Consolidated CDA (C-CDA)
3.0.0 - STU3 United States of America flag

This page is part of the CCDA: Consolidated CDA Release (v3.0.0: CCDA 3.0) generated with FHIR (HL7® FHIR® Standard) v5.0.0. This is the current published version. For a full list of available versions, see the Directory of published versions

Logical Model: Immunization Activity

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/ImmunizationActivity Version: 3.0.0
Draft as of 2024-05-18 Computable Name: ImmunizationActivity
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.4.52:2015-08-01

An Immunization Activity describes immunization substance administrations that have actually occurred or are intended to occur. Immunization Activities in “INT” mood are reflections of immunizations a clinician intends a patient to receive. Immunization Activities in “EVN” mood reflect immunizations actually received.

An Immunization Activity is very similar to a Medication Activity with some key differentiators. The drug code system is constrained to CVX codes. Administration timing is less complex. Patient refusal reasons should be captured. All vaccines administered should be fully documented in the patient’s permanent medical record. Healthcare providers who administer vaccines covered by the National Childhood Vaccine Injury Act are required to ensure that the permanent medical record of the recipient indicates:

  1. Date of administration
  2. Vaccine manufacturer
  3. Vaccine lot number
  4. Name and title of the person who administered the vaccine and the address of the clinic or facility where the permanent record will reside
  5. Vaccine information statement (VIS)

a. Date printed on the VIS b. Date VIS given to patient or parent/guardian.

This information should be included in an Immunization Activity when available. (Reference: [https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/c/vis-instruct.pdf])

Usage:

Formal Views of Template Content

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

This structure is derived from SubstanceAdministration

NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration C 1..1 SubstanceAdministration XML 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
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
should-doseQuantity: SHOULD contain doseQuantity
dose-unit-or-admin-unit: If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
should-performer: SHOULD contain performer
should-author: SHOULD contain author
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:immunization-activity 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.52
..... @extension 1..1 st Required Pattern: 2015-08-01
... @classCode 1..1 cs
... @moodCode 1..1 cs Binding: MoodCodeEvnInt . (required)
... code 0..1 CD SubstanceAdministration.code is an optional field. Per HL7 Pharmacy Committee, "this is intended to further specify the nature of the substance administration act. To date the committee has made no use of this attribute". Because the type of substance administration is generally implicit in the routeCode, in the consumable participant, etc., the field is generally not used and there is no defined value set.
... @negationInd 1..1 bl Use negationInd="true" to indicate that the immunization was not given.
... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
.... reference C 0..1 TEL value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... statusCode 1..1 CS
.... @nullFlavor 0..0
.... @code 1..1 cs Binding: ActStatus . (required)
... effectiveTime 1..1 SXCM_TS, IVL_TS, EIVL_TS, PIVL_TS, SXPR_TS
... repeatNumber C 0..1 IVL_INT 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.
value-only: Interval fields SHALL not be present
.... @value 0..1 int value should be used instead of low/high
... routeCode C 0..1 CE Binding: SPL Drug Route of Administration Terminology . (required)
should-translation: SHOULD contain translation
.... translation 0..* CD Binding: Medication Route . (preferred)
... approachSiteCode 0..1 CD Binding: Body Site Value Set . (required)
... doseQuantity C 0..1 IVL_PQ should-unit: SHOULD contain @unit
.... @unit 0..1 cs NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units
Binding: UnitsOfMeasureCaseSensitive . (preferred)
... administrationUnitCode 0..1 CE Binding: AdministrationUnitDoseForm . (required)
... consumable 1..1 InfrastructureRoot
.... manufacturedProduct 1..1 ImmunizationMedicationInformation Base for all types and resources
... performer 0..1 Performer2
... author 0..* AuthorParticipation Base for all types and resources
... Slices for participant 0..* Participant2 Slice: Unordered, Open by value:typeCode
.... participant:drugVehicle 0..* Participant2
..... @typeCode 1..1 cs Fixed Value: CSM
..... participantRole 1..1 DrugVehicle Base for all types and resources
... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation, profile:supply
.... entryRelationship:indication 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: RSON
..... observation 1..1 Indication Base for all types and resources
...... code 1..1 CD Indication for Immunization
....... @code 1..1 cs Required Pattern: 59785-6
....... @codeSystem 1..1 oid, uuid, ruid LOINC
Required Pattern: 2.16.840.1.113883.6.1
.... entryRelationship:instruction 0..1 EntryRelationship
..... @typeCode 1..1 cs Fixed Value: SUBJ
..... @inversionInd 1..1 bl Fixed Value: true
..... act 1..1 Instruction Base for all types and resources
.... entryRelationship:medSupplyOrder 0..1 EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... supply 1..1 MedicationSupplyOrder Base for all types and resources
.... entryRelationship:medDispense 0..1 EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... supply 1..1 MedicationDispense Base for all types and resources
.... entryRelationship:reactionObs 0..1 EntryRelationship
..... @typeCode 1..1 cs Fixed Value: CAUS
..... observation 1..1 ReactionObservation Base for all types and resources
.... entryRelationship:immunizationNotGiven 0..1 EntryRelationship
..... @typeCode 1..1 cs Fixed Value: RSON
..... observation 1..1 ImmunizationNotGivenReason Base for all types and resources
.... entryRelationship:substanceAdmin 0..* EntryRelationship The following entryRelationship is used to indicate a given immunization'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.
..... @typeCode 1..1 cs Fixed Value: COMP
..... @inversionInd 1..1 bl Fixed Value: true
..... sequenceNumber 0..1 INT
..... act 1..1 SubstanceAdministeredAct Base for all types and resources
... Slices for precondition 0..* Precondition Slice: Unordered, Open by profile:criterion
.... precondition:substanceAdmin 0..* Precondition
..... @typeCode 1..1 cs
..... criterion 1..1 PreconditionforSubstanceAdministration Base for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
SubstanceAdministration.moodCoderequiredMoodCodeEvnInt .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.18
SubstanceAdministration.statusCode.coderequiredActStatus .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.15933
SubstanceAdministration.routeCoderequiredSPLDrugRouteOfAdministrationTerminology .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.7
SubstanceAdministration.routeCode.translationpreferredMedicationRoute .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.12
SubstanceAdministration.approachSiteCoderequiredBodySiteValueSet .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9
SubstanceAdministration.doseQuantity.unitpreferredUnitsOfMeasureCaseSensitive . (a valid code from UCUM)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12839
SubstanceAdministration.administrationUnitCoderequiredAdministrationUnitDoseForm .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.30

Constraints

IdGradePath(s)DetailsRequirements
dose-unit-or-admin-uniterrorSubstanceAdministrationIf doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
: doseQuantity.unit.exists() implies administrationUnitCode.empty()
should-authorwarningSubstanceAdministrationSHOULD contain author
: author.exists()
should-doseQuantitywarningSubstanceAdministrationSHOULD contain doseQuantity
: doseQuantity.exists()
should-performerwarningSubstanceAdministrationSHOULD contain performer
: performer.exists()
should-text-ref-valuewarningSubstanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()
should-translationwarningSubstanceAdministration.routeCodeSHOULD contain translation
: translation.exists()
should-unitwarningSubstanceAdministration.doseQuantitySHOULD contain @unit
: nullFlavor.exists() or unit.exists()
value-onlyerrorSubstanceAdministration.repeatNumberInterval fields SHALL not be present
: (low | high | width | center).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 C 1..1 SubstanceAdministration XML 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
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
should-doseQuantity: SHOULD contain doseQuantity
dose-unit-or-admin-unit: If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
should-performer: SHOULD contain performer
should-author: SHOULD contain author
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:immunization-activity 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.52
..... @extension 1..1 st Required Pattern: 2015-08-01
... @classCode 1..1 cs Binding: CDAActClass (required)
Fixed Value: SBADM
... @moodCode 1..1 cs Binding: MoodCodeEvnInt . (required)
... code 0..1 CD SubstanceAdministration.code is an optional field. Per HL7 Pharmacy Committee, "this is intended to further specify the nature of the substance administration act. To date the committee has made no use of this attribute". Because the type of substance administration is generally implicit in the routeCode, in the consumable participant, etc., the field is generally not used and there is no defined value set.
Binding: CDAActSubstanceAdministrationCode (example)
... @negationInd 1..1 bl Use negationInd="true" to indicate that the immunization was not given.
... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
.... reference C 0..1 TEL value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... statusCode 1..1 CS Binding: ActStatus (required)
.... @code 1..1 cs Binding: ActStatus . (required)
... effectiveTime 1..1
.... effectiveTime SXCM_TS
.... effectiveTime IVL_TS
.... effectiveTime EIVL_TS
.... effectiveTime PIVL_TS
.... effectiveTime SXPR_TS
... repeatNumber C 0..1 IVL_INT 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.
value-only: Interval fields SHALL not be present
.... @value 0..1 int value should be used instead of low/high
... routeCode C 0..1 CE Binding: SPL Drug Route of Administration Terminology . (required)
should-translation: SHOULD contain translation
.... translation 0..* CD Binding: Medication Route . (preferred)
... approachSiteCode 0..1 CD Binding: Body Site Value Set . (required)
... doseQuantity C 0..1 IVL_PQ should-unit: SHOULD contain @unit
.... @unit 0..1 cs NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units
Binding: UnitsOfMeasureCaseSensitive . (preferred)
... administrationUnitCode 0..1 CE Binding: AdministrationUnitDoseForm . (required)
... consumable 1..1 InfrastructureRoot
.... manufacturedProduct C 1..1 ImmunizationMedicationInformation Base for all types and resources
product-choice: manufacturedLabeledDrug and manufacturedMaterial are mutually exclusive (one must be present)
should-manufacturerOrganization: SHOULD contain manufacturerOrganization
... performer 0..1 Performer2
... author 0..* AuthorParticipation Base for all types and resources
... Slices for participant 0..* Participant2 Slice: Unordered, Open by value:typeCode
.... participant:drugVehicle 0..* Participant2
..... @typeCode 1..1 cs Binding: CDAParticipationType (required)
Fixed Value: CSM
..... participantRole C 1..1 DrugVehicle Base for all types and resources
role-choice: playingDevice and playingEntity are mutually exclusive
... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation, profile:supply
.... entryRelationship:indication 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... observation C 1..1 Indication Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
indication-value: If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
...... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
....... templateId:indication 1..1 II
........ @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.19
........ @extension 1..1 st Required Pattern: 2023-05-01
...... @classCode 1..1 cs Binding: CDAActClassObservation (required)
Fixed Value: OBS
...... @moodCode 1..1 cs Binding: XActMoodDocumentObservation (2.0.0) (required)
Fixed Value: EVN
...... id 1..* II If the id element is used to reference a problem recorded elsewhere in the document then this id must equal another entry/id in the same document instance. Application Software must be responsible for resolving the identifier back to its original object and then rendering the information in the correct place in the containing section's narrative text. Its purpose is to obviate the need to repeat the complete XML representation of the referred to entry when relating one entry to another.
...... code 1..1 CD Indication for Immunization
Binding: Problem Type (preferred)
....... @code 1..1 cs Required Pattern: 59785-6
....... @codeSystem 1..1 oid, uuid, ruid LOINC
Required Pattern: 2.16.840.1.113883.6.1
...... statusCode 1..1 CS Binding: ActStatus (required)
....... @code 1..1 cs Fixed Value: completed
...... value 0..1 CD If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
Binding: US Core Condition Codes (preferred)
.... entryRelationship:instruction 0..1 EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
..... @inversionInd 1..1 bl Fixed Value: true
..... act C 1..1 Instruction Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:medSupplyOrder 0..1 EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... supply C 1..1 MedicationSupplyOrder Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-repeatNumber: SHOULD contain repeatNumber
should-quantity: SHOULD contain quantity
.... entryRelationship:medDispense 0..1 EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... supply C 1..1 MedicationDispense Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
should-repeatNumber: SHOULD contain repeatNumber
should-quantity: SHOULD contain quantity
.... entryRelationship:reactionObs 0..1 EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: CAUS
..... observation C 1..1 ReactionObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
.... entryRelationship:immunizationNotGiven 0..1 EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... observation C 1..1 ImmunizationNotGivenReason Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:substanceAdmin 0..* EntryRelationship The following entryRelationship is used to indicate a given immunization'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.
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... @inversionInd 1..1 bl Fixed Value: true
..... sequenceNumber 0..1 INT
..... act C 1..1 SubstanceAdministeredAct Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
... Slices for precondition 0..* Precondition Slice: Unordered, Open by profile:criterion
.... precondition:substanceAdmin 0..* Precondition
..... @typeCode 1..1 cs Binding: CDAActRelationshipType (required)
Fixed Value: PRCN
..... criterion 1..1 PreconditionforSubstanceAdministration Base for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
SubstanceAdministration.classCoderequiredFixed Value: SBADM
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
SubstanceAdministration.moodCoderequiredMoodCodeEvnInt .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.18
SubstanceAdministration.codeexampleCDAActSubstanceAdministrationCode
http://hl7.org/cda/stds/core/ValueSet/CDAActSubstanceAdministrationCode
SubstanceAdministration.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
SubstanceAdministration.statusCode.coderequiredActStatus .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.15933
SubstanceAdministration.routeCoderequiredSPLDrugRouteOfAdministrationTerminology .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.7
SubstanceAdministration.routeCode.translationpreferredMedicationRoute .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.12
SubstanceAdministration.approachSiteCoderequiredBodySiteValueSet .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9
SubstanceAdministration.doseQuantity.unitpreferredUnitsOfMeasureCaseSensitive . (a valid code from UCUM)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12839
SubstanceAdministration.administrationUnitCoderequiredAdministrationUnitDoseForm .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.30
SubstanceAdministration.participant:drugVehicle.typeCoderequiredFixed Value: CSM
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
SubstanceAdministration.entryRelationship:indication.typeCoderequiredFixed Value: RSON
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.entryRelationship:indication.observation.classCoderequiredFixed Value: OBS
http://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation
SubstanceAdministration.entryRelationship:indication.observation.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
SubstanceAdministration.entryRelationship:indication.observation.codepreferredProblemType
https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.1
SubstanceAdministration.entryRelationship:indication.observation.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
SubstanceAdministration.entryRelationship:indication.observation.valuepreferredUSCoreConditionCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
SubstanceAdministration.entryRelationship:instruction.typeCoderequiredFixed Value: SUBJ
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.entryRelationship:medSupplyOrder.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.entryRelationship:medDispense.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.entryRelationship:reactionObs.typeCoderequiredFixed Value: CAUS
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.entryRelationship:immunizationNotGiven.typeCoderequiredFixed Value: RSON
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.entryRelationship:substanceAdmin.typeCoderequiredFixed Value: COMP
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.precondition:substanceAdmin.typeCoderequiredFixed Value: PRCN
http://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType

Constraints

IdGradePath(s)DetailsRequirements
dose-unit-or-admin-uniterrorSubstanceAdministrationIf doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
: doseQuantity.unit.exists() implies administrationUnitCode.empty()
indication-valueerrorSubstanceAdministration.entryRelationship:indication.observationIf the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
: value.exists() or (%resource.descendants().ofType(CDA.Observation).where(id.exists($this.root = %context.id.first().root and $this.extension ~ %context.id.first().extension) and value.exists()))
product-choiceerrorSubstanceAdministration.consumable.manufacturedProductmanufacturedLabeledDrug and manufacturedMaterial are mutually exclusive (one must be present)
: (manufacturedLabeledDrug | manufacturedMaterial).count() = 1
role-choiceerrorSubstanceAdministration.participant:drugVehicle.participantRoleplayingDevice and playingEntity are mutually exclusive
: (playingDevice | playingEntity).count() <= 1
should-authorwarningSubstanceAdministrationSHOULD contain author
: author.exists()
should-doseQuantitywarningSubstanceAdministrationSHOULD contain doseQuantity
: doseQuantity.exists()
should-effectiveTimewarningSubstanceAdministration.entryRelationship:indication.observation, SubstanceAdministration.entryRelationship:medDispense.supply, SubstanceAdministration.entryRelationship:reactionObs.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-manufacturerOrganizationwarningSubstanceAdministration.consumable.manufacturedProductSHOULD contain manufacturerOrganization
: manufacturerOrganization.exists()
should-performerwarningSubstanceAdministrationSHOULD contain performer
: performer.exists()
should-quantitywarningSubstanceAdministration.entryRelationship:medSupplyOrder.supply, SubstanceAdministration.entryRelationship:medDispense.supplySHOULD contain quantity
: quantity.exists()
should-repeatNumberwarningSubstanceAdministration.entryRelationship:medSupplyOrder.supply, SubstanceAdministration.entryRelationship:medDispense.supplySHOULD contain repeatNumber
: repeatNumber.exists()
should-text-ref-valuewarningSubstanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningSubstanceAdministration.entryRelationship:indication.observation, SubstanceAdministration.entryRelationship:instruction.act, SubstanceAdministration.entryRelationship:medSupplyOrder.supply, SubstanceAdministration.entryRelationship:medDispense.supply, SubstanceAdministration.entryRelationship:reactionObs.observation, SubstanceAdministration.entryRelationship:immunizationNotGiven.observation, SubstanceAdministration.entryRelationship:substanceAdmin.actSHOULD contain text/reference/@value
: text.reference.value.exists()
should-translationwarningSubstanceAdministration.routeCodeSHOULD contain translation
: translation.exists()
should-unitwarningSubstanceAdministration.doseQuantitySHOULD contain @unit
: nullFlavor.exists() or unit.exists()
value-onlyerrorSubstanceAdministration.repeatNumberInterval fields SHALL not be present
: (low | high | width | center).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 C 1..1 SubstanceAdministration XML 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
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
should-doseQuantity: SHOULD contain doseQuantity
dose-unit-or-admin-unit: If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
should-performer: SHOULD contain performer
should-author: SHOULD contain author
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... typeId 0..1 II
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:immunization-activity 1..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.52
..... @extension 1..1 st Required Pattern: 2015-08-01
... @classCode 1..1 cs Binding: CDAActClass (required)
Fixed Value: SBADM
... @moodCode 1..1 cs Binding: MoodCodeEvnInt . (required)
... id 1..* II
... code 0..1 CD SubstanceAdministration.code is an optional field. Per HL7 Pharmacy Committee, "this is intended to further specify the nature of the substance administration act. To date the committee has made no use of this attribute". Because the type of substance administration is generally implicit in the routeCode, in the consumable participant, etc., the field is generally not used and there is no defined value set.
Binding: CDAActSubstanceAdministrationCode (example)
... @negationInd 1..1 bl Use negationInd="true" to indicate that the immunization was not given.
... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @compression 0..1 cs Binding: CDACompressionAlgorithm (required)
.... @integrityCheck 0..1 bin
.... @integrityCheckAlgorithm 0..1 cs Binding: IntegrityCheckAlgorithm (2.0.0) (required)
.... @language 0..1 cs
.... @mediaType 0..1 cs Binding: MediaType (example)
.... @representation 0..1 cs Binding: CDABinaryDataEncoding (required)
.... xmlText 0..1 st Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
.... reference C 0..1 TEL value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
.... thumbnail 0..1 ED
... statusCode 1..1 CS Binding: ActStatus (required)
.... @code 1..1 cs Binding: ActStatus . (required)
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 1..1
.... effectiveTime SXCM_TS
.... effectiveTime IVL_TS
.... effectiveTime EIVL_TS
.... effectiveTime PIVL_TS
.... effectiveTime SXPR_TS
... priorityCode 0..1 CE Binding: ActPriority (example)
... repeatNumber C 0..1 IVL_INT 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.
value-only: Interval fields SHALL not be present
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @value 0..1 int value should be used instead of low/high
.... @operator 0..1 cs Binding: CDASetOperator (required)
.... low 0..1 IVXB_INT
.... center 0..1 INT
.... width 0..1 INT
.... high 0..1 IVXB_INT
... routeCode C 0..1 CE Binding: SPL Drug Route of Administration Terminology . (required)
should-translation: SHOULD contain translation
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 0..1 cs
.... @codeSystem 0..1 oid, uuid, ruid
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... translation 0..* CD Binding: Medication Route . (preferred)
... approachSiteCode 0..1 CD Binding: Body Site Value Set . (required)
... doseQuantity C 0..1 IVL_PQ should-unit: SHOULD contain @unit
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @unit 0..1 cs NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units
Binding: UnitsOfMeasureCaseSensitive . (preferred)
.... @value 0..1 real
.... translation 0..* PQR
.... @operator 0..1 cs Binding: CDASetOperator (required)
.... low 0..1 IVXB_PQ
.... center 0..1 PQ
.... width 0..1 PQ
.... high 0..1 IVXB_PQ
... rateQuantity 0..1 IVL_PQ
... maxDoseQuantity 0..1 RTO_PQ_PQ
... administrationUnitCode 0..1 CE Binding: AdministrationUnitDoseForm . (required)
... consumable 1..1 InfrastructureRoot
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: CDAParticipationType (required)
Fixed Value: CSM
.... manufacturedProduct C 1..1 ImmunizationMedicationInformation Base for all types and resources
product-choice: manufacturedLabeledDrug and manufacturedMaterial are mutually exclusive (one must be present)
should-manufacturerOrganization: SHOULD contain manufacturerOrganization
... subject 0..1 Subject
... specimen 0..* Specimen
... performer 0..1 Performer2
... author 0..* AuthorParticipation Base for all types and resources
... informant 0..* Informant
... Slices for participant 0..* Participant2 Slice: Unordered, Open by value:typeCode
.... participant:drugVehicle 0..* Participant2
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: CDAParticipationType (required)
Fixed Value: CSM
..... @contextControlCode 0..1 cs Binding: CDAContextControl (required)
Fixed Value: OP
..... sdtcFunctionCode 0..1 CE XML Namespace: urn:hl7-org:sdtc
XML: functionCode (urn:hl7-org:sdtc)
..... time 0..1 IVL_TS
..... awarenessCode 0..1 CE
..... participantRole C 1..1 DrugVehicle Base for all types and resources
role-choice: playingDevice and playingEntity are mutually exclusive
... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation, profile:supply
.... entryRelationship:indication 0..* EntryRelationship
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 Indication Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
indication-value: If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
....... templateId:indication 1..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.19
........ @extension 1..1 st Required Pattern: 2023-05-01
...... @classCode 1..1 cs Binding: CDAActClassObservation (required)
Fixed Value: OBS
...... @moodCode 1..1 cs Binding: XActMoodDocumentObservation (2.0.0) (required)
Fixed Value: EVN
...... @negationInd 0..1 bl
...... id 1..* II If the id element is used to reference a problem recorded elsewhere in the document then this id must equal another entry/id in the same document instance. Application Software must be responsible for resolving the identifier back to its original object and then rendering the information in the correct place in the containing section's narrative text. Its purpose is to obviate the need to repeat the complete XML representation of the referred to entry when relating one entry to another.
...... code 1..1 CD Indication for Immunization
Binding: Problem Type (preferred)
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @code 1..1 cs Required Pattern: 59785-6
....... @codeSystem 1..1 oid, uuid, ruid LOINC
Required Pattern: 2.16.840.1.113883.6.1
....... @codeSystemName 0..1 st
....... @codeSystemVersion 0..1 st
....... @displayName 0..1 st
....... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
....... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1 ED
....... qualifier 0..* CR
....... translation 0..* CD
...... derivationExpr 0..1 ST
...... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @compression 0..1 cs Binding: CDACompressionAlgorithm (required)
....... @integrityCheck 0..1 bin
....... @integrityCheckAlgorithm 0..1 cs Binding: IntegrityCheckAlgorithm (2.0.0) (required)
....... @language 0..1 cs
....... @mediaType 0..1 cs Binding: MediaType (example)
....... @representation 0..1 cs Binding: CDABinaryDataEncoding (required)
....... xmlText 0..1 st Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
....... reference C 0..1 TEL value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
....... thumbnail 0..1 ED
...... statusCode 1..1 CS Binding: ActStatus (required)
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @code 1..1 cs Fixed Value: completed
....... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
....... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... effectiveTime 0..1 IVL_TS
...... priorityCode 0..1 CE Binding: ActPriority (example)
...... repeatNumber 0..1 IVL_INT
...... languageCode 0..1 CS Binding: AllLanguages (required)
...... value 0..1 CD If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
Binding: US Core Condition Codes (preferred)
...... interpretationCode 0..* CE Binding: CDAObservationInterpretation (required)
...... methodCode 0..* CE Binding: ObservationMethod (example)
...... targetSiteCode 0..* CD
...... subject 0..1 Subject
...... specimen 0..* Specimen
...... performer 0..* Performer2
...... author 0..* Author
...... informant 0..* Informant
...... participant 0..* Participant2
...... entryRelationship 0..* EntryRelationship
...... reference 0..* Reference
...... precondition 0..* Precondition
...... sdtcPrecondition2 0..* Precondition2 XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
...... referenceRange 0..* InfrastructureRoot
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... @typeCode 0..1 cs Binding: CDAActRelationshipType (required)
Fixed Value: REFV
....... observationRange 1..1 ObservationRange
...... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entryRelationship:instruction 0..1 EntryRelationship
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
..... @inversionInd 1..1 bl Fixed Value: true
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act C 1..1 Instruction Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... encounter 0..1 Encounter
..... observation 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entryRelationship:medSupplyOrder 0..1 EntryRelationship
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply C 1..1 MedicationSupplyOrder Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-repeatNumber: SHOULD contain repeatNumber
should-quantity: SHOULD contain quantity
.... entryRelationship:medDispense 0..1 EntryRelationship
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply C 1..1 MedicationDispense Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
should-repeatNumber: SHOULD contain repeatNumber
should-quantity: SHOULD contain quantity
.... entryRelationship:reactionObs 0..1 EntryRelationship
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: CAUS
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 ReactionObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entryRelationship:immunizationNotGiven 0..1 EntryRelationship
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 ImmunizationNotGivenReason Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entryRelationship:substanceAdmin 0..* EntryRelationship The following entryRelationship is used to indicate a given immunization'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.
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... @inversionInd 1..1 bl Fixed Value: true
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act C 1..1 SubstanceAdministeredAct Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... encounter 0..1 Encounter
..... observation 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
... reference 0..* Reference
... Slices for precondition 0..* Precondition Slice: Unordered, Open by profile:criterion
.... precondition:substanceAdmin 0..* Precondition
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: CDAActRelationshipType (required)
Fixed Value: PRCN
..... criterion 1..1 PreconditionforSubstanceAdministration Base for all types and resources
... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
SubstanceAdministration.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.templateId:immunization-activity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.classCoderequiredFixed Value: SBADM
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
SubstanceAdministration.moodCoderequiredMoodCodeEvnInt .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.18
SubstanceAdministration.codeexampleCDAActSubstanceAdministrationCode
http://hl7.org/cda/stds/core/ValueSet/CDAActSubstanceAdministrationCode
SubstanceAdministration.text.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.text.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
SubstanceAdministration.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
SubstanceAdministration.text.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
SubstanceAdministration.text.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
SubstanceAdministration.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
SubstanceAdministration.statusCode.coderequiredActStatus .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.15933
SubstanceAdministration.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
SubstanceAdministration.repeatNumber.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.repeatNumber.operatorrequiredCDASetOperator
http://hl7.org/cda/stds/core/ValueSet/CDASetOperator
SubstanceAdministration.routeCoderequiredSPLDrugRouteOfAdministrationTerminology .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.7
SubstanceAdministration.routeCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.routeCode.translationpreferredMedicationRoute .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.12
SubstanceAdministration.approachSiteCoderequiredBodySiteValueSet .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9
SubstanceAdministration.doseQuantity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.doseQuantity.unitpreferredUnitsOfMeasureCaseSensitive . (a valid code from UCUM)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12839
SubstanceAdministration.doseQuantity.operatorrequiredCDASetOperator
http://hl7.org/cda/stds/core/ValueSet/CDASetOperator
SubstanceAdministration.administrationUnitCoderequiredAdministrationUnitDoseForm .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.30
SubstanceAdministration.consumable.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.consumable.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.consumable.typeCoderequiredFixed Value: CSM
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
SubstanceAdministration.participant:drugVehicle.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.participant:drugVehicle.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.participant:drugVehicle.typeCoderequiredFixed Value: CSM
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
SubstanceAdministration.participant:drugVehicle.contextControlCoderequiredFixed Value: OP
http://hl7.org/cda/stds/core/ValueSet/CDAContextControl
SubstanceAdministration.entryRelationship:indication.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:indication.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:indication.typeCoderequiredFixed Value: RSON
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.entryRelationship:indication.observation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:indication.observation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:indication.observation.templateId:indication.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:indication.observation.classCoderequiredFixed Value: OBS
http://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation
SubstanceAdministration.entryRelationship:indication.observation.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
SubstanceAdministration.entryRelationship:indication.observation.codepreferredProblemType
https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.1
SubstanceAdministration.entryRelationship:indication.observation.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:indication.observation.text.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:indication.observation.text.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
SubstanceAdministration.entryRelationship:indication.observation.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
SubstanceAdministration.entryRelationship:indication.observation.text.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
SubstanceAdministration.entryRelationship:indication.observation.text.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
SubstanceAdministration.entryRelationship:indication.observation.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
SubstanceAdministration.entryRelationship:indication.observation.statusCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:indication.observation.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
SubstanceAdministration.entryRelationship:indication.observation.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
SubstanceAdministration.entryRelationship:indication.observation.valuepreferredUSCoreConditionCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
SubstanceAdministration.entryRelationship:indication.observation.interpretationCoderequiredCDAObservationInterpretation
http://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation
SubstanceAdministration.entryRelationship:indication.observation.methodCodeexampleObservationMethod
http://terminology.hl7.org/ValueSet/v3-ObservationMethod
SubstanceAdministration.entryRelationship:indication.observation.referenceRange.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:indication.observation.referenceRange.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:indication.observation.referenceRange.typeCoderequiredFixed Value: REFV
http://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType
SubstanceAdministration.entryRelationship:instruction.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:instruction.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:instruction.typeCoderequiredFixed Value: SUBJ
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.entryRelationship:medSupplyOrder.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:medSupplyOrder.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:medSupplyOrder.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.entryRelationship:medDispense.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:medDispense.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:medDispense.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.entryRelationship:reactionObs.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:reactionObs.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:reactionObs.typeCoderequiredFixed Value: CAUS
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.entryRelationship:immunizationNotGiven.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:immunizationNotGiven.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:immunizationNotGiven.typeCoderequiredFixed Value: RSON
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.entryRelationship:substanceAdmin.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:substanceAdmin.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:substanceAdmin.typeCoderequiredFixed Value: COMP
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.precondition:substanceAdmin.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.precondition:substanceAdmin.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.precondition:substanceAdmin.typeCoderequiredFixed Value: PRCN
http://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType

Constraints

IdGradePath(s)DetailsRequirements
dose-unit-or-admin-uniterrorSubstanceAdministrationIf doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
: doseQuantity.unit.exists() implies administrationUnitCode.empty()
indication-valueerrorSubstanceAdministration.entryRelationship:indication.observationIf the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
: value.exists() or (%resource.descendants().ofType(CDA.Observation).where(id.exists($this.root = %context.id.first().root and $this.extension ~ %context.id.first().extension) and value.exists()))
product-choiceerrorSubstanceAdministration.consumable.manufacturedProductmanufacturedLabeledDrug and manufacturedMaterial are mutually exclusive (one must be present)
: (manufacturedLabeledDrug | manufacturedMaterial).count() = 1
role-choiceerrorSubstanceAdministration.participant:drugVehicle.participantRoleplayingDevice and playingEntity are mutually exclusive
: (playingDevice | playingEntity).count() <= 1
should-authorwarningSubstanceAdministrationSHOULD contain author
: author.exists()
should-doseQuantitywarningSubstanceAdministrationSHOULD contain doseQuantity
: doseQuantity.exists()
should-effectiveTimewarningSubstanceAdministration.entryRelationship:indication.observation, SubstanceAdministration.entryRelationship:medDispense.supply, SubstanceAdministration.entryRelationship:reactionObs.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-manufacturerOrganizationwarningSubstanceAdministration.consumable.manufacturedProductSHOULD contain manufacturerOrganization
: manufacturerOrganization.exists()
should-performerwarningSubstanceAdministrationSHOULD contain performer
: performer.exists()
should-quantitywarningSubstanceAdministration.entryRelationship:medSupplyOrder.supply, SubstanceAdministration.entryRelationship:medDispense.supplySHOULD contain quantity
: quantity.exists()
should-repeatNumberwarningSubstanceAdministration.entryRelationship:medSupplyOrder.supply, SubstanceAdministration.entryRelationship:medDispense.supplySHOULD contain repeatNumber
: repeatNumber.exists()
should-text-ref-valuewarningSubstanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningSubstanceAdministration.entryRelationship:indication.observation, SubstanceAdministration.entryRelationship:instruction.act, SubstanceAdministration.entryRelationship:medSupplyOrder.supply, SubstanceAdministration.entryRelationship:medDispense.supply, SubstanceAdministration.entryRelationship:reactionObs.observation, SubstanceAdministration.entryRelationship:immunizationNotGiven.observation, SubstanceAdministration.entryRelationship:substanceAdmin.actSHOULD contain text/reference/@value
: text.reference.value.exists()
should-translationwarningSubstanceAdministration.routeCodeSHOULD contain translation
: translation.exists()
should-unitwarningSubstanceAdministration.doseQuantitySHOULD contain @unit
: nullFlavor.exists() or unit.exists()
value-onlyerrorSubstanceAdministration.repeatNumberInterval fields SHALL not be present
: (low | high | width | center).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('#')
value-starts-octothorpeerrorSubstanceAdministration.entryRelationship:indication.observation.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: 9 elements(12 nested mandatory elements)
Fixed: 10 elements
Prohibited: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 2 is sliced based on the values of SubstanceAdministration.templateId
  • The element 1 is sliced based on the value of SubstanceAdministration.participant
  • The element 3 is sliced based on the values of SubstanceAdministration.entryRelationship
  • The element 1 is sliced based on the value of SubstanceAdministration.precondition

Differential View

This structure is derived from SubstanceAdministration

NameFlagsCard.TypeDescription & Constraintsdoco
.. SubstanceAdministration C 1..1 SubstanceAdministration XML 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
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
should-doseQuantity: SHOULD contain doseQuantity
dose-unit-or-admin-unit: If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
should-performer: SHOULD contain performer
should-author: SHOULD contain author
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:immunization-activity 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.52
..... @extension 1..1 st Required Pattern: 2015-08-01
... @classCode 1..1 cs
... @moodCode 1..1 cs Binding: MoodCodeEvnInt . (required)
... code 0..1 CD SubstanceAdministration.code is an optional field. Per HL7 Pharmacy Committee, "this is intended to further specify the nature of the substance administration act. To date the committee has made no use of this attribute". Because the type of substance administration is generally implicit in the routeCode, in the consumable participant, etc., the field is generally not used and there is no defined value set.
... @negationInd 1..1 bl Use negationInd="true" to indicate that the immunization was not given.
... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
.... reference C 0..1 TEL value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... statusCode 1..1 CS
.... @nullFlavor 0..0
.... @code 1..1 cs Binding: ActStatus . (required)
... effectiveTime 1..1 SXCM_TS, IVL_TS, EIVL_TS, PIVL_TS, SXPR_TS
... repeatNumber C 0..1 IVL_INT 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.
value-only: Interval fields SHALL not be present
.... @value 0..1 int value should be used instead of low/high
... routeCode C 0..1 CE Binding: SPL Drug Route of Administration Terminology . (required)
should-translation: SHOULD contain translation
.... translation 0..* CD Binding: Medication Route . (preferred)
... approachSiteCode 0..1 CD Binding: Body Site Value Set . (required)
... doseQuantity C 0..1 IVL_PQ should-unit: SHOULD contain @unit
.... @unit 0..1 cs NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units
Binding: UnitsOfMeasureCaseSensitive . (preferred)
... administrationUnitCode 0..1 CE Binding: AdministrationUnitDoseForm . (required)
... consumable 1..1 InfrastructureRoot
.... manufacturedProduct 1..1 ImmunizationMedicationInformation Base for all types and resources
... performer 0..1 Performer2
... author 0..* AuthorParticipation Base for all types and resources
... Slices for participant 0..* Participant2 Slice: Unordered, Open by value:typeCode
.... participant:drugVehicle 0..* Participant2
..... @typeCode 1..1 cs Fixed Value: CSM
..... participantRole 1..1 DrugVehicle Base for all types and resources
... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation, profile:supply
.... entryRelationship:indication 0..* EntryRelationship
..... @typeCode 1..1 cs Fixed Value: RSON
..... observation 1..1 Indication Base for all types and resources
...... code 1..1 CD Indication for Immunization
....... @code 1..1 cs Required Pattern: 59785-6
....... @codeSystem 1..1 oid, uuid, ruid LOINC
Required Pattern: 2.16.840.1.113883.6.1
.... entryRelationship:instruction 0..1 EntryRelationship
..... @typeCode 1..1 cs Fixed Value: SUBJ
..... @inversionInd 1..1 bl Fixed Value: true
..... act 1..1 Instruction Base for all types and resources
.... entryRelationship:medSupplyOrder 0..1 EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... supply 1..1 MedicationSupplyOrder Base for all types and resources
.... entryRelationship:medDispense 0..1 EntryRelationship
..... @typeCode 1..1 cs Fixed Value: REFR
..... supply 1..1 MedicationDispense Base for all types and resources
.... entryRelationship:reactionObs 0..1 EntryRelationship
..... @typeCode 1..1 cs Fixed Value: CAUS
..... observation 1..1 ReactionObservation Base for all types and resources
.... entryRelationship:immunizationNotGiven 0..1 EntryRelationship
..... @typeCode 1..1 cs Fixed Value: RSON
..... observation 1..1 ImmunizationNotGivenReason Base for all types and resources
.... entryRelationship:substanceAdmin 0..* EntryRelationship The following entryRelationship is used to indicate a given immunization'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.
..... @typeCode 1..1 cs Fixed Value: COMP
..... @inversionInd 1..1 bl Fixed Value: true
..... sequenceNumber 0..1 INT
..... act 1..1 SubstanceAdministeredAct Base for all types and resources
... Slices for precondition 0..* Precondition Slice: Unordered, Open by profile:criterion
.... precondition:substanceAdmin 0..* Precondition
..... @typeCode 1..1 cs
..... criterion 1..1 PreconditionforSubstanceAdministration Base for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
SubstanceAdministration.moodCoderequiredMoodCodeEvnInt .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.18
SubstanceAdministration.statusCode.coderequiredActStatus .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.15933
SubstanceAdministration.routeCoderequiredSPLDrugRouteOfAdministrationTerminology .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.7
SubstanceAdministration.routeCode.translationpreferredMedicationRoute .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.12
SubstanceAdministration.approachSiteCoderequiredBodySiteValueSet .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9
SubstanceAdministration.doseQuantity.unitpreferredUnitsOfMeasureCaseSensitive . (a valid code from UCUM)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12839
SubstanceAdministration.administrationUnitCoderequiredAdministrationUnitDoseForm .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.30

Constraints

IdGradePath(s)DetailsRequirements
dose-unit-or-admin-uniterrorSubstanceAdministrationIf doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
: doseQuantity.unit.exists() implies administrationUnitCode.empty()
should-authorwarningSubstanceAdministrationSHOULD contain author
: author.exists()
should-doseQuantitywarningSubstanceAdministrationSHOULD contain doseQuantity
: doseQuantity.exists()
should-performerwarningSubstanceAdministrationSHOULD contain performer
: performer.exists()
should-text-ref-valuewarningSubstanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()
should-translationwarningSubstanceAdministration.routeCodeSHOULD contain translation
: translation.exists()
should-unitwarningSubstanceAdministration.doseQuantitySHOULD contain @unit
: nullFlavor.exists() or unit.exists()
value-onlyerrorSubstanceAdministration.repeatNumberInterval fields SHALL not be present
: (low | high | width | center).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 C 1..1 SubstanceAdministration XML 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
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
should-doseQuantity: SHOULD contain doseQuantity
dose-unit-or-admin-unit: If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
should-performer: SHOULD contain performer
should-author: SHOULD contain author
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:immunization-activity 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.52
..... @extension 1..1 st Required Pattern: 2015-08-01
... @classCode 1..1 cs Binding: CDAActClass (required)
Fixed Value: SBADM
... @moodCode 1..1 cs Binding: MoodCodeEvnInt . (required)
... code 0..1 CD SubstanceAdministration.code is an optional field. Per HL7 Pharmacy Committee, "this is intended to further specify the nature of the substance administration act. To date the committee has made no use of this attribute". Because the type of substance administration is generally implicit in the routeCode, in the consumable participant, etc., the field is generally not used and there is no defined value set.
Binding: CDAActSubstanceAdministrationCode (example)
... @negationInd 1..1 bl Use negationInd="true" to indicate that the immunization was not given.
... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
.... reference C 0..1 TEL value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... statusCode 1..1 CS Binding: ActStatus (required)
.... @code 1..1 cs Binding: ActStatus . (required)
... effectiveTime 1..1
.... effectiveTime SXCM_TS
.... effectiveTime IVL_TS
.... effectiveTime EIVL_TS
.... effectiveTime PIVL_TS
.... effectiveTime SXPR_TS
... repeatNumber C 0..1 IVL_INT 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.
value-only: Interval fields SHALL not be present
.... @value 0..1 int value should be used instead of low/high
... routeCode C 0..1 CE Binding: SPL Drug Route of Administration Terminology . (required)
should-translation: SHOULD contain translation
.... translation 0..* CD Binding: Medication Route . (preferred)
... approachSiteCode 0..1 CD Binding: Body Site Value Set . (required)
... doseQuantity C 0..1 IVL_PQ should-unit: SHOULD contain @unit
.... @unit 0..1 cs NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units
Binding: UnitsOfMeasureCaseSensitive . (preferred)
... administrationUnitCode 0..1 CE Binding: AdministrationUnitDoseForm . (required)
... consumable 1..1 InfrastructureRoot
.... manufacturedProduct C 1..1 ImmunizationMedicationInformation Base for all types and resources
product-choice: manufacturedLabeledDrug and manufacturedMaterial are mutually exclusive (one must be present)
should-manufacturerOrganization: SHOULD contain manufacturerOrganization
... performer 0..1 Performer2
... author 0..* AuthorParticipation Base for all types and resources
... Slices for participant 0..* Participant2 Slice: Unordered, Open by value:typeCode
.... participant:drugVehicle 0..* Participant2
..... @typeCode 1..1 cs Binding: CDAParticipationType (required)
Fixed Value: CSM
..... participantRole C 1..1 DrugVehicle Base for all types and resources
role-choice: playingDevice and playingEntity are mutually exclusive
... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation, profile:supply
.... entryRelationship:indication 0..* EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... observation C 1..1 Indication Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
indication-value: If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
...... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
....... templateId:indication 1..1 II
........ @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.19
........ @extension 1..1 st Required Pattern: 2023-05-01
...... @classCode 1..1 cs Binding: CDAActClassObservation (required)
Fixed Value: OBS
...... @moodCode 1..1 cs Binding: XActMoodDocumentObservation (2.0.0) (required)
Fixed Value: EVN
...... id 1..* II If the id element is used to reference a problem recorded elsewhere in the document then this id must equal another entry/id in the same document instance. Application Software must be responsible for resolving the identifier back to its original object and then rendering the information in the correct place in the containing section's narrative text. Its purpose is to obviate the need to repeat the complete XML representation of the referred to entry when relating one entry to another.
...... code 1..1 CD Indication for Immunization
Binding: Problem Type (preferred)
....... @code 1..1 cs Required Pattern: 59785-6
....... @codeSystem 1..1 oid, uuid, ruid LOINC
Required Pattern: 2.16.840.1.113883.6.1
...... statusCode 1..1 CS Binding: ActStatus (required)
....... @code 1..1 cs Fixed Value: completed
...... value 0..1 CD If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
Binding: US Core Condition Codes (preferred)
.... entryRelationship:instruction 0..1 EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
..... @inversionInd 1..1 bl Fixed Value: true
..... act C 1..1 Instruction Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:medSupplyOrder 0..1 EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... supply C 1..1 MedicationSupplyOrder Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-repeatNumber: SHOULD contain repeatNumber
should-quantity: SHOULD contain quantity
.... entryRelationship:medDispense 0..1 EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... supply C 1..1 MedicationDispense Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
should-repeatNumber: SHOULD contain repeatNumber
should-quantity: SHOULD contain quantity
.... entryRelationship:reactionObs 0..1 EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: CAUS
..... observation C 1..1 ReactionObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
.... entryRelationship:immunizationNotGiven 0..1 EntryRelationship
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... observation C 1..1 ImmunizationNotGivenReason Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
.... entryRelationship:substanceAdmin 0..* EntryRelationship The following entryRelationship is used to indicate a given immunization'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.
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... @inversionInd 1..1 bl Fixed Value: true
..... sequenceNumber 0..1 INT
..... act C 1..1 SubstanceAdministeredAct Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
... Slices for precondition 0..* Precondition Slice: Unordered, Open by profile:criterion
.... precondition:substanceAdmin 0..* Precondition
..... @typeCode 1..1 cs Binding: CDAActRelationshipType (required)
Fixed Value: PRCN
..... criterion 1..1 PreconditionforSubstanceAdministration Base for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
SubstanceAdministration.classCoderequiredFixed Value: SBADM
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
SubstanceAdministration.moodCoderequiredMoodCodeEvnInt .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.18
SubstanceAdministration.codeexampleCDAActSubstanceAdministrationCode
http://hl7.org/cda/stds/core/ValueSet/CDAActSubstanceAdministrationCode
SubstanceAdministration.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
SubstanceAdministration.statusCode.coderequiredActStatus .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.15933
SubstanceAdministration.routeCoderequiredSPLDrugRouteOfAdministrationTerminology .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.7
SubstanceAdministration.routeCode.translationpreferredMedicationRoute .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.12
SubstanceAdministration.approachSiteCoderequiredBodySiteValueSet .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9
SubstanceAdministration.doseQuantity.unitpreferredUnitsOfMeasureCaseSensitive . (a valid code from UCUM)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12839
SubstanceAdministration.administrationUnitCoderequiredAdministrationUnitDoseForm .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.30
SubstanceAdministration.participant:drugVehicle.typeCoderequiredFixed Value: CSM
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
SubstanceAdministration.entryRelationship:indication.typeCoderequiredFixed Value: RSON
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.entryRelationship:indication.observation.classCoderequiredFixed Value: OBS
http://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation
SubstanceAdministration.entryRelationship:indication.observation.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
SubstanceAdministration.entryRelationship:indication.observation.codepreferredProblemType
https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.1
SubstanceAdministration.entryRelationship:indication.observation.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
SubstanceAdministration.entryRelationship:indication.observation.valuepreferredUSCoreConditionCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
SubstanceAdministration.entryRelationship:instruction.typeCoderequiredFixed Value: SUBJ
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.entryRelationship:medSupplyOrder.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.entryRelationship:medDispense.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.entryRelationship:reactionObs.typeCoderequiredFixed Value: CAUS
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.entryRelationship:immunizationNotGiven.typeCoderequiredFixed Value: RSON
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.entryRelationship:substanceAdmin.typeCoderequiredFixed Value: COMP
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.precondition:substanceAdmin.typeCoderequiredFixed Value: PRCN
http://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType

Constraints

IdGradePath(s)DetailsRequirements
dose-unit-or-admin-uniterrorSubstanceAdministrationIf doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
: doseQuantity.unit.exists() implies administrationUnitCode.empty()
indication-valueerrorSubstanceAdministration.entryRelationship:indication.observationIf the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
: value.exists() or (%resource.descendants().ofType(CDA.Observation).where(id.exists($this.root = %context.id.first().root and $this.extension ~ %context.id.first().extension) and value.exists()))
product-choiceerrorSubstanceAdministration.consumable.manufacturedProductmanufacturedLabeledDrug and manufacturedMaterial are mutually exclusive (one must be present)
: (manufacturedLabeledDrug | manufacturedMaterial).count() = 1
role-choiceerrorSubstanceAdministration.participant:drugVehicle.participantRoleplayingDevice and playingEntity are mutually exclusive
: (playingDevice | playingEntity).count() <= 1
should-authorwarningSubstanceAdministrationSHOULD contain author
: author.exists()
should-doseQuantitywarningSubstanceAdministrationSHOULD contain doseQuantity
: doseQuantity.exists()
should-effectiveTimewarningSubstanceAdministration.entryRelationship:indication.observation, SubstanceAdministration.entryRelationship:medDispense.supply, SubstanceAdministration.entryRelationship:reactionObs.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-manufacturerOrganizationwarningSubstanceAdministration.consumable.manufacturedProductSHOULD contain manufacturerOrganization
: manufacturerOrganization.exists()
should-performerwarningSubstanceAdministrationSHOULD contain performer
: performer.exists()
should-quantitywarningSubstanceAdministration.entryRelationship:medSupplyOrder.supply, SubstanceAdministration.entryRelationship:medDispense.supplySHOULD contain quantity
: quantity.exists()
should-repeatNumberwarningSubstanceAdministration.entryRelationship:medSupplyOrder.supply, SubstanceAdministration.entryRelationship:medDispense.supplySHOULD contain repeatNumber
: repeatNumber.exists()
should-text-ref-valuewarningSubstanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningSubstanceAdministration.entryRelationship:indication.observation, SubstanceAdministration.entryRelationship:instruction.act, SubstanceAdministration.entryRelationship:medSupplyOrder.supply, SubstanceAdministration.entryRelationship:medDispense.supply, SubstanceAdministration.entryRelationship:reactionObs.observation, SubstanceAdministration.entryRelationship:immunizationNotGiven.observation, SubstanceAdministration.entryRelationship:substanceAdmin.actSHOULD contain text/reference/@value
: text.reference.value.exists()
should-translationwarningSubstanceAdministration.routeCodeSHOULD contain translation
: translation.exists()
should-unitwarningSubstanceAdministration.doseQuantitySHOULD contain @unit
: nullFlavor.exists() or unit.exists()
value-onlyerrorSubstanceAdministration.repeatNumberInterval fields SHALL not be present
: (low | high | width | center).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 C 1..1 SubstanceAdministration XML 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
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
should-doseQuantity: SHOULD contain doseQuantity
dose-unit-or-admin-unit: If doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
should-performer: SHOULD contain performer
should-author: SHOULD contain author
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... typeId 0..1 II
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1 st
.... @displayable 0..1 bl
.... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1 st
... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
.... templateId:immunization-activity 1..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.52
..... @extension 1..1 st Required Pattern: 2015-08-01
... @classCode 1..1 cs Binding: CDAActClass (required)
Fixed Value: SBADM
... @moodCode 1..1 cs Binding: MoodCodeEvnInt . (required)
... id 1..* II
... code 0..1 CD SubstanceAdministration.code is an optional field. Per HL7 Pharmacy Committee, "this is intended to further specify the nature of the substance administration act. To date the committee has made no use of this attribute". Because the type of substance administration is generally implicit in the routeCode, in the consumable participant, etc., the field is generally not used and there is no defined value set.
Binding: CDAActSubstanceAdministrationCode (example)
... @negationInd 1..1 bl Use negationInd="true" to indicate that the immunization was not given.
... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @compression 0..1 cs Binding: CDACompressionAlgorithm (required)
.... @integrityCheck 0..1 bin
.... @integrityCheckAlgorithm 0..1 cs Binding: IntegrityCheckAlgorithm (2.0.0) (required)
.... @language 0..1 cs
.... @mediaType 0..1 cs Binding: MediaType (example)
.... @representation 0..1 cs Binding: CDABinaryDataEncoding (required)
.... xmlText 0..1 st Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
.... reference C 0..1 TEL value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
.... thumbnail 0..1 ED
... statusCode 1..1 CS Binding: ActStatus (required)
.... @code 1..1 cs Binding: ActStatus . (required)
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 1..1
.... effectiveTime SXCM_TS
.... effectiveTime IVL_TS
.... effectiveTime EIVL_TS
.... effectiveTime PIVL_TS
.... effectiveTime SXPR_TS
... priorityCode 0..1 CE Binding: ActPriority (example)
... repeatNumber C 0..1 IVL_INT 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.
value-only: Interval fields SHALL not be present
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @value 0..1 int value should be used instead of low/high
.... @operator 0..1 cs Binding: CDASetOperator (required)
.... low 0..1 IVXB_INT
.... center 0..1 INT
.... width 0..1 INT
.... high 0..1 IVXB_INT
... routeCode C 0..1 CE Binding: SPL Drug Route of Administration Terminology . (required)
should-translation: SHOULD contain translation
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 0..1 cs
.... @codeSystem 0..1 oid, uuid, ruid
.... @codeSystemName 0..1 st
.... @codeSystemVersion 0..1 st
.... @displayName 0..1 st
.... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1 ED
.... translation 0..* CD Binding: Medication Route . (preferred)
... approachSiteCode 0..1 CD Binding: Body Site Value Set . (required)
... doseQuantity C 0..1 IVL_PQ should-unit: SHOULD contain @unit
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @unit 0..1 cs NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units
Binding: UnitsOfMeasureCaseSensitive . (preferred)
.... @value 0..1 real
.... translation 0..* PQR
.... @operator 0..1 cs Binding: CDASetOperator (required)
.... low 0..1 IVXB_PQ
.... center 0..1 PQ
.... width 0..1 PQ
.... high 0..1 IVXB_PQ
... rateQuantity 0..1 IVL_PQ
... maxDoseQuantity 0..1 RTO_PQ_PQ
... administrationUnitCode 0..1 CE Binding: AdministrationUnitDoseForm . (required)
... consumable 1..1 InfrastructureRoot
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... realmCode 0..* CS
.... typeId 0..1 II
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1 st
..... @displayable 0..1 bl
..... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1 st
.... templateId 0..* II
.... @typeCode 0..1 cs Binding: CDAParticipationType (required)
Fixed Value: CSM
.... manufacturedProduct C 1..1 ImmunizationMedicationInformation Base for all types and resources
product-choice: manufacturedLabeledDrug and manufacturedMaterial are mutually exclusive (one must be present)
should-manufacturerOrganization: SHOULD contain manufacturerOrganization
... subject 0..1 Subject
... specimen 0..* Specimen
... performer 0..1 Performer2
... author 0..* AuthorParticipation Base for all types and resources
... informant 0..* Informant
... Slices for participant 0..* Participant2 Slice: Unordered, Open by value:typeCode
.... participant:drugVehicle 0..* Participant2
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: CDAParticipationType (required)
Fixed Value: CSM
..... @contextControlCode 0..1 cs Binding: CDAContextControl (required)
Fixed Value: OP
..... sdtcFunctionCode 0..1 CE XML Namespace: urn:hl7-org:sdtc
XML: functionCode (urn:hl7-org:sdtc)
..... time 0..1 IVL_TS
..... awarenessCode 0..1 CE
..... participantRole C 1..1 DrugVehicle Base for all types and resources
role-choice: playingDevice and playingEntity are mutually exclusive
... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation, profile:supply
.... entryRelationship:indication 0..* EntryRelationship
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 Indication Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
indication-value: If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... realmCode 0..* CS
...... typeId 0..1 II
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @assigningAuthorityName 0..1 st
....... @displayable 0..1 bl
....... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
....... @extension 1..1 st
...... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
....... templateId:indication 1..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.19
........ @extension 1..1 st Required Pattern: 2023-05-01
...... @classCode 1..1 cs Binding: CDAActClassObservation (required)
Fixed Value: OBS
...... @moodCode 1..1 cs Binding: XActMoodDocumentObservation (2.0.0) (required)
Fixed Value: EVN
...... @negationInd 0..1 bl
...... id 1..* II If the id element is used to reference a problem recorded elsewhere in the document then this id must equal another entry/id in the same document instance. Application Software must be responsible for resolving the identifier back to its original object and then rendering the information in the correct place in the containing section's narrative text. Its purpose is to obviate the need to repeat the complete XML representation of the referred to entry when relating one entry to another.
...... code 1..1 CD Indication for Immunization
Binding: Problem Type (preferred)
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @code 1..1 cs Required Pattern: 59785-6
....... @codeSystem 1..1 oid, uuid, ruid LOINC
Required Pattern: 2.16.840.1.113883.6.1
....... @codeSystemName 0..1 st
....... @codeSystemVersion 0..1 st
....... @displayName 0..1 st
....... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
....... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
....... originalText 0..1 ED
....... qualifier 0..* CR
....... translation 0..* CD
...... derivationExpr 0..1 ST
...... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @compression 0..1 cs Binding: CDACompressionAlgorithm (required)
....... @integrityCheck 0..1 bin
....... @integrityCheckAlgorithm 0..1 cs Binding: IntegrityCheckAlgorithm (2.0.0) (required)
....... @language 0..1 cs
....... @mediaType 0..1 cs Binding: MediaType (example)
....... @representation 0..1 cs Binding: CDABinaryDataEncoding (required)
....... xmlText 0..1 st Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
....... reference C 0..1 TEL value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
....... thumbnail 0..1 ED
...... statusCode 1..1 CS Binding: ActStatus (required)
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... @code 1..1 cs Fixed Value: completed
....... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
....... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
...... effectiveTime 0..1 IVL_TS
...... priorityCode 0..1 CE Binding: ActPriority (example)
...... repeatNumber 0..1 IVL_INT
...... languageCode 0..1 CS Binding: AllLanguages (required)
...... value 0..1 CD If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
Binding: US Core Condition Codes (preferred)
...... interpretationCode 0..* CE Binding: CDAObservationInterpretation (required)
...... methodCode 0..* CE Binding: ObservationMethod (example)
...... targetSiteCode 0..* CD
...... subject 0..1 Subject
...... specimen 0..* Specimen
...... performer 0..* Performer2
...... author 0..* Author
...... informant 0..* Informant
...... participant 0..* Participant2
...... entryRelationship 0..* EntryRelationship
...... reference 0..* Reference
...... precondition 0..* Precondition
...... sdtcPrecondition2 0..* Precondition2 XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
...... referenceRange 0..* InfrastructureRoot
....... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
....... realmCode 0..* CS
....... typeId 0..1 II
........ @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
........ @assigningAuthorityName 0..1 st
........ @displayable 0..1 bl
........ @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
........ @extension 1..1 st
....... templateId 0..* II
....... @typeCode 0..1 cs Binding: CDAActRelationshipType (required)
Fixed Value: REFV
....... observationRange 1..1 ObservationRange
...... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entryRelationship:instruction 0..1 EntryRelationship
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
..... @inversionInd 1..1 bl Fixed Value: true
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act C 1..1 Instruction Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... encounter 0..1 Encounter
..... observation 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entryRelationship:medSupplyOrder 0..1 EntryRelationship
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply C 1..1 MedicationSupplyOrder Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-repeatNumber: SHOULD contain repeatNumber
should-quantity: SHOULD contain quantity
.... entryRelationship:medDispense 0..1 EntryRelationship
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply C 1..1 MedicationDispense Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
should-repeatNumber: SHOULD contain repeatNumber
should-quantity: SHOULD contain quantity
.... entryRelationship:reactionObs 0..1 EntryRelationship
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: CAUS
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 ReactionObservation Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entryRelationship:immunizationNotGiven 0..1 EntryRelationship
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... @inversionInd 0..1 bl
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act 0..1 Act
..... encounter 0..1 Encounter
..... observation C 1..1 ImmunizationNotGivenReason Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
.... entryRelationship:substanceAdmin 0..* EntryRelationship The following entryRelationship is used to indicate a given immunization'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.
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... @inversionInd 1..1 bl Fixed Value: true
..... @contextConductionInd 0..1 bl
..... @negationInd 0..1 bl
..... sequenceNumber 0..1 INT
..... seperatableInd 0..1 BL
..... act C 1..1 SubstanceAdministeredAct Base for all types and resources
should-text-ref-value: SHOULD contain text/reference/@value
..... encounter 0..1 Encounter
..... observation 0..1 Observation
..... observationMedia 0..1 ObservationMedia
..... organizer 0..1 Organizer
..... procedure 0..1 Procedure
..... regionOfInterest 0..1 RegionOfInterest
..... substanceAdministration 0..1 SubstanceAdministration
..... supply 0..1 Supply
... reference 0..* Reference
... Slices for precondition 0..* Precondition Slice: Unordered, Open by profile:criterion
.... precondition:substanceAdmin 0..* Precondition
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... realmCode 0..* CS
..... typeId 0..1 II
...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1 st
...... @displayable 0..1 bl
...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1 st
..... templateId 0..* II
..... @typeCode 1..1 cs Binding: CDAActRelationshipType (required)
Fixed Value: PRCN
..... criterion 1..1 PreconditionforSubstanceAdministration Base for all types and resources
... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
SubstanceAdministration.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.templateId:immunization-activity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.classCoderequiredFixed Value: SBADM
http://hl7.org/cda/stds/core/ValueSet/CDAActClass
SubstanceAdministration.moodCoderequiredMoodCodeEvnInt .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.18
SubstanceAdministration.codeexampleCDAActSubstanceAdministrationCode
http://hl7.org/cda/stds/core/ValueSet/CDAActSubstanceAdministrationCode
SubstanceAdministration.text.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.text.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
SubstanceAdministration.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
SubstanceAdministration.text.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
SubstanceAdministration.text.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
SubstanceAdministration.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
SubstanceAdministration.statusCode.coderequiredActStatus .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.15933
SubstanceAdministration.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
SubstanceAdministration.repeatNumber.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.repeatNumber.operatorrequiredCDASetOperator
http://hl7.org/cda/stds/core/ValueSet/CDASetOperator
SubstanceAdministration.routeCoderequiredSPLDrugRouteOfAdministrationTerminology .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.7
SubstanceAdministration.routeCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.routeCode.translationpreferredMedicationRoute .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.12
SubstanceAdministration.approachSiteCoderequiredBodySiteValueSet .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9
SubstanceAdministration.doseQuantity.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.doseQuantity.unitpreferredUnitsOfMeasureCaseSensitive . (a valid code from UCUM)
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.1.11.12839
SubstanceAdministration.doseQuantity.operatorrequiredCDASetOperator
http://hl7.org/cda/stds/core/ValueSet/CDASetOperator
SubstanceAdministration.administrationUnitCoderequiredAdministrationUnitDoseForm .
http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1021.30
SubstanceAdministration.consumable.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.consumable.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.consumable.typeCoderequiredFixed Value: CSM
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
SubstanceAdministration.participant:drugVehicle.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.participant:drugVehicle.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.participant:drugVehicle.typeCoderequiredFixed Value: CSM
http://hl7.org/cda/stds/core/ValueSet/CDAParticipationType
SubstanceAdministration.participant:drugVehicle.contextControlCoderequiredFixed Value: OP
http://hl7.org/cda/stds/core/ValueSet/CDAContextControl
SubstanceAdministration.entryRelationship:indication.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:indication.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:indication.typeCoderequiredFixed Value: RSON
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.entryRelationship:indication.observation.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:indication.observation.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:indication.observation.templateId:indication.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:indication.observation.classCoderequiredFixed Value: OBS
http://hl7.org/cda/stds/core/ValueSet/CDAActClassObservation
SubstanceAdministration.entryRelationship:indication.observation.moodCoderequiredFixed Value: EVN
http://terminology.hl7.org/ValueSet/v3-xActMoodDocumentObservation|2.0.0
SubstanceAdministration.entryRelationship:indication.observation.codepreferredProblemType
https://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.1
SubstanceAdministration.entryRelationship:indication.observation.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:indication.observation.text.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:indication.observation.text.compressionrequiredCDACompressionAlgorithm
http://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm
SubstanceAdministration.entryRelationship:indication.observation.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
http://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0
SubstanceAdministration.entryRelationship:indication.observation.text.mediaTypeexampleMediaType
http://terminology.hl7.org/ValueSet/v3-MediaType
SubstanceAdministration.entryRelationship:indication.observation.text.representationrequiredBinaryDataEncoding
http://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding
SubstanceAdministration.entryRelationship:indication.observation.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
SubstanceAdministration.entryRelationship:indication.observation.statusCode.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:indication.observation.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
SubstanceAdministration.entryRelationship:indication.observation.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
SubstanceAdministration.entryRelationship:indication.observation.valuepreferredUSCoreConditionCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
SubstanceAdministration.entryRelationship:indication.observation.interpretationCoderequiredCDAObservationInterpretation
http://hl7.org/cda/stds/core/ValueSet/CDAObservationInterpretation
SubstanceAdministration.entryRelationship:indication.observation.methodCodeexampleObservationMethod
http://terminology.hl7.org/ValueSet/v3-ObservationMethod
SubstanceAdministration.entryRelationship:indication.observation.referenceRange.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:indication.observation.referenceRange.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:indication.observation.referenceRange.typeCoderequiredFixed Value: REFV
http://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType
SubstanceAdministration.entryRelationship:instruction.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:instruction.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:instruction.typeCoderequiredFixed Value: SUBJ
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.entryRelationship:medSupplyOrder.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:medSupplyOrder.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:medSupplyOrder.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.entryRelationship:medDispense.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:medDispense.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:medDispense.typeCoderequiredFixed Value: REFR
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.entryRelationship:reactionObs.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:reactionObs.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:reactionObs.typeCoderequiredFixed Value: CAUS
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.entryRelationship:immunizationNotGiven.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:immunizationNotGiven.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:immunizationNotGiven.typeCoderequiredFixed Value: RSON
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.entryRelationship:substanceAdmin.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:substanceAdmin.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.entryRelationship:substanceAdmin.typeCoderequiredFixed Value: COMP
http://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship
SubstanceAdministration.precondition:substanceAdmin.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.precondition:substanceAdmin.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.precondition:substanceAdmin.typeCoderequiredFixed Value: PRCN
http://hl7.org/cda/stds/core/ValueSet/CDAActRelationshipType

Constraints

IdGradePath(s)DetailsRequirements
dose-unit-or-admin-uniterrorSubstanceAdministrationIf doseQuantity/@unit is present, then administrationUnitCode SHALL NOT be present.
: doseQuantity.unit.exists() implies administrationUnitCode.empty()
indication-valueerrorSubstanceAdministration.entryRelationship:indication.observationIf the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry.
: value.exists() or (%resource.descendants().ofType(CDA.Observation).where(id.exists($this.root = %context.id.first().root and $this.extension ~ %context.id.first().extension) and value.exists()))
product-choiceerrorSubstanceAdministration.consumable.manufacturedProductmanufacturedLabeledDrug and manufacturedMaterial are mutually exclusive (one must be present)
: (manufacturedLabeledDrug | manufacturedMaterial).count() = 1
role-choiceerrorSubstanceAdministration.participant:drugVehicle.participantRoleplayingDevice and playingEntity are mutually exclusive
: (playingDevice | playingEntity).count() <= 1
should-authorwarningSubstanceAdministrationSHOULD contain author
: author.exists()
should-doseQuantitywarningSubstanceAdministrationSHOULD contain doseQuantity
: doseQuantity.exists()
should-effectiveTimewarningSubstanceAdministration.entryRelationship:indication.observation, SubstanceAdministration.entryRelationship:medDispense.supply, SubstanceAdministration.entryRelationship:reactionObs.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-manufacturerOrganizationwarningSubstanceAdministration.consumable.manufacturedProductSHOULD contain manufacturerOrganization
: manufacturerOrganization.exists()
should-performerwarningSubstanceAdministrationSHOULD contain performer
: performer.exists()
should-quantitywarningSubstanceAdministration.entryRelationship:medSupplyOrder.supply, SubstanceAdministration.entryRelationship:medDispense.supplySHOULD contain quantity
: quantity.exists()
should-repeatNumberwarningSubstanceAdministration.entryRelationship:medSupplyOrder.supply, SubstanceAdministration.entryRelationship:medDispense.supplySHOULD contain repeatNumber
: repeatNumber.exists()
should-text-ref-valuewarningSubstanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningSubstanceAdministration.entryRelationship:indication.observation, SubstanceAdministration.entryRelationship:instruction.act, SubstanceAdministration.entryRelationship:medSupplyOrder.supply, SubstanceAdministration.entryRelationship:medDispense.supply, SubstanceAdministration.entryRelationship:reactionObs.observation, SubstanceAdministration.entryRelationship:immunizationNotGiven.observation, SubstanceAdministration.entryRelationship:substanceAdmin.actSHOULD contain text/reference/@value
: text.reference.value.exists()
should-translationwarningSubstanceAdministration.routeCodeSHOULD contain translation
: translation.exists()
should-unitwarningSubstanceAdministration.doseQuantitySHOULD contain @unit
: nullFlavor.exists() or unit.exists()
value-onlyerrorSubstanceAdministration.repeatNumberInterval fields SHALL not be present
: (low | high | width | center).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('#')
value-starts-octothorpeerrorSubstanceAdministration.entryRelationship:indication.observation.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: 9 elements(12 nested mandatory elements)
Fixed: 10 elements
Prohibited: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 2 is sliced based on the values of SubstanceAdministration.templateId
  • The element 1 is sliced based on the value of SubstanceAdministration.participant
  • The element 3 is sliced based on the values of SubstanceAdministration.entryRelationship
  • The element 1 is sliced based on the value of SubstanceAdministration.precondition

 

Other representations of profile: CSV, Excel