Consolidated CDA (C-CDA)
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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: PlannedMedicationActivity - Detailed Descriptions

Draft as of 2024-12-19

Definitions for the PlannedMedicationActivity 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())
dose-unit-or-admin-unit: If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. (doseQuantity.unit.exists() implies administrationUnitCode.empty())
should-author: SHOULD contain author (author.exists())
2. 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
  • value @ extension
  • 4. SubstanceAdministration.templateId:planned-med-activity
    Slice Nameplanned-med-activity
    Control1..1
    6. SubstanceAdministration.templateId:planned-med-activity.root
    Control1..?
    Pattern Value2.16.840.1.113883.10.20.22.4.42
    8. SubstanceAdministration.templateId:planned-med-activity.extension
    Control1..?
    Pattern Value2014-06-09
    10. SubstanceAdministration.classCode
    Comments

    SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8572).

    12. SubstanceAdministration.moodCode
    Comments

    SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet Planned moodCode (SubstanceAdministration/Supply) urn:oid:2.16.840.1.113883.11.20.9.24 STATIC 2011-09-30 (CONF:1098-8573).

    BindingThe codes SHALL be taken from Planned moodCode (SubstanceAdministration/Supply) .
    (required to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.24)
    14. SubstanceAdministration.id
    Comments

    SHALL contain at least one [1..*] id (CONF:1098-8575).

    Control1..?
    16. SubstanceAdministration.text
    ShortSHOULD reference the portion of section narrative text corresponding to this entry
    18. SubstanceAdministration.text.reference
    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('#'))
    20. SubstanceAdministration.statusCode
    Comments

    SHALL contain exactly one [1..1] statusCode (CONF:1098-32087).

    Control1..?
    22. SubstanceAdministration.statusCode.code
    Comments

    This statusCode SHALL contain exactly one [1..1] @code="active" Active (CodeSystem: HL7ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:1098-32088).

    Control1..?
    Fixed Valueactive
    24. SubstanceAdministration.effectiveTime
    Control1..?
    SlicingThis element introduces a set of slices on SubstanceAdministration.effectiveTime. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • type @ $this
    • 26. SubstanceAdministration.effectiveTime:duration
      Slice Nameduration
      ShortThe effectiveTime in a planned medication activity represents the time that the medication activity should occur.
      Comments

      SHALL contain exactly one [1..1] effectiveTime (CONF:1098-30468) such that it

      Control1..1
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/IVL-TS
      Invariants1098-32890: 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()))
      should-value-att: SHOULD contain @value (value.exists())
      should-low: SHOULD contain low (low.exists())
      28. SubstanceAdministration.effectiveTime:duration.value
      Shortindicates a single-administration timestamp
      Comments

      SHOULD contain zero or one [0..1] @value (CONF:1098-32775).

      30. SubstanceAdministration.effectiveTime:duration.low
      Shortindicates when medication started
      Comments

      SHOULD contain zero or one [0..1] low (CONF:1098-32776).

      32. SubstanceAdministration.effectiveTime:duration.high
      Shortindicates when medication stopped
      Comments

      MAY contain zero or one [0..1] high (CONF:1098-32777).

      34. SubstanceAdministration.effectiveTime:periodicFrequency
      Slice NameperiodicFrequency
      ShortThis effectiveTime represents a periodic medication frequency (e.g., administration times per day).
      Control0..1
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/EIVL-TS
      36. SubstanceAdministration.effectiveTime:periodicFrequency.operator
      Comments

      SHALL contain exactly one [1..1] @operator="A" (CONF:1098-9106).

      Control1..?
      Pattern ValueA
      38. SubstanceAdministration.effectiveTime:eventFrequency
      Slice NameeventFrequency
      ShortThis effectiveTime represents an event-based medication frequency (e.g., administration at bedtime).
      Control0..1
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/PIVL-TS
      40. SubstanceAdministration.effectiveTime:eventFrequency.operator
      Comments

      SHALL contain exactly one [1..1] @operator="A" (CONF:1098-9106).

      Control1..?
      Pattern ValueA
      42. SubstanceAdministration.repeatNumber
      ShortIn a Planned Medication Activity, repeatNumber defines the number of allowed administrations. For example, a repeatNumber of "3" means that the substance can be administered up to 3 times.
      Comments

      MAY contain zero or one [0..1] repeatNumber (CONF:1098-32066).

      44. SubstanceAdministration.routeCode
      Comments

      MAY contain zero or one [0..1] routeCode, which SHALL be selected from ValueSet SPL Drug Route of Administration Terminology urn:oid:2.16.840.1.113883.3.88.12.3221.8.7 DYNAMIC (CONF:1098-32067).

      BindingThe codes SHALL be taken from SPL Drug Route of Administration Terminology .
      (required to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.7)
      Invariantsshould-translation: SHOULD contain translation (translation.exists())
      46. SubstanceAdministration.routeCode.translation
      Comments

      The routeCode, if present, SHOULD contain zero or more [0..*] translation, which SHOULD be selected from ValueSet Medication Route urn:oid:2.16.840.1.113762.1.4.1099.12 DYNAMIC (CONF:1098-32952).

      BindingThe codes SHOULD be taken from Medication Route .
      (preferred to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.12)
      48. SubstanceAdministration.approachSiteCode
      Comments

      MAY contain zero or more [0..*] approachSiteCode, which SHALL be selected from ValueSet Body Site Value Set urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:1098-32078).

      BindingThe codes SHALL be taken from Body Site Value Set .
      (required to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9)
      50. SubstanceAdministration.doseQuantity
      Comments

      MAY contain zero or one [0..1] doseQuantity (CONF:1098-32068).

      Invariantsshould-unit: SHOULD contain @unit (nullFlavor.exists() or unit.exists())
      52. SubstanceAdministration.doseQuantity.unit
      ShortNOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units
      Comments

      The doseQuantity, if present, SHOULD contain zero or one [0..1] @unit, which SHOULD be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:1098-32133).

      BindingThe codes SHOULD be taken from UnitsOfMeasureCaseSensitive
      (preferred to http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive)
      54. SubstanceAdministration.rateQuantity
      Comments

      MAY contain zero or one [0..1] rateQuantity (CONF:1098-32079).

      Invariantsshould-unit: SHOULD contain @unit (nullFlavor.exists() or unit.exists())
      56. SubstanceAdministration.rateQuantity.unit
      ShortNOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units
      Comments

      The rateQuantity, if present, SHOULD contain zero or one [0..1] @unit, which SHALL be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:1098-32134).

      BindingThe codes SHALL be taken from UnitsOfMeasureCaseSensitive
      (required to http://terminology.hl7.org/ValueSet/v3-UnitsOfMeasureCaseSensitive)
      58. SubstanceAdministration.maxDoseQuantity
      Comments

      MAY contain zero or one [0..1] maxDoseQuantity (CONF:1098-32080).

      60. SubstanceAdministration.administrationUnitCode
      Comments

      MAY contain zero or one [0..1] administrationUnitCode, which SHALL be selected from ValueSet AdministrationUnitDoseForm urn:oid:2.16.840.1.113762.1.4.1021.30 DYNAMIC (CONF:1098-32081).

      BindingThe codes SHALL be taken from AdministrationUnitDoseForm .
      (required to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.30)
      62. SubstanceAdministration.consumable
      Comments

      SHALL contain exactly one [1..1] consumable (CONF:1098-32082).

      64. SubstanceAdministration.consumable.manufacturedProduct
      Comments

      This consumable SHALL contain exactly one [1..1] Medication Information (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.23:2014-06-09) (CONF:1098-32083).

      Typehttp://hl7.org/cda/stds/core/StructureDefinition/ManufacturedProduct(Medication Information)
      66. SubstanceAdministration.performer
      ShortThe clinician who is expected to perform the medication activity could be identified using substanceAdministration/performer.
      Comments

      MAY contain zero or more [0..*] performer (CONF:1098-30470).

      68. SubstanceAdministration.author
      ShortThe author in a planned medication activity represents the clinician who is requesting or planning the medication activity.
      Comments

      SHOULD contain zero or one [0..1] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-32046).

      Control0..1
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/Author(Author Participation)
      70. SubstanceAdministration.entryRelationship
      SlicingThis element introduces a set of slices on SubstanceAdministration.entryRelationship. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • profile @ observation
      • 72. SubstanceAdministration.entryRelationship:priorityPreference
        Slice NamepriorityPreference
        ShortThe following entryRelationship represents the priority that a patient or a provider places on the planned medication activity.
        Comments

        MAY contain zero or more [0..*] entryRelationship (CONF:1098-31104) such that it

        Control0..*
        74. SubstanceAdministration.entryRelationship:priorityPreference.typeCode
        Comments

        SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-31105).

        Fixed ValueREFR
        76. SubstanceAdministration.entryRelationship:priorityPreference.observation
        Comments

        SHALL contain exactly one [1..1] Priority Preference (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.143) (CONF:1098-31106).

        Control1..?
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Priority Preference)
        78. SubstanceAdministration.entryRelationship:indication
        Slice Nameindication
        ShortThe following entryRelationship represents the indication for the planned medication activity.
        Comments

        MAY contain zero or more [0..*] entryRelationship (CONF:1098-32069) such that it

        Control0..*
        80. SubstanceAdministration.entryRelationship:indication.typeCode
        Comments

        SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-32070).

        Fixed ValueRSON
        82. SubstanceAdministration.entryRelationship:indication.observation
        Comments

        SHALL contain exactly one [1..1] Indication (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:1098-32071).

        Control1..?
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Indication)
        84. SubstanceAdministration.entryRelationship:instruction
        Slice Nameinstruction
        ShortThe following entryRelationship captures any instructions associated with the planned medication activity.
        Comments

        MAY contain zero or more [0..*] entryRelationship (CONF:1098-32072) such that it

        Control0..*
        86. SubstanceAdministration.entryRelationship:instruction.typeCode
        Comments

        SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-32073).

        Fixed ValueSUBJ
        88. SubstanceAdministration.entryRelationship:instruction.observation
        Control1..?
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Instruction Observation)
        90. SubstanceAdministration.precondition
        Comments

        MAY contain zero or more [0..*] precondition (CONF:1098-32084).

        92. SubstanceAdministration.precondition.typeCode
        Comments

        The precondition, if present, SHALL contain exactly one [1..1] @typeCode="PRCN" Precondition (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-32085).

        Control1..?
        94. SubstanceAdministration.precondition.criterion
        Comments

        The precondition, if present, SHALL contain exactly one [1..1] Precondition for Substance Administration (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.25:2014-06-09) (CONF:1098-32086).

        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Criterion(Precondition for Substance Administration)