Id2.16.840.1.113883.10.20.22.4.147Effective Date2015‑08‑13
Statusdraft DraftVersion Label2.1
NameMedicationFreeTextSigDisplay NameMedication Free Text Sig
DescriptionThe template is available to explicitly identify the free text Sig within each medication. An example free text sig: Thyroxin 150 ug, take one tab by mouth every morning.
ContextParent nodes of template element with id 2.16.840.1.113883.10.20.22.4.147
ClassificationCDA Entry Level Template
Open/ClosedClosed (only defined elements are allowed)
Used by / Uses
Used by 17 transactions and 77 templates, Uses 0 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.29Transactionfinal Progress Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.4Transactionfinal Progress Note (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.21Transactionfinal Care Plan (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.3Transactionfinal Discharge Summary (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.2Transactionfinal Consultation Notes (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.28Transactionfinal Procedure Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.23Transactionfinal Continuity of Care Document (CCD) (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.30Transactionfinal Referral Note (V2)2015‑08‑01
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
2.16.840.1.113883.3.1937.99.3.4.27Transactionfinal Operative Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.31Transactionfinal Transfer Summary (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.26Transactionfinal History and Physical (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.5Transactionfinal Procedure Note (US Realm – Release 1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.1Transactionfinal Continuity of Care Document (CCD) (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.25Transactionfinal Discharge Summary (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.22Transactionfinal Consultation Note (V3)2015‑08‑01
1.3.6.1.4.1.19376.1.4.1.4.41Containmentdraft Medication Activity - Cardiac (1.0)2017‑03‑24 00:35:10
2.16.840.1.113883.3.1937.99.61.26.10.114Containmentrejected Medication Activity (V2) (2.1)2019‑03‑31 19:39:09
2.16.840.1.113883.10.20.21.2.3linkdraft Interventions Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.2linkdraft Continuity of Care Document (CCD) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.2linkdraft Continuity of Care Document (CCD) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.3linkdraft History and Physical (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.3linkdraft History and Physical (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.4linkdraft Consultation Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.4linkdraft Consultation Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.6linkdraft Procedure Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.6linkdraft Procedure Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.7linkdraft Operative Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.7linkdraft Operative Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.8linkdraft Discharge Summary (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.8linkdraft Discharge Summary (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.9linkdraft Progress Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.9linkdraft Progress Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.13linkdraft Transfer Summary (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.14linkdraft Referral Note (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.15linkdraft Care Plan (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.1linkdraft Medications Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.1linkdraft Medications Section (entries optional) (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.1.1linkdraft Medications Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.1.1linkdraft Medications Section (entries required) (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.2linkdraft Immunizations Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.2linkdraft Immunizations Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.2.1linkdraft Immunizations Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.2.1linkdraft Immunizations Section (entries required) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.6linkdraft Allergies Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.6linkdraft Allergies and Intolerances Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.6.1linkdraft Allergies Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.6.1linkdraft Allergies and Intolerances Section (entries required) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.7linkdraft Procedures Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.7linkdraft Procedures Section (entries optional) (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.7.1linkdraft Procedures Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.7.1linkdraft Procedures Section (entries required) (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.11linkdraft Hospital Discharge Medications Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.11linkdraft Discharge Medications Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.11.1linkdraft Hospital Discharge Medications Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.11.1linkdraft Discharge Medications Section (entries required) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.23linkdraft Medical Equipment Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.25linkdraft Anesthesia Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.25linkdraft Anesthesia Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.38linkdraft Medications Administered Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.38linkdraft Medications Administered Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.44linkdraft Hospital Admission Medications Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.44linkdraft Admission Medications Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.58linkdraft Health Concerns Section (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.78Containmentdraft BC CDA Medication Activity (V2) (2.1)2019‑03‑15 14:29:33
2.16.840.1.113883.10.20.22.4.7linkdraft Allergy - Intolerance Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.7linkdraft Allergy - Intolerance Observation (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.9linkdraft Reaction Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.9linkdraft Reaction Observation (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.12linkdraft Procedure Activity Act (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.12linkdraft Procedure Activity Act (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.13linkdraft Procedure Activity Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.13linkdraft Procedure Activity Observation (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.14linkdraft Procedure Activity Procedure (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.14linkdraft Procedure Activity Procedure (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.16linkdraft Medication Activity (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.16Containmentdraft Medication Activity (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.30linkdraft Allergy Problem Act (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.30linkdraft Allergy Concern Act (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.35linkdraft Discharge Medication (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.35linkcancelled Discharge Medication (V3) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.35linkdraft Discharge Medication (V3) (2.1)2016‑03‑01
2.16.840.1.113883.10.20.22.4.36linkdraft Admission Medication (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.36linkdraft Admission Medication (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.52linkdraft Immunization Activity (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.52linkdraft Immunization Activity (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.131linkdraft Intervention Act (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.132linkdraft Health Concern Act (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.135linkdraft Medical Equipment Organizer (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.136linkdraft Risk Concern Act (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.146linkdraft Planned Intervention Act (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.24.3.90linkdraft Substance or Device Allergy - Intolerance Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.24.3.90linkdraft Substance or Device Allergy - Intolerance Observation (V2) (2.1)2014‑06‑09
RelationshipSpecialization: template 2.16.840.1.113883.10.12.308 CDA SubstanceAdministration (2005‑09‑07)
ref
ad1bbr-
ItemDTCardConfDescriptionLabel
cda:substanceAdministration
MedidotstSig
@classCode
cs1 … 1FSBADMCONFdots2770
 SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1198-32770).
@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:1198-32771).CONFdots2771
 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:1198-32753) such that itCONFdots2753
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.147CONFdots2772
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.147" (CONF:1198-32772).
cda:code
1 … 1MSHALL contain exactly one [1..1] code (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1198-32775).

a. This code SHALL contain exactly one [1..1] @code="76662-6" Instructions Medication (CONF:1198-32780).
b. This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1 STATIC) (CONF:1198-32781).

CONFdots2775
@code
CONF1 … 1F76662-6
@codeSystem
1 … 1F2.16.840.1.113883.6.1
cda:text
1 … 1MSHALL contain exactly one [1..1] text (CONF:1198-32754).CONFdots2754
cda:reference
1 … 1MThis text SHALL contain exactly one [1..1] reference (CONF:1198-32755).

Reference into the section/text to a tag that only contains free text sig.		CONFdots2755
@value
0 … 1 This reference SHOULD contain zero or one [0..1] @value (CONF:1198-32756).CONFdots2756
 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:consumable
1 … 1MSHALL contain exactly one [1..1] consumable (CONF:1198-32776).CONFdots2776
cda:manufacturedProduct
1 … 1MThis consumable SHALL contain exactly one [1..1] manufacturedProduct (CONF:1198-32777).CONFdots2777
cda:manufacturedLabeledDrug
1 … 1This manufacturedProduct SHALL contain exactly one [1..1] manufacturedLabeledDrug (CONF:1198-32778).CONFdots2778
@nullFlavor
cs1 … 1FNACONFdots2779
 This manufacturedLabeledDrug SHALL contain exactly one [1..1] @nullFlavor="NA" Not Applicable (CONF:1198-32779).