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Difference between revisions of "PHARM Templates Implementationguide"

(Templates)
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|Short    = Pharmacy Templates
 
|Short    = Pharmacy Templates
 
|Namespace = cdapharm  
 
|Namespace = cdapharm  
|Type      = HL7 STU Ballot
+
|Type      = HL7 STU
|Version  = 1.51
+
|Version  = 1.60
 
|Sponsored = Pharmacy Workgroup
 
|Sponsored = Pharmacy Workgroup
|Date      = March 22, 2019
+
|Date      = September 4, 2019
 
|Status    = Draft
 
|Status    = Draft
 
|Period    = STU
 
|Period    = STU
Line 35: Line 35:
 
==Scope==
 
==Scope==
 
This Pharmacy Templates Implementation Guide defines common pharmacy artifacts (order, dispense, administration and statement) in CDA R2 format. The scope of the Implementation Guide is limited to ''Medication Order'' and ''Medication Statement'', '' Medication Dispense'' and ''Medication Administration''. The content was developed by aligning and harmonizing the existing specifications for Consolidated CDA (C-CDA Release 2.1<ref name="ccda21">http://www.hl7.org/implement/standards/product_brief.cfm?product_id=379</ref>).
 
This Pharmacy Templates Implementation Guide defines common pharmacy artifacts (order, dispense, administration and statement) in CDA R2 format. The scope of the Implementation Guide is limited to ''Medication Order'' and ''Medication Statement'', '' Medication Dispense'' and ''Medication Administration''. The content was developed by aligning and harmonizing the existing specifications for Consolidated CDA (C-CDA Release 2.1<ref name="ccda21">http://www.hl7.org/implement/standards/product_brief.cfm?product_id=379</ref>).
 
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<div style="background-color: #d9edf7; color: #31708f; padding: 10px;">
 
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<b>Ballot Scope</b>
 
<b>Ballot Scope</b>
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The scope of this ballot is limited to the new content for Medication Dispense and Medication Administration Templates. Feedback not related to these templates will be found "not related" and should be made via the STU change request process.
 
The scope of this ballot is limited to the new content for Medication Dispense and Medication Administration Templates. Feedback not related to these templates will be found "not related" and should be made via the STU change request process.
 
</div>
 
</div>
 
+
-->
 
==Ballot Status of the Document==
 
==Ballot Status of the Document==
The Implementation Guide is being balloted as Standard for Trial Use (STU) and then to Normative.
+
The Implementation Guide was balloted as Standard for Trial Use (STU) and then goes to Normative.
  
 
==Audience==
 
==Audience==

Revision as of 18:37, 9 September 2019

Document Information

This document contains: HL7 STU Pharmacy Templates (1.60). The text materials belong to category cdapharm.



Important Notes

HL7 licenses its standards and select IP free of charge. If you did not acquire a free license from HL7 for this document, you are not authorized to access or make any use of it. To obtain a free license, please visit http://www.HL7.org/implement/standards/index.cfm.

If you are the individual that obtained the license for this HL7 Standard, specification or other freely licensed work (in each and every instance "Specified Material"), the following describes the permitted uses of the Material.

A. HL7 INDIVIDUAL, STUDENT AND HEALTH PROFESSIONAL MEMBERS, who register and agree to the terms of HL7’s license, are authorized, without additional charge, to read, and to use Specified Material to develop and sell products and services that implement, but do not directly incorporate, the Specified Material in whole or in part without paying license fees to HL7.

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Licensee agrees and acknowledges that HL7 may not own all right, title, and interest, in and to the Materials and that the Materials may contain and/or reference intellectual property owned by third parties (“Third Party IP”). Acceptance of these License Terms does not grant Licensee any rights with respect to Third Party IP. Licensee alone is responsible for identifying and obtaining any necessary licenses or authorizations to utilize Third Party IP in connection with the Materials or otherwise. Any actions, claims or suits brought by a third party resulting from a breach of any Third Party IP right by the Licensee remains the Licensee’s liability.

Following is a non-exhaustive list of third-party terminologies that may require a separate license:

TerminologyOwner/Contact
Current Procedures Terminology (CPT) code setAmerican Medical Association https://www.ama-assn.org/practice-management/cpt-licensing
SNOMED CTSNOMED International http://www.snomed.org/snomed-ct/get-snomed-ct or info@ihtsdo.org
Logical Observation Identifiers Names & Codes (LOINC)Regenstrief Institute, Inc.
International Classification of Diseases (ICD) codesWorld Health Organization (WHO)
NUCC Health Care Provider Taxonomy code setAmerican Medical Association. Please see www.nucc.org. AMA licensing contact: 312-464-5022 (AMA IP services)
Co-Chair, Primary Editor Melva Peters
Jenaker Consulting
melva@jenakerconsulting.com
Co-Chair, Primary Editor John Hatem
jnhatem@hotmail.com
Co-Chair Scott Robertson PharmD
scott.m.robertson@kp.org
Co-Chair Jean Duteau
jean@duteaudesign.com
Contributor Dr Kai U. Heitmann
Heitmann Consulting and Services, Gefyra GmbH, HL7 Germany
info@kheitmann.de
Contributor Tom de Jong
VZVZ, HL7 The Netherlands
tom@nova-pro.nl
Contributor Dr Christof Geßner
Gematik GmbH, HL7 Germany
christof.gessner@gematik.de

Contents

Introduction

This Implementation Guide provides CDA R2 templates for Medication Order and Medication Statement, Medication Dispense and Medication Administration that can be used by HL7 standards developers and external projects to develop models for pharmacy related content. The implementation guide is intended to provide consistency of pharmacy related models across all uses regardless of the method of transport by creating a library of Universal (UV) Pharmacy Templates that can be used by other Work Groups to derive constrained versions.

Purpose

Background

Historically multiple HL7 Work Groups have developed specifications for pharmacy related content and as a result, there is inconsistency in how medication related content is represented in HL7 V2, V3, CDA and FHIR. The Pharmacy Work Group often receives questions as to how to model pharmacy related content but in some cases, the use case cannot be met with the existing models.

This Implementation Guide provides a CDA R2 library of pharmacy templates that can be used by HL7 Work Groups or external projects to derive constrained versions of models for pharmacy related content.

Scope

This Pharmacy Templates Implementation Guide defines common pharmacy artifacts (order, dispense, administration and statement) in CDA R2 format. The scope of the Implementation Guide is limited to Medication Order and Medication Statement, Medication Dispense and Medication Administration. The content was developed by aligning and harmonizing the existing specifications for Consolidated CDA (C-CDA Release 2.1[1]).

Ballot Status of the Document

The Implementation Guide was balloted as Standard for Trial Use (STU) and then goes to Normative.

Audience

  • Clinical and Public Health laboratories
  • Immunization Registries
  • Pharmaceutical Vendors
  • EHR/PHR vendors
  • Clinical Decision Support Systems
  • HIS Vendors
  • Emergency Services Providers
  • Healthcare Institutions
  • Pharmacists
  • Physicians and other Clinicians

Relationships with other projects and guides

  • Consolidated CDA (C-CDA)
  • HL7 Version 3 Pharmacy Models
  • HL7 FHIR® Pharmacy Resources
  • International Patient Summary (IPS), where all pharmacy related templates are specialisations of the corresponding templates defined in this guide

Principles and background

The Pharmacy Work Group has a set of rich set of existing models that were used as the basis for the implementation guide including HL7 V3 models and FHIR resources. 

This implementation guide was created by the Pharmacy Work Group using the following approach:

  • Review of Consolidated CDA (C-CDA[1]) to identify templates that include pharmacy related content
  • Compare C-CDA templates to existing Pharmacy HL7 V3 models and Pharmacy FHIR resources to identify differences and gaps
  • Create universal templates to that can be constrained for use for new templates.

For the Medication Model reflected in template 2.16.840.1.113883.10.21.4.11 UV Medication Information (detail), the Common Message Element Type CMET R_Medication Universal” (COCT_MT230100UV02), Release 2 (as published in HL7 V3 2017, V2.0.2 Dec 2010, derived from Common Product Model) was used to construct the CDA extension elements (see also "Extensions" used in this guide in the appendix).

The template rules are formalized using the computable format defined by the HL7 Templates Standard: Specification and Use of Reusable Information Constraint Templates, Release 1[2] in order to facilitate also the automatic generation of consistent testing and validation capabilities.

Technical Background

What is a CDA

CDA R2 is "… a document markup standard that specifies the structure and semantics of clinical documents for the purpose of exchange” [CDA R2, Section 1.1]. Clinical documents, according to CDA, have the following characteristics:

  • Persistence
  • Stewardship
  • Potential for authentication
  • Context
  • Wholeness
  • Human readability

CDA defines a header for classification and management and a document body that carries the clinical record. While the header metadata are prescriptive and designed for consistency across all instances, the body is highly generic, leaving the designation of semantic requirements to implementation.

Templated CDA

CDA R2 can be constrained by mechanisms defined in the “Refinement and Localization” section of the HL7 Version 3 Interoperability Standards. The mechanism most commonly used to constrain CDA is referred to as “templated CDA”. This specification created a set of artifacts containing modular CDA templates (and associated value sets) for the purpose of the International Patient Summary, and the templates can be reused across any number of CDA document types.

There are different kinds of templates that might be created. Among them, the most common ones are:

  • CDA Document Level Templates constrain fields in the Clinical Document Architecture (CDA) header, and define containment relationships to CDA sections.
    For example, a History-and-Physical document-level template might require that the patient’s name be present, and that the document contain a Physical Exam section.
  • CDA Header Level Templates constrain fields for parts of the CDA header, like the patient (record target), the author, participations or the service event.
  • CDA Section Level Templates constrain fields in the CDA section, and define containment relationships to CDA entries.
    For example, a Physical-exam section-level template might require that the section/code be fixed to a particular LOINC code, and that the section contain a Systolic Blood Pressure observation.
  • CDA Entry Level Templates constrain the CDA clinical statement model in accordance with real world observations and acts.
    For example, a Systolic-blood-pressure entry-level template defines how the CDA Observation class is constrained (how to populate observation/code, how to populate observation/value, etc.) to represent the notion of a systolic blood pressure.

Open and Closed Templates

Open templates permit anything to be done in the underlying standard that is not explicitly prohibited. This allows templates to be built up over time that extend and go beyond the original use cases for which they were originally designed.

Closed templates only permit what has been defined in the template, and do not permit anything beyond that. There are good reasons to use closed templates, sometimes having to do with local policy. For example, in communicating information from a healthcare provider to an insurance company, some information may need to be omitted to ensure patient privacy laws are followed. Most templates developed for CDA are of the open sort.

Template versioning

Template versioning is needed to enable template designs to evolve over time.

Template versioning enables template designers to control and shape the conformance statements that make up a template’s design over time tailoring the design to fit the template’s intended purpose.

Each template version is associated with a particular template. The template – as a whole – has a mandatory globally unique, non-semantic, identifier. The identifier serves as the identifier of the original intent of the template and as the identifier of the set of versions that represent the template over time.

Template versions have a mandatory timestamp (date and optional time), called the “effective date”. The date can be seen as the point in time when the template version “came into being”, i.e. was recognized as existent by the governance group. Use of the template prior to this date would be considered an invalid use of the template.

For further information on Templates, Template Versions and related topics refer to the HL7 Templates Standard[2].

Identifiers for Templates and Value Sets

This specification specifies CDA Entry Level Templates only. They can be re-used in any appropriate context, such as an Entry of a medication section.

Two "root" Entry Templates are provided as entry points for the four described use cases:

  • UV Medication Order (2.16.840.1.113883.10.21.4.1)
  • UV Medication Statement (2.16.840.1.113883.10.21.4.7)
  • UV Medication Administration (2.16.840.1.113883.10.21.4.13)
  • UV Medication Dispense (2.16.840.1.113883.10.21.4.15)

These templates use other Entry Level Templates that are all listed in a subsequent section of this document.

This specification uses the following OIDs for the artefacts that are registered at the HL7 OID registry.

  • The root OID for templates is 2.16.840.1.113883.10.21
    • Entry Level templates are summarized under 2.16.840.1.113883.10.21.4, e.g. 2.16.840.1.113883.10.21.4.5 UV Substitution Permission
    • “other” assistance templates are summarized under 2.16.840.1.113883.10.21.9, e.g. 2.16.840.1.113883.10.22.9.1 UV Use Period
  • The root OID for Value Sets is 2.16.840.1.113883.11

The sub branches for templates follow the recommendations of HL7 International and ISO 13582[3].

Namespace Identifier

The CDA extensions for Pharmacy defined by the Pharmacy Workgroup are handled under the XML namespace identifier urn:hl7-org:pharm and typically use the namespace prefix pharm:.

How to read this document

All artifacts (templates, value sets etc.) listed with the status Kyellow.png Draft or Korange.png Pending are subject to ballot comments.

Artifacts with other status information, especially Kgreen.png Final or Active are not (directly) part of the ballot and some artifacts actually even come from external sources (reference artifacts indicated by the symbol
ref
). These reference artifacts are also not subject to the ballot, as they might be balloted elsewhere already.

The PDF version contains a ruler on the left side of the pages. A ruler has the page number on top of it and allows locating a line at the page by simply specifying the number at the scale tick. This is more precise and allows also commenting on graphics and pictures.

For example if you have a comment on page 29 because of a typo (see figure), you simply specify the error with its location p0029-04.

Of course you can also refer by classical chapter and section numbers. The use of the ruler has the ballot team's preference, though.

IPS ballotruler.jpg
IPS ballotruler.jpg

[Figure 1] To locate a typo on page 29 as a ballot comment, simply specify the location p0029-04.

Reading Publication Artefacts

A reading guide is available that explains the formalisms used to express the publication artefacts, i.e. template meta data and template design. For convenience the guide is included in the appendix.

Functional requirements and high-level use cases

The following use cases are relevant to the pharmacy domain for both community and institutional settings:

  • Prescribing a medication (aka Prescription or Order or Request)
  • Dispensing a medication
  • Recording the administration of a medication
  • Recording the use of a medication (in the past, current or future)

The following definitions are relevant to this Implementation Guide:

  • Prescribing is an activity that can be performed by a variety of healthcare professionals and involves a variety of orderable items (see glossary entry). For the purposes of the following Implementation Guide, prescribing is defined as the act of authorizing the usage of a medication in various settings for example, inpatient, community, and long term care. This could include initiating a new medication order or making all kinds of modifications to existing orders.
  • Dispensing is the provision of a medication or other material to a caregiver in fulfillment of a prescription or medication order. It supplies the materials needed to perform the prescribed actions by those who will perform them. Examples of dispensing include eyeglasses, contact lenses and medications.

For the purposes of the following ballot material, dispensing is defined as supplying a medication in fulfillment of a prescription or medication order. While dispensing is usually performed by a pharmacist, other health care providers such as nurses or physicians may also dispense.

  • Administration is an activity undertaken to give medication to the patient. In the community, this process is usually not recorded, since the majority occurs in the patient's home; only administrations undertaken by a healthcare professional, such as vaccination, tend to be formally documented. Administration of medication in the institutional setting is usually recorded on a dose-by-dose basis, and may be messaged on that basis, or a summary of all the administrations occurring during an inpatient stay may be described.
  • Medication Statement is an activity that can be performed by a variety of healthcare professionals, or the patient, or non-healthcare professionals. Examples of recording medication statements include taking a patient's medication history, recording reported use of medications where the source of the patient information is from a third party and not the patient e.g. a family member when the patient is unable to communicate their medication history.

Templates

Use Case Entry Level Templates

As mentioned before, this specification defines two "root" Entry Level Templates, one for each of the covered use cases. All entry templates are used in the context of a CDA section.

UV Medication Order

The following graph gives an overview of the high-level template components of this template, followed by the actual definition.

Note: If you need to include multiple ordered medications as part of a single order, you can include multiple CDA entries under one CDA section. CDA Section definitions are not part of this guide.

  1. Entry
     UV Medication Order (2.16.840.1.113883.10.21.4.1)
    1. Entry
       UV Use Period (2.16.840.1.113883.10.21.9.1)
    2. Entry
       CDA Subject (Body) (2.16.840.1.113883.10.12.320)
    3. Entry
       UV Medication Information (detail) (2.16.840.1.113883.10.21.4.11)
      1. *
         CDA Organization (2.16.840.1.113883.10.12.151)
    4. Entry
       CDA Author (Body) (2.16.840.1.113883.10.12.318)
      1. *
         CDA Person (2.16.840.1.113883.10.12.152)
      2. Entry
         CDA Device (2.16.840.1.113883.10.12.315)
      3. *
         CDA Organization (2.16.840.1.113883.10.12.151)
    5. Entry
       CDA Participant (Body) (2.16.840.1.113883.10.12.321)
      1. Entry
         CDA Device (2.16.840.1.113883.10.12.315)
      2. Entry
         CDA PlayingEntity (2.16.840.1.113883.10.12.313)
    6. Entry
       CDA Participant (Body) (2.16.840.1.113883.10.12.321)
      1. Entry
         CDA Device (2.16.840.1.113883.10.12.315)
      2. Entry
         CDA PlayingEntity (2.16.840.1.113883.10.12.313)
    7. Entry
       UV Subordinate Substance Administration (2.16.840.1.113883.10.21.4.6)
    8. Entry
       UV Dispense Request (2.16.840.1.113883.10.21.4.2)
      1. Entry
         CDA Subject (Body) (2.16.840.1.113883.10.12.320)
      2. Entry
         CDA ManufacturedProduct (2.16.840.1.113883.10.12.312)
        1. Entry
           CDA LabeledDrug (2.16.840.1.113883.10.12.310)
        2. Entry
           CDA Material (2.16.840.1.113883.10.12.311)
        3. *
           CDA Organization (2.16.840.1.113883.10.12.151)
      3. Entry
         CDA Performer (Body) (2.16.840.1.113883.10.12.323)
        1. *
           CDA AssignedEntity (2.16.840.1.113883.10.12.153)
          1. *
             CDA Person (2.16.840.1.113883.10.12.152)
          2. *
             CDA Organization (2.16.840.1.113883.10.12.151)
      4. Entry
         CDA Participant (Body) (2.16.840.1.113883.10.12.321)
        1. Entry
           CDA Device (2.16.840.1.113883.10.12.315)
        2. Entry
           CDA PlayingEntity (2.16.840.1.113883.10.12.313)
      5. Entry
         CDA Participant (Body) (2.16.840.1.113883.10.12.321)
        1. Entry
           CDA Device (2.16.840.1.113883.10.12.315)
        2. Entry
           CDA PlayingEntity (2.16.840.1.113883.10.12.313)
      6. Entry
         CDA Participant (Body) (2.16.840.1.113883.10.12.321)
        1. Entry
           CDA Device (2.16.840.1.113883.10.12.315)
        2. Entry
           CDA PlayingEntity (2.16.840.1.113883.10.12.313)
      7. Entry
         CDA Participant (Body) (2.16.840.1.113883.10.12.321)
        1. Entry
           CDA Device (2.16.840.1.113883.10.12.315)
        2. Entry
           CDA PlayingEntity (2.16.840.1.113883.10.12.313)
    9. Entry
       Indication (V2) (2.16.840.1.113883.10.20.22.4.19)
    10. Entry
       UV ClinicalStatement Observation (2.16.840.1.113883.10.21.4.3)
      1. Entry
         CDA Subject (Body) (2.16.840.1.113883.10.12.320)
      2. Entry
         CDA Specimen (2.16.840.1.113883.10.12.322)
      3. Entry
         CDA Performer (Body) (2.16.840.1.113883.10.12.323)
        1. *
           CDA AssignedEntity (2.16.840.1.113883.10.12.153)
          1. *
             CDA Person (2.16.840.1.113883.10.12.152)
          2. *
             CDA Organization (2.16.840.1.113883.10.12.151)
      4. Entry
         CDA Author (Body) (2.16.840.1.113883.10.12.318)
        1. *
           CDA Person (2.16.840.1.113883.10.12.152)
        2. Entry
           CDA Device (2.16.840.1.113883.10.12.315)
        3. *
           CDA Organization (2.16.840.1.113883.10.12.151)
      5. Entry
         CDA Informant (Body) (2.16.840.1.113883.10.12.319)
        1. *
           CDA AssignedEntity (2.16.840.1.113883.10.12.153)
          1. *
             CDA Person (2.16.840.1.113883.10.12.152)
          2. *
             CDA Organization (2.16.840.1.113883.10.12.151)
        2. Entry
           CDA RelatedEntity (2.16.840.1.113883.10.12.316)
          1. *
             CDA Person (2.16.840.1.113883.10.12.152)
      6. Entry
         CDA Participant (Body) (2.16.840.1.113883.10.12.321)
        1. Entry
           CDA Device (2.16.840.1.113883.10.12.315)
        2. Entry
           CDA PlayingEntity (2.16.840.1.113883.10.12.313)
      7. Entry
         CDA Reference (2.16.840.1.113883.10.12.324)
        1. Entry
           CDA ExternalAct (2.16.840.1.113883.10.12.325)
        2. Entry
           CDA ExternalObservation (2.16.840.1.113883.10.12.326)
        3. Entry
           CDA ExternalProcedure (2.16.840.1.113883.10.12.327)
        4. Entry
           CDA ExternalDocument (2.16.840.1.113883.10.12.328)
      8. Entry
         CDA Precondition (2.16.840.1.113883.10.12.329)
    11. Entry
       UV Substitution Permission (2.16.840.1.113883.10.21.4.5)
    12. Entry
       UV ClinicalStatement Encounter (2.16.840.1.113883.10.21.4.4)
    13. Entry
       UV Comment Activity (2.16.840.1.113883.10.21.4.12)
      1. Entry
         CDA Author (Body) (2.16.840.1.113883.10.12.318)
        1. *
           CDA Person (2.16.840.1.113883.10.12.152)
        2. Entry
           CDA Device (2.16.840.1.113883.10.12.315)
        3. *
           CDA Organization (2.16.840.1.113883.10.12.151)
    14. Entry
       CDA Precondition (2.16.840.1.113883.10.12.329)

The boxes reflect the CDA Template Types. Symbols: * denotes templates with more than one classification, @ indicates a recursion in the definition

Id2.16.840.1.113883.10.21.4.1Effective Date2015‑10‑07
StatusKyellow.png DraftVersion Label
NameUVSubstanceadministrationrequestDisplay NameUV Medication Order
DescriptionUniversal Medication Order (Substance Administration Request)
ContextParent nodes of template element with id 2.16.840.1.113883.10.21.4.1
LabelMedicationOrder
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 13 templates
Uses as NameVersion
2.16.840.1.113883.10.21.9.1IncludeKyellow.png UV Use PeriodDYNAMIC
2.16.840.1.113883.10.12.320ContainmentKgreen.png CDA Subject (Body)DYNAMIC
2.16.840.1.113883.10.21.4.11ContainmentKyellow.png UV Medication Information (detail)DYNAMIC
2.16.840.1.113883.10.12.318ContainmentKgreen.png CDA Author (Body)DYNAMIC
2.16.840.1.113883.10.12.321ContainmentKgreen.png CDA Participant (Body)DYNAMIC
2.16.840.1.113883.10.21.4.6ContainmentKyellow.png UV Subordinate Substance AdministrationDYNAMIC
2.16.840.1.113883.10.21.4.2ContainmentKyellow.png UV Dispense RequestDYNAMIC
2.16.840.1.113883.10.20.22.4.19ContainmentKorange.png Indication (V2) (2.1)DYNAMIC
2.16.840.1.113883.10.21.4.3ContainmentKyellow.png UV ClinicalStatement ObservationDYNAMIC
2.16.840.1.113883.10.21.4.5ContainmentKyellow.png UV Substitution PermissionDYNAMIC
2.16.840.1.113883.10.21.4.4ContainmentKyellow.png UV ClinicalStatement EncounterDYNAMIC
2.16.840.1.113883.10.21.4.12ContainmentKyellow.png UV Comment ActivityDYNAMIC
2.16.840.1.113883.10.12.329ContainmentKgreen.png CDA PreconditionDYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.308 CDA SubstanceAdministration (2005‑09‑07)
ref
ad1bbr-
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="IPINHL" codeSystem="2.16.840.1.113883.5.112" displayName="Inhalation, respiratory Inhalation, intrapulmonary Inhalation, oral"/>  <approachSiteCode code="..." codeSystem="2.16.840.1.113883.5.1052"/>  <administrationUnitCode code="PUFF" codeSystem="2.16.840.1.113883.5.85" displayName="Puff"/>  <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>
ItemDTCardConfDescriptionLabel
hl7:substanceAdministration
Medi...rder
Treetree.png@classCode
cs1 … 1FSBADM
Treetree.png@moodCode
cs1 … 1FRQO
Treetree.pnghl7:templateId
II1 … 1MMedi...rder
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.21.4.1
Treetree.pnghl7:id
II1 … *RMedi...rder
Treetree.pnghl7:code
CD (extensible)0 … 1RMedi...rder
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.1.11.19708 ActSubstanceAdministrationCode (DYNAMIC)
Treetree.pnghl7:text
ED0 … 1Medi...rder
Treetree.pnghl7:statusCode
CS (required)1 … 1MMedi...rder
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.21.2 ActStatusActiveCompletedAbortedSuspended (DYNAMIC)
Included from 2.16.840.1.113883.10.21.9.1 UV Use Period (DYNAMIC)
Choice1 … 1
The effectiveTime element encodes the use period 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]
Treeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1CCase 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 (continuous therapy) 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 a prescription that has not been refilled 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.pngTreeblank.png where [hl7:low or
hl7:high]
Treeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 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
continous therapy
<effectiveTime xsi:type="IVL_TS">
  <low value="20130321"/>  <high nullFlavor="NA"/></effectiveTime>
Treeblank.pngTreeblank.pngTreetree.pnghl7:low
IVXB_TS1 … 1RMedi...rder
Treeblank.pngTreeblank.pngTreetree.pnghl7:high
IVXB_TS0 … 1RMedi...rder
Treeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1CCase 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.pngTreeblank.png where [hl7:width]
 Example
2 week period
<effectiveTime xsi:type="IVL_TS">
  <width value="2" unit="w"/></effectiveTime>
Treeblank.pngTreeblank.pngTreetree.pnghl7:low
NPMedi...rder
Treeblank.pngTreeblank.pngTreetree.pnghl7:width
PQ1 … 1RMedi...rder
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs1 … 1R
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.21.1 Medication Time Units (UCUM) (DYNAMIC)
Treetree.pnghl7:repeatNumber
IVL_INT0 … 1Medi...rder
Treetree.pnghl7:routeCode
CE (example)0 … 1Medi...rder
 CONF
Examples of the value of @code are in the valuet set 2.16.840.1.113883.1.11.14581 RouteOfAdministration (DYNAMIC)
Treetree.pnghl7:approachSiteCode
CD (example)0 … *Medi...rder
 CONF
Examples of the value of @code are in the valuet set 2.16.840.1.113883.1.11.19724 HumanSubstanceAdministrationSite (DYNAMIC)
Treetree.pnghl7:doseQuantity
IVL_PQNPMedi...rder
Treetree.pnghl7:rateQuantity
IVL_PQNPMedi...rder
Treetree.pnghl7:maxDoseQuantity
RTO_PQ_PQ0 … 1Medi...rder
Treetree.pnghl7:administrationUnitCode
CENPMedi...rder
Treetree.pnghl7:subject
0 … 1CThe patient, subject to requested dispenses or subject to substances being administered to.
Contains 2.16.840.1.113883.10.12.320 CDA Subject (Body) (DYNAMIC)
Medi...rder
Treeblank.png where [hl7:relatedSubject]
 ConstraintCondition: This can be omitted if the patient context that is provided in the CDA header is identical to the subject
Treetree.pnghl7:consumable
1 … 1MConsumable: The medication that is being administered
Contains 2.16.840.1.113883.10.21.4.11 UV Medication Information (detail) (DYNAMIC)
Medi...rder
Treeblank.png where [not(@nullFlavor)] [hl7:manufacturedProduct]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCSM
Treetree.pnghl7: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
Treeblank.png where [hl7:assignedAuthor]
Treetree.pnghl7:participant
0 … 1Record Target: indicates the person who's medical record holds the documentation of this medication statement. This element is only populated when the document is placed in a medical record of someone other than the patient (subject).
Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC)
Medi...rder
Treeblank.png where [@typeCode='RCT']
Treeblank.pngTreetree.png@typeCode
cs1 … 1FRCT
Treetree.pnghl7:participant
0 … 1Verifier: 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.png where [@typeCode='VRF']
Treeblank.pngTreetree.png@typeCode
cs1 … 1FVRF
Treetree.pnghl7:entryRelationship
0 … *CSubordinate Substance Administration Request as a component of the overall order.
At least one subordinated Substance Administration should be present to convey information about dosages (dose, frequency of intakes,..) unless dosage is unknown.
Subordinated Substance Administration 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.png where [hl7:substanceAdministration]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
 ConstraintAt least one subordinate element SHALL be present.
 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>
Treeblank.pngTreetree.pnghl7:sequenceNumber
INT0 … 1Sequence number of the Subordinate Substance Administration.Medi...rder
Treetree.pnghl7:entryRelationship
0 … 1RDispense Request as a component of the overall order. This element is used in the medication order when the dispense request information contains additional information to support a fully specified medication prescription. For example, to include the validity period of the dispense or the organization to dispense the medication.
Contains 2.16.840.1.113883.10.21.4.2 UV Dispense Request (DYNAMIC)
Medi...rder
Treeblank.png where [hl7:supply]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
 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>
Treetree.pnghl7:entryRelationship
0 … *RReason: 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.png where [cda:observation [cda:code [concat(@code, @codeSystem) = doc('include/voc-2.16.840.1.113883.3.88.12.3221.7.2-2014-09-02T000000.xml')//valueSet [1]/conceptList/concept/concat(@code, @codeSystem) or @nullFlavor]]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FRSON
 Example<entryRelationship typeCode="RSON">
  <priorityNumber value="1"/>  <act>
    <!-- Clinical Statement Minimal -->
  </act>
</entryRelationship>
Treeblank.pngTreetree.pngpharm:priorityNumber
INT.​NONNEG0 … 1RIndicates the priority of this reason for the order in relation to its sibling reasons.Medi...rder
Treetree.pnghl7:entryRelationship
0 … *RPertinent 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.png where [hl7:observation]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FPERT
 Example<entryRelationship typeCode="PERT">
  <observation>
    <!-- Clinical Statement Observation -->
  </observation>
</entryRelationship>
Treetree.pnghl7:entryRelationship
0 … 1RPermission: 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.png where [hl7:act]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treetree.pnghl7:entryRelationship
0 … 1REncounter: 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.png where [hl7:encounter]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
 Example<encounter classCode="ENC" moodCode="EVN">
  <id/>  <code code="..."/></encounter>
Treetree.pnghl7:entryRelationship
0 … *Annotations: The Medication Order can be the subject of annotations.
Contains 2.16.840.1.113883.10.21.4.12 UV Comment Activity (DYNAMIC)
Medi...rder
Treeblank.png where [hl7:act [hl7:code [(@code = '48767-8' and @codeSystem = '2.16.840.1.113883.6.1')]]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
Treetree.pnghl7: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
Treeblank.png where [hl7:criterion]

UV Medication Statement

The following graph gives an overview of the high-level template components of this template, followed by the actual definition.

  1. Entry
     UV Medication Statement (2.16.840.1.113883.10.21.4.7)
    1. Entry
       UV Use Period (2.16.840.1.113883.10.21.9.1)
    2. Entry
       CDA Subject (Body) (2.16.840.1.113883.10.12.320)
    3. Entry
       UV Medication Information (simple) (2.16.840.1.113883.10.21.4.10)
      1. *
         CDA Organization (2.16.840.1.113883.10.12.151)
    4. Entry
       UV Medication Information (detail) (2.16.840.1.113883.10.21.4.11)
      1. *
         CDA Organization (2.16.840.1.113883.10.12.151)
    5. Entry
       CDA Author (Body) (2.16.840.1.113883.10.12.318)
      1. *
         CDA Person (2.16.840.1.113883.10.12.152)
      2. Entry
         CDA Device (2.16.840.1.113883.10.12.315)
      3. *
         CDA Organization (2.16.840.1.113883.10.12.151)
    6. *
       CDA AssignedEntity (2.16.840.1.113883.10.12.153)
      1. *
         CDA Person (2.16.840.1.113883.10.12.152)
      2. *
         CDA Organization (2.16.840.1.113883.10.12.151)
    7. Entry
       CDA RelatedEntity (2.16.840.1.113883.10.12.316)
      1. *
         CDA Person (2.16.840.1.113883.10.12.152)
    8. Entry
       CDA Participant (Body) (2.16.840.1.113883.10.12.321)
      1. Entry
         CDA Device (2.16.840.1.113883.10.12.315)
      2. Entry
         CDA PlayingEntity (2.16.840.1.113883.10.12.313)
    9. Entry
       CDA Participant (Body) (2.16.840.1.113883.10.12.321)
      1. Entry
         CDA Device (2.16.840.1.113883.10.12.315)
      2. Entry
         CDA PlayingEntity (2.16.840.1.113883.10.12.313)
    10. Entry
       UV Subordinate Substance Administration (2.16.840.1.113883.10.21.4.6)
    11. Entry
       UV Medication Order Reference (2.16.840.1.113883.10.21.4.8)
      1. Entry
         CDA Author (Body) (2.16.840.1.113883.10.12.318)
        1. *
           CDA Person (2.16.840.1.113883.10.12.152)
        2. Entry
           CDA Device (2.16.840.1.113883.10.12.315)
        3. *
           CDA Organization (2.16.840.1.113883.10.12.151)
    12. Entry
       UV Dispense Event Reference (2.16.840.1.113883.10.21.4.9)

The boxes reflect the CDA Template Types. Symbols: * denotes templates with more than one classification, @ indicates a recursion in the definition

Id2.16.840.1.113883.10.21.4.7Effective Date2017‑05‑01
StatusKyellow.png DraftVersion Label
NameUVMedicationstatementDisplay NameUV Medication Statement
Description
Universal Medication Statement: Recording a "medication statement" is an activity that can be performed by a variety of healthcare professionals, or the patient, or non-healthcare professionals. Examples of recording medication statements include taking a patient's medication history, recording reported use of medications where the source of the patient information is from a third party and not the patient e.g. a family member when the patient is unable to communicate their medication history.
ContextParent nodes of template element with id 2.16.840.1.113883.10.21.4.7
LabelMedicationStatement
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 11 templates
Uses as NameVersion
2.16.840.1.113883.10.21.9.1IncludeKyellow.png UV Use PeriodDYNAMIC
2.16.840.1.113883.10.12.320ContainmentKgreen.png CDA Subject (Body)DYNAMIC
2.16.840.1.113883.10.21.4.10ContainmentKyellow.png UV Medication Information (simple)DYNAMIC
2.16.840.1.113883.10.21.4.11ContainmentKyellow.png UV Medication Information (detail)DYNAMIC
2.16.840.1.113883.10.12.318ContainmentKgreen.png CDA Author (Body)DYNAMIC
2.16.840.1.113883.10.12.153ContainmentKgreen.png CDA AssignedEntityDYNAMIC
2.16.840.1.113883.10.12.316ContainmentKgreen.png CDA RelatedEntityDYNAMIC
2.16.840.1.113883.10.12.321ContainmentKgreen.png CDA Participant (Body)DYNAMIC
2.16.840.1.113883.10.21.4.6ContainmentKyellow.png UV Subordinate Substance AdministrationDYNAMIC
2.16.840.1.113883.10.21.4.8ContainmentKyellow.png UV Medication Order ReferenceDYNAMIC
2.16.840.1.113883.10.21.4.9ContainmentKyellow.png UV Dispense Event ReferenceDYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.308 CDA SubstanceAdministration (2005‑09‑07)
ref
ad1bbr-
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"/>  <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="ASSERTION" displayName="Assertion" 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"/>  <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"/>  <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>
ItemDTCardConfDescriptionLabel
hl7:substanceAdministration
Medi...ment
Treetree.png@classCode
cs1 … 1FSBADM
Treetree.png@moodCode
cs1 … 1REVN will be used to record a medication statement where the patient is currently taking or has taken the medication in the past.
INT will be used to record a medication statement where the patient plans to take the medication or be administered the medication in the future.
 CONF
@moodCode shall be "EVN"
or
@moodCode shall be "INT"
Treetree.pnghl7:templateId
II1 … 1MMedi...ment
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.21.4.7
Treetree.pnghl7:id
II0 … *RMedi...ment
Treetree.pnghl7:code
CD (preferred)0 … 1RThe code element is valorized with the ACT code "ASSERTION" unless it is used for asserting the known absence of medication treatments or no information about them.Medi...ment
 CONF
@code shall be "ASSERTION"
@codeSystem shall be "2.16.840.1.113883.5.4"
or
The value of @code comes preferably from value set 2.16.840.1.113883.11.21.5 Unknown or absent medication (DYNAMIC)
Treetree.pnghl7:text
ED0 … 1Medi...ment
Treetree.pnghl7:statusCode
CS (required)1 … 1MMedi...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)
Choice1 … 1
The effectiveTime element encodes the use period 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]
Treeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1CCase 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 (continuous therapy) 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 a prescription that has not been refilled 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.pngTreeblank.png where [hl7:low or
hl7:high]
Treeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 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
continous therapy
<effectiveTime xsi:type="IVL_TS">
  <low value="20130321"/>  <high nullFlavor="NA"/></effectiveTime>
Treeblank.pngTreeblank.pngTreetree.pnghl7:low
IVXB_TS1 … 1RMedi...ment
Treeblank.pngTreeblank.pngTreetree.pnghl7:high
IVXB_TS0 … 1RMedi...ment
Treeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1CCase 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.pngTreeblank.png where [hl7:width]
 Example
2 week period
<effectiveTime xsi:type="IVL_TS">
  <width value="2" unit="w"/></effectiveTime>
Treeblank.pngTreeblank.pngTreetree.pnghl7:low
NPMedi...ment
Treeblank.pngTreeblank.pngTreetree.pnghl7:width
PQ1 … 1RMedi...ment
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs1 … 1R
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.21.1 Medication Time Units (UCUM) (DYNAMIC)
Treetree.pnghl7:repeatNumber
IVL_INT0 … 1Medi...ment
Treetree.pnghl7:routeCode
CE (example)0 … 1Medi...ment
 CONF
Examples of the value of @code are in the valuet set 2.16.840.1.113883.1.11.14581 RouteOfAdministration (DYNAMIC)
Treetree.pnghl7:approachSiteCode
CD (example)0 … *Medi...ment
 CONF
Examples of the value of @code are in the valuet set 2.16.840.1.113883.1.11.19724 HumanSubstanceAdministrationSite (DYNAMIC)
Treetree.pnghl7:doseQuantity
IVL_PQNPMedi...ment
Treetree.pnghl7:rateQuantity
IVL_PQNPMedi...ment
Treetree.pnghl7:maxDoseQuantity
RTO_PQ_PQ0 … 1Medi...ment
Treetree.pnghl7:administrationUnitCode
CENPMedi...ment
Treetree.pnghl7:subject
0 … 1CPatient: The patient that takes the medicine.
Contains 2.16.840.1.113883.10.12.320 CDA Subject (Body) (DYNAMIC)
Medi...ment
Treeblank.png where [hl7:relatedSubject]
 ConstraintCondition: This can be omitted if the patient context that is provided in the CDA header is identical to the subject
Choice1 … 1Elements to choose from:
  • hl7:consumable containing template 2.16.840.1.113883.10.21.4.10 UV Medication Information (simple) (DYNAMIC)
  • hl7:consumable containing template 2.16.840.1.113883.10.21.4.11 UV Medication Information (detail) (DYNAMIC)
Treeblank.pngTreetree.pnghl7:consumable
0 … 1RConsumable: The medication that is administered (simple)
Contains 2.16.840.1.113883.10.21.4.10 UV Medication Information (simple) (DYNAMIC)
Medi...ment
Treeblank.pngTreeblank.png where [hl7:manufacturedProduct]
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FCSM
Treeblank.pngTreetree.pnghl7:consumable
0 … 1RConsumable: The medication that is administered (detail)
Contains 2.16.840.1.113883.10.21.4.11 UV Medication Information (detail) (DYNAMIC)
Medi...ment
Treeblank.pngTreeblank.png where [hl7:manufacturedProduct]
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FCSM
Choice1 … 1
Required author of the medication statement: healthcare professional or patient
Elements to choose from:
  • hl7:author containing template 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC)
  • hl7:participant[@typeCode='AUT']
Treeblank.pngTreetree.pnghl7:author
Use this if the author of the medication statement is a healthcare professional
Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC)
Medi...ment
Treeblank.pngTreeblank.png where [hl7:assignedAuthor]
 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>
Treeblank.pngTreetree.pnghl7:participant
Use this if the author of the medication statement is the patientMedi...ment
Treeblank.pngTreeblank.png where [@typeCode='AUT']
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FAUT
 Example
Author of the medication statement is the patient
<participant typeCode="AUT">
  <time value="20170121091548"/>  <participantRole classCode="PAT"/></participant>
Treeblank.pngTreeblank.pngTreetree.pnghl7:time
TS1 … 1RMedi...ment
Treeblank.pngTreeblank.pngTreetree.pnghl7:participantRole
1 … 1MMedi...ment
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FPAT
Choice0 … 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)]
Treeblank.pngTreetree.pnghl7:informant
Use this if the informant of the medication statement is a healthcare professionalMedi...ment
Treeblank.pngTreeblank.png where [exists(hl7:assignedEntity)]
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs0 … 1FINF
Treeblank.pngTreeblank.pngTreetree.png@context​Control​Code
cs0 … 1FOP
 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>
Treeblank.pngTreeblank.pngTreetree.pnghl7:assignedEntity
1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)Medi...ment
Treeblank.pngTreetree.pnghl7:participant
Use this if the informant of the medication statement is the patientMedi...ment
Treeblank.pngTreeblank.png where [@typeCode='INF']
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FINF
 Example
Informant of the medication statement is the patient
<participant typeCode="INF">
  <time value="20170121091548"/>  <participantRole classCode="PAT"/></participant>
Treeblank.pngTreeblank.pngTreetree.pnghl7:time
TS1 … 1RMedi...ment
Treeblank.pngTreeblank.pngTreetree.pnghl7:participantRole
1 … 1MMedi...ment
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FPAT
Treeblank.pngTreetree.pnghl7:informant
Use this if the informant of the medication statement is a contact party (related party)Medi...ment
Treeblank.pngTreeblank.png where [exists(hl7:relatedEntity)]
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs0 … 1FINF
Treeblank.pngTreeblank.pngTreetree.png@context​Control​Code
cs0 … 1FOP
 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>
Treeblank.pngTreeblank.pngTreetree.pnghl7:relatedEntity
1 … 1Contains 2.16.840.1.113883.10.12.316 CDA RelatedEntity (DYNAMIC)Medi...ment
Treetree.pnghl7:participant
0 … 1Record Target: indicates the person who's medical record holds the documentation of this medication statement. This element is only populated when the document is placed in a medical record of someone other than the patient (subject).
Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC)
Medi...ment
Treeblank.png where [@typeCode='RCT']
Treeblank.pngTreetree.png@typeCode
cs1 … 1FRCT
Treetree.pnghl7:participant
0 … 1Verifier: 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.png where [@typeCode='VRF']
Treeblank.pngTreetree.png@typeCode
cs1 … 1FVRF
Treetree.pnghl7:entryRelationship
0 … *CSubordinate 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,..) unless medications are unknown or known absent.
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.png where [hl7:substanceAdministration]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
 ConstraintAt least one subordinate <substanceAdministration> element SHALL be present unless medications are unknown or known absent.
 Example<entryRelationship typeCode="COMP">
  <!-- component: Subordinate Substance Administration Statement. -->
  <substanceAdministration classCode="SBADM" moodCode="EVN">
    <templateId root="2.16.840.1.113883.10.21.4.6"/>    <!-- .. -->
  </substanceAdministration>
</entryRelationship>
Treeblank.pngTreetree.pnghl7:sequenceNumber
INT0 … 1Sequence number of the Subordinate Substance Administration.Medi...ment
Treetree.pnghl7:entryRelationship
0 … *RMedication Order Reference.
Contains 2.16.840.1.113883.10.21.4.8 UV Medication Order Reference (DYNAMIC)
Medi...ment
Treeblank.png where [@typeCode='REFR'] [hl7:substanceAdministration]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREFR
 Example<entryRelationship typeCode="REFR">
  <substanceAdministration classCode="SBADM" moodCode="RQO">
    <templateId root="2.16.840.1.113883.10.21.4.8"/>    <!-- .. -->
  </substanceAdministration>
</entryRelationship>
Treetree.pnghl7:entryRelationship
0 … *RDispense Event Reference.
Contains 2.16.840.1.113883.10.21.4.9 UV Dispense Event Reference (DYNAMIC)
Medi...ment
Treeblank.png where [@typeCode='REFR'] [ [hl7:supply]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREFR
 Example<entryRelationship typeCode="REFR">
  <supply classCode="SPLY" moodCode="EVN">
    <templateId root="2.16.840.1.113883.10.21.4.9"/>    <!-- .. -->
  </supply>
</entryRelationship>

UV Medication Administration

The following graph gives an overview of the high-level template components of this template, followed by the actual definition.

  1. Entry
     UV Medication Administration (2.16.840.1.113883.10.21.4.13)
    1. Entry
       UV Use Period (2.16.840.1.113883.10.21.9.1)
    2. Entry
       CDA Subject (Body) (2.16.840.1.113883.10.12.320)
    3. Entry
       UV Medication Information (simple) (2.16.840.1.113883.10.21.4.10)
      1. *
         CDA Organization (2.16.840.1.113883.10.12.151)
    4. Entry
       UV Medication Information (detail) (2.16.840.1.113883.10.21.4.11)
      1. *
         CDA Organization (2.16.840.1.113883.10.12.151)
    5. Entry
       CDA Author (Body) (2.16.840.1.113883.10.12.318)
      1. *
         CDA Person (2.16.840.1.113883.10.12.152)
      2. Entry
         CDA Device (2.16.840.1.113883.10.12.315)
      3. *
         CDA Organization (2.16.840.1.113883.10.12.151)
    6. *
       CDA AssignedEntity (2.16.840.1.113883.10.12.153)
      1. *
         CDA Person (2.16.840.1.113883.10.12.152)
      2. *
         CDA Organization (2.16.840.1.113883.10.12.151)
    7. Entry
       CDA RelatedEntity (2.16.840.1.113883.10.12.316)
      1. *
         CDA Person (2.16.840.1.113883.10.12.152)
    8. Entry
       CDA Participant (Body) (2.16.840.1.113883.10.12.321)
      1. Entry
         CDA Device (2.16.840.1.113883.10.12.315)
      2. Entry
         CDA PlayingEntity (2.16.840.1.113883.10.12.313)
    9. Entry
       CDA Participant (Body) (2.16.840.1.113883.10.12.321)
      1. Entry
         CDA Device (2.16.840.1.113883.10.12.315)
      2. Entry
         CDA PlayingEntity (2.16.840.1.113883.10.12.313)
    10. Entry
       CDA Participant (Body) (2.16.840.1.113883.10.12.321)
      1. Entry
         CDA Device (2.16.840.1.113883.10.12.315)
      2. Entry
         CDA PlayingEntity (2.16.840.1.113883.10.12.313)
    11. Entry
       UV Subordinate Substance Administration (2.16.840.1.113883.10.21.4.6)
    12. Entry
       UV Substitution Event Adminstration (2.16.840.1.113883.10.21.4.14)
    13. Entry
       UV Medication Order Reference (2.16.840.1.113883.10.21.4.8)
      1. Entry
         CDA Author (Body) (2.16.840.1.113883.10.12.318)
        1. *
           CDA Person (2.16.840.1.113883.10.12.152)
        2. Entry
           CDA Device (2.16.840.1.113883.10.12.315)
        3. *
           CDA Organization (2.16.840.1.113883.10.12.151)
    14. Entry
       UV Dispense Event Reference (2.16.840.1.113883.10.21.4.9)

The boxes reflect the CDA Template Types. Symbols: * denotes templates with more than one classification, @ indicates a recursion in the definition

Id2.16.840.1.113883.10.21.4.13Effective Date2019‑02‑17
StatusKyellow.png DraftVersion Label
NameUVMedicationadministrationDisplay NameUV Medication Administration
Description
Universal Medication Administration: This includes information about an actual administration of a medication. Medication administrations include information about medication use where the medications have been prescribed or not prescribed. Medication administrations may include "negative" statements such as "the patient was not given medication ABC". Due to implementation experience, dosage information is always put into the subordinate substance administration entries.
ContextParent nodes of template element with id 2.16.840.1.113883.10.21.4.13
LabelMedicationAdministration
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 12 templates
Uses as NameVersion
2.16.840.1.113883.10.21.9.1IncludeKyellow.png UV Use PeriodDYNAMIC
2.16.840.1.113883.10.12.320ContainmentKgreen.png CDA Subject (Body)DYNAMIC
2.16.840.1.113883.10.21.4.10ContainmentKyellow.png UV Medication Information (simple)DYNAMIC
2.16.840.1.113883.10.21.4.11ContainmentKyellow.png UV Medication Information (detail)DYNAMIC
2.16.840.1.113883.10.12.318ContainmentKgreen.png CDA Author (Body)DYNAMIC
2.16.840.1.113883.10.12.153ContainmentKgreen.png CDA AssignedEntityDYNAMIC
2.16.840.1.113883.10.12.316ContainmentKgreen.png CDA RelatedEntityDYNAMIC
2.16.840.1.113883.10.12.321ContainmentKgreen.png CDA Participant (Body)DYNAMIC
2.16.840.1.113883.10.21.4.6ContainmentKyellow.png UV Subordinate Substance AdministrationDYNAMIC
2.16.840.1.113883.10.21.4.14ContainmentKyellow.png UV Substitution Event AdminstrationDYNAMIC
2.16.840.1.113883.10.21.4.8ContainmentKyellow.png UV Medication Order ReferenceDYNAMIC
2.16.840.1.113883.10.21.4.9ContainmentKyellow.png UV Dispense Event ReferenceDYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.308 CDA SubstanceAdministration (2005‑09‑07)
ref
ad1bbr-
Example
Example
<substanceAdministration classCode="SBADM" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.21.4.13"/>  <id root="1.2.3.99.99.99" extension="988437489739"/>  <code code="DRUG" codeSystem="2.16.840.1.113883.5.4"/>  <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"/>  <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="2.16.840.1.113883.10.21.4.13"/>  <id root="1.2.3.999" extension="--example only--"/>  <code code="DRUG" codeSystem="2.16.840.1.113883.5.4"/>  <text>...</text>  <statusCode code="active"/>  <!-- include template 'UV Use Period' (dynamic) .. O -->
  <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"/>  <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']
-->
  <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>
ItemDTCardConfDescriptionLabel
hl7:substanceAdministration
Medi...tion
Treetree.png@classCode
cs1 … 1FSBADM
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1MMedi...tion
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.21.4.13
Treetree.pnghl7:id
II0 … *RMedi...tion
 ConstraintIf the use case requires updates on the order, the ID shall be made mandatory.
Treetree.pnghl7:code
CD (extensible)0 … 1The code element is valorized with the ACT code from the indicated value set unless it is used for asserting the known absence of medication treatments or no information about them.Medi...tion
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.1.11.19708 ActSubstanceAdministrationCode (DYNAMIC)
or
The value of @code should be drawn from value set 2.16.840.1.113883.11.21.5 Unknown or absent medication (DYNAMIC)
Treetree.pnghl7:text
ED0 … 1Medi...tion
Treetree.pnghl7:statusCode
CS (required)1 … 1MMedi...tion
 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)
Choice1 … 1
The effectiveTime element encodes the use period 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]
Treeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1CCase 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 (continuous therapy) 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 a prescription that has not been refilled 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...tion
Treeblank.pngTreeblank.png where [hl7:low or
hl7:high]
Treeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 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
continous therapy
<effectiveTime xsi:type="IVL_TS">
  <low value="20130321"/>  <high nullFlavor="NA"/></effectiveTime>
Treeblank.pngTreeblank.pngTreetree.pnghl7:low
IVXB_TS1 … 1RMedi...tion
Treeblank.pngTreeblank.pngTreetree.pnghl7:high
IVXB_TS0 … 1RMedi...tion
Treeblank.pngTreetree.pnghl7:effectiveTime
IVL_TS0 … 1CCase 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...tion
Treeblank.pngTreeblank.png where [hl7:width]
 Example
2 week period
<effectiveTime xsi:type="IVL_TS">
  <width value="2" unit="w"/></effectiveTime>
Treeblank.pngTreeblank.pngTreetree.pnghl7:low
NPMedi...tion
Treeblank.pngTreeblank.pngTreetree.pnghl7:width
PQ1 … 1RMedi...tion
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs1 … 1R
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.21.1 Medication Time Units (UCUM) (DYNAMIC)
Treetree.pnghl7:repeatNumber
IVL_INT0 … 1Medi...tion
Treetree.pnghl7:routeCode
CE (example)0 … 1Medi...tion
 CONF
Examples of the value of @code are in the valuet set 2.16.840.1.113883.1.11.14581 RouteOfAdministration (DYNAMIC)
Treetree.pnghl7:approachSiteCode
CD (example)0 … *Medi...tion
 CONF
Examples of the value of @code are in the valuet set 2.16.840.1.113883.1.11.19724 HumanSubstanceAdministrationSite (DYNAMIC)
Treetree.pnghl7:doseQuantity
IVL_PQNPMedi...tion
Treetree.pnghl7:rateQuantity
IVL_PQNPMedi...tion
Treetree.pnghl7:maxDoseQuantity
RTO_PQ_PQ0 … 1Medi...tion
Treetree.pnghl7:administrationUnitCode
CENPMedi...tion
Treetree.pnghl7:subject
0 … 1CPatient: The patient that takes the medicine.
Contains 2.16.840.1.113883.10.12.320 CDA Subject (Body) (DYNAMIC)
Medi...tion
Treeblank.png where [hl7:relatedSubject]
 ConstraintCondition: This can be omitted if the patient context that is provided in the CDA header is identical to the subject
Choice1 … 1Elements to choose from:
  • hl7:consumable containing template 2.16.840.1.113883.10.21.4.10 UV Medication Information (simple) (DYNAMIC)
  • hl7:consumable containing template 2.16.840.1.113883.10.21.4.11 UV Medication Information (detail) (DYNAMIC)
Treeblank.pngTreetree.pnghl7:consumable
0 … 1RConsumable: The medication that is administered (simple)
Contains 2.16.840.1.113883.10.21.4.10 UV Medication Information (simple) (DYNAMIC)
Medi...tion
Treeblank.pngTreeblank.png where [hl7:manufacturedProduct]
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FCSM
Treeblank.pngTreetree.pnghl7:consumable
0 … 1RConsumable: The medication that is administered (detail)
Contains 2.16.840.1.113883.10.21.4.11 UV Medication Information (detail) (DYNAMIC)
Medi...tion
Treeblank.pngTreeblank.png where [hl7:manufacturedProduct]
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FCSM
Choice1 … 1
Required author of the medication administration: healthcare professional or patient
Elements to choose from:
  • hl7:author containing template 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC)
  • hl7:participant[@typeCode='AUT']
Treeblank.pngTreetree.pnghl7:author
Use this if the author of the medication statement is a healthcare professional
Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC)
Medi...tion
Treeblank.pngTreeblank.png where [hl7:assignedAuthor]
 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>
Treeblank.pngTreetree.pnghl7:participant
Use this if the author of the medication administration is the patientMedi...tion
Treeblank.pngTreeblank.png where [@typeCode='AUT']
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FAUT
 Example
Author of the medication statement is the patient
<participant typeCode="AUT">
  <time value="20170121091548"/>  <participantRole classCode="PAT"/></participant>
Treeblank.pngTreeblank.pngTreetree.pnghl7:time
TS1 … 1RMedi...tion
Treeblank.pngTreeblank.pngTreetree.pnghl7:participantRole
1 … 1MMedi...tion
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FPAT
Choice0 … 1
Optional informants of the medication administration: 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)]
Treeblank.pngTreetree.pnghl7:informant
Use this if the informant of the medication statement is a healthcare professionalMedi...tion
Treeblank.pngTreeblank.png where [exists(hl7:assignedEntity)]
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs0 … 1FINF
Treeblank.pngTreeblank.pngTreetree.png@context​Control​Code
cs0 … 1FOP
 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>
Treeblank.pngTreeblank.pngTreetree.pnghl7:assignedEntity
1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)Medi...tion
Treeblank.pngTreetree.pnghl7:participant
Use this if the informant of the medication statement is the patientMedi...tion
Treeblank.pngTreeblank.png where [@typeCode='INF']
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs1 … 1FINF
 Example
Informant of the medication statement is the patient
<participant typeCode="INF">
  <time value="20170121091548"/>  <participantRole classCode="PAT"/></participant>
Treeblank.pngTreeblank.pngTreetree.pnghl7:time
TS1 … 1RMedi...tion
Treeblank.pngTreeblank.pngTreetree.pnghl7:participantRole
1 … 1MMedi...tion
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FPAT
Treeblank.pngTreetree.pnghl7:informant
Use this if the informant of the medication statement is a contact party (related party)Medi...tion
Treeblank.pngTreeblank.png where [exists(hl7:relatedEntity)]
Treeblank.pngTreeblank.pngTreetree.png@typeCode
cs0 … 1FINF
Treeblank.pngTreeblank.pngTreetree.png@context​Control​Code
cs0 … 1FOP
 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>
Treeblank.pngTreeblank.pngTreetree.pnghl7:relatedEntity
1 … 1Contains 2.16.840.1.113883.10.12.316 CDA RelatedEntity (DYNAMIC)Medi...tion
Treetree.pnghl7:participant
0 … 1Record Target: indicates the person who's medical record holds the documentation of this medication statement. This element is only populated when the document is placed in a medical record of someone other than the patient (subject).
Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC)
Medi...tion
Treeblank.png where [@typeCode='RCT']
Treeblank.pngTreetree.png@typeCode
cs1 … 1FRCT
Treetree.pnghl7:participant
0 … 1Verifier: 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...tion
Treeblank.png where [@typeCode='VRF']
Treeblank.pngTreetree.png@typeCode
cs1 … 1FVRF
Treetree.pnghl7:participant
0 … 1Location
Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC)
Medi...tion
Treeblank.png where [@typeCode='LOC']
Treeblank.pngTreetree.png@typeCode
1 … 1FLOC
Treetree.pnghl7:entryRelationship
0 … *CSubordinate 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,..) unless medications are unknown or known absent.
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...tion
Treeblank.png where [hl7:substanceAdministration]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
 ConstraintAt least one subordinate <substanceAdministration> element SHALL be present unless medications are unknown or known absent.
 Example<entryRelationship typeCode="COMP">
  <!-- component: Subordinate Substance Administration Statement. -->
  <substanceAdministration classCode="SBADM" moodCode="EVN">
    <templateId root="2.16.840.1.113883.10.21.4.6"/>    <!-- .. -->
  </substanceAdministration>
</entryRelationship>
Treeblank.pngTreetree.pnghl7:sequenceNumber
INT0 … 1Sequence number of the Subordinate Substance Administration.Medi...tion
Treetree.pnghl7:entryRelationship
0 … 1RInformation about any substitutions in medication that have been made.
Contains 2.16.840.1.113883.10.21.4.14 UV Substitution Event Adminstration (DYNAMIC)
Medi...tion
Treeblank.png where [@typeCode='COMP']
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP
 Example<entryRelationship typeCode="COMP">
  <act classCode="ACT" moodCode="EVN">
    <!-- .. -->
  </act>
</entryRelationship>
Treetree.pnghl7:entryRelationship
0 … *RMedication Order Reference.
Contains 2.16.840.1.113883.10.21.4.8 UV Medication Order Reference (DYNAMIC)
Medi...tion
Treeblank.png where [@typeCode='REFR'] [hl7:substanceAdministration]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREFR
 Example<entryRelationship typeCode="REFR">
  <substanceAdministration classCode="SBADM" moodCode="EVN">
    <templateId root="2.16.840.1.113883.10.21.4.8"/>    <!-- .. -->
  </substanceAdministration>
</entryRelationship>
Treetree.pnghl7:entryRelationship
0 … *RDispense Event Reference.
Contains 2.16.840.1.113883.10.21.4.9 UV Dispense Event Reference (DYNAMIC)
Medi...tion
Treeblank.png where [@typeCode='REFR'] [ [hl7:supply]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREFR
 Example<entryRelationship typeCode="REFR">
  <supply classCode="SPLY" moodCode="EVN">
    <templateId root="2.16.840.1.113883.10.21.4.9"/>    <!-- .. -->
  </supply>
</entryRelationship>

UV Medication Dispense

The following graph gives an overview of the high-level template components of this template, followed by the actual definition.

  1. Entry
     UV Medication Dispense (2.16.840.1.113883.10.21.4.15)
    1. Entry
       CDA Subject (Body) (2.16.840.1.113883.10.12.320)
    2. Entry
       CDA ManufacturedProduct (2.16.840.1.113883.10.12.312)
      1. Entry
         CDA LabeledDrug (2.16.840.1.113883.10.12.310)
      2. Entry
         CDA Material (2.16.840.1.113883.10.12.311)
      3. *
         CDA Organization (2.16.840.1.113883.10.12.151)
    3. Entry
       CDA Performer (Body) (2.16.840.1.113883.10.12.323)
      1. *
         CDA AssignedEntity (2.16.840.1.113883.10.12.153)
        1. *
           CDA Person (2.16.840.1.113883.10.12.152)
        2. *
           CDA Organization (2.16.840.1.113883.10.12.151)
    4. Entry
       CDA Participant (Body) (2.16.840.1.113883.10.12.321)
      1. Entry
         CDA Device (2.16.840.1.113883.10.12.315)
      2. Entry
         CDA PlayingEntity (2.16.840.1.113883.10.12.313)
    5. Entry
       CDA Participant (Body) (2.16.840.1.113883.10.12.321)
      1. Entry
         CDA Device (2.16.840.1.113883.10.12.315)
      2. Entry
         CDA PlayingEntity (2.16.840.1.113883.10.12.313)
    6. Entry
       CDA Participant (Body) (2.16.840.1.113883.10.12.321)
      1. Entry
         CDA Device (2.16.840.1.113883.10.12.315)
      2. Entry
         CDA PlayingEntity (2.16.840.1.113883.10.12.313)
    7. Entry
       CDA Participant (Body) (2.16.840.1.113883.10.12.321)
      1. Entry
         CDA Device (2.16.840.1.113883.10.12.315)
      2. Entry
         CDA PlayingEntity (2.16.840.1.113883.10.12.313)
    8. Entry
       UV Medication Order Reference (2.16.840.1.113883.10.21.4.8)
      1. Entry
         CDA Author (Body) (2.16.840.1.113883.10.12.318)
        1. *
           CDA Person (2.16.840.1.113883.10.12.152)
        2. Entry
           CDA Device (2.16.840.1.113883.10.12.315)
        3. *
           CDA Organization (2.16.840.1.113883.10.12.151)
    9. Entry
       UV Comment Activity (2.16.840.1.113883.10.21.4.12)
      1. Entry
         CDA Author (Body) (2.16.840.1.113883.10.12.318)
        1. *
           CDA Person (2.16.840.1.113883.10.12.152)
        2. Entry
           CDA Device (2.16.840.1.113883.10.12.315)
        3. *
           CDA Organization (2.16.840.1.113883.10.12.151)

The boxes reflect the CDA Template Types. Symbols: * denotes templates with more than one classification, @ indicates a recursion in the definition

Id2.16.840.1.113883.10.21.4.15Effective Date2019‑02‑17
StatusKyellow.png DraftVersion Label
NameUVMedicationDispenseDisplay NameUV Medication Dispense
DescriptionUniversal Dispense Request (Supply Request)
ContextParent nodes of template element with id 2.16.840.1.113883.10.21.4.15
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 6 templates
Uses as NameVersion
2.16.840.1.113883.10.12.320ContainmentKgreen.png CDA Subject (Body)DYNAMIC
2.16.840.1.113883.10.12.312ContainmentKgreen.png CDA ManufacturedProductDYNAMIC
2.16.840.1.113883.10.12.323ContainmentKgreen.png CDA Performer (Body)DYNAMIC
2.16.840.1.113883.10.12.321ContainmentKgreen.png CDA Participant (Body)DYNAMIC
2.16.840.1.113883.10.21.4.8ContainmentKyellow.png UV Medication Order ReferenceDYNAMIC
2.16.840.1.113883.10.21.4.12ContainmentKyellow.png UV Comment ActivityDYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.309 CDA Supply (2005‑09‑07)
ref
ad1bbr-
Example
Example
<supply classCode="SPLY" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.21.4.15"/>  <id root="..." extension="--example only--"/>  <code/>  <text/>  <statusCode code="active"/>  <effectiveTime value="20170601"/>  <independentInd value="false"/>  <quantity value="1"/>  <expectedUseTime>
    <low value="20170601"/>    <low value="20170615"/>  </expectedUseTime>
  <subject>
    <!-- template 'CDA Subject (Body)' (dynamic) -->
  </subject>
  <product typeCode="PRD">
    <!-- template 'CDA ManufacturedProduct' (dynamic) -->
  </product>
  <performer>
    <!-- template 'CDA Performer (Body)' (dynamic) -->
  </performer>
  <participant typeCode="ORG">
    <!-- template 'CDA Participant (Body)' (dynamic) -->
  </participant>
  <participant typeCode="DST">
    <!-- template 'CDA Participant (Body)' (dynamic) -->
  </participant>
  <participant typeCode="RCV">
    <!-- template 'CDA Participant (Body)' (dynamic) -->
  </participant>
  <participant typeCode="LOC">
    <!-- template 'CDA Participant (Body)' (dynamic) -->
  </participant>
  <entryRelationship typeCode="COMP">
    <!-- template 'DispenseRequest' (dynamic) -->
  </entryRelationship>
</supply>
ItemDTCardConfDescriptionLabel
hl7:supply
(UVM...nse)
Treetree.png@classCode
cs1 … 1FSPLY
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(UVM...nse)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.21.4.15
Treetree.pnghl7:id
II0 … *(UVM...nse)
Treetree.pnghl7:code
CD (extensible)0 … 1(UVM...nse)
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.1.11.16208 ActPharmacySupplyType (DYNAMIC)
Treetree.pnghl7:text
ED0 … 1(UVM...nse)
Treetree.pnghl7:statusCode
CS0 … 1(UVM...nse)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.21.6 ActStatusActiveCompleted (DYNAMIC)
Treetree.pnghl7:effectiveTime
TS0 … 1Date/Time of Dispense(UVM...nse)
Treetree.pnghl7:independentInd
BL0 … 1(UVM...nse)
Treetree.pnghl7:quantity
PQ0 … 1(UVM...nse)
Treetree.pnghl7:expectedUseTime
IVL_TS0 … 1(UVM...nse)
Treetree.pnghl7:subject
0 … 1Contains 2.16.840.1.113883.10.12.320 CDA Subject (Body) (DYNAMIC)(UVM...nse)
Treeblank.png where [hl7:relatedSubject]
Treetree.pnghl7:product
0 … 1RContains 2.16.840.1.113883.10.12.312 CDA ManufacturedProduct (DYNAMIC)(UVM...nse)
Treeblank.png where [hl7:manufacturedProduct]
Treeblank.pngTreetree.png@typeCode
cs0 … 1FPRD
Treetree.pnghl7:performer
0 … *Dispenser
Contains 2.16.840.1.113883.10.12.323 CDA Performer (Body) (DYNAMIC)
(UVM...nse)
Treeblank.png where [hl7:assignedEntity]
Treetree.pnghl7:participant
0 … 1Origin
Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC)
(UVM...nse)
Treeblank.png where [hl7:participantRole]
Treeblank.pngTreetree.png@typeCode
1 … 1FORG
Treetree.pnghl7:participant
0 … 1Destination
Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC)
(UVM...nse)
Treeblank.png where [@typeCode='DST']
Treeblank.pngTreetree.png@typeCode
1 … 1FDST
Treetree.pnghl7:participant
0 … *Receiver
Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC)
(UVM...nse)
Treeblank.png where [@typeCode='RCV']
Treeblank.pngTreetree.png@typeCode
1 … 1FRCV
Treetree.pnghl7:participant
0 … 1Location
Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC)
(UVM...nse)
Treeblank.png where [@typeCode='LOC']
Treeblank.pngTreetree.png@typeCode
1 … 1FLOC
Treetree.pnghl7:entryRelationship
0 … *RReference to the fulfilled Medication Order
Contains 2.16.840.1.113883.10.21.4.8 UV Medication Order Reference (DYNAMIC)
(UVM...nse)
Treeblank.png where [@typeCode='REFR'] [hl7:substanceAdministration]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREFR
 Example<entryRelationship typeCode="REFR">
  <substanceAdministration classCode="SBADM" moodCode="RQO">
    <templateId root="2.16.840.1.113883.10.21.4.8"/>    <!-- .. -->
  </substanceAdministration>
</entryRelationship>
Treetree.pnghl7:entryRelationship
0 … *Annotations: The Medication Dispense can be the subject of annotations.
Contains 2.16.840.1.113883.10.21.4.12 UV Comment Activity (DYNAMIC)
(UVM...nse)
Treeblank.png where [hl7:act [hl7:code [(@code = '48767-8' and @codeSystem = '2.16.840.1.113883.6.1')]]]
Treeblank.pngTreetree.png@typeCode
cs1 … 1FCOMP

Entry Level Templates

These entry level templates are used Section "Use Case Entry Level Templates".

UV ClinicalStatement Encounter

Id2.16.840.1.113883.10.21.4.4Effective Date2017‑01‑02
StatusKyellow.png DraftVersion Label
NameUVClinicalStatementMinimalEncounterDisplay NameUV ClinicalStatement Encounter
DescriptionUniversal Clinical Statement Minimal Encounter
ContextParent nodes of template element with id 2.16.840.1.113883.10.21.4.4
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
RelationshipSpecialization: template 2.16.840.1.113883.10.12.302 CDA Encounter (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 2.16.840.1.113883.10.20.22.4.49 Encounter Activity (V3) (DYNAMIC)
ref
ccda-
ItemDTCardConfDescriptionLabel
hl7:encounter
(UVC...ter)
Treetree.png@classCode
cs1 … 1FENC
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1R(UVC...ter)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.21.4.4
Treetree.pnghl7:id
II0 … *(UVC...ter)

UV ClinicalStatement Observation

Id2.16.840.1.113883.10.21.4.3Effective Date2016‑05‑01
StatusKyellow.png DraftVersion Label
NameUVClinicalStatementMinimalObservationDisplay NameUV ClinicalStatement Observation
DescriptionUniversal Clinical Statement Minimal Observation
ContextParent nodes of template element with id 2.16.840.1.113883.10.21.4.3
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 8 templates
Uses as NameVersion
2.16.840.1.113883.10.12.320ContainmentKgreen.png CDA Subject (Body)DYNAMIC
2.16.840.1.113883.10.12.322ContainmentKgreen.png CDA SpecimenDYNAMIC
2.16.840.1.113883.10.12.323ContainmentKgreen.png CDA Performer (Body)DYNAMIC
2.16.840.1.113883.10.12.318ContainmentKgreen.png CDA Author (Body)DYNAMIC
2.16.840.1.113883.10.12.319ContainmentKgreen.png CDA Informant (Body)DYNAMIC
2.16.840.1.113883.10.12.321ContainmentKgreen.png CDA Participant (Body)DYNAMIC
2.16.840.1.113883.10.12.324ContainmentKgreen.png CDA ReferenceDYNAMIC
2.16.840.1.113883.10.12.329ContainmentKgreen.png CDA PreconditionDYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-
ItemDTCardConfDescriptionLabel
hl7:observation
(UVC...ion)
Treetree.png@classCode
cs1 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.png@negationInd
bl0 … 1 
Treetree.pnghl7:templateId
II1 … 1R(UVC...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.21.4.3
Treetree.pnghl7:id
II0 … *(UVC...ion)
Treetree.pnghl7:code
CD1 … 1RThis code (e.g. drawn from LOINC) specifies the type of observation, e.g. a lab value (creatinine) or a measurement of the body weight or a body surface.(UVC...ion)
 CONF
shall be drawn from concept domain "ObservationCode"
Treetree.pnghl7:derivationExpr
ST0 … 1(UVC...ion)
Treetree.pnghl7:text
ED0 … 1(UVC...ion)
Treetree.pnghl7:statusCode
CS0 … 1(UVC...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC)
Treetree.pnghl7:effectiveTime
IVL_TS0 … 1(UVC...ion)
Treetree.pnghl7:priorityCode
CE0 … 1(UVC...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC)
Treetree.pnghl7:repeatNumber
IVL_INT0 … 1(UVC...ion)
Treetree.pnghl7:language​Code
CS0 … 1(UVC...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
Treetree.pnghl7:value
ANY0 … *(UVC...ion)
Treetree.pnghl7:interpretationCode
CE0 … *(UVC...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)
Treetree.pnghl7:methodCode
CE0 … *(UVC...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14079 ObservationMethod (DYNAMIC)
Treetree.pnghl7:target​Site​Code
CD0 … *(UVC...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19724 HumanSubstanceAdministrationSite (DYNAMIC)
Treetree.pnghl7:subject
0 … 1Contains 2.16.840.1.113883.10.12.320 CDA Subject (Body) (DYNAMIC)(UVC...ion)
Treeblank.png where [hl7:relatedSubject]
Treetree.pnghl7:specimen
0 … *Contains 2.16.840.1.113883.10.12.322 CDA Specimen (DYNAMIC)(UVC...ion)
Treeblank.png where [hl7:specimenRole]
Treetree.pnghl7:performer
0 … *Contains 2.16.840.1.113883.10.12.323 CDA Performer (Body) (DYNAMIC)(UVC...ion)
Treeblank.png where [hl7:assignedEntity]
Treetree.pnghl7:author
0 … *Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC)(UVC...ion)
Treeblank.png where [hl7:assignedAuthor]
Treetree.pnghl7:informant
0 … *Contains 2.16.840.1.113883.10.12.319 CDA Informant (Body) (DYNAMIC)(UVC...ion)
Treetree.pnghl7:participant
0 … *Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC)(UVC...ion)
Treeblank.png where [hl7:participantRole]
Treetree.pnghl7:reference
0 … *Contains 2.16.840.1.113883.10.12.324 CDA Reference (DYNAMIC)(UVC...ion)
Treetree.pnghl7:precondition
0 … *Contains 2.16.840.1.113883.10.12.329 CDA Precondition (DYNAMIC)(UVC...ion)
Treeblank.png where [hl7:criterion]
Treetree.pnghl7:referenceRange
0 … *(UVC...ion)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREFV
Treeblank.pngTreetree.pnghl7:observationRange
1 … 1R(UVC...ion)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FOBS
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs0 … 1FEVN.CRT
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CD0 … 1(UVC...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
CONF0 … 1F2.16.840.1.113883.5.4 (Act Code)
Treeblank.pngTreeblank.pngTreetree.pnghl7:text
ED0 … 1(UVC...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:value
ANY0 … 1(UVC...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:interpretationCode
CE0 … 1(UVC...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)

UV Comment Activity

Id2.16.840.1.113883.10.21.4.12Effective Date2018‑03‑21
StatusKyellow.png DraftVersion Label
NameUVCommentactivityDisplay NameUV Comment Activity
Description
Comments that the provider makes about the activity, e.g. order or dispense. Comments are free text data that cannot otherwise be recorded using data elements already defined by this specification. They are not to be used to record information that can be recorded elsewhere. For example, a free text description of the severity of an allergic reaction would not be recorded in a comment.
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 1 template
Uses as NameVersion
2.16.840.1.113883.10.12.318ContainmentKgreen.png CDA Author (Body)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.301 CDA Act (2005‑09‑07)
ref
ad1bbr-
ItemDTCardConfDescriptionLabel
hl7:act
(UVC...ity)
Treetree.png@classCode
1 … 1FACT
Treetree.png@moodCode
1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(UVC...ity)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.21.4.12
Treetree.pnghl7:code
CD1 … 1M(UVC...ity)
Treeblank.pngTreetree.png@code
CONF1 … 1F48767-8
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Treetree.pnghl7:text
1 … 1M(UVC...ity)
Treeblank.pngTreetree.pnghl7:reference
TEL1 … 1R(UVC...ity)
Treeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1FNA
Treetree.pnghl7:author
0 … 1Contains 2.16.840.1.113883.10.12.318 CDA Author (Body) (DYNAMIC)(UVC...ity)
Treeblank.png where [hl7:assignedAuthor]

UV Dispense Request

Id2.16.840.1.113883.10.21.4.2Effective Date2016‑05‑01
StatusKyellow.png DraftVersion Label
NameUVDispenseRequestDisplay NameUV Dispense Request
DescriptionUniversal Dispense Request (Supply Request)
ContextParent nodes of template element with id 2.16.840.1.113883.10.21.4.2
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 4 templates
Uses as NameVersion
2.16.840.1.113883.10.12.320ContainmentKgreen.png CDA Subject (Body)DYNAMIC
2.16.840.1.113883.10.12.312ContainmentKgreen.png CDA ManufacturedProductDYNAMIC
2.16.840.1.113883.10.12.323ContainmentKgreen.png CDA Performer (Body)DYNAMIC
2.16.840.1.113883.10.12.321ContainmentKgreen.png CDA Participant (Body)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.309 CDA Supply (2005‑09‑07)
ref
ad1bbr-
Example
Example
<supply classCode="SPLY" moodCode="RQO">
  <templateId root="2.16.840.1.113883.10.21.4.2"/>  <id root="..." extension="--example only--"/>  <code/>  <text/>  <statusCode code="active"/>  <effectiveTime xsi:type="IVL_TS">
    <low value="20170601"/>    <high value="20170801"/>  </effectiveTime>
  <repeatNumber/>  <independentInd value="false"/>  <quantity value="1"/>  <expectedUseTime>
    <low value="20160511153724"/>  </expectedUseTime>
  <subject>
    <!-- template 'CDA Subject (Body)' (dynamic) -->
  </subject>
  <product typeCode="PRD">
    <!-- template 'CDA ManufacturedProduct' (dynamic) -->
  </product>
  <performer>
    <!-- template 'CDA Performer (Body)' (dynamic) -->
  </performer>
  <participant typeCode="ORG">
    <!-- template 'CDA Participant (Body)' (dynamic) -->
  </participant>
  <participant typeCode="DST">
    <!-- template 'CDA Participant (Body)' (dynamic) -->
  </participant>
  <participant typeCode="RCV">
    <!-- template 'CDA Participant (Body)' (dynamic) -->
  </participant>
  <participant typeCode="LOC">
    <!-- template 'CDA Participant (Body)' (dynamic) -->
  </participant>
  <entryRelationship typeCode="COMP">
    <!-- template 'DispenseRequest' (dynamic) -->
  </entryRelationship>
</supply>
ItemDTCardConfDescriptionLabel
hl7:supply
(UVD...est)
Treetree.png@classCode
cs1 … 1FSPLY
Treetree.png@moodCode
cs1 … 1FRQO
Treetree.pnghl7:templateId
II1 … 1M(UVD...est)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.21.4.2
Treetree.pnghl7:id
II0 … *(UVD...est)
Treetree.pnghl7:code
CD (extensible)0 … 1(UVD...est)
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.1.11.16208 ActPharmacySupplyType (DYNAMIC)
Treetree.pnghl7:text
ED0 … 1(UVD...est)
Treetree.pnghl7:statusCode
CS0 … 1(UVD...est)
Treeblank.pngTreetree.png@code
CONF0 … 1Factive
Treetree.pnghl7:effectiveTime
IVL_TS0 … 1Validity period of the Dispense Request(UVD...est)
Treetree.pnghl7:repeatNumber
IVL_INT0 … 1(UVD...est)
Treetree.pnghl7:independentInd
BL0 … 1(UVD...est)
Treetree.pnghl7:quantity
PQ0 … 1(UVD...est)
Treetree.pnghl7:expectedUseTime
IVL_TS0 … 1(UVD...est)
Treetree.pnghl7:subject
0 … 1Contains 2.16.840.1.113883.10.12.320 CDA Subject (Body) (DYNAMIC)(UVD...est)
Treeblank.png where [hl7:relatedSubject]
Treetree.pnghl7:product
0 … 1RContains 2.16.840.1.113883.10.12.312 CDA ManufacturedProduct (DYNAMIC)(UVD...est)
Treeblank.png where [hl7:manufacturedProduct]
Treeblank.pngTreetree.png@typeCode
cs0 … 1FPRD
Treetree.pnghl7:performer
0 … *Contains 2.16.840.1.113883.10.12.323 CDA Performer (Body) (DYNAMIC)(UVD...est)
Treeblank.png where [hl7:assignedEntity]
Treetree.pnghl7:participant
0 … 1Origin
Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC)
(UVD...est)
Treeblank.png where [hl7:participantRole]
Treeblank.pngTreetree.png@typeCode
1 … 1FORG
Treetree.pnghl7:participant
0 … 1Destination
Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC)
(UVD...est)
Treeblank.png where [@typeCode='DST']
Treeblank.pngTreetree.png@typeCode
1 … 1FDST
Treetree.pnghl7:participant
0 … *Receiver
Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC)
(UVD...est)
Treeblank.png where [@typeCode='RCV']
Treeblank.pngTreetree.png@typeCode
1 … 1FRCV
Treetree.pnghl7:participant
0 … 1Location
Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC)
(UVD...est)
Treeblank.png where [@typeCode='LOC']
Treeblank.pngTreetree.png@typeCode
1 … 1FLOC

UV Dispense Event Reference

Id2.16.840.1.113883.10.21.4.9Effective Date2017‑03‑30
StatusKyellow.png DraftVersion Label
NameUVDispenseEventReferenceDisplay NameUV Dispense Event Reference
DescriptionThis is a reference to a Dispense Event
ContextParent nodes of template element with id 2.16.840.1.113883.10.21.4.9
LabelDispenseEventReference
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
RelationshipSpecialization: template 2.16.840.1.113883.10.12.309 CDA Supply (2005‑09‑07)
ref
ad1bbr-
Example
Example
<supply classCode="SPLY" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.21.4.9"/>  <id root="1.2.3.99.99.99" extension="978437489739"/></supply>
ItemDTCardConfDescriptionLabel
hl7:supply
Disp...ence
Treetree.png@classCode
cs1 … 1FSPLY
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1MDisp...ence
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.21.4.9
Treetree.pnghl7:id
II1 … 1RDisp...ence

UV Medication Information (detail)

Id2.16.840.1.113883.10.21.4.11Effective Date2017‑05‑10
StatusKyellow.png DraftVersion Label
NameUVMedicationInformationdetailDisplay NameUV Medication Information (detail)
DescriptionUniversal Medication Information (detail)
ContextParent nodes of template element with id 2.16.840.1.113883.10.21.4.11
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 1 template
Uses as NameVersion
2.16.840.1.113883.10.12.151ContainmentKgreen.png CDA OrganizationDYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.312 CDA ManufacturedProduct (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 1.3.6.1.4.1.19376.1.9.1.3.1 IHE MedicineEntryContentModule (DYNAMIC)
ref
ch-pharm-
ItemDTCardConfDescriptionLabel
hl7:manufacturedProduct
(UVM...ail)
Treetree.png@classCode
cs1 … 1FMANU
Treetree.pnghl7:templateId
II1 … 1M(UVM...ail)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.21.4.11
Treetree.pnghl7:manufactured​Material
(UVM...ail)
Treeblank.pngTreetree.png@classCode
0 … 1FMMAT
Treeblank.pngTreetree.png@determiner​Code
0 … 1FKIND
Treeblank.pngTreetree.pnghl7:code
CE1 … 1RThe code element SHALL be present and describes the code of the medication. The medication may be either
  • a brand/product or
  • described as a generic/scientific name or
  • a descriptor of a magistral preparation/compound medicine
If the medicine has no code / is uncoded (e.g., magistral preparations, compound medicine, ...) nullFlavor="NA" SHALL be used.
(UVM...ail)
Treeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs0 … 1 
Treeblank.pngTreeblank.pngTreetree.pnghl7:originalText
ED1 … 1RThe originalText shall contain a reference whose URI value points to the name and strength of the medication in the corresponding section.text, or just the name alone if strength is not relevant.(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:reference
TEL1 … 1R(UVM...ail)
Treeblank.pngTreeblank.pngTreetree.pnghl7:translation
CE0 … *Product code(s) from any organizational or juristdictional system(UVM...ail)
 CONF
shall be drawn from concept domain "Product Code"
Treeblank.pngTreetree.pnghl7:name
EN0 … 1RThe element SHOULD contain the name of the medication (e.g., "Adol 500mg Caplet"). The medication may be either
  • a brand/product or
  • described as a generic/scientific name or
  • a descriptor of a magistral preparation/compound medicine
(UVM...ail)
Treeblank.pngTreetree.pngpharm:formCode
CE0 … 1This code represents the pharmaceutical dose form (e.g., tablet, capsule, liquid) and SHOULD be present, if not implied by the product. It MAY be present if implied by the product. The value of this code may affect the units used in the substance administration quantity element.(UVM...ail)
Treeblank.pngTreetree.pnghl7:lotNumberText
ST0 … 1The lotNumberText element MAY be present and is a string representation of a lot number of this specific instance of the product. The provided lot number SHALL refer to the primary packaged item described in the Packaging element.(UVM...ail)
Treeblank.pngTreetree.pngpharm:expirationTime
TS0 … 1The pharm:expirationTime element MAY be present and SHALL contain a value attribute containing the date (e.g., specific date, specific date including time) of expiration of this specific instance of the product. The value given in the pharm:expirationTime element SHALL refer to the primary packaged item described in the Medicine Packaging element.(UVM...ail)
Treeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
Treeblank.pngTreetree.pngpharm:asContent
0 … *This structure describes the packaging of the medication and MAY be present. It represents the primary description of the packaging of the medicine (e.g., the medicine is packaged in ampoules of 50ml volume each) and may include additional packaging information of how many of the primary packaged items are within an outer package (e.g., 5 ampoules are packaged in a box).
The primary description of the package SHOULD be consistent with the given pharmaceutical dose form (pharm:formCode of the medication, see chapter “Medication Form Code”). Example: a consistent pharmaceutical dose form to the package form “Ampoules” would be e.g., “Solution for injection”.
In case the package describes a product, the pharm:code element provides the code for the product and SHOULD be present.
In case the package describes a product, and the package has a brand name, it SHOULD be described in the pharm:name element (e.g., Xylocaine 1% with Adrenaline Inj, 5 injections package).
The pharm:formCode element represents the form of the product (e.g., tablet container, bottle, ...) and SHOULD be present, if not implied by the product. It MAY be present if implied by the product. It SHALL be present if the asSuperContent element is present.
The pharm:capacity​Quantity element SHALL be present and describes the capacity of the packaging.
If the capacityQuantity is given in countable units, the unit attribute SHALL NOT be present. If the capacityQuantity is given in non-countable units, the unit attribute SHALL be present and the value SHALL be out of the UCUM code system.
A pharm:asSuperContent element MAY be present to represent the quantity of the given primary packaged item (e.g., ampoule of 50ml) within an outer package (e.g., 5 ampoules in a box). It SHALL contain a pharm:container​Packaged​Medicine element which SHALL contain a pharm:capacity​Quantity element describing the quantity of the given primary packaged item present in the outer package. If the capacityQuantity is given in countable units, the unit attribute SHALL NOT be present. If the capacityQuantity is given in non-countable units, the unit attribute SHALL be present and the value SHALL be out of the UCUM code system.
(UVM...ail)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
 Example
Packaged Medicinal Product with formCode
<pharm:asContent classCode="CONT">
  <pharm:containerPackagedProduct classCode="CONT" determinerCode="INSTANCE">
    <!-- Packaged Medicinal Product -->
    <pharm:code codeSystem="1.999.999" code="PC_ID" displayName="Packaged Product Name"/>    <pharm:name>100 MIRACLE PILLS(TM)</pharm:name>    <pharm:formCode codeSystem="0.4.0.127.0.16.1.1.2.1" code="30009000" displayName="Box" CodeSystemName="EDQM"/>  </pharm:containerPackagedProduct>
</pharm:asContent>
 Example
General example
<pharm:asContent classCode="CONT">
  <pharm:containerPackagedProduct classCode="CONT" determinerCode="INSTANCE">
    <!-- Medicinal product code (package-level) -->
    <pharm:code code=" " displayName=" " codeSystem=" " codeSystemName=" "/>    <!-- Brand name (package) -->
    <pharm:name> . . . </pharm:name>    <pharm:formCode code=" " displayName=" " codeSystem=" " codeSystemName=" "/>    <pharm:capacityQuantity value=" " unit=" "/>    <pharm:asContent>
      <pharm:containerPackagedProduct classCode="CONT" determinerCode="INSTANCE">
        <pharm:capacityQuantity value=" " unit=" "/>      </pharm:containerPackagedProduct>
    </pharm:asContent>
  </pharm:containerPackagedProduct>
</pharm:asContent>
 Example
Medicinal product with pharmaceutical dose form ”Tablets”, available as a “Tablet container” with 30 tablets
<pharm:asContent classCode="CONT">
  <pharm:containerPackagedProduct classCode="CONT" determinerCode="INSTANCE">
    <!-- .. -->
    <pharm:formCode code=" " displayName="Tablet container" codeSystem=" " codeSystemName=" "/>    <!-- 30 tablets in the package -->
    <pharm:capacityQuantity value="30"/>  </pharm:containerPackagedProduct>
</pharm:asContent>
 Example
Medicinal product with pharmaceutical dose form 'Solution for injection', available as “Ampoules” with 50ml volume, packaged as 5 ampoules per box
<pharm:asContent classCode="CONT">
  <pharm:containerPackagedProduct classCode="CONT" determinerCode="INSTANCE">
    <!-- .. -->
    <pharm:formCode code=" " displayName="Ampoules" codeSystem=" " codeSystemName=" "/>    <pharm:capacityQuantity value="50" unit="ml"/>    <!-- 50ml per ampoule -->
    <pharm:asContent>
      <pharm:containerPackagedProduct classCode="CONT" determinerCode="INSTANCE">
        <!-- 5 ampoules in a box -->
        <pharm:capacityQuantity value="5"/>      </pharm:containerPackagedProduct>
    </pharm:asContent>
  </pharm:containerPackagedProduct>
</pharm:asContent>
 Example
Packaged Medicinal Product with multiple layers packaging
<pharm:asContent>
  <pharm:containerPackagedProduct>
    <!-- Inner Package -->
    <pharm:code codeSystem="..." code="..." displayName="..."/>    <pharm:asContent>
      <pharm:containerPackagedProduct>
        <!-- Intermediate Package -->
        <pharm:asContent>
          <pharm:containerPackagedProduct>
            <!-- Outer Package / Packaged Medicinal Product -->
          </pharm:containerPackagedProduct>
        </pharm:asContent>
      </pharm:containerPackagedProduct>
    </pharm:asContent>
  </pharm:containerPackagedProduct>
</pharm:asContent>
Treeblank.pngTreeblank.pngTreetree.pngpharm:quantity
PQ0 … 1(UVM...ail)
Treeblank.pngTreeblank.pngTreetree.pngpharm:containerPackagedProduct
1 … *R(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs1 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:code
CE0 … 1(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:name
EN0 … *(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:formCode
CE0 … 1(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:capacity​Quantity
PQ1 … 1M(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs0 … 1 
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:asContent
0 … *In case of multiple layers of packaging (5 vials 10 ml; box with 2 blisters of 20 tablets) this element can be used for describing the intermediate Packaged Medicinal Product Item or the Packaged Medicinal Product.

For example in the case 
  \--Box 
  \-----2 blisters 
  \--------20 tablets 
it describes the "2 blisters" 

In the case of 
  \--Box 
  \-----5 vials
it represents the Packaged Medicinal Product. 
(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:quantity
PQ0 … 1(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:containerPackagedProduct
1 … *R(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs1 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:code
CD0 … 1(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:name
ST0 … 1RIt represents the Name of the Package Item or of the Packaged Medicinal Product.
If this is the most inner  <pharm:containerPackagedProduct> than this element can be used for the brand name.
(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:formCode
CE1 … 1(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:capacity​Quantity
PQ1 … 1M(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs0 … 1 
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:asContent
0 … *RIn case of multiple layers of packaging (5 vials 10 ml; box with 2 blisters of 20 tablets) this element can be used for describing the intermediate Packaged Medicinal Product Item or the Packaged Medicinal Product.

For example in the case 
  \--Box 
  \-----2 blisters 
  \--------20 tablets 
it describes the "2 blisters" 

In the case of 
  \--Box 
  \-----5 vials
it represents the Packaged Medicinal Product. 
(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:quantity
PQ0 … 1(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:containerPackagedProduct
1 … *RIt represents the intermediate Package Item or the Packaged Medicinal Product(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs1 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:code
CD0 … 1(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:name
ST0 … 1R(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:formCode
CE1 … 1R(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:capacity​Quantity
PQ0 … 1R(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@value
1 … 1R
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@unit
cs0 … 1 
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:asContent
0 … *RIn case of multiple layers of packaging (box with 2 blisters of 20 tablets) this element is used for describing the most outer Packaged Medicinal Product Item or the Packaged Medicinal Product.

For example in the case 
  \--Box 
  \-----2 blisters 
  \--------20 tablets 
it describes the Packaged Medicinal Product. 
(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:quantity
PQ0 … 1(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:containerPackagedProduct
1 … *RWhen present, it represents the Packaged Medicinal Product(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FCONT
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs1 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:code
CD0 … *(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:name
ST0 … *RWhen present, it can be used to represent the brand name.(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:formCode
CE1 … 1R(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:capacity​Quantity
PQ0 … 1(UVM...ail)
Treeblank.pngTreetree.pngpharm:quantity
PQ0 … *(UVM...ail)
Treeblank.pngTreetree.pngpharm:asSpecializedKind
0 … *R(UVM...ail)
Treeblank.pngTreeblank.pngTreetree.png@classCode
1 … 1FGRIC
 Example<pharm:asSpecializedKind classCode="GRIC">
  <pharm:generalizedMedicineClass classCode="MMAT">
    <pharm:code code=" " displayName=" " codeSystem=" " codeSystemName=" "/>  </pharm:generalizedMedicineClass>
</pharm:asSpecializedKind>
Treeblank.pngTreeblank.pngTreetree.pngpharm:generalizedMedicineClass
0 … *(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
1 … 1FMMAT
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:code
1 … 1R(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:name
0 … *(UVM...ail)
Treeblank.pngTreetree.pngpharm:ingredient
0 … *(UVM...ail)
Treeblank.pngTreeblank.pngTreetree.png@classCode
1 … 1FACTI
 Example<pharm:ingredient classCode="ACTI">
  <pharm:quantity>
    <numerator xsi:type="PQ" value=" " unit=" "/>    <denominator xsi:type="PQ" value=" " unit=" "/>  </pharm:quantity>
  <pharm:ingredient classCode="MMAT" determinerCode="KIND">
    <pharm:code code=" " displayName=" " codeSystem="2.16.840.1.113883.6.73" codeSystemName="ATC WHO"/>  </pharm:ingredient>
</pharm:ingredient>
Treeblank.pngTreeblank.pngTreetree.pngpharm:quantity
0 … 1(UVM...ail)
 Example
10 mg of the ingredient per ml
<pharm:quantity>
  <numerator xsi:type="PQ" value="10" unit="mg"/>  <denominator xsi:type="PQ" value="1" unit="ml"/></pharm:quantity>
 Example
2% of the ingredient
<pharm:quantity>
  <numerator xsi:type="PQ" value="2" unit="%"/>  <denominator xsi:type="PQ" value="1"/></pharm:quantity>
 Example
5mg of the ingredient
<pharm:quantity>
  <numerator xsi:type="PQ" value="5" unit="mg"/>  <denominator xsi:type="PQ" value="1"/></pharm:quantity>
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:numerator
0 … 1(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:denominator
0 … 1(UVM...ail)
Treeblank.pngTreeblank.pngTreetree.pngpharm:ingredientSubstance
0 … 1(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
1 … 1FMMAT
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
1 … 1FKIND
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:code
0 … 1(UVM...ail)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pngpharm:name
1 … 1R(UVM...ail)
Treetree.pnghl7:manufacturerOrganization
0 … 1RContains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)(UVM...ail)

UV Medication Information (simple)

Id2.16.840.1.113883.10.21.4.10Effective Date2017‑05‑10
StatusKyellow.png DraftVersion Label
NameUVMedicationInformationsimpleDisplay NameUV Medication Information (simple)
DescriptionUniversal Medication Information (simple)
ContextParent nodes of template element with id 2.16.840.1.113883.10.21.4.10
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 1 template
Uses as NameVersion
2.16.840.1.113883.10.12.151ContainmentKgreen.png CDA OrganizationDYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.312 CDA ManufacturedProduct (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 2.16.840.1.113883.10.20.22.4.54 Immunization Medication Information (V2) (2014‑06‑09)
ref
ccda-
Example
US RxNorm Code
<hl7:manufacturedProduct classCode="MANU">
  <hl7:templateId root="2.16.840.1.113883.10.21.4.10"/>  <hl7:manufacturedMaterial classCode="MMAT" determinerCode="KIND">
    <hl7:code code="243670" codeSystem="2.16.840.1.113883.6.88" displayName="Aspirin 81 MG Oral Tablet"/>  </hl7:manufacturedMaterial>
</hl7:manufacturedProduct>
Example
Dutch G-Standaard Artikel Code
<hl7:manufacturedProduct classCode="MANU">
  <hl7:templateId root="2.16.840.1.113883.10.21.4.10"/>  <hl7:manufacturedMaterial classCode="MMAT" determinerCode="KIND">
    <hl7:code code="14145839" codeSystem="2.16.840.1.113883.2.4.4.8" codeSystemName="G-Standaard Artikel" displayName="FUROSEMIDE CF 40MG TABLET"/>  </hl7:manufacturedMaterial>
</hl7:manufacturedProduct>
Example
German Pharmaceutical Product Code
<hl7:manufacturedProduct classCode="MANU">
  <hl7:templateId root="2.16.840.1.113883.10.21.4.10"/>  <hl7:manufacturedMaterial classCode="MMAT" determinerCode="KIND">
    <hl7:code code="4213974" codeSystem="1.2.276.0.76.4.6" displayName="RAMIPRIL STADA 5 mg"/>    <hl7:lotNumberText>675-86574</hl7:lotNumberText>  </hl7:manufacturedMaterial>
  <hl7:manufacturerOrganization>
    <hl7:name>STADA GmbH</hl7:name>  </hl7:manufacturerOrganization>
</hl7:manufacturedProduct>
ItemDTCardConfDescriptionLabel
hl7:manufacturedProduct
(UVM...ple)
Treetree.png@classCode
cs1 … 1FMANU
Treetree.pnghl7:templateId
II1 … 1M(UVM...ple)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.21.4.10
Treetree.pnghl7:manufactured​Material
1 … 1M(UVM...ple)
Treeblank.pngTreetree.png@classCode
cs0 … 1FMMAT
Treeblank.pngTreetree.png@determiner​Code
cs0 … 1FKIND
Treeblank.pngTreetree.pnghl7:code
CD1 … 1R(UVM...ple)
Treeblank.pngTreeblank.pngTreetree.pnghl7:translation
CE0 … *(UVM...ple)
 CONF
shall be drawn from concept domain "Product Code"
Treeblank.pngTreetree.pnghl7:lotNumberText
0 … 1(UVM...ple)
Treetree.pnghl7:manufacturerOrganization
0 … 1RContains 2.16.840.1.113883.10.12.151 CDA Organization (DYNAMIC)(UVM...ple)

UV Medication Order Reference

Id2.16.840.1.113883.10.21.4.8Effective Date2017‑03‑30
StatusKyellow.png DraftVersion Label
NameUVMedicationOrderReferenceDisplay NameUV Medication Order Reference
DescriptionUniversal Medication Medication Order Reference
ContextParent nodes of template element with id 2.16.840.1.113883.10.21.4.8
LabelMedicationOrderReference
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 1 template
Uses as NameVersion
2.16.840.1.113883.10.12.318ContainmentKgreen.png CDA Author (Body)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.308 CDA SubstanceAdministration (2005‑09‑07)
ref
ad1bbr-
Example
Example
<substanceAdministration classCode="SBADM" moodCode="RQO">
  <templateId root="2.16.840.1.113883.10.21.4.8"/>  <id root="1.2.3.99.99.99" extension="988437489739"/></substanceAdministration>
ItemDTCardConfDescriptionLabel
hl7:substanceAdministration
Medi...ence
Treetree.png@classCode
cs1 … 1FSBADM
Treetree.png@moodCode
cs1 … 1FRQO
Treetree.pnghl7:templateId
II1 … 1MMedi...ence
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.21.4.8
Treetree.pnghl7:id
II1 … 1RMedi...ence
Treetree.pnghl7: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...ence
Treeblank.png where [hl7:assignedAuthor]

UV Subordinate Substance Administration

Id2.16.840.1.113883.10.21.4.6Effective Date2017‑04‑30
StatusKyellow.png DraftVersion Label
NameUVSubordinateadministrationDisplay NameUV Subordinate Substance Administration
DescriptionUniversal Subordinate Substance Administration to convey information about dosages
ContextParent nodes of template element with id 2.16.840.1.113883.10.21.4.6
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
RelationshipSpecialization: template 2.16.840.1.113883.10.12.308 CDA SubstanceAdministration (2005‑09‑07)
ref
ad1bbr-
Example
Example
<substanceAdministration classCode="SBADM" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.21.4.6"/>  <statusCode code="active"/>  <effectiveTime xsi:type="PIVL_TS" institutionSpecified="true">
    <period value="12" unit="h"/>  </effectiveTime>
  <doseQuantity xsi:type="IVL_PQ" value="2" unit="{puff}"/>  <consumable>
    <manufacturedProduct>
      <manufacturedMaterial nullFlavor="NA"/>    </manufacturedProduct>
  </consumable>
</substanceAdministration>
ItemDTCardConfDescriptionLabel
hl7:substanceAdministration
1 … 1R(UVS...ion)
Treetree.png@classCode
cs1 … 1FSBADM
Treetree.png@moodCode
cs1 … 1RIf the subordinate substance administration refers to Medication Order then a substance administration request (moodCode is 'RQO') is used.
If it refers to a Medication Statement, the moodCode shall be set to event/intent (moodCode is 'EVN' or 'INT').
 CONF
The value of @moodCode shall be drawn from value set 2.16.840.1.113883.11.21.4 Mood Code Evn Int Rqo (DYNAMIC)
 ConstraintThe moodCode of this subordinate substance administration SHALL be the same of the parent substance administration
Treetree.pnghl7:templateId
II1 … 1M(UVS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.21.4.6
Treetree.pnghl7:statusCode
CS1 … 1M(UVS...ion)
 ConstraintThe statusCode of this subordinate substance administration SHALL be the same of that of the parent substance administration.
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.21.2 ActStatusActiveCompletedAbortedSuspended (DYNAMIC)
Choice1 … 1Elements to choose from:
  • hl7:effectiveTime[@value or @nullFlavor]
  • hl7:effectiveTime[@xsi:type='PIVL_TS']
  • hl7:effectiveTime[@xsi:type='EIVL_TS']
  • hl7:effectiveTime[@xsi:type='SXPR_TS']
Treeblank.pngTreetree.pnghl7:effectiveTime
TS0 … 1CThis required element describes the frequency of intakes. If not known it shall be valued with the nullflavor "UNK"(UVS...ion)
Treeblank.pngTreeblank.png where [@value or @nullFlavor]
 Example
Once (known date)
<effectiveTime value="20170404"/>
 Example
Unknown
<effectiveTime nullFlavor="UNK"/>
Treeblank.pngTreetree.pnghl7:effectiveTime
PIVL_TS0 … 1CPeriodic Time Interval(UVS...ion)
Treeblank.pngTreeblank.png where [@xsi:type='PIVL_TS']
 Example
Every 4 hours
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="false">
  <period value="4" unit="h"/></effectiveTime>
 Example
Twice a day
<effectiveTime xsi:type="PIVL_TS" institutionSpecified="true">
  <period value="12" unit="h"/></effectiveTime>
Treeblank.pngTreetree.pnghl7:effectiveTime
EIVL_TS0 … 1CEvent Related Time Interval(UVS...ion)
Treeblank.pngTreeblank.png where [@xsi:type='EIVL_TS']
 Example
After meal
<effectiveTime xsi:type="EIVL_TS">
  <event code="PC" codeSystem="2.16.840.1.113883.5.139"/></effectiveTime>
 Example
One hour before breakfast
<effectiveTime xsi:type="EIVL_TS">
  <event code="ACM" codeSystem="2.16.840.1.113883.5.139"/>  <offset>
    <low value="1" unit="h"/>  </offset>
</effectiveTime>
Treeblank.pngTreeblank.pngTreetree.pnghl7:event
EIVL.event0 … 1C(UVS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
cs0 … 1 
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10706 TimingEvent (DYNAMIC)
Treeblank.pngTreetree.pnghl7:effectiveTime
SXPR_TS0 … 1RCombined Time Interval(UVS...ion)
Treeblank.pngTreeblank.png where [@xsi:type='SXPR_TS']
Treetree.pnghl7:doseQuantity
IVL_PQ0 … 1RThe doseQuantity describes the amount of the medication given (the dosage).

If a dose range is given (e.g., 1-2 tablets, or 325-750mg), then the <low> and <high> bounds are specified in their respective elements; otherwise only one physical quantity is specified (e.g. 2 drops)

The dose can be in some known and measurable unit, such as grams, milligrams,or described in "administration" units (unit of presentation, such as capsules).

If the dose is in countable items (tablets, caplets, "eaches"), then the unit could be omitted or valorized using the UCUM annotations for describing the type of countable items (e.g. .{tablet}, {puff},..).

The unit attribute – when expresses unit of measures- shall be derived from the UCUM code system.
The used elements should contain a <translation> element that provides a reference to the originalText found in the narrative body of the document.
(UVS...ion)
Treeblank.pngTreetree.png@unit
cs0 … 1 
 Example
Not pre-coordinated consumable
<doseQuantity value="25" unit="mg"/>
 Example
Pre-coordinated consumable - Dose Range
<doseQuantity>
  <low value="1" unit="{tablet}"/>  <high value="2" unit="{tablet}"/></doseQuantity>
 Example
Pre-coordinated consumable
<doseQuantity value="2" unit="{puff}"/>
 Example
Pre-coordinated consumable with text reference
<doseQuantity value="2" unit="{puff}">
  <translation>
    <originalText>
      <reference value="#text-ref-1"/>    </originalText>
  </translation>
</doseQuantity>
 Example
Textual dosage
<doseQuantity nullFlavor="OTH">
  <translation>
    <originalText>
      <reference value="#text-ref-1"/>    </originalText>
  </translation>
</doseQuantity>
Treetree.pnghl7:rateQuantity
IVL_PQ0 … 1(UVS...ion)
Treetree.pnghl7:maxDoseQuantity
RTO_PQ_PQ0 … 1(UVS...ion)
Treetree.pnghl7:administrationUnitCode
CE0 … 1(UVS...ion)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14570 AdministrableDrugForm (DYNAMIC)
Treetree.pnghl7:consumable
1 … 1R(UVS...ion)
Treeblank.pngTreetree.pnghl7:manufacturedProduct
1 … 1R(UVS...ion)
Treeblank.pngTreeblank.pngTreetree.pnghl7:manufactured​Material
1 … 1R(UVS...ion)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@nullFlavor
cs1 … 1FNA

UV Substitution Event Adminstration

Id2.16.840.1.113883.10.21.4.14Effective Date2019‑02‑17
StatusKyellow.png DraftVersion Label
NameUVSubstitutionEventAdministrationDisplay NameUV Substitution Event Adminstration
DescriptionInformation about a substitution made for this adminstration.
ContextParent nodes of template element with id 2.16.840.1.113883.10.21.4.14
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
RelationshipSpecialization: template 2.16.840.1.113883.10.12.301 CDA Act (2005‑09‑07)
ref
ad1bbr-
Example
Example
<act classCode="ACT" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.21.4.14"/>  <code code="TE" codeSystem="2.16.840.1.113883.5.1070" displayName="therapeutic alternative"/>  <entryRelationship typeCode="RSON">
    <act classCode="ACT" moodCode="EVN">
      <!-- Reason for substitution -->
    </act>
  </entryRelationship>
</act>
ItemDTCardConfDescriptionLabel
hl7:act
1 … 1M(UVS...ion)
Treetree.png@classCode
cs1 … 1FACT
Treetree.png@moodCode
cs1 … 1FDEF
Treetree.pnghl7:templateId
II1 … 1M(UVS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.21.4.14
Treetree.pnghl7:code
CE (example)1 … 1The type of substitution made.(UVS...ion)
 CONF
Examples of the value of @code are in the valuet set 2.16.840.1.113883.1.11.16621 ActSubstanceAdminSubstitutionCode (DYNAMIC)
Treetree.pnghl7:entryRelationship
0 … 1CIndicates the reason substitution.(UVS...ion)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FRSON
 Example<entryRelationship typeCode="RSON">
  <code code="FP" codeSystem="2.16.840.1.113883.5.8" displayName="formulary policy">
    <originalText>Formulary policy</originalText>  </code>
</entryRelationship>
Treeblank.pngTreetree.pnghl7:act
1 … 1(UVS...ion)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FACT
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs1 … 1FEVN
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CD (example)1 … 1(UVS...ion)
 CONF
Examples of the value of @code are in the valuet set 2.16.840.1.113883.1.11.19377 SubstanceAdminSubstitutionReason (DYNAMIC)

UV Substitution Permission

Id2.16.840.1.113883.10.21.4.5Effective Date2017‑01‑02
StatusKyellow.png DraftVersion Label
NameUVSubstitutionPermissionDisplay NameUV Substitution Permission
DescriptionInformation about a substitution permission for this adminstration.
ContextParent nodes of template element with id 2.16.840.1.113883.10.21.4.5
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
RelationshipSpecialization: template 2.16.840.1.113883.10.12.301 CDA Act (2005‑09‑07)
ref
ad1bbr-
Example
Example
<act classCode="ACT" moodCode="DEF">
  <templateId root="2.16.840.1.113883.10.21.4.5"/>  <code code="TE" codeSystem="2.16.840.1.113883.5.1070" displayName="therapeutic alternative"/>  <entryRelationship typeCode="RSON">
    <act classCode="ACT" moodCode="EVN">
      <!-- Reason no substitution -->
    </act>
  </entryRelationship>
</act>
ItemDTCardConfDescriptionLabel
hl7:act
1 … 1M(UVS...ion)
Treetree.png@classCode
cs1 … 1FACT
Treetree.png@moodCode
cs1 … 1FDEF
Treetree.pnghl7:templateId
II1 … 1M(UVS...ion)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.21.4.5
Treetree.pnghl7:code
CE (example)1 … 1The type of substitution that this permission relates to.(UVS...ion)
 CONF
Examples of the value of @code are in the valuet set 2.16.840.1.113883.1.11.16621 ActSubstanceAdminSubstitutionCode (DYNAMIC)
Treetree.pnghl7:entryRelationship
0 … 1CUsed when substitution is not allowed and may indicate the reason for why substitution is not allowed.(UVS...ion)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FRSON
 Example<entryRelationship typeCode="RSON">
  <code code="PAT" codeSystem="2.16.840.1.113883.5.8" displayName="Patient request">
    <originalText>Patient objects</originalText>  </code>
</entryRelationship>
Treeblank.pngTreetree.pnghl7:act
1 … 1(UVS...ion)
Treeblank.pngTreeblank.pngTreetree.png@classCode
cs1 … 1FACT
Treeblank.pngTreeblank.pngTreetree.png@moodCode
cs1 … 1FEVN
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CD (example)1 … 1(UVS...ion)
 CONF
Examples of the value of @code are in the valuet set 2.16.840.1.113883.1.11.19719 SubstanceAdminSubstitutionNotAllowedReason (DYNAMIC)

UV Use Period

Id2.16.840.1.113883.10.21.9.1Effective Date2017‑05‑02
Other versions this id:
  • Kblank.png Useperiod as of 2017‑01‑02
StatusKyellow.png DraftVersion Label
NameUseperiodDisplay NameUV Use Period
Description
This element encodes the start and stop time of the medication regimen. This is an interval of time (xsi:type='IVL_TS'), and must be specified as shown. This is an additional constraint placed upon CDA Release 2.0 by this profile, and simplifies the exchange of start/stop and frequency information between EMR systems.
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
ItemDTCardConfDescriptionLabel
Choice1 … 1
The effectiveTime element encodes the use period 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]
Treetree.pnghl7:effectiveTime
IVL_TS0 … 1CCase 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 (continuous therapy) 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 a prescription that has not been refilled 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.
(Use...iod)
Treeblank.png where [hl7:low or
hl7:high]
Treeblank.pngTreetree.png@nullFlavor
cs0 … 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
continous therapy
<effectiveTime xsi:type="IVL_TS">
  <low value="20130321"/>  <high nullFlavor="NA"/></effectiveTime>
Treeblank.pngTreetree.pnghl7:low
IVXB_TS1 … 1R(Use...iod)
Treeblank.pngTreetree.pnghl7:high
IVXB_TS0 … 1R(Use...iod)
Treetree.pnghl7:effectiveTime
IVL_TS0 … 1CCase 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)
(Use...iod)
Treeblank.png where [hl7:width]
 Example
2 week period
<effectiveTime xsi:type="IVL_TS">
  <width value="2" unit="w"/></effectiveTime>
Treeblank.pngTreetree.pnghl7:low
NP(Use...iod)
Treeblank.pngTreetree.pnghl7:width
PQ1 … 1R(Use...iod)
Treeblank.pngTreeblank.pngTreetree.png@unit
cs1 … 1R
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.11.21.1 Medication Time Units (UCUM) (DYNAMIC)

Templates drawn from C-CDA (not subject of this guide)

Indication (V2)

Id2.16.840.1.113883.10.20.22.4.19
ref
ccda-
Effective Date2014‑06‑09
Other versions this id:
  • Kblank.png Indication as of 2013‑01‑31
StatusKorange.png Under pre-publication reviewVersion Label2.1
NameIndicationV2Display NameIndication (V2)
Description
This template represents the rationale for an action such as an encounter, a medication administration, or a procedure. The id element can be used to reference a problem recorded elsewhere in the document, or can be used with a code and value to record the problem. Indications for treatment are not laboratory results; rather the problem associated with the laboratory result should be sited (e.g., hypokalemia instead of a laboratory result of Potassium 2.0 mEq/L). Use the Drug Monitoring Act [templateId 2.16.840.1.113883.10.20.22.4.123] to indicate if a particular drug needs special monitoring (e.g., anticoagulant therapy). Use Precondition for Substance Administration (V2) [templateId 2.16.840.1.113883.10.20.22.4.25.2] to represent that a medication is to be administered only when the associated criteria are met.
ContextParent nodes of template element with id 2.16.840.1.113883.10.20.22.4.19
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
RelationshipSpecialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-

Version: template 2.16.840.1.113883.10.20.22.4.19 Indication (2013‑01‑31)
ref
ccda-
ItemDTCardConfDescriptionLabel
cda:observation
(Ind...nV2)
Treetree.png@classCode
1 … 1FOBSCONF...7480
 SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7480).
Treetree.png@moodCode
1 … 1FEVNCONF...7481
 SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7481).
Treetree.pngcda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:1098-7482) such that itCONF...7482
Treeblank.pngTreetree.png@root
1 … 1F2.16.840.1.113883.10.20.22.4.19CONF...0502
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.19" (CONF:1098-10502).
Treeblank.pngTreetree.png@extension
1 … 1F2014-06-09CONF...2570
 SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32570).
Treetree.pngcda:id
II1 … *SHALL contain at least one [1..*] id (CONF:1098-7483).CONF...7483
Treetree.pngcda:code
CD (extensible)1 … 1SHALL contain exactly one [1..1] code, which MAY be selected from ValueSet Problem Type urn:oid:2.16.840.1.113883.3.88.12.3221.7.2 STATIC 2014-09-02 (CONF:1098-31229).CONF...1229
 CONF
The value of @code should be drawn from value set 2.16.840.1.113883.3.88.12.3221.7.2 Problem Type (2014‑09‑02)