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ref Template  UV Medication Order

Id 2.16.840.1.113883.10.21.4.1 Effective Date valid from 2015‑10‑07
Status draft Draft Version Label
Name UVsubstanceadministrationrequest Display Name UV Medication Order
Description This is the universal Medication Order (Substance Administration Request)
Context Parent nodes of template element with id 2.16.840.1.113883.10.21.4.1
Label MedicationOrder
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 0 templates, Uses 13 templates
Used by as Name Version
pharmcda-transaction-2 Transaction draft Create Medication Order 2017‑05‑10
Uses as Name Version
2.16.840.1.113883.10.21.9.1 Include draft UV Use Period DYNAMIC
2.16.840.1.113883.10.12.320 Containment active CDA Subject (Body) DYNAMIC
2.16.840.1.113883.10.21.4.11 Containment draft UV Medication Information (detail) DYNAMIC
2.16.840.1.113883.10.12.318 Containment active CDA Author (Body) DYNAMIC
2.16.840.1.113883.10.12.321 Containment active CDA Participant (Body) DYNAMIC
2.16.840.1.113883.10.21.4.6 Containment draft UV Subordinate Substance Administration DYNAMIC
2.16.840.1.113883.10.21.4.2 Containment draft UV Dispense Request DYNAMIC
2.16.840.1.113883.10.20.22.4.19 Containment pending Indication (V2) (2.1) DYNAMIC
2.16.840.1.113883.10.21.4.3 Containment draft UV ClinicalStatement Observation DYNAMIC
2.16.840.1.113883.10.21.4.5 Containment draft UV Substitution Permission DYNAMIC
2.16.840.1.113883.10.21.4.4 Containment draft UV ClinicalStatement Encounter DYNAMIC
2.16.840.1.113883.10.20.22.4.64 Containment pending Comment Activity (2.1) DYNAMIC
2.16.840.1.113883.10.12.329 Containment active CDA Precondition DYNAMIC
Relationship Specialization: template 2.16.840.1.113883.10.12.308 (2005‑09‑07)
Example
Example
<substanceAdministration classCode="SBADM" moodCode="RQO">
  <templateId root="2.16.840.1.113883.10.21.4.1"/>  <id root="1.2.3.99.99.99" extension="58768437489739"/>  <code code="..." codeSystem="..."/>  <text>...</text>  <statusCode code="active"/>  <effectiveTime value="..."/>  <repeatNumber value="..."/>  <routeCode code="SOAK" codeSystem="2.16.840.1.113883.5.112" displayName="Immersion (soak)"/>  <approachSiteCode code="..." codeSystem="2.16.840.1.113883.5.1052"/>  <doseQuantity>
    <low value="1" unit="1"/>  </doseQuantity>
  <rateQuantity>
    <low value="1" unit="1"/>  </rateQuantity>
  <maxDoseQuantity>
    <numerator value="100" unit="mg"/>    <denominator value="1" unit="d"/>  </maxDoseQuantity>
  <administrationUnitCode code="PUFF" displayName="Puff" codeSystem="2.16.840.1.113883.5.85"/>  <consumable typeCode="CSM">
    <!-- Consumable -->
  </consumable>
  <participant typeCode="DEV">
    <!-- Device -->
  </participant>
  <participant typeCode="LOC">
    <!-- Location -->
  </participant>
  <entryRelationship typeCode="COMP">
    <!-- Subordinate Substance Administrations -->
  </entryRelationship>
  <entryRelationship typeCode="COMP">
    <!-- Annotations -->
  </entryRelationship>
  <precondition>
    <!-- Precondition -->
  </precondition>
</substanceAdministration>
Item DT Card Conf Description Label
hl7:substanceAdministration
Medi…rder
@classCode
cs 1 … 1 F SBADM
@moodCode
cs 1 … 1 F RQO
hl7:templateId
II 1 … 1 M Medi…rder
@root
uid 1 … 1 F 2.16.840.1.113883.10.21.4.1
hl7:id
II 0 … * R Medi…rder
hl7:code
CD CWE 0 … 1 R Medi…rder
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19708 ActSubstanceAdministrationCode (DYNAMIC)
hl7:text
ED 0 … 1 Medi…rder
hl7:statusCode
CS CNE 1 … 1 M Medi…rder
@code
CONF 1 … 1 F active
Included from 2.16.840.1.113883.10.21.9.1 UV Use Period (DYNAMIC)
Choice 1 … 1
The <effectiveTime> element encodes the period of administration of the medication, it is always expressed as an interval of time.
It may be expressed using the <low> and <high> OR with the <width> element.
The first is used to indicate a specified interval (e.g. from march 15th, 2017); the latter for indicating a 'floating' period (e.g. 2 weeks).
Elements to choose from:
  • hl7:effectiveTime[hl7:low | hl7:high]
  • hl7:effectiveTime[hl7:width]
hl7:effectiveTime
IVL_TS 0 … 1 R Case 1: specified interval
The <low> and <high> values of the first <effectiveTime> element represent the start and stop times for the medication. The <low> value represents the start time, and the <high> value represents the stop time. If either the <low> or the <high> value is unknown, this shall be recorded by setting the nullFlavor attribute to UNK.

In case of unbounded period (continous terapy) the <high> element will be valued with the nullFlavor attribute to NA.

The <high> value records the end of the medication regime according to the information provided in the prescription or order. For example, if the prescription is for enough medication to last 30 days, then the high value should contain a date that is 30 days later then the <low> value. The rationale is that a provider, seeing an un-refilled prescription would normally assume that the medication is no longer being taken, even if the intent of the treatment plan is to continue the medication indefinitely.
Medi…rder
treeblank treeblank where [hl7:low or
hl7:high]
@nullFlavor
cs 0 … 1  
  Example
Known Interval
<effectiveTime xsi:type="IVL_TS">
  <low value="20130321"/>  <high value="20140321"/></effectiveTime>
  Example
Information not available about the period
<effectiveTime xsi:type="IVL_TS" nullFlavor="NI"/>
  Example
Unknown end date
<effectiveTime xsi:type="IVL_TS">
  <low value="20130321"/>  <high nullFlavor="UNK"/></effectiveTime>
  Example
Continuous terapy
<effectiveTime xsi:type="IVL_TS">
  <low value="20130321"/>  <high nullFlavor="NA"/></effectiveTime>
hl7:low
IVXB_TS 1 … 1 R Medi…rder
hl7:high
IVXB_TS 0 … 1 R Medi…rder
hl7:effectiveTime
IVL_TS 0 … 1 R Case 2: 'floating' period:
The width element is used to specify a period of (actual or intended) administration that is not anchored to any specific date (e.g. a two weeks therapy.....)
Medi…rder
treeblank treeblank where [hl7:width]
  Example
2 week period
<effectiveTime xsi:type="IVL_TS">
  <width value="2" unit="w"/></effectiveTime>
hl7:width
PQ 1 … 1 R Medi…rder
@unit
cs 1 … 1 R
  CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.21.1 Medication Time Units (UCUM) (DYNAMIC)
hl7:repeatNumber
IVL_INT 0 … 1 Medi…rder
hl7:routeCode
CE 0 … 1 Medi…rder
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14581 RouteOfAdministration (DYNAMIC)
hl7:approachSiteCode
CD 0 … * Medi…rder
@codeSystem
CONF 1 … 1 F 2.16.840.1.113883.5.1052 (Act Site)
hl7:doseQuantity
IVL_PQ 0 … 1 Medi…rder
hl7:rateQuantity
IVL_PQ 0 … 1 Medi…rder
hl7:maxDoseQuantity
RTO_PQ_PQ 0 … 1 Medi…rder
hl7:administrationUnitCode
CE 0 … 1 Medi…rder
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14570 AdministrableDrugForm (DYNAMIC)
hl7:subject
0 … 1 C Patient: The patient that the medicine is intended for dispenses or introduced into/applied to for substance administrations.
Contains 2.16.840.1.113883.10.12.320 CDA Subject (Body) (DYNAMIC)
Medi…rder
  Constraint Condition: This can be omitted if the patient context that is provided in the CDA header is identical to the subject
hl7:consumable
1 … 1 M Consumable: The medication that is being administered
Contains 2.16.840.1.113883.10.21.4.11 UV Medication Information (detail) (DYNAMIC)
Medi…rder
treeblank where [hl7:manufacturedMaterial [hl7:templateId [@root='2.16.840.1.113883.10.21.4.11']]]
@typeCode
cs 1 … 1 F CSM
hl7:author
0 … * Prescriber: A party that originates the order and therefore has responsibility for the information given in the order.
Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC)
Medi…rder
hl7:participant
0 … 1 Record Target: indicates whose medical record holds the documentation of this order; Rationale: This is especially important when the subject of the order is not the patient him/herself.
Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC)
Medi…rder
treeblank where [@typeCode='RCT']
@typeCode
cs 1 … 1 F RCT
hl7:participant
0 … 1 Verifier: The person or organization that has primary responsibility for the order. The responsible party is not necessarily present in an action, but is accountable for the action through the power to delegate.
Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC)
Medi…rder
treeblank where [@typeCode='VRF']
@typeCode
cs 1 … 1 F VRF
hl7:entryRelationship
0 … * C Subordinate Substance Administration Request as a component of the overall order.
At least one subordinated <substanceAdministration> has to be present to convey information about dosages (dose, frequency of intakes,..).
Subordinated <substanceAdministration> elements can be also used either to handle split dosing, or to support combination medications.
Contains 2.16.840.1.113883.10.21.4.6 UV Subordinate Substance Administration (DYNAMIC)
Medi…rder
treeblank where [hl7:substanceAdministration]
@typeCode
1 … 1 F COMP
  Example <entryRelationship typeCode="COMP">
  <!-- component: Subordinate Substance Administration Request. -->
  <substanceAdministration classCode="SBADM" moodCode="RQO">
    <templateId root="2.16.840.1.113883.10.21.4.6"/>    <!-- .. -->
  </substanceAdministration>
</entryRelationship>
hl7:sequenceNumber
INT 0 … 1 Sequence number of the Subordinate Substance Administration. Medi…rder
hl7:entryRelationship
0 … 1 R Dispense Request as a component of the overall order.
Contains 2.16.840.1.113883.10.21.4.2 UV Dispense Request (DYNAMIC)
Medi…rder
treeblank where [hl7:supply]
@typeCode
1 … 1 F COMP
  Example <entryRelationship typeCode="COMP">
  <!-- component: The Dispense Request is a component of the overall order. -->
  <supply classCode="SPLY" moodCode="RQO">
    <templateId root="2.16.840.1.113883.10.21.4.2"/>    <!-- .. -->
  </supply>
</entryRelationship>
hl7:entryRelationship
0 … 1 R Reason: Specifies the reason (indication) for authoring the order.
Contains 2.16.840.1.113883.10.20.22.4.19 Indication (V2) (DYNAMIC)
Medi…rder
treeblank where [cda:observation [hl7:templateId [@root='2.16.840.1.113883.10.20.22.4.19'] [@extension='2014-06-09']]]
@typeCode
1 … 1 F RSON
  Example <entryRelationship typeCode="RSON">
  <priorityNumber value="1"/>  <act>
    <!-- Clinical Statement Minimal -->
  </act>
</entryRelationship>
pharm:priorityNumber
INT.NONNEG 0 … 1 R Indiciates the priority of this reason for the order in relation to its sibling reasons. Medi…rder
hl7:entryRelationship
0 … 1 R Pertinent Information: Specifies any pertinent information (observation) relevant to the order.
Contains 2.16.840.1.113883.10.21.4.3 UV ClinicalStatement Observation (DYNAMIC)
Medi…rder
treeblank where [hl7:observation [hl7:templateId [@root='2.16.840.1.113883.10.21.4.3']]]
@typeCode
1 … 1 F PERT
  Example <entryRelationship typeCode="PERT">
  <observation>
    <!-- Clinical Statement Observation -->
  </observation>
</entryRelationship>
hl7:entryRelationship
0 … 1 R Permission: The order can be the subject of the permissions related to substitution.
Contains 2.16.840.1.113883.10.21.4.5 UV Substitution Permission (DYNAMIC)
Medi…rder
treeblank where [hl7:act]
@typeCode
1 … 1 F COMP
hl7:entryRelationship
0 … 1 R Encounter: Used to link an order to a specific encounter.
Contains 2.16.840.1.113883.10.21.4.4 UV ClinicalStatement Encounter (DYNAMIC)
Medi…rder
treeblank where [hl7:encounter]
@typeCode
1 … 1 F COMP
  Example <encounter classCode="ENC" moodCode="EVN">
  <id/>  <code code="..."/></encounter>
hl7:entryRelationship
0 … * Annotations: The SubstanceAdministrationRequest can be the subject of annotations.
Contains 2.16.840.1.113883.10.20.22.4.64 Comment Activity (DYNAMIC)
Medi…rder
treeblank where [cda:act [hl7:templateId [@root='2.16.840.1.113883.10.20.22.4.64']]]
@typeCode
cs 1 … 1 F COMP
hl7:precondition
0 … * Precondition: A requirement to be true before the SubstanceAdministration is performed.
Contains 2.16.840.1.113883.10.12.329 CDA Precondition (DYNAMIC)
Medi…rder