HRSA 2023 Uniform Data System (UDS) Patient Level Submission (PLS) (UDS+) FHIR IG
1.0.1 - STU1 Release 1 - Standard for Trial-Use
HRSA 2023 Uniform Data System (UDS) Patient Level Submission (PLS) (UDS+) FHIR IG
1.0.1 - STU1 Release 1 - Standard for Trial-Use
This page is part of the HRSA Uniform Data System (UDS) Patient Level Submission (PLS) (UDS+ or uds-plus) FHIR IG (v1.0.1: STU1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
| Official URL: http://fhir.org/guides/hrsa/uds-plus/StructureDefinition/uds-plus-medicationstatement | Version: 1.0.1 | |||
| Standards status: Trial-use | Maturity Level: 2 | Computable Name: UDSPlusMedicationStatement | ||
The UDS+ profile is based on the MedicationStatement resource and establishes the core elements, extensions, vocabularies and value sets for representing MedicationStatement for UDS+ program.
This profile is used to represent de-identified MedicationStatement information. The de-identification process has to remove all data elements not explicitly identified as “SUPPORTED” in the profile.
The HHS De-identification Guidance is to be followed to ensure appropriate level of de-identification is performed.
According to the HHS guidance, dates should not have a precision of more than the year. This means month and day cannot be included. This includes MedicationStatement.authoredOn.
In FHIR Resources, text elements and reference.display elements which provide human readable information to the providers may be generated using programs and tools from the data present within the resource. For e.g a MedicationStatement resource text element may contain information such as the MedicationStatement date, patient information. This type of information will enable identification of the individuals. In order to avoid inadvertent revealing of PII/PHI, text elements cannot be included in the De-identified FHIR resource and the submission will be rejected when text elements are present by the validation process.
Ids and References
The original MedicationStatement resource id should not be included in the De-identified MedicationStatement instance. Instead a new id should be created and provided as part of the FHIR resource. The Data Submitter should be capable of using the generated id to relink the data to the original MedicationStatement. All resource references to the MedicationStatement submitted as part of the UDS+ report should refer to newly generated id.
Resource references cannot contain text element as it may contain PHI/PII. The text element for following references are not allowed
Date Truncation
The Data Submitter has to truncate the following dates to only have a precision of year
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from MedicationStatement
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  MedicationStatement | 0..* | MedicationStatement | De-Identified UDS Plus MedicationStatement | |
  id | S | 0..1 | id | The de-identified MedicationStatement identifier created by the health center to send data to UDS+ Data Receiver |
| text | 0..0 | |||
| contained | 0..0 | |||
| status | S | 1..1 | code | active | completed | entered-in-error | intended | stopped | on-hold | unknown | not-taken |
| medication[x] | S | 1..1 | CodeableConcept, Reference(Medication) | What medication was taken |
  subject | S | 1..1 | Reference(De-Identified UDS Plus Patient) | Who is/was taking the medication |
  display | 0..0 | |||
 effective[x] | S | 0..1 | dateTime | The date/time or interval when the medication is/was/will be taken |
| dateAsserted | S | 0..1 | dateTime | When the statement was asserted? |
| dosage | S | 0..* | Dosage | Details of how medication is/was taken or should be taken |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| MedicationStatement | 0..* | MedicationStatement | De-Identified UDS Plus MedicationStatement | |
| id | SΣ | 0..1 | id | The de-identified MedicationStatement identifier created by the health center to send data to UDS+ Data Receiver |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!SΣ | 1..1 | code | active | completed | entered-in-error | intended | stopped | on-hold | unknown | not-taken Binding: Medication Status Codes (required): A coded concept indicating the current status of a MedicationStatement. |
 medication[x] | SΣ | 1..1 | What medication was taken Binding: SNOMEDCTMedicationCodes (example): A coded concept identifying the substance or product being taken. | |
 medicationCodeableConcept | CodeableConcept | |||
| medicationReference | Reference(Medication) | |||
| subject | SΣ | 1..1 | Reference(De-Identified UDS Plus Patient) | Who is/was taking the medication |
| effective[x] | SΣ | 0..1 | dateTime | The date/time or interval when the medication is/was/will be taken |
| dateAsserted | SΣ | 0..1 | dateTime | When the statement was asserted? |
| dosage | S | 0..* | Dosage | Details of how medication is/was taken or should be taken |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| MedicationStatement.status | required | Medication Status Codes |
| MedicationStatement.medication[x] | example | SNOMEDCTMedicationCodes |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | MedicationStatement | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | MedicationStatement | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | MedicationStatement | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | MedicationStatement | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | MedicationStatement | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| MedicationStatement | 0..* | MedicationStatement | De-Identified UDS Plus MedicationStatement | |||||
| id | SΣ | 0..1 | id | The de-identified MedicationStatement identifier created by the health center to send data to UDS+ Data Receiver | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
 extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 0..* | Identifier | External identifier | ||||
| basedOn | Σ | 0..* | Reference(MedicationRequest | CarePlan | ServiceRequest) | Fulfils plan, proposal or order | ||||
| partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Observation) | Part of referenced event | ||||
| status | ?!SΣ | 1..1 | code | active | completed | entered-in-error | intended | stopped | on-hold | unknown | not-taken Binding: Medication Status Codes (required): A coded concept indicating the current status of a MedicationStatement. | ||||
| statusReason | 0..* | CodeableConcept | Reason for current status Binding: SNOMEDCTDrugTherapyStatusCodes (example): A coded concept indicating the reason for the status of the statement. | |||||
| category | Σ | 0..1 | CodeableConcept | Type of medication usage Binding: Medication usage category codes (preferred): A coded concept identifying where the medication included in the MedicationStatement is expected to be consumed or administered. | ||||
| medication[x] | SΣ | 1..1 | What medication was taken Binding: SNOMEDCTMedicationCodes (example): A coded concept identifying the substance or product being taken. | |||||
| medicationCodeableConcept | CodeableConcept | |||||||
| medicationReference | Reference(Medication) | |||||||
| subject | SΣ | 1..1 | Reference(De-Identified UDS Plus Patient) | Who is/was taking the medication | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference | ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| context | Σ | 0..1 | Reference(Encounter | EpisodeOfCare) | Encounter / Episode associated with MedicationStatement | ||||
| effective[x] | SΣ | 0..1 | dateTime | The date/time or interval when the medication is/was/will be taken | ||||
| dateAsserted | SΣ | 0..1 | dateTime | When the statement was asserted? | ||||
| informationSource | 0..1 | Reference(Patient | Practitioner | PractitionerRole | RelatedPerson | Organization) | Person or organization that provided the information about the taking of this medication | |||||
| derivedFrom | 0..* | Reference(Resource) | Additional supporting information | |||||
| reasonCode | 0..* | CodeableConcept | Reason for why the medication is being/was taken Binding: Condition/Problem/DiagnosisCodes (example): A coded concept identifying why the medication is being taken. | |||||
| reasonReference | 0..* | Reference(Condition | Observation | DiagnosticReport) | Condition or observation that supports why the medication is being/was taken | |||||
| note | 0..* | Annotation | Further information about the statement | |||||
| dosage | S | 0..* | Dosage | Details of how medication is/was taken or should be taken | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | ||||
| MedicationStatement.language | preferred | CommonLanguages
| ||||
| MedicationStatement.status | required | Medication Status Codes | ||||
| MedicationStatement.statusReason | example | SNOMEDCTDrugTherapyStatusCodes | ||||
| MedicationStatement.category | preferred | Medication usage category codes | ||||
| MedicationStatement.medication[x] | example | SNOMEDCTMedicationCodes | ||||
| MedicationStatement.subject.type | extensible | ResourceType | ||||
| MedicationStatement.reasonCode | example | Condition/Problem/DiagnosisCodes |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | MedicationStatement | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | MedicationStatement | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | MedicationStatement | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | MedicationStatement | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | MedicationStatement | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from MedicationStatement
Summary
Mandatory: 3 elements
Must-Support: 7 elements
Prohibited: 3 elements
Structures
This structure refers to these other structures:
Maturity: 2
Differential View
This structure is derived from MedicationStatement
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| MedicationStatement | 0..* | MedicationStatement | De-Identified UDS Plus MedicationStatement | |
| id | S | 0..1 | id | The de-identified MedicationStatement identifier created by the health center to send data to UDS+ Data Receiver |
| text | 0..0 | |||
| contained | 0..0 | |||
| status | S | 1..1 | code | active | completed | entered-in-error | intended | stopped | on-hold | unknown | not-taken |
| medication[x] | S | 1..1 | CodeableConcept, Reference(Medication) | What medication was taken |
| subject | S | 1..1 | Reference(De-Identified UDS Plus Patient) | Who is/was taking the medication |
| display | 0..0 | |||
| effective[x] | S | 0..1 | dateTime | The date/time or interval when the medication is/was/will be taken |
| dateAsserted | S | 0..1 | dateTime | When the statement was asserted? |
| dosage | S | 0..* | Dosage | Details of how medication is/was taken or should be taken |
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| MedicationStatement | 0..* | MedicationStatement | De-Identified UDS Plus MedicationStatement | |
| id | SΣ | 0..1 | id | The de-identified MedicationStatement identifier created by the health center to send data to UDS+ Data Receiver |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!SΣ | 1..1 | code | active | completed | entered-in-error | intended | stopped | on-hold | unknown | not-taken Binding: Medication Status Codes (required): A coded concept indicating the current status of a MedicationStatement. |
| medication[x] | SΣ | 1..1 | What medication was taken Binding: SNOMEDCTMedicationCodes (example): A coded concept identifying the substance or product being taken. | |
| medicationCodeableConcept | CodeableConcept | |||
| medicationReference | Reference(Medication) | |||
| subject | SΣ | 1..1 | Reference(De-Identified UDS Plus Patient) | Who is/was taking the medication |
| effective[x] | SΣ | 0..1 | dateTime | The date/time or interval when the medication is/was/will be taken |
| dateAsserted | SΣ | 0..1 | dateTime | When the statement was asserted? |
| dosage | S | 0..* | Dosage | Details of how medication is/was taken or should be taken |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| MedicationStatement.status | required | Medication Status Codes |
| MedicationStatement.medication[x] | example | SNOMEDCTMedicationCodes |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | MedicationStatement | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | MedicationStatement | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | MedicationStatement | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | MedicationStatement | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | MedicationStatement | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| MedicationStatement | 0..* | MedicationStatement | De-Identified UDS Plus MedicationStatement | |||||
| id | SΣ | 0..1 | id | The de-identified MedicationStatement identifier created by the health center to send data to UDS+ Data Receiver | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 0..* | Identifier | External identifier | ||||
| basedOn | Σ | 0..* | Reference(MedicationRequest | CarePlan | ServiceRequest) | Fulfils plan, proposal or order | ||||
| partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Observation) | Part of referenced event | ||||
| status | ?!SΣ | 1..1 | code | active | completed | entered-in-error | intended | stopped | on-hold | unknown | not-taken Binding: Medication Status Codes (required): A coded concept indicating the current status of a MedicationStatement. | ||||
| statusReason | 0..* | CodeableConcept | Reason for current status Binding: SNOMEDCTDrugTherapyStatusCodes (example): A coded concept indicating the reason for the status of the statement. | |||||
| category | Σ | 0..1 | CodeableConcept | Type of medication usage Binding: Medication usage category codes (preferred): A coded concept identifying where the medication included in the MedicationStatement is expected to be consumed or administered. | ||||
| medication[x] | SΣ | 1..1 | What medication was taken Binding: SNOMEDCTMedicationCodes (example): A coded concept identifying the substance or product being taken. | |||||
| medicationCodeableConcept | CodeableConcept | |||||||
| medicationReference | Reference(Medication) | |||||||
| subject | SΣ | 1..1 | Reference(De-Identified UDS Plus Patient) | Who is/was taking the medication | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference | ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| context | Σ | 0..1 | Reference(Encounter | EpisodeOfCare) | Encounter / Episode associated with MedicationStatement | ||||
| effective[x] | SΣ | 0..1 | dateTime | The date/time or interval when the medication is/was/will be taken | ||||
| dateAsserted | SΣ | 0..1 | dateTime | When the statement was asserted? | ||||
| informationSource | 0..1 | Reference(Patient | Practitioner | PractitionerRole | RelatedPerson | Organization) | Person or organization that provided the information about the taking of this medication | |||||
| derivedFrom | 0..* | Reference(Resource) | Additional supporting information | |||||
| reasonCode | 0..* | CodeableConcept | Reason for why the medication is being/was taken Binding: Condition/Problem/DiagnosisCodes (example): A coded concept identifying why the medication is being taken. | |||||
| reasonReference | 0..* | Reference(Condition | Observation | DiagnosticReport) | Condition or observation that supports why the medication is being/was taken | |||||
| note | 0..* | Annotation | Further information about the statement | |||||
| dosage | S | 0..* | Dosage | Details of how medication is/was taken or should be taken | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | ||||
| MedicationStatement.language | preferred | CommonLanguages
| ||||
| MedicationStatement.status | required | Medication Status Codes | ||||
| MedicationStatement.statusReason | example | SNOMEDCTDrugTherapyStatusCodes | ||||
| MedicationStatement.category | preferred | Medication usage category codes | ||||
| MedicationStatement.medication[x] | example | SNOMEDCTMedicationCodes | ||||
| MedicationStatement.subject.type | extensible | ResourceType | ||||
| MedicationStatement.reasonCode | example | Condition/Problem/DiagnosisCodes |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | MedicationStatement | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | MedicationStatement | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | MedicationStatement | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | MedicationStatement | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | MedicationStatement | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from MedicationStatement
Summary
Mandatory: 3 elements
Must-Support: 7 elements
Prohibited: 3 elements
Structures
This structure refers to these other structures:
Maturity: 2
Other representations of profile: CSV, Excel, Schematron
IG © 2023+ HRSA BPHC. Package fhir.hrsa.uds-plus#1.0.1 based on FHIR 4.0.1. Generated 2023-12-01
Links: Table of Contents |
License |
QA Report
| New Issue | Issues
| Version History 
|