To accurately process the Header and Medications sections of a C-CDA CCD, in the Clinical:MedicationCcda Data Space, certain elements are required and must contain valid information. There are also certain elements that are optional but, if present, must also contain valid information.  There are also certain elements that are optional but, if present, must also contain valid information.

In the Header section, there are eight elements that are required and three elements that are optional. For more information see Header.

In the Medications section, there are six elements that are required and sixteen elements that are optional

This checklist provides a description of the Medications elements and how they should be validated prior to processing in CDS.  

The medications section of a CCD will typically have several sub-sections to represent different medication-related activities:

  • Medication Activity
  • Medication Information
  • Medication Supply Order
  • Medication Instruction
  • Medication Indication

Each sub-section is uniquely identified by its templateId. When elements occur in multiple sub-sections (for example, valuecodeeffectiveTime), the templateId helps differentiate validation requirements.

 Section or Sub-SectionElementXPath
Required Elements

Medication Section 

templateIdsection/templateID
Medication Activity 

templateIdsection/entry/substanceAdministration/templateId
statusCodesection/entry/substanceAdministration/statusCode
effectiveTimesection/entry/substanceAdministration/effectiveTime
Medication InformationtemplateIdsection/entry/substanceAdministration/consumable/manufacturedProduct/templateId
codesection/entry/substanceAdministration/consumable/manufacturedProduct/manufacturedMaterial/code
Optional (but validated 
if present) Elements
Medication Section 
confidentialityCodesection/confidentialityCode
Medication Activity 

routeCodesection/entry/substanceAdministration/routeCode
doseQuantitysection/entry/substanceAdministration/doseQuantity
administrationUnitCodesection/entry/substanceAdministration/administrationUnitCode 
authorsection/entry/substanceAdministration/author
performersection/entry/substanceAdministration/performer
informantsection/entry/substanceAdministration/informant
Medication Supply Order 

templateIdsection/substanceAdministration/entryRelationship/supply/templateId
idsection/substanceAdministration/entryRelationship/supply/id
effectiveTimesection/substanceAdministration/entryRelationship/supply/effectiveTime
quantitysection/substanceAdministration/entryRelationship/supply/quantity
authorsection/substanceAdministration/entryRelationship/supply/author
Medication Instruction

templateIdsection/substanceAdministration/entryRelationship/supply/entryRelationship/act/templateId
textsection/substanceAdministration/entryRelationship/supply/entryRelationship/act/text
Medication Indication
templateIdsection/substanceAdministration/entryRelationship/observation/templateId
valuesection/substanceAdministration/entryRelationship/observation/value

A full copy of the sample Continuity of Care Document (CCD) used in this section is attached.

 


Required Elements

This section details the elements that are required for processing in Clinical Data Spaces, that is, they must be present, contain certain information, and be correct.

Medication Section templateId

XPath:section/templateID
Purpose:

Specifies which CCDA R2.1 template is being used to structure the medication section. R2.1 templates define the requirements, format, and structure of a CCD section. This section contains a patient's current medications and pertinent medication history. At a minimum it lists currently active medications. The section can describe a patient's prescription and dispense history and information about intended monitoring.

The templateID element must:

  • be present

  • contain a root attribute 

    AttributeValuePurpose
    rootMust have a value of:
    2.16.840.1.113883.10.20.22.2.1 OR 
    2.16.840.1.113883.10.20.22.2.1.1
    Uniquely identifies the medications section template
 <section> 
    <templateID root="2.16.840.1.113883.10.20.22.2.1.1"/> 
</section>

The entire medications section is ignored if the templateId element is not provided with a root attribute of 2.16.840.1.113883.10.20.22.2.1 or 2.16.840.1.113883.10.20.22.2.1.1. The information provided in this section will not be processed and you will not receive any notification that this section was ignored.

 

Medication Activity templateId

XPath:section/entry/substanceAdministration/templateId
Purpose:

Specifies which CCDA R2.1 template is being used to structure the medication activity sub-section. R2.1 templates define the requirements, format, and structure of a CCD section. This sub-section describes the administration of substances that have actually occurred (for example, pills ingested or injections given) or are intended to occur (for example, take pills twice a day for five days).

The templateID element must:

  • be present

  • contain a root attribute 

    AttributeValuePurpose
    rootMust have a value of: 2.16.840.1.1113883.10.20.22.4.16Uniquely identifies the medications activity template
 <entry typeCode="DRIV"> 
    <substanceAdministration classCode="SBADM" moodCode="EVN"> 
    <templateId root="2.16.840.1.113883.10.20.22.4.16"/>
    </substanceAdministration> 
</entry>

The entire medications activity sub-section is ignored if the templateId element is not provided with a root attribute of 2.16.840.1.113883.10.20.22.4.16. The information provided in this section will not be processed and you will not receive any notification that this section was ignored.

 

Medication Activity statusCode

XPath:section/entry/substanceAdministration/statusCode
Purpose:Indicates whether the medication in this entry is still being taken or administered.

The statusCode element must:

  • be present

  • contain a code attribute 

    AttributeValuePurpose
    codeMust be "completed" or "active"Indicates whether the medication is still being taken (active) or not (completed)
 <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>

Processing of the statusCode element will fail if it does not contain a correct populated code attribute.

 

Medication Activity effectiveTime

XPath:section/entry/substanceAdministration/effectiveTime
Purpose:Specifies when the medication was administered or taken
The effectiveTime element must:
  • be present
  • contain an attribute of xsi:typevalue, OR nullFlavor

    AttributeValuePurpose
    xsi:type

    Must be populated with IVL_TS and effectiveTimemust:

    1. have a low child element, which can be:
      • empty
      • have a nullFlavor attribute
      • have a value attribute indicating a specific date and time
    2. optionally have a high child element which can be:
      • empty
      • have a nullFlavor attribute
      • have a value attribute indicating a specific date and time
    Indicates the period over which the medication was administered or taken
    valueMust be populated with a date in the format YYYY[MM[DD[HHMM[SS[.S[S[S[S]]]]]]]][+/-ZZZZ]where +/-ZZZZ specifies the offset from Coordinated Universal Time. Indicates the specific time a medication was administered or taken
    nullFlavor

    Must be one of the following:

    • ASKU - asked but unknown
    • MSK - masked (for sensitivity or confidentiality reasons)
    • NA - not available, system down
    • NASK - not asked
    • NAV - not available
    • NI - no information
    • OTH - other
    • UNK - unknown 
    Indicates that an attribute was required, but was not provided, and gives a reason for why the information is not present. In this case, it suggests the medication was administered, but it was not recorded when.

     

 <entry typeCode="DRIV"> 
    <substanceAdministration classCode="SBADM" moodCode="EVN"> 
    <templateId root="2.16.840.1.113883.10.20.22.4.16"/>
    <effectiveTime xsi:type="IVL_TS">
        <low value="20110301"/>
        <high value="20120301"/>
    </effectiveTime> 
    </substanceAdministration> 
</entry> 

Processing of the effectiveTime element will fail if it does not contain correctly populated nullFlavorxsi:type, or value attributes.

 

Medication Information templateId

XPath:section/entry/substanceAdministration/consumable/manufacturedProduct/templateId
Purpose:

Specifies which CCDA R2.1 template is being used to structure the medication information sub-section. R2.1 templates define the requirements, format, and structure of a CCD section.

The templateId element must:
  • be present
  • contain a root attribute

    AttributeValuePurpose

    root

    Must have a value of 2.16.840.1.113883.10.20.22.4.23

    Uniquely identifies the Medication Information template

<entry typeCode="DRIV"> 
    <substanceAdministration classCode="SBADM" moodCode="EVN"> 
        <consumable> 
            <manufacturedProduct> 
                <templateId root="2.16.840.1.113883.10.20.22.4.23"/>
            </manufacturedProduct> 
        </consumable> 
    </substanceAdministration> 
</entry> 

The entire medication information sub-section is ignored if the templateId element is not provided with a root attribute of 2.16.840.1.113883.10.20.22.4.23. The information provided in this section will not be processed and you will not receive any notification that this section was ignored.

 

Medication Information code

XPath:section/entry/substanceAdministration/consumable/manufacturedProduct/manufacturedMaterial/code
Purpose:Provides information about the medication in a combined form, which includes its ingredients, strengths, and dose.
The consumable element must:
  • have a child element of code
  • contain code and codeSystem attributes

    AttributeValuePurpose

    code

    Must include an alphanumeric string of any length

    Identifies the specific medication in the coding system. For example, "329498" specifies Alburterol 0.09 MG.ACTUAT

    codeSystem

    Must have a value of 2.16.840.1.113883.6.88

    Identifies the coding system, RXNorm. RXNorm is used to normalize generic and brand name drugs

    displayName and codingSystemName are not required attributes for processing

    For accurate processing, we except to see code with code and codeSystem attributes, as documented above. However <code nullFlavor="UNK"/>or <code nullFlavor="OTH"/> is acceptable.

    If code is populated with nullFlavor="OTH", a child element of translation must be present and contain code and codeSystem attributes. Clinical Data Spaces will process the information provided here instead.

 <entry typeCode="DRIV"> 
    <substanceAdministration classCode="SBADM" moodCode="EVN"> 
        <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>

Processing of the code element will fail if it does not contain correctly populated code and codeSystem attributes.

 

 


Optional Elements

This section details elements that are not required but if present, must contact certain information and be correct for accurate processing in Clinical Data Spaces (CDS). 

Medication Section confidentialityCode

XPath:section/confidentialityCode
Purpose:

Indicates the level of security that should be applied to the Medications section of this Continuity of Care Document. The level of security that should be applied is typically driven by the guidelines of the system that generated the Continuity of Care Document (CCD).

If present, the confidentialityCode element must:

contain code AND codeSystem attributes:

AttributeValuePurpose

code

Must include an alphanumeric string of any length, typically indicated by a single character. The HL7-supported confidentiality coding system is typically used, where security levels are indicated as:

  • U - unrestricted
  • L - low
  • N - normal 
  • M - moderate
  • R - restricted
  • V - very restricted 

The unique identifier for the level of security to be applied to the CCD

codeSystem

Must include an alphanumeric string of any length, typically in the following format: 2.16.840.1.1113883.X.XX.X

Note: our example document and code use the HL7-supported confidentiality coding system. This is indicated by: 2.16.840.1.113883.5.25

A numerical string that specifies which system will be used to translate the identifier provided in the code attribute.

The HL7-supported confidentiality coding system is not a requirement for processing in Clinical Data Spaces. The values in code and codeSystem can align with another codingSystem. However, if a value other than ULNMRV is provided in the code attribute, Clinical Data Spaces will process as R to ensure FHIR compliance.

 <section> 
    <templateID root="2.16.840.1.113883.10.20.22.2.1.1"/> 
    <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
</section>

The confidentialityCode element will be ignored if it does not contain correctly populated code and codeSystem attributes. Information provided within the confidentialityCode element in the document header will be processed instead.

 

Medication Activity routeCode

XPath:section/entry/substanceAdministration/routeCode
Purpose:Indicates how the medication was administered or taken for example, nasal, oral, or injection.
If present, the routeCode element must:

contain code AND codeSystem attributes

AttributeValuePurpose

code

Must include an alphanumeric string of any length

Identifies the specific medication in the coding system

codeSystem

Must include an alphanumeric string of any length, but typically in the following format: 2.16.840.1.113883.X.XX.X.X

Identifies the coding system used to translate the identifier provided in the code attribute

 

displayName and codeSystemName are not required for processing

<entry typeCode="DRIV"> 
    <substanceAdministration classCode="SBADM" moodCode="EVN"> 
        <routeCode code="C38216" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="RESPIRATORY (INHALATION)"/>
    </substanceAdministration> 
</entry> 

Processing of the routeCode element will fail if it does not contain correctly populated code AND codeSystem attributes.

 

Medication Activity doseQuantity

XPath:section/entry/substanceAdministration/doseQuantity
Purpose:Indicates the number of products given per medication administration
If present, the doseQuantity element must:

contain a value attribute and optionally contain a unit attribute

AttributeValuePurpose

value

Must be alphanumerical 

Identifies the number of products administered (for example, "2" refers to 2x tablets)

unit

Must be alphanumerical 

Identifies the unit in with the product was administered in (for example, mg)

 <entry typeCode="DRIV"> 
    <substanceAdministration classCode="SBADM" moodCode="EVN"> 
        <doseQuantity value="1"/>
    </substanceAdministration> 
</entry>

Processing of the doseQuantity element will fail if it does not contain a correctly populated value attribute.

 

Medication Activity administrationUnitCode

XPath:section/entry/substanceAdministration/administrationUnitCode
Purpose:Indicates the physical unit form of a medication (for example, ointment, powder, solution)
If present, the administrationUnitCode element must:

contain code AND codeSystem attributes

AttributeValuePurpose

code

Must include an alphanumeric string of any length

Identifies the specific physical unit form of the medication in the coding system.

codeSystem

Must include an alphanumeric string of any length, but typically in the following format: 2.16.840.1.1113883.X.XX.X.X

Identifies the coding system used to translate the identifier provided in the code attribute

displayName and codeSystemName are not required for processing

For accurate processing, we except to see code with code and codeSystem attributes, as documented above. However <code nullFlavor="UNK"/> or <code nullFlavor="OTH"/> is acceptable.

If code is populated with nullFlavor="OTH", a child element of translation must be present and contain code and codeSystemattributes. Clinical Data Spaces will process the information provided here instead.

<entry typeCode="DRIV"> 
    <substanceAdministration classCode="SBADM" moodCode="EVN"> 
        <administrationUnitCode code="C42944" codeSystem="2.16.840.1.113883.3.88.12.3221.8.11" codeSystemName="NCI Thesaurus" displayName="INHALANT"/>
    </substanceAdministration> 
</entry>

Processing of the administrationUnitCode element will fail if it does not contain correctly populated code AND codeSystem attributes.

 

Medication Activity author

XPath:section/entry/substanceAdministration/author
Purpose:Indicates the unique identifier of the person prescribing the medication (for example, the site-specific alphanumerical ID for a consulting doctor) or the person adding notes to the document about the medication.
If an author element is present, it must
  • have a child element of assignedAuthor, which must
  • have a child element of id, which must
  • contain a root attribute and optionally contain an extension attribute

    AttributeValuePurpose
    root

    Must include 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

    Uniquely identifies the author of the current medications entry

    extension

    Is optional and can include an alphanumeric string of any length

    Uniquely identifies the author of the current medications entry

<entry typeCode="DRIV"> 
    <substanceAdministration classCode="SBADM" moodCode="EVN"> 
        <author>
            <assignedAuthor>
                <id extension="12345" root="2.16.840.1.113883.19.5"/>
            </assignedAuthor>
        </author>
    </substanceAdministration> 
</entry>

The author element and its contents will be ignored if the id element does not contain a correctly populated root attribute. Information provided within the author element in the document header will be processed instead.

 

Medication Activity performer

XPath:

section/entry/substanceAdministration/performer

Purpose:Indicates the unique identifier of the person administering the medication (for example, the site-specific alphanumerical ID for a nurse in a hospital ward giving a patient a dose of medication)
If a performer element is present, it must:
  • have a child element of assignedEntity, which must
  • have a child element of id, which must
  • contain a root attribute and optionally contain an extension attribute

    AttributeValuePurpose
    root

    Must include 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

    Uniquely identifies the performer of the current medications entry

    extension

    Is optional and can include an alphanumeric string of any length

    Uniquely identifies the performer of the current medications entry

<entry typeCode="DRIV"> 
    <substanceAdministration classCode="SBADM" moodCode="EVN"> 
        <performer>
            <assignedEntity>
                <id extension="56789" root="2.16.840.1.113883.19.5"/>
            </assignedEntity>
        </performer>
    </substanceAdministration> 
</entry>

 

 

The performer element and its contents will be ignored if the id element does not contain a correctly populated root attribute. Information provided within the performer element in the document header will be processed instead.

 

 

 

Medication Activity informant

XPath:section/entry/substanceAdministration/informant
Purpose:Indicates 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)
If an informant element is present it must:
  • have a child element of assignedEntity, which must
  • have a child element of id, which must
  • contain a root attribute and optionally contain an extension attribute

    AttributeValuePurpose
    root

    Must include 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

    Uniquely identifies the informant of the current medications entry

    extension

    Is optional and can include an alphanumeric string of any length

    Uniquely identifies the informant of the current medications entry

<entry typeCode="DRIV"> 
    <substanceAdministration classCode=”SBADM” moodCode=”EVN”> 
        <informant>
            <assignedEntity>
                <id extension="KP00017" root="2.16.840.1.113883.19.5"/>
            </assignedEntity>
        </informant
    </substanceAdministration> 
</entry>

The informant element and its contents will be ignored if the id element does not contain a correctly populated root attribute. Information provided within the informant element in the document header will be processed instead.

 

Medication Supply Order templateId

XPath:section/substanceAdministration/entryRelationship/supply/templateId
Purpose:

Specifies which CCDA R2.1 template is being used to structure the medication supply order sub-section. R2.1 templates define the requirements, format, and structure of a CCD section. This sub-section details the intent to supply a patient with the medication.

If present, the templateId element must:
  • be contained within an entryRelationship element with a typeCode attribute of "REFR"
  • have a parent element of supply
  • contain a root attribute

    AttributeValuePurpose

    root

    2.16.840.1.113883.10.20.22.4.17

    Uniquely identifies the template which describes the intent to supply the medication.

<substanceAdministration classCode="SBADM" moodCode="EVN"> 
            <entryRelationship typeCode="REFR">
                        <supply classCode="SPLY" moodCode="INT">
                                <templateId root="2.16.840.1.113883.10.20.22.4.17"/>
                        </supply>
            </entryRelationship>
</substanceAdministration> 

The entire medications supply order sub-section is ignored if the supply/templateId element is not provided with a root value of 2.16.840.1.113883.10.20.22.4.17. You will not receive any notification that that this sub-section was ignored.

 

Medication Supply Order id

XPath:section/substanceAdministration/entryRelationship/supply/id
Purpose:

Provides a unique identifier for the sub-section, including information concerning the organization responsible for the sub-section.

If present, the author element must:
  • be contained within an entryRelationship element with a typeCode attribute of "REFR", which has a templateId of 2.16.840.1.113883.10.20.22.4.17
  • have a parent element of supply 
  • contain a root attribute and optionally contain an extension attribute, OR contain a nullFlavor attribute

    AttributeValuePurpose
    root

    Must include 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

    Uniquely identifies the organization responsible for the medications supply order

    extension

    Is optional and can include an alphanumeric string of any length

    Uniquely identifies the organization responsible for the medications supply order

    nullFlavor

    Must be one of the following:

    • ASKU - asked but unknown
    • MSK - masked (for sensitivity or confidentiality reasons)
    • NA - not available, system down
    • NASK - not asked
    • NAV - not available
    • NI - no information
    • OTH - other
    • UNK - unknown

     

    Indicates that an attribute was required, but was not provided, and gives a reason for why the information is not present.
<substanceAdministration classCode="SBADM" moodCode="EVN"> 
            <entryRelationship typeCode="REFR">
                        <supply classCode="SPLY" moodCode="INT">
                                <templateId root="2.16.840.1.113883.10.20.22.4.17"/>
                                <id nullFlavor="NI"/>
                        </supply>
            </entryRelationship>
</substanceAdministration>

Processing of the id element will fail if it does not contain a correctly populated root OR nullFlavor attribute.

 

Medication Supply Order effectiveTime

XPath:section/substanceAdministration/entryRelationship/supply/effectiveTime
Purpose:

Specifies the time period in which the medication order (that is, prescription) can be filled.

If present, the author element must:
  • be contained within an entryRelationship element with a typeCode attribute of "REFR", which has a templateId of: 2.16.840.1.113883.10.20.22.4.17
  • have a parent element of supply
  • contain a xsi:type OR value OR nullFlavor attribute

    AttributeValuePurpose
    xsi:type

    Must be populated with IVL_TS and effectiveTime must:

    1. have a low child element, which can be:
      • empty
      • have a nullFlavor attribute
      • have a value attribute indicating a specific date and time
    2. optionally have a high child element which can be:
      • empty
      • have a nullFlavor attribute
      • have a value attribute indicating a specific date and time
    Indicates the period over which the medications order (that is, prescription) can be supplied
    valueMust be populated with a date in the format YYYY[MM[DD[HHMM[SS[.S[S[S[S]]]]]]]][+/-ZZZZ] where +/-ZZZZspecifies the offset from Coordinated Universal Time. Indicates the specific date the medication order can be supplied.
    nullFlavor

    Must be one of the following:

    • ASKU - asked but unknown
    • MSK - masked (for sensitivity or confidentiality reasons)
    • NA - not available, system down
    • NASK - not asked
    • NAV - not available
    • NI - no information
    • OTH - other
    • UNK - unknown
    Indicates that an attribute was required, but was not provided, and gives a reason for why the information is not present. In this case, a medication order can be supplied, but it was not recorded when.
<substanceAdministration classCode="SBADM" moodCode="EVN"> 
            <entryRelationship typeCode="REFR">
                        <supply classCode="SPLY" moodCode="INT">
                                <templateId root="2.16.840.1.113883.10.20.22.4.17"/>
                                <effectiveTime xsi:type="IVL_TS">
                                     <low value="20070103" />
                                     <high nullFlavor="UNK" />
                                </effectiveTime>
                        </supply>
            </entryRelationship>
</substanceAdministration>

Processing of the effectiveTime element will fail if it does not contain a correctly populated xsi:type, value OR nullFlavor attribute.

 

Medication Supply Order quantity

XPath:section/substanceAdministration/entryRelationship/supply/quantity
Purpose:

Indicates the number of products to administered in the medication order.

If present, the author element must:
  • be contained within an entryRelationship element with a typeCode attribute of "REFR", which has a templateId of 2.16.840.1.113883.10.20.22.4.17
  • have a parent element of supply
  • contain a value attribute and optionally contain a unit attribute 

    AttributeValuePurpose

    value

    Must be alphanumerical

    Identifies the number of products administered (for example, "2" refers to 2x tablets)

    unit

    Must be alphanumerical

    Identifies the unit in with the product was administered in (for example, mg)

<substanceAdministration classCode="SBADM" moodCode="EVN"> 
            <entryRelationship typeCode="REFR">
                        <supply classCode="SPLY" moodCode="INT">
                                <templateId root="2.16.840.1.113883.10.20.22.4.17"/>
                                <quantity value="75"/>
                        </supply>
            </entryRelationship>
</substanceAdministration>

Processing of the quantity element will fail if it does not contain a correctly populated value attribute.

 

Medication Supply Order author

XPath:section/substanceAdministration/entryRelationship/supply/author
Purpose:

Identifies the author of the medications supply order sub-section, typically the clinician that wrote the prescription and/or is authorizing the medications order.

If present, the author element must:
  • be contained within an entryRelationship with a typeCode attribute of "REFR", which has a templateId of: 2.16.840.1.113883.10.20.22.4.17
  • have a child element of assignedAuthor, which must 
  • have a child element of id, which must 
  • contain a root attribute and optionally contain an extension attribute 

    AttributeValuePurpose
    root

    Must include 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

    Uniquely identifies the author of the medications supply order sub-section

    extension

    Is optional and can include an alphanumeric string of any lengt

    Uniquely identifies the author of the medications supply order sub-section

<substanceAdministration classCode="SBADM" moodCode="EVN"> 
            <entryRelationship typeCode="REFR">
                        <supply classCode="SPLY" moodCode="INT">
                                <templateId root="2.16.840.1.113883.10.20.22.4.17"/>
                                <author>
                                    <assignedAuthor>
                                        <id extension="12345" root="2.16.840.1.113883.19.5"/>
                                    </assignedAuthor>
                                </author>
            </entryRelationship>
</substanceAdministration>  

Processing of the author/id element will fail if it does not contain a correctly populated root attribute. Information provided within the author element in the document header will be processed instead.

 

Medication Instruction templateId

XPath:section/entry/entryRelationship/act/templateId
Purpose:

Specifies which CCDA R2.1 template is being used to structure the medication instruction sub-section. R2.1 templates define the requirements, format, and structure of a CCD section. This sub-section provides patient instructions for the medication.

If present, the templateId element must:
  • be contained within an entryRelationship element with a typeCode attribute of "SUBJ"
  • have a parent element of act
  • contain a root attribute

    AttributeValuePurpose

    root

    2.16.840.1.113883.10.20.22.4.20

    Uniquely identifies the template detailing instructions for the dispense of the medication.

<substanceAdministration classCode="SBADM" moodCode="EVN"> 
            <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>  

The entire medications instruction sub-section is ignored if the act/templateId element is not provided with a root value of 2.16.840.1.113883.10.20.22.4.20. You will not receive any notification that that this sub-section was ignored.

 

Medication Instruction text

XPath:section/entry/act/entryRelationship/supply/entryRelationship/act/text
Purpose:

Provides patient instructions for the medication

If present, the text element must:
  • be contained within an entryRelationship element with a typeCode attribute of "SUBJ", which has a templateId of: 2.16.840.1.113883.10.20.22.4.20
  • have a parent element of act
  • contain text of any type or length
 <substanceAdministration classCode="SBADM" moodCode="EVN"> 
        <entryRelationship typeCode="SUBJ" inversionInd="true">
                <act classCode="ACT" moodCode="INT">
                            <templateId root="2.16.840.1.113883.10.20.22.4.20"/> 
                            <text>label in spanish</text>
                </act>
        </entryRelationship>
</substanceAdministration>

Processing of the text element will fail if it is not populated with text of some type.

 

Medication Indication templateId

XPath:section/substanceAdministration/entryRelationship/observation/templateId
Purpose:

Specifies which CCDA R2.1 template is being used to structure the medication indication sub-section. R2.1 templates define the requirements, format, and structure of a CCD section. This sub-section provides the reason and/or rationale for the administration of the medication

If present, the templateIdelement must:
  • be contained within an entryRelationship element with a typeCode attribute of "RSON"
  • have a parent element of observation
  • contain a root attribute

    AttributeValuePurpose

    root

    2.16.840.1.113883.10.20.22.4.19

    Uniquely identifies the template which describes the reason and/or rationale or the administration of the medication.

 <substanceAdministration classCode="SBADM" moodCode="EVN"> 
        <entryRelationship typeCode="RSON">
                        <observation classCode="COND" moodCode="EVN">
                                <templateId root="2.16.840.1.113883.10.20.22.4.19"/>                                    
                        </observation>
        </entryRelationship>
</substanceAdministration>

The entire medications indication sub-section is ignored if the observation/templateId element is not populated with a root attribute of 2.16.840.1.113883.10.20.22.4.19. You will not receive any notification that that this sub-section was ignored.

 

 

Medication Indication value

XPath:section/substanceAdministration/entryRelationship/observation/value
Purpose:

Indicates the specific reason and/or rationale for the administration of the medication

If present, the value
element must:
  • be contained within an entryRelationship element with a typeCode attribute of "RSON", which has a templateIdof: 2.16.840.1.113883.10.20.22.4.19
  • have a parent element of observation
  • contain xsi:typecode, and codeSystem attributes

    AttributeValuePurpose
    xsi:typeCDIndicates that the value element is providing code and codeSystem information
    code

    Must include an alphanumeric string of any length. Could be one of the following:

    • 46635009 - Diabetes mellitus type
    • 132398004 - Bronchitis
    • 31712002 - Primary Biliary Cirrhosis
    Identifies the specific reason and/or rationale for the administration of the medication
    codeSystemMust have a value of 2.16.840.1.113883.6.96Identifies the SNOMED CT coding system used to translate the identifier provided in the code attribute

    displayName and codeSystemName are not required for processing

    For accurate processing, we except to see code with code and codeSystem attributes, as documented above. However <value nullFlavor="UNK"/>or <value nullFlavor="OTH"/> is acceptable.

    If value is populated with nullFlavor="OTH", a child element of translation must be present and contain code and codeSystem attributes. Clinical Data Spaces will process the information provided here instead.

<substanceAdministration classCode="SBADM" moodCode="EVN"> 
        <entryRelationship typeCode="RSON">
                        <observation classCode="COND" 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>

Processing of the observation/value element will fail if it does not contain correctly populated xsi:typecode, and codeSystem attributes.