Item | DT | Card | Conf | Description | Label |
---|
cda:substanceAdministration
| | | | | BCCDtyV2 |
@classCode
| cs | 1 … 1 | F | SBADM | CONF7496 |
| SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7496). |
@moodCode
| cs | 1 … 1 | R | SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet MoodCodeEvnInt urn:oid:2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03 (CONF:1098-7497). | CONF7497 |
| CONF | |
hl7:templateId
| II | 1 … 1 | M | | BCCDtyV2 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.2.78 |
cda:templateId
| II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:1098-7499) such that it | CONF7499 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.2.78 | CONF0504 |
| SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.16" (CONF:1098-10504). |
@extension
| st | 1 … 1 | F | 2014-06-09 | CONF2498 |
| SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32498). |
cda:id
| II | 1 … * | | SHALL contain at least one [1..*] id (CONF:1098-7500). | CONF7500 |
cda:code
| | 0 … 1 | | MAY contain zero or one [0..1] code (CONF:1098-7506). | CONF7506 |
cda:statusCode
| CS | 1 … 1 | R | SHALL contain exactly one [1..1] statusCode (CONF:1098-7507). | CONF7507 |
cda:effectiveTime
| IVL_TS | 1 … 1 | M | The substance administration effectiveTime field can repeat, in order to represent varying levels of complex dosing. effectiveTime can be used to represent the duration of administration (e.g., "10 days"), the frequency of administration (e.g., "every 8 hours"), and more. Here, we require that there SHALL be an effectiveTime documentation of the duration (or single-administration timestamp), and that there SHOULD be an effectiveTime documentation of the frequency. Other timing nuances, supported by the base CDA R2 standard, may also be included. | CONF7508 |
where [not(@operator='A')] | |
@value
| | 0 … 1 | | SHOULD contain zero or one [0..1] @value (CONF:1098-32775). | CONF2775 |
cda:low
| | 0 … 1 | R | SHOULD contain zero or one [0..1] low (CONF:1098-32776). | CONF2776 |
cda:high
| | 0 … 1 | | MAY contain zero or one [0..1] high (CONF:1098-32777). | CONF2777 |
| Schematron assert | role | error | |
| test | (cda:low or @value) and not(cda:low and @value) | |
| Message | This effectiveTime *SHALL* contain either a low or a @value but not both. | |
cda:effectiveTime
| | 0 … 1 | R | | CONF7513 |
where [@operator='A'] | |
@operator
| cs | 1 … 1 | F | A |
| Constraint | *SHALL* contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" |
| Schematron assert | role | error | |
| test | count(preceding-sibling::cda:effectiveTime) = 1 and .[@operator='A'][@xsi:type='PIVL_TS' or @xsi:type='EIVL_TS'] | |
| Message | SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it | |
cda:repeatNumber
| | 0 … 1 | | MAY contain zero or one [0..1] repeatNumber (CONF:1098-7555). In "INT" (intent) mood, the repeatNumber defines the number of allowed administrations. For example, a repeatNumber of "3" means that the substance can be administered up to 3 times. In "EVN" (event) mood, the repeatNumber is the number of occurrences. For example, a repeatNumber of "3" in a substance administration event means that the current administration is the 3rd in a series. | CONF7555 |
cda:routeCode
| | 0 … 1 | R | SHOULD contain zero or one [0..1] routeCode, which SHALL be selected from ValueSet Medication Route FDA urn:oid:2.16.840.1.113883.3.88.12.3221.8.7 DYNAMIC (CONF:1098-7514). | CONF7514 |
| CONF | |
cda:approachSiteCode
| CD | 0 … 1 | | MAY contain zero or one [0..1] approachSiteCode, where the code SHALL be selected from ValueSet Body Site urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:1098-7515). | CONF7515 |
| CONF | |
Choice | 1 … | | Medication Activity *SHOULD* include doseQuantity *OR* rateQuantity Elements to choose from:- cda:doseQuantity[not(@nullFlavor)]
- cda:rateQuantity
|
cda:doseQuantity
| | 1 … 1 | M | SHALL contain exactly one [1..1] doseQuantity (CONF:1098-7516). | CONF7516 |
@unit
| cs | 0 … 1 | | This doseQuantity SHOULD contain zero or one [0..1] @unit, which SHALL be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:1098-7526). | CONF7526 |
| CONF | |
| Constraint | Pre-coordinated consumable: If the consumable code is a pre-coordinated unit dose (e.g., "metoprolol 25mg tablet") then doseQuantity is a unitless number that indicates the number of products given per administration (e.g., "2", meaning 2 x "metoprolol 25mg tablet" per administration). Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g., is simply "metoprolol"), then doseQuantity must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration. |
cda:rateQuantity
| | 0 … 1 | | MAY contain zero or one [0..1] rateQuantity (CONF:1098-7517). | CONF7517 |
@unit
| cs | 1 … 1 | R | The rateQuantity, if present, SHALL contain exactly one [1..1] @unit, which SHALL be selected from ValueSet UnitsOfMeasureCaseSensitive urn:oid:2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:1098-7525). | CONF7525 |
| CONF | |
cda:maxDoseQuantity
| RTO_PQ_PQ | 0 … 1 | | MAY contain zero or one [0..1] maxDoseQuantity (CONF:1098-7518). | CONF7518 |
cda:administrationUnitCode
| CE | 0 … 1 | | MAY contain zero or one [0..1] administrationUnitCode, which SHALL be selected from ValueSet AdministrationUnitDoseForm urn:oid:2.16.840.1.113762.1.4.1021.30 DYNAMIC (CONF:1098-7519). administrationUnitCode@code describes the units of medication administration for an item using a code that is pre-coordinated to include a physical unit form (ointment, powder, solution, etc.) which differs from the units used in administering the consumable (capful, spray, drop, etc.). For example when recording medication administrations, “metric drop (C48491)” would be appropriate to accompany the RxNorm code of 198283 (Timolol 0.25% Ophthalmic Solution) where the number of drops would be specified in doseQuantity@value. | CONF7519 |
| CONF | |
cda:consumable
| | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.4.23 Medication Information (V2) (2014‑06‑09) | CONF7520 |
cda:performer
| | 0 … 1 | | MAY contain zero or one [0..1] performer (CONF:1098-7522). | CONF7522 |
cda:author
| | 0 … * | R | SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-31150). Contains | Error: Cannot find template "2.16.840.1.113883.10.20.22.2.81" (DYNAMIC) |
| CONF1150 |
cda:participant
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.24 Drug Vehicle (2015‑08‑13) | CONF7523 |
@typeCode
| cs | 1 … 1 | F | CSM | CONF7524 |
| SHALL contain exactly one [1..1] @typeCode="CSM" (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1098-7524). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.19 Indication (V2) (2014‑06‑09) | CONF7536 |
@typeCode
| cs | 1 … 1 | F | RSON | CONF7537 |
| SHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7537). |
cda:entryRelationship
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.4.20 Instruction (V2) (2014‑06‑09) | CONF7539 |
@typeCode
| cs | 1 … 1 | F | SUBJ | CONF7540 |
| SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7540). |
@inversionInd
| bl | 1 … 1 | F | true | CONF7542 |
| SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1098-7542). |
cda:entryRelationship
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.4.17 Medication Supply Order (V2) (2014‑06‑09) | CONF7543 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF7547 |
| SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7547). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.18 Medication Dispense (V2) (2014‑06‑09) | CONF7549 |
@typeCode
| cs | 1 … 1 | F | REFR | CONF7553 |
| SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7553). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.9 Reaction Observation (V2) (2014‑06‑09) | CONF7552 |
@typeCode
| cs | 1 … 1 | F | CAUS | CONF7544 |
| SHALL contain exactly one [1..1] @typeCode="CAUS" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7544). |
cda:entryRelationship
| | 0 … * | | Contains 2.16.840.1.113883.10.20.22.4.147 Medication Free Text Sig (2015‑08‑13) | CONF2907 |
@typeCode
| cs | 1 … 1 | F | COMP | CONF2908 |
| SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-32908). |