ARCHETYPE Medication Order List (openEHR-EHR-SECTION.medication_order_list.v0)

ARCHETYPE IDopenEHR-EHR-SECTION.medication_order_list.v0
ConceptMedication Order List
DescriptionSuggested design pattern for including an Medication Order List in a template.
UseUse to support the representation of statements about medication orders that have been recorded PLUS to make positive statements about the absence of medication orders - either general statements of absence or specific statements of absence of an identified medication order. The existence of known medication orders can be persisted in records. Statements about the absence of medication orders, either general or specific, can only indicate the state of the subject at the time that the information was actually recorded - that is, they are event based. It is not sensible to persist the recording of a positive absence of a medication order as it may subsequently be ordered or self-administered by the patient, which may render any or all previous positive statements of absence obsolete. It is possible to represent both positive statements about identified medication orders alongside specific positive statements about the absence of identified medication orders in a template (eg patient is taking salbutamol and glibenclamide, but has never taken prednisolone). However in most use cases either specific statements about the presence of identified problems/diagnoses (eg patient is taking salbutamol and glibenclamide) or general statements about the positive absence of any known problems/diagnoses will be represented (eg Not currently taking any medication), but not both. While INSTRUCTION.medication and EVALUATION.exclusion-medication and their specialisations have been explicitly included in the slot constraints, other archetypes have not been explicitly excluded. This means that any other archetypes can also be included here, if needed - for example, where structured data is not available or there is a need to provide a synopis, the EVALUATION.clinical_synopsis can be inserted and used. INSTRUCTION.medication is suggested as the best archetype to represent a Medication list in this instance as it generally provides the best representation of a local Current Medication List. Clinicians can enter patient-administered medications or 'over the counter' medications into a Prescribing system as INSTRUCTIONs, which in turn can enable adverse reaction checking against all INSTRUCTIONS, whether prescribed/printed or not. So Current Medication lists can effectively contain all orders for medications, given by both the recording clinician, other clinicians and the patient. A Medication list comprising only ACTIONs will represent only those medication that have been prescribed/printed by the recording clinician.
PurposeTo demonstrate a design pattern for representation of a Medication Order List.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 7/03/2010
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 7/03/2010
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, references=, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=C8E3ADC1BD9F001642D5E28CAC0235CC, build_uid=8b5686e1-2020-4bb3-8d05-ee2feefa80f5, revision=0.0.1-alpha}
Keywordsmedication, exclusion, absence, current, list
Lifecyclein_development
UIDe017f833-04e4-4e8a-ae51-3ba9735c5b01
Language useden
Citeable Identifier1013.1.609
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Suggested design pattern for including an Medication Order List in a template., archetypeConceptComment=null, otherContributors=Ian McNicoll, Ocean Informatics, United Kingdom
Heath Frankel, Ocean Informatics, Australia, originalLanguage=en, translators=Russian: Art Latyp; Латыпов Артур Шамилевич, RusBITech; РусБИТех, Москва, alatypov@asteis.net, hmm
Spanish (Argentina): Alan March, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina., alandmarch@gmail.com, MD
Portuguese (Brazil): Adriana Kitajima, Débora Farage, Fernanda Maia, Laíse Figueiredo, Marivan Abrahão, Core Consulting, contato@coreconsulting.com.br, Hospital Alemão Oswaldo Cruz (HAOC)
Spanish (Spain): Pablo Pazos, CaboLabs, Computer Engineer, Pablo,Pazos@Cabolabs.Com: pablo,pazos@cabolabs.com
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openEHR-EHR-INSTRUCTION.medication.v1 and specialisations Or
openEHR-EHR-EVALUATION.exclusion-medication.v1 and specialisations, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]