Consolidated CDA (C-CDA)
4.0.0 - STU4 United States of America flag

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 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

Logical Model: Medication Activity

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/MedicationActivity Version: 4.0.0
Draft as of 2025-10-02 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".

Templates Used

Although open templates may contain any valid CDA content, the following templates are specifically called out by this template:

Optional EntryRelationships: DrugMonitoringAct, Indication, InstructionObservation, MedicationAdherence, MedicationDispense, MedicationFreeTextSig, MedicationSupplyOrder, ReactionObservation, SubstanceAdministeredAct

Usages:

You can also check for usages in the FHIR IG Statistics

Changes since version 3.0.0:

  • New Content

    • Formal Views of Template Content

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

    This structure is derived from SubstanceAdministration

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. SubstanceAdministration C 1..1 SubstanceAdministration XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value, 1098-7513, should-routeCode, dose-unit-or-admin-unit, should-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)
    ... 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 Constraints: value-starts-octothorpe
    ... 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.
    Constraints: 1098-32890, should-value-att, should-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 PIVL_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 EIVL_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)
    Constraints: should-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).
    Constraints: should-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
    ... performer 0..1 Performer2
    ... author 0..* AuthorParticipation
    ... 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
    ... 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
    .... entryRelationship:instruction 0..1 EntryRelationship
    ..... @typeCode 1..1 cs Fixed Value: SUBJ
    ..... @inversionInd 1..1 bl Fixed Value: true
    ..... observation 1..1 InstructionObservation
    .... entryRelationship:supplyOrder 0..1 EntryRelationship
    ..... @typeCode 1..1 cs Fixed Value: REFR
    ..... supply 1..1 MedicationSupplyOrder
    .... entryRelationship:medicationDispense 0..* EntryRelationship
    ..... @typeCode 1..1 cs Fixed Value: REFR
    ..... supply 1..1 MedicationDispense
    .... entryRelationship:reaction 0..* EntryRelationship
    ..... @typeCode 1..1 cs Fixed Value: CAUS
    ..... observation 1..1 ReactionObservation
    .... entryRelationship:drugMonitoring 0..1 EntryRelationship
    ..... @typeCode 1..1 cs Fixed Value: COMP
    ..... act 1..1 DrugMonitoringAct
    .... 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
    .... entryRelationship:adherence 0..* EntryRelationship 𝗨𝗦𝗖𝗗𝗜: Medication Adherence
    ..... @typeCode 1..1 cs Fixed Value: COMP
    ..... observation 1..1 MedicationAdherence
    .... entryRelationship:signature 0..* EntryRelationship 𝗨𝗦𝗖𝗗𝗜: Medication Instructions
    ..... @typeCode 1..1 cs Fixed Value: COMP
    ..... substanceAdministration 1..1 MedicationFreeTextSig
    ... precondition 0..* Precondition
    .... @typeCode 1..1 cs
    .... criterion 1..1 PreconditionforSubstanceAdministration

    doco Documentation for this format

    Terminology Bindings (Differential)

    Path Status Usage ValueSet Version Source
    SubstanceAdministration.​moodCode Base required MoodCodeEvnInt . 📦20240606 VSAC v0.23
    SubstanceAdministration.​statusCode.code Base required Medication Status . 📦20240606 VSAC v0.23
    SubstanceAdministration.​routeCode Base required SPL Drug Route of Administration Terminology . 📦20240716 VSAC v0.23
    SubstanceAdministration.​routeCode.translation Base required Medication Route . 📦20240606 VSAC v0.23
    SubstanceAdministration.​approachSiteCode Base required Body Site Value Set . 📦20240606 VSAC v0.23
    SubstanceAdministration.​doseQuantity.unit Base preferred UnitsOfMeasureCaseSensitive 📦3.0.0 THO v6.5
    SubstanceAdministration.​rateQuantity.unit Base required UnitsOfMeasureCaseSensitive 📦3.0.0 THO v6.5
    SubstanceAdministration.​administrationUnitCode Base required AdministrationUnitDoseForm . 📦20240606 VSAC v0.23

    Constraints

    Id Grade Path(s) Description Expression
    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('#')
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. SubstanceAdministration C 1..1 SubstanceAdministration XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value, 1098-7513, should-routeCode, dose-unit-or-admin-unit, should-author
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @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 Constraints: value-starts-octothorpe
    .... 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.
    Constraints: 1098-32890, should-value-att, should-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 PIVL_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
    ..... phase 0..1 IVL_TS
    ..... period 0..1 PQ
    ..... @alignment 0..1 cs
    ..... @institutionSpecified 0..1 bl
    .... effectiveTime:eventFrequency 0..1 EIVL_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
    ..... event 0..1 CE
    ..... offset 0..1 IVL_PQ
    ... 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)
    Constraints: should-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).
    Constraints: should-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 Constraints: II-1
    ..... @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 1..1 MedicationInformation
    ... subject 0..1 Subject
    ... specimen 0..* Specimen
    ... performer 0..1 Performer2
    ... author 0..* AuthorParticipation
    ... 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 Constraints: II-1
    ...... @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 1..1 DrugVehicle
    ... 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 Constraints: II-1
    ...... @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 1..1 Indication
    ..... 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 Constraints: II-1
    ...... @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 1..1 InstructionObservation
    ..... 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 Constraints: II-1
    ...... @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 1..1 MedicationSupplyOrder
    .... entryRelationship:medicationDispense 0..* EntryRelationship
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 MedicationDispense
    .... entryRelationship:reaction 0..* EntryRelationship
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 ReactionObservation
    ..... 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 Constraints: II-1
    ...... @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 1..1 DrugMonitoringAct
    ..... 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 Constraints: II-1
    ...... @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 1..1 SubstanceAdministeredAct
    ..... 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 Constraints: II-1
    ...... @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 1..1 MedicationAdherence
    ..... 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 Constraints: II-1
    ...... @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 1..1 MedicationFreeTextSig
    ..... 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 Constraints: II-1
    ..... @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
    ... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
    XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    SubstanceAdministration.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​templateId:medication-activity.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​classCode Base required CDAActClass 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​moodCode Base required MoodCodeEvnInt . 📦20240606 VSAC v0.23
    SubstanceAdministration.​code Base example CDAActSubstanceAdministrationCode 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​text.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​text.compression Base required CDACompressionAlgorithm 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
    SubstanceAdministration.​text.mediaType Base example MediaType 📦3.0.0 THO v6.5
    SubstanceAdministration.​text.representation Base required CDABinaryDataEncoding 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​statusCode Base required ActStatus 📦3.0.0 THO v6.5
    SubstanceAdministration.​statusCode.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​statusCode.code Base required Medication Status . 📦20240606 VSAC v0.23
    SubstanceAdministration.​effectiveTime:duration.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​effectiveTime:duration.​operator Base required CDASetOperator 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​effectiveTime:periodicFrequency.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​effectiveTime:periodicFrequency.​operator Base required CDASetOperator 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​effectiveTime:eventFrequency.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​effectiveTime:eventFrequency.​operator Base required CDASetOperator 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​priorityCode Base example ActPriority 📦3.0.0 THO v6.5
    SubstanceAdministration.​routeCode Base required SPL Drug Route of Administration Terminology . 📦20240716 VSAC v0.23
    SubstanceAdministration.​routeCode.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​routeCode.translation Base required Medication Route . 📦20240606 VSAC v0.23
    SubstanceAdministration.​approachSiteCode Base required Body Site Value Set . 📦20240606 VSAC v0.23
    SubstanceAdministration.​doseQuantity.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​doseQuantity.unit Base preferred UnitsOfMeasureCaseSensitive 📦3.0.0 THO v6.5
    SubstanceAdministration.​doseQuantity.operator Base required CDASetOperator 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​rateQuantity.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​rateQuantity.unit Base required UnitsOfMeasureCaseSensitive 📦3.0.0 THO v6.5
    SubstanceAdministration.​rateQuantity.operator Base required CDASetOperator 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​administrationUnitCode Base required AdministrationUnitDoseForm . 📦20240606 VSAC v0.23
    SubstanceAdministration.​consumable.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​consumable.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​consumable.typeCode Base required CDAParticipationType 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​participant:drugVehicle.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​participant:drugVehicle.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​participant:drugVehicle.​typeCode Base required CDAParticipationType 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​participant:drugVehicle.​contextControlCode Base required CDAContextControl 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:indication.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:indication.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:indication.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:instruction.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:instruction.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:instruction.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:supplyOrder.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:supplyOrder.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:supplyOrder.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:medicationDispense.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:medicationDispense.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:medicationDispense.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:reaction.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:reaction.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:reaction.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:drugMonitoring.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:drugMonitoring.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:drugMonitoring.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:substanceAdministered.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:substanceAdministered.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:substanceAdministered.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:adherence.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:adherence.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:adherence.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:signature.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:signature.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:signature.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​precondition.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​precondition.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​precondition.typeCode Base required CDAActRelationshipType 📦2.0.1-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    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()
    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('#')
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. SubstanceAdministration C 1..1 SubstanceAdministration XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value, 1098-7513, should-routeCode, dose-unit-or-admin-unit, should-author
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @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 Constraints: value-starts-octothorpe
    .... 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.
    Constraints: 1098-32890, should-value-att, should-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 PIVL_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
    ..... phase 0..1 IVL_TS
    ..... period 0..1 PQ
    ..... @alignment 0..1 cs
    ..... @institutionSpecified 0..1 bl
    .... effectiveTime:eventFrequency 0..1 EIVL_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
    ..... event 0..1 CE
    ..... offset 0..1 IVL_PQ
    ... 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)
    Constraints: should-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).
    Constraints: should-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 Constraints: II-1
    ..... @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 1..1 MedicationInformation
    ... subject 0..1 Subject
    ... specimen 0..* Specimen
    ... performer 0..1 Performer2
    ... author 0..* AuthorParticipation
    ... 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 Constraints: II-1
    ...... @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 1..1 DrugVehicle
    ... 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 Constraints: II-1
    ...... @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 1..1 Indication
    ..... 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 Constraints: II-1
    ...... @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 1..1 InstructionObservation
    ..... 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 Constraints: II-1
    ...... @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 1..1 MedicationSupplyOrder
    .... entryRelationship:medicationDispense 0..* EntryRelationship
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 MedicationDispense
    .... entryRelationship:reaction 0..* EntryRelationship
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 ReactionObservation
    ..... 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 Constraints: II-1
    ...... @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 1..1 DrugMonitoringAct
    ..... 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 Constraints: II-1
    ...... @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 1..1 SubstanceAdministeredAct
    ..... 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 Constraints: II-1
    ...... @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 1..1 MedicationAdherence
    ..... 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 Constraints: II-1
    ...... @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 1..1 MedicationFreeTextSig
    ..... 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 Constraints: II-1
    ..... @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
    ... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
    XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    SubstanceAdministration.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​templateId:medication-activity.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​classCode Base required CDAActClass 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​moodCode Base required MoodCodeEvnInt . 📦20240606 VSAC v0.23
    SubstanceAdministration.​code Base example CDAActSubstanceAdministrationCode 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​text.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​text.compression Base required CDACompressionAlgorithm 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
    SubstanceAdministration.​text.mediaType Base example MediaType 📦3.0.0 THO v6.5
    SubstanceAdministration.​text.representation Base required CDABinaryDataEncoding 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​statusCode Base required ActStatus 📦3.0.0 THO v6.5
    SubstanceAdministration.​statusCode.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​statusCode.code Base required Medication Status . 📦20240606 VSAC v0.23
    SubstanceAdministration.​effectiveTime:duration.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​effectiveTime:duration.​operator Base required CDASetOperator 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​effectiveTime:periodicFrequency.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​effectiveTime:periodicFrequency.​operator Base required CDASetOperator 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​effectiveTime:eventFrequency.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​effectiveTime:eventFrequency.​operator Base required CDASetOperator 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​priorityCode Base example ActPriority 📦3.0.0 THO v6.5
    SubstanceAdministration.​routeCode Base required SPL Drug Route of Administration Terminology . 📦20240716 VSAC v0.23
    SubstanceAdministration.​routeCode.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​routeCode.translation Base required Medication Route . 📦20240606 VSAC v0.23
    SubstanceAdministration.​approachSiteCode Base required Body Site Value Set . 📦20240606 VSAC v0.23
    SubstanceAdministration.​doseQuantity.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​doseQuantity.unit Base preferred UnitsOfMeasureCaseSensitive 📦3.0.0 THO v6.5
    SubstanceAdministration.​doseQuantity.operator Base required CDASetOperator 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​rateQuantity.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​rateQuantity.unit Base required UnitsOfMeasureCaseSensitive 📦3.0.0 THO v6.5
    SubstanceAdministration.​rateQuantity.operator Base required CDASetOperator 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​administrationUnitCode Base required AdministrationUnitDoseForm . 📦20240606 VSAC v0.23
    SubstanceAdministration.​consumable.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​consumable.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​consumable.typeCode Base required CDAParticipationType 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​participant:drugVehicle.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​participant:drugVehicle.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​participant:drugVehicle.​typeCode Base required CDAParticipationType 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​participant:drugVehicle.​contextControlCode Base required CDAContextControl 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:indication.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:indication.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:indication.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:instruction.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:instruction.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:instruction.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:supplyOrder.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:supplyOrder.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:supplyOrder.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:medicationDispense.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:medicationDispense.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:medicationDispense.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:reaction.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:reaction.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:reaction.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:drugMonitoring.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:drugMonitoring.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:drugMonitoring.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:substanceAdministered.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:substanceAdministered.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:substanceAdministered.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:adherence.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:adherence.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:adherence.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:signature.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:signature.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:signature.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​precondition.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​precondition.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​precondition.typeCode Base required CDAActRelationshipType 📦2.0.1-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    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()
    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('#')

    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:

    • The element 2 is sliced based on the values of SubstanceAdministration.templateId
    • The element 1 is sliced based on the value of SubstanceAdministration.effectiveTime
    • The element 1 is sliced based on the value of SubstanceAdministration.participant
    • The element 4 is sliced based on the values of SubstanceAdministration.entryRelationship

    Differential View

    This structure is derived from SubstanceAdministration

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. SubstanceAdministration C 1..1 SubstanceAdministration XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value, 1098-7513, should-routeCode, dose-unit-or-admin-unit, should-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)
    ... 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 Constraints: value-starts-octothorpe
    ... 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.
    Constraints: 1098-32890, should-value-att, should-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 PIVL_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 EIVL_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)
    Constraints: should-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).
    Constraints: should-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
    ... performer 0..1 Performer2
    ... author 0..* AuthorParticipation
    ... 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
    ... 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
    .... entryRelationship:instruction 0..1 EntryRelationship
    ..... @typeCode 1..1 cs Fixed Value: SUBJ
    ..... @inversionInd 1..1 bl Fixed Value: true
    ..... observation 1..1 InstructionObservation
    .... entryRelationship:supplyOrder 0..1 EntryRelationship
    ..... @typeCode 1..1 cs Fixed Value: REFR
    ..... supply 1..1 MedicationSupplyOrder
    .... entryRelationship:medicationDispense 0..* EntryRelationship
    ..... @typeCode 1..1 cs Fixed Value: REFR
    ..... supply 1..1 MedicationDispense
    .... entryRelationship:reaction 0..* EntryRelationship
    ..... @typeCode 1..1 cs Fixed Value: CAUS
    ..... observation 1..1 ReactionObservation
    .... entryRelationship:drugMonitoring 0..1 EntryRelationship
    ..... @typeCode 1..1 cs Fixed Value: COMP
    ..... act 1..1 DrugMonitoringAct
    .... 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
    .... entryRelationship:adherence 0..* EntryRelationship 𝗨𝗦𝗖𝗗𝗜: Medication Adherence
    ..... @typeCode 1..1 cs Fixed Value: COMP
    ..... observation 1..1 MedicationAdherence
    .... entryRelationship:signature 0..* EntryRelationship 𝗨𝗦𝗖𝗗𝗜: Medication Instructions
    ..... @typeCode 1..1 cs Fixed Value: COMP
    ..... substanceAdministration 1..1 MedicationFreeTextSig
    ... precondition 0..* Precondition
    .... @typeCode 1..1 cs
    .... criterion 1..1 PreconditionforSubstanceAdministration

    doco Documentation for this format

    Terminology Bindings (Differential)

    Path Status Usage ValueSet Version Source
    SubstanceAdministration.​moodCode Base required MoodCodeEvnInt . 📦20240606 VSAC v0.23
    SubstanceAdministration.​statusCode.code Base required Medication Status . 📦20240606 VSAC v0.23
    SubstanceAdministration.​routeCode Base required SPL Drug Route of Administration Terminology . 📦20240716 VSAC v0.23
    SubstanceAdministration.​routeCode.translation Base required Medication Route . 📦20240606 VSAC v0.23
    SubstanceAdministration.​approachSiteCode Base required Body Site Value Set . 📦20240606 VSAC v0.23
    SubstanceAdministration.​doseQuantity.unit Base preferred UnitsOfMeasureCaseSensitive 📦3.0.0 THO v6.5
    SubstanceAdministration.​rateQuantity.unit Base required UnitsOfMeasureCaseSensitive 📦3.0.0 THO v6.5
    SubstanceAdministration.​administrationUnitCode Base required AdministrationUnitDoseForm . 📦20240606 VSAC v0.23

    Constraints

    Id Grade Path(s) Description Expression
    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

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. SubstanceAdministration C 1..1 SubstanceAdministration XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value, 1098-7513, should-routeCode, dose-unit-or-admin-unit, should-author
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @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 Constraints: value-starts-octothorpe
    .... 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.
    Constraints: 1098-32890, should-value-att, should-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 PIVL_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
    ..... phase 0..1 IVL_TS
    ..... period 0..1 PQ
    ..... @alignment 0..1 cs
    ..... @institutionSpecified 0..1 bl
    .... effectiveTime:eventFrequency 0..1 EIVL_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
    ..... event 0..1 CE
    ..... offset 0..1 IVL_PQ
    ... 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)
    Constraints: should-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).
    Constraints: should-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 Constraints: II-1
    ..... @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 1..1 MedicationInformation
    ... subject 0..1 Subject
    ... specimen 0..* Specimen
    ... performer 0..1 Performer2
    ... author 0..* AuthorParticipation
    ... 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 Constraints: II-1
    ...... @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 1..1 DrugVehicle
    ... 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 Constraints: II-1
    ...... @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 1..1 Indication
    ..... 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 Constraints: II-1
    ...... @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 1..1 InstructionObservation
    ..... 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 Constraints: II-1
    ...... @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 1..1 MedicationSupplyOrder
    .... entryRelationship:medicationDispense 0..* EntryRelationship
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 MedicationDispense
    .... entryRelationship:reaction 0..* EntryRelationship
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 ReactionObservation
    ..... 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 Constraints: II-1
    ...... @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 1..1 DrugMonitoringAct
    ..... 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 Constraints: II-1
    ...... @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 1..1 SubstanceAdministeredAct
    ..... 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 Constraints: II-1
    ...... @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 1..1 MedicationAdherence
    ..... 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 Constraints: II-1
    ...... @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 1..1 MedicationFreeTextSig
    ..... 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 Constraints: II-1
    ..... @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
    ... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
    XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    SubstanceAdministration.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​templateId:medication-activity.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​classCode Base required CDAActClass 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​moodCode Base required MoodCodeEvnInt . 📦20240606 VSAC v0.23
    SubstanceAdministration.​code Base example CDAActSubstanceAdministrationCode 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​text.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​text.compression Base required CDACompressionAlgorithm 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
    SubstanceAdministration.​text.mediaType Base example MediaType 📦3.0.0 THO v6.5
    SubstanceAdministration.​text.representation Base required CDABinaryDataEncoding 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​statusCode Base required ActStatus 📦3.0.0 THO v6.5
    SubstanceAdministration.​statusCode.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​statusCode.code Base required Medication Status . 📦20240606 VSAC v0.23
    SubstanceAdministration.​effectiveTime:duration.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​effectiveTime:duration.​operator Base required CDASetOperator 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​effectiveTime:periodicFrequency.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​effectiveTime:periodicFrequency.​operator Base required CDASetOperator 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​effectiveTime:eventFrequency.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​effectiveTime:eventFrequency.​operator Base required CDASetOperator 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​priorityCode Base example ActPriority 📦3.0.0 THO v6.5
    SubstanceAdministration.​routeCode Base required SPL Drug Route of Administration Terminology . 📦20240716 VSAC v0.23
    SubstanceAdministration.​routeCode.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​routeCode.translation Base required Medication Route . 📦20240606 VSAC v0.23
    SubstanceAdministration.​approachSiteCode Base required Body Site Value Set . 📦20240606 VSAC v0.23
    SubstanceAdministration.​doseQuantity.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​doseQuantity.unit Base preferred UnitsOfMeasureCaseSensitive 📦3.0.0 THO v6.5
    SubstanceAdministration.​doseQuantity.operator Base required CDASetOperator 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​rateQuantity.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​rateQuantity.unit Base required UnitsOfMeasureCaseSensitive 📦3.0.0 THO v6.5
    SubstanceAdministration.​rateQuantity.operator Base required CDASetOperator 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​administrationUnitCode Base required AdministrationUnitDoseForm . 📦20240606 VSAC v0.23
    SubstanceAdministration.​consumable.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​consumable.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​consumable.typeCode Base required CDAParticipationType 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​participant:drugVehicle.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​participant:drugVehicle.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​participant:drugVehicle.​typeCode Base required CDAParticipationType 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​participant:drugVehicle.​contextControlCode Base required CDAContextControl 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:indication.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:indication.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:indication.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:instruction.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:instruction.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:instruction.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:supplyOrder.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:supplyOrder.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:supplyOrder.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:medicationDispense.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:medicationDispense.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:medicationDispense.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:reaction.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:reaction.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:reaction.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:drugMonitoring.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:drugMonitoring.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:drugMonitoring.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:substanceAdministered.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:substanceAdministered.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:substanceAdministered.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:adherence.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:adherence.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:adherence.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:signature.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:signature.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:signature.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​precondition.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​precondition.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​precondition.typeCode Base required CDAActRelationshipType 📦2.0.1-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    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()
    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('#')

    Snapshot View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. SubstanceAdministration C 1..1 SubstanceAdministration XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value, 1098-7513, should-routeCode, dose-unit-or-admin-unit, should-author
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @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 Constraints: value-starts-octothorpe
    .... 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.
    Constraints: 1098-32890, should-value-att, should-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 PIVL_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
    ..... phase 0..1 IVL_TS
    ..... period 0..1 PQ
    ..... @alignment 0..1 cs
    ..... @institutionSpecified 0..1 bl
    .... effectiveTime:eventFrequency 0..1 EIVL_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
    ..... event 0..1 CE
    ..... offset 0..1 IVL_PQ
    ... 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)
    Constraints: should-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).
    Constraints: should-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 Constraints: II-1
    ..... @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 1..1 MedicationInformation
    ... subject 0..1 Subject
    ... specimen 0..* Specimen
    ... performer 0..1 Performer2
    ... author 0..* AuthorParticipation
    ... 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 Constraints: II-1
    ...... @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 1..1 DrugVehicle
    ... 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 Constraints: II-1
    ...... @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 1..1 Indication
    ..... 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 Constraints: II-1
    ...... @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 1..1 InstructionObservation
    ..... 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 Constraints: II-1
    ...... @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 1..1 MedicationSupplyOrder
    .... entryRelationship:medicationDispense 0..* EntryRelationship
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 MedicationDispense
    .... entryRelationship:reaction 0..* EntryRelationship
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @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 1..1 ReactionObservation
    ..... 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 Constraints: II-1
    ...... @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 1..1 DrugMonitoringAct
    ..... 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 Constraints: II-1
    ...... @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 1..1 SubstanceAdministeredAct
    ..... 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 Constraints: II-1
    ...... @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 1..1 MedicationAdherence
    ..... 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 Constraints: II-1
    ...... @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 1..1 MedicationFreeTextSig
    ..... 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 Constraints: II-1
    ..... @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
    ... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
    XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    SubstanceAdministration.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​templateId:medication-activity.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​classCode Base required CDAActClass 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​moodCode Base required MoodCodeEvnInt . 📦20240606 VSAC v0.23
    SubstanceAdministration.​code Base example CDAActSubstanceAdministrationCode 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​text.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​text.compression Base required CDACompressionAlgorithm 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
    SubstanceAdministration.​text.mediaType Base example MediaType 📦3.0.0 THO v6.5
    SubstanceAdministration.​text.representation Base required CDABinaryDataEncoding 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​statusCode Base required ActStatus 📦3.0.0 THO v6.5
    SubstanceAdministration.​statusCode.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​statusCode.code Base required Medication Status . 📦20240606 VSAC v0.23
    SubstanceAdministration.​effectiveTime:duration.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​effectiveTime:duration.​operator Base required CDASetOperator 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​effectiveTime:periodicFrequency.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​effectiveTime:periodicFrequency.​operator Base required CDASetOperator 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​effectiveTime:eventFrequency.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​effectiveTime:eventFrequency.​operator Base required CDASetOperator 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​priorityCode Base example ActPriority 📦3.0.0 THO v6.5
    SubstanceAdministration.​routeCode Base required SPL Drug Route of Administration Terminology . 📦20240716 VSAC v0.23
    SubstanceAdministration.​routeCode.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​routeCode.translation Base required Medication Route . 📦20240606 VSAC v0.23
    SubstanceAdministration.​approachSiteCode Base required Body Site Value Set . 📦20240606 VSAC v0.23
    SubstanceAdministration.​doseQuantity.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​doseQuantity.unit Base preferred UnitsOfMeasureCaseSensitive 📦3.0.0 THO v6.5
    SubstanceAdministration.​doseQuantity.operator Base required CDASetOperator 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​rateQuantity.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​rateQuantity.unit Base required UnitsOfMeasureCaseSensitive 📦3.0.0 THO v6.5
    SubstanceAdministration.​rateQuantity.operator Base required CDASetOperator 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​administrationUnitCode Base required AdministrationUnitDoseForm . 📦20240606 VSAC v0.23
    SubstanceAdministration.​consumable.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​consumable.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​consumable.typeCode Base required CDAParticipationType 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​participant:drugVehicle.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​participant:drugVehicle.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​participant:drugVehicle.​typeCode Base required CDAParticipationType 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​participant:drugVehicle.​contextControlCode Base required CDAContextControl 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:indication.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:indication.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:indication.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:instruction.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:instruction.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:instruction.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:supplyOrder.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:supplyOrder.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:supplyOrder.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:medicationDispense.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:medicationDispense.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:medicationDispense.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:reaction.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:reaction.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:reaction.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:drugMonitoring.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:drugMonitoring.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:drugMonitoring.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:substanceAdministered.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:substanceAdministered.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:substanceAdministered.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:adherence.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:adherence.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:adherence.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​entryRelationship:signature.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:signature.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​entryRelationship:signature.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    SubstanceAdministration.​precondition.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​precondition.typeId.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​precondition.typeCode Base required CDAActRelationshipType 📦2.0.1-sd Clinical Document Architecture v2.0

    Constraints

    Id Grade Path(s) Description Expression
    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()
    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('#')

    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:

    • The element 2 is sliced based on the values of SubstanceAdministration.templateId
    • The element 1 is sliced based on the value of SubstanceAdministration.effectiveTime
    • The element 1 is sliced based on the value of SubstanceAdministration.participant
    • The element 4 is sliced based on the values of SubstanceAdministration.entryRelationship

     

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