Non-Normative Content The Normative content for these specifications may be found on the HL7, IHE, and HITSP web sites.

Medication Activity

[SubstanceAdministration: templateId 2.16.840.1.113883.10.20.22.4.16]

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.

  1. SHALL contain exactly one [1..1] templateId ( CONF:7499, CONF:10504 ) such that it
    1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.16"
  2. SHALL contain exactly one [1..1] @classCode="SBADM" (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) (CONF:7496)
  3. SHALL contain exactly one [1..1] @moodCode, where the @code SHALL be selected from ValueSet MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03 (CONF:7497)
  4. SHALL contain at least one [1..*] id (CONF:7500)
  5. MAY contain zero or one [0..1] code (CONF:7506)
  6. SHALL contain exactly one [1..1] statusCode (CONF:7507)
  7. MAY contain zero or one [0..1] routeCode, where the @code SHALL be selected from ValueSet Medication Route FDA Value Set 2.16.840.1.113883.3.88.12.3221.8.7 STATIC 1 (CONF:7514)
  8. MAY contain zero or one [0..1] approachSiteCode, where the @code SHALL be selected from ValueSet Body Site Value Set 2.16.840.1.113883.3.88.12.3221.8.9 STATIC 2 (CONF:7515)
  9. SHOULD contain zero or one [0..1] doseQuantity (CONF:7516)
    • Pre-coordinated consumable: If the consumable code is a precoordinated 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

  10. MAY contain zero or one [0..1] rateQuantity (CONF:7517)
  11. MAY contain zero or one [0..1] maxDoseQuantity (CONF:7518)
  12. MAY contain zero or one [0..1] administrationUnitCode, where the @code MAY be selected from ValueSet Medication Product Form Value Set 2.16.840.1.113883.3.88.12.3221.8.11 STATIC 1 (CONF:7519)
  13. MAY contain zero or one [0..1] performer (CONF:7522)
    1. Contains exactly one [1..1] CDA Performer2
  14. MAY contain zero or one [0..1] entryRelationship (CONF:7539, CONF:7540, CONF:16088)
    1. Contains @typeCode="SUBJ" SUBJ
    2. Contains exactly one [1..1] Instructions (templateId: 2.16.840.1.113883.10.20.22.4.20)
  15. MAY contain zero or one [0..1] entryRelationship (CONF:7543, CONF:7547, CONF:16089)
    1. Contains @typeCode="REFR" REFR
    2. Contains exactly one [1..1] Medication Supply Order (templateId: 2.16.840.1.113883.10.20.22.4.17)
  16. MAY contain zero or one [0..1] entryRelationship (CONF:7552, CONF:7544, CONF:16091)
    1. Contains @typeCode="CAUS" CAUS
    2. Contains exactly one [1..1] Reaction Observation (templateId: 2.16.840.1.113883.10.20.22.4.9)
  17. MAY contain zero or more [0..*] entryRelationship (CONF:7536, CONF:7537, CONF:16087)
    1. Contains @typeCode="RSON" RSON
    2. Contains exactly one [1..1] Indication (templateId: 2.16.840.1.113883.10.20.22.4.19)
  18. MAY contain zero or more [0..*] entryRelationship (CONF:7549, CONF:7553, CONF:16090)
    1. Contains @typeCode="REFR" REFR
    2. Contains exactly one [1..1] Medication Dispense (templateId: 2.16.840.1.113883.10.20.22.4.18)
  19. MAY contain zero or more [0..*] precondition (CONF:7546, CONF:16092)
    1. Contains exactly one [1..1] Precondition For Substance Administration (templateId: 2.16.840.1.113883.10.20.22.4.25)
  20. MAY contain zero or more [0..*] participant (CONF:7523, CONF:7524, CONF:16086)
    1. Contains exactly one [1..1] Drug Vehicle (templateId: 2.16.840.1.113883.10.20.22.4.24)
  21. SHOULD contain zero or one [0..1] text (CONF:7501)
  22. 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

  23. SHALL contain exactly one [1..1] consumable (CONF:7520)
    1. This consumable SHALL contain exactly one [1..1] manufacturedProduct, where its type is Medication Information (CONF:16085)
      1. Contains exactly one [1..1] Medication Information (templateId: 2.16.840.1.113883.10.20.22.4.23)
  24. Medication Activity SHOULD include doseQuantity OR rateQuantity
  25. text, if present, SHOULD contain zero or one [0..1] reference (CONF:15977)
  26. reference, if present, SHOULD contain zero or one [0..1] @value (CONF:15978)
  27. 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:15979)
  28. SHALL contain exactly one [1..1] effectiveTime such that it SHALL contain exactly one [1..1] @xsi:type = "IVL_TS" (CONF:7508, CONF:9104)
  29. effectiveTime with @xsi:type="IVL_TS" SHALL contain exactly one [1..1] low
  30. effectiveTime with @xsi:type="IVL_TS" SHALL contain exactly one [1..1] high
  31. SHOULD contain zero or one [0..1] effectiveTime such that it SHALL contain exactly one [1..1] @xsi:type = "PIVL_TS" or "EIVL_TS" (CONF:7513, CONF:9105)
  32. effectiveTime with @xsi:type = "PIVL_TS" or "EIVL_TS" SHALL contain exactly one [1..1] @operator="A" (CONF:9106)
  33. doseQuantity, if present, SHOULD contain zero or one [0..1] @unit, which SHALL be selected from ValueSet UCUM Units of Measure (case sensitive) 2.16.840.1.113883.1.11.12839 DYNAMIC (CONF:7526)
  34. participant with target entry Drug Vehicle SHALL contain exactly one [1..1] @typeCode="CSM" (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90) (CONF:7524)
  35. entryRelationship with target entry Instructions SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:7542)
  36. Precondition for Substance Administration SHALL contain exactly one [1..1] @typeCode="PRCN" (CodeSystem: HL7ActRelationshipType 2.16.840.1.113883.5.1002) (CONF:7550)

Medication Activity example

<substanceadministration xmlns="urn:hl7-org:v3">
  <id root="MDHT" extension="1197734584"/>
  <code code="767741391"/>
  <text>Text Value</text>
  <statusCode code="completed"/>
  <effectiveTime value="20130627"/>
  <repeatNumber value="1"/>
  <routeCode code="870642998"/>
  <approachSiteCode code="2141252607"/>
  <doseQuantity/>
  <rateQuantity/>
  <maxDoseQuantity/>
  <consumable>
    <manufacturedProduct>
      <id root="MDHT" extension="1075021350"/>
      <manufacturedMaterial>
        <code codeSystem="2.16.840.1.113883.6.88" codeSystemName="RxNorm"/>
      </manufacturedMaterial>
      <manufacturerOrganization/>
    </manufacturedProduct>
  </consumable>
  <performer/>
  <entryRelationship>
    <supply>
      <id root="MDHT" extension="986791119"/>
      <code code="1330027243"/>
      <text>Text Value</text>
      <statusCode code="completed"/>
      <effectiveTime value="20130627"/>
      <repeatNumber value="1"/>
      <author/>
      <entryRelationship>
        <act>
          <id root="MDHT" extension="836891308"/>
          <code code="801529695"/>
          <text>Text Value</text>
          <statusCode code="completed"/>
          <effectiveTime>
            <low value="2013"/>
            <high value="2013"/>
          </effectiveTime>
        </act>
      </entryRelationship>
    </supply>
  </entryRelationship>
  <entryRelationship>
    <observation>
      <id root="MDHT" extension="1153896159"/>
      <code code="1888065095"/>
      <text>Text Value</text>
      <statusCode code="completed"/>
      <effectiveTime>
        <low value="2013"/>
        <high value="2013"/>
      </effectiveTime>
      <repeatNumber value="1"/>
      <entryRelationship>
        <observation>
          <id root="MDHT" extension="764342790"/>
          <code code="1389155745"/>
          <text>Text Value</text>
          <statusCode code="completed"/>
          <effectiveTime>
            <low value="2013"/>
            <high value="2013"/>
          </effectiveTime>
          <repeatNumber value="1"/>
        </observation>
      </entryRelationship>
      <entryRelationship>
        <procedure>
          <id root="MDHT" extension="2021477495"/>
          <code code="1774611513"/>
          <text>Text Value</text>
          <statusCode code="completed"/>
          <effectiveTime>
            <low value="2013"/>
            <high value="2013"/>
          </effectiveTime>
          <approachSiteCode code="758227294"/>
          <specimen/>
          <performer/>
          <entryRelationship typeCode="COMP" inversionInd="true"/>
          <entryRelationship>
            <observation/>
          </entryRelationship>
          <entryRelationship>
            <substanceAdministration/>
          </entryRelationship>
          <entryRelationship>
            <act/>
          </entryRelationship>
        </procedure>
      </entryRelationship>
      <entryRelationship>
        <substanceAdministration>
          <id root="MDHT" extension="1621034455"/>
          <code code="1776010886"/>
          <text>Text Value</text>
          <statusCode code="completed"/>
          <effectiveTime value="20130627"/>
          <repeatNumber value="1"/>
          <routeCode code="1249043323"/>
          <approachSiteCode code="634232641"/>
          <doseQuantity/>
          <rateQuantity/>
          <maxDoseQuantity/>
          <consumable/>
          <performer/>
          <entryRelationship>
            <supply/>
          </entryRelationship>
          <entryRelationship>
            <observation/>
          </entryRelationship>
          <entryRelationship>
            <act/>
          </entryRelationship>
          <entryRelationship>
            <observation/>
          </entryRelationship>
          <entryRelationship>
            <supply/>
          </entryRelationship>
          <precondition/>
        </substanceAdministration>
      </entryRelationship>
    </observation>
  </entryRelationship>
  <entryRelationship>
    <act>
      <id root="MDHT" extension="743140864"/>
      <code code="356322747"/>
      <text>Text Value</text>
      <statusCode code="completed"/>
      <effectiveTime>
        <low value="2013"/>
        <high value="2013"/>
      </effectiveTime>
    </act>
  </entryRelationship>
  <entryRelationship>
    <observation>
      <id root="MDHT" extension="2132327396"/>
      <code code="308941225"/>
      <text>Text Value</text>
      <statusCode code="completed"/>
      <effectiveTime>
        <low value="2013"/>
        <high value="2013"/>
      </effectiveTime>
      <repeatNumber value="1"/>
    </observation>
  </entryRelationship>
  <entryRelationship>
    <supply>
      <id root="MDHT" extension="1041418140"/>
      <code code="2072647019"/>
      <text>Text Value</text>
      <statusCode code="completed"/>
      <effectiveTime value="20130627"/>
      <repeatNumber value="1"/>
      <performer>
        <assignedEntity/>
      </performer>
      <entryRelationship>
        <supply>
          <id root="MDHT" extension="1193700439"/>
          <code code="1643207886"/>
          <text>Text Value</text>
          <statusCode code="completed"/>
          <effectiveTime value="20130627"/>
          <repeatNumber value="1"/>
          <author/>
          <entryRelationship>
            <act/>
          </entryRelationship>
        </supply>
      </entryRelationship>
    </supply>
  </entryRelationship>
  <precondition>
    <criterion/>
  </precondition>
</substanceadministration>