Id2.16.840.1.113883.10.20.22.2.78Effective Date2019‑03‑15 14:29:33
Statusdraft DraftVersion Label2.1
NameBCCDAMedicationActivityV2Display NameBC CDA Medication Activity (V2)
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. For example, a clinician may intend that a patient to be administered Lisinopril 20 mg PO for blood pressure control. If what was actually administered was Lisinopril 10 mg., then the Medication activities in the "EVN" mood would reflect actual use. A moodCode of INT is allowed, but it is recommended that the Planned Medication Activity (V2) template be used for moodCodes other than EVN if the document type contains a section that includes Planned Medication Activity (V2) (for example a Care Plan document with Plan of Treatment, Intervention, or Goal sections). At a minimum, a Medication Activity shall include an effectiveTime indicating the duration of the administration (or single-administration timestamp). Ambulatory medication lists generally provide a summary of use for a given medication over time - a medication activity in event mood with the duration reflecting when the medication started and stopped. Ongoing medications will not have a stop date (or will have a stop date with a suitable NULL value). Ambulatory medication lists will generally also have a frequency (e.g., a medication is being taken twice a day). Inpatient medications generally record each administration as a separate act. The dose (doseQuantity) represents how many of the consumables are to be administered at each administration event. As a result, the dose is always relative to the consumable and the interval of administration. Thus, a patient consuming a single "metoprolol 25mg tablet" per administration will have a doseQuantity of "1", whereas a patient consuming "metoprolol" will have a dose of "25 mg".
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 9 templates
Uses as NameVersion
2.16.840.1.113883.10.20.22.2.81ContainmentDYNAMIC
2.16.840.1.113883.10.20.22.4.9Containmentdraft Reaction Observation (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.17Containmentdraft Medication Supply Order (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.18Containmentdraft Medication Dispense (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.19Containmentdraft Indication (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.20Containmentdraft Instruction (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.23Containmentdraft Medication Information (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.24Containmentdraft Drug Vehicle (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.147Containmentdraft Medication Free Text Sig (2.1)2015‑08‑13
RelationshipSpecialization: template 2.16.840.1.113883.10.20.22.2.78 (2014‑06‑09)
Specialization: template 2.16.840.1.113883.10.12.308 CDA SubstanceAdministration (2005‑09‑07)
ref
ad1bbr-

Version: template 2.16.840.1.113883.10.20.22.2.78 (2013‑01‑31)
ItemDTCardConfDescriptionLabel
cda:substanceAdministration
BCCDdotstyV2
@classCode
cs1 … 1FSBADMCONFdots7496
 SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7496).
@moodCode
cs1 … 1RSHALL 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).CONFdots7497
 CONF
The value of @moodCode shall be drawn from value set 2.16.840.1.113883.11.20.9.18 MoodCodeEvnInt (2011‑04‑03)
hl7:templateId
II1 … 1MBCCDdotstyV2
@root
uid1 … 1F2.16.840.1.113883.10.20.22.2.78
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:1098-7499) such that itCONFdots7499
@root
uid1 … 1F2.16.840.1.113883.10.20.22.2.78CONFdots0504
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.16" (CONF:1098-10504).
@extension
st1 … 1F2014-06-09CONFdots2498
 SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32498).
cda:id
II1 … *SHALL contain at least one [1..*] id (CONF:1098-7500).CONFdots7500
cda:code
0 … 1MAY contain zero or one [0..1] code (CONF:1098-7506).CONFdots7506
cda:statusCode
CS1 … 1RSHALL contain exactly one [1..1] statusCode (CONF:1098-7507).CONFdots7507
cda:effectiveTime
IVL_TS1 … 1MThe 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.CONFdots7508
where [not(@operator='A')]
@value
0 … 1 SHOULD contain zero or one [0..1] @value (CONF:1098-32775).CONFdots2775
cda:low
0 … 1RSHOULD contain zero or one [0..1] low (CONF:1098-32776).CONFdots2776
cda:high
0 … 1MAY contain zero or one [0..1] high (CONF:1098-32777).CONFdots2777
 Schematron assertrolered error 
 test(cda:low or @value) and not(cda:low and @value) 
 MessageThis effectiveTime *SHALL* contain either a low or a @value but not both. 
cda:effectiveTime
0 … 1RCONFdots7513
where [@operator='A']
@operator
cs1 … 1FA
 Constraint*SHALL* contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS"
 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:1098-7513) such that it 
cda:repeatNumber
0 … 1MAY 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.

CONFdots7555
cda:routeCode
0 … 1RSHOULD 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).CONFdots7514
 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 urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:1098-7515).CONFdots7515
 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)
Choice1 … 
nl-NL Medication Activity *SHOULD* include doseQuantity *OR* rateQuantity
Elements to choose from:
  • cda:doseQuantity[not(@nullFlavor)]
  • cda:rateQuantity
cda:doseQuantity
1 … 1MSHALL contain exactly one [1..1] doseQuantity (CONF:1098-7516).CONFdots7516
@unit
cs0 … 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).CONFdots7526
 CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.1.11.12839 UnitsOfMeasureCaseSensitive (DYNAMIC)
 ConstraintPre-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 … 1MAY contain zero or one [0..1] rateQuantity (CONF:1098-7517).CONFdots7517
@unit
cs1 … 1RThe 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).CONFdots7525
 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:1098-7518).CONFdots7518
cda:administrationUnitCode
CE0 … 1MAY 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.

CONFdots7519
 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 … 1MContains 2.16.840.1.113883.10.20.22.4.23 Medication Information (V2) (2014‑06‑09)CONFdots7520
cda:performer
0 … 1MAY contain zero or one [0..1] performer (CONF:1098-7522).CONFdots7522
cda:author
0 … *RSHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-31150).
Contains
alertError: Cannot find template "2.16.840.1.113883.10.20.22.2.81" (DYNAMIC)
CONFdots1150
cda:participant
0 … *Contains 2.16.840.1.113883.10.20.22.4.24 Drug Vehicle (2015‑08‑13)CONFdots7523
@typeCode
cs1 … 1FCSMCONFdots7524
 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)CONFdots7536
@typeCode
cs1 … 1FRSONCONFdots7537
 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 … 1Contains 2.16.840.1.113883.10.20.22.4.20 Instruction (V2) (2014‑06‑09)CONFdots7539
@typeCode
cs1 … 1FSUBJCONFdots7540
 SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7540).
@inversionInd
bl1 … 1FtrueCONFdots7542
 SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1098-7542).
cda:entryRelationship
0 … 1Contains 2.16.840.1.113883.10.20.22.4.17 Medication Supply Order (V2) (2014‑06‑09)CONFdots7543
@typeCode
cs1 … 1FREFRCONFdots7547
 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)CONFdots7549
@typeCode
cs1 … 1FREFRCONFdots7553
 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)CONFdots7552
@typeCode
cs1 … 1FCAUSCONFdots7544
 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)CONFdots2907
@typeCode
cs1 … 1FCOMPCONFdots2908
 SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-32908).