ARCHETYPE Medication list (openEHR-EHR-COMPOSITION.medication_list.v1)

ARCHETYPE IDopenEHR-EHR-COMPOSITION.medication_list.v1
ConceptMedication list
DescriptionA persistent and versioned list of medicines for an individual.
UseUse 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.
MisuseNot 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.
PurposeTo 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
AuthorsAuthor name: Chunlan Ma
Organisation: Ocean Informatics, Australia
Email: chunlan.ma@oceaninformatics.com
Date originally authored: 2006-11-06
Other Details LanguageAuthor 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, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=FC27CA9802E3608CB3E7FF598A6E6032, build_uid=282e5ede-5303-4671-87bf-93f6da4c7ade, revision=1.0.0}
Keywordsmedication, medicine, list, drug, current, prescription
Lifecyclepublished
UIDbab02c90-e1f6-4a9c-b03a-8d854d3242f7
Language useden
Citeable Identifier1013.1.286
Revision Number1.0.0
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Nadim Anani, Karolinska Institutet, Sweden
Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)
Koray Atalag, University of Auckland, New Zealand
Heidi Aursand, Oslo universitetssykehus, Norway
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)
Sistine Barretto-Daniels, Australia
Lars Bitsch-Larsen, Haukeland University hospital, Norway
Rong Chen, Cambio Healthcare Systems, Sweden
Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway
Stig Erik Hegrestad, Helse Førde, Norway
Shahla Foozonkhah, Iran ministry of health and education, Iran
Heather Grain, Llewelyn Grain Informatics, Australia
Sam Heard, Ocean Informatics, Australia
Anca Heyd, DIPS ASA, Norway
Hilde Hollås, DIPS AS, Norway
Evelyn Hovenga, EJSH Consulting, Australia
Lars Morgan Karlsen, DIPS ASA, Norway
Shinji Kobayashi, Kyoto University, Japan
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Hallvard Lærum, Norwegian Directorate of e-health, Norway
Colin Macfarlane, Elsevier, United Kingdom
Siv Marie Lien, DIPS ASA, Norway
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)
Andrej Orel, Marand d.o.o., Slovenia
Pablo Pazos, CaboLabs.com Health Informatics, Uruguay
Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil
Gro-Hilde Severinsen, Norwegian center for ehealthresearch, Norway
Line Silsand, Universitetssykehuset i Nord-Norge, Norway
Norwegian Review Summary, Nasjonal IKT HF, Norway
Nyree Taylor, Ocean Informatics, Australia
Tesfay Teame, Folkehelseinstituttet, Norway
Micaela Thierley, Helse Bergen, Norway
Rowan Thomas, St. Vincent's Hospital Melbourne, Australia
John Tore Valand, Helse Bergen, Norway (openEHR Editor), originalLanguage=en, translators=Spanish (Argentina): Edgardo Vazquez, VinculoMedico, edgardo.vazquez@vinculomedico.com, Medical Doctor
Norwegian Bokmål: John Tore Valand and Vebjørn Arntzen, Helse Bergen HF and Oslo University Hospital, john.tore.valand@helse-bergen.no, varntzen@ous-hf.no
Arabic (Syria): Mona Saleh
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