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

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

Resource Profile: Instruction

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.20 Version: 2.2
Active as of 2022-05-13 Computable Name: Instruction
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.4.20:2014-06-09

The Instruction template can be used in several ways, such as to record patient instructions within a Medication Activity or to record fill instructions within a supply order. The template’s moodCode can only be INT. If an instruction was already given, the Procedure Activity Act template (instead of this template) should be used to represent the already occurred instruction. The act/code defines the type of instruction. Though not defined in this template, a Vaccine Information Statement (VIS) document could be referenced through act/reference/externalDocument, and patient awareness of the instructions can be represented with the generic participant and the participant/awarenessCode.

Usage:

Formal Views of Profile Content

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

This structure is derived from CDAR2.Act

Summary

Mandatory: 8 elements

Slices

This structure defines the following Slices:

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

This structure is derived from CDAR2.Act

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act 1..1CDAR2.Act
... classCode 1..1codeRequired Pattern: ACT
... moodCode 1..1codeRequired Pattern: INT
... Slices for templateId 0..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.20
..... extension 1..1stringRequired Pattern: 2014-06-09
... statusCode 1..1CS
.... code 1..1stringRequired Pattern: completed

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Act 1..1CDAR2.Act
... classCode 1..1codeRequired Pattern: ACT
... moodCode 1..1codeRequired Pattern: INT
... realmCode 0..*CS
... Slices for templateId 0..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.20
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 0..*II
... code 1..1CDBinding: Patient Education (preferred)
... negationInd 0..1boolean
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: completed
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Participant2
... entryRelationship I0..*Element
.... typeCode 1..1code
.... inversionInd 0..1boolean
.... contextConductionInd 1..1boolean
.... sequenceNumber 0..1INT
.... negationInd 0..1boolean
.... seperatableInd 0..1BL
.... (Choice of one) 1..1
..... observation 0..1Observation
..... regionOfInterest 0..1RegionOfInterest
..... observationMedia 0..1ObservationMedia
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
..... procedure 0..1Procedure
..... encounter 0..1Encounter
..... organizer 0..1Organizer
..... act 0..1Act
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition

doco Documentation for this format

This structure is derived from CDAR2.Act

Summary

Mandatory: 8 elements

Slices

This structure defines the following Slices:

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

Differential View

This structure is derived from CDAR2.Act

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act 1..1CDAR2.Act
... classCode 1..1codeRequired Pattern: ACT
... moodCode 1..1codeRequired Pattern: INT
... Slices for templateId 0..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.20
..... extension 1..1stringRequired Pattern: 2014-06-09
... statusCode 1..1CS
.... code 1..1stringRequired Pattern: completed

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act 1..1CDAR2.Act
... classCode 1..1codeRequired Pattern: ACT
... moodCode 1..1codeRequired Pattern: INT
... realmCode 0..*CS
... Slices for templateId 0..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.20
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 0..*II
... code 1..1CDBinding: Patient Education (preferred)
... negationInd 0..1boolean
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: completed
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Participant2
... entryRelationship I0..*Element
.... typeCode 1..1code
.... inversionInd 0..1boolean
.... contextConductionInd 1..1boolean
.... sequenceNumber 0..1INT
.... negationInd 0..1boolean
.... seperatableInd 0..1BL
.... (Choice of one) 1..1
..... observation 0..1Observation
..... regionOfInterest 0..1RegionOfInterest
..... observationMedia 0..1ObservationMedia
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
..... procedure 0..1Procedure
..... encounter 0..1Encounter
..... organizer 0..1Organizer
..... act 0..1Act
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / Code
Act.templateId:primary.nullFlavorrequiredNullFlavor
Act.codepreferredPatientEducation
Act.statusCoderequiredActStatus
Act.statusCode.nullFlavorrequiredNullFlavor
Act.priorityCodeextensibleActPriority
Act.languageCoderequiredHumanLanguage
Act.subject.typeCoderequiredFixed Value: SBJ
Act.subject.contextControlCoderequiredFixed Value: OP
Act.subject.awarenessCodeextensibleTargetAwareness
Act.informant.typeCoderequiredFixed Value: INF
Act.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePathDetailsRequirements
act-er-1errorAct.entryRelationshipOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1