Consolidated CDA
3.0.0-ballot - ballot United States of America flag

This page is part of the CCDA: Consolidated CDA Release (v3.0.0-ballot: CCDA 3.0 Ballot 1) based on FHIR (HL7® FHIR® Standard) v5.0.0. . For a full list of available versions, see the Directory of published versions

Logical Model: Medication Free Text Sig

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/MedicationFreeTextSig Version: 3.0.0-ballot
Draft as of 2023-12-21 Computable Name: MedicationFreeTextSig
Other Identifiers: id: urn:oid:2.16.840.1.113883.10.20.22.4.147

The 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.

Usage:

Formal Views of Profile Content

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

This structure is derived from SubstanceAdministration

NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration C1..1SubstanceAdministrationXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, repeatNumber, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode, consumable, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcInFulfillmentOf1
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
sig-closed: This is a closed template and shall not contain any elements besides code, text, and consumable
... Slices for templateId 1..*IISlice: Unordered, Open by value:root
.... templateId:med-freeTextSig 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.147
..... @extension 0..0
... @classCode 1..1cs
... @moodCode 1..1csmoodCode must match the parent substanceAdministration EVN or INT
Binding: MoodCodeEvnInt (required)
.... @code 1..1csRequired Pattern: 76662-6
.... @codeSystem 1..1oid, uuid, ruidLOINC
Required Pattern: 2.16.840.1.113883.6.1
... text 1..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... reference C1..1TELReference into the section/text to a tag that only contains free text sig.
value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
..... @value 0..1url
... consumable 1..1InfrastructureRoot
.... manufacturedProduct 1..1ManufacturedProduct
..... manufacturedLabeledDrug 1..1LabeledDrug
...... @nullFlavor 1..1csFixed Value: NA

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
SubstanceAdministration.moodCoderequiredMoodCodeEvnInt

Constraints

IdGradePath(s)DetailsRequirements
should-text-ref-valuewarningSubstanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()
sig-closederrorSubstanceAdministrationThis is a closed template and shall not contain any elements besides code, text, and consumable
: (typeId | statusCode | effectiveTime | priorityCode | repeatNumber | routeCode | approachSiteCode | doseQuantity | rateQuantity | maxDoseQuantity | administrationUnitCode | subject | specimen | performer | informant | participant | entryRelationship | precondition).empty()
value-starts-octothorpeerrorSubstanceAdministration.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')
NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration C1..1SubstanceAdministrationXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, repeatNumber, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode, consumable, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcInFulfillmentOf1
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
sig-closed: This is a closed template and shall not contain any elements besides code, text, and consumable
... Slices for templateId 1..*IISlice: Unordered, Open by value:root
.... templateId:med-freeTextSig 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.147
... @classCode 1..1csBinding: ActClass (2.0.0) (required)
Fixed Value: SBADM
... @moodCode 1..1csmoodCode must match the parent substanceAdministration EVN or INT
Binding: MoodCodeEvnInt (required)
.... @code 1..1csRequired Pattern: 76662-6
.... @codeSystem 1..1oid, uuid, ruidLOINC
Required Pattern: 2.16.840.1.113883.6.1
... text 1..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... reference C1..1TELReference into the section/text to a tag that only contains free text sig.
value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
..... @value 0..1url
... consumable 1..1InfrastructureRoot
.... manufacturedProduct 1..1ManufacturedProduct
..... manufacturedLabeledDrug 1..1LabeledDrug
...... @nullFlavor 1..1csBinding: CDANullFlavor (required)
Fixed Value: NA

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
SubstanceAdministration.classCoderequiredFixed Value: SBADM
SubstanceAdministration.moodCoderequiredMoodCodeEvnInt
SubstanceAdministration.codeexampleActSubstanceAdministrationCode
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.nullFlavorrequiredFixed Value: NA

Constraints

IdGradePath(s)DetailsRequirements
should-text-ref-valuewarningSubstanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()
sig-closederrorSubstanceAdministrationThis is a closed template and shall not contain any elements besides code, text, and consumable
: (typeId | statusCode | effectiveTime | priorityCode | repeatNumber | routeCode | approachSiteCode | doseQuantity | rateQuantity | maxDoseQuantity | administrationUnitCode | subject | specimen | performer | informant | participant | entryRelationship | precondition).empty()
value-starts-octothorpeerrorSubstanceAdministration.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')
NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration C1..1SubstanceAdministrationXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, repeatNumber, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode, consumable, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcInFulfillmentOf1
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
sig-closed: This is a closed template and shall not contain any elements besides code, text, and consumable
... @nullFlavor 0..1csBinding: CDANullFlavor (required)
... realmCode 0..*CS
... typeId 0..1II
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1st
.... @displayable 0..1bl
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1st
... Slices for templateId 1..*IISlice: Unordered, Open by value:root
.... templateId:med-freeTextSig 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.147
... @classCode 1..1csBinding: ActClass (2.0.0) (required)
Fixed Value: SBADM
... @moodCode 1..1csmoodCode must match the parent substanceAdministration EVN or INT
Binding: MoodCodeEvnInt (required)
... id 0..*II
... code 1..1CDInstructions Medication Narrative
Binding: ActSubstanceAdministrationCode (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: 76662-6
.... @codeSystem 1..1oid, uuid, ruidLOINC
Required Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... qualifier 0..*CR
.... translation 0..*CD
... @negationInd 0..1bl
... text 1..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @compression 0..1csBinding: CompressionAlgorithm (required)
.... @integrityCheck 0..1bin
.... @integrityCheckAlgorithm 0..1csBinding: IntegrityCheckAlgorithm (2.0.0) (required)
.... @language 0..1cs
.... @mediaType 0..1csBinding: MediaType (example)
.... @representation 0..1csBinding: Binary Data Encoding Value Set (required)
.... xmlText 0..1stAllows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
.... reference C1..1TELReference into the section/text to a tag that only contains free text sig.
value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @value 0..1url
..... useablePeriod 0..*
...... useablePeriodIVL_TS
...... useablePeriodEIVL_TS
...... useablePeriodPIVL_TS
...... useablePeriodSXPR_TS
..... @use 0..*csBinding: TelecommunicationAddressUse (2.0.0) (required)
.... thumbnail 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..*
.... effectiveTimeSXCM_TS
.... effectiveTimeIVL_TS
.... effectiveTimeEIVL_TS
.... effectiveTimePIVL_TS
.... effectiveTimeSXPR_TS
... priorityCode 0..1CEBinding: ActPriority (example)
... repeatNumber 0..1IVL_INT
... routeCode 0..1CEBinding: RouteOfAdministration (example)
... approachSiteCode 0..*CDBinding: v3 Value Set ActSite (example)
... doseQuantity 0..1IVL_PQ
... rateQuantity 0..1IVL_PQ
... maxDoseQuantity 0..1RTO_PQ_PQ
... administrationUnitCode 0..1CEBinding: AdministrableDrugForm (example)
... consumable 1..1InfrastructureRoot
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: CSM
.... manufacturedProduct 1..1ManufacturedProduct
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassManufacturedProduct (required)
Fixed Value: MANU
..... id 0..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... manufacturedLabeledDrug 1..1LabeledDrug
...... @nullFlavor 1..1csBinding: CDANullFlavor (required)
Fixed Value: NA
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassManufacturedMaterial (required)
Fixed Value: MMAT
...... @determinerCode 0..1csBinding: EntityDeterminerDetermined (required)
Fixed Value: KIND
...... code 0..1CEBinding: Drug Entity (example)
...... name 0..1EN
..... manufacturedMaterial 0..1Material
..... manufacturerOrganization 0..1Organization
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Informant
... participant 0..*Participant2
... entryRelationship 0..*EntryRelationship
... reference 0..*Reference
... precondition 0..*Precondition
... sdtcInFulfillmentOf1 0..*InFulfillmentOf1XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
SubstanceAdministration.nullFlavorrequiredCDANullFlavor
SubstanceAdministration.typeId.nullFlavorrequiredCDANullFlavor
SubstanceAdministration.templateId:med-freeTextSig.nullFlavorrequiredCDANullFlavor
SubstanceAdministration.classCoderequiredFixed Value: SBADM
SubstanceAdministration.moodCoderequiredMoodCodeEvnInt
SubstanceAdministration.codeexampleActSubstanceAdministrationCode
SubstanceAdministration.code.nullFlavorrequiredCDANullFlavor
SubstanceAdministration.text.nullFlavorrequiredCDANullFlavor
SubstanceAdministration.text.compressionrequiredCDACompressionAlgorithm
SubstanceAdministration.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
SubstanceAdministration.text.mediaTypeexampleMediaType
SubstanceAdministration.text.representationrequiredBinaryDataEncoding
SubstanceAdministration.text.reference.nullFlavorrequiredCDANullFlavor
SubstanceAdministration.text.reference.userequiredTelecommunicationAddressUse
SubstanceAdministration.statusCoderequiredActStatus
SubstanceAdministration.priorityCodeexampleActPriority
SubstanceAdministration.routeCodeexampleRouteOfAdministration
SubstanceAdministration.approachSiteCodeexampleActSite
SubstanceAdministration.administrationUnitCodeexampleAdministrableDrugForm
SubstanceAdministration.consumable.nullFlavorrequiredCDANullFlavor
SubstanceAdministration.consumable.typeId.nullFlavorrequiredCDANullFlavor
SubstanceAdministration.consumable.typeCoderequiredFixed Value: CSM
SubstanceAdministration.consumable.manufacturedProduct.nullFlavorrequiredCDANullFlavor
SubstanceAdministration.consumable.manufacturedProduct.typeId.nullFlavorrequiredCDANullFlavor
SubstanceAdministration.consumable.manufacturedProduct.classCoderequiredFixed Value: MANU
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.nullFlavorrequiredFixed Value: NA
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.typeId.nullFlavorrequiredCDANullFlavor
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.classCoderequiredFixed Value: MMAT
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.determinerCoderequiredFixed Value: KIND
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.codeexampleDrugEntity

Constraints

IdGradePath(s)DetailsRequirements
should-text-ref-valuewarningSubstanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()
sig-closederrorSubstanceAdministrationThis is a closed template and shall not contain any elements besides code, text, and consumable
: (typeId | statusCode | effectiveTime | priorityCode | repeatNumber | routeCode | approachSiteCode | doseQuantity | rateQuantity | maxDoseQuantity | administrationUnitCode | subject | specimen | performer | informant | participant | entryRelationship | precondition).empty()
value-starts-octothorpeerrorSubstanceAdministration.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

This structure is derived from SubstanceAdministration

Summary

Mandatory: 10 elements
Fixed Value: 1 element
Prohibited: 1 element

Slices

This structure defines the following Slices:

  • The element SubstanceAdministration.templateId is sliced based on the value of value:root

Differential View

This structure is derived from SubstanceAdministration

NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration C1..1SubstanceAdministrationXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, repeatNumber, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode, consumable, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcInFulfillmentOf1
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
sig-closed: This is a closed template and shall not contain any elements besides code, text, and consumable
... Slices for templateId 1..*IISlice: Unordered, Open by value:root
.... templateId:med-freeTextSig 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.147
..... @extension 0..0
... @classCode 1..1cs
... @moodCode 1..1csmoodCode must match the parent substanceAdministration EVN or INT
Binding: MoodCodeEvnInt (required)
.... @code 1..1csRequired Pattern: 76662-6
.... @codeSystem 1..1oid, uuid, ruidLOINC
Required Pattern: 2.16.840.1.113883.6.1
... text 1..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... reference C1..1TELReference into the section/text to a tag that only contains free text sig.
value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
..... @value 0..1url
... consumable 1..1InfrastructureRoot
.... manufacturedProduct 1..1ManufacturedProduct
..... manufacturedLabeledDrug 1..1LabeledDrug
...... @nullFlavor 1..1csFixed Value: NA

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
SubstanceAdministration.moodCoderequiredMoodCodeEvnInt

Constraints

IdGradePath(s)DetailsRequirements
should-text-ref-valuewarningSubstanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()
sig-closederrorSubstanceAdministrationThis is a closed template and shall not contain any elements besides code, text, and consumable
: (typeId | statusCode | effectiveTime | priorityCode | repeatNumber | routeCode | approachSiteCode | doseQuantity | rateQuantity | maxDoseQuantity | administrationUnitCode | subject | specimen | performer | informant | participant | entryRelationship | precondition).empty()
value-starts-octothorpeerrorSubstanceAdministration.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration C1..1SubstanceAdministrationXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, repeatNumber, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode, consumable, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcInFulfillmentOf1
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
sig-closed: This is a closed template and shall not contain any elements besides code, text, and consumable
... Slices for templateId 1..*IISlice: Unordered, Open by value:root
.... templateId:med-freeTextSig 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.147
... @classCode 1..1csBinding: ActClass (2.0.0) (required)
Fixed Value: SBADM
... @moodCode 1..1csmoodCode must match the parent substanceAdministration EVN or INT
Binding: MoodCodeEvnInt (required)
.... @code 1..1csRequired Pattern: 76662-6
.... @codeSystem 1..1oid, uuid, ruidLOINC
Required Pattern: 2.16.840.1.113883.6.1
... text 1..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... reference C1..1TELReference into the section/text to a tag that only contains free text sig.
value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
..... @value 0..1url
... consumable 1..1InfrastructureRoot
.... manufacturedProduct 1..1ManufacturedProduct
..... manufacturedLabeledDrug 1..1LabeledDrug
...... @nullFlavor 1..1csBinding: CDANullFlavor (required)
Fixed Value: NA

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
SubstanceAdministration.classCoderequiredFixed Value: SBADM
SubstanceAdministration.moodCoderequiredMoodCodeEvnInt
SubstanceAdministration.codeexampleActSubstanceAdministrationCode
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.nullFlavorrequiredFixed Value: NA

Constraints

IdGradePath(s)DetailsRequirements
should-text-ref-valuewarningSubstanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()
sig-closederrorSubstanceAdministrationThis is a closed template and shall not contain any elements besides code, text, and consumable
: (typeId | statusCode | effectiveTime | priorityCode | repeatNumber | routeCode | approachSiteCode | doseQuantity | rateQuantity | maxDoseQuantity | administrationUnitCode | subject | specimen | performer | informant | participant | entryRelationship | precondition).empty()
value-starts-octothorpeerrorSubstanceAdministration.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration C1..1SubstanceAdministrationXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, repeatNumber, routeCode, approachSiteCode, doseQuantity, rateQuantity, maxDoseQuantity, administrationUnitCode, consumable, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcInFulfillmentOf1
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
sig-closed: This is a closed template and shall not contain any elements besides code, text, and consumable
... @nullFlavor 0..1csBinding: CDANullFlavor (required)
... realmCode 0..*CS
... typeId 0..1II
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1st
.... @displayable 0..1bl
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1st
... Slices for templateId 1..*IISlice: Unordered, Open by value:root
.... templateId:med-freeTextSig 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.147
... @classCode 1..1csBinding: ActClass (2.0.0) (required)
Fixed Value: SBADM
... @moodCode 1..1csmoodCode must match the parent substanceAdministration EVN or INT
Binding: MoodCodeEvnInt (required)
... id 0..*II
... code 1..1CDInstructions Medication Narrative
Binding: ActSubstanceAdministrationCode (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: 76662-6
.... @codeSystem 1..1oid, uuid, ruidLOINC
Required Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... qualifier 0..*CR
.... translation 0..*CD
... @negationInd 0..1bl
... text 1..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @compression 0..1csBinding: CompressionAlgorithm (required)
.... @integrityCheck 0..1bin
.... @integrityCheckAlgorithm 0..1csBinding: IntegrityCheckAlgorithm (2.0.0) (required)
.... @language 0..1cs
.... @mediaType 0..1csBinding: MediaType (example)
.... @representation 0..1csBinding: Binary Data Encoding Value Set (required)
.... xmlText 0..1stAllows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
.... reference C1..1TELReference into the section/text to a tag that only contains free text sig.
value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @value 0..1url
..... useablePeriod 0..*
...... useablePeriodIVL_TS
...... useablePeriodEIVL_TS
...... useablePeriodPIVL_TS
...... useablePeriodSXPR_TS
..... @use 0..*csBinding: TelecommunicationAddressUse (2.0.0) (required)
.... thumbnail 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..*
.... effectiveTimeSXCM_TS
.... effectiveTimeIVL_TS
.... effectiveTimeEIVL_TS
.... effectiveTimePIVL_TS
.... effectiveTimeSXPR_TS
... priorityCode 0..1CEBinding: ActPriority (example)
... repeatNumber 0..1IVL_INT
... routeCode 0..1CEBinding: RouteOfAdministration (example)
... approachSiteCode 0..*CDBinding: v3 Value Set ActSite (example)
... doseQuantity 0..1IVL_PQ
... rateQuantity 0..1IVL_PQ
... maxDoseQuantity 0..1RTO_PQ_PQ
... administrationUnitCode 0..1CEBinding: AdministrableDrugForm (example)
... consumable 1..1InfrastructureRoot
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationType (required)
Fixed Value: CSM
.... manufacturedProduct 1..1ManufacturedProduct
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @classCode 0..1csBinding: RoleClassManufacturedProduct (required)
Fixed Value: MANU
..... id 0..*II
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... manufacturedLabeledDrug 1..1LabeledDrug
...... @nullFlavor 1..1csBinding: CDANullFlavor (required)
Fixed Value: NA
...... realmCode 0..*CS
...... typeId 0..1II
....... @nullFlavor 0..1csBinding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1st
....... @displayable 0..1bl
....... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1st
...... templateId 0..*II
...... @classCode 0..1csBinding: EntityClassManufacturedMaterial (required)
Fixed Value: MMAT
...... @determinerCode 0..1csBinding: EntityDeterminerDetermined (required)
Fixed Value: KIND
...... code 0..1CEBinding: Drug Entity (example)
...... name 0..1EN
..... manufacturedMaterial 0..1Material
..... manufacturerOrganization 0..1Organization
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Informant
... participant 0..*Participant2
... entryRelationship 0..*EntryRelationship
... reference 0..*Reference
... precondition 0..*Precondition
... sdtcInFulfillmentOf1 0..*InFulfillmentOf1XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
SubstanceAdministration.nullFlavorrequiredCDANullFlavor
SubstanceAdministration.typeId.nullFlavorrequiredCDANullFlavor
SubstanceAdministration.templateId:med-freeTextSig.nullFlavorrequiredCDANullFlavor
SubstanceAdministration.classCoderequiredFixed Value: SBADM
SubstanceAdministration.moodCoderequiredMoodCodeEvnInt
SubstanceAdministration.codeexampleActSubstanceAdministrationCode
SubstanceAdministration.code.nullFlavorrequiredCDANullFlavor
SubstanceAdministration.text.nullFlavorrequiredCDANullFlavor
SubstanceAdministration.text.compressionrequiredCDACompressionAlgorithm
SubstanceAdministration.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
SubstanceAdministration.text.mediaTypeexampleMediaType
SubstanceAdministration.text.representationrequiredBinaryDataEncoding
SubstanceAdministration.text.reference.nullFlavorrequiredCDANullFlavor
SubstanceAdministration.text.reference.userequiredTelecommunicationAddressUse
SubstanceAdministration.statusCoderequiredActStatus
SubstanceAdministration.priorityCodeexampleActPriority
SubstanceAdministration.routeCodeexampleRouteOfAdministration
SubstanceAdministration.approachSiteCodeexampleActSite
SubstanceAdministration.administrationUnitCodeexampleAdministrableDrugForm
SubstanceAdministration.consumable.nullFlavorrequiredCDANullFlavor
SubstanceAdministration.consumable.typeId.nullFlavorrequiredCDANullFlavor
SubstanceAdministration.consumable.typeCoderequiredFixed Value: CSM
SubstanceAdministration.consumable.manufacturedProduct.nullFlavorrequiredCDANullFlavor
SubstanceAdministration.consumable.manufacturedProduct.typeId.nullFlavorrequiredCDANullFlavor
SubstanceAdministration.consumable.manufacturedProduct.classCoderequiredFixed Value: MANU
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.nullFlavorrequiredFixed Value: NA
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.typeId.nullFlavorrequiredCDANullFlavor
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.classCoderequiredFixed Value: MMAT
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.determinerCoderequiredFixed Value: KIND
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.codeexampleDrugEntity

Constraints

IdGradePath(s)DetailsRequirements
should-text-ref-valuewarningSubstanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()
sig-closederrorSubstanceAdministrationThis is a closed template and shall not contain any elements besides code, text, and consumable
: (typeId | statusCode | effectiveTime | priorityCode | repeatNumber | routeCode | approachSiteCode | doseQuantity | rateQuantity | maxDoseQuantity | administrationUnitCode | subject | specimen | performer | informant | participant | entryRelationship | precondition).empty()
value-starts-octothorpeerrorSubstanceAdministration.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

This structure is derived from SubstanceAdministration

Summary

Mandatory: 10 elements
Fixed Value: 1 element
Prohibited: 1 element

Slices

This structure defines the following Slices:

  • The element SubstanceAdministration.templateId is sliced based on the value of value:root

 

Other representations of profile: CSV, Excel