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pending Template  Medication Activity (V2)

Id 2.16.840.1.113883.10.20.22.4.16
ref
ccda-
 		Effective Date 2014‑06‑09
Other versions this id:
Status pending Under pre-publication review Version Label 2.1
Name MedicationActivityV2 Display Name 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".
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.16
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 22 templates, Uses 12 templates
Used by as Name Version
2.16.840.1.113883.10.20.22.2.58 Containment draft Reaction Observation (V2) (2.1) 2019‑03‑08 05:57:43
notice Circular reference found with ReactionObservationV2, please check
2.16.840.1.113883.10.20.22.2.77 link draft BC CDA Allergy - Intolerance Observation (V2) (2.1) 2019‑03‑31 09:08:58
2.16.840.1.113883.10.20.22.2.61 link draft BC CDA Allergy Concern Act (V3) (2.1) 2019‑03‑15 13:09:01
2.16.840.1.113883.10.20.22.2.62 link draft BC CDA Allergies and Intolerances Section (entries optional) (V3) (2.1) 2019‑03‑15 13:13:08
2.16.840.1.113883.3.51.60.2.4.1 link draft BC CDA ClinicalDocumentDischargeSummary (V3) (2.1) 2019‑03‑19 14:15:51
2.16.840.1.113883.10.20.22.2.83 link draft Medication Activity (V2) (2.1) 2019‑03‑31 19:39:08
2.16.840.1.113883.10.20.22.2.82 link draft Discharge Medication (V2) (2.1) 2019‑03‑31 19:24:50
2.16.840.1.113883.10.20.22.2.11 link draft BC CDA Discharge Medications Section (entries optional) (V3) (2.1) 2019‑03‑15 14:34:42
2.16.840.1.113883.10.20.22.2.89 link draft Admission Medication (V2) (2.1) 2019‑04‑01 01:46:48
2.16.840.1.113883.10.20.22.2.43 link draft Admission Diagnosis Section (V3) (2.1) 2019‑03‑16 20:59:38
2.16.840.1.113883.10.20.22.2.44 link draft BC CDA Admission Medications Section (entries optional) (V3) (2.1) 2019‑03‑16 21:05:50
2.16.840.1.113883.10.20.22.2.90 link draft Immunization Activity (V3) (2.1) 2019‑04‑01 01:57:35
2.16.840.1.113883.10.20.22.2.78 link draft Immunizations Section (entries optional) (V3) (2.1) 2019‑03‑16 21:11:13
2.16.840.1.113883.10.20.22.2.73 Containment draft Procedure Activity Procedure (V2) (2.1) 2019‑03‑06 15:51:00
notice Circular reference found with ProcedureActivityProcedureV2, please check
2.16.840.1.113883.10.20.22.2.95 link draft Result Organizer (V3) (2.1) 2019‑04‑03 23:40:21
2.16.840.1.113883.10.20.22.2.47 link draft BC CDA Results Section (entries optional) (V3) (2.1) 2019‑03‑16 19:55:12
2.16.840.1.113883.10.20.22.4.12 Containment pending Procedure Activity Act (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.2.7 link draft Procedures Section (entries optional) (V2) (2.1) 2019‑03‑16 21:12:43
2.16.840.1.113883.10.20.22.4.13 Containment pending Procedure Activity Observation (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.14 Containment pending Procedure Activity Procedure (V2) (2.1) 2014‑06‑09
notice Circular reference found with 2.16.840.1.113883.10.20.22.4.14, please check
2.16.840.1.113883.10.20.22.4.9 link pending Reaction Observation (V2) (2.1) 2014‑06‑09
notice Circular reference found with 2.16.840.1.113883.10.20.22.4.9, please check
2.16.840.1.113883.10.20.22.4.16 link pending Medication Activity (V2) (2.1) 2014‑06‑09
Uses as Name Version
2.16.840.1.113883.10.20.22.4.23 Containment pending Medication Information (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.119 Containment pending Author Participation (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.24 Containment pending Drug Vehicle (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.19 Containment pending Indication (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.20 Containment pending Instruction (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.17 Containment pending Medication Supply Order (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.18 Containment pending Medication Dispense (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.9 Containment pending Reaction Observation (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.123 Containment pending Drug Monitoring Act (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.118 Containment pending Substance Administered Act (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.147 Containment pending Medication Free Text Sig (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.25 Containment pending Precondition for Substance Administration (V2) (2.1) 2014‑06‑09
Relationship Specialization: template 2.16.840.1.113883.10.12.308 CDA SubstanceAdministration (2005‑09‑07)
ref
ad1bbr-

Version: template 2.16.840.1.113883.10.20.22.4.16 Medication Activity (2013‑01‑31)
ref
ccda-
Item DT Card Conf Description Label
cda:substanceAdministration
(MeddotsyV2)
treetree @classCode
1 … 1 F SBADM CONFdots7496
  SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7496).
treetree @moodCode
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). 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)
treetree cda:templateId
II 1 … 1 M SHALL contain exactly one [1..1] templateId (CONF:1098-7499) such that it CONFdots7499
treeblank treetree @root
1 … 1 F 2.16.840.1.113883.10.20.22.4.16 CONFdots0504
  SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.16" (CONF:1098-10504).
treeblank treetree @extension
1 … 1 F 2014-06-09 CONFdots2498
  SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32498).
treetree cda:id
II 1 … * SHALL contain at least one [1..*] id (CONF:1098-7500). CONFdots7500
treetree cda:code
0 … 1 MAY contain zero or one [0..1] code (CONF:1098-7506). CONFdots7506
treetree cda:statusCode
CS 1 … 1 R SHALL contain exactly one [1..1] statusCode (CONF:1098-7507). CONFdots7507
treetree 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. CONFdots7508
treeblank where [not(@operator='A')]
treeblank treetree @value
0 … 1   SHOULD contain zero or one [0..1] @value (CONF:1098-32775). CONFdots2775
treeblank treetree cda:low
0 … 1 R SHOULD contain zero or one [0..1] low (CONF:1098-32776). CONFdots2776
treeblank treetree cda:high
0 … 1 MAY contain zero or one [0..1] high (CONF:1098-32777). CONFdots2777
  Schematron assert role red 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.  
treetree cda:effectiveTime
0 … 1 R CONFdots7513
treeblank where [@operator='A']
treeblank treetree @operator
1 … 1 F A
  Constraint *SHALL* contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS"
  Schematron assert role red 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  
treetree 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. 		CONFdots7555
treetree 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). 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)
treetree 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). 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)
Choice 1 … 
nl-NL Medication Activity *SHOULD* include doseQuantity *OR* rateQuantity
Elements to choose from:
  • cda:doseQuantity[not(@nullFlavor)]
  • cda:rateQuantity
treeblank treetree cda:doseQuantity
1 … 1 M SHALL contain exactly one [1..1] doseQuantity (CONF:1098-7516). CONFdots7516
treeblank treeblank treetree @unit
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). CONFdots7526
  CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.1.11.12839 UnitsOfMeasureCaseSensitive (DYNAMIC)
  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.
treeblank treetree cda:rateQuantity
0 … 1 MAY contain zero or one [0..1] rateQuantity (CONF:1098-7517). CONFdots7517
treeblank treeblank treetree @unit
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). CONFdots7525
  CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.1.11.12839 UnitsOfMeasureCaseSensitive (DYNAMIC)
treetree cda:maxDoseQuantity
RTO_PQ_PQ 0 … 1 MAY contain zero or one [0..1] maxDoseQuantity (CONF:1098-7518). CONFdots7518
treetree 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. 		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)
treetree cda:consumable
1 … 1 M Contains 2.16.840.1.113883.10.20.22.4.23 Medication Information (V2) (2014‑06‑09) CONFdots7520
treeblank where [cda:manufacturedProduct [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.23'] [@extension = '2014-06-09']]]
treetree cda:performer
0 … 1 MAY contain zero or one [0..1] performer (CONF:1098-7522). CONFdots7522
treetree 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 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13) 		CONFdots1150
treeblank where [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.119']]
treetree cda:participant
0 … * Contains 2.16.840.1.113883.10.20.22.4.24 Drug Vehicle (2015‑08‑13) CONFdots7523
treeblank where [cda:participantRole [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.24']]]
treeblank treetree @typeCode
1 … 1 F CSM CONFdots7524
  SHALL contain exactly one [1..1] @typeCode="CSM" (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1098-7524).
treetree cda:entryRelationship
0 … * Contains 2.16.840.1.113883.10.20.22.4.19 Indication (V2) (2014‑06‑09) CONFdots7536
treeblank where [cda:observation [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.19'] [@extension = '2014-06-09']]]
treeblank treetree @typeCode
1 … 1 F RSON CONFdots7537
  SHALL contain exactly one [1..1] @typeCode="RSON" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7537).
treetree cda:entryRelationship
0 … 1 Contains 2.16.840.1.113883.10.20.22.4.20 Instruction (V2) (2014‑06‑09) CONFdots7539
treeblank where [cda:act [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.20'] [@extension = '2014-06-09']]]
treeblank treetree @typeCode
1 … 1 F SUBJ CONFdots7540
  SHALL contain exactly one [1..1] @typeCode="SUBJ" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7540).
treeblank treetree @inversionInd
1 … 1 F true CONFdots7542
  SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1098-7542).
treetree cda:entryRelationship
0 … 1 Contains 2.16.840.1.113883.10.20.22.4.17 Medication Supply Order (V2) (2014‑06‑09) CONFdots7543
treeblank where [cda:supply [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.17'] [@extension = '2014-06-09']]]
treeblank treetree @typeCode
1 … 1 F REFR CONFdots7547
  SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7547).
treetree cda:entryRelationship
0 … * Contains 2.16.840.1.113883.10.20.22.4.18 Medication Dispense (V2) (2014‑06‑09) CONFdots7549
treeblank where [cda:supply [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.18'] [@extension = '2014-06-09']]]
treeblank treetree @typeCode
1 … 1 F REFR CONFdots7553
  SHALL contain exactly one [1..1] @typeCode="REFR" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7553).
treetree cda:entryRelationship
0 … * Contains 2.16.840.1.113883.10.20.22.4.9 Reaction Observation (V2) (2014‑06‑09) CONFdots7552
treeblank where [cda:observation [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.9'] [@extension = '2014-06-09']]]
treeblank treetree @typeCode
1 … 1 F CAUS CONFdots7544
  SHALL contain exactly one [1..1] @typeCode="CAUS" (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7544).
treetree cda:entryRelationship
0 … 1 Contains 2.16.840.1.113883.10.20.22.4.123 Drug Monitoring Act (2015‑08‑13) CONFdots0820
treeblank where [cda:act [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.123']]]
treeblank treetree @typeCode
1 … 1 F COMP CONFdots0821
  SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CONF:1098-30821).
treetree cda:entryRelationship
0 … * The following entryRelationship is used to indicate a given medication's order in a series. The nested Substance Administered Act identifies an administration in the series. The entryRelationship/sequenceNumber shows the order of this particular administration in that series.
Contains 2.16.840.1.113883.10.20.22.4.118 Substance Administered Act (2015‑08‑13) 		CONFdots1515
treeblank where [cda:act [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.118']]]
treeblank treetree @typeCode
1 … 1 F COMP CONFdots1516
  SHALL contain exactly one [1..1] @typeCode="COMP" Component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-31516).
treeblank treetree @inversionInd
1 … 1 F true CONFdots1517
  SHALL contain exactly one [1..1] @inversionInd="true" (CONF:1098-31517).
treeblank treetree cda:sequenceNumber
0 … 1 MAY contain zero or one [0..1] sequenceNumber (CONF:1098-31518). CONFdots1518
treetree cda:entryRelationship
0 … * Contains 2.16.840.1.113883.10.20.22.4.147 Medication Free Text Sig (2015‑08‑13) CONFdots2907
treeblank where [cda:substanceAdministration [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.147']]]
treeblank treetree @typeCode
1 … 1 F COMP CONFdots2908
  SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-32908).
treetree cda:precondition
0 … * Contains 2.16.840.1.113883.10.20.22.4.25 Precondition for Substance Administration (V2) (2014‑06‑09) CONFdots1520
treeblank where [cda:criterion [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.25'] [@extension = '2014-06-09']]]
treeblank treetree @typeCode
1 … 1 F PRCN CONFdots1882
  The precondition, if present, SHALL contain exactly one [1..1] @typeCode="PRCN" (CONF:1098-31882).