| ARCHETYPE ID | openEHR-EHR-COMPOSITION.medication_list.v1 |
| Concept | Medication list |
| Description | A persistent and versioned list of medicines for an individual. |
| Use | Use to record a persistent and managed list of medicines for an individual, potentially including all prescribed and 'over the counter' medicines, supplements or natural remedies. Alternatively, it may contain positive and explicit statements about known exclusions or absence of information about medications. The intent of this archetype is to be a generic container for any Medication list, which may have a specific context or limitation of scope set within a template. This list can be utilised as a source of medicines data for an active current medication list within a clinical system, for transition of care, data exchange, or as the basis for decision support. Most commonly, this list will be comprised of three types of archetype: - statements about the positive use of medications are recorded using the INSTRUCTION.medication_order and/or ACTION.medication archetypes; OR - a positive statement about the general exclusion of medication use can be recorded using the general EVALUATION.exclusion_global archetype - for example: "Not currently taking any medications"; OR - a positive statement about the exclusion of use of a specific medication can be recorded using the EVALUATION.exclusion_specific archetype - for example: "Not currently taking penicillin" - a positive statement about no information being available - neither a positive known use of medication nor a positive exclusion - can be recorded using the EVALUATION.absence archetype. In order for a Medication list to be accurate and safe to use as the basis for decision support activities and for exchange, this Medication list should ideally be curated by a clinician responsible for the health record, rather than managed automatically by the clinical system through business rules alone. There can be a subtle but important difference between types of medication lists. Some examples include: 'Current Medication' or 'Regular Medication'. A 'Current medication list' may be regarded as a list of all medicines that the individual would have in their body at a given time, including any stat or prn doses of a medicine that should be considered when prescribing to ensure that drug-drug interaction checking continues for the duration of its physiological effect. A 'Regular Medication' list may only include those medicines that are taken by the individual on a regular and ongoing basis. In addition, it is common in clinical practice to create Medication Lists that have temporal constraints, including 'Admission Medication List' and 'Discharge Medication List', which will be relevant only at a specified point in time. Other examples include 'Past Medications' or 'Inactive Medications'. This will ultimately be an implementation decision for each clinical system - an alternative approach may be to record these contextual clinical constructs as the result of a query or use of a different COMPOSITION archetype, yet to be determined. This archetype is intended to be represented and managed as a persistent list, however there are situations where the list may be used within episodic care and require additional attributes such as context etc to enable accurate recording. The openEHR reference model currently only allows context to be recorded within Event-based COMPOSITION archetypes. As a result, this archetype has been modelled as an Event, rather than Persistent, COMPOSITION, to allow for flexibility so that some clinical systems can safely manage Medication lists for episodes of care, while others will choose to implement this COMPOSITION to act in a persistent manner. |
| Misuse | Not to be used to record lists of Medications that are not intended for persistence and ongoing revision and curation. Not to be used to record individual Prescriptions - use COMPOSITION.prescription for this purpose. Not to be used to record actual changes to therapy, including dose changes, new medicines and ceased medications. Each order will be recorded using individual instances of the INSTRUCTION.medication_order archetype, and only the latest one should be represented within the latest version of this COMPOSITION. Not to be used to record vaccinations administered - use COMPOSITION.immunisation_list for this purpose. |
| Purpose | To record a persistent and managed list of medicines for an individual or, alternatively, positive and explicit statements about known exclusions or actual absence of any information about medications; all of which may influence clinical decision-making and care provision. |
| References | |
| Copyright | © openEHR Foundation |
| Authors | Author name: Chunlan Ma Organisation: Ocean Informatics, Australia Email: chunlan.ma@oceaninformatics.com Date originally authored: 2006-11-06 |
| Other Details Language | Author name: Chunlan Ma Organisation: Ocean Informatics, Australia Email: chunlan.ma@oceaninformatics.com Date originally authored: 2006-11-06 |
| OtherDetails Language Independent | {licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, current_contact=Heather Leslie, Atomica Informatics |
| Keywords | medication, medicine, list, drug, current, prescription |
| Lifecycle | published |
| UID | bab02c90-e1f6-4a9c-b03a-8d854d3242f7 |
| Language used | en |
| Citeable Identifier | 1013.1.286 |
| Revision Number | 1.0.3 |
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