| # | Name | Source | Ver | Description | |
| 1 | Immunization Activity | hl7.cda.us.ccdar2dot2#current | R5 | An Immunization Activity describes immunization substance administrations that have actually occurred or are intended to occur. Immunization Activities in "INT" mood are reflections of immunizations a clinician intends a patient to receive. Immunization Activities in "EVN" mood reflect immunizations actually received. An Immunization Activity is very similar to a Medication Activity with some key differentiators. The drug code system is constrained to CVX codes. Administration timing is less complex. Patient refusal reasons should be captured. All vaccines administered should be fully documented in the patient's permanent medical record. Healthcare providers who administer vaccines covered by the National Childhood Vaccine Injury Act are required to ensure that the permanent medical record of the recipient indicates: 1. Date of administration 2. Vaccine manufacturer 3. Vaccine lot number 4. Name and title of the person who administered the vaccine and the address of the clinic or facility where the permanent record will reside 5. Vaccine information statement (VIS) a. Date printed on the VIS b. Date VIS given to patient or parent/guardian. This information should be included in an Immunization Activity when available. (Reference: [https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/c/vis-instruct.pdf]) | |
| 2 | Medication Activity | hl7.cda.us.ccdar2dot2#current | R5 | 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 (V2) template be used for moodCodes other than EVN if the document type contains a section that includes Planned Medication Activity (V2) (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" will have a dose of "25 mg". | |
| 3 | Medication Free Text Sig | hl7.cda.us.ccdar2dot2#current | R5 | The template is available to explicitly identify the free text Sig within each medication. An example free text sig: Thyroxin 150 ug, take one tab by mouth every morning. | |
| 4 | Planned Immunization Activity | hl7.cda.us.ccdar2dot2#current | R5 | This template represents planned immunizations. Planned Immunization Activity is very similar to Planned Medication Activity with some key differences, for example, the drug code system is constrained to CVX codes. The priority of the immunization activity to the patient and provider is communicated through Priority Preference. The effectiveTime indicates the time when the immunization activity is intended to take place and authorTime indicates when the documentation of the plan occurred. | |
| 5 | Planned Medication Activity | hl7.cda.us.ccdar2dot2#current | R5 | This template represents planned medication activities. The priority of the medication activity to the patient and provider is communicated through Priority Preference. The effectiveTime indicates the time when the medication activity is intended to take place. The authorTime indicates when the documentation of the plan occurred. |
Produced 08 Sep 2023