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Template Medication Activity 2013‑01‑31

Id2.16.840.1.113883.10.20.22.4.16
ref
ccda-
Effective Date2013‑01‑31
Statusdraft DraftVersion Label1.1
NameMedicationActivityDisplay NameMedication Activity
Description
A medication activity describes substance administrations that have actually occurred (e.g. pills ingested or injections given) or are intended to occur (e.g. "take 2 tablets twice a day for the next 10 days"). Medication activities in "INT" mood are reflections of what a clinician intends a patient to be taking. Medication activities in "EVN" mood reflect actual use. Medication timing is complex. This template requires that there be a substanceAdministration/effectiveTime valued with a time interval, representing the start and stop dates. Additional effectiveTime elements are optional, and can be used to represent frequency and other aspects of more detailed dosing regimens.
ContextParent nodes of template element with id 2.16.840.1.113883.10.20.22.4.16
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 7 transactions and 33 templates, Uses 9 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.4Transactionfinal Progress Note (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.3Transactionfinal Discharge Summary (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.5Transactionfinal Procedure Note (US Realm – Release 1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.2Transactionfinal Consultation Notes (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.1Transactionfinal Continuity of Care Document (CCD) (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.6Transactionfinal Operative Note (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.7Transactionfinal History and Physical (H and P) (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.61.26.10.52Containmentdraft Procedure Activity Procedure (1.1)2019‑03‑06 11:55:46
2.16.840.1.113883.3.1937.99.61.41.10.4linkdraft Discharge Summary (1.1)2018‑02‑19 15:30:38
2.16.840.1.113883.10.20.22.1.2linkdraft Continuity of Care Document (CCD) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.3linkdraft History and Physical (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.4linkdraft Consultation Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.6linkdraft Procedure Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.7linkdraft Operative Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.8linkdraft Discharge Summary (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.9linkdraft Progress Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.1Containmentdraft Medications Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.1.1Containmentdraft Medications Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.2linkdraft Immunizations Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.2.1linkdraft Immunizations Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.6linkdraft Allergies Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.6.1linkdraft Allergies Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.7linkdraft Procedures Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.7.1linkdraft Procedures Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.11linkdraft Hospital Discharge Medications Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.11.1linkdraft Hospital Discharge Medications Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.25Containmentdraft Anesthesia Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.38Containmentdraft Medications Administered Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.44linkdraft Hospital Admission Medications Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.7linkdraft Allergy - Intolerance Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.9linkdraft Reaction Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.12Containmentdraft Procedure Activity Act (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.13Containmentdraft Procedure Activity Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.14Containmentdraft Procedure Activity Procedure (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.16linkdraft Medication Activity (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.30linkdraft Allergy Problem Act (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.35Containmentdraft Discharge Medication (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.36Containmentdraft Admission Medication (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.52linkdraft Immunization Activity (1.1)2013‑01‑31
2.16.840.1.113883.10.20.24.3.90linkdraft Substance or Device Allergy - Intolerance Observation (1.1)2013‑01‑31
Uses as NameVersion
2.16.840.1.113883.10.20.22.4.9Containmentdraft Reaction Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.17Containmentdraft Medication Supply Order (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.18Containmentdraft Medication Dispense (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.19Containmentdraft Indication (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.20Containmentdraft Instructions (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.23Containmentdraft Medication Information (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.24Containmentdraft Drug Vehicle (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.25Containmentdraft Precondition for Substance Administration (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.147Containmentdraft Medication Free Text Sig (2.1)2015‑08‑13
ItemDTCardConfDescriptionLabel
cda:substanceAdministration
Medication Activity SHOULD include doseQuantity OR rateQuantityMedidotsvity
@classCode
cs1 … 1FSBADMconf‑7496
@moodCode
cs1 … 1Rconf‑7497
 CONF
The value of @moodCode shall be drawn from value set 2.16.840.1.113883.11.20.9.18 MoodCodeEvnInt (DYNAMIC)
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:7499) such that itconf‑7499
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.16confdots0504
cda:id
II1 … *RSHALL contain at least one [1..*] id (CONF:7500).conf‑7500
cda:code
CD0 … 1MAY contain zero or one [0..1] code (CONF:7506).conf‑7506
cda:text
ED0 … 1RSHOULD contain zero or one [0..1] text (CONF:7501).conf‑7501
cda:reference
0 … 1RThe text, if present, SHOULD contain zero or one [0..1] reference (CONF:15977).

This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1)		confdots5977
@value
0 … 1 confdots5978
 Schematron assertrolered error 
 testnot(@value) or starts-with(@value, '#') 
 MessageThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) 
cda:statusCode
CS1 … 1RSHALL contain exactly one [1..1] statusCode (CONF:7507).conf‑7507
Choice1 … 1
This effectiveTime SHALL contain either a low or a @value but not both (CONF:26528).
Elements to choose from:
  • cda:effectiveTime
  • cda:effectiveTime[not(@operator='A')]
cda:effectiveTime
TS0 … 1CNote: This effectiveTime represents either the medication duration (i.e., the time the medication was started and stopped) or the single-administration timestamp.
confdots6525
@value
ts0 … 1 
cda:effectiveTime
IVL_TS0 … 1CSHALL contain exactly one [1..1] effectiveTime (CONF:7508) such that itconf‑7508
where [not(@operator='A')]
cda:low
TS1 … 1RSHALL contain exactly one [1..1] low (CONF:26526).
Note: indicates when medication started
confdots6526
cda:high
TS1 … 1RSHALL contain exactly one [1..1] high (CONF:26527).
Note: indicates when medication stopped
confdots6527
cda:effectiveTime
SXCM_TS0 … 1RSHOULD contain zero or one [0..1] effectiveTime (CONF:7513) such that it

SHALL contain exactly one [1..1] @xsi:type=”PIVL_TS” or “EIVL_TS”		conf‑7513
where [@operator='A']
@operator
cs1 … 1FAconf‑9106
 Schematron assertrolered error 
 testcount(preceding-sibling::cda:effectiveTime) = 1 and .[@operator='A'][@xsi:type='PIVL_TS' or @xsi:type='EIVL_TS'] 
 MessageSHOULD contain zero or one [0..1] effectiveTime (CONF:7513) such that it 
cda:repeatNumber
IVL_INT0 … 1MAY contain zero or one [0..1] repeatNumber (CONF: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.		conf‑7555
cda:routeCode
CE0 … 1MAY contain zero or one [0..1] routeCode, which SHALL be selected from ValueSet Medication Route FDA 2.16.840.1.113883.3.88.12.3221.8.7 DYNAMIC (CONF:7514).conf‑7514
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.3221.8.7 Medication Route FDA (DYNAMIC)
cda:approachSiteCode
CD0 … 1MAY contain zero or one [0..1] approachSiteCode, where the code SHALL be selected from ValueSet Body Site 2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:7515).conf‑7515
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.3221.8.9 Body Site (DYNAMIC)
Choice0 … 
nl-NL Medication Activity SHOULD include doseQuantity OR rateQuantity
Elements to choose from:
  • cda:doseQuantity
  • cda:rateQuantity
cda:doseQuantity
IVL_PQ0 … 1RSHOULD contain zero or one [0..1] doseQuantity (CONF:7516).

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").

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.		conf‑7516
@unit
cs0 … 1 conf‑7526
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.1.11.12839 UnitsOfMeasureCaseSensitive (DYNAMIC)
cda:rateQuantity
IVL_PQ0 … 1MAY contain zero or one [0..1] rateQuantity (CONF:7517).conf‑7517
@unit
cs1 … 1Rconf‑7525
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.1.11.12839 UnitsOfMeasureCaseSensitive (DYNAMIC)
cda:maxDoseQuantity
RTO_PQ_PQ0 … 1MAY contain zero or one [0..1] maxDoseQuantity (CONF:7518).conf‑7518
cda:administrationUnitCode
CE0 … 1MAY contain zero or one [0..1] administrationUnitCode, which SHALL be selected from ValueSet AdministrationUnitDoseForm 2.16.840.1.113762.1.4.1021.30 DYNAMIC (CONF:7519).
conf‑7519
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113762.1.4.1021.30 Administration Unit Dose Form (DYNAMIC)
cda:consumable
1 … 1RContains 2.16.840.1.113883.10.20.22.4.23 Medication Information (2013‑01‑31)conf‑7520
cda:performer
0 … 1MAY contain zero or one [0..1] performer (CONF:7522).conf‑7522
cda:participant
0 … *Contains 2.16.840.1.113883.10.20.22.4.24 Drug Vehicle (2013‑01‑31)conf‑7523
@typeCode
cs1 … 1FCSMconf‑7524
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.19 Indication (2013‑01‑31)conf‑7536
@typeCode
cs1 … 1FRSONconf‑7537
cda:entryRelationship
0 … 1Contains 2.16.840.1.113883.10.20.22.4.20 Instructions (2013‑01‑31)conf‑7539
@typeCode
cs1 … 1FSUBJconf‑7540
@inversionInd
bl1 … 1Ftrueconf‑7542
cda:entryRelationship
0 … 1Contains 2.16.840.1.113883.10.20.22.4.17 Medication Supply Order (2013‑01‑31)conf‑7543
@typeCode
cs1 … 1FREFRconf‑7547
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.18 Medication Dispense (2013‑01‑31)conf‑7549
@typeCode
cs1 … 1FREFRconf‑7553
cda:entryRelationship
0 … 1Contains 2.16.840.1.113883.10.20.22.4.9 Reaction Observation (2013‑01‑31)conf‑7552
@typeCode
cs1 … 1FCAUSconf‑7544
cda:entryRelationship
0 … 1Contains 2.16.840.1.113883.10.20.22.4.147 Medication Free Text Sig (2015‑08‑13)Medidotsvity
@typeCode
cs1 … 1FCOMPconfdots2908
cda:precondition
0 … *Contains 2.16.840.1.113883.10.20.22.4.25 Precondition for Substance Administration (2013‑01‑31)conf‑7546
@typeCode
cs1 … 1FPRCNconf‑7550