern: A | |
| repeatNumber | 0..1 | IVL_INT | In "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..1 | CE | Binding: SPL Drug Route of Administration Terminology (required) | |
| translation | 0..* | CD | Binding: Medication Route (required) | |
| approachSiteCode | 0..1 | CD | Binding: Body Site Value Set (required) | |
| doseQuantity | C | 1..1 | IVL_PQ | 1098-16879: Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is "simply metoprolol Oral Product" (RxCUI 1163523), then doseQuantity must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration (CONF:1098-16879). 1098-16878: Pre-coordinated consumable: If the consumable code is a pre-coordinated unit dose (e.g., "metoprolol 25mg tablet") then doseQuantity is a unitless number that indicates the number of products given per administration (e.g., "2", meaning 2 x "metoprolol 25mg tablet" per administration) (CONF:1098-16878). |
| @unit | 0..1 | cs | Binding: UnitsOfMeasureCaseSensitive (required) | |
| rateQuantity | 0..1 | IVL_PQ | ||
| @unit | 1..1 | cs | Binding: UnitsOfMeasureCaseSensitive (required) | |
| maxDoseQuantity | 0..1 | RTO_PQ_PQ | ||
| administrationUnitCode | 0..1 | CE | administrationUnitCode@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..1 | InfrastructureRoot | ||
| manufacturedProduct | 1..1 | MedicationInformation | Base for all types and resources | |
| performer | 0..1 | Performer2 | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for participant | 0..* | Participant2 | Slice: Unordered, Open by value:participantRole, value:typeCode | |
| participant:drugVehicle | 0..* | Participant2 | ||
| @typeCode | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: CSM | |
| participantRole | 1..1 | DrugVehicle | Base for all types and resources | |
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:substanceAdministration, profile:observation, profile:act, profile:supply | |
| entryRelationship:indication | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |
| observation | 1..1 | Indication | Base for all types and resources | |
| entryRelationship:instruction | 0..1 | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| @inversionInd | 1..1 | bl | Fixed Value: true | |
| act | 1..1 | Instruction | Base for all types and resources | |
| entryRelationship:supplyOrder | 0..1 | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| supply | 1..1 | MedicationSupplyOrder | Base for all types and resources | |
| entryRelationship:medicationDispense | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| supply | C | 1..1 | MedicationDispense | Base for all types and resources |
| entryRelationship:reaction | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: CAUS | |
| observation | 1..1 | ReactionObservation | Base for all types and resources | |
| entryRelationship:drugMonitoring | 0..1 | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| act | 1..1 | DrugMonitoringAct | Base for all types and resources | |
| entryRelationship:substanceAdministered | 0..* | EntryRelationship | The 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..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| @inversionInd | 1..1 | bl | Fixed Value: true | |
| sequenceNumber | 0..1 | INT | ||
| act | 1..1 | SubstanceAdministeredAct | Base for all types and resources | |
| entryRelationship:adherence | 0..* | EntryRelationship | The following entryRelationship is used to indicate the patient's adherence to the medication order. | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| observation | 1..1 | MedicationAdherence | Base for all types and resources | |
| entryRelationship:signature | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| substanceAdministration | 1..1 | MedicationFreeTextSig | Base for all types and resources | |
| precondition | 0..* | Precondition | ||
| @typeCode | 1..1 | cs | Binding: ActRelationshipType (required) Fixed Value: PRCN | |
| criterion | 1..1 | PreconditionforSubstanceAdministration | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| SubstanceAdministration.classCode | required | Fixed Value: SBADM |
| SubstanceAdministration.moodCode | required | MoodCodeEvnInt |
| SubstanceAdministration.code | extensible | ActSubstanceAdministrationCode |
| SubstanceAdministration.statusCode | required | ActStatus |
| SubstanceAdministration.statusCode.code | required | Medication Status |
| SubstanceAdministration.effectiveTime:periodicFrequency.operator | required | Pattern: A |
| SubstanceAdministration.effectiveTime:eventFrequency.operator | required | Pattern: A |
| SubstanceAdministration.routeCode | required | SPL Drug Route of Administration Terminology |
| SubstanceAdministration.routeCode.translation | required | Medication Route |
| SubstanceAdministration.approachSiteCode | required | Body Site Value Set |
| SubstanceAdministration.doseQuantity.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM) |
| SubstanceAdministration.rateQuantity.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM) |
| SubstanceAdministration.administrationUnitCode | required | AdministrationUnitDoseForm |
| SubstanceAdministration.participant:drugVehicle.typeCode | required | Fixed Value: CSM |
| SubstanceAdministration.entryRelationship:indication.typeCode | required | Fixed Value: RSON |
| SubstanceAdministration.entryRelationship:instruction.typeCode | required | Fixed Value: SUBJ |
| SubstanceAdministration.entryRelationship:supplyOrder.typeCode | required | Fixed Value: REFR |
| SubstanceAdministration.entryRelationship:medicationDispense.typeCode | required | Fixed Value: REFR |
| SubstanceAdministration.entryRelationship:reaction.typeCode | required | Fixed Value: CAUS |
| SubstanceAdministration.entryRelationship:drugMonitoring.typeCode | required | Fixed Value: COMP |
| SubstanceAdministration.entryRelationship:substanceAdministered.typeCode | required | Fixed Value: COMP |
| SubstanceAdministration.entryRelationship:adherence.typeCode | required | Fixed Value: COMP |
| SubstanceAdministration.entryRelationship:signature.typeCode | required | Fixed Value: COMP |
| SubstanceAdministration.precondition.typeCode | required | Fixed Value: PRCN |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-7513 | error | SubstanceAdministration.effectiveTime | SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499). : | |
| 1098-16878 | warning | SubstanceAdministration.doseQuantity | 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). : | |
| 1098-16879 | warning | SubstanceAdministration.doseQuantity | Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is "simply metoprolol Oral Product" (RxCUI 1163523), then doseQuantity must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration (CONF:1098-16879). : | |
| 1098-30800 | warning | SubstanceAdministration | Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800). : | |
| 1098-32890 | error | SubstanceAdministration.effectiveTime:duration | This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890). : | |
| 4537-9333 | error | SubstanceAdministration.entryRelationship:medicationDispense.supply | A supply act **SHALL** contain one product/Medication Information *OR* one product/Immunization Medication Information template (CONF:4537-9333). : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| SubstanceAdministration | C | 1..1 | CDAR2.SubstanceAdministration | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, repeatNumber, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode, consumable, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition Base for all types and resources 1098-30800: Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800). |
| @classCode | 1..1 | cs | Binding: ActClass (required) Fixed Value: SBADM | |
| @moodCode | 1..1 | cs | Binding: MoodCodeEvnInt (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:extension, value:root | |
| templateId:primary | 1..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.16 | |
| @extension | 1..1 | st | Required Pattern: 2014-06-09 | |
| id | 1..* | II | ||
| code | 0..1 | CD | 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: ActSubstanceAdministrationCode (extensible) | |
| @negationInd | 0..1 | bl | ||
| text | 0..1 | ED | ||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 1..1 | cs | The substance administration effectiveTime field can repeat, in order to represent varying levels of complex dosing. effectiveTime can be used to represent the duration of administration (e.g., "10 days"), the frequency of administration (e.g., "every 8 hours"), and more. Here, we require that there SHALL be an effectiveTime documentation of the duration (or single-administration timestamp), and that there SHOULD be an effectiveTime documentation of the frequency. Other timing nuances, supported by the base CDA R2 standard, may also be included. Binding: Medication Status (required) | |
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| Slices for effectiveTime | C | 1..* | Slice: Unordered, Open by value:operator 1098-7513: SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499). | |
| effectiveTime | SXCM_TS | |||
| effectiveTime | IVL_TS | |||
| effectiveTime | EIVL_TS | |||
| effectiveTime | PIVL_TS | |||
| effectiveTime | SXPR_TS | |||
| effectiveTime:duration | C | 1..1 | IVL_TS | This effectiveTime represents either the medication duration (i.e., the time the medication was started and stopped) or the single-administration timestamp. 1098-32890: This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890). |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | ts | indicates a single-administration timestamp Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator | 0..1 | cs | Binding: SetOperator (required) | |
| low | 0..1 | IVXB_TS | indicates when medication started | |
| center | 0..1 | TS | ||
| width | 0..1 | PQ | ||
| high | 0..1 | IVXB_TS | indicates when medication stopped | |
| effectiveTime:periodicFrequency | 0..1 | EIVL_TS | This effectiveTime represents a periodic medication frequency (e.g., administration times per day). | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @operator | 1..1 | cs | Binding: SetOperator (required) Required Pattern: A | |
| event | 0..1 | CE | ||
| offset | 0..1 | IVL_PQ | ||
| effectiveTime:eventFrequency | 0..1 | PIVL_TS | This effectiveTime represents an event-based medication frequency (e.g., administration at bedtime). | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @operator | 1..1 | cs | Binding: SetOperator (required) Required Pattern: A | |
| phase | 0..1 | IVL_TS | ||
| period | 0..1 | PQ | ||
| @alignment | 0..1 | cs | ||
| @institutionSpecified | 0..1 | bl | ||
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| repeatNumber | 0..1 | IVL_INT | In "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..1 | CE | Binding: SPL Drug Route of Administration Terminology (required) | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 0..1 | cs | ||
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | Binding: Medication Route (required) | |
| approachSiteCode | 0..1 | CD | Binding: Body Site Value Set (required) | |
| doseQuantity | C | 1..1 | IVL_PQ | 1098-16879: Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is "simply metoprolol Oral Product" (RxCUI 1163523), then doseQuantity must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration (CONF:1098-16879). 1098-16878: Pre-coordinated consumable: If the consumable code is a pre-coordinated unit dose (e.g., "metoprolol 25mg tablet") then doseQuantity is a unitless number that indicates the number of products given per administration (e.g., "2", meaning 2 x "metoprolol 25mg tablet" per administration) (CONF:1098-16878). |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @unit | 0..1 | cs | Binding: UnitsOfMeasureCaseSensitive (required) | |
| @value | 0..1 | real | ||
| @operator | 0..1 | cs | Binding: SetOperator (required) | |
| low | 0..1 | IVXB_PQ | ||
| center | 0..1 | PQ | ||
| width | 0..1 | PQ | ||
| high | 0..1 | IVXB_PQ | ||
| rateQuantity | 0..1 | IVL_PQ | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @unit | 1..1 | cs | Binding: UnitsOfMeasureCaseSensitive (required) | |
| @value | 0..1 | real | ||
| @operator | 0..1 | cs | Binding: SetOperator (required) | |
| low | 0..1 | IVXB_PQ | ||
| center | 0..1 | PQ | ||
| width | 0..1 | PQ | ||
| high | 0..1 | IVXB_PQ | ||
| maxDoseQuantity | 0..1 | RTO_PQ_PQ | ||
| administrationUnitCode | 0..1 | CE | administrationUnitCode@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..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationTargetDirect (required) Fixed Value: CSM | |
| manufacturedProduct | 1..1 | MedicationInformation | Base for all types and resources | |
| subject | 0..1 | Subject | ||
| specimen | 0..* | Specimen | ||
| performer | 0..1 | Performer2 | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| informant | 0..* | Informant | ||
| Slices for participant | 0..* | Participant2 | Slice: Unordered, Open by value:participantRole, value:typeCode | |
| participant:drugVehicle | 0..* | Participant2 | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: CSM | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| sdtcFunctionCode | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: functionCode (urn:hl7-org:sdtc) | |
| time | 0..1 | IVL_TS | ||
| awarenessCode | 0..1 | CE | ||
| participantRole | 1..1 | DrugVehicle | Base for all types and resources | |
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:substanceAdministration, profile:observation, profile:act, profile:supply | |
| entryRelationship:indication | 0..* | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | 1..1 | Indication | Base for all types and resources | |
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:instruction | 0..1 | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| @inversionInd | 1..1 | bl | Fixed Value: true | |
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 1..1 | Instruction | Base for all types and resources | |
| encounter | 0..1 | Encounter | ||
| observation | 0..1 | Observation | ||
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:supplyOrder | 0..1 | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | 0..1 | Observation | ||
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 1..1 | MedicationSupplyOrder | Base for all types and resources | |
| entryRelationship:medicationDispense | 0..* | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | 0..1 | Observation | ||
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | C | 1..1 | MedicationDispense | Base for all types and resources |
| entryRelationship:reaction | 0..* | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: CAUS | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | 1..1 | ReactionObservation | Base for all types and resources | |
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:drugMonitoring | 0..1 | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 1..1 | DrugMonitoringAct | Base for all types and resources | |
| encounter | 0..1 | Encounter | ||
| observation | 0..1 | Observation | ||
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:substanceAdministered | 0..* | EntryRelationship | The following entryRelationship is used to indicate a given medication's order in a series. The nested Substance Administered Act identifies an administration in the series. The entryRelationship/sequenceNumber shows the order of this particular administration in that series. | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| @inversionInd | 1..1 | bl | Fixed Value: true | |
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 1..1 | SubstanceAdministeredAct | Base for all types and resources | |
| encounter | 0..1 | Encounter | ||
| observation | 0..1 | Observation | ||
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:adherence | 0..* | EntryRelationship | The following entryRelationship is used to indicate the patient's adherence to the medication order. | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | 1..1 | MedicationAdherence | Base for all types and resources | |
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:signature | 0..* | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | 0..1 | Observation | ||
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 1..1 | MedicationFreeTextSig | Base for all types and resources | |
| supply | 0..1 | Supply | ||
| reference | 0..* | Reference | ||
| precondition | 0..* | Precondition | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 1..1 | cs | Binding: ActRelationshipType (required) Fixed Value: PRCN | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| criterion | 1..1 | PreconditionforSubstanceAdministration | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| SubstanceAdministration.classCode | required | Fixed Value: SBADM |
| SubstanceAdministration.moodCode | required | MoodCodeEvnInt |
| SubstanceAdministration.templateId:primary.nullFlavor | required | NullFlavor |
| SubstanceAdministration.code | extensible | ActSubstanceAdministrationCode |
| SubstanceAdministration.statusCode | required | ActStatus |
| SubstanceAdministration.statusCode.nullFlavor | required | NullFlavor |
| SubstanceAdministration.statusCode.code | required | Medication Status |
| SubstanceAdministration.effectiveTime:duration.nullFlavor | required | NullFlavor |
| SubstanceAdministration.effectiveTime:duration.operator | required | SetOperator |
| SubstanceAdministration.effectiveTime:periodicFrequency.nullFlavor | required | NullFlavor |
| SubstanceAdministration.effectiveTime:periodicFrequency.operator | required | Pattern: A |
| SubstanceAdministration.effectiveTime:eventFrequency.nullFlavor | required | NullFlavor |
| SubstanceAdministration.effectiveTime:eventFrequency.operator | required | Pattern: A |
| SubstanceAdministration.priorityCode | extensible | ActPriority |
| SubstanceAdministration.routeCode | required | SPL Drug Route of Administration Terminology |
| SubstanceAdministration.routeCode.nullFlavor | required | NullFlavor |
| SubstanceAdministration.routeCode.translation | required | Medication Route |
| SubstanceAdministration.approachSiteCode | required | Body Site Value Set |
| SubstanceAdministration.doseQuantity.nullFlavor | required | NullFlavor |
| SubstanceAdministration.doseQuantity.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM) |
| SubstanceAdministration.doseQuantity.operator | required | SetOperator |
| SubstanceAdministration.rateQuantity.nullFlavor | required | NullFlavor |
| SubstanceAdministration.rateQuantity.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM) |
| SubstanceAdministration.rateQuantity.operator | required | SetOperator |
| SubstanceAdministration.administrationUnitCode | required | AdministrationUnitDoseForm |
| SubstanceAdministration.consumable.nullFlavor | required | NullFlavor |
| SubstanceAdministration.consumable.typeCode | required | Fixed Value: CSM |
| SubstanceAdministration.participant:drugVehicle.nullFlavor | required | NullFlavor |
| SubstanceAdministration.participant:drugVehicle.typeCode | required | Fixed Value: CSM |
| SubstanceAdministration.participant:drugVehicle.contextControlCode | required | Fixed Value: OP |
| SubstanceAdministration.entryRelationship:indication.nullFlavor | required | NullFlavor |
| SubstanceAdministration.entryRelationship:indication.typeCode | required | Fixed Value: RSON |
| SubstanceAdministration.entryRelationship:instruction.nullFlavor | required | NullFlavor |
| SubstanceAdministration.entryRelationship:instruction.typeCode | required | Fixed Value: SUBJ |
| SubstanceAdministration.entryRelationship:supplyOrder.nullFlavor | required | NullFlavor |
| SubstanceAdministration.entryRelationship:supplyOrder.typeCode | required | Fixed Value: REFR |
| SubstanceAdministration.entryRelationship:medicationDispense.nullFlavor | required | NullFlavor |
| SubstanceAdministration.entryRelationship:medicationDispense.typeCode | required | Fixed Value: REFR |
| SubstanceAdministration.entryRelationship:reaction.nullFlavor | required | NullFlavor |
| SubstanceAdministration.entryRelationship:reaction.typeCode | required | Fixed Value: CAUS |
| SubstanceAdministration.entryRelationship:drugMonitoring.nullFlavor | required | NullFlavor |
| SubstanceAdministration.entryRelationship:drugMonitoring.typeCode | required | Fixed Value: COMP |
| SubstanceAdministration.entryRelationship:substanceAdministered.nullFlavor | required | NullFlavor |
| SubstanceAdministration.entryRelationship:substanceAdministered.typeCode | required | Fixed Value: COMP |
| SubstanceAdministration.entryRelationship:adherence.nullFlavor | required | NullFlavor |
| SubstanceAdministration.entryRelationship:adherence.typeCode | required | Fixed Value: COMP |
| SubstanceAdministration.entryRelationship:signature.nullFlavor | required | NullFlavor |
| SubstanceAdministration.entryRelationship:signature.typeCode | required | Fixed Value: COMP |
| SubstanceAdministration.precondition.nullFlavor | required | NullFlavor |
| SubstanceAdministration.precondition.typeCode | required | Fixed Value: PRCN |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-7513 | error | SubstanceAdministration.effectiveTime | SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499). : | |
| 1098-16878 | warning | SubstanceAdministration.doseQuantity | 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). : | |
| 1098-16879 | warning | SubstanceAdministration.doseQuantity | Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is "simply metoprolol Oral Product" (RxCUI 1163523), then doseQuantity must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration (CONF:1098-16879). : | |
| 1098-30800 | warning | SubstanceAdministration | Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800). : | |
| 1098-32890 | error | SubstanceAdministration.effectiveTime:duration | This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890). : | |
| 4537-9333 | error | SubstanceAdministration.entryRelationship:medicationDispense.supply | A supply act **SHALL** contain one product/Medication Information *OR* one product/Immunization Medication Information template (CONF:4537-9333). : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
This structure is derived from CDAR2.SubstanceAdministration
Summary
Mandatory: 10 elements (16 nested mandatory elements)
Fixed Value: 13 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CDAR2.SubstanceAdministration
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| SubstanceAdministration | C | 1..1 | CDAR2.SubstanceAdministration | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, repeatNumber, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode, consumable, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition Base for all types and resources 1098-30800: Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800). |
| classCode | 1..1 | cs | ||
| moodCode | 1..1 | cs | Binding: MoodCodeEvnInt (required) | |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:extension, value:root | |
| templateId:primary | 1..1 | II | ||
| root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.16 | |
| extension | 1..1 | st | Required Pattern: 2014-06-09 | |
| id | 1..* | II | ||
| code | 0..1 | CD | 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. | |
| statusCode | 1..1 | CS | ||
| code | 1..1 | cs | The substance administration effectiveTime field can repeat, in order to represent varying levels of complex dosing. effectiveTime can be used to represent the duration of administration (e.g., "10 days"), the frequency of administration (e.g., "every 8 hours"), and more. Here, we require that there SHALL be an effectiveTime documentation of the duration (or single-administration timestamp), and that there SHOULD be an effectiveTime documentation of the frequency. Other timing nuances, supported by the base CDA R2 standard, may also be included. Binding: Medication Status (required) | |
| Slices for effectiveTime | C | 1..* | SXCM_TS, IVL_TS, EIVL_TS, PIVL_TS, SXPR_TS | Slice: Unordered, Open by value:operator 1098-7513: SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499). |
| effectiveTime:duration | C | 1..1 | IVL_TS | This effectiveTime represents either the medication duration (i.e., the time the medication was started and stopped) or the single-administration timestamp. 1098-32890: This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890). |
| value | 0..1 | ts | indicates a single-administration timestamp | |
| low | 0..1 | IVXB_TS | indicates when medication started | |
| high | 0..1 | IVXB_TS | indicates when medication stopped | |
| effectiveTime:periodicFrequency | 0..1 | EIVL_TS | This effectiveTime represents a periodic medication frequency (e.g., administration times per day). | |
| operator | 1..1 | cs | Required Pattern: A | |
| effectiveTime:eventFrequency | 0..1 | PIVL_TS | This effectiveTime represents an event-based medication frequency (e.g., administration at bedtime). | |
| operator | 1..1 | cs | Required Pattern: A | |
| repeatNumber | 0..1 | IVL_INT | In "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..1 | CE | Binding: SPL Drug Route of Administration Terminology (required) | |
| translation | 0..* | CD | Binding: Medication Route (required) | |
| approachSiteCode | 0..1 | CD | Binding: Body Site Value Set (required) | |
| doseQuantity | C | 1..1 | IVL_PQ | 1098-16879: Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is "simply metoprolol Oral Product" (RxCUI 1163523), then doseQuantity must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration (CONF:1098-16879). 1098-16878: Pre-coordinated consumable: If the consumable code is a pre-coordinated unit dose (e.g., "metoprolol 25mg tablet") then doseQuantity is a unitless number that indicates the number of products given per administration (e.g., "2", meaning 2 x "metoprolol 25mg tablet" per administration) (CONF:1098-16878). |
| unit | 0..1 | cs | Binding: UnitsOfMeasureCaseSensitive (required) | |
| rateQuantity | 0..1 | IVL_PQ | ||
| unit | 1..1 | cs | Binding: UnitsOfMeasureCaseSensitive (required) | |
| maxDoseQuantity | 0..1 | RTO_PQ_PQ | ||
| administrationUnitCode | 0..1 | CE | administrationUnitCode@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..1 | InfrastructureRoot | ||
| manufacturedProduct | 1..1 | MedicationInformation | Base for all types and resources | |
| performer | 0..1 | Performer2 | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for participant | 0..* | Participant2 | Slice: Unordered, Open by value:participantRole, value:typeCode | |
| participant:drugVehicle | 0..* | Participant2 | ||
| typeCode | 1..1 | cs | Fixed Value: CSM | |
| participantRole | 1..1 | DrugVehicle | Base for all types and resources | |
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:substanceAdministration, profile:observation, profile:act, profile:supply | |
| entryRelationship:indication | 0..* | EntryRelationship | ||
| typeCode | 1..1 | cs | Fixed Value: RSON | |
| observation | 1..1 | Indication | Base for all types and resources | |
| entryRelationship:instruction | 0..1 | EntryRelationship | ||
| typeCode | 1..1 | cs | Fixed Value: SUBJ | |
| inversionInd | 1..1 | bl | Fixed Value: true | |
| act | 1..1 | Instruction | Base for all types and resources | |
| entryRelationship:supplyOrder | 0..1 | EntryRelationship | ||
| typeCode | 1..1 | cs | Fixed Value: REFR | |
| supply | 1..1 | MedicationSupplyOrder | Base for all types and resources | |
| entryRelationship:medicationDispense | 0..* | EntryRelationship | ||
| typeCode | 1..1 | cs | Fixed Value: REFR | |
| supply | 1..1 | MedicationDispense | Base for all types and resources | |
| entryRelationship:reaction | 0..* | EntryRelationship | ||
| typeCode | 1..1 | cs | Fixed Value: CAUS | |
| observation | 1..1 | ReactionObservation | Base for all types and resources | |
| entryRelationship:drugMonitoring | 0..1 | EntryRelationship | ||
| typeCode | 1..1 | cs | Fixed Value: COMP | |
| act | 1..1 | DrugMonitoringAct | Base for all types and resources | |
| entryRelationship:substanceAdministered | 0..* | EntryRelationship | The 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..1 | cs | Fixed Value: COMP | |
| inversionInd | 1..1 | bl | Fixed Value: true | |
| sequenceNumber | 0..1 | INT | ||
| act | 1..1 | SubstanceAdministeredAct | Base for all types and resources | |
| entryRelationship:adherence | 0..* | EntryRelationship | The following entryRelationship is used to indicate the patient's adherence to the medication order. | |
| typeCode | 1..1 | cs | Fixed Value: COMP | |
| observation | 1..1 | MedicationAdherence | Base for all types and resources | |
| entryRelationship:signature | 0..* | EntryRelationship | ||
| typeCode | 1..1 | cs | Fixed Value: COMP | |
| substanceAdministration | 1..1 | MedicationFreeTextSig | Base for all types and resources | |
| precondition | 0..* | Precondition | ||
| typeCode | 1..1 | cs | Fixed Value: PRCN | |
| criterion | 1..1 | PreconditionforSubstanceAdministration | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| SubstanceAdministration.moodCode | required | MoodCodeEvnInt |
| SubstanceAdministration.statusCode.code | required | Medication Status |
| SubstanceAdministration.routeCode | required | SPL Drug Route of Administration Terminology |
| SubstanceAdministration.routeCode.translation | required | Medication Route |
| SubstanceAdministration.approachSiteCode | required | Body Site Value Set |
| SubstanceAdministration.doseQuantity.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM) |
| SubstanceAdministration.rateQuantity.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM) |
| SubstanceAdministration.administrationUnitCode | required | AdministrationUnitDoseForm |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-7513 | error | SubstanceAdministration.effectiveTime | SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499). : | |
| 1098-16878 | warning | SubstanceAdministration.doseQuantity | 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). : | |
| 1098-16879 | warning | SubstanceAdministration.doseQuantity | Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is "simply metoprolol Oral Product" (RxCUI 1163523), then doseQuantity must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration (CONF:1098-16879). : | |
| 1098-30800 | warning | SubstanceAdministration | Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800). : | |
| 1098-32890 | error | SubstanceAdministration.effectiveTime:duration | This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890). : |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| SubstanceAdministration | C | 1..1 | CDAR2.SubstanceAdministration | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, repeatNumber, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode, consumable, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition Base for all types and resources 1098-30800: Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800). |
| @classCode | 1..1 | cs | Binding: ActClass (required) Fixed Value: SBADM | |
| @moodCode | 1..1 | cs | Binding: MoodCodeEvnInt (required) | |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:extension, value:root | |
| templateId:primary | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.16 | |
| @extension | 1..1 | st | Required Pattern: 2014-06-09 | |
| id | 1..* | II | ||
| code | 0..1 | CD | 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: ActSubstanceAdministrationCode (extensible) | |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| @code | 1..1 | cs | The substance administration effectiveTime field can repeat, in order to represent varying levels of complex dosing. effectiveTime can be used to represent the duration of administration (e.g., "10 days"), the frequency of administration (e.g., "every 8 hours"), and more. Here, we require that there SHALL be an effectiveTime documentation of the duration (or single-administration timestamp), and that there SHOULD be an effectiveTime documentation of the frequency. Other timing nuances, supported by the base CDA R2 standard, may also be included. Binding: Medication Status (required) | |
| Slices for effectiveTime | C | 1..* | Slice: Unordered, Open by value:operator 1098-7513: SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499). | |
| effectiveTime | SXCM_TS | |||
| effectiveTime | IVL_TS | |||
| effectiveTime | EIVL_TS | |||
| effectiveTime | PIVL_TS | |||
| effectiveTime | SXPR_TS | |||
| effectiveTime:duration | C | 1..1 | IVL_TS | This effectiveTime represents either the medication duration (i.e., the time the medication was started and stopped) or the single-administration timestamp. 1098-32890: This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890). |
| @value | 0..1 | ts | indicates a single-administration timestamp Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| low | 0..1 | IVXB_TS | indicates when medication started | |
| high | 0..1 | IVXB_TS | indicates when medication stopped | |
| effectiveTime:periodicFrequency | 0..1 | EIVL_TS | This effectiveTime represents a periodic medication frequency (e.g., administration times per day). | |
| @operator | 1..1 | cs | Binding: SetOperator (required) Required Pattern: A | |
| effectiveTime:eventFrequency | 0..1 | PIVL_TS | This effectiveTime represents an event-based medication frequency (e.g., administration at bedtime). | |
| @operator | 1..1 | cs | Binding: SetOperator (required) Required Pattern: A | |
| repeatNumber | 0..1 | IVL_INT | In "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..1 | CE | Binding: SPL Drug Route of Administration Terminology (required) | |
| translation | 0..* | CD | Binding: Medication Route (required) | |
| approachSiteCode | 0..1 | CD | Binding: Body Site Value Set (required) | |
| doseQuantity | C | 1..1 | IVL_PQ | 1098-16879: Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is "simply metoprolol Oral Product" (RxCUI 1163523), then doseQuantity must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration (CONF:1098-16879). 1098-16878: Pre-coordinated consumable: If the consumable code is a pre-coordinated unit dose (e.g., "metoprolol 25mg tablet") then doseQuantity is a unitless number that indicates the number of products given per administration (e.g., "2", meaning 2 x "metoprolol 25mg tablet" per administration) (CONF:1098-16878). |
| @unit | 0..1 | cs | Binding: UnitsOfMeasureCaseSensitive (required) | |
| rateQuantity | 0..1 | IVL_PQ | ||
| @unit | 1..1 | cs | Binding: UnitsOfMeasureCaseSensitive (required) | |
| maxDoseQuantity | 0..1 | RTO_PQ_PQ | ||
| administrationUnitCode | 0..1 | CE | administrationUnitCode@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..1 | InfrastructureRoot | ||
| manufacturedProduct | 1..1 | MedicationInformation | Base for all types and resources | |
| performer | 0..1 | Performer2 | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| Slices for participant | 0..* | Participant2 | Slice: Unordered, Open by value:participantRole, value:typeCode | |
| participant:drugVehicle | 0..* | Participant2 | ||
| @typeCode | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: CSM | |
| participantRole | 1..1 | DrugVehicle | Base for all types and resources | |
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:substanceAdministration, profile:observation, profile:act, profile:supply | |
| entryRelationship:indication | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |
| observation | 1..1 | Indication | Base for all types and resources | |
| entryRelationship:instruction | 0..1 | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| @inversionInd | 1..1 | bl | Fixed Value: true | |
| act | 1..1 | Instruction | Base for all types and resources | |
| entryRelationship:supplyOrder | 0..1 | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| supply | 1..1 | MedicationSupplyOrder | Base for all types and resources | |
| entryRelationship:medicationDispense | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| supply | C | 1..1 | MedicationDispense | Base for all types and resources |
| entryRelationship:reaction | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: CAUS | |
| observation | 1..1 | ReactionObservation | Base for all types and resources | |
| entryRelationship:drugMonitoring | 0..1 | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| act | 1..1 | DrugMonitoringAct | Base for all types and resources | |
| entryRelationship:substanceAdministered | 0..* | EntryRelationship | The 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..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| @inversionInd | 1..1 | bl | Fixed Value: true | |
| sequenceNumber | 0..1 | INT | ||
| act | 1..1 | SubstanceAdministeredAct | Base for all types and resources | |
| entryRelationship:adherence | 0..* | EntryRelationship | The following entryRelationship is used to indicate the patient's adherence to the medication order. | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| observation | 1..1 | MedicationAdherence | Base for all types and resources | |
| entryRelationship:signature | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| substanceAdministration | 1..1 | MedicationFreeTextSig | Base for all types and resources | |
| precondition | 0..* | Precondition | ||
| @typeCode | 1..1 | cs | Binding: ActRelationshipType (required) Fixed Value: PRCN | |
| criterion | 1..1 | PreconditionforSubstanceAdministration | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| SubstanceAdministration.classCode | required | Fixed Value: SBADM |
| SubstanceAdministration.moodCode | required | MoodCodeEvnInt |
| SubstanceAdministration.code | extensible | ActSubstanceAdministrationCode |
| SubstanceAdministration.statusCode | required | ActStatus |
| SubstanceAdministration.statusCode.code | required | Medication Status |
| SubstanceAdministration.effectiveTime:periodicFrequency.operator | required | Pattern: A |
| SubstanceAdministration.effectiveTime:eventFrequency.operator | required | Pattern: A |
| SubstanceAdministration.routeCode | required | SPL Drug Route of Administration Terminology |
| SubstanceAdministration.routeCode.translation | required | Medication Route |
| SubstanceAdministration.approachSiteCode | required | Body Site Value Set |
| SubstanceAdministration.doseQuantity.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM) |
| SubstanceAdministration.rateQuantity.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM) |
| SubstanceAdministration.administrationUnitCode | required | AdministrationUnitDoseForm |
| SubstanceAdministration.participant:drugVehicle.typeCode | required | Fixed Value: CSM |
| SubstanceAdministration.entryRelationship:indication.typeCode | required | Fixed Value: RSON |
| SubstanceAdministration.entryRelationship:instruction.typeCode | required | Fixed Value: SUBJ |
| SubstanceAdministration.entryRelationship:supplyOrder.typeCode | required | Fixed Value: REFR |
| SubstanceAdministration.entryRelationship:medicationDispense.typeCode | required | Fixed Value: REFR |
| SubstanceAdministration.entryRelationship:reaction.typeCode | required | Fixed Value: CAUS |
| SubstanceAdministration.entryRelationship:drugMonitoring.typeCode | required | Fixed Value: COMP |
| SubstanceAdministration.entryRelationship:substanceAdministered.typeCode | required | Fixed Value: COMP |
| SubstanceAdministration.entryRelationship:adherence.typeCode | required | Fixed Value: COMP |
| SubstanceAdministration.entryRelationship:signature.typeCode | required | Fixed Value: COMP |
| SubstanceAdministration.precondition.typeCode | required | Fixed Value: PRCN |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-7513 | error | SubstanceAdministration.effectiveTime | SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499). : | |
| 1098-16878 | warning | SubstanceAdministration.doseQuantity | 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). : | |
| 1098-16879 | warning | SubstanceAdministration.doseQuantity | Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is "simply metoprolol Oral Product" (RxCUI 1163523), then doseQuantity must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration (CONF:1098-16879). : | |
| 1098-30800 | warning | SubstanceAdministration | Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800). : | |
| 1098-32890 | error | SubstanceAdministration.effectiveTime:duration | This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890). : | |
| 4537-9333 | error | SubstanceAdministration.entryRelationship:medicationDispense.supply | A supply act **SHALL** contain one product/Medication Information *OR* one product/Immunization Medication Information template (CONF:4537-9333). : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| SubstanceAdministration | C | 1..1 | CDAR2.SubstanceAdministration | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, repeatNumber, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode, consumable, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition Base for all types and resources 1098-30800: Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800). |
| @classCode | 1..1 | cs | Binding: ActClass (required) Fixed Value: SBADM | |
| @moodCode | 1..1 | cs | Binding: MoodCodeEvnInt (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:extension, value:root | |
| templateId:primary | 1..1 | II | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @assigningAuthorityName | 0..1 | st | ||
| @displayable | 0..1 | bl | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.16 | |
| @extension | 1..1 | st | Required Pattern: 2014-06-09 | |
| id | 1..* | II | ||
| code | 0..1 | CD | 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: ActSubstanceAdministrationCode (extensible) | |
| @negationInd | 0..1 | bl | ||
| text | 0..1 | ED | ||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 1..1 | cs | The substance administration effectiveTime field can repeat, in order to represent varying levels of complex dosing. effectiveTime can be used to represent the duration of administration (e.g., "10 days"), the frequency of administration (e.g., "every 8 hours"), and more. Here, we require that there SHALL be an effectiveTime documentation of the duration (or single-administration timestamp), and that there SHOULD be an effectiveTime documentation of the frequency. Other timing nuances, supported by the base CDA R2 standard, may also be included. Binding: Medication Status (required) | |
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| Slices for effectiveTime | C | 1..* | Slice: Unordered, Open by value:operator 1098-7513: SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499). | |
| effectiveTime | SXCM_TS | |||
| effectiveTime | IVL_TS | |||
| effectiveTime | EIVL_TS | |||
| effectiveTime | PIVL_TS | |||
| effectiveTime | SXPR_TS | |||
| effectiveTime:duration | C | 1..1 | IVL_TS | This effectiveTime represents either the medication duration (i.e., the time the medication was started and stopped) or the single-administration timestamp. 1098-32890: This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890). |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @value | 0..1 | ts | indicates a single-administration timestamp Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator | 0..1 | cs | Binding: SetOperator (required) | |
| low | 0..1 | IVXB_TS | indicates when medication started | |
| center | 0..1 | TS | ||
| width | 0..1 | PQ | ||
| high | 0..1 | IVXB_TS | indicates when medication stopped | |
| effectiveTime:periodicFrequency | 0..1 | EIVL_TS | This effectiveTime represents a periodic medication frequency (e.g., administration times per day). | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @operator | 1..1 | cs | Binding: SetOperator (required) Required Pattern: A | |
| event | 0..1 | CE | ||
| offset | 0..1 | IVL_PQ | ||
| effectiveTime:eventFrequency | 0..1 | PIVL_TS | This effectiveTime represents an event-based medication frequency (e.g., administration at bedtime). | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @operator | 1..1 | cs | Binding: SetOperator (required) Required Pattern: A | |
| phase | 0..1 | IVL_TS | ||
| period | 0..1 | PQ | ||
| @alignment | 0..1 | cs | ||
| @institutionSpecified | 0..1 | bl | ||
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| repeatNumber | 0..1 | IVL_INT | In "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..1 | CE | Binding: SPL Drug Route of Administration Terminology (required) | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @code | 0..1 | cs | ||
| @codeSystem | 0..1 | oid, uuid, ruid | ||
| @codeSystemName | 0..1 | st | ||
| @codeSystemVersion | 0..1 | st | ||
| @displayName | 0..1 | st | ||
| @sdtcValueSet | 0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
| @sdtcValueSetVersion | 0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
| originalText | 0..1 | ED | ||
| translation | 0..* | CD | Binding: Medication Route (required) | |
| approachSiteCode | 0..1 | CD | Binding: Body Site Value Set (required) | |
| doseQuantity | C | 1..1 | IVL_PQ | 1098-16879: Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is "simply metoprolol Oral Product" (RxCUI 1163523), then doseQuantity must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration (CONF:1098-16879). 1098-16878: Pre-coordinated consumable: If the consumable code is a pre-coordinated unit dose (e.g., "metoprolol 25mg tablet") then doseQuantity is a unitless number that indicates the number of products given per administration (e.g., "2", meaning 2 x "metoprolol 25mg tablet" per administration) (CONF:1098-16878). |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @unit | 0..1 | cs | Binding: UnitsOfMeasureCaseSensitive (required) | |
| @value | 0..1 | real | ||
| @operator | 0..1 | cs | Binding: SetOperator (required) | |
| low | 0..1 | IVXB_PQ | ||
| center | 0..1 | PQ | ||
| width | 0..1 | PQ | ||
| high | 0..1 | IVXB_PQ | ||
| rateQuantity | 0..1 | IVL_PQ | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @unit | 1..1 | cs | Binding: UnitsOfMeasureCaseSensitive (required) | |
| @value | 0..1 | real | ||
| @operator | 0..1 | cs | Binding: SetOperator (required) | |
| low | 0..1 | IVXB_PQ | ||
| center | 0..1 | PQ | ||
| width | 0..1 | PQ | ||
| high | 0..1 | IVXB_PQ | ||
| maxDoseQuantity | 0..1 | RTO_PQ_PQ | ||
| administrationUnitCode | 0..1 | CE | administrationUnitCode@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..1 | InfrastructureRoot | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 0..1 | cs | Binding: ParticipationTargetDirect (required) Fixed Value: CSM | |
| manufacturedProduct | 1..1 | MedicationInformation | Base for all types and resources | |
| subject | 0..1 | Subject | ||
| specimen | 0..* | Specimen | ||
| performer | 0..1 | Performer2 | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| informant | 0..* | Informant | ||
| Slices for participant | 0..* | Participant2 | Slice: Unordered, Open by value:participantRole, value:typeCode | |
| participant:drugVehicle | 0..* | Participant2 | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: CSM | |
| @contextControlCode | 0..1 | cs | Binding: ContextControl (required) Fixed Value: OP | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| sdtcFunctionCode | 0..1 | CE | XML Namespace: urn:hl7-org:sdtc XML: functionCode (urn:hl7-org:sdtc) | |
| time | 0..1 | IVL_TS | ||
| awarenessCode | 0..1 | CE | ||
| participantRole | 1..1 | DrugVehicle | Base for all types and resources | |
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:substanceAdministration, profile:observation, profile:act, profile:supply | |
| entryRelationship:indication | 0..* | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | 1..1 | Indication | Base for all types and resources | |
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:instruction | 0..1 | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| @inversionInd | 1..1 | bl | Fixed Value: true | |
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 1..1 | Instruction | Base for all types and resources | |
| encounter | 0..1 | Encounter | ||
| observation | 0..1 | Observation | ||
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:supplyOrder | 0..1 | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | 0..1 | Observation | ||
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 1..1 | MedicationSupplyOrder | Base for all types and resources | |
| entryRelationship:medicationDispense | 0..* | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | 0..1 | Observation | ||
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | C | 1..1 | MedicationDispense | Base for all types and resources |
| entryRelationship:reaction | 0..* | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: CAUS | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | 1..1 | ReactionObservation | Base for all types and resources | |
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:drugMonitoring | 0..1 | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 1..1 | DrugMonitoringAct | Base for all types and resources | |
| encounter | 0..1 | Encounter | ||
| observation | 0..1 | Observation | ||
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:substanceAdministered | 0..* | EntryRelationship | The following entryRelationship is used to indicate a given medication's order in a series. The nested Substance Administered Act identifies an administration in the series. The entryRelationship/sequenceNumber shows the order of this particular administration in that series. | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| @inversionInd | 1..1 | bl | Fixed Value: true | |
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 1..1 | SubstanceAdministeredAct | Base for all types and resources | |
| encounter | 0..1 | Encounter | ||
| observation | 0..1 | Observation | ||
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:adherence | 0..* | EntryRelationship | The following entryRelationship is used to indicate the patient's adherence to the medication order. | |
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | 1..1 | MedicationAdherence | Base for all types and resources | |
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| entryRelationship:signature | 0..* | EntryRelationship | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
| @inversionInd | 0..1 | bl | ||
| @contextConductionInd | 0..1 | bl | ||
| @negationInd | 0..1 | bl | ||
| sequenceNumber | 0..1 | INT | ||
| seperatableInd | 0..1 | BL | ||
| act | 0..1 | Act | ||
| encounter | 0..1 | Encounter | ||
| observation | 0..1 | Observation | ||
| observationMedia | 0..1 | ObservationMedia | ||
| organizer | 0..1 | Organizer | ||
| procedure | 0..1 | Procedure | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| substanceAdministration | 1..1 | MedicationFreeTextSig | Base for all types and resources | |
| supply | 0..1 | Supply | ||
| reference | 0..* | Reference | ||
| precondition | 0..* | Precondition | ||
| @nullFlavor | 0..1 | cs | Binding: NullFlavor (required) | |
| @typeCode | 1..1 | cs | Binding: ActRelationshipType (required) Fixed Value: PRCN | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| templateId | 0..* | II | ||
| criterion | 1..1 | PreconditionforSubstanceAdministration | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| SubstanceAdministration.classCode | required | Fixed Value: SBADM |
| SubstanceAdministration.moodCode | required | MoodCodeEvnInt |
| SubstanceAdministration.templateId:primary.nullFlavor | required | NullFlavor |
| SubstanceAdministration.code | extensible | ActSubstanceAdministrationCode |
| SubstanceAdministration.statusCode | required | ActStatus |
| SubstanceAdministration.statusCode.nullFlavor | required | NullFlavor |
| SubstanceAdministration.statusCode.code | required | Medication Status |
| SubstanceAdministration.effectiveTime:duration.nullFlavor | required | NullFlavor |
| SubstanceAdministration.effectiveTime:duration.operator | required | SetOperator |
| SubstanceAdministration.effectiveTime:periodicFrequency.nullFlavor | required | NullFlavor |
| SubstanceAdministration.effectiveTime:periodicFrequency.operator | required | Pattern: A |
| SubstanceAdministration.effectiveTime:eventFrequency.nullFlavor | required | NullFlavor |
| SubstanceAdministration.effectiveTime:eventFrequency.operator | required | Pattern: A |
| SubstanceAdministration.priorityCode | extensible | ActPriority |
| SubstanceAdministration.routeCode | required | SPL Drug Route of Administration Terminology |
| SubstanceAdministration.routeCode.nullFlavor | required | NullFlavor |
| SubstanceAdministration.routeCode.translation | required | Medication Route |
| SubstanceAdministration.approachSiteCode | required | Body Site Value Set |
| SubstanceAdministration.doseQuantity.nullFlavor | required | NullFlavor |
| SubstanceAdministration.doseQuantity.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM) |
| SubstanceAdministration.doseQuantity.operator | required | SetOperator |
| SubstanceAdministration.rateQuantity.nullFlavor | required | NullFlavor |
| SubstanceAdministration.rateQuantity.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM) |
| SubstanceAdministration.rateQuantity.operator | required | SetOperator |
| SubstanceAdministration.administrationUnitCode | required | AdministrationUnitDoseForm |
| SubstanceAdministration.consumable.nullFlavor | required | NullFlavor |
| SubstanceAdministration.consumable.typeCode | required | Fixed Value: CSM |
| SubstanceAdministration.participant:drugVehicle.nullFlavor | required | NullFlavor |
| SubstanceAdministration.participant:drugVehicle.typeCode | required | Fixed Value: CSM |
| SubstanceAdministration.participant:drugVehicle.contextControlCode | required | Fixed Value: OP |
| SubstanceAdministration.entryRelationship:indication.nullFlavor | required | NullFlavor |
| SubstanceAdministration.entryRelationship:indication.typeCode | required | Fixed Value: RSON |
| SubstanceAdministration.entryRelationship:instruction.nullFlavor | required | NullFlavor |
| SubstanceAdministration.entryRelationship:instruction.typeCode | required | Fixed Value: SUBJ |
| SubstanceAdministration.entryRelationship:supplyOrder.nullFlavor | required | NullFlavor |
| SubstanceAdministration.entryRelationship:supplyOrder.typeCode | required | Fixed Value: REFR |
| SubstanceAdministration.entryRelationship:medicationDispense.nullFlavor | required | NullFlavor |
| SubstanceAdministration.entryRelationship:medicationDispense.typeCode | required | Fixed Value: REFR |
| SubstanceAdministration.entryRelationship:reaction.nullFlavor | required | NullFlavor |
| SubstanceAdministration.entryRelationship:reaction.typeCode | required | Fixed Value: CAUS |
| SubstanceAdministration.entryRelationship:drugMonitoring.nullFlavor | required | NullFlavor |
| SubstanceAdministration.entryRelationship:drugMonitoring.typeCode | required | Fixed Value: COMP |
| SubstanceAdministration.entryRelationship:substanceAdministered.nullFlavor | required | NullFlavor |
| SubstanceAdministration.entryRelationship:substanceAdministered.typeCode | required | Fixed Value: COMP |
| SubstanceAdministration.entryRelationship:adherence.nullFlavor | required | NullFlavor |
| SubstanceAdministration.entryRelationship:adherence.typeCode | required | Fixed Value: COMP |
| SubstanceAdministration.entryRelationship:signature.nullFlavor | required | NullFlavor |
| SubstanceAdministration.entryRelationship:signature.typeCode | required | Fixed Value: COMP |
| SubstanceAdministration.precondition.nullFlavor | required | NullFlavor |
| SubstanceAdministration.precondition.typeCode | required | Fixed Value: PRCN |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-7513 | error | SubstanceAdministration.effectiveTime | SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499). : | |
| 1098-16878 | warning | SubstanceAdministration.doseQuantity | 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). : | |
| 1098-16879 | warning | SubstanceAdministration.doseQuantity | Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is "simply metoprolol Oral Product" (RxCUI 1163523), then doseQuantity must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration (CONF:1098-16879). : | |
| 1098-30800 | warning | SubstanceAdministration | Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800). : | |
| 1098-32890 | error | SubstanceAdministration.effectiveTime:duration | This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890). : | |
| 4537-9333 | error | SubstanceAdministration.entryRelationship:medicationDispense.supply | A supply act **SHALL** contain one product/Medication Information *OR* one product/Immunization Medication Information template (CONF:4537-9333). : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
This structure is derived from CDAR2.SubstanceAdministration
Summary
Mandatory: 10 elements (16 nested mandatory elements)
Fixed Value: 13 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#2.1 based on FHIR 5.0.0. Generated 2023-09-29
Links: Table of Contents |
QA Report
| Version History 
|
|
Propose a change