Consolidated CDA (C-CDA)
4.0.0-ballot - STU4 Ballot
Consolidated CDA (C-CDA)
4.0.0-ballot - STU4 Ballot
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/MedicationActivity | Version: 4.0.0-ballot | |||
| Draft as of 2024-12-19 | Computable Name: MedicationActivity | |||
| Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#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 Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from SubstanceAdministration
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  SubstanceAdministration |
C | 1..1 | SubstanceAdministration | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, repeatNumber, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode, consumable, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, 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 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 |
  Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:medication-activity |
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 | |
 @classCode |
1..1 | cs | ||
| @moodCode |
1..1 | cs | Binding: MoodCodeEvnInt  (required) | |
| 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. | |
| 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 | 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 |
1..* | SXCM_TS, IVL_TS, EIVL_TS, PIVL_TS, SXPR_TS | Slice: Unordered, Open by type:$this | |
 effectiveTime:duration |
C | 1..1 | IVL_TS | 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. Note: This effectiveTime represents either 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). should-value-att: SHOULD contain @value should-low: SHOULD contain low |
 @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 |
C | 0..1 | CE | 𝗨𝗦𝗖𝗗𝗜: Route Code - SPL Binding: SPL Drug Route of Administration Terminology (required)should-translation: SHOULD contain translation |
| translation |
0..* | CD | 𝗨𝗦𝗖𝗗𝗜: Route Code - SNOMED Binding: Medication Route (required) | |
| approachSiteCode |
0..1 | CD | Binding: Body Site Value Set (required) | |
| doseQuantity |
C | 1..1 | IVL_PQ | 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). 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). should-unit: SHOULD contain @unit |
| @unit |
0..1 | cs | 𝗨𝗦𝗖𝗗𝗜: Dose Unit of Measure. NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: UnitsOfMeasureCaseSensitive (preferred) | |
| rateQuantity |
0..1 | IVL_PQ | ||
| @unit |
1..1 | cs | NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units 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 | 𝗨𝗦𝗖𝗗𝗜: Medications | |
 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: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 | 𝗨𝗦𝗖𝗗𝗜: Indication | |
| @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 | |
| observation |
1..1 | InstructionObservation | 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 | 𝗨𝗦𝗖𝗗𝗜: Medication Adherence | |
| @typeCode |
1..1 | cs | Fixed Value: COMP | |
| observation |
1..1 | MedicationAdherence | Base for all types and resources | |
| entryRelationship:signature |
0..* | EntryRelationship | 𝗨𝗦𝗖𝗗𝗜: Medication Instructions | |
| @typeCode |
1..1 | cs | Fixed Value: COMP | |
| substanceAdministration |
1..1 | MedicationFreeTextSig | Base for all types and resources | |
 precondition |
0..* | Precondition | ||
| @typeCode |
1..1 | cs | ||
| criterion |
1..1 | PreconditionforSubstanceAdministration | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| SubstanceAdministration.moodCode | required | MoodCodeEvnInt http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.18 | |
| SubstanceAdministration.statusCode.code | required | MedicationStatus http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.11 | |
| SubstanceAdministration.routeCode | required | SPLDrugRouteOfAdministrationTerminology http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.7 | |
| SubstanceAdministration.routeCode.translation | required | MedicationRoute http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.12 | |
| SubstanceAdministration.approachSiteCode | required | BodySiteValueSet http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9 | |
| SubstanceAdministration.doseQuantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| SubstanceAdministration.rateQuantity.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| SubstanceAdministration.administrationUnitCode | required | AdministrationUnitDoseForm http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.30 |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-7513 | warning | 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() | |
| 1098-32890 | error | SubstanceAdministration.effectiveTime:duration | This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890). : (value.exists() or low.exists()) and ((value.exists() and low.exists()).not()) | |
| dose-unit-or-admin-unit | error | SubstanceAdministration | If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. : doseQuantity.unit.exists() implies administrationUnitCode.empty() | |
| should-author | warning | SubstanceAdministration | SHOULD contain author : author.exists() | |
| should-low | warning | SubstanceAdministration.effectiveTime:duration | SHOULD contain low : low.exists() | |
| should-routeCode | warning | SubstanceAdministration | SHOULD contain routeCode : routeCode.exists() | |
| should-text-ref-value | warning | SubstanceAdministration | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-translation | warning | SubstanceAdministration.routeCode | SHOULD contain translation : translation.exists() | |
| should-unit | warning | SubstanceAdministration.doseQuantity | SHOULD contain @unit : nullFlavor.exists() or unit.exists() | |
| should-value-att | warning | SubstanceAdministration.effectiveTime:duration | SHOULD contain @value : value.exists() | |
| value-starts-octothorpe | error | SubstanceAdministration.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 |
|---|---|---|---|---|
| SubstanceAdministration |
C | 1..1 | SubstanceAdministration | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, repeatNumber, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode, consumable, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, 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 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 |
 @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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:medication-activity |
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: 2.16.840.1.113883.10.20.22.4.16 | |
| @extension |
1..1 | st | Required Pattern: 2014-06-09 | |
| @classCode |
1..1 | cs | Binding: CDAActClass (required) Fixed Value: SBADM | |
| @moodCode |
1..1 | cs | Binding: MoodCodeEvnInt (required) | |
| 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: CDAActSubstanceAdministrationCode (example) | |
| @negationInd |
0..1 | bl | ||
| 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 | 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 |
1..* | Slice: Unordered, Open by type:$this | ||
  effectiveTime |
SXCM_TS | |||
| effectiveTime |
IVL_TS | |||
| effectiveTime |
EIVL_TS | |||
| effectiveTime |
PIVL_TS | |||
| effectiveTime |
SXPR_TS | |||
| effectiveTime:duration |
C | 1..1 | IVL_TS | 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. Note: This effectiveTime represents either 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). should-value-att: SHOULD contain @value should-low: SHOULD contain low |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | ts | indicates a single-administration timestamp Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator |
0..1 | cs | Binding: CDASetOperator (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: CDANullFlavor (required) | |
| @operator |
1..1 | cs | Binding: CDASetOperator (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: CDANullFlavor (required) | |
| @operator |
1..1 | cs | Binding: CDASetOperator (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 (example) | |
| 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 |
C | 0..1 | CE | 𝗨𝗦𝗖𝗗𝗜: Route Code - SPL Binding: SPL Drug Route of Administration Terminology (required)should-translation: SHOULD contain translation |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (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 | 𝗨𝗦𝗖𝗗𝗜: Route Code - SNOMED Binding: Medication Route (required) | |
| approachSiteCode |
0..1 | CD | Binding: Body Site Value Set (required) | |
| doseQuantity |
C | 1..1 | IVL_PQ | 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). 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). should-unit: SHOULD contain @unit |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @unit |
0..1 | cs | 𝗨𝗦𝗖𝗗𝗜: Dose Unit of Measure. NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: UnitsOfMeasureCaseSensitive (preferred) | |
| @value |
0..1 | real | ||
| translation |
0..* | PQR | ||
| @operator |
0..1 | cs | Binding: CDASetOperator (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: CDANullFlavor (required) | |
| @unit |
1..1 | cs | NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: UnitsOfMeasureCaseSensitive (required) | |
| @value |
0..1 | real | ||
| translation |
0..* | PQR | ||
| @operator |
0..1 | cs | Binding: CDASetOperator (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 | 𝗨𝗦𝗖𝗗𝗜: Medications | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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 |
0..1 | cs | Binding: CDAParticipationType (required) Fixed Value: CSM | |
| manufacturedProduct |
C | 1..1 | MedicationInformation | Base for all types and resources product-choice: manufacturedLabeledDrug and manufacturedMaterial are mutually exclusive (one must be present) |
| 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:typeCode | |
| participant:drugVehicle |
0..* | Participant2 | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
 typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
 @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: CDAParticipationType (required) Fixed Value: CSM | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| 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 |
C | 1..1 | DrugVehicle | Base for all types and resources role-choice: playingDevice and playingEntity are mutually exclusive |
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:substanceAdministration, profile:observation, profile:act, profile:supply | |
| entryRelationship:indication |
0..* | EntryRelationship | 𝗨𝗦𝗖𝗗𝗜: Indication | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 |
C | 1..1 | Indication | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime indication-value: If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry. |
| 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: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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 |
1..1 | bl | Fixed Value: true | |
| @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 |
C | 1..1 | InstructionObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| 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: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 | MedicationSupplyOrder | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-repeatNumber: SHOULD contain repeatNumber should-quantity: SHOULD contain quantity |
| entryRelationship:medicationDispense |
0..* | EntryRelationship | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-repeatNumber: SHOULD contain repeatNumber should-quantity: SHOULD contain quantity |
| entryRelationship:reaction |
0..* | EntryRelationship | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 |
C | 1..1 | ReactionObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime |
| 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: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: COMP | |
| @inversionInd |
0..1 | bl | ||
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
C | 1..1 | DrugMonitoringAct | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| 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: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 |
C | 1..1 | SubstanceAdministeredAct | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| 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 | 𝗨𝗦𝗖𝗗𝗜: Medication Adherence | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 |
C | 1..1 | MedicationAdherence | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-informant: SHOULD contain informant |
| 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 | 𝗨𝗦𝗖𝗗𝗜: Medication Instructions | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 |
C | 1..1 | MedicationFreeTextSig | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| supply |
0..1 | Supply | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: CDAActRelationshipType (required) Fixed Value: PRCN | |
| criterion |
1..1 | PreconditionforSubstanceAdministration | Base for all types and resources | |
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| SubstanceAdministration.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.templateId:medication-activity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.classCode | required | Fixed Value: SBADMhttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
| SubstanceAdministration.moodCode | required | MoodCodeEvnInt http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.18 | |
| SubstanceAdministration.code | example | CDAActSubstanceAdministrationCodehttp://hl7.org/cda/stds/core/ValueSet/CDAActSubstanceAdministrationCode | |
| SubstanceAdministration.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| SubstanceAdministration.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| SubstanceAdministration.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| SubstanceAdministration.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| SubstanceAdministration.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| SubstanceAdministration.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.statusCode.code | required | MedicationStatus http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.11 | |
| SubstanceAdministration.effectiveTime:duration.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.effectiveTime:duration.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.effectiveTime:periodicFrequency.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.effectiveTime:periodicFrequency.operator | required | Pattern: Ahttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.effectiveTime:eventFrequency.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.effectiveTime:eventFrequency.operator | required | Pattern: Ahttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| SubstanceAdministration.routeCode | required | SPLDrugRouteOfAdministrationTerminology http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.7 | |
| SubstanceAdministration.routeCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.routeCode.translation | required | MedicationRoute http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.12 | |
| SubstanceAdministration.approachSiteCode | required | BodySiteValueSet http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9 | |
| SubstanceAdministration.doseQuantity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.doseQuantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| SubstanceAdministration.doseQuantity.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.rateQuantity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.rateQuantity.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| SubstanceAdministration.rateQuantity.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.administrationUnitCode | required | AdministrationUnitDoseForm http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.30 | |
| SubstanceAdministration.consumable.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.consumable.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.consumable.typeCode | required | Fixed Value: CSMhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| SubstanceAdministration.participant:drugVehicle.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.participant:drugVehicle.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.participant:drugVehicle.typeCode | required | Fixed Value: CSMhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| SubstanceAdministration.participant:drugVehicle.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
| SubstanceAdministration.entryRelationship:indication.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:indication.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:indication.typeCode | required | Fixed Value: RSONhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:instruction.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:instruction.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:instruction.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:supplyOrder.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:supplyOrder.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:supplyOrder.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:medicationDispense.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:medicationDispense.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:medicationDispense.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:reaction.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:reaction.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:reaction.typeCode | required | Fixed Value: CAUShttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:drugMonitoring.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:drugMonitoring.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:drugMonitoring.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:substanceAdministered.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:substanceAdministered.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:substanceAdministered.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:adherence.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:adherence.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:adherence.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:signature.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:signature.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:signature.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.precondition.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.precondition.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.precondition.typeCode | required | Fixed Value: PRCNhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-7513 | warning | 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() | |
| 1098-32890 | error | SubstanceAdministration.effectiveTime:duration | This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890). : (value.exists() or low.exists()) and ((value.exists() and low.exists()).not()) | |
| II-1 | error | SubstanceAdministration.typeId, SubstanceAdministration.consumable.typeId, SubstanceAdministration.participant:drugVehicle.typeId, SubstanceAdministration.entryRelationship:indication.typeId, SubstanceAdministration.entryRelationship:instruction.typeId, SubstanceAdministration.entryRelationship:supplyOrder.typeId, SubstanceAdministration.entryRelationship:medicationDispense.typeId, SubstanceAdministration.entryRelationship:reaction.typeId, SubstanceAdministration.entryRelationship:drugMonitoring.typeId, SubstanceAdministration.entryRelationship:substanceAdministered.typeId, SubstanceAdministration.entryRelationship:adherence.typeId, SubstanceAdministration.entryRelationship:signature.typeId, SubstanceAdministration.precondition.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
| dose-unit-or-admin-unit | error | SubstanceAdministration | If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. : doseQuantity.unit.exists() implies administrationUnitCode.empty() | |
| indication-value | error | SubstanceAdministration.entryRelationship:indication.observation | If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry. : value.exists() or (%resource.descendants().ofType(CDA.Observation).where(id.exists($this.root = %context.id.first().root and $this.extension ~ %context.id.first().extension) and value.exists())) | |
| product-choice | error | SubstanceAdministration.consumable.manufacturedProduct | manufacturedLabeledDrug and manufacturedMaterial are mutually exclusive (one must be present) : (manufacturedLabeledDrug | manufacturedMaterial).count() = 1 | |
| role-choice | error | SubstanceAdministration.participant:drugVehicle.participantRole | playingDevice and playingEntity are mutually exclusive : (playingDevice | playingEntity).count() <= 1 | |
| should-author | warning | SubstanceAdministration | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | SubstanceAdministration.entryRelationship:indication.observation, SubstanceAdministration.entryRelationship:medicationDispense.supply, SubstanceAdministration.entryRelationship:reaction.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-informant | warning | SubstanceAdministration.entryRelationship:adherence.observation | SHOULD contain informant : informant.exists() | |
| should-low | warning | SubstanceAdministration.effectiveTime:duration | SHOULD contain low : low.exists() | |
| should-quantity | warning | SubstanceAdministration.entryRelationship:supplyOrder.supply, SubstanceAdministration.entryRelationship:medicationDispense.supply | SHOULD contain quantity : quantity.exists() | |
| should-repeatNumber | warning | SubstanceAdministration.entryRelationship:supplyOrder.supply, SubstanceAdministration.entryRelationship:medicationDispense.supply | SHOULD contain repeatNumber : repeatNumber.exists() | |
| should-routeCode | warning | SubstanceAdministration | SHOULD contain routeCode : routeCode.exists() | |
| should-text-ref-value | warning | SubstanceAdministration | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | SubstanceAdministration.entryRelationship:indication.observation, SubstanceAdministration.entryRelationship:instruction.observation, SubstanceAdministration.entryRelationship:supplyOrder.supply, SubstanceAdministration.entryRelationship:medicationDispense.supply, SubstanceAdministration.entryRelationship:reaction.observation, SubstanceAdministration.entryRelationship:drugMonitoring.act, SubstanceAdministration.entryRelationship:substanceAdministered.act, SubstanceAdministration.entryRelationship:adherence.observation, SubstanceAdministration.entryRelationship:signature.substanceAdministration | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-translation | warning | SubstanceAdministration.routeCode | SHOULD contain translation : translation.exists() | |
| should-unit | warning | SubstanceAdministration.doseQuantity | SHOULD contain @unit : nullFlavor.exists() or unit.exists() | |
| should-value-att | warning | SubstanceAdministration.effectiveTime:duration | SHOULD contain @value : value.exists() | |
| value-starts-octothorpe | error | SubstanceAdministration.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 |
|---|---|---|---|---|
| SubstanceAdministration |
C | 1..1 | SubstanceAdministration | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, repeatNumber, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode, consumable, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, 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 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 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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:medication-activity |
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: 2.16.840.1.113883.10.20.22.4.16 | |
| @extension |
1..1 | st | Required Pattern: 2014-06-09 | |
| @classCode |
1..1 | cs | Binding: CDAActClass (required) Fixed Value: SBADM | |
| @moodCode |
1..1 | cs | Binding: MoodCodeEvnInt (required) | |
| 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: CDAActSubstanceAdministrationCode (example) | |
| @negationInd |
0..1 | bl | ||
| 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 | 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 |
1..* | Slice: Unordered, Open by type:$this | ||
| effectiveTime |
SXCM_TS | |||
| effectiveTime |
IVL_TS | |||
| effectiveTime |
EIVL_TS | |||
| effectiveTime |
PIVL_TS | |||
| effectiveTime |
SXPR_TS | |||
| effectiveTime:duration |
C | 1..1 | IVL_TS | 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. Note: This effectiveTime represents either 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). should-value-att: SHOULD contain @value should-low: SHOULD contain low |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | ts | indicates a single-administration timestamp Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator |
0..1 | cs | Binding: CDASetOperator (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: CDANullFlavor (required) | |
| @operator |
1..1 | cs | Binding: CDASetOperator (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: CDANullFlavor (required) | |
| @operator |
1..1 | cs | Binding: CDASetOperator (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 (example) | |
| 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 |
C | 0..1 | CE | 𝗨𝗦𝗖𝗗𝗜: Route Code - SPL Binding: SPL Drug Route of Administration Terminology (required)should-translation: SHOULD contain translation |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (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 | 𝗨𝗦𝗖𝗗𝗜: Route Code - SNOMED Binding: Medication Route (required) | |
| approachSiteCode |
0..1 | CD | Binding: Body Site Value Set (required) | |
| doseQuantity |
C | 1..1 | IVL_PQ | 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). 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). should-unit: SHOULD contain @unit |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @unit |
0..1 | cs | 𝗨𝗦𝗖𝗗𝗜: Dose Unit of Measure. NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: UnitsOfMeasureCaseSensitive (preferred) | |
| @value |
0..1 | real | ||
| translation |
0..* | PQR | ||
| @operator |
0..1 | cs | Binding: CDASetOperator (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: CDANullFlavor (required) | |
| @unit |
1..1 | cs | NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: UnitsOfMeasureCaseSensitive (required) | |
| @value |
0..1 | real | ||
| translation |
0..* | PQR | ||
| @operator |
0..1 | cs | Binding: CDASetOperator (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 | 𝗨𝗦𝗖𝗗𝗜: Medications | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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 |
0..1 | cs | Binding: CDAParticipationType (required) Fixed Value: CSM | |
| manufacturedProduct |
C | 1..1 | MedicationInformation | Base for all types and resources product-choice: manufacturedLabeledDrug and manufacturedMaterial are mutually exclusive (one must be present) |
| 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:typeCode | |
| participant:drugVehicle |
0..* | Participant2 | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: CDAParticipationType (required) Fixed Value: CSM | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| 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 |
C | 1..1 | DrugVehicle | Base for all types and resources role-choice: playingDevice and playingEntity are mutually exclusive |
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:substanceAdministration, profile:observation, profile:act, profile:supply | |
| entryRelationship:indication |
0..* | EntryRelationship | 𝗨𝗦𝗖𝗗𝗜: Indication | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 |
C | 1..1 | Indication | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime indication-value: If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry. |
| 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: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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 |
1..1 | bl | Fixed Value: true | |
| @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 |
C | 1..1 | InstructionObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| 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: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 | MedicationSupplyOrder | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-repeatNumber: SHOULD contain repeatNumber should-quantity: SHOULD contain quantity |
| entryRelationship:medicationDispense |
0..* | EntryRelationship | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-repeatNumber: SHOULD contain repeatNumber should-quantity: SHOULD contain quantity |
| entryRelationship:reaction |
0..* | EntryRelationship | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 |
C | 1..1 | ReactionObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime |
| 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: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: COMP | |
| @inversionInd |
0..1 | bl | ||
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
C | 1..1 | DrugMonitoringAct | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| 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: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 |
C | 1..1 | SubstanceAdministeredAct | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| 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 | 𝗨𝗦𝗖𝗗𝗜: Medication Adherence | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 |
C | 1..1 | MedicationAdherence | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-informant: SHOULD contain informant |
| 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 | 𝗨𝗦𝗖𝗗𝗜: Medication Instructions | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 |
C | 1..1 | MedicationFreeTextSig | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| supply |
0..1 | Supply | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: CDAActRelationshipType (required) Fixed Value: PRCN | |
| criterion |
1..1 | PreconditionforSubstanceAdministration | Base for all types and resources | |
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| SubstanceAdministration.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.templateId:medication-activity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.classCode | required | Fixed Value: SBADMhttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
| SubstanceAdministration.moodCode | required | MoodCodeEvnInt http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.18 | |
| SubstanceAdministration.code | example | CDAActSubstanceAdministrationCodehttp://hl7.org/cda/stds/core/ValueSet/CDAActSubstanceAdministrationCode | |
| SubstanceAdministration.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| SubstanceAdministration.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| SubstanceAdministration.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| SubstanceAdministration.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| SubstanceAdministration.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| SubstanceAdministration.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.statusCode.code | required | MedicationStatus http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.11 | |
| SubstanceAdministration.effectiveTime:duration.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.effectiveTime:duration.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.effectiveTime:periodicFrequency.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.effectiveTime:periodicFrequency.operator | required | Pattern: Ahttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.effectiveTime:eventFrequency.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.effectiveTime:eventFrequency.operator | required | Pattern: Ahttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| SubstanceAdministration.routeCode | required | SPLDrugRouteOfAdministrationTerminology http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.7 | |
| SubstanceAdministration.routeCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.routeCode.translation | required | MedicationRoute http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.12 | |
| SubstanceAdministration.approachSiteCode | required | BodySiteValueSet http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9 | |
| SubstanceAdministration.doseQuantity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.doseQuantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| SubstanceAdministration.doseQuantity.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.rateQuantity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.rateQuantity.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| SubstanceAdministration.rateQuantity.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.administrationUnitCode | required | AdministrationUnitDoseForm http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.30 | |
| SubstanceAdministration.consumable.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.consumable.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.consumable.typeCode | required | Fixed Value: CSMhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| SubstanceAdministration.participant:drugVehicle.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.participant:drugVehicle.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.participant:drugVehicle.typeCode | required | Fixed Value: CSMhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| SubstanceAdministration.participant:drugVehicle.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
| SubstanceAdministration.entryRelationship:indication.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:indication.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:indication.typeCode | required | Fixed Value: RSONhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:instruction.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:instruction.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:instruction.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:supplyOrder.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:supplyOrder.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:supplyOrder.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:medicationDispense.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:medicationDispense.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:medicationDispense.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:reaction.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:reaction.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:reaction.typeCode | required | Fixed Value: CAUShttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:drugMonitoring.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:drugMonitoring.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:drugMonitoring.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:substanceAdministered.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:substanceAdministered.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:substanceAdministered.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:adherence.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:adherence.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:adherence.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:signature.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:signature.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:signature.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.precondition.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.precondition.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.precondition.typeCode | required | Fixed Value: PRCNhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-7513 | warning | 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() | |
| 1098-32890 | error | SubstanceAdministration.effectiveTime:duration | This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890). : (value.exists() or low.exists()) and ((value.exists() and low.exists()).not()) | |
| II-1 | error | SubstanceAdministration.typeId, SubstanceAdministration.consumable.typeId, SubstanceAdministration.participant:drugVehicle.typeId, SubstanceAdministration.entryRelationship:indication.typeId, SubstanceAdministration.entryRelationship:instruction.typeId, SubstanceAdministration.entryRelationship:supplyOrder.typeId, SubstanceAdministration.entryRelationship:medicationDispense.typeId, SubstanceAdministration.entryRelationship:reaction.typeId, SubstanceAdministration.entryRelationship:drugMonitoring.typeId, SubstanceAdministration.entryRelationship:substanceAdministered.typeId, SubstanceAdministration.entryRelationship:adherence.typeId, SubstanceAdministration.entryRelationship:signature.typeId, SubstanceAdministration.precondition.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
| dose-unit-or-admin-unit | error | SubstanceAdministration | If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. : doseQuantity.unit.exists() implies administrationUnitCode.empty() | |
| indication-value | error | SubstanceAdministration.entryRelationship:indication.observation | If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry. : value.exists() or (%resource.descendants().ofType(CDA.Observation).where(id.exists($this.root = %context.id.first().root and $this.extension ~ %context.id.first().extension) and value.exists())) | |
| product-choice | error | SubstanceAdministration.consumable.manufacturedProduct | manufacturedLabeledDrug and manufacturedMaterial are mutually exclusive (one must be present) : (manufacturedLabeledDrug | manufacturedMaterial).count() = 1 | |
| role-choice | error | SubstanceAdministration.participant:drugVehicle.participantRole | playingDevice and playingEntity are mutually exclusive : (playingDevice | playingEntity).count() <= 1 | |
| should-author | warning | SubstanceAdministration | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | SubstanceAdministration.entryRelationship:indication.observation, SubstanceAdministration.entryRelationship:medicationDispense.supply, SubstanceAdministration.entryRelationship:reaction.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-informant | warning | SubstanceAdministration.entryRelationship:adherence.observation | SHOULD contain informant : informant.exists() | |
| should-low | warning | SubstanceAdministration.effectiveTime:duration | SHOULD contain low : low.exists() | |
| should-quantity | warning | SubstanceAdministration.entryRelationship:supplyOrder.supply, SubstanceAdministration.entryRelationship:medicationDispense.supply | SHOULD contain quantity : quantity.exists() | |
| should-repeatNumber | warning | SubstanceAdministration.entryRelationship:supplyOrder.supply, SubstanceAdministration.entryRelationship:medicationDispense.supply | SHOULD contain repeatNumber : repeatNumber.exists() | |
| should-routeCode | warning | SubstanceAdministration | SHOULD contain routeCode : routeCode.exists() | |
| should-text-ref-value | warning | SubstanceAdministration | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | SubstanceAdministration.entryRelationship:indication.observation, SubstanceAdministration.entryRelationship:instruction.observation, SubstanceAdministration.entryRelationship:supplyOrder.supply, SubstanceAdministration.entryRelationship:medicationDispense.supply, SubstanceAdministration.entryRelationship:reaction.observation, SubstanceAdministration.entryRelationship:drugMonitoring.act, SubstanceAdministration.entryRelationship:substanceAdministered.act, SubstanceAdministration.entryRelationship:adherence.observation, SubstanceAdministration.entryRelationship:signature.substanceAdministration | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-translation | warning | SubstanceAdministration.routeCode | SHOULD contain translation : translation.exists() | |
| should-unit | warning | SubstanceAdministration.doseQuantity | SHOULD contain @unit : nullFlavor.exists() or unit.exists() | |
| should-value-att | warning | SubstanceAdministration.effectiveTime:duration | SHOULD contain @value : value.exists() | |
| value-starts-octothorpe | error | SubstanceAdministration.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 SubstanceAdministration
Summary
Mandatory: 10 elements(15 nested mandatory elements)
Fixed: 12 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from SubstanceAdministration
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| SubstanceAdministration |
C | 1..1 | SubstanceAdministration | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, repeatNumber, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode, consumable, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, 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 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 |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:medication-activity |
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 | |
| @classCode |
1..1 | cs | ||
| @moodCode |
1..1 | cs | Binding: MoodCodeEvnInt (required) | |
| 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. | |
| 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 | 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 |
1..* | SXCM_TS, IVL_TS, EIVL_TS, PIVL_TS, SXPR_TS | Slice: Unordered, Open by type:$this | |
| effectiveTime:duration |
C | 1..1 | IVL_TS | 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. Note: This effectiveTime represents either 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). should-value-att: SHOULD contain @value should-low: SHOULD contain low |
| @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 |
C | 0..1 | CE | 𝗨𝗦𝗖𝗗𝗜: Route Code - SPL Binding: SPL Drug Route of Administration Terminology (required)should-translation: SHOULD contain translation |
| translation |
0..* | CD | 𝗨𝗦𝗖𝗗𝗜: Route Code - SNOMED Binding: Medication Route (required) | |
| approachSiteCode |
0..1 | CD | Binding: Body Site Value Set (required) | |
| doseQuantity |
C | 1..1 | IVL_PQ | 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). 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). should-unit: SHOULD contain @unit |
| @unit |
0..1 | cs | 𝗨𝗦𝗖𝗗𝗜: Dose Unit of Measure. NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: UnitsOfMeasureCaseSensitive (preferred) | |
| rateQuantity |
0..1 | IVL_PQ | ||
| @unit |
1..1 | cs | NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units 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 | 𝗨𝗦𝗖𝗗𝗜: Medications | |
| 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: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 | 𝗨𝗦𝗖𝗗𝗜: Indication | |
| @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 | |
| observation |
1..1 | InstructionObservation | 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 | 𝗨𝗦𝗖𝗗𝗜: Medication Adherence | |
| @typeCode |
1..1 | cs | Fixed Value: COMP | |
| observation |
1..1 | MedicationAdherence | Base for all types and resources | |
| entryRelationship:signature |
0..* | EntryRelationship | 𝗨𝗦𝗖𝗗𝗜: Medication Instructions | |
| @typeCode |
1..1 | cs | Fixed Value: COMP | |
| substanceAdministration |
1..1 | MedicationFreeTextSig | Base for all types and resources | |
| precondition |
0..* | Precondition | ||
| @typeCode |
1..1 | cs | ||
| criterion |
1..1 | PreconditionforSubstanceAdministration | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| SubstanceAdministration.moodCode | required | MoodCodeEvnInt http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.18 | |
| SubstanceAdministration.statusCode.code | required | MedicationStatus http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.11 | |
| SubstanceAdministration.routeCode | required | SPLDrugRouteOfAdministrationTerminology http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.7 | |
| SubstanceAdministration.routeCode.translation | required | MedicationRoute http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.12 | |
| SubstanceAdministration.approachSiteCode | required | BodySiteValueSet http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9 | |
| SubstanceAdministration.doseQuantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| SubstanceAdministration.rateQuantity.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| SubstanceAdministration.administrationUnitCode | required | AdministrationUnitDoseForm http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.30 |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-7513 | warning | 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() | |
| 1098-32890 | error | SubstanceAdministration.effectiveTime:duration | This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890). : (value.exists() or low.exists()) and ((value.exists() and low.exists()).not()) | |
| dose-unit-or-admin-unit | error | SubstanceAdministration | If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. : doseQuantity.unit.exists() implies administrationUnitCode.empty() | |
| should-author | warning | SubstanceAdministration | SHOULD contain author : author.exists() | |
| should-low | warning | SubstanceAdministration.effectiveTime:duration | SHOULD contain low : low.exists() | |
| should-routeCode | warning | SubstanceAdministration | SHOULD contain routeCode : routeCode.exists() | |
| should-text-ref-value | warning | SubstanceAdministration | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-translation | warning | SubstanceAdministration.routeCode | SHOULD contain translation : translation.exists() | |
| should-unit | warning | SubstanceAdministration.doseQuantity | SHOULD contain @unit : nullFlavor.exists() or unit.exists() | |
| should-value-att | warning | SubstanceAdministration.effectiveTime:duration | SHOULD contain @value : value.exists() | |
| value-starts-octothorpe | error | SubstanceAdministration.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 |
|---|---|---|---|---|
| SubstanceAdministration |
C | 1..1 | SubstanceAdministration | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, repeatNumber, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode, consumable, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, 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 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 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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:medication-activity |
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: 2.16.840.1.113883.10.20.22.4.16 | |
| @extension |
1..1 | st | Required Pattern: 2014-06-09 | |
| @classCode |
1..1 | cs | Binding: CDAActClass (required) Fixed Value: SBADM | |
| @moodCode |
1..1 | cs | Binding: MoodCodeEvnInt (required) | |
| 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: CDAActSubstanceAdministrationCode (example) | |
| @negationInd |
0..1 | bl | ||
| 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 | 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 |
1..* | Slice: Unordered, Open by type:$this | ||
| effectiveTime |
SXCM_TS | |||
| effectiveTime |
IVL_TS | |||
| effectiveTime |
EIVL_TS | |||
| effectiveTime |
PIVL_TS | |||
| effectiveTime |
SXPR_TS | |||
| effectiveTime:duration |
C | 1..1 | IVL_TS | 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. Note: This effectiveTime represents either 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). should-value-att: SHOULD contain @value should-low: SHOULD contain low |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | ts | indicates a single-administration timestamp Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator |
0..1 | cs | Binding: CDASetOperator (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: CDANullFlavor (required) | |
| @operator |
1..1 | cs | Binding: CDASetOperator (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: CDANullFlavor (required) | |
| @operator |
1..1 | cs | Binding: CDASetOperator (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 (example) | |
| 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 |
C | 0..1 | CE | 𝗨𝗦𝗖𝗗𝗜: Route Code - SPL Binding: SPL Drug Route of Administration Terminology (required)should-translation: SHOULD contain translation |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (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 | 𝗨𝗦𝗖𝗗𝗜: Route Code - SNOMED Binding: Medication Route (required) | |
| approachSiteCode |
0..1 | CD | Binding: Body Site Value Set (required) | |
| doseQuantity |
C | 1..1 | IVL_PQ | 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). 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). should-unit: SHOULD contain @unit |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @unit |
0..1 | cs | 𝗨𝗦𝗖𝗗𝗜: Dose Unit of Measure. NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: UnitsOfMeasureCaseSensitive (preferred) | |
| @value |
0..1 | real | ||
| translation |
0..* | PQR | ||
| @operator |
0..1 | cs | Binding: CDASetOperator (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: CDANullFlavor (required) | |
| @unit |
1..1 | cs | NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: UnitsOfMeasureCaseSensitive (required) | |
| @value |
0..1 | real | ||
| translation |
0..* | PQR | ||
| @operator |
0..1 | cs | Binding: CDASetOperator (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 | 𝗨𝗦𝗖𝗗𝗜: Medications | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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 |
0..1 | cs | Binding: CDAParticipationType (required) Fixed Value: CSM | |
| manufacturedProduct |
C | 1..1 | MedicationInformation | Base for all types and resources product-choice: manufacturedLabeledDrug and manufacturedMaterial are mutually exclusive (one must be present) |
| 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:typeCode | |
| participant:drugVehicle |
0..* | Participant2 | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: CDAParticipationType (required) Fixed Value: CSM | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| 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 |
C | 1..1 | DrugVehicle | Base for all types and resources role-choice: playingDevice and playingEntity are mutually exclusive |
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:substanceAdministration, profile:observation, profile:act, profile:supply | |
| entryRelationship:indication |
0..* | EntryRelationship | 𝗨𝗦𝗖𝗗𝗜: Indication | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 |
C | 1..1 | Indication | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime indication-value: If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry. |
| 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: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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 |
1..1 | bl | Fixed Value: true | |
| @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 |
C | 1..1 | InstructionObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| 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: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 | MedicationSupplyOrder | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-repeatNumber: SHOULD contain repeatNumber should-quantity: SHOULD contain quantity |
| entryRelationship:medicationDispense |
0..* | EntryRelationship | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-repeatNumber: SHOULD contain repeatNumber should-quantity: SHOULD contain quantity |
| entryRelationship:reaction |
0..* | EntryRelationship | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 |
C | 1..1 | ReactionObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime |
| 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: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: COMP | |
| @inversionInd |
0..1 | bl | ||
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
C | 1..1 | DrugMonitoringAct | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| 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: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 |
C | 1..1 | SubstanceAdministeredAct | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| 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 | 𝗨𝗦𝗖𝗗𝗜: Medication Adherence | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 |
C | 1..1 | MedicationAdherence | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-informant: SHOULD contain informant |
| 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 | 𝗨𝗦𝗖𝗗𝗜: Medication Instructions | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 |
C | 1..1 | MedicationFreeTextSig | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| supply |
0..1 | Supply | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: CDAActRelationshipType (required) Fixed Value: PRCN | |
| criterion |
1..1 | PreconditionforSubstanceAdministration | Base for all types and resources | |
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| SubstanceAdministration.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.templateId:medication-activity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.classCode | required | Fixed Value: SBADMhttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
| SubstanceAdministration.moodCode | required | MoodCodeEvnInt http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.18 | |
| SubstanceAdministration.code | example | CDAActSubstanceAdministrationCodehttp://hl7.org/cda/stds/core/ValueSet/CDAActSubstanceAdministrationCode | |
| SubstanceAdministration.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| SubstanceAdministration.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| SubstanceAdministration.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| SubstanceAdministration.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| SubstanceAdministration.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| SubstanceAdministration.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.statusCode.code | required | MedicationStatus http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.11 | |
| SubstanceAdministration.effectiveTime:duration.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.effectiveTime:duration.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.effectiveTime:periodicFrequency.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.effectiveTime:periodicFrequency.operator | required | Pattern: Ahttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.effectiveTime:eventFrequency.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.effectiveTime:eventFrequency.operator | required | Pattern: Ahttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| SubstanceAdministration.routeCode | required | SPLDrugRouteOfAdministrationTerminology http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.7 | |
| SubstanceAdministration.routeCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.routeCode.translation | required | MedicationRoute http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.12 | |
| SubstanceAdministration.approachSiteCode | required | BodySiteValueSet http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9 | |
| SubstanceAdministration.doseQuantity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.doseQuantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| SubstanceAdministration.doseQuantity.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.rateQuantity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.rateQuantity.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| SubstanceAdministration.rateQuantity.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.administrationUnitCode | required | AdministrationUnitDoseForm http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.30 | |
| SubstanceAdministration.consumable.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.consumable.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.consumable.typeCode | required | Fixed Value: CSMhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| SubstanceAdministration.participant:drugVehicle.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.participant:drugVehicle.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.participant:drugVehicle.typeCode | required | Fixed Value: CSMhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| SubstanceAdministration.participant:drugVehicle.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
| SubstanceAdministration.entryRelationship:indication.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:indication.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:indication.typeCode | required | Fixed Value: RSONhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:instruction.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:instruction.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:instruction.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:supplyOrder.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:supplyOrder.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:supplyOrder.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:medicationDispense.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:medicationDispense.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:medicationDispense.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:reaction.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:reaction.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:reaction.typeCode | required | Fixed Value: CAUShttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:drugMonitoring.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:drugMonitoring.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:drugMonitoring.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:substanceAdministered.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:substanceAdministered.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:substanceAdministered.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:adherence.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:adherence.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:adherence.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:signature.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:signature.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:signature.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.precondition.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.precondition.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.precondition.typeCode | required | Fixed Value: PRCNhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-7513 | warning | 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() | |
| 1098-32890 | error | SubstanceAdministration.effectiveTime:duration | This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890). : (value.exists() or low.exists()) and ((value.exists() and low.exists()).not()) | |
| II-1 | error | SubstanceAdministration.typeId, SubstanceAdministration.consumable.typeId, SubstanceAdministration.participant:drugVehicle.typeId, SubstanceAdministration.entryRelationship:indication.typeId, SubstanceAdministration.entryRelationship:instruction.typeId, SubstanceAdministration.entryRelationship:supplyOrder.typeId, SubstanceAdministration.entryRelationship:medicationDispense.typeId, SubstanceAdministration.entryRelationship:reaction.typeId, SubstanceAdministration.entryRelationship:drugMonitoring.typeId, SubstanceAdministration.entryRelationship:substanceAdministered.typeId, SubstanceAdministration.entryRelationship:adherence.typeId, SubstanceAdministration.entryRelationship:signature.typeId, SubstanceAdministration.precondition.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
| dose-unit-or-admin-unit | error | SubstanceAdministration | If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. : doseQuantity.unit.exists() implies administrationUnitCode.empty() | |
| indication-value | error | SubstanceAdministration.entryRelationship:indication.observation | If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry. : value.exists() or (%resource.descendants().ofType(CDA.Observation).where(id.exists($this.root = %context.id.first().root and $this.extension ~ %context.id.first().extension) and value.exists())) | |
| product-choice | error | SubstanceAdministration.consumable.manufacturedProduct | manufacturedLabeledDrug and manufacturedMaterial are mutually exclusive (one must be present) : (manufacturedLabeledDrug | manufacturedMaterial).count() = 1 | |
| role-choice | error | SubstanceAdministration.participant:drugVehicle.participantRole | playingDevice and playingEntity are mutually exclusive : (playingDevice | playingEntity).count() <= 1 | |
| should-author | warning | SubstanceAdministration | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | SubstanceAdministration.entryRelationship:indication.observation, SubstanceAdministration.entryRelationship:medicationDispense.supply, SubstanceAdministration.entryRelationship:reaction.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-informant | warning | SubstanceAdministration.entryRelationship:adherence.observation | SHOULD contain informant : informant.exists() | |
| should-low | warning | SubstanceAdministration.effectiveTime:duration | SHOULD contain low : low.exists() | |
| should-quantity | warning | SubstanceAdministration.entryRelationship:supplyOrder.supply, SubstanceAdministration.entryRelationship:medicationDispense.supply | SHOULD contain quantity : quantity.exists() | |
| should-repeatNumber | warning | SubstanceAdministration.entryRelationship:supplyOrder.supply, SubstanceAdministration.entryRelationship:medicationDispense.supply | SHOULD contain repeatNumber : repeatNumber.exists() | |
| should-routeCode | warning | SubstanceAdministration | SHOULD contain routeCode : routeCode.exists() | |
| should-text-ref-value | warning | SubstanceAdministration | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | SubstanceAdministration.entryRelationship:indication.observation, SubstanceAdministration.entryRelationship:instruction.observation, SubstanceAdministration.entryRelationship:supplyOrder.supply, SubstanceAdministration.entryRelationship:medicationDispense.supply, SubstanceAdministration.entryRelationship:reaction.observation, SubstanceAdministration.entryRelationship:drugMonitoring.act, SubstanceAdministration.entryRelationship:substanceAdministered.act, SubstanceAdministration.entryRelationship:adherence.observation, SubstanceAdministration.entryRelationship:signature.substanceAdministration | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-translation | warning | SubstanceAdministration.routeCode | SHOULD contain translation : translation.exists() | |
| should-unit | warning | SubstanceAdministration.doseQuantity | SHOULD contain @unit : nullFlavor.exists() or unit.exists() | |
| should-value-att | warning | SubstanceAdministration.effectiveTime:duration | SHOULD contain @value : value.exists() | |
| value-starts-octothorpe | error | SubstanceAdministration.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 |
|---|---|---|---|---|
| SubstanceAdministration |
C | 1..1 | SubstanceAdministration | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, repeatNumber, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode, consumable, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, 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 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 |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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:medication-activity |
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: 2.16.840.1.113883.10.20.22.4.16 | |
| @extension |
1..1 | st | Required Pattern: 2014-06-09 | |
| @classCode |
1..1 | cs | Binding: CDAActClass (required) Fixed Value: SBADM | |
| @moodCode |
1..1 | cs | Binding: MoodCodeEvnInt (required) | |
| 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: CDAActSubstanceAdministrationCode (example) | |
| @negationInd |
0..1 | bl | ||
| 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 | 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 |
1..* | Slice: Unordered, Open by type:$this | ||
| effectiveTime |
SXCM_TS | |||
| effectiveTime |
IVL_TS | |||
| effectiveTime |
EIVL_TS | |||
| effectiveTime |
PIVL_TS | |||
| effectiveTime |
SXPR_TS | |||
| effectiveTime:duration |
C | 1..1 | IVL_TS | 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. Note: This effectiveTime represents either 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). should-value-att: SHOULD contain @value should-low: SHOULD contain low |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @value |
0..1 | ts | indicates a single-administration timestamp Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| @operator |
0..1 | cs | Binding: CDASetOperator (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: CDANullFlavor (required) | |
| @operator |
1..1 | cs | Binding: CDASetOperator (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: CDANullFlavor (required) | |
| @operator |
1..1 | cs | Binding: CDASetOperator (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 (example) | |
| 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 |
C | 0..1 | CE | 𝗨𝗦𝗖𝗗𝗜: Route Code - SPL Binding: SPL Drug Route of Administration Terminology (required)should-translation: SHOULD contain translation |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (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 | 𝗨𝗦𝗖𝗗𝗜: Route Code - SNOMED Binding: Medication Route (required) | |
| approachSiteCode |
0..1 | CD | Binding: Body Site Value Set (required) | |
| doseQuantity |
C | 1..1 | IVL_PQ | 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). 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). should-unit: SHOULD contain @unit |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @unit |
0..1 | cs | 𝗨𝗦𝗖𝗗𝗜: Dose Unit of Measure. NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: UnitsOfMeasureCaseSensitive (preferred) | |
| @value |
0..1 | real | ||
| translation |
0..* | PQR | ||
| @operator |
0..1 | cs | Binding: CDASetOperator (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: CDANullFlavor (required) | |
| @unit |
1..1 | cs | NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units Binding: UnitsOfMeasureCaseSensitive (required) | |
| @value |
0..1 | real | ||
| translation |
0..* | PQR | ||
| @operator |
0..1 | cs | Binding: CDASetOperator (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 | 𝗨𝗦𝗖𝗗𝗜: Medications | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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 |
0..1 | cs | Binding: CDAParticipationType (required) Fixed Value: CSM | |
| manufacturedProduct |
C | 1..1 | MedicationInformation | Base for all types and resources product-choice: manufacturedLabeledDrug and manufacturedMaterial are mutually exclusive (one must be present) |
| 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:typeCode | |
| participant:drugVehicle |
0..* | Participant2 | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: CDAParticipationType (required) Fixed Value: CSM | |
| @contextControlCode |
0..1 | cs | Binding: CDAContextControl (required) Fixed Value: OP | |
| 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 |
C | 1..1 | DrugVehicle | Base for all types and resources role-choice: playingDevice and playingEntity are mutually exclusive |
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:substanceAdministration, profile:observation, profile:act, profile:supply | |
| entryRelationship:indication |
0..* | EntryRelationship | 𝗨𝗦𝗖𝗗𝗜: Indication | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 |
C | 1..1 | Indication | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime indication-value: If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry. |
| 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: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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 |
1..1 | bl | Fixed Value: true | |
| @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 |
C | 1..1 | InstructionObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| 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: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 | MedicationSupplyOrder | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-repeatNumber: SHOULD contain repeatNumber should-quantity: SHOULD contain quantity |
| entryRelationship:medicationDispense |
0..* | EntryRelationship | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-repeatNumber: SHOULD contain repeatNumber should-quantity: SHOULD contain quantity |
| entryRelationship:reaction |
0..* | EntryRelationship | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 |
C | 1..1 | ReactionObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime |
| 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: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: COMP | |
| @inversionInd |
0..1 | bl | ||
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
C | 1..1 | DrugMonitoringAct | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| 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: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 |
C | 1..1 | SubstanceAdministeredAct | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| 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 | 𝗨𝗦𝗖𝗗𝗜: Medication Adherence | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 |
C | 1..1 | MedicationAdherence | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-informant: SHOULD contain informant |
| 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 | 𝗨𝗦𝗖𝗗𝗜: Medication Instructions | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: 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 |
C | 1..1 | MedicationFreeTextSig | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| supply |
0..1 | Supply | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
| @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: CDAActRelationshipType (required) Fixed Value: PRCN | |
| criterion |
1..1 | PreconditionforSubstanceAdministration | Base for all types and resources | |
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| SubstanceAdministration.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.templateId:medication-activity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.classCode | required | Fixed Value: SBADMhttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
| SubstanceAdministration.moodCode | required | MoodCodeEvnInt http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.18 | |
| SubstanceAdministration.code | example | CDAActSubstanceAdministrationCodehttp://hl7.org/cda/stds/core/ValueSet/CDAActSubstanceAdministrationCode | |
| SubstanceAdministration.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| SubstanceAdministration.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| SubstanceAdministration.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| SubstanceAdministration.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| SubstanceAdministration.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| SubstanceAdministration.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.statusCode.code | required | MedicationStatus http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.11 | |
| SubstanceAdministration.effectiveTime:duration.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.effectiveTime:duration.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.effectiveTime:periodicFrequency.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.effectiveTime:periodicFrequency.operator | required | Pattern: Ahttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.effectiveTime:eventFrequency.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.effectiveTime:eventFrequency.operator | required | Pattern: Ahttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| SubstanceAdministration.routeCode | required | SPLDrugRouteOfAdministrationTerminology http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.7 | |
| SubstanceAdministration.routeCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.routeCode.translation | required | MedicationRoute http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.12 | |
| SubstanceAdministration.approachSiteCode | required | BodySiteValueSet http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9 | |
| SubstanceAdministration.doseQuantity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.doseQuantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| SubstanceAdministration.doseQuantity.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.rateQuantity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.rateQuantity.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive | |
| SubstanceAdministration.rateQuantity.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.administrationUnitCode | required | AdministrationUnitDoseForm http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.30 | |
| SubstanceAdministration.consumable.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.consumable.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.consumable.typeCode | required | Fixed Value: CSMhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| SubstanceAdministration.participant:drugVehicle.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.participant:drugVehicle.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.participant:drugVehicle.typeCode | required | Fixed Value: CSMhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| SubstanceAdministration.participant:drugVehicle.contextControlCode | required | Fixed Value: OPhttp://hl7.org/cda/stds/core/ValueSet/CDAContextControl | |
| SubstanceAdministration.entryRelationship:indication.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:indication.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:indication.typeCode | required | Fixed Value: RSONhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:instruction.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:instruction.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:instruction.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:supplyOrder.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:supplyOrder.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:supplyOrder.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:medicationDispense.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:medicationDispense.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:medicationDispense.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:reaction.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:reaction.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:reaction.typeCode | required | Fixed Value: CAUShttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:drugMonitoring.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:drugMonitoring.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:drugMonitoring.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:substanceAdministered.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:substanceAdministered.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:substanceAdministered.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:adherence.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:adherence.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:adherence.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:signature.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:signature.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:signature.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.precondition.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.precondition.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.precondition.typeCode | required | Fixed Value: PRCNhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-7513 | warning | 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() | |
| 1098-32890 | error | SubstanceAdministration.effectiveTime:duration | This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890). : (value.exists() or low.exists()) and ((value.exists() and low.exists()).not()) | |
| II-1 | error | SubstanceAdministration.typeId, SubstanceAdministration.consumable.typeId, SubstanceAdministration.participant:drugVehicle.typeId, SubstanceAdministration.entryRelationship:indication.typeId, SubstanceAdministration.entryRelationship:instruction.typeId, SubstanceAdministration.entryRelationship:supplyOrder.typeId, SubstanceAdministration.entryRelationship:medicationDispense.typeId, SubstanceAdministration.entryRelationship:reaction.typeId, SubstanceAdministration.entryRelationship:drugMonitoring.typeId, SubstanceAdministration.entryRelationship:substanceAdministered.typeId, SubstanceAdministration.entryRelationship:adherence.typeId, SubstanceAdministration.entryRelationship:signature.typeId, SubstanceAdministration.precondition.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() | |
| dose-unit-or-admin-unit | error | SubstanceAdministration | If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. : doseQuantity.unit.exists() implies administrationUnitCode.empty() | |
| indication-value | error | SubstanceAdministration.entryRelationship:indication.observation | If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry. : value.exists() or (%resource.descendants().ofType(CDA.Observation).where(id.exists($this.root = %context.id.first().root and $this.extension ~ %context.id.first().extension) and value.exists())) | |
| product-choice | error | SubstanceAdministration.consumable.manufacturedProduct | manufacturedLabeledDrug and manufacturedMaterial are mutually exclusive (one must be present) : (manufacturedLabeledDrug | manufacturedMaterial).count() = 1 | |
| role-choice | error | SubstanceAdministration.participant:drugVehicle.participantRole | playingDevice and playingEntity are mutually exclusive : (playingDevice | playingEntity).count() <= 1 | |
| should-author | warning | SubstanceAdministration | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | SubstanceAdministration.entryRelationship:indication.observation, SubstanceAdministration.entryRelationship:medicationDispense.supply, SubstanceAdministration.entryRelationship:reaction.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-informant | warning | SubstanceAdministration.entryRelationship:adherence.observation | SHOULD contain informant : informant.exists() | |
| should-low | warning | SubstanceAdministration.effectiveTime:duration | SHOULD contain low : low.exists() | |
| should-quantity | warning | SubstanceAdministration.entryRelationship:supplyOrder.supply, SubstanceAdministration.entryRelationship:medicationDispense.supply | SHOULD contain quantity : quantity.exists() | |
| should-repeatNumber | warning | SubstanceAdministration.entryRelationship:supplyOrder.supply, SubstanceAdministration.entryRelationship:medicationDispense.supply | SHOULD contain repeatNumber : repeatNumber.exists() | |
| should-routeCode | warning | SubstanceAdministration | SHOULD contain routeCode : routeCode.exists() | |
| should-text-ref-value | warning | SubstanceAdministration | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | SubstanceAdministration.entryRelationship:indication.observation, SubstanceAdministration.entryRelationship:instruction.observation, SubstanceAdministration.entryRelationship:supplyOrder.supply, SubstanceAdministration.entryRelationship:medicationDispense.supply, SubstanceAdministration.entryRelationship:reaction.observation, SubstanceAdministration.entryRelationship:drugMonitoring.act, SubstanceAdministration.entryRelationship:substanceAdministered.act, SubstanceAdministration.entryRelationship:adherence.observation, SubstanceAdministration.entryRelationship:signature.substanceAdministration | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-translation | warning | SubstanceAdministration.routeCode | SHOULD contain translation : translation.exists() | |
| should-unit | warning | SubstanceAdministration.doseQuantity | SHOULD contain @unit : nullFlavor.exists() or unit.exists() | |
| should-value-att | warning | SubstanceAdministration.effectiveTime:duration | SHOULD contain @value : value.exists() | |
| value-starts-octothorpe | error | SubstanceAdministration.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 SubstanceAdministration
Summary
Mandatory: 10 elements(15 nested mandatory elements)
Fixed: 12 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 2024-12-19
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