MedicationActivity

Medication Activity

draftC-CDA Templates4.0.0logical25 key elements

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. For example, a clinician may intend that a patient be administered Lisinopril 20 mg PO for blood pressure control. If what was actually administered was Lisinopril 10 mg., then the Medication activities in the "EVN" mood would reflect actual use.

A moodCode of INT is allowed, but it is recommended that the Planned Medication Activity template be used for moodCodes other than EVN if the document type contains a section that includes Planned Medication Activity (for example a Care Plan document with Plan of Treatment, Intervention, or Goal sections).

At a minimum, a Medication Activity shall include an effectiveTime indicating the duration of the administration (or single-administration timestamp). Ambulatory medication lists generally provide a summary of use for a given medication over time - a medication activity in event mood with the duration reflecting when the medication started and stopped. Ongoing medications will not have a stop date (or will have a stop date with a suitable NULL value). Ambulatory medication lists will generally also have a frequency (e.g., a medication is being taken twice a day). Inpatient medications generally record each administration as a separate act.

The dose (doseQuantity) represents how many of the consumables are to be administered at each administration event. As a result, the dose is always relative to the consumable and the interval of administration. Thus, a patient consuming a single "metoprolol 25mg tablet" per administration will have a doseQuantity of "1", whereas a patient consuming "metoprolol Oral Product" (RxCUI 1163523) will have a dose of "25 mg".

#### Templates Used Although open templates may contain any valid CDA content, the following templates are specifically called out by this template:

Optional EntryRelationships: DrugMonitoringAct, Indication, InstructionObservation, MedicationAdherence, MedicationDispense, MedicationFreeTextSig, MedicationSupplyOrder, ReactionObservation, SubstanceAdministeredAct

Metadata

hl7.org/fhir
Canonical URL
http://hl7.org/cda/us/ccda/StructureDefinition/MedicationActivity
ID
MedicationActivity
Type
Base Definition
SubstanceAdministration
Derivation
constraint
Mandatory and Must-Support Elements

Elements with cardinality > 0 or marked as Must Support (S)

PathCard.TypeFlagsDescription
templateId
1+
:medication-activity1..1
1+
templateId.root
1+
templateId.extension
1+
id
1+
statusCode
1+
statusCode.code
1+
The substance administration effectiveTime field can repeat, in order to represent varying levels of complex dosing. effectiveTime can be used to represent the duration of administration (e.g., "10 days"), the frequency of administration (e.g., "every 8 hours"), and more. Here, we require that there SHALL be an effectiveTime documentation of the duration (or single-administration timestamp), and that there SHOULD be an effectiveTime documentation of the frequency. Other timing nuances, supported by the base CDA R2 standard, may also be included.
effectiveTime
1+
:duration1..1
http://hl7.org/cda/stds/core/StructureDefinition/IVL-TS
1+
The substance administration effectiveTime field can repeat, in order to represent varying levels of complex dosing. effectiveTime can be used to represent the duration of administration (e.g., "10 days"), the frequency of administration (e.g., "every 8 hours"), and more. Here, we require that there **SHALL** be an effectiveTime documentation of the duration (or single-administration timestamp), and that there **SHOULD** be an effectiveTime documentation of the frequency. Other timing nuances, supported by the base CDA R2 standard, may also be included. Note: This effectiveTime represents either the time the medication was started and stopped or the single-administration timestamp.
effectiveTime.operator
1+
effectiveTime.operator
1+
doseQuantity
1+
If the consumable code is not pre-coordinated (e.g., is "simply metoprolol Oral Product" (RxCUI 1163523), then doseQuantity must represent a physical quantity with @unit, e.g., "25" and "mg", specifying the amount of product given per administration (CONF:1098-16879).
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" per administration) (CONF:1098-16878).
rateQuantity.unit
1+
NOTE: The base CDA R2.0 standard requires @unit to be drawn from UCUM, and best practice is to use case sensitive UCUM units
entryRelationship.observation
http://hl7.org/cda/stds/core/StructureDefinition/Observation
1+
entryRelationship.inversionInd
1+
entryRelationship.observation
http://hl7.org/cda/stds/core/StructureDefinition/Observation
1+
entryRelationship.supply
http://hl7.org/cda/stds/core/StructureDefinition/Supply
1+
entryRelationship.supply
http://hl7.org/cda/stds/core/StructureDefinition/Supply
1+
entryRelationship.observation
http://hl7.org/cda/stds/core/StructureDefinition/Observation
1+
entryRelationship.act
http://hl7.org/cda/stds/core/StructureDefinition/Act
1+
entryRelationship.inversionInd
1+
entryRelationship.act
http://hl7.org/cda/stds/core/StructureDefinition/Act
1+
entryRelationship.observation
http://hl7.org/cda/stds/core/StructureDefinition/Observation
1+
entryRelationship.substanceAdministration
http://hl7.org/cda/stds/core/StructureDefinition/SubstanceAdministration
1+
precondition.typeCode
1+