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: Medications Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/MedicationsSection Version: 3.0.0-ballot
Draft as of 2023-12-21 Computable Name: MedicationsSection
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 Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-med-activity: SHALL contain at least one Medication Activity
... @nullFlavor 0..1csIf a required section contains no information, the @nullFlavor MAY be set to NI
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.1.1
..... @extension 1..1stRequired Pattern: 2014-06-09
... code 1..1CEHistory of medication use
.... @code 1..1csRequired Pattern: 10160-0
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... Slices for entry 0..*EntryIf section/@nullFlavor is not present:
Slice: Unordered, Open by profile:substanceAdministration
.... entry:medActivity 0..*Entry
..... substanceAdministration 1..1MedicationActivityBase for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
shall-med-activityerrorSectionSHALL contain at least one Medication Activity
: nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/MedicationActivity'))
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-med-activity: SHALL contain at least one Medication Activity
... @nullFlavor 0..1csIf a required section contains no information, the @nullFlavor MAY be set to NI
Binding: CDANullFlavor (required)
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.1.1
..... @extension 1..1stRequired Pattern: 2014-06-09
... code 1..1CEHistory of medication use
Binding: DocumentSectionType (example)
.... @code 1..1csRequired Pattern: 10160-0
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... Slices for entry 0..*EntryIf section/@nullFlavor is not present:
Slice: Unordered, Open by profile:substanceAdministration
.... entry:medActivity 0..*Entry
..... substanceAdministration C1..1MedicationActivityBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.nullFlavorrequiredCDANullFlavor
Section.codeexampleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
1098-7513warningSection.entry:medActivity.substanceAdministrationSHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499).
: effectiveTime.ofType(CDA.PIVL_TS).exists() or effectiveTime.ofType(CDA.EIVL_TS).exists()
dose-unit-or-admin-uniterrorSection.entry:medActivity.substanceAdministrationIf doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
: doseQuantity.unit.exists() implies administrationUnitCode.empty()
shall-med-activityerrorSectionSHALL contain at least one Medication Activity
: nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/MedicationActivity'))
should-authorwarningSection.entry:medActivity.substanceAdministrationSHOULD contain author
: author.exists()
should-routeCodewarningSection.entry:medActivity.substanceAdministrationSHOULD contain routeCode
: routeCode.exists()
should-text-ref-valuewarningSection.entry:medActivity.substanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-med-activity: SHALL contain at least one Medication Activity
... @nullFlavor 0..1csIf a required section contains no information, the @nullFlavor MAY be set to NI
Binding: 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:section 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.1.1
..... @extension 1..1stRequired Pattern: 2014-06-09
... @ID 0..1xs:ID
... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... id 0..1II
... code 1..1CEHistory of medication use
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: 10160-0
.... @codeSystem 1..1oid, uuid, ruidRequired 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
.... translation 0..*CD
... title 1..1ST
... text 1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: AllLanguages (required)
... subject 0..1Subject
... author 0..*Author
... informant 0..*Informant
... Slices for entry 0..*EntryIf section/@nullFlavor is not present:
Slice: Unordered, Open by profile:substanceAdministration
.... entry:medActivity 0..*Entry
..... @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: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1blFixed Value: true
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration C1..1MedicationActivityBase for all types and resources
..... supply 0..1Supply
... component 0..*InfrastructureRoot
.... @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..1csFixed Value: COMP
.... @contextConductionInd 0..1blFixed Value: true
.... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredCDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.codeexampleDocumentSectionType
Section.code.nullFlavorrequiredCDANullFlavor
Section.languageCoderequiredAllLanguages
Section.entry:medActivity.nullFlavorrequiredCDANullFlavor
Section.entry:medActivity.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:medActivity.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
1098-7513warningSection.entry:medActivity.substanceAdministrationSHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499).
: effectiveTime.ofType(CDA.PIVL_TS).exists() or effectiveTime.ofType(CDA.EIVL_TS).exists()
dose-unit-or-admin-uniterrorSection.entry:medActivity.substanceAdministrationIf doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
: doseQuantity.unit.exists() implies administrationUnitCode.empty()
shall-med-activityerrorSectionSHALL contain at least one Medication Activity
: nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/MedicationActivity'))
should-authorwarningSection.entry:medActivity.substanceAdministrationSHOULD contain author
: author.exists()
should-routeCodewarningSection.entry:medActivity.substanceAdministrationSHOULD contain routeCode
: routeCode.exists()
should-text-ref-valuewarningSection.entry:medActivity.substanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()

This structure is derived from Section

Summary

Mandatory: 9 elements (1 nested mandatory element)

Structures

This structure refers to these other structures:

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 profile:substanceAdministration

Differential View

This structure is derived from Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-med-activity: SHALL contain at least one Medication Activity
... @nullFlavor 0..1csIf a required section contains no information, the @nullFlavor MAY be set to NI
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.1.1
..... @extension 1..1stRequired Pattern: 2014-06-09
... code 1..1CEHistory of medication use
.... @code 1..1csRequired Pattern: 10160-0
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... Slices for entry 0..*EntryIf section/@nullFlavor is not present:
Slice: Unordered, Open by profile:substanceAdministration
.... entry:medActivity 0..*Entry
..... substanceAdministration 1..1MedicationActivityBase for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
shall-med-activityerrorSectionSHALL contain at least one Medication Activity
: nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/MedicationActivity'))

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-med-activity: SHALL contain at least one Medication Activity
... @nullFlavor 0..1csIf a required section contains no information, the @nullFlavor MAY be set to NI
Binding: CDANullFlavor (required)
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.1.1
..... @extension 1..1stRequired Pattern: 2014-06-09
... code 1..1CEHistory of medication use
Binding: DocumentSectionType (example)
.... @code 1..1csRequired Pattern: 10160-0
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... Slices for entry 0..*EntryIf section/@nullFlavor is not present:
Slice: Unordered, Open by profile:substanceAdministration
.... entry:medActivity 0..*Entry
..... substanceAdministration C1..1MedicationActivityBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.nullFlavorrequiredCDANullFlavor
Section.codeexampleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
1098-7513warningSection.entry:medActivity.substanceAdministrationSHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499).
: effectiveTime.ofType(CDA.PIVL_TS).exists() or effectiveTime.ofType(CDA.EIVL_TS).exists()
dose-unit-or-admin-uniterrorSection.entry:medActivity.substanceAdministrationIf doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
: doseQuantity.unit.exists() implies administrationUnitCode.empty()
shall-med-activityerrorSectionSHALL contain at least one Medication Activity
: nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/MedicationActivity'))
should-authorwarningSection.entry:medActivity.substanceAdministrationSHOULD contain author
: author.exists()
should-routeCodewarningSection.entry:medActivity.substanceAdministrationSHOULD contain routeCode
: routeCode.exists()
should-text-ref-valuewarningSection.entry:medActivity.substanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-med-activity: SHALL contain at least one Medication Activity
... @nullFlavor 0..1csIf a required section contains no information, the @nullFlavor MAY be set to NI
Binding: 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:section 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.1.1
..... @extension 1..1stRequired Pattern: 2014-06-09
... @ID 0..1xs:ID
... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... id 0..1II
... code 1..1CEHistory of medication use
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: 10160-0
.... @codeSystem 1..1oid, uuid, ruidRequired 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
.... translation 0..*CD
... title 1..1ST
... text 1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: AllLanguages (required)
... subject 0..1Subject
... author 0..*Author
... informant 0..*Informant
... Slices for entry 0..*EntryIf section/@nullFlavor is not present:
Slice: Unordered, Open by profile:substanceAdministration
.... entry:medActivity 0..*Entry
..... @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: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1blFixed Value: true
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration C1..1MedicationActivityBase for all types and resources
..... supply 0..1Supply
... component 0..*InfrastructureRoot
.... @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..1csFixed Value: COMP
.... @contextConductionInd 0..1blFixed Value: true
.... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredCDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.codeexampleDocumentSectionType
Section.code.nullFlavorrequiredCDANullFlavor
Section.languageCoderequiredAllLanguages
Section.entry:medActivity.nullFlavorrequiredCDANullFlavor
Section.entry:medActivity.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:medActivity.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
1098-7513warningSection.entry:medActivity.substanceAdministrationSHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7513) such that it **SHALL** contain exactly one [1..1] @xsi:type="PIVL_TS" or "EIVL_TS" (CONF:1098-28499).
: effectiveTime.ofType(CDA.PIVL_TS).exists() or effectiveTime.ofType(CDA.EIVL_TS).exists()
dose-unit-or-admin-uniterrorSection.entry:medActivity.substanceAdministrationIf doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
: doseQuantity.unit.exists() implies administrationUnitCode.empty()
shall-med-activityerrorSectionSHALL contain at least one Medication Activity
: nullFlavor.exists() or entry.where(substanceAdministration.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/MedicationActivity'))
should-authorwarningSection.entry:medActivity.substanceAdministrationSHOULD contain author
: author.exists()
should-routeCodewarningSection.entry:medActivity.substanceAdministrationSHOULD contain routeCode
: routeCode.exists()
should-text-ref-valuewarningSection.entry:medActivity.substanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()

This structure is derived from Section

Summary

Mandatory: 9 elements (1 nested mandatory element)

Structures

This structure refers to these other structures:

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 profile:substanceAdministration

 

Other representations of profile: CSV, Excel