Consolidated CDA (C-CDA)
3.0.0 - STU3
Consolidated CDA (C-CDA)
3.0.0 - STU3
Consolidated CDA (C-CDA), published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 3.0.0 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
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/PlannedMedicationActivity | Version: 3.0.0 | |||
| Draft as of 2024-07-23 | Computable Name: PlannedMedicationActivity | |||
| Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.4.42:2014-06-09 | ||||
This template represents planned medication activities. The priority of the medication activity to the patient and provider is communicated through Priority Preference. The effectiveTime indicates the time when the medication activity is intended to take place. The authorTime indicates when the documentation of the plan occurred.
Usage:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from SubstanceAdministration
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  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 dose-unit-or-admin-unit: If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. should-author: SHOULD contain author |
  Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:planned-med-activity |
1..1 | II | ||
  @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.42 | |
  @extension |
1..1 | st | Required Pattern: 2014-06-09 | |
 @classCode |
1..1 | cs | ||
| @moodCode |
1..1 | cs | Binding: Planned moodCode (SubstanceAdministration/Supply)  (required) | |
| id |
1..* | II | ||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
 reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| statusCode |
1..1 | CS | ||
| @code |
1..1 | cs | Fixed Value: active | |
| 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 effectiveTime in a planned medication activity represents the time that the medication activity should occur. 1098-32890: This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890). should-value-att: SHOULD contain @value should-low: SHOULD contain 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 | EIVL_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 | PIVL_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 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. | |
| routeCode |
C | 0..1 | CE | Binding: SPL Drug Route of Administration Terminology (required) should-translation: SHOULD contain translation |
| translation |
0..* | CD | Binding: Medication Route (preferred) | |
| approachSiteCode |
0..* | CD | Binding: Body Site Value Set (required) | |
| doseQuantity |
C | 0..1 | IVL_PQ | should-unit: SHOULD contain @unit |
| @unit |
0..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 (preferred) | |
| rateQuantity |
C | 0..1 | IVL_PQ | should-unit: SHOULD contain @unit |
| @unit |
0..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 | Binding: AdministrationUnitDoseForm (required) | |
| consumable |
1..1 | InfrastructureRoot | ||
 manufacturedProduct |
1..1 | MedicationInformation | Base for all types and resources | |
| performer |
0..* | Performer2 | The clinician who is expected to perform the medication activity could be identified using substanceAdministration/performer. | |
| author |
0..1 | AuthorParticipation | The author in a planned medication activity represents the clinician who is requesting or planning the medication activity. | |
| Slices for entryRelationship |
0..* | EntryRelationship | The following entryRelationship captures any instructions associated with the planned medication activity. Slice: Unordered, Open by profile:act, profile:observation | |
| entryRelationship:priorityPreference |
0..* | EntryRelationship | The following entryRelationship represents the priority that a patient or a provider places on the planned medication activity. | |
| @typeCode |
1..1 | cs | Fixed Value: REFR | |
| observation |
1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:indication |
0..* | EntryRelationship | The following entryRelationship represents the indication for the planned medication activity. | |
| @typeCode |
1..1 | cs | Fixed Value: RSON | |
| observation |
1..1 | Indication | Base for all types and resources | |
| entryRelationship:instruction |
0..* | EntryRelationship | ||
| @typeCode |
1..1 | cs | Fixed Value: SUBJ | |
| act |
1..1 | Instruction | Base for all types and resources | |
 precondition |
0..* | Precondition | ||
| @typeCode |
1..1 | cs | ||
| criterion |
1..1 | PreconditionforSubstanceAdministration | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| SubstanceAdministration.moodCode | required | PlannedMoodCodeSubstanceAdministrationSupply http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.24 | |
| SubstanceAdministration.routeCode | required | SPLDrugRouteOfAdministrationTerminology http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.7 | |
| SubstanceAdministration.routeCode.translation | preferred | MedicationRoute http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.12 | |
| SubstanceAdministration.approachSiteCode | required | BodySiteValueSet http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9 | |
| SubstanceAdministration.doseQuantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12839 | |
| SubstanceAdministration.rateQuantity.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12839 | |
| SubstanceAdministration.administrationUnitCode | required | AdministrationUnitDoseForm http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.30 |
| Id | Grade | Path(s) | Details | Requirements |
| 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-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, SubstanceAdministration.rateQuantity | 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('#') |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| 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 dose-unit-or-admin-unit: If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. should-author: SHOULD contain author |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:planned-med-activity |
1..1 | II | ||
 @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.42 | |
| @extension |
1..1 | st | Required Pattern: 2014-06-09 | |
| @classCode |
1..1 | cs | Binding: CDAActClass (required) Fixed Value: SBADM | |
| @moodCode |
1..1 | cs | Binding: Planned moodCode (SubstanceAdministration/Supply) (required) | |
| id |
1..* | II | ||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |
| @code |
1..1 | cs | Fixed Value: active | |
| 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 effectiveTime in a planned medication activity represents the time that the medication activity should occur. 1098-32890: This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890). should-value-att: SHOULD contain @value should-low: SHOULD contain low |
| @value |
0..1 | ts | indicates a single-administration timestamp Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| low |
0..1 | IVXB_TS | indicates when medication started | |
| high |
0..1 | IVXB_TS | indicates when medication stopped | |
| effectiveTime:periodicFrequency |
0..1 | EIVL_TS | This effectiveTime represents a periodic medication frequency (e.g., administration times per day). | |
| @operator |
1..1 | cs | Binding: CDASetOperator (required) Required Pattern: A | |
| effectiveTime:eventFrequency |
0..1 | PIVL_TS | This effectiveTime represents an event-based medication frequency (e.g., administration at bedtime). | |
| @operator |
1..1 | cs | Binding: CDASetOperator (required) Required Pattern: A | |
| repeatNumber |
0..1 | IVL_INT | In 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. | |
| routeCode |
C | 0..1 | CE | Binding: SPL Drug Route of Administration Terminology (required) should-translation: SHOULD contain translation |
| translation |
0..* | CD | Binding: Medication Route (preferred) | |
| approachSiteCode |
0..* | CD | Binding: Body Site Value Set (required) | |
| doseQuantity |
C | 0..1 | IVL_PQ | should-unit: SHOULD contain @unit |
| @unit |
0..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 (preferred) | |
| rateQuantity |
C | 0..1 | IVL_PQ | should-unit: SHOULD contain @unit |
| @unit |
0..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 | Binding: AdministrationUnitDoseForm (required) | |
| consumable |
1..1 | InfrastructureRoot | ||
| manufacturedProduct |
C | 1..1 | MedicationInformation | Base for all types and resources product-choice: manufacturedLabeledDrug and manufacturedMaterial are mutually exclusive (one must be present) |
| performer |
0..* | Performer2 | The clinician who is expected to perform the medication activity could be identified using substanceAdministration/performer. | |
| author |
0..1 | AuthorParticipation | The author in a planned medication activity represents the clinician who is requesting or planning the medication activity. | |
| Slices for entryRelationship |
0..* | EntryRelationship | The following entryRelationship captures any instructions associated with the planned medication activity. Slice: Unordered, Open by profile:act, profile:observation | |
| entryRelationship:priorityPreference |
0..* | EntryRelationship | The following entryRelationship represents the priority that a patient or a provider places on the planned medication activity. | |
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| observation |
C | 1..1 | PriorityPreference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author |
| entryRelationship:indication |
0..* | EntryRelationship | The following entryRelationship represents the indication for the planned medication activity. | |
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |
| observation |
C | 1..1 | Indication | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime indication-value: If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry. |
| entryRelationship:instruction |
0..* | EntryRelationship | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| act |
C | 1..1 | Instruction | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| precondition |
0..* | Precondition | ||
| @typeCode |
1..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: PRCN | |
| criterion |
1..1 | PreconditionforSubstanceAdministration | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| SubstanceAdministration.classCode | required | Fixed Value: SBADMhttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
| SubstanceAdministration.moodCode | required | PlannedMoodCodeSubstanceAdministrationSupply http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.24 | |
| SubstanceAdministration.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| SubstanceAdministration.effectiveTime:periodicFrequency.operator | required | Pattern: Ahttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.effectiveTime:eventFrequency.operator | required | Pattern: Ahttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.routeCode | required | SPLDrugRouteOfAdministrationTerminology http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.7 | |
| SubstanceAdministration.routeCode.translation | preferred | MedicationRoute http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.12 | |
| SubstanceAdministration.approachSiteCode | required | BodySiteValueSet http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9 | |
| SubstanceAdministration.doseQuantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12839 | |
| SubstanceAdministration.rateQuantity.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12839 | |
| SubstanceAdministration.administrationUnitCode | required | AdministrationUnitDoseForm http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.30 | |
| SubstanceAdministration.entryRelationship:priorityPreference.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:indication.typeCode | required | Fixed Value: RSONhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:instruction.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.precondition.typeCode | required | Fixed Value: PRCNhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType |
| Id | Grade | Path(s) | Details | Requirements |
| 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() | |
| indication-value | error | SubstanceAdministration.entryRelationship:indication.observation | If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry. : value.exists() or (%resource.descendants().ofType(CDA.Observation).where(id.exists($this.root = %context.id.first().root and $this.extension ~ %context.id.first().extension) and value.exists())) | |
| product-choice | error | SubstanceAdministration.consumable.manufacturedProduct | manufacturedLabeledDrug and manufacturedMaterial are mutually exclusive (one must be present) : (manufacturedLabeledDrug | manufacturedMaterial).count() = 1 | |
| should-author | warning | SubstanceAdministration | SHOULD contain author : author.exists() | |
| should-author | warning | SubstanceAdministration.entryRelationship:priorityPreference.observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | SubstanceAdministration.entryRelationship:priorityPreference.observation, SubstanceAdministration.entryRelationship:indication.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-low | warning | SubstanceAdministration.effectiveTime:duration | SHOULD contain low : low.exists() | |
| should-text-ref-value | warning | SubstanceAdministration | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | SubstanceAdministration.entryRelationship:priorityPreference.observation, SubstanceAdministration.entryRelationship:indication.observation, SubstanceAdministration.entryRelationship:instruction.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-translation | warning | SubstanceAdministration.routeCode | SHOULD contain translation : translation.exists() | |
| should-unit | warning | SubstanceAdministration.doseQuantity, SubstanceAdministration.rateQuantity | 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('#') |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| 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 dose-unit-or-admin-unit: If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. should-author: SHOULD contain author |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @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:planned-med-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: 2.16.840.1.113883.10.20.22.4.42 | |
| @extension |
1..1 | st | Required Pattern: 2014-06-09 | |
| @classCode |
1..1 | cs | Binding: CDAActClass (required) Fixed Value: SBADM | |
| @moodCode |
1..1 | cs | Binding: Planned moodCode (SubstanceAdministration/Supply) (required) | |
| id |
1..* | II | ||
| code |
0..1 | CD | 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 | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| thumbnail |
0..1 | ED | ||
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Fixed Value: active | |
| @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 effectiveTime in a planned medication activity represents the time that the medication activity should occur. 1098-32890: This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890). should-value-att: SHOULD contain @value should-low: SHOULD contain 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 | EIVL_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 | |
| event |
0..1 | CE | ||
| offset |
0..1 | IVL_PQ | ||
| effectiveTime:eventFrequency |
0..1 | PIVL_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 | |
| phase |
0..1 | IVL_TS | ||
| period |
0..1 | PQ | ||
| @alignment |
0..1 | cs | ||
| @institutionSpecified |
0..1 | bl | ||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| repeatNumber |
0..1 | IVL_INT | In 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. | |
| routeCode |
C | 0..1 | CE | Binding: SPL Drug Route of Administration Terminology (required) should-translation: SHOULD contain 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 | Binding: Medication Route (preferred) | |
| approachSiteCode |
0..* | CD | Binding: Body Site Value Set (required) | |
| doseQuantity |
C | 0..1 | IVL_PQ | should-unit: SHOULD contain @unit |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @unit |
0..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 (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 |
C | 0..1 | IVL_PQ | should-unit: SHOULD contain @unit |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @unit |
0..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 | Binding: AdministrationUnitDoseForm (required) | |
| consumable |
1..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @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 |
C | 1..1 | MedicationInformation | Base for all types and resources product-choice: manufacturedLabeledDrug and manufacturedMaterial are mutually exclusive (one must be present) |
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | The clinician who is expected to perform the medication activity could be identified using substanceAdministration/performer. | |
| author |
0..1 | AuthorParticipation | The author in a planned medication activity represents the clinician who is requesting or planning the medication activity. | |
| informant |
0..* | Informant | ||
| participant |
0..* | Participant2 | ||
| Slices for entryRelationship |
0..* | EntryRelationship | The following entryRelationship captures any instructions associated with the planned medication activity. Slice: Unordered, Open by profile:act, profile:observation | |
| entryRelationship:priorityPreference |
0..* | EntryRelationship | The following entryRelationship represents the priority that a patient or a provider places on the planned medication activity. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
 typeId |
0..1 | II | ||
 @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 |
C | 1..1 | PriorityPreference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author |
| 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:indication |
0..* | EntryRelationship | The following entryRelationship represents the indication for the planned medication activity. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @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 |
C | 1..1 | Indication | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime indication-value: If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry. |
| 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..* | EntryRelationship | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @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 |
0..1 | bl | ||
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
C | 1..1 | Instruction | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| 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 | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @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 | Base for all types and resources | |
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| SubstanceAdministration.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.templateId:planned-med-activity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.classCode | required | Fixed Value: SBADMhttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
| SubstanceAdministration.moodCode | required | PlannedMoodCodeSubstanceAdministrationSupply http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.24 | |
| SubstanceAdministration.code | example | CDAActSubstanceAdministrationCodehttp://hl7.org/cda/stds/core/ValueSet/CDAActSubstanceAdministrationCode | |
| SubstanceAdministration.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| SubstanceAdministration.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| SubstanceAdministration.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| SubstanceAdministration.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| SubstanceAdministration.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| SubstanceAdministration.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.effectiveTime:duration.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.effectiveTime:duration.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.effectiveTime:periodicFrequency.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.effectiveTime:periodicFrequency.operator | required | Pattern: Ahttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.effectiveTime:eventFrequency.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.effectiveTime:eventFrequency.operator | required | Pattern: Ahttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| SubstanceAdministration.routeCode | required | SPLDrugRouteOfAdministrationTerminology http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.7 | |
| SubstanceAdministration.routeCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.routeCode.translation | preferred | MedicationRoute http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.12 | |
| SubstanceAdministration.approachSiteCode | required | BodySiteValueSet http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9 | |
| SubstanceAdministration.doseQuantity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.doseQuantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12839 | |
| SubstanceAdministration.doseQuantity.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.rateQuantity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.rateQuantity.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12839 | |
| SubstanceAdministration.rateQuantity.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.administrationUnitCode | required | AdministrationUnitDoseForm http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.30 | |
| SubstanceAdministration.consumable.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.consumable.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.consumable.typeCode | required | Fixed Value: CSMhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| SubstanceAdministration.entryRelationship:priorityPreference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:priorityPreference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:priorityPreference.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:indication.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:indication.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:indication.typeCode | required | Fixed Value: RSONhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:instruction.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:instruction.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:instruction.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.precondition.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.precondition.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.precondition.typeCode | required | Fixed Value: PRCNhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType |
| Id | Grade | Path(s) | Details | Requirements |
| 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() | |
| indication-value | error | SubstanceAdministration.entryRelationship:indication.observation | If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry. : value.exists() or (%resource.descendants().ofType(CDA.Observation).where(id.exists($this.root = %context.id.first().root and $this.extension ~ %context.id.first().extension) and value.exists())) | |
| product-choice | error | SubstanceAdministration.consumable.manufacturedProduct | manufacturedLabeledDrug and manufacturedMaterial are mutually exclusive (one must be present) : (manufacturedLabeledDrug | manufacturedMaterial).count() = 1 | |
| should-author | warning | SubstanceAdministration | SHOULD contain author : author.exists() | |
| should-author | warning | SubstanceAdministration.entryRelationship:priorityPreference.observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | SubstanceAdministration.entryRelationship:priorityPreference.observation, SubstanceAdministration.entryRelationship:indication.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-low | warning | SubstanceAdministration.effectiveTime:duration | SHOULD contain low : low.exists() | |
| should-text-ref-value | warning | SubstanceAdministration | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | SubstanceAdministration.entryRelationship:priorityPreference.observation, SubstanceAdministration.entryRelationship:indication.observation, SubstanceAdministration.entryRelationship:instruction.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-translation | warning | SubstanceAdministration.routeCode | SHOULD contain translation : translation.exists() | |
| should-unit | warning | SubstanceAdministration.doseQuantity, SubstanceAdministration.rateQuantity | 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: 9 elements(6 nested mandatory elements)
Fixed: 4 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from SubstanceAdministration
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| 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 dose-unit-or-admin-unit: If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. should-author: SHOULD contain author |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:planned-med-activity |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.42 | |
| @extension |
1..1 | st | Required Pattern: 2014-06-09 | |
| @classCode |
1..1 | cs | ||
| @moodCode |
1..1 | cs | Binding: Planned moodCode (SubstanceAdministration/Supply) (required) | |
| id |
1..* | II | ||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| statusCode |
1..1 | CS | ||
| @code |
1..1 | cs | Fixed Value: active | |
| 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 effectiveTime in a planned medication activity represents the time that the medication activity should occur. 1098-32890: This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890). should-value-att: SHOULD contain @value should-low: SHOULD contain 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 | EIVL_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 | PIVL_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 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. | |
| routeCode |
C | 0..1 | CE | Binding: SPL Drug Route of Administration Terminology (required) should-translation: SHOULD contain translation |
| translation |
0..* | CD | Binding: Medication Route (preferred) | |
| approachSiteCode |
0..* | CD | Binding: Body Site Value Set (required) | |
| doseQuantity |
C | 0..1 | IVL_PQ | should-unit: SHOULD contain @unit |
| @unit |
0..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 (preferred) | |
| rateQuantity |
C | 0..1 | IVL_PQ | should-unit: SHOULD contain @unit |
| @unit |
0..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 | Binding: AdministrationUnitDoseForm (required) | |
| consumable |
1..1 | InfrastructureRoot | ||
| manufacturedProduct |
1..1 | MedicationInformation | Base for all types and resources | |
| performer |
0..* | Performer2 | The clinician who is expected to perform the medication activity could be identified using substanceAdministration/performer. | |
| author |
0..1 | AuthorParticipation | The author in a planned medication activity represents the clinician who is requesting or planning the medication activity. | |
| Slices for entryRelationship |
0..* | EntryRelationship | The following entryRelationship captures any instructions associated with the planned medication activity. Slice: Unordered, Open by profile:act, profile:observation | |
| entryRelationship:priorityPreference |
0..* | EntryRelationship | The following entryRelationship represents the priority that a patient or a provider places on the planned medication activity. | |
| @typeCode |
1..1 | cs | Fixed Value: REFR | |
| observation |
1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:indication |
0..* | EntryRelationship | The following entryRelationship represents the indication for the planned medication activity. | |
| @typeCode |
1..1 | cs | Fixed Value: RSON | |
| observation |
1..1 | Indication | Base for all types and resources | |
| entryRelationship:instruction |
0..* | EntryRelationship | ||
| @typeCode |
1..1 | cs | Fixed Value: SUBJ | |
| act |
1..1 | Instruction | Base for all types and resources | |
| precondition |
0..* | Precondition | ||
| @typeCode |
1..1 | cs | ||
| criterion |
1..1 | PreconditionforSubstanceAdministration | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| SubstanceAdministration.moodCode | required | PlannedMoodCodeSubstanceAdministrationSupply http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.24 | |
| SubstanceAdministration.routeCode | required | SPLDrugRouteOfAdministrationTerminology http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.7 | |
| SubstanceAdministration.routeCode.translation | preferred | MedicationRoute http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.12 | |
| SubstanceAdministration.approachSiteCode | required | BodySiteValueSet http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9 | |
| SubstanceAdministration.doseQuantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12839 | |
| SubstanceAdministration.rateQuantity.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12839 | |
| SubstanceAdministration.administrationUnitCode | required | AdministrationUnitDoseForm http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.30 |
| Id | Grade | Path(s) | Details | Requirements |
| 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-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, SubstanceAdministration.rateQuantity | 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
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| 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 dose-unit-or-admin-unit: If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. should-author: SHOULD contain author |
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:planned-med-activity |
1..1 | II | ||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.42 | |
| @extension |
1..1 | st | Required Pattern: 2014-06-09 | |
| @classCode |
1..1 | cs | Binding: CDAActClass (required) Fixed Value: SBADM | |
| @moodCode |
1..1 | cs | Binding: Planned moodCode (SubstanceAdministration/Supply) (required) | |
| id |
1..* | II | ||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |
| @code |
1..1 | cs | Fixed Value: active | |
| 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 effectiveTime in a planned medication activity represents the time that the medication activity should occur. 1098-32890: This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890). should-value-att: SHOULD contain @value should-low: SHOULD contain low |
| @value |
0..1 | ts | indicates a single-administration timestamp Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz] | |
| low |
0..1 | IVXB_TS | indicates when medication started | |
| high |
0..1 | IVXB_TS | indicates when medication stopped | |
| effectiveTime:periodicFrequency |
0..1 | EIVL_TS | This effectiveTime represents a periodic medication frequency (e.g., administration times per day). | |
| @operator |
1..1 | cs | Binding: CDASetOperator (required) Required Pattern: A | |
| effectiveTime:eventFrequency |
0..1 | PIVL_TS | This effectiveTime represents an event-based medication frequency (e.g., administration at bedtime). | |
| @operator |
1..1 | cs | Binding: CDASetOperator (required) Required Pattern: A | |
| repeatNumber |
0..1 | IVL_INT | In 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. | |
| routeCode |
C | 0..1 | CE | Binding: SPL Drug Route of Administration Terminology (required) should-translation: SHOULD contain translation |
| translation |
0..* | CD | Binding: Medication Route (preferred) | |
| approachSiteCode |
0..* | CD | Binding: Body Site Value Set (required) | |
| doseQuantity |
C | 0..1 | IVL_PQ | should-unit: SHOULD contain @unit |
| @unit |
0..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 (preferred) | |
| rateQuantity |
C | 0..1 | IVL_PQ | should-unit: SHOULD contain @unit |
| @unit |
0..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 | Binding: AdministrationUnitDoseForm (required) | |
| consumable |
1..1 | InfrastructureRoot | ||
| manufacturedProduct |
C | 1..1 | MedicationInformation | Base for all types and resources product-choice: manufacturedLabeledDrug and manufacturedMaterial are mutually exclusive (one must be present) |
| performer |
0..* | Performer2 | The clinician who is expected to perform the medication activity could be identified using substanceAdministration/performer. | |
| author |
0..1 | AuthorParticipation | The author in a planned medication activity represents the clinician who is requesting or planning the medication activity. | |
| Slices for entryRelationship |
0..* | EntryRelationship | The following entryRelationship captures any instructions associated with the planned medication activity. Slice: Unordered, Open by profile:act, profile:observation | |
| entryRelationship:priorityPreference |
0..* | EntryRelationship | The following entryRelationship represents the priority that a patient or a provider places on the planned medication activity. | |
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |
| observation |
C | 1..1 | PriorityPreference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author |
| entryRelationship:indication |
0..* | EntryRelationship | The following entryRelationship represents the indication for the planned medication activity. | |
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |
| observation |
C | 1..1 | Indication | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime indication-value: If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry. |
| entryRelationship:instruction |
0..* | EntryRelationship | ||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| act |
C | 1..1 | Instruction | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| precondition |
0..* | Precondition | ||
| @typeCode |
1..1 | cs | Binding: CDAActRelationshipType (required) Fixed Value: PRCN | |
| criterion |
1..1 | PreconditionforSubstanceAdministration | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| SubstanceAdministration.classCode | required | Fixed Value: SBADMhttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
| SubstanceAdministration.moodCode | required | PlannedMoodCodeSubstanceAdministrationSupply http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.24 | |
| SubstanceAdministration.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| SubstanceAdministration.effectiveTime:periodicFrequency.operator | required | Pattern: Ahttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.effectiveTime:eventFrequency.operator | required | Pattern: Ahttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.routeCode | required | SPLDrugRouteOfAdministrationTerminology http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.7 | |
| SubstanceAdministration.routeCode.translation | preferred | MedicationRoute http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.12 | |
| SubstanceAdministration.approachSiteCode | required | BodySiteValueSet http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9 | |
| SubstanceAdministration.doseQuantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12839 | |
| SubstanceAdministration.rateQuantity.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12839 | |
| SubstanceAdministration.administrationUnitCode | required | AdministrationUnitDoseForm http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.30 | |
| SubstanceAdministration.entryRelationship:priorityPreference.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:indication.typeCode | required | Fixed Value: RSONhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:instruction.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.precondition.typeCode | required | Fixed Value: PRCNhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType |
| Id | Grade | Path(s) | Details | Requirements |
| 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() | |
| indication-value | error | SubstanceAdministration.entryRelationship:indication.observation | If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry. : value.exists() or (%resource.descendants().ofType(CDA.Observation).where(id.exists($this.root = %context.id.first().root and $this.extension ~ %context.id.first().extension) and value.exists())) | |
| product-choice | error | SubstanceAdministration.consumable.manufacturedProduct | manufacturedLabeledDrug and manufacturedMaterial are mutually exclusive (one must be present) : (manufacturedLabeledDrug | manufacturedMaterial).count() = 1 | |
| should-author | warning | SubstanceAdministration | SHOULD contain author : author.exists() | |
| should-author | warning | SubstanceAdministration.entryRelationship:priorityPreference.observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | SubstanceAdministration.entryRelationship:priorityPreference.observation, SubstanceAdministration.entryRelationship:indication.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-low | warning | SubstanceAdministration.effectiveTime:duration | SHOULD contain low : low.exists() | |
| should-text-ref-value | warning | SubstanceAdministration | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | SubstanceAdministration.entryRelationship:priorityPreference.observation, SubstanceAdministration.entryRelationship:indication.observation, SubstanceAdministration.entryRelationship:instruction.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-translation | warning | SubstanceAdministration.routeCode | SHOULD contain translation : translation.exists() | |
| should-unit | warning | SubstanceAdministration.doseQuantity, SubstanceAdministration.rateQuantity | 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
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| 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 dose-unit-or-admin-unit: If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present. should-author: SHOULD contain author |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @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:planned-med-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: 2.16.840.1.113883.10.20.22.4.42 | |
| @extension |
1..1 | st | Required Pattern: 2014-06-09 | |
| @classCode |
1..1 | cs | Binding: CDAActClass (required) Fixed Value: SBADM | |
| @moodCode |
1..1 | cs | Binding: Planned moodCode (SubstanceAdministration/Supply) (required) | |
| id |
1..* | II | ||
| code |
0..1 | CD | 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 | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| thumbnail |
0..1 | ED | ||
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @code |
1..1 | cs | Fixed Value: active | |
| @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 effectiveTime in a planned medication activity represents the time that the medication activity should occur. 1098-32890: This effectiveTime **SHALL** contain either a low or a @value but not both (CONF:1098-32890). should-value-att: SHOULD contain @value should-low: SHOULD contain 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 | EIVL_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 | |
| event |
0..1 | CE | ||
| offset |
0..1 | IVL_PQ | ||
| effectiveTime:eventFrequency |
0..1 | PIVL_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 | |
| phase |
0..1 | IVL_TS | ||
| period |
0..1 | PQ | ||
| @alignment |
0..1 | cs | ||
| @institutionSpecified |
0..1 | bl | ||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |
| repeatNumber |
0..1 | IVL_INT | In 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. | |
| routeCode |
C | 0..1 | CE | Binding: SPL Drug Route of Administration Terminology (required) should-translation: SHOULD contain 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 | Binding: Medication Route (preferred) | |
| approachSiteCode |
0..* | CD | Binding: Body Site Value Set (required) | |
| doseQuantity |
C | 0..1 | IVL_PQ | should-unit: SHOULD contain @unit |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @unit |
0..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 (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 |
C | 0..1 | IVL_PQ | should-unit: SHOULD contain @unit |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| @unit |
0..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 | Binding: AdministrationUnitDoseForm (required) | |
| consumable |
1..1 | InfrastructureRoot | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @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 |
C | 1..1 | MedicationInformation | Base for all types and resources product-choice: manufacturedLabeledDrug and manufacturedMaterial are mutually exclusive (one must be present) |
| subject |
0..1 | Subject | ||
| specimen |
0..* | Specimen | ||
| performer |
0..* | Performer2 | The clinician who is expected to perform the medication activity could be identified using substanceAdministration/performer. | |
| author |
0..1 | AuthorParticipation | The author in a planned medication activity represents the clinician who is requesting or planning the medication activity. | |
| informant |
0..* | Informant | ||
| participant |
0..* | Participant2 | ||
| Slices for entryRelationship |
0..* | EntryRelationship | The following entryRelationship captures any instructions associated with the planned medication activity. Slice: Unordered, Open by profile:act, profile:observation | |
| entryRelationship:priorityPreference |
0..* | EntryRelationship | The following entryRelationship represents the priority that a patient or a provider places on the planned medication activity. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @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 |
C | 1..1 | PriorityPreference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author |
| 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:indication |
0..* | EntryRelationship | The following entryRelationship represents the indication for the planned medication activity. | |
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @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 |
C | 1..1 | Indication | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime indication-value: If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry. |
| 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..* | EntryRelationship | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @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 |
0..1 | bl | ||
| @contextConductionInd |
0..1 | bl | ||
| @negationInd |
0..1 | bl | ||
| sequenceNumber |
0..1 | INT | ||
| seperatableInd |
0..1 | BL | ||
| act |
C | 1..1 | Instruction | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value |
| 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 | ||
| reference |
0..* | Reference | ||
| precondition |
0..* | Precondition | ||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |
| realmCode |
0..* | CS | ||
| typeId |
0..1 | II | ||
| @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 | Base for all types and resources | |
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| SubstanceAdministration.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.templateId:planned-med-activity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.classCode | required | Fixed Value: SBADMhttp://hl7.org/cda/stds/core/ValueSet/CDAActClass | |
| SubstanceAdministration.moodCode | required | PlannedMoodCodeSubstanceAdministrationSupply http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.24 | |
| SubstanceAdministration.code | example | CDAActSubstanceAdministrationCodehttp://hl7.org/cda/stds/core/ValueSet/CDAActSubstanceAdministrationCode | |
| SubstanceAdministration.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| SubstanceAdministration.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| SubstanceAdministration.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| SubstanceAdministration.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| SubstanceAdministration.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| SubstanceAdministration.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.effectiveTime:duration.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.effectiveTime:duration.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.effectiveTime:periodicFrequency.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.effectiveTime:periodicFrequency.operator | required | Pattern: Ahttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.effectiveTime:eventFrequency.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.effectiveTime:eventFrequency.operator | required | Pattern: Ahttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| SubstanceAdministration.routeCode | required | SPLDrugRouteOfAdministrationTerminology http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.7 | |
| SubstanceAdministration.routeCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.routeCode.translation | preferred | MedicationRoute http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.12 | |
| SubstanceAdministration.approachSiteCode | required | BodySiteValueSet http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9 | |
| SubstanceAdministration.doseQuantity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.doseQuantity.unit | preferred | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12839 | |
| SubstanceAdministration.doseQuantity.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.rateQuantity.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.rateQuantity.unit | required | UnitsOfMeasureCaseSensitive (a valid code from UCUM)http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12839 | |
| SubstanceAdministration.rateQuantity.operator | required | CDASetOperatorhttp://hl7.org/cda/stds/core/ValueSet/CDASetOperator | |
| SubstanceAdministration.administrationUnitCode | required | AdministrationUnitDoseForm http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.30 | |
| SubstanceAdministration.consumable.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.consumable.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.consumable.typeCode | required | Fixed Value: CSMhttp://hl7.org/cda/stds/core/ValueSet/CDAParticipationType | |
| SubstanceAdministration.entryRelationship:priorityPreference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:priorityPreference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:priorityPreference.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:indication.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:indication.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:indication.typeCode | required | Fixed Value: RSONhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.entryRelationship:instruction.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:instruction.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.entryRelationship:instruction.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| SubstanceAdministration.precondition.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.precondition.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| SubstanceAdministration.precondition.typeCode | required | Fixed Value: PRCNhttp://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType |
| Id | Grade | Path(s) | Details | Requirements |
| 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() | |
| indication-value | error | SubstanceAdministration.entryRelationship:indication.observation | If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry. : value.exists() or (%resource.descendants().ofType(CDA.Observation).where(id.exists($this.root = %context.id.first().root and $this.extension ~ %context.id.first().extension) and value.exists())) | |
| product-choice | error | SubstanceAdministration.consumable.manufacturedProduct | manufacturedLabeledDrug and manufacturedMaterial are mutually exclusive (one must be present) : (manufacturedLabeledDrug | manufacturedMaterial).count() = 1 | |
| should-author | warning | SubstanceAdministration | SHOULD contain author : author.exists() | |
| should-author | warning | SubstanceAdministration.entryRelationship:priorityPreference.observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | SubstanceAdministration.entryRelationship:priorityPreference.observation, SubstanceAdministration.entryRelationship:indication.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-low | warning | SubstanceAdministration.effectiveTime:duration | SHOULD contain low : low.exists() | |
| should-text-ref-value | warning | SubstanceAdministration | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | SubstanceAdministration.entryRelationship:priorityPreference.observation, SubstanceAdministration.entryRelationship:indication.observation, SubstanceAdministration.entryRelationship:instruction.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-translation | warning | SubstanceAdministration.routeCode | SHOULD contain translation : translation.exists() | |
| should-unit | warning | SubstanceAdministration.doseQuantity, SubstanceAdministration.rateQuantity | 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: 9 elements(6 nested mandatory elements)
Fixed: 4 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#3.0.0 based on FHIR 5.0.0. Generated 2024-07-23
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