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        CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG
        2.0.0 - Release 2 US

        This page is part of the NHSN Digital Quality Measures (dQM) Content Package Implementation Guide (v2.0.0: Release) based on FHIR (HL7? FHIR? Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

        Resource Profile: AcuteCareHospitalDailyEventMedication - Detailed Descriptions

        Page standards status: Trial-use Maturity Level: 2

        Definitions for the ach-daily-medication resource profile.

        Guidance on how to interpret the contents of this table can be foundhere

        0. Medication
        Definition

        -


        This resource is primarily used for the identification and definition of a medication for the purposes of prescribing, dispensing, and administering a medication as well as for making statements about medication use.

        Short Definition of a Medication
        Comments

        -

        Control 0..*
        Is Modifier false
        Must Support false
        Summary false
        Invariants dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
        dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
        dom-6: A resource should have narrative for robust management (text.`div`.exists())
        2. Medication.id
        Definition

        The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

        Short icon Changed:(NHSN-MS) Logical id of this artifactLogical id of this artifact
        Comments

        The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

        Control 10..1
        Type idstring
        Is Modifier false
        Must Support icon Added:true
        Summary true
        4. Medication.implicitRules
        Definition

        A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

        Short A set of rules under which this content was created
        Comments

        Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

        Control 0..1
        Type uri
        Is Modifier true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
        Primitive Value This primitive element may be present, or absent, or replaced by an extension
        Summary true
        Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        6. Medication.modifierExtension
        Definition

        May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

        Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

        Short Extensions that cannot be ignored
        Comments

        There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

        Control 0..*
        Type Extension
        Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
        Summary false
        Requirements

        Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

        Alternate Names extensions, user content
        Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        8. Medication.code
        Definition

        A code (or set of codes) that specify this medication, or a textual description if no code is available. Usage note: This could be a standard medication code such as a code from RxNorm, SNOMED CT, IDMP etc. It could also be a national or local formulary code, optionally with translations to other code systems.

        Short icon Changed:(NHSN-MS)(USCDI) Codes that identify this medicationCodes that identify this medication
        Comments

        Depending on the context of use, the code that was actually selected by the user (prescriber, dispenser, etc.) will have the coding.userSelected set to true. As described in the coding datatype: "A coding may be marked as a "userSelected" if a user selected the particular coded value in a user interface (e.g. the user selects an item in a pick-list). If a user selected coding exists, it is the preferred choice for performing translations etc. Other codes can only be literal translations to alternative code systems, or codes at a lower level of granularity (e.g. a generic code for a vendor-specific primary one).

        Control 10..1
        Binding Unless not suitable, these codes SHALL be taken from For example codes, see MedicationClinicalDrug (20240606) .http://hl7.org/fhir/ValueSet/medication-codes|4.0.1
        (extensible to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1010.4|20240606)
        Type CodeableConcept
        Is Modifier false
        Must Support true
        Summary true
        Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        10. Medication.status
        Definition

        A code to indicate if the medication is in active use.

        Short icon Changed:(NHSN-MS) active | inactive | entered-in-erroractive | inactive | entered-in-error
        Comments

        This status is intended to identify if the medication in a local system is in active use within a drug database or inventory. For example, a pharmacy system may create a new drug file record for a compounded product "ABC Hospital Special Cream" with an active status. At some point in the future, it may be determined that the drug record was created with an error and the status is changed to "entered in error". This status is not intended to specify if a medication is part of a particular formulary. It is possible that the drug record may be referenced by multiple formularies or catalogues and each of those entries would have a separate status.

        Control 0..1
        Binding The codes SHALL be taken from Medication Status Codeshttp://hl7.org/fhir/ValueSet/medication-status|4.0.1
        (required to http://hl7.org/fhir/ValueSet/medication-status|4.0.1)

        A coded concept defining if the medication is in active use.

        Type code
        Is Modifier true because This element changes the interpretation of all descriptive attributes.
        Primitive Value This primitive element may be present, or absent, or replaced by an extension
        Must Support true
        Summary true
        Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        12. Medication.form
        Definition

        Describes the form of the item. Powder; tablets; capsule.

        Short icon Changed:(NHSN-MS) powder | tablets | capsule +powder | tablets | capsule +
        Comments

        When Medication is referenced from MedicationRequest, this is the ordered form. When Medication is referenced within MedicationDispense, this is the dispensed form. When Medication is referenced within MedicationAdministration, this is administered form.

        Control 0..1
        Binding Unless not suitable, these codes SHALL be taken from For example codes, see SNOMEDCTFormCodeshttp://hl7.org/fhir/ValueSet/medication-form-codes|4.0.1
        (extensible to http://hl7.org/fhir/ValueSet/medication-form-codes)
        Type CodeableConcept
        Is Modifier false
        Must Support true
        Summary false
        Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        14. Medication.amount
        Definition

        Specific amount of the drug in the packaged product. For example, when specifying a product that has the same strength (For example, Insulin glargine 100 unit per mL solution for injection), this attribute provides additional clarification of the package amount (For example, 3 mL, 10mL, etc.).

        Short icon Changed:(NHSN-MS) Amount of drug in packageAmount of drug in package
        Control 0..1
        Type Ratio
        Is Modifier false
        Must Support true
        Summary true
        Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        16. Medication.ingredient
        Definition

        Identifies a particular constituent of interest in the product.

        Short icon Changed:(NHSN-MS) Active or inactive ingredientActive or inactive ingredient
        Comments

        The ingredients need not be a complete list. If an ingredient is not specified, this does not indicate whether an ingredient is present or absent. If an ingredient is specified it does not mean that all ingredients are specified. It is possible to specify both inactive and active ingredients.

        Control 0..*
        Type BackboneElement
        Is Modifier false
        Must Support true
        Summary false
        Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        18. Medication.ingredient.modifierExtension
        Definition

        May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

        Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

        Short Extensions that cannot be ignored even if unrecognized
        Comments

        There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

        Control 0..*
        Type Extension
        Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
        Summary true
        Requirements

        Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

        Alternate Names extensions, user content, modifiers
        Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        20. Medication.ingredient.item[x]
        Definition

        The actual ingredient - either a substance (simple ingredient) or another medication of a medication.

        Short icon Changed:(NHSN-MS) The actual ingredient or contentThe actual ingredient or content
        Control 1..1
        Type Choice of: CodeableConcept, Reference(QICore Substance, QICore Medication, Substance, Medication)bundled
        [x] Note SeeChoice of Data Typesfor further information about how to use [x]
        Is Modifier false
        Must Support icon Added:true
        Must Support Types No must-support rules about the choice of types/profiles
        Summary false
        Requirements

        The ingredient may reference a substance (for example, amoxicillin) or another medication (for example in the case of a compounded product, Glaxal Base).

        Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        Slicing This element introduces a set of slices on Medication.ingredient.item[x]. The slices areUnordered and Open, and can be differentiated using the following discriminators:
        • type @ $this
        • 22. Medication.ingredient.item[x]:itemReference
          Slice Name itemReference
          Definition

          The actual ingredient - either a substance (simple ingredient) or another medication of a medication.

          Short The actual ingredient or content
          Control 01..1
          Type Reference(QICore Substance, QICore Medication, Substance, Medication)bundled, CodeableConcept
          [x] Note SeeChoice of Data Typesfor further information about how to use [x]
          Is Modifier false
          Must Support true
          Must Support Types No must-support rules about the choice of types/profiles
          Summary false
          Requirements

          The ingredient may reference a substance (for example, amoxicillin) or another medication (for example in the case of a compounded product, Glaxal Base).

          Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          24. Medication.ingredient.item[x]:itemReference.reference
          Definition

          A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

          Short (NHSN-MS) The actual ingredient or contentLiteral reference, Relative, internal or absolute URL
          Comments

          Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

          Control 10..1
          This element is affected by the following invariants: ref-1
          Type string
          Is Modifier false
          Primitive Value This primitive element may be present, or absent, or replaced by an extension
          Must Support true
          Summary true
          Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

          Guidance on how to interpret the contents of this table can be foundhere

          0. Medication
          2. Medication.id
          Short icon Added:(NHSN-MS) Logical id of this artifact
          Control 1..?
          Must Support icon Added:true
          4. Medication.meta
          6. Medication.meta.extension:link-received-date-extension
          Slice Name link-received-date-extension
          Control 0..1
          Type Extension(Received Date) (Extension Type: dateTime)
          8. Medication.code
          Short icon Added:(NHSN-MS)(USCDI) Codes that identify this medication
          10. Medication.status
          Short icon Added:(NHSN-MS) active | inactive | entered-in-error
          Must Support true
          12. Medication.form
          Short icon Added:(NHSN-MS) powder | tablets | capsule +
          Binding Unless not suitable, these codes SHALL be taken from SNOMEDCTFormCodes
          (extensible to http://hl7.org/fhir/ValueSet/medication-form-codes)
          Must Support true
          14. Medication.amount
          Short icon Added:(NHSN-MS) Amount of drug in package
          Must Support true
          16. Medication.ingredient
          Short icon Added:(NHSN-MS) Active or inactive ingredient
          Must Support true
          18. Medication.ingredient.item[x]
          Short icon Added:(NHSN-MS) The actual ingredient or content
          Type Choice of: icon Added:CodeableConcept, icon Added:Reference(QICore Substance, QICore Medication)bundled
          [x] Note SeeChoice of Data Typesfor further information about how to use [x]
          Must Support icon Added:true
          Must Support Types No must-support rules about the choice of types/profiles
          Slicing This element introduces a set of slices on Medication.ingredient.item[x]. The slices areUnordered and Open, and can be differentiated using the following discriminators:
          • type @ $this
          • 20. Medication.ingredient.item[x]:itemReference
            Slice Name itemReference
            Control 0..1
            Type Reference(QICore Substance, QICore Medication)bundled
            [x] Note SeeChoice of Data Typesfor further information about how to use [x]
            Must Support icon Added:true
            Must Support Types No must-support rules about the choice of types/profiles
            22. Medication.ingredient.item[x]:itemReference.reference
            Short icon Added:(NHSN-MS) The actual ingredient or content
            Control 1..?
            Must Support true

            Guidance on how to interpret the contents of this table can be foundhere

            0. Medication
            Definition

            icon Changed:

            -

            Short Definition of a Medication
            Comments

            icon Added:

            -

            Control 0..*
            Is Modifier false
            Must Support false
            Summary false
            Invariants dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
            dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
            dom-6: A resource should have narrative for robust management (text.`div`.exists())
            2. Medication.id
            Definition

            The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

            Short icon Changed:(NHSN-MS) Logical id of this artifact
            Comments

            The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

            Control 1..1
            Type id
            Is Modifier false
            Must Support icon Added:true
            Summary true
            4. Medication.meta
            Definition

            The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

            Short Metadata about the resource
            Control 0..1
            Type Meta
            Is Modifier false
            Summary true
            Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            6. Medication.meta.id
            Definition

            Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

            Short Unique id for inter-element referencing
            Control 0..1
            Type string
            Is Modifier false
            XML Format In the XML format, this property is represented as an attribute.
            Summary false
            8. Medication.meta.extension
            Definition

            May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

            Short Additional content defined by implementations
            Comments

            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

            Control 0..*
            Type Extension
            Is Modifier false
            Summary false
            Alternate Names extensions, user content
            Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            Slicing This element introduces a set of slices on Medication.meta.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
            • value @ url
            • 10. Medication.meta.extension:link-received-date-extension
              Slice Name link-received-date-extension
              Definition

              This extension stores the date and time a Resource was received by the processing system (e.g., NHSNLink).

              Short Received Date
              Control 0..1
              Type Extension(Received Date) (Extension Type: dateTime)
              Is Modifier false
              Summary false
              Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
              12. Medication.meta.versionId
              Definition

              The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.

              Short Version specific identifier
              Comments

              The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.

              Control 0..1
              Type id
              Is Modifier false
              Primitive Value This primitive element may be present, or absent, or replaced by an extension
              Summary true
              Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              14. Medication.meta.lastUpdated
              Definition

              When the resource last changed - e.g. when the version changed.

              Short When the resource version last changed
              Comments

              This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.

              Control 0..1
              Type instant
              Is Modifier false
              Primitive Value This primitive element may be present, or absent, or replaced by an extension
              Summary true
              Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              16. Medication.meta.source
              Definition

              A uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.

              Short Identifies where the resource comes from
              Comments

              In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used.

              This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.

              Control 0..1
              Type uri
              Is Modifier false
              Primitive Value This primitive element may be present, or absent, or replaced by an extension
              Summary true
              Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              18. Medication.meta.profile
              Definition

              A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url.

              Short Profiles this resource claims to conform to
              Comments

              It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.

              Control 0..*
              Type canonical(StructureDefinition)
              Is Modifier false
              Primitive Value This primitive element may be present, or absent, or replaced by an extension
              Summary true
              Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              20. Medication.meta.security
              Definition

              Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.

              Short Security Labels applied to this resource
              Comments

              The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.

              Control 0..*
              Binding Unless not suitable, these codes SHALL be taken from All Security Labels
              (extensible to http://hl7.org/fhir/ValueSet/security-labels|4.0.1)

              Security Labels from the Healthcare Privacy and Security Classification System.

              Type Coding
              Is Modifier false
              Summary true
              Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              22. Medication.meta.tag
              Definition

              Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.

              Short Tags applied to this resource
              Comments

              The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.

              Control 0..*
              Binding For example codes, see CommonTags
              (example to http://hl7.org/fhir/ValueSet/common-tags|4.0.1)

              Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".

              Type Coding
              Is Modifier false
              Summary true
              Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              24. Medication.implicitRules
              Definition

              A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

              Short A set of rules under which this content was created
              Comments

              Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

              Control 0..1
              Type uri
              Is Modifier true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
              Primitive Value This primitive element may be present, or absent, or replaced by an extension
              Summary true
              Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              26. Medication.language
              Definition

              The base language in which the resource is written.

              Short Language of the resource content
              Comments

              Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

              Control 0..1
              Binding The codes SHOULD be taken from CommonLanguages
              (preferred to http://hl7.org/fhir/ValueSet/languages)

              A human language.

              Additional Bindings Purpose
              AllLanguages Max Binding
              Type code
              Is Modifier false
              Primitive Value This primitive element may be present, or absent, or replaced by an extension
              Summary false
              Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              28. Medication.text
              Definition

              A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

              Short Text summary of the resource, for human interpretation
              Comments

              Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

              Control 0..1
              Type Narrative
              Is Modifier false
              Summary false
              Alternate Names narrative, html, xhtml, display
              Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              30. Medication.contained
              Definition

              These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

              Short Contained, inline Resources
              Comments

              This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

              Control 0..*
              Type Resource
              Is Modifier false
              Summary false
              Alternate Names inline resources, anonymous resources, contained resources
              32. Medication.extension
              Definition

              May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

              Short Additional content defined by implementations
              Comments

              There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

              Control 0..*
              Type Extension
              Is Modifier false
              Summary false
              Alternate Names extensions, user content
              Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
              34. Medication.modifierExtension
              Definition

              May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

              Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

              Short Extensions that cannot be ignored
              Comments

              There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

              Control 0..*
              Type Extension
              Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
              Summary false
              Requirements

              Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

              Alternate Names extensions, user content
              Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
              36. Medication.identifier
              Definition

              Business identifier for this medication.

              Short Business identifier for this medication
              Comments

              The serial number could be included as an identifier.

              Note This is a business identifier, not a resource identifier (see discussion)
              Control 0..*
              Type Identifier
              Is Modifier false
              Summary true
              Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              38. Medication.code
              Definition

              A code (or set of codes) that specify this medication, or a textual description if no code is available. Usage note: This could be a standard medication code such as a code from RxNorm, SNOMED CT, IDMP etc. It could also be a national or local formulary code, optionally with translations to other code systems.

              Short icon Changed:(NHSN-MS)(USCDI) Codes that identify this medication
              Comments

              Depending on the context of use, the code that was actually selected by the user (prescriber, dispenser, etc.) will have the coding.userSelected set to true. As described in the coding datatype: "A coding may be marked as a "userSelected" if a user selected the particular coded value in a user interface (e.g. the user selects an item in a pick-list). If a user selected coding exists, it is the preferred choice for performing translations etc. Other codes can only be literal translations to alternative code systems, or codes at a lower level of granularity (e.g. a generic code for a vendor-specific primary one).

              Control 1..1
              Binding Unless not suitable, these codes SHALL be taken from MedicationClinicalDrug (20240606) .
              (extensible to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1010.4|20240606)
              Type CodeableConcept
              Is Modifier false
              Must Support true
              Summary true
              Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              40. Medication.status
              Definition

              A code to indicate if the medication is in active use.

              Short icon Changed:(NHSN-MS) active | inactive | entered-in-error
              Comments

              This status is intended to identify if the medication in a local system is in active use within a drug database or inventory. For example, a pharmacy system may create a new drug file record for a compounded product "ABC Hospital Special Cream" with an active status. At some point in the future, it may be determined that the drug record was created with an error and the status is changed to "entered in error". This status is not intended to specify if a medication is part of a particular formulary. It is possible that the drug record may be referenced by multiple formularies or catalogues and each of those entries would have a separate status.

              Control 0..1
              Binding The codes SHALL be taken from Medication Status Codes
              (required to http://hl7.org/fhir/ValueSet/medication-status|4.0.1)

              A coded concept defining if the medication is in active use.

              Type code
              Is Modifier true because This element changes the interpretation of all descriptive attributes.
              Primitive Value This primitive element may be present, or absent, or replaced by an extension
              Must Support true
              Summary true
              Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              42. Medication.manufacturer
              Definition

              Describes the details of the manufacturer of the medication product. This is not intended to represent the distributor of a medication product.

              Short Manufacturer of the item
              Control 0..1
              Type Reference(QICore Organization)
              Is Modifier false
              Must Support icon Added:false
              Summary true
              Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              44. Medication.form
              Definition

              Describes the form of the item. Powder; tablets; capsule.

              Short icon Changed:(NHSN-MS) powder | tablets | capsule +
              Comments

              When Medication is referenced from MedicationRequest, this is the ordered form. When Medication is referenced within MedicationDispense, this is the dispensed form. When Medication is referenced within MedicationAdministration, this is administered form.

              Control 0..1
              Binding Unless not suitable, these codes SHALL be taken from SNOMEDCTFormCodes
              (extensible to http://hl7.org/fhir/ValueSet/medication-form-codes)
              Type CodeableConcept
              Is Modifier false
              Must Support true
              Summary false
              Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              46. Medication.amount
              Definition

              Specific amount of the drug in the packaged product. For example, when specifying a product that has the same strength (For example, Insulin glargine 100 unit per mL solution for injection), this attribute provides additional clarification of the package amount (For example, 3 mL, 10mL, etc.).

              Short icon Changed:(NHSN-MS) Amount of drug in package
              Control 0..1
              Type Ratio
              Is Modifier false
              Must Support true
              Summary true
              Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              48. Medication.ingredient
              Definition

              Identifies a particular constituent of interest in the product.

              Short icon Changed:(NHSN-MS) Active or inactive ingredient
              Comments

              The ingredients need not be a complete list. If an ingredient is not specified, this does not indicate whether an ingredient is present or absent. If an ingredient is specified it does not mean that all ingredients are specified. It is possible to specify both inactive and active ingredients.

              Control 0..*
              Type BackboneElement
              Is Modifier false
              Must Support true
              Summary false
              Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              50. Medication.ingredient.id
              Definition

              Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

              Short Unique id for inter-element referencing
              Control 0..1
              Type string
              Is Modifier false
              XML Format In the XML format, this property is represented as an attribute.
              Summary false
              52. Medication.ingredient.extension
              Definition

              May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

              Short Additional content defined by implementations
              Comments

              There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

              Control 0..*
              Type Extension
              Is Modifier false
              Summary false
              Alternate Names extensions, user content
              Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
              54. Medication.ingredient.modifierExtension
              Definition

              May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

              Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

              Short Extensions that cannot be ignored even if unrecognized
              Comments

              There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

              Control 0..*
              Type Extension
              Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
              Summary true
              Requirements

              Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

              Alternate Names extensions, user content, modifiers
              Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
              56. Medication.ingredient.item[x]
              Definition

              The actual ingredient - either a substance (simple ingredient) or another medication of a medication.

              Short icon Changed:(NHSN-MS) The actual ingredient or content
              Control 1..1
              Type Choice of: CodeableConcept, Reference(QICore Substance, QICore Medication)bundled
              [x] Note SeeChoice of Data Typesfor further information about how to use [x]
              Is Modifier false
              Must Support icon Added:true
              Must Support Types No must-support rules about the choice of types/profiles
              Summary false
              Requirements

              The ingredient may reference a substance (for example, amoxicillin) or another medication (for example in the case of a compounded product, Glaxal Base).

              Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              Slicing This element introduces a set of slices on Medication.ingredient.item[x]. The slices areUnordered and Open, and can be differentiated using the following discriminators:
              • type @ $this
              • 58. Medication.ingredient.item[x]:itemReference
                Slice Name itemReference
                Definition

                The actual ingredient - either a substance (simple ingredient) or another medication of a medication.

                Short The actual ingredient or content
                Control 0..1
                Type Reference(QICore Substance, QICore Medication)bundled
                [x] Note SeeChoice of Data Typesfor further information about how to use [x]
                Is Modifier false
                Must Support true
                Must Support Types No must-support rules about the choice of types/profiles
                Summary false
                Requirements

                The ingredient may reference a substance (for example, amoxicillin) or another medication (for example in the case of a compounded product, Glaxal Base).

                Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                60. Medication.ingredient.item[x]:itemReference.id
                Definition

                Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                Short Unique id for inter-element referencing
                Control 0..1
                Type string
                Is Modifier false
                XML Format In the XML format, this property is represented as an attribute.
                Summary false
                62. Medication.ingredient.item[x]:itemReference.extension
                Definition

                May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                Short Additional content defined by implementations
                Comments

                There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                Control 0..*
                Type Extension
                Is Modifier false
                Summary false
                Alternate Names extensions, user content
                Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                Slicing This element introduces a set of slices on Medication.ingredient.item[x].extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                • value @ url
                • 64. Medication.ingredient.item[x]:itemReference.reference
                  Definition

                  A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

                  Short (NHSN-MS) The actual ingredient or content
                  Comments

                  Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

                  Control 1..1
                  This element is affected by the following invariants: ref-1
                  Type string
                  Is Modifier false
                  Primitive Value This primitive element may be present, or absent, or replaced by an extension
                  Must Support true
                  Summary true
                  Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  66. Medication.ingredient.item[x]:itemReference.type
                  Definition

                  The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

                  The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).

                  Short Type the reference refers to (e.g. "Patient")
                  Comments

                  This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.

                  Control 0..1
                  Binding Unless not suitable, these codes SHALL be taken from ResourceType
                  (extensible to http://hl7.org/fhir/ValueSet/resource-types|4.0.1)

                  Aa resource (or, for logical models, the URI of the logical model).

                  Type uri
                  Is Modifier false
                  Primitive Value This primitive element may be present, or absent, or replaced by an extension
                  Summary true
                  Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  68. Medication.ingredient.item[x]:itemReference.identifier
                  Definition

                  An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

                  Short Logical reference, when literal reference is not known
                  Comments

                  When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

                  When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

                  Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

                  Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

                  Note This is a business identifier, not a resource identifier (see discussion)
                  Control 0..1
                  Type Identifier
                  Is Modifier false
                  Summary true
                  Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  70. Medication.ingredient.item[x]:itemReference.display
                  Definition

                  Plain text narrative that identifies the resource in addition to the resource reference.

                  Short Text alternative for the resource
                  Comments

                  This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

                  Control 0..1
                  Type string
                  Is Modifier false
                  Primitive Value This primitive element may be present, or absent, or replaced by an extension
                  Summary true
                  Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  72. Medication.ingredient.isActive
                  Definition

                  Indication of whether this ingredient affects the therapeutic action of the drug.

                  Short Active ingredient indicator
                  Control 0..1
                  Type boolean
                  Is Modifier false
                  Primitive Value This primitive element may be present, or absent, or replaced by an extension
                  Must Support icon Added:false
                  Summary false
                  Requirements

                  True indicates that the ingredient affects the therapeutic action of the drug (i.e. active). False indicates that the ingredient does not affect the therapeutic action of the drug (i.e. inactive).

                  Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  74. Medication.ingredient.strength
                  Definition

                  Specifies how many (or how much) of the items there are in this Medication. For example, 250 mg per tablet. This is expressed as a ratio where the numerator is 250mg and the denominator is 1 tablet.

                  Short Quantity of ingredient present
                  Control 0..1
                  Type Ratio
                  Is Modifier false
                  Summary false
                  Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  76. Medication.batch
                  Definition

                  Information that only applies to packages (not products).

                  Short Details about packaged medications
                  Control 0..1
                  Type BackboneElement
                  Is Modifier false
                  Summary false
                  Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  78. Medication.batch.id
                  Definition

                  Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                  Short Unique id for inter-element referencing
                  Control 0..1
                  Type string
                  Is Modifier false
                  XML Format In the XML format, this property is represented as an attribute.
                  Summary false
                  80. Medication.batch.extension
                  Definition

                  May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                  Short Additional content defined by implementations
                  Comments

                  There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                  Control 0..*
                  Type Extension
                  Is Modifier false
                  Summary false
                  Alternate Names extensions, user content
                  Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  82. Medication.batch.modifierExtension
                  Definition

                  May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                  Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                  Short Extensions that cannot be ignored even if unrecognized
                  Comments

                  There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                  Control 0..*
                  Type Extension
                  Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                  Summary true
                  Requirements

                  Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                  Alternate Names extensions, user content, modifiers
                  Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  84. Medication.batch.lotNumber
                  Definition

                  The assigned lot number of a batch of the specified product.

                  Short Identifier assigned to batch
                  Control 0..1
                  Type string
                  Is Modifier false
                  Primitive Value This primitive element may be present, or absent, or replaced by an extension
                  Summary false
                  Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  86. Medication.batch.expirationDate
                  Definition

                  When this specific batch of product will expire.

                  Short When batch will expire
                  Control 0..1
                  Type dateTime
                  Is Modifier false
                  Primitive Value This primitive element may be present, or absent, or replaced by an extension
                  Summary false
                  Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

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