ARCHETYPE Medication use statement (openEHR-EHR-OBSERVATION.medication_statement.v0)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.medication_statement.v0
ConceptMedication use statement
DescriptionAn assertion about the current use of a single medication by an individual.
UseUse to record an assertion about the current use of a single medication by an individual at a specified point in time. In this medication statement context, ‘medication’ describes a wide range of items that may be prescribed or obtained 'over the counter'. This includes: - a single pharmaceutical item or agent; - an extemporaneous preparation; - a combination therapy product; - a nutritional product; or - another therapeutic item used to treat or prevent disease, such as a bandage or dressing containing an antimicrobial agent. It is anticipated that this archetype will commonly be used within an exchange context, for example as part of a health summary or transition of care summary, where one or more instances of this data group may be used to represent a ‘Current medication list’. For example: - on admission to hospital; - as part of a specialist referral; or - as the basis for a medication review. The source of information may be an individual, their carer or a clinician. This archetype has been designed to align with INSTRUCTION.medictation or ACTION.medication_management, where possible. However, it has been constrained to represent only essential information necessary for exchange or summary purposes, plus the addition of event-based data elements such as the ‘Last administered’ data element to support a seamless transition of care. Record one instance of this archetype per medication or combination pack. If the same medication is being used in different dose amounts or varying dose frequencies, each unique dosage and frequency variation should be recorded as a separate instance. This archetype should only be considered up-to-date at the time of authoring. This archetype has been designed to align with the FHIR MedicationStatement resource but is intentionally constrained to 'current use', rather than past or future use.
MisuseNot to be used to record summary or persistent information about past use of a medication - use EVALUATION.medication_summary for this purpose. Not to be used to record details about a medication order - use INSTRUCTION.medication_order for this purpose. Not to be used to record details about specific medication related activities, such as administration or dispensing - use ACTION.medication for this purpose. Not to be used to create a framework for recording answers to pre-defined screening questions about the use of any specified medication or grouping of medications - use OBSERVATION.medication_screening for this purpose. Not to be used to represent a vaccination that has been administered - use an appropriate archetype for this purpose. Not to be used to record information about medical devices that are used or implanted.
PurposeTo record an assertion about the current use of a single medication by an individual at a specified point in time.
ReferencesMedicationStatement, HL7 FHIR Resource [Internet]. Health Level Seven International; [accessed 2024 Jan 30]. Available from: https://hl7.org/fhir/R5/medicationstatement.html.
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2020-08-26
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2020-08-26
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=openEHR Foundation, references=MedicationStatement, HL7 FHIR Resource [Internet]. Health Level Seven International; [accessed 2024 Jan 30]. Available from: https://hl7.org/fhir/R5/medicationstatement.html., original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=AA0BE8C0835250EE579F834B51A6633C, build_uid=c4e8c89d-fafe-4384-819a-0934b3d4abcb, revision=0.0.1-alpha}
Keywordsstatement, snapshot
Lifecyclein_development
UID3c3cd4d6-8573-4376-b843-e9c0ab6ab74e
Language useden
Citeable Identifier1013.1.4949
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=An assertion about the current use of a single medication by an individual., archetypeConceptComment=null, otherContributors=, originalLanguage=en, translators=
  • German: Natalia Strauch, Darin Leonhardt, Medizinische Hochschule Hannover, PLRI für medizinische Informatik/ Medizinische Hochschule, Strauch.Natalia@mh-hannover.de, leonhardt.darin@mh-hannover.de
  • Norwegian Bokmål: Marit Alice Venheim, John Tore Valand, Hanne Marte Bårholm, Helse Vest IKT, Helse Bergen, marit.alice.venheim@helse-vest-ikt.no, john.tore.valand@helse-vest-ikt.no, hanne.marte.sandal.barholm@helse-vest-ikt.no
  • Dutch: Joost Holslag, Nedap, joost.holslag@nedap.com, MD
, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={source=[], identities=[], contacts=[], ism_transition=[], provider=[], protocol=[ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0005], code=at0005, itemType=SLOT, level=2, text=Extension, description=Additional information required to extend the model with local content or to align with other reference models or formalisms., comment=For example: local information requirements; or additional metadata to align with FHIR., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null]], description=[], events=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=2, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=null, extendedValues=null]], details=[], context=[], target=[], capabilities=[], items=[], other_participations=[], content=[], state=[], activities=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0006], code=at0006, itemType=ELEMENT, level=4, text=Medication name, description=Name of the medication., comment=It is strongly recommended that the 'Medication name' be coded with a terminology capable of triggering decision support, where possible. Free text entry should only be used if there is no appropriate terminology available or for customised extemporaneous preparations. The extent of coding may vary from the simple generic or product name of the medication item through to structured details about the actual medication pack to be used. Free text entry should only be used if there is no appropriate terminology available. For example: 'Plaquenil'; 'Ibrutinib 420 mg tablet'; 'Rectinol ointment, 50 g, tube'; or 'Hydrofibre dressing with silver'. , uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0046], code=at0046, itemType=SLOT, level=4, text=Medication details, description=Structured details about the overall medication including strength, form and constituent substances., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.medication.v2 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0047], code=at0047, itemType=ELEMENT, level=4, text=Overall directions description, description=Complete narrative description about how the ordered item is to be used., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0045], code=at0045, itemType=SLOT, level=4, text=Structured dose and timing, description=Details of structured dose and timing directions., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.timing_daily.v1 and specialisations or
openEHR-EHR-CLUSTER.timing_nondaily.v1 and specialisations or
openEHR-EHR-CLUSTER.therapeutic_direction.v1 and specialisations or
openEHR-EHR-CLUSTER.dosage.v2 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0030], code=at0030, itemType=ELEMENT, level=4, text=Route of administration, description=The route by which the medication is administrated into the body., comment=For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0032], code=at0032, itemType=ELEMENT, level=4, text=Description, description=Narrative description of the use of the medication., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0023], code=at0023, itemType=ELEMENT, level=4, text=Clinical indication, description=The clinical symptom, sign or diagnosis that necessitates the use of the medication., comment=For example: 'Angina' or 'Migraine'. Coding of the clinical indication with a terminology is preferred, where possible. This data element has multiple occurrences to allow recording of more than one clinical indication per medication., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0026], code=at0026, itemType=ELEMENT, level=4, text=Last administered, description=The date and time when the medication was last taken by, or administered to, the individual., comment=For example: the time warfarin was last taken at home prior to admission to hospital; or when the last dose was administered before a transfer from hospital to aged care., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0037], code=at0037, itemType=ELEMENT, level=4, text=Endpoint, description=The intended absolute end date for the use of the medication or a textual indication that the medication will be used indefinitely., comment=The DV_DATE_TIME datatype can indicate a precise, absolute date and optional time for the intended end of a limited course of medication - for example, the endpoint of a course of antibiotics the sender has just initiated. The DV_CODED_TEXT option can also be used to record that the medication is intended for indefinite use, for example, potentially lifelong use of an antihypertensive medication., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Date/Time
  •  Coded Text
    • Indefinite [There is no proposed end date for this medication.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0048], code=at0048, itemType=SLOT, level=4, text=Addtional details, description=Structured details about the medication use., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0029], code=at0029, itemType=ELEMENT, level=4, text=Comment, description=Additional narrative about the medication statement not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], relationships=[], credentials=[]}, topLevelItems={protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0004], code=at0004, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], data=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=ITEM_TREE, level=2, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0005], code=at0005, itemType=SLOT, level=2, text=Extension, description=Additional information required to extend the model with local content or to align with other reference models or formalisms., comment=For example: local information requirements; or additional metadata to align with FHIR., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]