Consolidated CDA Release 2.1 StructureDefinition Prototype Publication
2.1.0-draft1 - CI Build United States of America

This page is part of the CCDA: Consolidated CDA Release (v2.1.0-draft1: CCDA 2.1 Draft) based on FHIR v5.0.0. . For a full list of available versions, see the Directory of published versions

Resource Profile: Medications Section - entries required

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.1.1 Version: 2.1.0-draft1
Active as of 2023-01-16 Computable Name: MedicationsSectionEntriesRequired
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.2.1.1:2014-06-09

The Medications Section contains a patient’s current medications and pertinent medication history. At a minimum, the currently active medications are listed. An entire medication history is an option. The section can describe a patient’s prescription and dispense history and information about intended drug monitoring.

This section requires either an entry indicating the subject is not known to be on any medications or entries summarizing the subject’s medications.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from MedicationsSectionEntriesOptional

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1MedicationsSectionEntriesOptionalBase for all types and resources
... nullFlavor 0..1codeRequired Pattern: NI
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:secondary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.1.1
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CE
.... code 1..1stringRequired Pattern: 10160-0
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... Slices for entry 1..*ElementIf section/@nullFlavor is not present:
Slice: Unordered, Open by value:substanceAdministration
.... entry:medActivity 1..*Element

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1MedicationsSectionEntriesOptionalBase for all types and resources
... nullFlavor 0..1codeBinding: NullFlavor (required)
Required Pattern: NI
... classCode 1..1codeBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.1
..... extension 1..1stringRequired Pattern: 2014-06-09
.... templateId:secondary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.1.1
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CEBinding: DocumentSectionType (extensible)
.... code 1..1stringRequired Pattern: 10160-0
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ED
... text S1..1xhtml
... Slices for entry C1..*ElementIf section/@nullFlavor is not present:
Slice: Unordered, Open by value:substanceAdministration
.... entry:medActivity C1..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... substanceAdministration C1..1MedicationActivityBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredPattern: NI
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.codeextensibleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
1098-30800warningSection.entry:medActivity.substanceAdministrationMedication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
only-one-statementerrorSection.entry, Section.entry:medActivitySHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1MedicationsSectionEntriesOptionalBase for all types and resources
... ID 0..1string
... nullFlavor 0..1codeBinding: NullFlavor (required)
Required Pattern: NI
... classCode 1..1codeBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.1
..... extension 1..1stringRequired Pattern: 2014-06-09
.... templateId:secondary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.1.1
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 10160-0
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ED
... text S1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... author 0..*Author
... informant 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... Slices for entry C1..*ElementIf section/@nullFlavor is not present:
Slice: Unordered, Open by value:substanceAdministration
.... entry:medActivity C1..*Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... substanceAdministration C1..1MedicationActivityBase for all types and resources
... component 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeFixed Value: COMP
.... contextConductionInd 1..1boolean
.... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredPattern: NI
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.templateId:primary.nullFlavorrequiredNullFlavor
Section.templateId:secondary.nullFlavorrequiredNullFlavor
Section.codeextensibleDocumentSectionType
Section.code.nullFlavorrequiredNullFlavor
Section.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Section.subject.typeCoderequiredFixed Value: SBJ
Section.subject.contextControlCoderequiredFixed Value: OP
Section.subject.awarenessCodeextensibleTargetAwareness
Section.informant.typeCoderequiredFixed Value: INF
Section.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePath(s)DetailsRequirements
1098-30800warningSection.entry:medActivity.substanceAdministrationMedication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
only-one-statementerrorSection.entry, Section.entry:medActivitySHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1

This structure is derived from MedicationsSectionEntriesOptional

Summary

Mandatory: 10 elements

Slices

This structure defines the following Slices:

  • The element Section.templateId is sliced based on the values of value:root, value:extension
  • The element Section.entry is sliced based on the value of value:substanceAdministration

Differential View

This structure is derived from MedicationsSectionEntriesOptional

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1MedicationsSectionEntriesOptionalBase for all types and resources
... nullFlavor 0..1codeRequired Pattern: NI
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:secondary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.1.1
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CE
.... code 1..1stringRequired Pattern: 10160-0
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... Slices for entry 1..*ElementIf section/@nullFlavor is not present:
Slice: Unordered, Open by value:substanceAdministration
.... entry:medActivity 1..*Element

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1MedicationsSectionEntriesOptionalBase for all types and resources
... nullFlavor 0..1codeBinding: NullFlavor (required)
Required Pattern: NI
... classCode 1..1codeBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.1
..... extension 1..1stringRequired Pattern: 2014-06-09
.... templateId:secondary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.1.1
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CEBinding: DocumentSectionType (extensible)
.... code 1..1stringRequired Pattern: 10160-0
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ED
... text S1..1xhtml
... Slices for entry C1..*ElementIf section/@nullFlavor is not present:
Slice: Unordered, Open by value:substanceAdministration
.... entry:medActivity C1..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... substanceAdministration C1..1MedicationActivityBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredPattern: NI
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.codeextensibleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
1098-30800warningSection.entry:medActivity.substanceAdministrationMedication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
only-one-statementerrorSection.entry, Section.entry:medActivitySHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1MedicationsSectionEntriesOptionalBase for all types and resources
... ID 0..1string
... nullFlavor 0..1codeBinding: NullFlavor (required)
Required Pattern: NI
... classCode 1..1codeBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.1
..... extension 1..1stringRequired Pattern: 2014-06-09
.... templateId:secondary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.1.1
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 10160-0
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ED
... text S1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... author 0..*Author
... informant 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... Slices for entry C1..*ElementIf section/@nullFlavor is not present:
Slice: Unordered, Open by value:substanceAdministration
.... entry:medActivity C1..*Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... substanceAdministration C1..1MedicationActivityBase for all types and resources
... component 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeFixed Value: COMP
.... contextConductionInd 1..1boolean
.... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredPattern: NI
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.templateId:primary.nullFlavorrequiredNullFlavor
Section.templateId:secondary.nullFlavorrequiredNullFlavor
Section.codeextensibleDocumentSectionType
Section.code.nullFlavorrequiredNullFlavor
Section.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Section.subject.typeCoderequiredFixed Value: SBJ
Section.subject.contextControlCoderequiredFixed Value: OP
Section.subject.awarenessCodeextensibleTargetAwareness
Section.informant.typeCoderequiredFixed Value: INF
Section.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePath(s)DetailsRequirements
1098-30800warningSection.entry:medActivity.substanceAdministrationMedication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
only-one-statementerrorSection.entry, Section.entry:medActivitySHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1

This structure is derived from MedicationsSectionEntriesOptional

Summary

Mandatory: 10 elements

Slices

This structure defines the following Slices:

  • The element Section.templateId is sliced based on the values of value:root, value:extension
  • The element Section.entry is sliced based on the value of value:substanceAdministration

 

​Other representations of profile: CSV, Excel, Schematron