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The Medication section details a patient's current medications and pertinent medication history.  At a minimum it lists currently active medications.  It can also describe a patient's prescription and dispense history and information about intended monitoring. There is a separate Entry section for each medication.

This topic details the data elements that must be present in the Medication section of a Continuity of Care Document (CCD) for it to be processed by the Clinical:MedicationCcda data space (hosted in Data Engine).

(R) - Required elements for the Medication section and its sub-sections to be processed correctly in the Clinical:MedicationCcda data space.

(O) - Optional elements that are processed if provided in correct format.

Required (R) elements that are children of an Optional (O) element are only required for the immediate parent element to be processed.

Medications Section Details

Medication Section Template ID

component/section/templateId

Specifies which CCDA R2.1 template is being used to determine the requirements, format and structure of the information in the Medication section.

...
<component>
	<section>
    	<templateId root="2.16.840.1.113883.10.20.22.2.1"/>
	</section>
</component>
...
SectionElementAttributeValueNotes
MedicationtemplateIdrootMust be either 2.16.840.1.113883.10.20.22.2.1 or 2.16.840.1.113883.10.20.22.2.1.1The unique identifier for the CCDA R2.1 template that defines the requirements, format and structure for the entire Medication section in Continuity of Care (CCD) documents.

Medication Section Code

component/section/code

Labels this section as Medications History.

...
<component>
	<section>
    	<templateID root="2.16.840.1.113883.10.20.22.2.1"/>
 		<code code="10160-0" codeSystem=”2.16.840.1.113883.6.1"/>
	</section>
</component>
...
SectionElementAttributeValueNotes
MedicationcodecodeMust be 10160-0In the Logical Observation Identifiers Names and Codes (LOINC) coding system this alphanumeric string (or 'code') represents Medications History.
codeSystemMust be 2.16.840.1.113883.6.1The unique numerical identifier for the Logical Observation Identifiers Names and Codes (LOINC) coding system. This system will be used to resolve the value in the code attribute (10160-0).

Medication Section Confidentiality Code

component/section/confidentialityCode

Indicates the level of security that should be applied to this Medication section. The level of security that should be applied is typically driven by the guidelines of the system that generated the CCD.

...
<component>
	<section>
    	<templateID root="2.16.840.1.113883.10.20.22.2.1"/>
		<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
	</section>
</component>
... 
SectionElementAttributeValueNotes
Medication
confidentialityCode
codeMust include an alphanumeric string of any length. The HL7-supported confidentiality coding system is typically used, where security levels are indicated as:
  • U - unrestricted
  • L - low
  • N - normal
  • - moderate
  • R - restricted
  • V - very restricted

If no code attribute is present, a nullFlavor attribute MUST be present instead. Otherwise, the code element will not be processed. Refer to How nullFlavor Values are Processed in Coded Elements for details on nullFlavor attributes.

codeSystemMust include an alphanumeric string of any length, typically in the following format: 2.16.840.1.113883.X.XX.X. The HL7-supported confidentiality coding system is indicated by 2.16.840.1.113883.5.25A numerical string that specifies which system will be used to translate the identifier provided in the code attribute.

Medication Section Author

component/section/entry/author

Details information about the author of the section. Refer to Assigned Author Element for more details on what information can be available for the author section. 

...
<component>
	<section>
    	<templateID root="2.16.840.1.113883.10.20.22.2.1"/>
		<author>
			<assignedAuthor>
				...
			</assignedAuthor>
		</author>
	</section>
</component>
...

Medication Section Informant

component/section/entry/informant

The person providing specific clinical information regarding the medication. For example, any clinician interacting with the patient and this medication. 

...
<component>
	<section>
    	<templateID root="2.16.840.1.113883.10.20.22.2.1"/>
 		<code code="10160-0" codeSystem=”2.16.840.1.113883.6.1"/>
		<informant>
			<assignedEntity>
				<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
			<assignedEntity>
		</informant>
	</section>
</component>
...
SectionElementAttributeValueNotes

Medication

  • information
    • assignedEntity
      • id
extensionMust be an alphanumeric string of any lengthThis attribute is optional.
root

Must be an alphanumeric string in an OID (object identifier) or UUID (universally unique identifier) format.

For example, OID: 2.16.840.1.1113883.x.xx.x or UUID: 53459040-b1b4-49ed-ae1f-a52c8c502df4.


Substance Administration

component/section/entry/substanceAdministration/templateId 

Describes the administration of substances that have actually occurred (e.g.: pills ingested or injections given) or are intended to occur (e.g.: take pills twice a day for five days).

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			...
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Substance AdministrationsubstanceAdministrationclassCode

Must be SBADM

Uniquely identifies the medication substance administrations (SBADM) that have occurred or are intended to occur.
moodCodeMust be EVNIndicates that this entry is an event (EVN) that has happened or is an ongoing activity, or was documented from a past activity.

Substance Administration Template ID

component/section/entry/substanceAdministration/templateId 

Specifies which CCDA R2.1 template is being used to determine the requirements, format and structure of the information in the Substance Administration (or 'Medication Activity') subsection.

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...
 
SubsectionElementAttributeValueNotes
Substance AdministrationtemplateIdroot

Must be 2.16.840.1.113883.10.20.22.4.16

The unique identifier for the CCDA R2.1 template that defines the requirements, format and structure for the Substance Administration (or 'Medication Activity') subsection in Continuity of Care Documents (CCDs).

Substance Administration Status Code

component/section/entry/substanceAdministration/statusCode 

Indicates whether the medication in this entry is still being taken or administered.

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<statusCode code="completed"/>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Substance AdministrationstatusCodecode

Must be either:

  • completed; or
  • active

Manufactured Product Template ID

component/section/entry/substanceAdministration/consumable/manufacturedProduct/templateId

Specifies which CCDA R2.1 template is being used to determine the requirements, format and structure of the information in the Manufactured Product subsection which contains information about the medication substance in a combined form, which includes its ingredients, strengths, and dose.

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<consumable> 
            		<manufacturedProduct> 
                		<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
            		</manufacturedProduct> 
        		</consumable>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Substance Administration
  • consumable
    • manufacturedProduct
      • templateId
root

Must be 2.16.840.1.113883.10.20.22.4.23

The unique identifier for the CCDA R2.1 template that defines the requirements, format and structure of the Manufactured Product subsection in Continuity of Care Documents (CCDs).

Manufactured Material Code

component/section/entry/substanceAdministration/consumable/manufacturedProduct/manufacturedMaterial/code

Provides information about the medication including its ingredients, strengths and dose.

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<consumable> 
            		<manufacturedProduct> 
                		<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
						<manufacturedMaterial>
							<code code="329498" codeSystem="2.16.840.1.113883.6.88" displayName="Albuterol 0.09 MG/ACTUAT inhalant solution"/> 
						</manufacturedMaterial>
            		</manufacturedProduct> 
        		</consumable> 
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Substance Administrationcodecode

Must be an alphanumeric string (or 'code') that represents the medication in the RxNorm coding system.

If no code attribute is present, a nullFlavor attribute MUST be present instead. Otherwise, the code element will not be processed. Refer to How nullFlavor Values are Processed in Coded Elements for details on nullFlavor attributes.

codeSystemMust be 2.16.840.1.113883.6.88.This is the unique identifier for the RxNorm Coding System. This is the coding system that will be used to resolve the value provided in the code attribute.
The Clinical:MedicationCcda data space attempts to resolve codes, using the Coding System specified, during message processing. If the values provided for code and codeSystem are correct, the code is resolved. If the values provided for code and codeSystem are not correct, they are simply stored as provided.

Substance Administration Effective Time

component/section/entry/substanceAdministration/effectiveTime

Indicates the date and time that the substance was administered. Refer to How Effective Time values are processed for details on the different ways effectiveTime information can be processed.

...
<component>
	<section>
    	<templateID root="2.16.840.1.113883.10.20.22.2.1"/>
 		<code code="10160-0" codeSystem=”2.16.840.1.113883.6.1"/>
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
  				<effectiveTime>
					<value="20170101#231833-0500"/>
    			</effectiveTime> 
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...

Substance Administration Author

component/section/entry/substanceAdministration/author

Details of the person prescribing the medication or the person adding notes to the document about the medication. Refer to Assigned Author Element for more details on what information can be available for the author section.

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<author>
            		<assignedAuthor>
                		...
            		</assignedAuthor>
       		 	</author>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...

Substance Administration routeCode

component/section/entry/substanceAdministration/routeCode

Indicates how the medication was administered or taken (e.g.: nasal, oral or injection).

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<routeCode code="C38216" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="RESPIRATORY (INHALATION)"/>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...
SectionElementAttributeValueNotes
Substance AdministrationrouteCodecode

Alphanumeric string that represents the way the medication is taken or administered.


codeSystem

The unique identifier for the Coding System that should be used to resolve the value specified in the code attribute. Typically in the following format: 2.16.840.1.113883.x.xx.x.x.

This Coding System will be used to resolve the value in the code attribute.
The Clinical:MedicationCcda data space attempts to resolve codes, using the Coding System specified, during message processing.
If the values provided for code and codeSystem are correct, the code is resolved.
If the values provided for code and codeSystem are not correct, they are simply stored as provided

Substance Administration Dose Quantity

component/section/entry/substanceAdministration/doseQuantity

Indicates the number of products given per medication administration.

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<doseQuantity value="1"/>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...
SectionElementAttributeValueNotes
Substance AdministrationdoseQuantityvalueMust be an alphanumeric string of any length

This attribute is required. It identifies the number of products administered. For example, 2 refers to 2 tablets.

unit

Should be an alphanumeric string of any length that indicates a unit of measurement. For example:

  • min (minutes)
  • hour (hours)
  • % (percent)
  • cm (centimetres)
  • g (grams)
  • g/L (grams per litre)
  • mol (mole)

This attribute is optional. It identifies the unit in which the product was administered. For example, mg indicates milligrams.

Substance Administration Unit Code

component/section/entry/substanceAdministration/administrationUnitCode

Indicates the physical form of a medication (e.g.: ointment, powder or solution).

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<administrationUnitCode code="C42944" codeSystem="2.16.840.1.113883.3.88.12.3221.8.11" codeSystemName="NCI Thesaurus" displayName="INHALANT"/>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...
SectionElementAttributeValueNotes
Substance AdministrationadministrationUnitCodecode 

 Alphanumeric string that represents the physical form of the medication.

Each Coding System assigns a unique alphanumeric string (or 'code') to represent each physical form.

If no code attribute is present, a nullFlavor attribute MUST be present instead. Otherwise, the code element will not be processed. Refer to How nullFlavor Values are Processed in Coded Elements for details on nullFlavor attributes.

codeSystemThe unique identifier for the Coding System that should be used to resolve the value specified in the code attribute.
Typically in the following format: 2.16.840.1.113883.x.xx.x.x.

The Clinical:MedicationCcda data space attempts to resolve codes, using the Coding System specified, during message processing.
If the values provided for code and codeSystem are correct, the code is resolved.
If the values provided for code and codeSystem are not correct, they are simply stored as provided.

Substance Administration Text

component/section/entry/substanceAdministration/text

Provides additional information about the medication or its administration.

This element can be expressed as a String or Reference.

Substance Administration Text as a String

Provides the additional information about the medication, or its administration, as a simple string.

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<text="Additional information text"/>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...
SectionElementAttributeValueNotes
Substance AdministrationtextN/A

Alphanumeric string with spaces but no line breaks.


Substance Administration Text as a Reference

References the section where the additional information about the medication, or its administration, is provided.

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<text>
					<reference value="#MEDSIG48586243" />
				</text>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...
SectionElementAttributeValueNotes
Substance Administration
  • text
    • reference
value

Specifies the Content ID for the text in a separate section. For example, #MEDSIG48586243.

For more information about the use of reference numbers for textual information see Text Sample.

Substance Administration Performer

component/section/entry/substanceAdministration/performer

Details of the person administering the medication. Refer to Performer Element for more details on what information can be available for the performer section. 

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<performer>
					<assignedEntity>
						...
					<assignedEntity>
				</performer>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...

Substance Administration Informant

component/section/entry/substanceAdministration/informant

The unique identifier of the person providing specific clinical information regarding the medication. For example, the site-specific alphanumerical ID for any clinician interacting with the patient and this medication.

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<informant>
					<assignedEntity>
						<id extension="KP00017" root="2.16.840.1.113883.19.5"/>
					<assignedEntity>
				</informant>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...
SectionElementAttributeValueNotes
Substance Administration
  • informat
    • assignedEntity
      • id
extensionAlphanumeric string of any lengthThis attribute is optional. Part of the information that uniquely identifies the entity providing clinical information regarding the medication.
root

Alphanumeric string in an OID (object identifier) or UUID (universally unique identifier) format.

For example, OID: 2.16.840.1.1113883.x.xx.x or UUID: 53459040-b1b4-49ed-ae1f-a52c8c502df4.


Medication Indication

component/section/entry/substanceAdministration/entryRelationship

Indicates that the information being provided in this subsection explains the reason and/or rationale for the administration of the medication (or 'medication indication').

...
<component>
	<section>
		...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<entryRelationship typeCode="RSON">
					<observation classCode="OBS" moodCode="EVN">
						...
					</observation>
				</entryRelationship>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...

Subsection

Element

Attribute

Value

Notes

Medication Indication

entryRelationship

typeCode

Must be RSON

Indicates that the information in this subsection provides reason (RSON) for the administration of the immunization. Contains a child observation element.

  • entryRelationship
    • observation
classCodeMust be OBSSpecifies the general nature of the entry, which in this case is an observation (OBS).
moodCodeMust be EVNIndicates that this entry is an event (EVN) that has happened or is an ongoing activity, or was documented from a past activity.

Medication Indication Template ID

component/section/entry/substanceAdministration/entryRelationship/templateId

Specifies which CCDA R2.1 template is being used to determine the requirements, format and structure of the information in this subsection - which explains why the medication was prescribed ('medication indication').

...
<component>
	<section>
		...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<entryRelationship typeCode="RSON">
					<observation classCode="OBS" moodCode="EVN">
						<templateId root="2.16.840.1.113883.10.20.22.4.19">
					</observation>
				</entryRelationship>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...

Section

Element

Attribute

Value

Notes

Medication Indication

templateId

root

Must be 2.16.840.1.113883.10.20.22.4.19.

The unique identifier for the CCDA R2.1 template that defines the requirements, format and structure of the 'Medication Indication' subsection in Continuity of Care (CCD) documents.

Medication Indication Value

component/section/substanceAdministration/entryRelationship/observation/value

Indicates the specific reason and/or rationale for the administration of the medication (or 'medication indication').

If no value is available, a nullFlavor attribute MUST be present instead. Otherwise, the value element will not be processed. Refer to How nullFlavor Values are Processed in Coded Elements for details on nullFlavor attributes.

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
					<observation classCode="OBS" moodCode="EVN">
						<templateId root="2.16.840.1.113883.10.20.22.4.19">
						<value xsi:type="CD" code="32398004" displayName="Bronchitis" codeSystem="2.16.840.1.113883.6.96"/> 
					<observation>
				</entryRelationship>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Medication Indicationvaluexsi:typeMust be CD

Indicates that this is a 'Coded Value'.

'Coded Values' provide a code (an alphanumeric string that represents a name or description) and the unique identifier for the code system that specifies that the alphanumeric string represents a specific name or description.

For example, in the SNOMED CT coding system, the code 46635009 represents Diabetes mellitus type.

code

Must be one of the the codes specified by the SNOMED CT coding system.

For example, 46635009 (Diabetes mellitus type), 132398004 (Bronchitis) or 31712002 (Primary Biliary Cirrhosis).


codeSystem Must be 2.16.840.1.113883.6.96This is the unique identifier for the SNOMED CT coding system. It will be used to translate the value provided in the code attribute.

The Clinical:MedicationCcda data space attempts to resolve codes, using the Coding System specified, during message processing.
If the values provided for code and codeSystem are correct, the code is resolved.
If the values provided for code and codeSystem are not correct, they are simply stored as provided.

Medication Instruction

component/section/entry/entryRelationship

Indicates that the information in this subsection explains how the medication should be taken or administered (or 'Medication Instruction').

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<entryRelationship typeCode="SUBJ" inversionInd="true">
					<act classCode="ACT" moodCode="INT">
						...
					</act>
				</entryRelationship>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...

Subsection

Element

Attribute

Value

Notes

Medication Instruction

entryRelationship

typeCode

Must be SUBJ

When combined with a templateId of 2.16.840.1.113883.10.20.22.4.20, this value indicates that this subsection contains the 'Medication Instruction' - which details how the medication should be taken or administered.

  • entryRelationship
    • act
classCodeMust be ACTSpecifies the general nature of the entry, which in this case is an activity (ACT).
moodCodeMust be INTIndicates that this entry is a clinical statement that is intended (INT) to happen.

Medication Instruction Template ID

component/section/entry/entryRelationship/act/templateId

Specifies which CCDA R2.1 template is being used to determine the requirements, format and structure of the information in the 'Medication Instruction' subsection - which explains how the medication should be administered.

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<entryRelationship typeCode="SUBJ" inversionInd="true">
					<act classCode="ACT" moodCode="INT">
						<templateId root="2.16.840.1.113883.10.20.22.4.20"/>
					</act>
				</entryRelationship>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...
SectionElementAttributeValueNotes
Medication InstructiontemplateIdroot

Must be 2.16.840.1.113883.10.20.22.4.20

The unique identifier for the CCDA R2.1 template that defines the requirements, format and structure of the 'Medication Instruction' subsection in Continuity of Care Documents (CCDs).

Medication Instruction Text

component/section/entry/act/entryRelationship/supply/entryRelationship/act/text

Details how the medication should be taken or administered (or 'medication instructions').

This element can be expressed as a String or Reference.

Instruction Text as a String

Provides the information about how the medication should be taken or administered as a simple string.

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<entryRelationship typeCode="SUBJ" inversionInd="true">
					<act classCode="ACT" moodCode="INT">
						<templateId root="2.16.840.1.113883.10.20.22.4.20"/>
						<text>This is a simple text string.</text>
					</act>
				</entryRelationship>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Medication InstructiontextN/A Alphanumeric string including spaces but not line breaks.

Instruction Text as a Reference

References the section where the additional information, about how the medication should be taken or administered, can be found in the Continuity of Care Document (CCD).

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<entryRelationship typeCode="SUBJ" inversionInd="true">
					<act classCode="ACT" moodCode="INT">
						<templateId root="2.16.840.1.113883.10.20.22.4.20"/>
						<text>
							<reference value="#MEDSIG48586243"/>
						</text>
					</act>
				</entryRelationship>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Medication Instruction
  • text
    • reference
valueSpecifies the Content ID for the ext in a separate section. For example, #MEDSIG48586243.For more information about the use of reference values for textual information see Text Sample.

Medication Supply Order

component/section/substanceAdministration/entryRelationship

Details the medication prescription (or 'medication supply order').

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<entryRelationship typeCode="REFR">
					<supply classCode="SPLY" moodCode="INT">
						...
					</supply>
				</entryRelationship>
    		</substanceAdministration>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes

Medication Supply Order

entryRelationshiptypeCodeMust be REFRIndicates that the information in this subsection relates to the parent substance administration act. Contains a child supply element.
  • entryRelationship
    • supply
classCodeMust be SPLYSpecifies the general nature of the entry, which in this case is an act of supplying the relevant substance (SPLY).
moodCodeMust be INTIndicates that this entry is a clinical statement that is intended (INT) to happen.

Medication Supply Order Template ID

component/section/substanceAdministration/entryRelationship/supply/templateId

Specifies which CCDA R2.1 template is being used to determine the requirements, format and structure of the information in the 'Medication Supply Order' section - which details the prescription.

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<entryRelationship typeCode="REFR">
					<supply classCode="SPLY" moodCode="INT">
						<templateId root="2.16.840.1.113883.10.20.22.4.17"/>
					</supply>
				</entryRelationship>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Medication Supply OrdertemplateIdrootMust be 2.16.840.1.113883.10.20.22.4.17The unique identifier for the CCDA R2.1 template that defines the requirements, format and structure of the 'Medication Supply Order' subsection in Continuity of Care Documents (CCDs).

Medication Supply Order ID

component/section/substanceAdministration/entryRelationship/supply/id

Identifies the person or organization responsible for the prescription (or 'Medication Supply Order').

If the id element has a nullFlavor attribute set, the id will not be mapped to the model.

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<entryRelationship typeCode="REFR">
					<supply classCode="SPLY" moodCode="INT">
						<templateId root="2.16.840.1.113883.10.20.22.4.17"/>
						<id root="2.16.840.1.1113883.2.23.4" extension="Organization Name"/> 
					</supply>
				</entryRelationship>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...

Subsection

Element

Attribute

Value

Notes

Medication Supply Order

id

extension

 Alphanumeric string of any length

This attribute is optional. Part of the information that uniquely identifies the supply order ID of the person or organization responsible for the prescription

root

Alphanumeric string in an OID (object identifier) or UUID (universally unique identifier) format.

For example, OID: 2.16.840.1.1113883.x.xx.x or UUID: 53459040-b1b4-49ed-ae1f-a52c8c502df4.



Medication Supply Order Effective Time

component/section/substanceAdministration/entryRelationship/supply/effectiveTime

Specifies the time period within which the prescription (or 'Medication Supply Order') can be filled. Refer to How Effective Time values are processed for details on the different ways effectiveTime information can be processed.

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<entryRelationship typeCode="REFR">
					<supply classCode="SPLY" moodCode="INT">
						<templateId root="2.16.840.1.113883.10.20.22.4.17"/>
						<effectiveTime>
							<value="20170101#231833-0500"/> 
						</effectiveTime>
					</supply>
				</entryRelationship>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...

Medication Supply Order Quantity

component/section/substanceAdministration/entryRelationship/supply/quantity

Specifies the amount of medication in the prescription (or 'Medication Supply Order').

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<entryRelationship typeCode="REFR">
					<supply classCode="SPLY" moodCode="INT">
						<templateId root="2.16.840.1.113883.10.20.22.4.17"/>
						<quantity value="10" unit="mg"/>
					</supply>
				</entryRelationship>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Medication Supply OrderquantityvalueMust be an alphanumeric string of any length
unit

Should be an alphanumeric string of any length that indicates a unit of measurement. For example:

  • min (minutes)
  • hour (hours)
  • % (percent)
  • cm (centimetres)
  • g (grams)
  • g/L (grams per litre)
  • mol (mole)
This attribute is optional. It identifies the unit in which the product was administered. For example, mg indicates milligrams.

Medication Supply Order Author

component/section/substanceAdministration/entryRelationship/supply/author

The unique identifier for the person, department or organization that created or authorized the prescription (or 'Medication Supply Order'). Refer to Assigned Author Element for more details on what information can be available for the author section.

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<entryRelationship typeCode="REFR">
					<supply classCode="SPLY" moodCode="INT">
						<templateId root="2.16.840.1.113883.10.20.22.4.17"/>
						<author>
                        	<assignedAuthor>
                        		...
                        	</assignedAuthor>
                    	</author>
					</supply>
				</entryRelationship>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...

Medication Free Text Sig

component/section/substanceAdministration/entryRelationship/substanceAdministration

Indicates specific instructions on how the medication should be administered or taken.

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<entryRelationship typeCode="COMP">
					<substanceAdministration classCode="SBADM" moodCode="EVN">
						...
					</substanceAdministration>
				</entryRelationship>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Medication Free Text Sig

entryRelationship

typeCodeMust be COMP

Indicates that this is a component (COMP) of the administered substance.

  • entryRelationship
    • substanceAdministration
classCodeMust be SBADMUniquely identifies the medication administrations that have occurred or are intended to occur.
moodCodeMust be EVNIndicates that this entry is an event (EVN) that has happened or is an ongoing activity, or was documented from a past activity.

Medication Free Text Sig Template ID

component/section/substanceAdministration/entryRelationship/substanceAdministration/templateId

Specifies which CCDA R2.1 template is being used to determine the requirements, format and structure of the information in the 'Free Text Sig' section - which details the prescription.

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<entryRelationship typeCode="COMP">
					<substanceAdministration classCode="SBADM" moodCode="EVN">
						<templateId root="2.16.840.1.113883.10.20.22.4.147"/>
					</substanceAdministration>
				</entryRelationship>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Medication Free Text Sig

templateId

rootMust be 2.16.840.1.113883.10.20.22.4.147

Medication Free Text Sig Text

component/section/substanceAdministration/entryRelationship/substanceAdministration/text

Details how the medication should be taken or administered (or 'medication instructions').

This element can be expressed as a String or Reference.

Free Text Sig Text as a String

Provides the information about how the medication should be taken or administered as a simple string.

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<entryRelationship typeCode="COMP">
					<substanceAdministration classCode="SBADM" moodCode="EVN">
						<templateId root="2.16.840.1.113883.10.20.22.4.147"/>
						<text>Take 150mg of the paracetamol twice a day</text>
					</substanceAdministration>
				</entryRelationship>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Medication Free Text SigtextN/A Alphanumeric string including spaces but not line breaks.

Free Text Sig Text as a Reference

References the section where the additional information, about how the medication should be taken or administered, can be found in the Continuity of Care Document (CCD).

...
<component>
	<section>
    	...
		<entry typeCode="DRIV"> 
    		<substanceAdministration classCode="SBADM" moodCode="EVN"> 
    			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
				<entryRelationship typeCode="COMP">
					<substanceAdministration classCode="SBADM" moodCode="EVN">
						<templateId root="2.16.840.1.113883.10.20.22.4.147"/>
						<text>
							<reference value="#MEDSIG48586243"/>
						</text>
					</substanceAdministration>
				</entryRelationship>
    		</substanceAdministration> 
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Medication Free Text Sig
  • text
    • reference
valueSpecifies the Content ID for the ext in a separate section. For example, #MEDSIG48586243.For more information about the use of reference values for textual information see Text Sample.


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1 Comment

  1. The "Medication Section Informant" section contains two opening "assignedEntity" tags, but no matching close tag:


        /component/section/informant/assignedEntity