Consolidated CDA (C-CDA)
4.0.0-ballot - STU4
Consolidated CDA (C-CDA)
4.0.0-ballot - STU4
Consolidated CDA (C-CDA), published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 4.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-ccda/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/DischargeMedication | Version: 4.0.0-ballot | |||
| Draft as of 2024-11-21 | Computable Name: DischargeMedication | |||
| Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.4.35:2016-03-01 | ||||
This template represents medications that the patient is intended to take (or stop) after discharge.
Usage:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Act
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Act |
C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value |
  Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:discharge-med |
1..1 | II | ||
  @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.35 | |
  @extension |
1..1 | st | Required Pattern: 2016-03-01 | |
 @classCode |
1..1 | cs | Fixed Value: ACT | |
| @moodCode |
1..1 | cs | Fixed Value: EVN | |
| code |
1..1 | CD | Hospital discharge medication | |
| @code |
1..1 | cs | Required Pattern: 10183-2 | |
| @codeSystem |
1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
 translation |
1..1 | CD | Discharge Medication | |
| @code |
1..1 | cs | Required Pattern: 75311-1 | |
 @codeSystem |
1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| statusCode |
1..1 | CS | ||
| @code |
1..1 | cs | Fixed Value: completed | |
| Slices for entryRelationship |
1..* | EntryRelationship | Slice: Unordered, Open by profile:substanceAdministration, value:typeCode | |
| entryRelationship:medicationActivity |
1..* | EntryRelationship | ||
| @typeCode |
1..1 | cs | Fixed Value: SUBJ | |
 substanceAdministration |
1..1 | MedicationActivity | Base for all types and resources | |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Details | Requirements |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Act |
C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:discharge-med |
1..1 | II | ||
 @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.35 | |
| @extension |
1..1 | st | Required Pattern: 2016-03-01 | |
| @classCode |
1..1 | cs | Binding: XActClassDocumentEntryAct (2.0.0) (required) Fixed Value: ACT | |
| @moodCode |
1..1 | cs | Binding: XDocumentActMood (2.0.0) (required) Fixed Value: EVN | |
| code |
1..1 | CD | Hospital discharge medication Binding: v3 Code System ActCode (example) | |
| @code |
1..1 | cs | Required Pattern: 10183-2 | |
| @codeSystem |
1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| translation |
1..1 | CD | Discharge Medication | |
| @code |
1..1 | cs | Required Pattern: 75311-1 | |
| @codeSystem |
1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |
| @code |
1..1 | cs | Fixed Value: completed | |
| Slices for entryRelationship |
1..* | EntryRelationship | Slice: Unordered, Open by profile:substanceAdministration, value:typeCode | |
| entryRelationship:medicationActivity |
1..* | EntryRelationship | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| substanceAdministration |
C | 1..1 | MedicationActivity | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value 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). should-routeCode: SHOULD contain routeCode dose-unit-or-admin-unit: If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. should-author: SHOULD contain author |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Act.classCode | required | Fixed Value: ACThttp://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0 | |
| Act.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0 | |
| Act.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| Act.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Act.entryRelationship:medicationActivity.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-7513 | warning | Act.entryRelationship:medicationActivity.substanceAdministration | 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.ofType(CDA.PIVL_TS).exists() or effectiveTime.ofType(CDA.EIVL_TS).exists() | |
| dose-unit-or-admin-unit | error | Act.entryRelationship:medicationActivity.substanceAdministration | If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. : doseQuantity.unit.exists() implies administrationUnitCode.empty() | |
| should-author | warning | Act.entryRelationship:medicationActivity.substanceAdministration | SHOULD contain author : author.exists() | |
| should-routeCode | warning | Act.entryRelationship:medicationActivity.substanceAdministration | SHOULD contain routeCode : routeCode.exists() | |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Act.entryRelationship:medicationActivity.substanceAdministration | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Act |
C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:discharge-med |
1..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.35 | |
| @extension |
1..1 | st | Required Pattern: 2016-03-01 | |
| @classCode |
1..1 | cs | Binding: XActClassDocumentEntryAct (2.0.0) (required) Fixed Value: ACT | |
| @moodCode |
1..1 | cs | Binding: XDocumentActMood (2.0.0) (required) Fixed Value: EVN | |
| @negationInd |
0..1 | bl | ||
| id |
0..* | II | ||
| code |
1..1 | CD | Hospital discharge medication Binding: v3 Code System ActCode (example) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 10183-2 | |
| @codeSystem |
1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| @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 | ||
| qualifier |
0..* | CR | ||
| translation |
1..1 | CD | Discharge Medication | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 75311-1 | |
| @codeSystem |
1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| @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 | ||
| qualifier |
0..* | CR | ||
| translation |
0..* | CD | ||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @compression |
0..1 | cs | Binding: CDACompressionAlgorithm (required) | |
| @integrityCheck |
0..1 | bin | ||
| @integrityCheckAlgorithm |
0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |
| @language |
0..1 | cs | ||
| @mediaType |
0..1 | cs | Binding: MediaType (example) | |
| @representation |
0..1 | cs | Binding: CDABinaryDataEncoding (required) | |
| xmlText |
0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| thumbnail |
0..1 | ED | ||
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Fixed Value: completed | |
| @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) | |
| effectiveTime |
0..1 | IVL_TS | ||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | Author | ||
| informant |
0..* | Informant | ||
| participant |
0..* | Participant2 | ||
| Slices for entryRelationship |
1..* | EntryRelationship | Slice: Unordered, Open by profile:substanceAdministration, value:typeCode | |
| entryRelationship:medicationActivity |
1..* | EntryRelationship | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
 typeId |
0..1 | II | ||
 @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| @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 |
C | 1..1 | MedicationActivity | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value 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). should-routeCode: SHOULD contain routeCode dose-unit-or-admin-unit: If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. should-author: SHOULD contain author |
| supply |
0..1 | Supply | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Act.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.templateId:discharge-med.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.classCode | required | Fixed Value: ACThttp://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0 | |
| Act.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0 | |
| Act.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| Act.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.code.translation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Act.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Act.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| Act.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Act.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Act.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Act.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Act.entryRelationship:medicationActivity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:medicationActivity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:medicationActivity.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-7513 | warning | Act.entryRelationship:medicationActivity.substanceAdministration | 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.ofType(CDA.PIVL_TS).exists() or effectiveTime.ofType(CDA.EIVL_TS).exists() | |
| dose-unit-or-admin-unit | error | Act.entryRelationship:medicationActivity.substanceAdministration | If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. : doseQuantity.unit.exists() implies administrationUnitCode.empty() | |
| should-author | warning | Act.entryRelationship:medicationActivity.substanceAdministration | SHOULD contain author : author.exists() | |
| should-routeCode | warning | Act.entryRelationship:medicationActivity.substanceAdministration | SHOULD contain routeCode : routeCode.exists() | |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Act.entryRelationship:medicationActivity.substanceAdministration | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
This structure is derived from Act
Summary
Mandatory: 14 elements
Fixed: 4 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Act
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Act |
C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:discharge-med |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.35 | |
| @extension |
1..1 | st | Required Pattern: 2016-03-01 | |
| @classCode |
1..1 | cs | Fixed Value: ACT | |
| @moodCode |
1..1 | cs | Fixed Value: EVN | |
| code |
1..1 | CD | Hospital discharge medication | |
| @code |
1..1 | cs | Required Pattern: 10183-2 | |
| @codeSystem |
1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| translation |
1..1 | CD | Discharge Medication | |
| @code |
1..1 | cs | Required Pattern: 75311-1 | |
| @codeSystem |
1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| statusCode |
1..1 | CS | ||
| @code |
1..1 | cs | Fixed Value: completed | |
| Slices for entryRelationship |
1..* | EntryRelationship | Slice: Unordered, Open by profile:substanceAdministration, value:typeCode | |
| entryRelationship:medicationActivity |
1..* | EntryRelationship | ||
| @typeCode |
1..1 | cs | Fixed Value: SUBJ | |
| substanceAdministration |
1..1 | MedicationActivity | Base for all types and resources | |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Details | Requirements |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Act |
C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:discharge-med |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.35 | |
| @extension |
1..1 | st | Required Pattern: 2016-03-01 | |
| @classCode |
1..1 | cs | Binding: XActClassDocumentEntryAct (2.0.0) (required) Fixed Value: ACT | |
| @moodCode |
1..1 | cs | Binding: XDocumentActMood (2.0.0) (required) Fixed Value: EVN | |
| code |
1..1 | CD | Hospital discharge medication Binding: v3 Code System ActCode (example) | |
| @code |
1..1 | cs | Required Pattern: 10183-2 | |
| @codeSystem |
1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| translation |
1..1 | CD | Discharge Medication | |
| @code |
1..1 | cs | Required Pattern: 75311-1 | |
| @codeSystem |
1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |
| @code |
1..1 | cs | Fixed Value: completed | |
| Slices for entryRelationship |
1..* | EntryRelationship | Slice: Unordered, Open by profile:substanceAdministration, value:typeCode | |
| entryRelationship:medicationActivity |
1..* | EntryRelationship | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| substanceAdministration |
C | 1..1 | MedicationActivity | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value 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). should-routeCode: SHOULD contain routeCode dose-unit-or-admin-unit: If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. should-author: SHOULD contain author |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Act.classCode | required | Fixed Value: ACThttp://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0 | |
| Act.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0 | |
| Act.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| Act.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Act.entryRelationship:medicationActivity.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-7513 | warning | Act.entryRelationship:medicationActivity.substanceAdministration | 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.ofType(CDA.PIVL_TS).exists() or effectiveTime.ofType(CDA.EIVL_TS).exists() | |
| dose-unit-or-admin-unit | error | Act.entryRelationship:medicationActivity.substanceAdministration | If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. : doseQuantity.unit.exists() implies administrationUnitCode.empty() | |
| should-author | warning | Act.entryRelationship:medicationActivity.substanceAdministration | SHOULD contain author : author.exists() | |
| should-routeCode | warning | Act.entryRelationship:medicationActivity.substanceAdministration | SHOULD contain routeCode : routeCode.exists() | |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Act.entryRelationship:medicationActivity.substanceAdministration | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Act |
C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:discharge-med |
1..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.35 | |
| @extension |
1..1 | st | Required Pattern: 2016-03-01 | |
| @classCode |
1..1 | cs | Binding: XActClassDocumentEntryAct (2.0.0) (required) Fixed Value: ACT | |
| @moodCode |
1..1 | cs | Binding: XDocumentActMood (2.0.0) (required) Fixed Value: EVN | |
| @negationInd |
0..1 | bl | ||
| id |
0..* | II | ||
| code |
1..1 | CD | Hospital discharge medication Binding: v3 Code System ActCode (example) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 10183-2 | |
| @codeSystem |
1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| @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 | ||
| qualifier |
0..* | CR | ||
| translation |
1..1 | CD | Discharge Medication | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Required Pattern: 75311-1 | |
| @codeSystem |
1..1 | oid, uuid, ruid | LOINC Required Pattern: 2.16.840.1.113883.6.1 | |
| @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 | ||
| qualifier |
0..* | CR | ||
| translation |
0..* | CD | ||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @compression |
0..1 | cs | Binding: CDACompressionAlgorithm (required) | |
| @integrityCheck |
0..1 | bin | ||
| @integrityCheckAlgorithm |
0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |
| @language |
0..1 | cs | ||
| @mediaType |
0..1 | cs | Binding: MediaType (example) | |
| @representation |
0..1 | cs | Binding: CDABinaryDataEncoding (required) | |
| xmlText |
0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| thumbnail |
0..1 | ED | ||
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Fixed Value: completed | |
| @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) | |
| effectiveTime |
0..1 | IVL_TS | ||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | ||
| author |
0..* | Author | ||
| informant |
0..* | Informant | ||
| participant |
0..* | Participant2 | ||
| Slices for entryRelationship |
1..* | EntryRelationship | Slice: Unordered, Open by profile:substanceAdministration, value:typeCode | |
| entryRelationship:medicationActivity |
1..* | EntryRelationship | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @assigningAuthorityName |
0..1 | st | ||
| @displayable |
0..1 | bl | ||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
| @extension |
1..1 | st | ||
| templateId |
0..* | II | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| @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 |
C | 1..1 | MedicationActivity | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value 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). should-routeCode: SHOULD contain routeCode dose-unit-or-admin-unit: If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. should-author: SHOULD contain author |
| supply |
0..1 | Supply | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Act.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.templateId:discharge-med.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.classCode | required | Fixed Value: ACThttp://terminology.hl7.org/ValueSet/v3-xActClassDocumentEntryAct|2.0.0 | |
| Act.moodCode | required | Fixed Value: EVNhttp://terminology.hl7.org/ValueSet/v3-xDocumentActMood|2.0.0 | |
| Act.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | |
| Act.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.code.translation.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Act.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Act.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| Act.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Act.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Act.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Act.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Act.entryRelationship:medicationActivity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:medicationActivity.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Act.entryRelationship:medicationActivity.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-7513 | warning | Act.entryRelationship:medicationActivity.substanceAdministration | 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.ofType(CDA.PIVL_TS).exists() or effectiveTime.ofType(CDA.EIVL_TS).exists() | |
| dose-unit-or-admin-unit | error | Act.entryRelationship:medicationActivity.substanceAdministration | If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. : doseQuantity.unit.exists() implies administrationUnitCode.empty() | |
| should-author | warning | Act.entryRelationship:medicationActivity.substanceAdministration | SHOULD contain author : author.exists() | |
| should-routeCode | warning | Act.entryRelationship:medicationActivity.substanceAdministration | SHOULD contain routeCode : routeCode.exists() | |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Act.entryRelationship:medicationActivity.substanceAdministration | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
This structure is derived from Act
Summary
Mandatory: 14 elements
Fixed: 4 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#4.0.0-ballot based on FHIR 5.0.0. Generated 2024-11-21
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