Clinical Statements
The article Clinical act statements, provides an overview of the clinical statements that form the “core” of a CDA document. Clinical statements are contained within entry elements, which in turn are contained within section elements, which in turn comprise the structured CDA Body, located in the XML path: ClinicalDocument/component/structuredBody.

Clinical statements begin with an XML element of: act, encounter, procedure, observation, substanceAdministration, supply, or organizer.

The article What goes inside a clinical statement XML entry?, overviews some of the sub-elements and attributes that all clinical act statements have in common.

“Substance Administration” Clinical Statements
In the underlying HL7 v3 model on which CDA is based, a “substance administration” is defined as: A type of procedure that involves a performer introducing or otherwise applying a material into or to the subject. Typically, this is either a medication or an immunization – although, formally, the “substance administration” may not be related to treatment (i.e. it could be something harmful the patient ingested). The XML element used with a substance administration clinical act statement is named substanceAdministration.

substanceAdministration is an Extension of procedure
As implied by the definition above (“A type of procedure…”), a substance administration is a specific kind of procedure. Thus, the substanceAdministration element shares many of the attributes and sub-elements of procedure (which, like all clinical act statements, shares many of the common attributes and sub-elements of the act element). Refer to The procedure element, for additional information.

classCode and moodCode Attributes of substanceAdministration
The classCode attribute of the substanceAdministration element is a fixed/default value of “SBADM”. As its value is a fixed default, the classCode attribute is not explicitly included in the XML syntax for the substanceAdministration element.

The moodCode attribute of the substanceAdministration element is usually either set to “EVN”, if the substance was already administered, or “INT”, if the substance is intended to be administered in the future. Three variations of “INT” (“PRMS”, “PRP”, and “RQO”) are also supported. Refer to The moodCode attribute, for additional information.

Common Sub-Elements of substanceAdministration
Like the procedure clinical statement element, the substanceAdministration element supports the sub-elements of the act clinical statement element. This includes the three common sub-elements used throughout CDA (realmCode, typeId, and templateId).

It also includes the common clinical act sub-elements: id, code, text, statusCode, effetiveTime, and priorityCode.

It further includes three sub-elements (entryRelationship, reference, and precondition) used to express entry relationships (refer to Act relationship elements), and five sub-elements (specimen, informant, author, participant, and performer) used to express participations (refer to Participation elements).

Special Sub-Elements of substanceAdministration
There are also sub-elements that are unique to substanceAdministration:

  • repeatNumber: A numeric interval representing the number of times to repeat the substance administration.
  • routeCode: A coded element that indicates how the substance is administered (oral, intravenous, etc.). In the C-CDA template for Medication Activity that is applied to the substanceAdministration element, the code system that is required for use with routeCode is the National Cancer Institute (NCI) Thesaurus (OID: 2.16.840.1.113883.
  • approachSiteCode: Takes one of the SNOMED-CT codes for describing the parts of the body (from the relevant SNOMED-CT “code hierarchies” related to body structure). Represents the anatomical site or system through which the substance is administered. It is optionally (and rarely) used to further refine the routeCode.
  • doseQuantity: This is a range/interval of a physical quantity that indicates the dosage of the substance that was (or will be) administered in a single administration event. Refer to Using “Parenthetical Expressions” in SIGs, for information about how to represent the schedule for taking medication.
  • rateQuantity: This is a range/interval of a physical quantity that expresses in “quantity over time” (such as mL/h), the speed at which an administered substance (liquid or gas) is introduced.
  • maxDoseQuantity: This indicates the maximum dosage of the substance that may be administered over a period of time. Refer to The maxDoseQuantity element, for additional information.
  • administrationUnitCode: This is used in the special (and rare) case where there is a problem expressing the dose to be administered in a precise way. For example, if the substance is administered via an inhaler and the doseQuantity is “1”, the administrationUnitCode can be used to indicate that the intention is “one actuation” (puff) and not the entire quantity of substance in the inhaler.

The consumable Sub-Element
The most significant sub-element of the substanceAdministration element is the participation sub-element named consumable that connects the actual substance role and entity to the substanceAdministration clinical act statement. Refer to The consumable element, for a complete overview of this sub-element and its component parts.

The negationInd Attribute
The substanceAdministration clinical act statement can also be used to indicate that particular substance was not administered. This is achieved by setting the optional negationInd attribute to the value “true” (its default value is “false”). Refer to The negationInd attribute, for additional information.

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