Consolidated CDA (C-CDA)
4.0.0-ballot - STU4 Ballot 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-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-ccda/ and changes regularly. See the Directory of published versions

Logical Model: MedicationFreeTextSig - Detailed Descriptions

Draft as of 2024-12-19

Definitions for the MedicationFreeTextSig logical model.

Guidance on how to interpret the contents of this table can be found here

0. SubstanceAdministration
Logical ContainerClinicalDocument (CDA Class)
ValidationInstance of this type are validated by templateId
XML FormatIn the XML format, this property has the namespace urn:hl7-org:v3.
Invariantsshould-text-ref-value: SHOULD contain text/reference/@value (text.reference.value.exists())
2. SubstanceAdministration.typeId
Control0..0
4. SubstanceAdministration.templateId
Control1..?
SlicingThis element introduces a set of slices on SubstanceAdministration.templateId. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ root
  • 6. SubstanceAdministration.templateId:med-freeTextSig
    Slice Namemed-freeTextSig
    Control1..1
    8. SubstanceAdministration.templateId:med-freeTextSig.root
    Control1..?
    Pattern Value2.16.840.1.113883.10.20.22.4.147
    10. SubstanceAdministration.templateId:med-freeTextSig.extension
    Control0..0
    12. SubstanceAdministration.classCode
    Comments

    SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:81-32770).

    14. SubstanceAdministration.moodCode
    ShortmoodCode must match the parent substanceAdministration EVN or INT
    Comments

    SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet MoodCodeEvnInt urn:oid:2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03 (CONF:81-32771).

    BindingThe codes SHALL be taken from MoodCodeEvnInt .
    (required to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.18)
    16. SubstanceAdministration.code
    ShortInstructions Medication Narrative
    Comments

    SHALL contain exactly one [1..1] code (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:81-32775).

    Control1..?
    18. SubstanceAdministration.code.code
    Control1..?
    Pattern Value76662-6
    20. SubstanceAdministration.code.codeSystem
    ShortLOINC
    Control1..?
    Pattern Value2.16.840.1.113883.6.1
    22. SubstanceAdministration.text
    ShortSHOULD reference the portion of section narrative text corresponding to this entry
    Comments

    SHALL contain exactly one [1..1] text (CONF:81-32754).

    Control1..?
    24. SubstanceAdministration.text.reference
    ShortReference into the section/text to a tag that only contains free text sig.
    Comments

    This text SHALL contain exactly one [1..1] reference (CONF:81-32755).

    Control1..?
    Invariantsvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative (value.exists() implies value.startsWith('#'))
    26. SubstanceAdministration.text.reference.value
    Comments

    This reference SHOULD contain zero or one [0..1] @value (CONF:81-32756).

    28. SubstanceAdministration.statusCode
    Control0..0
    30. SubstanceAdministration.effectiveTime
    Control0..0
    32. SubstanceAdministration.priorityCode
    Control0..0
    34. SubstanceAdministration.repeatNumber
    Control0..0
    36. SubstanceAdministration.routeCode
    Control0..0
    38. SubstanceAdministration.approachSiteCode
    Control0..0
    40. SubstanceAdministration.doseQuantity
    Control0..0
    42. SubstanceAdministration.rateQuantity
    Control0..0
    44. SubstanceAdministration.maxDoseQuantity
    Control0..0
    46. SubstanceAdministration.administrationUnitCode
    Control0..0
    48. SubstanceAdministration.consumable
    Comments

    SHALL contain exactly one [1..1] consumable (CONF:81-32776).

    50. SubstanceAdministration.consumable.manufacturedProduct
    Comments

    This consumable SHALL contain exactly one [1..1] manufacturedProduct (CONF:81-32777).

    52. SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug
    Comments

    This manufacturedProduct SHALL contain exactly one [1..1] manufacturedLabeledDrug (CONF:81-32778).

    Control1..?
    54. SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.nullFlavor
    Comments

    This manufacturedLabeledDrug SHALL contain exactly one [1..1] @nullFlavor="NA" Not Applicable (CONF:81-32779).

    Control1..?
    Fixed ValueNA
    56. SubstanceAdministration.subject
    Control0..0
    58. SubstanceAdministration.specimen
    Control0..0
    60. SubstanceAdministration.performer
    Control0..0
    62. SubstanceAdministration.informant
    Control0..0
    64. SubstanceAdministration.participant
    Control0..0
    66. SubstanceAdministration.entryRelationship
    Control0..0
    68. SubstanceAdministration.precondition
    Control0..0