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pending Template  Medication Activity

Template 2.16.840.1.113883.10.20.22.4.16 - MedicationActivity
Id 2.16.840.1.113883.10.20.22.4.16
Version valid from 2013‑01‑31 status pending Under pre-publication review
Classification CDA Entry Level Template
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.16
Open/Closed Open (other than defined elements are allowed)
Description A medication activity describes substance administrations that have actually occurred (e.g. pills ingested or injections given) or are intended to occur (e.g. "take 2 tablets twice a day for the next 10 days"). Medication activities in "INT" mood are reflections of what a clinician intends a patient to be taking. Medication activities in "EVN" mood reflect actual use. Medication timing is complex. This template requires that there be a substanceAdministration/effectiveTime valued with a time interval, representing the start and stop dates. Additional effectiveTime elements are optional, and can be used to represent frequency and other aspects of more detailed dosing regimens.
Used by / Uses
Used by / Uses 240 templates
Used by Template id as Name Version
2.16.840.1.113883.10.20.22.2.1 Containment MedicationsSectionentriesoptional Medications Section (entries optional) 2013‑01‑31
2.16.840.1.113883.10.20.22.1.3 link HistoryandPhysical History and Physical 2013‑01‑31
2.16.840.1.113883.10.20.22.1.4 link ConsultationNote Consultation Note 2013‑01‑31
2.16.840.1.113883.10.20.22.1.6 link ProcedureNote Procedure Note 2013‑01‑31
2.16.840.1.113883.10.20.22.1.9 link ProgressNote Progress Note 2013‑01‑31
2.16.840.1.113883.10.20.22.2.1.1 Containment MedicationsSectionentriesrequired Medications Section (entries required) 2013‑01‑31
2.16.840.1.113883.10.20.22.1.2 link ContinuityofCareDocumentCCD Continuity of Care Document (CCD) 2013‑01‑31
2.16.840.1.113883.10.20.22.2.25 Containment AnesthesiaSection Anesthesia Section 2013‑01‑31
2.16.840.1.113883.10.20.22.1.7 link OperativeNote Operative Note 2013‑01‑31
2.16.840.1.113883.10.20.22.2.38 Containment MedicationsAdministeredSection Medications Administered Section 2013‑01‑31
2.16.840.1.113883.10.20.22.4.12 Containment ProcedureActivityAct Procedure Activity Act 2013‑01‑31
2.16.840.1.113883.10.20.22.2.7 link ProceduresSectionentriesoptional Procedures Section (entries optional) 2013‑01‑31
2.16.840.1.113883.10.20.22.1.8 link DischargeSummary Discharge Summary 2013‑01‑31
2.16.840.1.113883.10.20.22.2.7.1 link ProceduresSectionentriesrequired Procedures Section (entries required) 2013‑01‑31
2.16.840.1.113883.10.20.22.4.13 Containment ProcedureActivityObservation Procedure Activity Observation 2013‑01‑31
2.16.840.1.113883.10.20.22.4.14 Containment ProcedureActivityProcedure Procedure Activity Procedure 2013‑01‑31
2.16.840.1.113883.10.20.22.4.9 link ReactionObservation Reaction Observation 2013‑01‑31
2.16.840.1.113883.10.20.22.4.16 link MedicationActivity Medication Activity 2013‑01‑31
2.16.840.1.113883.10.20.22.4.35 link DischargeMedication Discharge Medication 2013‑01‑31
2.16.840.1.113883.10.20.22.2.11 link HospitalDischargeMedicationsSectionentriesoptional Hospital Discharge Medications Section (entries optional) 2013‑01‑31
2.16.840.1.113883.10.20.22.2.11.1 link HospitalDischargeMedicationsSectionentriesrequired Hospital Discharge Medications Section (entries required) 2013‑01‑31
2.16.840.1.113883.10.20.22.4.36 link AdmissionMedication Admission Medication 2013‑01‑31
2.16.840.1.113883.10.20.22.2.44 link HospitalAdmissionMedicationsSectionentriesoptional Hospital Admission Medications Section (entries optional) 2013‑01‑31
2.16.840.1.113883.10.20.22.4.52 link ImmunizationActivity Immunization Activity 2013‑01‑31
2.16.840.1.113883.10.20.22.2.2 link ImmunizationsSectionentriesoptional Immunizations Section (entries optional) 2013‑01‑31
2.16.840.1.113883.10.20.22.2.2.1 link ImmunizationsSectionentriesrequired Immunizations Section (entries required) 2013‑01‑31
2.16.840.1.113883.10.20.22.4.7 link Allergy-IntoleranceObservation Allergy - Intolerance Observation 2013‑01‑31
2.16.840.1.113883.10.20.22.4.30 link AllergyProblemAct Allergy Problem Act 2013‑01‑31
2.16.840.1.113883.10.20.22.2.6 link AllergiesSectionentriesoptional Allergies Section (entries optional) 2013‑01‑31
2.16.840.1.113883.10.20.22.2.6.1 link AllergiesSectionentriesrequired Allergies Section (entries required) 2013‑01‑31
2.16.840.1.113883.10.20.24.3.90 link SubstanceorDeviceAllergy-IntoleranceObservation Substance or Device Allergy - Intolerance Observation 2013‑01‑31
Uses Template id as Name Version
2.16.840.1.113883.10.20.22.4.23 Containment MedicationInformation DYNAMIC
2.16.840.1.113883.10.20.22.4.24 Containment DrugVehicle DYNAMIC
2.16.840.1.113883.10.20.22.4.19 Containment Indication DYNAMIC
2.16.840.1.113883.10.20.22.4.20 Containment Instructions DYNAMIC
2.16.840.1.113883.10.20.22.4.17 Containment MedicationSupplyOrder DYNAMIC
2.16.840.1.113883.10.20.22.4.18 Containment MedicationDispense DYNAMIC
2.16.840.1.113883.10.20.22.4.25 Containment PreconditionforSubstanceAdministration DYNAMIC
Item DT Card Conf Description Label
cda:substanceAdministration
Medication Activity SHOULD include doseQuantity OR rateQuantity (MedicationActivity)
treetree @classCode
1 .. 1 F SBADM
treetree @moodCode
1 .. 1 R
  CONF
The value of @moodCode shall be drawn from value set 2.16.840.1.113883.11.20.9.18 MoodCodeEvnInt (DYNAMIC)
treetree cda:templateId
1 .. 1 M SHALL contain exactly one [1..1] templateId (CONF:7499) such that it conf‑7499
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.4.16
treetree cda:id
1 .. * M SHALL contain at least one [1..*] id (CONF:7500). conf‑7500
treetree cda:code
0 .. 1 MAY contain zero or one [0..1] code (CONF:7506). conf‑7506
treetree cda:text
0 .. 1 R SHOULD contain zero or one [0..1] text (CONF:7501). conf‑7501
treeblank treetree cda:reference
0 .. 1 R The text, if present, SHOULD contain zero or one [0..1] reference (CONF:15977).

This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1)
conf‑15977
treeblank treeblank treetree @value
0 .. 1  
  Schematron assert role red error
  test count(cda:text/cda:reference[@value])=0 or starts-with(cda:text/cda:reference/@value, '#')
  Message This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1)
treetree cda:statusCode
1 .. 1 M SHALL contain exactly one [1..1] statusCode (CONF:7507). conf‑7507
treetree cda:effectiveTime
1 .. 1 M SHALL contain exactly one [1..1] effectiveTime (CONF:7508) such that it conf‑7508
treeblank treetree cda:low
1 .. 1 M SHALL contain exactly one [1..1] low (CONF:7511). conf‑7511
treeblank treetree cda:high
1 .. 1 M SHALL contain exactly one [1..1] high (CONF:7512). conf‑7512
treetree cda:effectiveTime
0 .. 1 R SHOULD contain zero or one [0..1] effectiveTime (CONF:7513) such that it

SHALL contain exactly one [1..1] @xsi:type=”PIVL_TS” or “EIVL_TS”
conf‑7513
treeblank treetree @operator
1 .. 1 F A
  Schematron assert role red error
  test count(cda:effectiveTime) = 2 and cda:effectiveTime[@operator='A'][@xsi:type='PIVL_TS' or @xsi:type='EIVL_TS']
  Message SHOULD contain zero or one [0..1] effectiveTime (CONF:7513) such that it
treetree cda:repeatNumber
0 .. 1 MAY contain zero or one [0..1] repeatNumber (CONF:7555).

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.
conf‑7555
treetree cda:routeCode
0 .. 1 MAY contain zero or one [0..1] routeCode, which SHALL be selected from ValueSet Medication Route FDA 2.16.840.1.113883.3.88.12.3221.8.7 DYNAMIC (CONF:7514). conf‑7514
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.3221.8.7 Medication Route FDA (DYNAMIC)
treetree cda:approachSiteCode
CD 0 .. 1 MAY contain zero or one [0..1] approachSiteCode, where the code SHALL be selected from ValueSet Body Site 2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:7515). conf‑7515
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.3221.8.9 Body Site (DYNAMIC)
treetree cda:doseQuantity
0 .. 1 R SHOULD contain zero or one [0..1] doseQuantity (CONF:7516).

Pre-coordinated consumable: If the consumable code is a pre-coordinated unit dose (e.g. "metoprolol 25mg tablet") then doseQuantity is a unitless number that indicates the number of products given per administration (e.g. "2", meaning 2 x "metoprolol 25mg tablet").

Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g. is simply "metoprolol"), then doseQuantity must represent a physical quantity with @unit, e.g. "25" and "mg", specifying the amount of product given per administration.
conf‑7516
treeblank treetree @unit
0 .. 1  
  CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.1.11.12839 UnitsOfMeasureCaseSensitive (DYNAMIC)
treetree cda:rateQuantity
0 .. 1 MAY contain zero or one [0..1] rateQuantity (CONF:7517). conf‑7517
treeblank treetree @unit
1 .. 1 R
  CONF
The value of @unit shall be drawn from value set 2.16.840.1.113883.1.11.12839 UnitsOfMeasureCaseSensitive (DYNAMIC)
treetree cda:maxDoseQuantity
RTO_PQ_PQ 0 .. 1 MAY contain zero or one [0..1] maxDoseQuantity (CONF:7518). conf‑7518
treetree cda:administrationUnitCode
0 .. 1 MAY contain zero or one [0..1] administrationUnitCode, which SHALL be selected from ValueSet Medication Product Form Value Set 2.16.840.1.113883.3.88.12.3221.8.11 DYNAMIC (CONF:7519). conf‑7519
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.3221.8.11 Medication Product Form (DYNAMIC)
treetree cda:consumable
where
[cda:manufacturedProduct [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.23']]
1 .. 1 M conf‑7520
  Contains 2.16.840.1.113883.10.20.22.4.23 Medication Information (DYNAMIC)
treetree cda:performer
0 .. 1 MAY contain zero or one [0..1] performer (CONF:7522). conf‑7522
treetree cda:participant
where
[cda:participantRole [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.24']]
0 .. * conf‑7523
treeblank treetree @typeCode
1 .. 1 F CSM
  Contains 2.16.840.1.113883.10.20.22.4.24 Drug Vehicle (DYNAMIC)
treetree cda:entryRelationship
where
[cda:observation [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.19']]
0 .. * conf‑7536
treeblank treetree @typeCode
1 .. 1 F RSON
  Contains 2.16.840.1.113883.10.20.22.4.19 Indication (DYNAMIC)
treetree cda:entryRelationship
where
[cda:act [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.20']]
0 .. 1 conf‑7539
treeblank treetree @typeCode
1 .. 1 F SUBJ
treeblank treetree @inversionInd
1 .. 1 F true
  Contains 2.16.840.1.113883.10.20.22.4.20 Instructions (DYNAMIC)
treetree cda:entryRelationship
where
[cda:supply [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.17']]
0 .. 1 conf‑7543
treeblank treetree @typeCode
1 .. 1 F REFR
  Contains 2.16.840.1.113883.10.20.22.4.17 Medication Supply Order (DYNAMIC)
treetree cda:entryRelationship
where
[cda:supply [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.18']]
0 .. * conf‑7549
treeblank treetree @typeCode
1 .. 1 F REFR
  Contains 2.16.840.1.113883.10.20.22.4.18 Medication Dispense (DYNAMIC)
treetree cda:entryRelationship
where
[cda:observation [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.9']]
0 .. 1 conf‑7552
treeblank treetree @typeCode
1 .. 1 F CAUS
  Contains 2.16.840.1.113883.10.20.22.4.9 Reaction Observation (DYNAMIC)
treetree cda:precondition
where
[cda:criterion [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.25']]
0 .. * conf‑7546
treeblank treetree @typeCode
1 .. 1 F PRCN
  Contains 2.16.840.1.113883.10.20.22.4.25 Precondition for Substance Administration (DYNAMIC)
  Schematron assert role red error
  test cda:doseQuantity | cda:rateQuantity
  Message Medication Activity SHOULD include doseQuantity OR rateQuantity