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ref Template  UV Medication Statement

Id 2.16.840.1.113883.10.21.4.7 Effective Date valid from 2017‑05‑01
Status draft Draft Version Label
Name UVsubstanceadministrationevent Display Name UV Medication Statement
Description This is the universal Medication Order (Substance Administration Request)
Context Parent nodes of template element with id 2.16.840.1.113883.10.21.4.7
Label MedicationStatement
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 10 templates
Used by as Name Version
pharmcda-transaction-4 Transaction draft Create Medication Statement 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
2.16.840.1.113883.10.21.4.10 Containment draft UV Medication Information (simple) DYNAMIC
2.16.840.1.113883.10.12.318 Include active CDA Author (Body) DYNAMIC
2.16.840.1.113883.10.12.153 Containment active CDA AssignedEntity DYNAMIC
2.16.840.1.113883.10.12.316 Containment active CDA RelatedEntity 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
2.16.840.1.113883.10.21.4.8 Containment draft UV Medication Order Reference DYNAMIC
2.16.840.1.113883.10.21.4.9 Containment draft UV Dispense Event Reference DYNAMIC
Relationship Specialization: template 2.16.840.1.113883.10.12.308 (2005‑09‑07)
Example
Example
<substanceAdministration classCode="SBADM" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.21.4.7"/>  <id root="1.2.3.99.99.99" extension="988437489739"/>  <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>
Example
Example
<substanceAdministration classCode="SBADM" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.21.4.7"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="DRUG" displayName="Drug therapy" codeSystem="2.16.840.1.113883.5.4"/>  <text/>  <statusCode code="active"/>  <!-- include template 'UV Use Period' (dynamic) .. O -->
  <repeatNumber/>  <routeCode code="SOAK" displayName="Immersion (soak)" codeSystem="2.16.840.1.113883.5.112"/>  <approachSiteCode code="--code--" codeSystem="2.16.840.1.113883.5.1052"/>  <doseQuantity>
    <low value="1"/>  </doseQuantity>  <rateQuantity>
    <low value="1"/>  </rateQuantity>  <maxDoseQuantity/>  <administrationUnitCode code="APPFUL" displayName="Applicatorful" codeSystem="2.16.840.1.113883.5.85"/>  <subject>
    <!-- template 'CDA Subject (Body)' (dynamic) -->
  </subject>  <consumable typeCode="CSM">
    <!-- template 2.16.840.1.113883.10.12.312 'CDA ManufacturedProduct' (dynamic) -->
  </consumable>  <!-- choice: 1..1
element hl7:author
element hl7:participant[@typeCode='AUT']
-->
  <!-- choice: 0..1
element hl7:informant[exists(hl7:assignedEntity)]
element hl7:participant[@typeCode='INF']
element hl7:informant[exists(hl7:relatedEntity)]
-->
  <participant typeCode="RCT">
    <!-- template 2.16.840.1.113883.10.12.321 'CDA Participant (Body)' (dynamic) -->
  </participant>  <participant typeCode="VRF">
    <!-- template 2.16.840.1.113883.10.12.321 'CDA Participant (Body)' (dynamic) -->
  </participant>  <entryRelationship typeCode="COMP">
    <sequenceNumber value="1"/>    <!-- template 2.16.840.1.113883.10.21.4.6 'Subordinate Substance Administration' (dynamic) -->
  </entryRelationship>  <entryRelationship typeCode="REFR">
    <!-- template 2.16.840.1.113883.10.21.4.8 'UV Medication Order Reference' (dynamic) -->
  </entryRelationship>  <entryRelationship typeCode="REFR">
    <!-- template 2.16.840.1.113883.10.21.4.9 'UV Dispense Event Reference' (dynamic) -->
  </entryRelationship></substanceAdministration>
Example
Example
<substanceAdministration classCode="SBADM" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.21.4.7"/>  <id root="1.2.3.99.99.99" extension="988437489739"/>  <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…ment
@classCode
 cs 1 … 1 F SBADM
@moodCode
 cs 1 … 1 F EVN
hl7:templateId
 II 1 … 1 M Medi…ment
@root
 uid 1 … 1 F 2.16.840.1.113883.10.21.4.7
hl7:id
 II 0 … * R Medi…ment
hl7:code
 CD CWE 0 … 1 R Medi…ment
  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…ment
hl7:statusCode
 CS CNE 1 … 1 M Medi…ment
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19890 x_ActStatusActiveComplete (DYNAMIC)
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…ment
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…ment
hl7:high
 IVXB_TS 0 … 1 R Medi…ment
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…ment
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…ment
@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…ment
hl7:routeCode
 CE 0 … 1 Medi…ment
  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…ment
@codeSystem
 CONF 1 … 1 F 2.16.840.1.113883.5.1052 (Act Site)
hl7:doseQuantity
 IVL_PQ 0 … 1 Medi…ment
hl7:rateQuantity
 IVL_PQ 0 … 1 Medi…ment
hl7:maxDoseQuantity
 RTO_PQ_PQ 0 … 1 Medi…ment
hl7:administrationUnitCode
 CE 0 … 1 Medi…ment
  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 takes the medicine.
Contains 2.16.840.1.113883.10.12.320 CDA Subject (Body) (DYNAMIC) 		Medi…ment
  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 administered
Contains 2.16.840.1.113883.10.21.4.10 UV Medication Information (simple) (DYNAMIC) 		Medi…ment
treeblank where [hl7:manufacturedProduct [hl7:templateId [@root='2.16.840.1.113883.10.21.4.10']]]
@typeCode
 cs 1 … 1 F CSM
Choice 1 … 1
Reuqired author of the medication statement: healthcare professional or patient
Elements to choose from:
  • hl7:author
  • hl7:participant[@typeCode='AUT']
hl7:author
 Use this if the author of the medication statement is a healthcare professional Medi…ment
  Example
Author of the medication statement is a healthcare professional
<author>
  <time value="20170221"/>  <assignedAuthor>
    <id root="1.2.3.99.99.99" extension="75487435893498"/>    <assignedPerson>
      <name>
        <given qualifier="IN">Ampu</given>        <prefix qualifier="VV">L.</prefix>        <family>Lee</family>      </name>    </assignedPerson>  </assignedAuthor></author>
Included from 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC)
@typeCode
 0 … 1 F AUT
@contextControlCode
 0 … 1 F OP
hl7:functionCode
 CE 0 … 1 Medi…ment
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)
hl7:time
 TS 1 … 1 R Medi…ment
hl7:assignedAuthor
 1 … 1 Medi…ment
@classCode
 0 … 1 F ASSIGNED
hl7:id
 II 1 … * R Medi…ment
hl7:code
 CE 0 … 1 Medi…ment
@codeSystem
 CONF 1 … 1 F 2.16.840.1.113883.5.111 (Role Code)
hl7:addr
 AD 0 … * Medi…ment
hl7:telecom
 TEL 0 … * Medi…ment
Choice 0 … 1 Elements to choose from:
hl7:assignedPerson
 Contains 2.16.840.1.113883.10.12.152 CDA Person (DYNAMIC) Medi…ment
hl7:assignedAuthoringDevice
 Contains 2.16.840.1.113883.10.12.315 CDA Device (DYNAMIC) Medi…ment
hl7:representedOrganization
 0 … 1 Contains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC) Medi…ment
hl7:participant
 Use this if the author of the medication statement is the patient Medi…ment
treeblank treeblank where [@typeCode='AUT']
@typeCode
 cs 1 … 1 F AUT
  Example
Author of the medication statement is the patient
<participant typeCode="AUT">
  <time value="20170121091548"/>  <participantRole classCode="PAT"/></participant>
hl7:time
 TS 1 … 1 R Medi…ment
hl7:participantRole
 1 … 1 M Medi…ment
@classCode
 cs 1 … 1 F PAT
Choice 0 … 1
Optional informants of the medication statement: healthcare professional or patient contact party (related party)
Elements to choose from:
  • hl7:informant[exists(hl7:assignedEntity)]
  • hl7:participant[@typeCode='INF']
  • hl7:informant[exists(hl7:relatedEntity)]
hl7:informant
 Use this if the informant of the medication statement is a healthcare professional Medi…ment
treeblank treeblank where [exists(hl7:assignedEntity)]
@typeCode
 cs 0 … 1 F INF
@contextControlCode
 cs 0 … 1 F OP
  Example
Informant of the medication statement is a healthcare professional
<informant>
  <assignedEntity>
    <id root="1.2.3.99.99.99" extension="75487435893498"/>    <assignedPerson>
      <name>
        <given qualifier="IN">Ampu</given>        <prefix qualifier="VV">L.</prefix>        <family>Lee</family>      </name>    </assignedPerson>  </assignedEntity></informant>
hl7:assignedEntity
 1 … 1 Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC) Medi…ment
hl7:participant
 Use this if the informant of the medication statement is the patient Medi…ment
treeblank treeblank where [@typeCode='INF']
@typeCode
 cs 1 … 1 F INF
  Example
Informant of the medication statement is the patient
<participant typeCode="INF">
  <time value="20170121091548"/>  <participantRole classCode="PAT"/></participant>
hl7:time
 TS 1 … 1 R Medi…ment
hl7:participantRole
 1 … 1 M Medi…ment
@classCode
 cs 1 … 1 F PAT
hl7:informant
 Use this if the informant of the medication statement is a contact party (related party) Medi…ment
treeblank treeblank where [exists(hl7:relatedEntity)]
@typeCode
 cs 0 … 1 F INF
@contextControlCode
 cs 0 … 1 F OP
  Example
Informant of the medication statement is a contact party (related party)
<informant>
  <relatedEntity classCode="AGNT">
    <relatedPerson classCode="PSN" determinerCode="INSTANCE">
      <name>
        <!-- .. -->
      </name>    </relatedPerson>  </relatedEntity></informant>
hl7:relatedEntity
 1 … 1 Contains 2.16.840.1.113883.10.12.316 CDA RelatedEntity (DYNAMIC) Medi…ment
hl7:participant
 0 … 1 Record Target: indicates whose medical record holds the documentation of this medication statement; Rationale: This is especially important when the subject of the medication statement is not the patient him/herself.
Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC) 		Medi…ment
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 medication statement. 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…ment
treeblank where [@typeCode='VRF']
@typeCode
 cs 1 … 1 F VRF
hl7:entryRelationship
 0 … * C Subordinate Substance Administration Statament as a component of the overall medication statement.
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…ment
treeblank where [hl7:substanceAdministration]
@typeCode
 cs 1 … 1 F COMP
  Example <entryRelationship typeCode="COMP">
  <!-- component: Subordinate Substance Administration Statement. -->
  <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…ment
hl7:entryRelationship
 0 … * R Medication Order Reference.
Contains 2.16.840.1.113883.10.21.4.8 UV Medication Order Reference (DYNAMIC) 		Medi…ment
treeblank where [@typeCode='REFR'] [hl7:substanceAdministration]
@typeCode
 cs 1 … 1 F REFR
  Example <entryRelationship typeCode="REFR">
  <substanceAdministration classCode="SBADM" moodCode="EVN">
    <templateId root="2.16.840.1.113883.10.21.4.8"/>    <!-- .. -->
  </substanceAdministration></entryRelationship>
hl7:entryRelationship
 0 … * R Dispense Event Reference.
Contains 2.16.840.1.113883.10.21.4.9 UV Dispense Event Reference (DYNAMIC) 		Medi…ment
treeblank where [@typeCode='REFR'] [ [hl7:supply]
@typeCode
 cs 1 … 1 F REFR
  Example <entryRelationship typeCode="REFR">
  <supply classCode="SPLY" moodCode="EVN">
    <templateId root="2.16.840.1.113883.10.21.4.9"/>    <!-- .. -->
  </supply></entryRelationship>