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: Medication Free Text Sig

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/MedicationFreeTextSig Version: 4.0.0-ballot
Draft as of 2024-12-19 Computable Name: MedicationFreeTextSig
Other Identifiers: OID:2.16.840.1.113883.10.20.22.4.147

The template is available to explicitly identify the free text Sig within each medication.

An example free text sig: Thyroxin 150 ug, take one tab by mouth every morning.

NOTE: This is a Closed template so only the elements needed for the template are allowed. All other elements are not allowed.

Usage:

Formal Views of Template Content

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration C 1..1 SubstanceAdministration XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, repeatNumber, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode, consumable, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcInFulfillmentOf1
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... Slices for templateId 1..* II Slice: Unordered, Open by value:root
.... templateId:med-freeTextSig 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: 2.16.840.1.113883.10.20.22.4.147
... @moodCode 1..1 cs moodCode must match the parent substanceAdministration EVN or INT
Binding: MoodCodeEvnInt . (required)
... id 0..* II
... code 1..1 CD Instructions Medication Narrative
Binding: CDAActSubstanceAdministrationCode (example)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 76662-6
.... @codeSystem 1..1 oid, uuid, ruid LOINC
Required Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... qualifier 0..* CR
.... translation 0..* CD
... @negationInd 0..1 bl
... text 1..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 1..1 TEL Reference into the section/text to a tag that only contains free text sig.
value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @value 0..1 url
..... useablePeriod 0..*
...... useablePeriod IVL_TS
...... useablePeriod EIVL_TS
...... useablePeriod PIVL_TS
...... useablePeriod SXPR_TS
..... @use 0..* cs Binding: TelecommunicationAddressUse (2.0.0) (required)
.... thumbnail 0..1 ED
... consumable 1..1 InfrastructureRoot
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: CDAParticipationType (required)
Fixed Value: CSM
.... manufacturedProduct 1..1 ManufacturedProduct
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @classCode 0..1 cs Binding: RoleClassManufacturedProduct (required)
Fixed Value: MANU
..... id 0..* II
..... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... manufacturedLabeledDrug 1..1 LabeledDrug
...... @nullFlavor 1..1 cs Binding: CDANullFlavor (required)
Fixed Value: NA
...... realmCode 0..* CS
...... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... templateId 0..* II
...... @classCode 0..1 cs Binding: EntityClassManufacturedMaterial (required)
Fixed Value: MMAT
...... @determinerCode 0..1 cs Binding: EntityDeterminerDetermined (required)
Fixed Value: KIND
...... code 0..1 CE
...... name 0..1 EN
..... manufacturedMaterial 0..1 Material
..... manufacturerOrganization 0..1 Organization
... author 0..* Author
... reference 0..* Reference
... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
SubstanceAdministration.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.templateId:med-freeTextSig.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.classCoderequiredFixed Value: SBADM
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
SubstanceAdministration.moodCoderequiredMoodCodeEvnInt .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.18
SubstanceAdministration.codeexampleCDAActSubstanceAdministrationCode
http://hl7.org/cda/stds/core/ValueSet/CDAActSubstanceAdministrationCode
SubstanceAdministration.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.text.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.text.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
SubstanceAdministration.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
SubstanceAdministration.text.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
SubstanceAdministration.text.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
SubstanceAdministration.text.reference.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.text.reference.userequiredTelecommunicationAddressUse
http://terminology.hl7.org/ValueSet/v3-TelecommunicationAddressUse|2.0.0
SubstanceAdministration.consumable.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.consumable.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.consumable.typeCoderequiredFixed Value: CSM
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
SubstanceAdministration.consumable.manufacturedProduct.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.consumable.manufacturedProduct.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.consumable.manufacturedProduct.classCoderequiredFixed Value: MANU
http://terminology.hl7.org/ValueSet/v3-RoleClassManufacturedProduct
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.nullFlavorrequiredFixed Value: NA
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.classCoderequiredFixed Value: MMAT
http://terminology.hl7.org/ValueSet/v3-EntityClassManufacturedMaterial
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.determinerCoderequiredFixed Value: KIND
http://terminology.hl7.org/ValueSet/v3-EntityDeterminerDetermined

Constraints

IdGradePath(s)DetailsRequirements
II-1errorSubstanceAdministration.consumable.typeId, SubstanceAdministration.consumable.manufacturedProduct.typeId, SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.typeIdAn II instance must have either a root or an nullFlavor.
: root.exists() or nullFlavor.exists()
should-text-ref-valuewarningSubstanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorSubstanceAdministration.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

 

Other representations of profile: CSV, Excel