TEMPLATE Administration of antiglaucoma drugs (Administration of antiglaucoma drugs)

TEMPLATE ID	Administration of antiglaucoma drugs
Concept	Administration of antiglaucoma drugs
Description	To schedule and register the therapeutic procedure consisting of adjusting the medication regimen for patients with chronic glaucoma.
Purpose	To schedule and register the therapeutic procedure consisting of adjusting the medication regimen for patients with chronic glaucoma.
References
Authors	name: Aitor Eguzkitza; organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra; email: aitor.eguzkiza@unavarra.es; date: 2016-07-24
Other Details Language	name: Aitor Eguzkitza; organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra; email: aitor.eguzkiza@unavarra.es; date: 2016-07-24
Other Details (Language Independent)	MetaDataSet:Sample Set : Template metadata sample set Copyright: © openEHR Foundation Owner: Aitor Eguzkitza, aitor.eguzkiza@unavarra.es Speciality: Ophthalmology
Language used	en
Citeable Identifier	1013.26.147
Root archetype id	openEHR-EHR-SECTION.medication_administration.v0
Medication administration procedure	Medication administration procedure: Manages the process of planning and then carrying out an ophthalmic treatment by means of use, administration, dispensing or other care step relating to a medicine.
Medication order	Medication order: Instructions for use of a medication, vaccine or other therapeutic item.
Order	Order: Order.
Description
Medication item	Medication item: Identification of the medication, vaccine or other therapeutic item being ordered. It is strongly recommended that the 'Medication item' be coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple 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. Value set: terminology:Snomed?subset=IOP%20lowering%20agents&language=en-GB
Route	Route: The route of administration. For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible. Multiple potential routes may be specified.
Dose directions description	Dose directions description: Complete narrative description about how the medication is to be used. Including the amount, when to take it and additional instructions for use. Where the medication dose directions are fully carried by the structured, computable dose directions, this element should carry the narrative equivalent, generally auto-generated. If it is not possible to represent the intended dosage directions fully in computable form, partial representation is not recommended, and the directions should be only recorded in narrative form using this data element.
Parsable dose directions	Parsable dose directions: The structured, parsable and computable representation of the dose directions. Generally this is only used when passing information between legacy systems. For example: '10mg bd; 20mg n' as used by the NHS Dose syntax (in development). Formalism text/html text/plain text/xml text/rtf
Dose amount description	Dose amount description: The narrative description of the dose amount of the medication, vaccine or other therapeutic item. Will generally only be used for legacy formats where dose directions are simply split between textual representations of dose and amount.
Dose timing description	Dose timing description: The narrative description of the dose frequency and other timing of the medication, vaccine or other therapeutic item. Will generally only be used for legacy formats where dose directions are simply split between textual representations of dose and amount.
Patient guidance	Patient guidance: An additional instruction directed primarily at the patient or carers. For example: 'To reduce your blood pressure', 'To thin your blood'. This data element allows multiple occurrences and should be coded with a reference terminology, where possible. If required it is possible to use a LINK attribute to associate this element with, for example, the 'original diagnosis' in a separate Problem list composition but the indication should be explicitly recorded here, as the link target may change over time.
Clinical indication	Clinical indication: The clinical reason for ordering the medication, vaccine or other therapeutic good. For example: 'Angina'. Coding of the clinical indication with a terminology is preferred, where possible. This data element allows multiple occurrences. Default value: The current medical treatment does not achieves the target IOP.
Therapeutic intent	Therapeutic intent: The overall therapeutic intent of the medication. For example: 'palliative care', 'low-dose propylaxis'. Default value: The new medication regimen must curb the progression of chronic glaucoma into a medically stable state.
Order details	Order details: Details about the intended course of the medication.
Order start date/time	Order start date/time: The date and optional time to commence use of the medication, vaccine or other therapeutic good.
Order stop date/time	Order stop date/time: The date and optional time to cease use of the medication, vaccine or other therapeutic good.
Order start criterion	Order start criterion: A condition which, when met, requires the commencement of administration or use. For example: 'Start if symptoms recur'.
Order stop criterion	Order stop criterion: A condition which, when met, requires the cessation of administration or use. For example: 'Stop after symptoms disappear''.
Administrations already complete	Administrations already complete: The number of administrations of the medication, vaccine or other therapeutic good that have been completed, as part of the proposed overall course but prior to the issue of this order. For example: To record that the patient had been taking antibiotics three days prior to hospital admission, in the context of a 7-day course.
Duration of course already complete	Duration of course already complete: The time period during which the patient has already been using the medication, vaccine or other therapeutic good, as a part of the proposed overall course but prior to the issue of this order. For example: To record that the patient had been taking antibiotics 3 days prior to hospital admission, in the context of a 7 day course. >=PT0H Units: Week Day Hour
Administration directions	Administration directions: Details about the administration of the medication, vaccine or other therapeutic good.
Administration instruction	Administration instruction: An additional instruction directed primarily at the person administering the medication, vaccine or therapeutic good. For example: 'Give slowly', 'Avoid right arm - risk of lymphoedema'. This data element allows multiple occurrences.
Infusion purpose	Infusion purpose: The purpose of the infusion. Baseline electrolyte infusion Active medication infusion Nutritional infusion
Body site	Body site: Identification of the site of administration of the medication, vaccine or therapeutic good. For example: 'left upper arm', 'intravenous catheter right hand'. Coding of the body site with a terminology is preferred, where possible.
Delivery method	Delivery method: The method by which the medication is to be delivered. For example: 'via nebuliser'.
Comment	Comment: Additional narrative about the medication order not captured in other fields.
Protocol	Protocol: The amount and units of the medication, vaccine or other therapeutic good to be used or administered at one time.
Order identifier	Order identifier: Unique identifier for the medication order.
Dosage formula	Dosage formula: The formula used to calculate the Dose amount or administration rate where this is dependent on some other factor such as patient weight. For example: 10mg/kg/day.
Medication	Medication: Details of use, administration, dispensing or other care step relating to a medicine, vaccine or other therapeutic good which may arise from an instruction from a clinician.
Description
Medication	Medication: The medicine, vaccine or other therapeutic good which was the focus of the action. This element will normally be coded with a medicines terminology but free text may be required in some cases. For example: 'Atenolol 100mg' or 'Atenolol tablets 100mg'. Value set: terminology:Snomed?subset=IOP%20lowering%20agents&language=en-GB
Product	Product: Details of the product dispensed, authorised or administered.
Manufacturer	Manufacturer: The manufacturer of the medication.
Batch ID	Batch ID: Assigned by the manufacturer to identify the manufacturing batch of the item.
Expiry date	Expiry date: The expiry date of the medicine administered as documented by the manufacturer.
Max class dose administered	Max class dose administered: The proportion of the maximum allowed dose equivalent administered. Used in mental health to allow monitoring of total amount of a drug class andministered e.g. anti-psychotics, where each medication is associated with a percentage contribution towards a total daily maximum, normally 100%. Percent
Dispensing substitution	Dispensing substitution: Subsitution action taken by the dispenser. Substitute product dispensed Substitute product not dispensed
Dispensing substitution reason	Dispensing substitution reason: The reason or justification for the substitution action taken.
Order scheduled datetime	Order scheduled datetime: The datetime at which the medication order was scheduled to occur. Used to compare variance from actual action time where this is not readily calculable from the original instruction.
Reason	Reason: The reason(s) the specific action or step was carried out. Note: This is not the reason for the medication instruction, rather the specific reason e.g. for administration. Default value: This medication regimen must curb the progression of chronic glaucoma into a medically stable state.
Reason course amended/stopped	Reason course amended/stopped: The reason(s) for amending or stopping a course of medication. Coded Text Allergy/Adverse Reaction/ Intolerance Inadequate clinical response Patient choice / difficulty Prescribed in error Additional information available Temporarily suspended Change to dose form/ strength /route Text
Reason dose not administered	Reason dose not administered: The reason(s) why a particular dose administration did not take place, including complte omission of the dose and deferral of the dose. Patient refused Nil by mouth Medicine unavailable Patient unavailable Clinical reason
Delivery details	Delivery details: Details of body site and delivery of the medication.
Body site	Body site: Identification of the site of administration of the medication, vaccine or therapeutic good. For example: 'left upper arm', 'intravenous catheter right hand'. Coding of the body site with a terminology is preferred, where possible.
Delivery method	Delivery method: The method by which the medication is to be delivered. For example: 'via nebuliser'.
Patient guidance	Patient guidance: Any guidance, instructions or advice given to the subject of care or carer at the time of the action.
Sequence number	Sequence number: The sequence number specific to the action being recorded.
Comment	Comment: A comment on the action taken including details of any variance between the intended action and the action actually performed.
Protocol
Order ID	Order ID: The identifier assigned with the original order.
Other contributors	Jose Andonegui, Complejo hospitalario de Navarra (CHN), jose.andonegui.navarro@cfnavarra.es; Luis Serrano, Universidad Pública de Navarra (UPNA), lserrano@unavarra.es; Jesús D. Trigo, Universidad Pública de Navarra (UPNA), jesusdaniel.trigo@unavarra.es