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 Free Text Sig

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

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
    ... typeId 0..0
    ... Slices for templateId 1..* II Slice: Unordered, Open by value:root
    .... templateId:med-freeTextSig 1..1 II
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.147
    ..... @extension 0..0
    ... @classCode 1..1 cs
    ... code 1..1 CD Instructions Medication Narrative
    .... @code 1..1 cs Required Pattern: 76662-6
    .... @codeSystem 1..1 oid, uuid, ruid LOINC
    Required Pattern: 2.16.840.1.113883.6.1
    ... text 1..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
    .... reference C 1..1 TEL Reference into the section/text to a tag that only contains free text sig.
    Constraints: value-starts-octothorpe
    ..... @value 0..1 url
    ... statusCode 0..0
    ... effectiveTime 0..0
    ... priorityCode 0..0
    ... repeatNumber 0..0
    ... routeCode 0..0
    ... approachSiteCode 0..0
    ... doseQuantity 0..0
    ... rateQuantity 0..0
    ... maxDoseQuantity 0..0
    ... administrationUnitCode 0..0
    ... consumable 1..1 InfrastructureRoot
    .... manufacturedProduct 1..1 ManufacturedProduct
    ..... manufacturedLabeledDrug 1..1 LabeledDrug
    ...... @nullFlavor 1..1 cs Fixed Value: NA
    ... subject 0..0
    ... specimen 0..0
    ... performer 0..0
    ... informant 0..0
    ... participant 0..0
    ... entryRelationship 0..0
    ... precondition 0..0

    doco Documentation for this format

    Terminology Bindings (Differential)

    Path Status Usage ValueSet Version Source
    SubstanceAdministration.​moodCode Base required MoodCodeEvnInt . 📦20240606 VSAC v0.23

    Constraints

    Id Grade Path(s) Description Expression
    should-text-ref-value warning SubstanceAdministration SHOULD contain text/reference/@value text.reference.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
    ... @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.
    Constraints: value-starts-octothorpe
    ..... @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 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 ManufacturedProduct
    ..... @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
    ..... @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 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
    ...... @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

    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:med-freeTextSig.​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.​code.nullFlavor Base required CDANullFlavor 📦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.​text.reference.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​text.reference.use Base required TelecommunicationAddressUse 📍2.0.0 THO v5.2
    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.​consumable.manufacturedProduct.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​consumable.manufacturedProduct.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​consumable.manufacturedProduct.​classCode Base required RoleClassManufacturedProduct 📦3.0.0 THO v6.5
    SubstanceAdministration.​consumable.manufacturedProduct.​manufacturedLabeledDrug.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​consumable.manufacturedProduct.​manufacturedLabeledDrug.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​consumable.manufacturedProduct.​manufacturedLabeledDrug.​classCode Base required EntityClassManufacturedMaterial 📦3.0.0 THO v6.5
    SubstanceAdministration.​consumable.manufacturedProduct.​manufacturedLabeledDrug.​determinerCode Base required EntityDeterminerDetermined 📦3.0.0 THO v6.5

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error SubstanceAdministration.consumable.typeId, SubstanceAdministration.consumable.manufacturedProduct.typeId, SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    should-text-ref-value warning SubstanceAdministration SHOULD contain text/reference/@value text.reference.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
    ... @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.
    Constraints: value-starts-octothorpe
    ..... @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 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 ManufacturedProduct
    ..... @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
    ..... @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 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
    ...... @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

    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:med-freeTextSig.​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.​code.nullFlavor Base required CDANullFlavor 📦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.​text.reference.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​text.reference.use Base required TelecommunicationAddressUse 📍2.0.0 THO v5.2
    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.​consumable.manufacturedProduct.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​consumable.manufacturedProduct.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​consumable.manufacturedProduct.​classCode Base required RoleClassManufacturedProduct 📦3.0.0 THO v6.5
    SubstanceAdministration.​consumable.manufacturedProduct.​manufacturedLabeledDrug.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​consumable.manufacturedProduct.​manufacturedLabeledDrug.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​consumable.manufacturedProduct.​manufacturedLabeledDrug.​classCode Base required EntityClassManufacturedMaterial 📦3.0.0 THO v6.5
    SubstanceAdministration.​consumable.manufacturedProduct.​manufacturedLabeledDrug.​determinerCode Base required EntityDeterminerDetermined 📦3.0.0 THO v6.5

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error SubstanceAdministration.consumable.typeId, SubstanceAdministration.consumable.manufacturedProduct.typeId, SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    should-text-ref-value warning SubstanceAdministration SHOULD contain text/reference/@value text.reference.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
    Fixed: 1 element
    Prohibited: 19 elements

    Slices

    This structure defines the following Slices:

    • The element 1 is sliced based on the value of SubstanceAdministration.templateId

    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
    ... typeId 0..0
    ... Slices for templateId 1..* II Slice: Unordered, Open by value:root
    .... templateId:med-freeTextSig 1..1 II
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.147
    ..... @extension 0..0
    ... @classCode 1..1 cs
    ... code 1..1 CD Instructions Medication Narrative
    .... @code 1..1 cs Required Pattern: 76662-6
    .... @codeSystem 1..1 oid, uuid, ruid LOINC
    Required Pattern: 2.16.840.1.113883.6.1
    ... text 1..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
    .... reference C 1..1 TEL Reference into the section/text to a tag that only contains free text sig.
    Constraints: value-starts-octothorpe
    ..... @value 0..1 url
    ... statusCode 0..0
    ... effectiveTime 0..0
    ... priorityCode 0..0
    ... repeatNumber 0..0
    ... routeCode 0..0
    ... approachSiteCode 0..0
    ... doseQuantity 0..0
    ... rateQuantity 0..0
    ... maxDoseQuantity 0..0
    ... administrationUnitCode 0..0
    ... consumable 1..1 InfrastructureRoot
    .... manufacturedProduct 1..1 ManufacturedProduct
    ..... manufacturedLabeledDrug 1..1 LabeledDrug
    ...... @nullFlavor 1..1 cs Fixed Value: NA
    ... subject 0..0
    ... specimen 0..0
    ... performer 0..0
    ... informant 0..0
    ... participant 0..0
    ... entryRelationship 0..0
    ... precondition 0..0

    doco Documentation for this format

    Terminology Bindings (Differential)

    Path Status Usage ValueSet Version Source
    SubstanceAdministration.​moodCode Base required MoodCodeEvnInt . 📦20240606 VSAC v0.23

    Constraints

    Id Grade Path(s) Description Expression
    should-text-ref-value warning SubstanceAdministration SHOULD contain text/reference/@value text.reference.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
    ... @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.
    Constraints: value-starts-octothorpe
    ..... @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 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 ManufacturedProduct
    ..... @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
    ..... @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 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
    ...... @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

    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:med-freeTextSig.​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.​code.nullFlavor Base required CDANullFlavor 📦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.​text.reference.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​text.reference.use Base required TelecommunicationAddressUse 📍2.0.0 THO v5.2
    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.​consumable.manufacturedProduct.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​consumable.manufacturedProduct.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​consumable.manufacturedProduct.​classCode Base required RoleClassManufacturedProduct 📦3.0.0 THO v6.5
    SubstanceAdministration.​consumable.manufacturedProduct.​manufacturedLabeledDrug.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​consumable.manufacturedProduct.​manufacturedLabeledDrug.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​consumable.manufacturedProduct.​manufacturedLabeledDrug.​classCode Base required EntityClassManufacturedMaterial 📦3.0.0 THO v6.5
    SubstanceAdministration.​consumable.manufacturedProduct.​manufacturedLabeledDrug.​determinerCode Base required EntityDeterminerDetermined 📦3.0.0 THO v6.5

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error SubstanceAdministration.consumable.typeId, SubstanceAdministration.consumable.manufacturedProduct.typeId, SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    should-text-ref-value warning SubstanceAdministration SHOULD contain text/reference/@value text.reference.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
    ... @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.
    Constraints: value-starts-octothorpe
    ..... @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 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 ManufacturedProduct
    ..... @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
    ..... @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 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
    ...... @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

    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:med-freeTextSig.​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.​code.nullFlavor Base required CDANullFlavor 📦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.​text.reference.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​text.reference.use Base required TelecommunicationAddressUse 📍2.0.0 THO v5.2
    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.​consumable.manufacturedProduct.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​consumable.manufacturedProduct.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​consumable.manufacturedProduct.​classCode Base required RoleClassManufacturedProduct 📦3.0.0 THO v6.5
    SubstanceAdministration.​consumable.manufacturedProduct.​manufacturedLabeledDrug.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​consumable.manufacturedProduct.​manufacturedLabeledDrug.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    SubstanceAdministration.​consumable.manufacturedProduct.​manufacturedLabeledDrug.​classCode Base required EntityClassManufacturedMaterial 📦3.0.0 THO v6.5
    SubstanceAdministration.​consumable.manufacturedProduct.​manufacturedLabeledDrug.​determinerCode Base required EntityDeterminerDetermined 📦3.0.0 THO v6.5

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error SubstanceAdministration.consumable.typeId, SubstanceAdministration.consumable.manufacturedProduct.typeId, SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    should-text-ref-value warning SubstanceAdministration SHOULD contain text/reference/@value text.reference.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
    Fixed: 1 element
    Prohibited: 19 elements

    Slices

    This structure defines the following Slices:

    • The element 1 is sliced based on the value of SubstanceAdministration.templateId

     

    Other representations of profile: CSV, Excel