Clinical Document Architecture V2.1
2.1.0 - CI Build

Clinical Document Architecture V2.1, published by Health Level 7. This is not an authorized publication; it is the continuous build for version 2.1.0). This version is based on the current content of https://github.com/HL7/cda-core-2.0/ and changes regularly. See the Directory of published versions

Logical Model: CDAR2.SubstanceAdministration

A derivative of the RIM SubstanceAdministration class, used for representing medication-related events such as medication history or planned medication administration orders. SubstanceAdministration.negationInd, when set to “true”, is a positive assertion that the SubstanceAdministration as a whole is negated. Some properties such as SubstanceAdministration.id, SubstanceAdministration.moodCode, and the participations are not affected. These properties always have the same meaning: i.e., the author remains the author of the negative SubstanceAdministration. A substance administration statement with negationInd is still a statement about the specific fact described by the SubstanceAdministration. For instance, a negated “aspirin administration” means that the author positively denies that aspirin is being administered, and that he takes the same responsibility for such statement and the same requirement to have evidence for such statement than if he had not used negation. SubstanceAdministration.priorityCode categorizes the priority of a substance administration. SubstanceAdministration.doseQuantity indicates how much medication is given per dose. SubstanceAdministration.rateQuantity can be used to indicate the rate at which the dose is to be administered (e.g., the flow rate for intravenous infusions). SubstanceAdministration.maxDoseQuantity is used to capture the maximum dose of the medication that can be given over a stated time interval (e.g., maximum daily dose of morphine, maximum lifetime dose of doxorubicin). SubstanceAdministration.effectiveTime is used to describe the timing of administration. It is modeled using the GTS data type to accommodate various dosing scenarios. The capture of medication-related information also involves the interrelationship of SubstanceAdministration with several other classes. The consumable participation is used to bring in the LabeledDrug or Material entity that describes the administered substance. The LabeledDrug class, which is an Entity class playing the Role of Manufactured Product, identifies the drug that is consumed in the substance administration. The medication is identified by means of the LabeledDrug.code or the LabeledDrug.name. The Material entity is used to identify non-drug administered substances such as vaccines and blood products.

The official URL for this profile is:

http://hl7.org/fhir/cda/StructureDefinition/SubstanceAdministration

Formal Views of Profile Content

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

This structure is derived from Base

Summary

Mandatory: 0 element (22 nested mandatory elements)
Fixed Value: 10 elements

This structure is derived from Base

NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration 1..1
... classCode 1..1codeBinding: ActClass (required)
Fixed Value: SBADM
... moodCode 1..1code
... templateId 0..*II
... negationInd 0..1boolean
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..*
.... effectiveTimeSXCM_TS
.... effectiveTimeIVL_TS
.... effectiveTimeEIVL_TS
.... effectiveTimePIVL_TS
.... effectiveTimeSXPR_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... routeCode 0..1CEBinding: RouteOfAdministration (extensible)
... approachSiteCode 0..*CDBinding: v3 Code System ActSite (extensible)
... doseQuantity 0..1IVL_PQ
... rateQuantity 0..1IVL_PQ
... maxDoseQuantity 0..1RTO_PQ_PQ
... administrationUnitCode 0..1CEBinding: AdministrableDrugForm (extensible)
... consumable 1..1Element
.... typeCode 1..1codeBinding: ParticipationTargetDirect (required)
Fixed Value: CSM
.... manufacturedProduct 1..1ManufacturedProduct
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Element
.... typeCode 1..1codeBinding: ParticipationTargetDirect (required)
Fixed Value: SPC
.... specimenRole 1..1SpecimenRole
... performer 0..*Element
.... typeCode 1..1codeBinding: ParticipationPhysicalPerformer (required)
Fixed Value: PRF
.... time 0..1IVL_TS
.... modeCode 0..1CEBinding: ParticipationMode (extensible)
.... assignedEntity 1..1AssignedEntity
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Element
.... typeCode 1..1codeBinding: ParticipationType (required)
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... time 0..1IVL_TS
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... participantRole 1..1ParticipantRole
... entryRelationship I0..*Elementsubst-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
.... typeCode 1..1code
.... inversionInd 0..1boolean
.... contextConductionInd 1..1boolean
.... sequenceNumber 0..1INT
.... negationInd 0..1boolean
.... seperatableInd 0..1BL
.... (Choice of one) 1..1
..... observation 0..1Observation
..... regionOfInterest 0..1RegionOfInterest
..... observationMedia 0..1ObservationMedia
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
..... procedure 0..1Procedure
..... encounter 0..1Encounter
..... organizer 0..1Organizer
..... act 0..1Act
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Element
.... typeCode 1..1codeBinding: ActRelationshipConditional (required)
Fixed Value: PRCN
.... criterion 1..1Criterion

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration 1..1
... classCode 1..1codeBinding: ActClass (required)
Fixed Value: SBADM
... moodCode 1..1code
... templateId 0..*II
... negationInd 0..1boolean
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..*
.... effectiveTimeSXCM_TS
.... effectiveTimeIVL_TS
.... effectiveTimeEIVL_TS
.... effectiveTimePIVL_TS
.... effectiveTimeSXPR_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... routeCode 0..1CEBinding: RouteOfAdministration (extensible)
... approachSiteCode 0..*CDBinding: v3 Code System ActSite (extensible)
... doseQuantity 0..1IVL_PQ
... rateQuantity 0..1IVL_PQ
... maxDoseQuantity 0..1RTO_PQ_PQ
... administrationUnitCode 0..1CEBinding: AdministrableDrugForm (extensible)
... consumable 1..1Element
.... typeCode 1..1codeBinding: ParticipationTargetDirect (required)
Fixed Value: CSM
.... manufacturedProduct 1..1ManufacturedProduct
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Element
.... typeCode 1..1codeBinding: ParticipationTargetDirect (required)
Fixed Value: SPC
.... specimenRole 1..1SpecimenRole
... performer 0..*Element
.... typeCode 1..1codeBinding: ParticipationPhysicalPerformer (required)
Fixed Value: PRF
.... time 0..1IVL_TS
.... modeCode 0..1CEBinding: ParticipationMode (extensible)
.... assignedEntity 1..1AssignedEntity
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Element
.... typeCode 1..1codeBinding: ParticipationType (required)
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... time 0..1IVL_TS
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... participantRole 1..1ParticipantRole
... entryRelationship I0..*Elementsubst-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
.... typeCode 1..1code
.... inversionInd 0..1boolean
.... contextConductionInd 1..1boolean
.... sequenceNumber 0..1INT
.... negationInd 0..1boolean
.... seperatableInd 0..1BL
.... (Choice of one) 1..1
..... observation 0..1Observation
..... regionOfInterest 0..1RegionOfInterest
..... observationMedia 0..1ObservationMedia
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
..... procedure 0..1Procedure
..... encounter 0..1Encounter
..... organizer 0..1Organizer
..... act 0..1Act
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Element
.... typeCode 1..1codeBinding: ActRelationshipConditional (required)
Fixed Value: PRCN
.... criterion 1..1Criterion

doco Documentation for this format

This structure is derived from Base

Summary

Mandatory: 0 element (22 nested mandatory elements)
Fixed Value: 10 elements

Differential View

This structure is derived from Base

NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration 1..1
... classCode 1..1codeBinding: ActClass (required)
Fixed Value: SBADM
... moodCode 1..1code
... templateId 0..*II
... negationInd 0..1boolean
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..*
.... effectiveTimeSXCM_TS
.... effectiveTimeIVL_TS
.... effectiveTimeEIVL_TS
.... effectiveTimePIVL_TS
.... effectiveTimeSXPR_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... routeCode 0..1CEBinding: RouteOfAdministration (extensible)
... approachSiteCode 0..*CDBinding: v3 Code System ActSite (extensible)
... doseQuantity 0..1IVL_PQ
... rateQuantity 0..1IVL_PQ
... maxDoseQuantity 0..1RTO_PQ_PQ
... administrationUnitCode 0..1CEBinding: AdministrableDrugForm (extensible)
... consumable 1..1Element
.... typeCode 1..1codeBinding: ParticipationTargetDirect (required)
Fixed Value: CSM
.... manufacturedProduct 1..1ManufacturedProduct
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Element
.... typeCode 1..1codeBinding: ParticipationTargetDirect (required)
Fixed Value: SPC
.... specimenRole 1..1SpecimenRole
... performer 0..*Element
.... typeCode 1..1codeBinding: ParticipationPhysicalPerformer (required)
Fixed Value: PRF
.... time 0..1IVL_TS
.... modeCode 0..1CEBinding: ParticipationMode (extensible)
.... assignedEntity 1..1AssignedEntity
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Element
.... typeCode 1..1codeBinding: ParticipationType (required)
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... time 0..1IVL_TS
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... participantRole 1..1ParticipantRole
... entryRelationship I0..*Elementsubst-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
.... typeCode 1..1code
.... inversionInd 0..1boolean
.... contextConductionInd 1..1boolean
.... sequenceNumber 0..1INT
.... negationInd 0..1boolean
.... seperatableInd 0..1BL
.... (Choice of one) 1..1
..... observation 0..1Observation
..... regionOfInterest 0..1RegionOfInterest
..... observationMedia 0..1ObservationMedia
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
..... procedure 0..1Procedure
..... encounter 0..1Encounter
..... organizer 0..1Organizer
..... act 0..1Act
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Element
.... typeCode 1..1codeBinding: ActRelationshipConditional (required)
Fixed Value: PRCN
.... criterion 1..1Criterion

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration 1..1
... classCode 1..1codeBinding: ActClass (required)
Fixed Value: SBADM
... moodCode 1..1code
... templateId 0..*II
... negationInd 0..1boolean
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..*
.... effectiveTimeSXCM_TS
.... effectiveTimeIVL_TS
.... effectiveTimeEIVL_TS
.... effectiveTimePIVL_TS
.... effectiveTimeSXPR_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... repeatNumber 0..1IVL_INT
... routeCode 0..1CEBinding: RouteOfAdministration (extensible)
... approachSiteCode 0..*CDBinding: v3 Code System ActSite (extensible)
... doseQuantity 0..1IVL_PQ
... rateQuantity 0..1IVL_PQ
... maxDoseQuantity 0..1RTO_PQ_PQ
... administrationUnitCode 0..1CEBinding: AdministrableDrugForm (extensible)
... consumable 1..1Element
.... typeCode 1..1codeBinding: ParticipationTargetDirect (required)
Fixed Value: CSM
.... manufacturedProduct 1..1ManufacturedProduct
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Element
.... typeCode 1..1codeBinding: ParticipationTargetDirect (required)
Fixed Value: SPC
.... specimenRole 1..1SpecimenRole
... performer 0..*Element
.... typeCode 1..1codeBinding: ParticipationPhysicalPerformer (required)
Fixed Value: PRF
.... time 0..1IVL_TS
.... modeCode 0..1CEBinding: ParticipationMode (extensible)
.... assignedEntity 1..1AssignedEntity
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Element
.... typeCode 1..1codeBinding: ParticipationType (required)
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... time 0..1IVL_TS
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... participantRole 1..1ParticipantRole
... entryRelationship I0..*Elementsubst-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
.... typeCode 1..1code
.... inversionInd 0..1boolean
.... contextConductionInd 1..1boolean
.... sequenceNumber 0..1INT
.... negationInd 0..1boolean
.... seperatableInd 0..1BL
.... (Choice of one) 1..1
..... observation 0..1Observation
..... regionOfInterest 0..1RegionOfInterest
..... observationMedia 0..1ObservationMedia
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
..... procedure 0..1Procedure
..... encounter 0..1Encounter
..... organizer 0..1Organizer
..... act 0..1Act
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Element
.... typeCode 1..1codeBinding: ActRelationshipConditional (required)
Fixed Value: PRCN
.... criterion 1..1Criterion

doco Documentation for this format

 

Other representations of profile: Schematron

Terminology Bindings

PathConformanceValueSet / Code
SubstanceAdministration.classCoderequiredFixed Value: SBADM
SubstanceAdministration.codeextensiblehttp://terminology.hl7.org/ValueSet/v3-SubstanceAdministrationActCode
SubstanceAdministration.statusCoderequiredActStatus
SubstanceAdministration.priorityCodeextensibleActPriority
SubstanceAdministration.routeCodeextensibleRouteOfAdministration
SubstanceAdministration.approachSiteCodeextensiblev3.ActSite
SubstanceAdministration.administrationUnitCodeextensibleAdministrableDrugForm
SubstanceAdministration.consumable.typeCoderequiredFixed Value: CSM
SubstanceAdministration.subject.typeCoderequiredFixed Value: SBJ
SubstanceAdministration.subject.contextControlCoderequiredFixed Value: OP
SubstanceAdministration.subject.awarenessCodeextensibleTargetAwareness
SubstanceAdministration.specimen.typeCoderequiredFixed Value: SPC
SubstanceAdministration.performer.typeCoderequiredFixed Value: PRF
SubstanceAdministration.performer.modeCodeextensibleParticipationMode
SubstanceAdministration.informant.typeCoderequiredFixed Value: INF
SubstanceAdministration.informant.contextControlCoderequiredFixed Value: OP
SubstanceAdministration.participant.typeCoderequiredParticipationType
SubstanceAdministration.participant.contextControlCoderequiredFixed Value: OP
SubstanceAdministration.participant.awarenessCodeextensibleTargetAwareness
SubstanceAdministration.precondition.typeCoderequiredFixed Value: PRCN

Constraints

IdPathDetailsRequirements
subst-er-1SubstanceAdministration.entryRelationshipOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1