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2.16.840.1.113883.10.21.4.7/static-2017-05-01T000000

Id
2.16.840.1.113883.10.21.4.7
Effective 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
Relationship
Specialization: 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
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
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
 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.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.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
 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
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
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
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
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
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
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
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
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
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>