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: Medication Free Text Sig

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/MedicationFreeTextSig Version: 3.0.0
Draft as of 2024-05-18 Computable Name: MedicationFreeTextSig
Other Identifiers: OID:2.16.840.1.113883.10.20.22.4.147

The template is available to explicitly identify the free text Sig within each medication.

An example free text sig: Thyroxin 150 ug, take one tab by mouth every morning.

NOTE: This is a Closed template so only the elements needed for the template are allowed. All other elements are not allowed.

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
... typeId 0..0
... Slices for templateId 1..* II Slice: Unordered, Open by value:root
.... templateId:med-freeTextSig 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.147
..... @extension 0..0
... @classCode 1..1 cs
... code 1..1 CD Instructions Medication Narrative
.... @code 1..1 cs Required Pattern: 76662-6
.... @codeSystem 1..1 oid, uuid, ruid LOINC
Required Pattern: 2.16.840.1.113883.6.1
... text 1..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
.... reference C 1..1 TEL Reference into the section/text to a tag that only contains free text sig.
value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
..... @value 0..1 url
... statusCode 0..0
... effectiveTime 0..0
... priorityCode 0..0
... repeatNumber 0..0
... routeCode 0..0
... approachSiteCode 0..0
... doseQuantity 0..0
... rateQuantity 0..0
... maxDoseQuantity 0..0
... administrationUnitCode 0..0
... consumable 1..1 InfrastructureRoot
.... manufacturedProduct 1..1 ManufacturedProduct
..... manufacturedLabeledDrug 1..1 LabeledDrug
...... @nullFlavor 1..1 cs Fixed Value: NA
... subject 0..0
... specimen 0..0
... performer 0..0
... informant 0..0
... participant 0..0
... entryRelationship 0..0
... precondition 0..0

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

Constraints

IdGradePath(s)DetailsRequirements
should-text-ref-valuewarningSubstanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()
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
... Slices for templateId 1..* II Slice: Unordered, Open by value:root
.... templateId:med-freeTextSig 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.147
... @classCode 1..1 cs Binding: CDAActClass (required)
Fixed Value: SBADM
... @moodCode 1..1 cs moodCode must match the parent substanceAdministration EVN or INT
Binding: MoodCodeEvnInt . (required)
.... @code 1..1 cs Required Pattern: 76662-6
.... @codeSystem 1..1 oid, uuid, ruid LOINC
Required Pattern: 2.16.840.1.113883.6.1
... text 1..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
.... reference C 1..1 TEL Reference into the section/text to a tag that only contains free text sig.
value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
..... @value 0..1 url
... consumable 1..1 InfrastructureRoot
.... manufacturedProduct 1..1 ManufacturedProduct
..... manufacturedLabeledDrug 1..1 LabeledDrug
...... @nullFlavor 1..1 cs Binding: CDANullFlavor (required)
Fixed Value: NA

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.consumable.manufacturedProduct.manufacturedLabeledDrug.nullFlavorrequiredFixed Value: NA
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
should-text-ref-valuewarningSubstanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()
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
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... Slices for templateId 1..* II Slice: Unordered, Open by value:root
.... templateId:med-freeTextSig 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: 2.16.840.1.113883.10.20.22.4.147
... @moodCode 1..1 cs moodCode must match the parent substanceAdministration EVN or INT
Binding: MoodCodeEvnInt . (required)
... id 0..* II
... code 1..1 CD Instructions Medication Narrative
Binding: CDAActSubstanceAdministrationCode (example)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 76662-6
.... @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
... @negationInd 0..1 bl
... text 1..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 1..1 TEL Reference into the section/text to a tag that only contains free text sig.
value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @value 0..1 url
..... useablePeriod 0..*
...... useablePeriod IVL_TS
...... useablePeriod EIVL_TS
...... useablePeriod PIVL_TS
...... useablePeriod SXPR_TS
..... @use 0..* cs Binding: TelecommunicationAddressUse (2.0.0) (required)
.... thumbnail 0..1 ED
... 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 1..1 ManufacturedProduct
..... @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
..... @classCode 0..1 cs Binding: RoleClassManufacturedProduct (required)
Fixed Value: MANU
..... id 0..* II
..... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... manufacturedLabeledDrug 1..1 LabeledDrug
...... @nullFlavor 1..1 cs Binding: CDANullFlavor (required)
Fixed Value: NA
...... 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
...... @classCode 0..1 cs Binding: EntityClassManufacturedMaterial (required)
Fixed Value: MMAT
...... @determinerCode 0..1 cs Binding: EntityDeterminerDetermined (required)
Fixed Value: KIND
...... code 0..1 CE
...... name 0..1 EN
..... manufacturedMaterial 0..1 Material
..... manufacturerOrganization 0..1 Organization
... author 0..* Author
... reference 0..* Reference
... 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:med-freeTextSig.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.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
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.text.reference.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.text.reference.userequiredTelecommunicationAddressUse
http://terminology.hl7.org/ValueSet/v3-TelecommunicationAddressUse|2.0.0
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.consumable.manufacturedProduct.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.consumable.manufacturedProduct.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.consumable.manufacturedProduct.classCoderequiredFixed Value: MANU
http://terminology.hl7.org/ValueSet/v3-RoleClassManufacturedProduct
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.nullFlavorrequiredFixed Value: NA
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.classCoderequiredFixed Value: MMAT
http://terminology.hl7.org/ValueSet/v3-EntityClassManufacturedMaterial
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.determinerCoderequiredFixed Value: KIND
http://terminology.hl7.org/ValueSet/v3-EntityDeterminerDetermined

Constraints

IdGradePath(s)DetailsRequirements
should-text-ref-valuewarningSubstanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorSubstanceAdministration.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

This structure is derived from SubstanceAdministration

Summary

Mandatory: 10 elements
Fixed: 1 element
Prohibited: 19 elements

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of SubstanceAdministration.templateId

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
... typeId 0..0
... Slices for templateId 1..* II Slice: Unordered, Open by value:root
.... templateId:med-freeTextSig 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.147
..... @extension 0..0
... @classCode 1..1 cs
... code 1..1 CD Instructions Medication Narrative
.... @code 1..1 cs Required Pattern: 76662-6
.... @codeSystem 1..1 oid, uuid, ruid LOINC
Required Pattern: 2.16.840.1.113883.6.1
... text 1..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
.... reference C 1..1 TEL Reference into the section/text to a tag that only contains free text sig.
value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
..... @value 0..1 url
... statusCode 0..0
... effectiveTime 0..0
... priorityCode 0..0
... repeatNumber 0..0
... routeCode 0..0
... approachSiteCode 0..0
... doseQuantity 0..0
... rateQuantity 0..0
... maxDoseQuantity 0..0
... administrationUnitCode 0..0
... consumable 1..1 InfrastructureRoot
.... manufacturedProduct 1..1 ManufacturedProduct
..... manufacturedLabeledDrug 1..1 LabeledDrug
...... @nullFlavor 1..1 cs Fixed Value: NA
... subject 0..0
... specimen 0..0
... performer 0..0
... informant 0..0
... participant 0..0
... entryRelationship 0..0
... precondition 0..0

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

Constraints

IdGradePath(s)DetailsRequirements
should-text-ref-valuewarningSubstanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()
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
... Slices for templateId 1..* II Slice: Unordered, Open by value:root
.... templateId:med-freeTextSig 1..1 II
..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.147
... @classCode 1..1 cs Binding: CDAActClass (required)
Fixed Value: SBADM
... @moodCode 1..1 cs moodCode must match the parent substanceAdministration EVN or INT
Binding: MoodCodeEvnInt . (required)
.... @code 1..1 cs Required Pattern: 76662-6
.... @codeSystem 1..1 oid, uuid, ruid LOINC
Required Pattern: 2.16.840.1.113883.6.1
... text 1..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
.... reference C 1..1 TEL Reference into the section/text to a tag that only contains free text sig.
value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
..... @value 0..1 url
... consumable 1..1 InfrastructureRoot
.... manufacturedProduct 1..1 ManufacturedProduct
..... manufacturedLabeledDrug 1..1 LabeledDrug
...... @nullFlavor 1..1 cs Binding: CDANullFlavor (required)
Fixed Value: NA

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.consumable.manufacturedProduct.manufacturedLabeledDrug.nullFlavorrequiredFixed Value: NA
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
should-text-ref-valuewarningSubstanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()
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
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... Slices for templateId 1..* II Slice: Unordered, Open by value:root
.... templateId:med-freeTextSig 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: 2.16.840.1.113883.10.20.22.4.147
... @moodCode 1..1 cs moodCode must match the parent substanceAdministration EVN or INT
Binding: MoodCodeEvnInt . (required)
... id 0..* II
... code 1..1 CD Instructions Medication Narrative
Binding: CDAActSubstanceAdministrationCode (example)
.... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
.... @code 1..1 cs Required Pattern: 76662-6
.... @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
... @negationInd 0..1 bl
... text 1..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 1..1 TEL Reference into the section/text to a tag that only contains free text sig.
value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
..... @value 0..1 url
..... useablePeriod 0..*
...... useablePeriod IVL_TS
...... useablePeriod EIVL_TS
...... useablePeriod PIVL_TS
...... useablePeriod SXPR_TS
..... @use 0..* cs Binding: TelecommunicationAddressUse (2.0.0) (required)
.... thumbnail 0..1 ED
... 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 1..1 ManufacturedProduct
..... @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
..... @classCode 0..1 cs Binding: RoleClassManufacturedProduct (required)
Fixed Value: MANU
..... id 0..* II
..... sdtcIdentifiedBy 0..* IdentifiedBy XML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... manufacturedLabeledDrug 1..1 LabeledDrug
...... @nullFlavor 1..1 cs Binding: CDANullFlavor (required)
Fixed Value: NA
...... 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
...... @classCode 0..1 cs Binding: EntityClassManufacturedMaterial (required)
Fixed Value: MMAT
...... @determinerCode 0..1 cs Binding: EntityDeterminerDetermined (required)
Fixed Value: KIND
...... code 0..1 CE
...... name 0..1 EN
..... manufacturedMaterial 0..1 Material
..... manufacturerOrganization 0..1 Organization
... author 0..* Author
... reference 0..* Reference
... 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:med-freeTextSig.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.code.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
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.text.reference.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.text.reference.userequiredTelecommunicationAddressUse
http://terminology.hl7.org/ValueSet/v3-TelecommunicationAddressUse|2.0.0
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.consumable.manufacturedProduct.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.consumable.manufacturedProduct.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.consumable.manufacturedProduct.classCoderequiredFixed Value: MANU
http://terminology.hl7.org/ValueSet/v3-RoleClassManufacturedProduct
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.nullFlavorrequiredFixed Value: NA
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.classCoderequiredFixed Value: MMAT
http://terminology.hl7.org/ValueSet/v3-EntityClassManufacturedMaterial
SubstanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.determinerCoderequiredFixed Value: KIND
http://terminology.hl7.org/ValueSet/v3-EntityDeterminerDetermined

Constraints

IdGradePath(s)DetailsRequirements
should-text-ref-valuewarningSubstanceAdministrationSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorSubstanceAdministration.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

This structure is derived from SubstanceAdministration

Summary

Mandatory: 10 elements
Fixed: 1 element
Prohibited: 19 elements

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of SubstanceAdministration.templateId

 

Other representations of profile: CSV, Excel