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draft Template  Medication Activity (V2)

Id 2.16.840.1.113883.10.20.22.4.16
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ccda-
 		Effective Date 2014‑06‑09
Status draft Draft 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 4 templates, Uses 12 templates
Used by as Name Version
2.16.840.1.113883.10.20.22.4.14 Containment draft 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 draft 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 draft Medication Activity (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.52 link draft Immunization Activity (V3) (2.1) 2015‑08‑01
Uses as Name Version
2.16.840.1.113883.10.20.22.4.23 Containment draft Medication Information (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.119 Containment draft Author Participation (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.24 Containment draft Drug Vehicle (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.19 Containment draft Indication (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.20 Containment draft Instruction (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.17 Containment draft Medication Supply Order (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.18 Containment draft Medication Dispense (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.9 Containment draft Reaction Observation (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.123 Containment draft Drug Monitoring Act (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.118 Containment draft Substance Administered Act (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.147 Containment draft Medication Free Text Sig (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.25 Containment draft 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)
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ad1bbr-

Version: template 2.16.840.1.113883.10.20.22.4.16 Medication Activity (2013‑01‑31)
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ccda-
Item DT Card Conf Description Label
cda:substanceAdministration
 		(MeddotsyV2)
@classCode
 		cs 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).
@moodCode
 		cs 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 (DYNAMIC)
cda:templateId
 		II 1 … 1 M C-CDA R1.1 templateId root without an extension CONFdots2936
@root
 		uid 1 … 1 F 2.16.840.1.113883.10.20.22.4.16
cda:templateId
 		II 1 … 1 M SHALL contain exactly one [1..1] templateId (CONF:1098-7499) such that it CONFdots7499
@root
 		uid 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).
@extension
 		st 1 … 1 F 2014-06-09 CONFdots2498
  SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32498).
cda:id
 		II 1 … * SHALL contain at least one [1..*] id (CONF:1098-7500). CONFdots7500
cda:code
 		0 … 1 MAY contain zero or one [0..1] code (CONF:1098-7506). CONFdots7506
cda:statusCode
 		CS 1 … 1 SHALL contain exactly one [1..1] statusCode (CONF:1098-7507). CONFdots7507
@code
 		cs 1 … 1 R This statusCode SHALL contain exactly one [1..1] @code , which SHALL be selected from ValueSet Medication Status urn:oid:2.16.840.1.113762.1.4.1099.11 DYNAMIC (CONF:1098-32360).
CONFdots2360
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.15933 ActStatus (DYNAMIC)
cda:effectiveTime
 		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
where [not(@operator='A')]
@value
 		0 … 1   SHOULD contain zero or one [0..1] @value (CONF:1098-32775). CONFdots2775
cda:low
 		0 … 1 R SHOULD contain zero or one [0..1] low (CONF:1098-32776). CONFdots2776
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.  
cda:effectiveTime
 		0 … 1 R CONFdots7513
where [@operator='A']
@operator
 		cs 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  
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
cda:routeCode
 		CD 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)
hl7:translation
 		CD 0 … * The routeCode, if present, SHOULD contain zero or more [0..*] translation, which SHOULD be selected from ValueSet Medication Route urn:oid:2.16.840.1.113762.1.4.1099.12 DYNAMIC (CONF:1098-32950).
 CONFdots2950
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113762.1.4.1099.12 Medication Route (DYNAMIC)
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
  • cda:rateQuantity
cda:doseQuantity
 		 (extensible) 1 … 1 SHALL contain exactly one [1..1] doseQuantity (CONF:1098-7516). CONFdots7516
@unit
 		cs 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.
cda:rateQuantity
 		0 … 1 MAY contain zero or one [0..1] rateQuantity (CONF:1098-7517). CONFdots7517
@unit
 		cs 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)
cda:maxDoseQuantity
 		RTO_PQ_PQ 0 … 1 MAY contain zero or one [0..1] maxDoseQuantity (CONF:1098-7518). CONFdots7518
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)
cda:consumable
 		1 … 1 Contains 2.16.840.1.113883.10.20.22.4.23 Medication Information (V2) (2014‑06‑09) CONFdots7520
cda:performer
 		0 … 1 MAY contain zero or one [0..1] performer (CONF:1098-7522). CONFdots7522
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
cda:participant
 		0 … * Contains 2.16.840.1.113883.10.20.22.4.24 Drug Vehicle (2015‑08‑13) CONFdots7523
@typeCode
 		cs 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).
cda:entryRelationship
 		0 … * Contains 2.16.840.1.113883.10.20.22.4.19 Indication (V2) (2014‑06‑09) CONFdots7536
@typeCode
 		cs 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).
cda:entryRelationship
 		0 … 1 Contains 2.16.840.1.113883.10.20.22.4.20 Instruction (V2) (2014‑06‑09) CONFdots7539
@typeCode
 		cs 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).
@inversionInd
 		bl 1 … 1 F true CONFdots7542
  SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1098-7542).
cda:entryRelationship
 		0 … 1 Contains 2.16.840.1.113883.10.20.22.4.17 Medication Supply Order (V2) (2014‑06‑09) CONFdots7543
@typeCode
 		cs 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).
cda:entryRelationship
 		0 … * Contains 2.16.840.1.113883.10.20.22.4.18 Medication Dispense (V2) (2014‑06‑09) CONFdots7549
@typeCode
 		cs 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).
cda:entryRelationship
 		0 … * Contains 2.16.840.1.113883.10.20.22.4.9 Reaction Observation (V2) (2014‑06‑09) CONFdots7552
@typeCode
 		cs 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).
cda:entryRelationship
 		0 … 1 Contains 2.16.840.1.113883.10.20.22.4.123 Drug Monitoring Act (2015‑08‑13) CONFdots0820
@typeCode
 		cs 1 … 1 F COMP CONFdots0821
  SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CONF:1098-30821).
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
@typeCode
 		cs 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).
@inversionInd
 		bl 1 … 1 F true CONFdots1517
  SHALL contain exactly one [1..1] @inversionInd="true" (CONF:1098-31517).
cda:sequenceNumber
 		0 … 1 MAY contain zero or one [0..1] sequenceNumber (CONF:1098-31518). CONFdots1518
cda:entryRelationship
 		0 … * Contains 2.16.840.1.113883.10.20.22.4.147 Medication Free Text Sig (2015‑08‑13) CONFdots2907
@typeCode
 		cs 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).
cda:precondition
 		0 … * Contains 2.16.840.1.113883.10.20.22.4.25 Precondition for Substance Administration (V2) (2014‑06‑09) CONFdots1520
@typeCode
 		cs 1 … 1 F PRCN CONFdots1882
  The precondition, if present, SHALL contain exactly one [1..1] @typeCode="PRCN" (CONF:1098-31882).