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2.16.840.1.113883.10.21.4.1/static-2015-10-07T000000

Id
2.16.840.1.113883.10.21.4.1
Effective 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
Relationship
Specialization: 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
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
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
 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.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
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
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
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
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
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.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.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
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
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.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