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Template UV Medication Administration 2019‑02‑17

Id2.16.840.1.113883.10.21.4.13Effective Date2019‑02‑17
Statuspending Under pre-publication reviewVersion LabelR1-STU2-ballot
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)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 12 templates
Uses as NameVersion
2.16.840.1.113883.10.12.153Containmentactive CDA AssignedEntityDYNAMIC
2.16.840.1.113883.10.12.316Containmentactive CDA RelatedEntityDYNAMIC
2.16.840.1.113883.10.12.318Containmentactive CDA Author (Body)DYNAMIC
2.16.840.1.113883.10.12.320Containmentactive CDA Subject (Body)DYNAMIC
2.16.840.1.113883.10.12.321Containmentactive CDA Participant (Body)DYNAMIC
2.16.840.1.113883.10.21.4.6Containmentdraft UV Subordinate Substance Administration (2023)DYNAMIC
2.16.840.1.113883.10.21.4.8Containmentpending UV Medication Order Reference (R1-STU2-ballot)DYNAMIC
2.16.840.1.113883.10.21.4.9Containmentpending UV Dispense Event Reference (R1-STU2-ballot)DYNAMIC
2.16.840.1.113883.10.21.4.10Containmentpending UV Medication Information (simple) (R1-STU2-ballot)DYNAMIC
2.16.840.1.113883.10.21.4.11Containmentdraft UV Medication Information (detail) (2023)DYNAMIC
2.16.840.1.113883.10.21.4.14Containmentdraft UV Substitution Event Adminstration (2023)DYNAMIC
2.16.840.1.113883.10.21.9.1Includedraft UV Use Period (2023)DYNAMIC
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
Medidotstion
@classCode
cs1 … 1FSBADM
@moodCode
cs1 … 1FEVN
hl7:templateId
II1 … 1MMedidotstion
@root
uid1 … 1F2.16.840.1.113883.10.21.4.13
hl7:id
II0 … *RMedidotstion
 ConstraintIf the use case requires updates on the order, the ID shall be made mandatory.
hl7: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.Medidotstion
 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)
hl7:text
ED0 … 1Medidotstion
hl7:statusCode
CS (required)1 … 1MMedidotstion
 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][not(hl7:width)]
  • hl7:effectiveTime[hl7:width][not(hl7:low|hl7:high)]
  • hl7:effectiveTime[hl7:low | hl7:width][not(hl7:high)]
hl7: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.		Useperiod
where [hl7:low or
[not(hl7:width)]
@nullFlavor
cs0 … 1 
 Example
Known Interval
<effectiveTime type="IVL_TS">
  <low value="20130321"/>  <high value="20140321"/></effectiveTime>
 Example
Information not available about the period
<effectiveTime type="IVL_TS" nullFlavor="NI"/>
 Example
Unknown end date
<effectiveTime type="IVL_TS">
  <low value="20130321"/>  <high nullFlavor="UNK"/></effectiveTime>
 Example
continous therapy
<effectiveTime type="IVL_TS">
  <low value="20130321"/>  <high nullFlavor="NA"/></effectiveTime>
hl7:low
IVXB_TS1 … 1RUseperiod
hl7:high
IVXB_TS0 … 1RUseperiod
hl7: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)		Useperiod
where [hl7:width] [not(hl7:lowor
hl7:high)]
 Example
2 week period
<effectiveTime type="IVL_TS">
  <width value="2" unit="w"/></effectiveTime>
hl7:low
NPUseperiod
hl7:high
NPUseperiod
hl7:center
NPUseperiod
hl7:width
PQ1 … 1RUseperiod
@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)
hl7:effectiveTime
IVL_TS0 … 1CCase 3: anchored period:
The width element is used to specify a period of (actual or intended) administration anchored to a specific date (e.g. a two weeks therapy starting today)		Useperiod
where [hl7:low or
[not(hl7:high)]
 Example
2 week period starting on 2013-03-21
<effectiveTime type="IVL_TS">
  <low value="20130321"/>  <width value="2" unit="w"/></effectiveTime>
hl7:low
IVXB_TS0 … 1CUseperiod
hl7:width
PQ1 … 1RUseperiod
@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)
hl7:repeatNumber
IVL_INT0 … 1Medidotstion
hl7:routeCode
CE (example)0 … 1Medidotstion
 CONF
Examples of the value of @code are in the value set 2.16.840.1.113883.1.11.14581 RouteOfAdministration (DYNAMIC)
hl7:approachSiteCode
CD (example)0 … *Medidotstion
 CONF
Examples of the value of @code are in the value set 2.16.840.1.113883.1.11.19724 HumanSubstanceAdministrationSite (DYNAMIC)
hl7:doseQuantity
IVL_PQNPMedidotstion
hl7:rateQuantity
IVL_PQNPMedidotstion
hl7:maxDoseQuantity
RTO_PQ_PQ0 … 1Medidotstion
hl7:administrationUnitCode
CENPMedidotstion
hl7:subject
0 … 1CPatient: The patient that takes the medicine.
Contains 2.16.840.1.113883.10.12.320 CDA Subject (Body) (DYNAMIC)		Medidotstion
 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
0 … 1RConsumable: The medication that is administered (simple)
Contains 2.16.840.1.113883.10.21.4.10 UV Medication Information (simple) (DYNAMIC)		Medidotstion
@typeCode
cs1 … 1FCSM
hl7:consumable
0 … 1RConsumable: The medication that is administered (detail)
Contains 2.16.840.1.113883.10.21.4.11 UV Medication Information (detail) (DYNAMIC)		Medidotstion
@typeCode
cs1 … 1FCSM
Choice1 … 1
Required author of the medication administration: healthcare professional or patient
Elements to choose from:
hl7: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)		Medidotstion
 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>
hl7:participant
Use this if the author of the medication administration is the patientMedidotstion
where [@typeCode='AUT']
@typeCode
cs1 … 1FAUT
 Example
Author of the medication statement is the patient
<participant typeCode="AUT">
  <time value="20170121091548"/>  <participantRole classCode="PAT"/></participant>
hl7:time
TS1 … 1RMedidotstion
hl7:participantRole
1 … 1MMedidotstion
@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)]
hl7:informant
Use this if the informant of the medication statement is a healthcare professionalMedidotstion
where [exists(hl7:assignedEntity)]
@typeCode
cs0 … 1FINF
@contextControlCode
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>
hl7:assignedEntity
1 … 1Contains 2.16.840.1.113883.10.12.153 CDA AssignedEntity (DYNAMIC)Medidotstion
hl7:participant
Use this if the informant of the medication statement is the patientMedidotstion
where [@typeCode='INF']
@typeCode
cs1 … 1FINF
 Example
Informant of the medication statement is the patient
<participant typeCode="INF">
  <time value="20170121091548"/>  <participantRole classCode="PAT"/></participant>
hl7:time
TS1 … 1RMedidotstion
hl7:participantRole
1 … 1MMedidotstion
@classCode
cs1 … 1FPAT
hl7:informant
Use this if the informant of the medication statement is a contact party (related party)Medidotstion
where [exists(hl7:relatedEntity)]
@typeCode
cs0 … 1FINF
@contextControlCode
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>
hl7:relatedEntity
1 … 1Contains 2.16.840.1.113883.10.12.316 CDA RelatedEntity (DYNAMIC)Medidotstion
hl7: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)		Medidotstion
where [@typeCode='RCT']
@typeCode
cs1 … 1FRCT
hl7: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)		Medidotstion
where [@typeCode='VRF']
@typeCode
cs1 … 1FVRF
hl7:participant
0 … 1Location
Contains 2.16.840.1.113883.10.12.321 CDA Participant (Body) (DYNAMIC)		Medidotstion
where [@typeCode='LOC']
@typeCode
cs1 … 1FLOC
hl7: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)		Medidotstion
where [hl7:substanceAdministration]
@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>
hl7:sequenceNumber
INT0 … 1Sequence number of the Subordinate Substance Administration.Medidotstion
hl7: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)		Medidotstion
where [@typeCode='COMP']
@typeCode
cs1 … 1FCOMP
 Example<entryRelationship typeCode="COMP">
  <act classCode="ACT" moodCode="EVN">
    <!-- .. -->
  </act></entryRelationship>
hl7:entryRelationship
0 … *RMedication Order Reference.
Contains 2.16.840.1.113883.10.21.4.8 UV Medication Order Reference (DYNAMIC)		Medidotstion
where [@typeCode='REFR'] [hl7:substanceAdministration]
@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>
hl7:entryRelationship
0 … *RDispense Event Reference.
Contains 2.16.840.1.113883.10.21.4.9 UV Dispense Event Reference (DYNAMIC)		Medidotstion
where [@typeCode='REFR'] [ [hl7:supply]
@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>