The following table describes the use of medication statements and related
classes to convey information about personal administration of a medication by
a doctor or other health professional in the practice. The approach is similar
to that used for dispensing with the main difference being that the dosage
moodCode is "EVN" indicating an event of dosage rather than a
recommendation "RMD" related to dosage.
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MedicationStatement (MedicationStatement)
A statement that represents the supply and
administration a substance.
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[1..1] classCode (CS){ Fixed="SBADM " }
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[1..1] moodCode (CS) {CNE:EVN}
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[1..1] id (II)
An instance identifier of this statement represented
using the Identifier
Global flavour of the II
data type.
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[1..1] statusCode
(CS) {CNE:EhrMedicationState}
If the administration record is valid (i.e. believed to
be accurate) the status is "complete".
The other possible values ("obsolete" and
"nullified") are only used if the record was subsequently
corrected or deleted due an error.
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[1..1] effectiveTime
(IVL<TS>)
The clinically relevant date/time or period of
administration. E.g. for an infusion or injection.
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[1..1] availabilityTime
(TS)
The date and time of recording this substance
administration action.
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[0..1] pertinentInformation
(MedicationStatement/pertinentInformation)
Relationship to the administered dosage.
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[1..1] typeCode
(CS){
Fixed="COMP " }
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[1..1] MedicationDosage
(MedicationDosage)
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[1..1] classCode
(CS){
Fixed="SBADM " }
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[1..1] moodCode
(CS) {CNE:EVN}
Indicates that this is an event . This
distinguishes dispensing from dispensing or prescribing where the
dosage moodCode is "RMD" recommendation..
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[1..1] text
(ED)
A textual description of the dosage
administration.
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[1..1] consumable
(MedicationStatement/consumable)
Include this to identify the nature of the product.
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[1..1] typeCode
(CS){
Fixed="CSM " }
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[1..1] manufacturedProduct
(ManufacturedProduct)
Details of the medicinal product prescribed.
- May include, drugs, nutritional supplements,
devices used to administer drugs, dressing, appliances,
diagnostic reagents, etc.
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[1..1] classCode
(CS){
Fixed="MANU " }
Indicates that this is a manufactured
product.
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[1..1] manufacturedMaterial
(Material)
Information about the material or substance that forms the
medicinal product.
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[1..1] Material
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The details of a medicinal product.
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[1..1] classCode
(CS){
Fixed="MMAT " }
Indicates that this is a manufactured
material.
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[1..1] determinerCode
(CS)
{CNE:INSTANCE}
Indicates that this represents a
specific instance of a material.
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[1..1] code
(CE)
The code representing the nature of the
product as one of the following:
- actual medicinal product
- actual medicinal product pack.
If the native coding scheme for medicinal product is the
Read Codes then the appropriate code is represented using
the Coded
with Original Text flavour of the data type CE.
Otherwise the Coded
Translated flavour should be used with the medicinal
product represented in the coding system used in the
sending system with a translation to an appropriate
(possibly more generalised) Read Code.
Note
- The source of these codes should
eventually be an agreed UK medicinal product
dictionary.
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[0..1] quantity
(PQ)
The quantity of the product.
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[0..*] participant
(EhrStatement/participant)
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[1..1] typeCode
(CS) {CNE:PRF}
Identifies that this agent performed the associated
action (i.e. in this case administering the medication).
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[1..1] AgentRef
(AgentRef)
A reference to a role which contains detailed
information about the person who administered the medication.
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[1..1] classCode
(CS){
Fixed="AGNT " }
Indicates that this is a reference to a related
agent.
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[1..1] id
(II)
The unique instance identifier of the referenced
role as specified in the role directory.
- If a message contains several Folders, the
referenced role directory is in the
same Folder as the component that refers to it.
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[1..3] component (MedicationStatement/component)
For administration there is always one instance of MedicationStatement/component
containing the actual supply (Dispense)
as detailed here.
There may optionally be one or two additional instances of MedicationStatement/component
containing details of the prescription (Prescribe) and authorisation (Authorise).
First instance of
MedicationStatement/component (mandatory for Administration)
Relationship to details of the supply product that
was administered.
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[1..1] typeCode
(CS){
Fixed="COMP " }
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[1..1] Dispense
(EhrSupply)
A record of the actual supply of a medicinal
product.
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[1..1] classCode
(CS){
Fixed="SPLY" }
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[1..1] moodCode
(CS){
Fixed="EVN" }
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[1..1] id (II)
An identifier of the prescription.
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[1..1] code
(CV) {CNE:EhrSupplyType}
A code representing the type of prescription.
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[1..1] statusCode
(CS) {CNE:EhrSupplyState}
If the dispensing record is valid (i.e. believed
to be accurate) the status is "complete".
The other possible values ("obsolete" and
"nullified") are only used if the record was subsequently
corrected or deleted due an error.
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[1..1] availabilityTime
(TS)
The date and time that the supply action was
recorded.
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[1..1] quantity
(PQ)
The quantity supplied.
- Express simple quantities such as "100
ml" or "3 grams" using Quantity
in Standard Units.
- Express numbers of doses, tablets, capsules,
etc. where the size of the dose or item is explicit elsewhere in
the prescribing data using Quantity
in Standard Units with the unit "1" (unity).
- Express quantities that cannot be represented
adequately using standard units using Quantity
in Arbitrary Units (e.g. "3 packs each containing 21
tablets of substance A and 7 tablets of substance B".
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[0..1] pertinentInformation
(EhrSupply/pertinentInformation)
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[1..1] typeCode
(CS){
Fixed="PERT " }
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[1..1] pertinentSupplyAnnotation
(SupplyAnnotation)
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Details of the annotation.
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[1..1] classCode
(CS){
Fixed="OBS " }
Indicates that this is an Observation.
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[1..1] moodCode
(CS){
Fixed="EVN " }
Indicates that this is an actual event.
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[1..1] text
(ED)
A textual note that was sent from the
prescriber to the dispenser as part of the prescription.
Note
- This is not the place for
recording dosage instructions.
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[0..1] performer
(EhrSupply/performer)
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[1..1] typeCode
(CS){
Fixed="PRF " }
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[1..1] AgentRef
(AgentRef)
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Refers to the person (or other agent)
responsible for supplying the administered product..
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[1..1] classCode
(CS){
Fixed="AGNT " }
Indicates that this is a reference to a
related agent.
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[1..1] id
(II)
The unique instance identifier of the
referenced role as specified in the role
directory.
- If a message contains several Folders,
the referenced role directory is in the
same Folder as the component that refers
to it.
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[0..1] consumable
(EhrSupply/consumable)
Include this only where necessary to provide
more detailed information about the prescribed product.
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[1..1] typeCode
(CS){
Fixed="CSM " }
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[1..1] manufacturedProduct
(ManufacturedProduct)
Details of the medicinal product
prescribed.
- May include, drugs, nutritional
supplements, devices used to administer drugs, dressing,
appliances, diagnostic reagents, etc.
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[1..1] classCode
(CS){
Fixed="MANU " }
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[1..1] manufacturedMaterial
(Material)
Information about the material or substance that forms the
medicinal product.
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[1..1] Material
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The details of a medicinal product.
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[1..1] classCode
(CS){
Fixed="MMAT "
}
Indicates that this is a manufactured
material.
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[1..1] determinerCode
(CS)
{CNE:INSTANCE}
Indicates that this represents a
specific instance of a material.
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[1..1] code
(CE)
The code representing the nature of
the product as one of the following:
- actual medicinal product
- actual medicinal product pack.
If the native coding scheme for medicinal product is
the Read Codes then the appropriate code is represented
using the Coded
with Original Text flavour of the CE data
type. Otherwise the Coded
Translated flavour should be used with the medicinal
product represented in the coding system used in
the sending system with a translation to an appropriate
(possibly more generalised) Read Code.
Note
- The source of these codes should
eventually be an agreed UK medicinal product
dictionary.
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[0..1] quantity
(PQ)
The quantity of the product.
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[0..1] inFulfillmentOf
(Dispense/inFulfillmentOf)
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Include if this fulfils a prescription issue.
Refers to the prescription fulfilled by this supply
actions.
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[1..1] typeCode
(CS){
Fixed="FLFS" }
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[1..1] MedicationRef
(MedicationRef)
A reference to a previously recorded MedicationStatement
statement associated with the prescription fulfilled by this
supply.
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[1..1] classCode
(CS){
Fixed="SBADM" }
Indicates that the referenced class is
based on the Substance Administration class.
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[1..1] id
(II)
Refers to the id of the referenced
medication statement.
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Optional second instance of
MedicationStatement/component
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MedicationStatement/component (MedicationStatement/component)
Relationship to details of the prescribing action
associated with this administration action described.
This is included only if the administration and prescribing actions
are recorded together. Otherwise the prescription is referenced by the Dispense/inFulfillmentOf
relationship.
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[1..1] typeCode
(CS){
Fixed="COMP " }
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[1..1] Prescribe
(EhrSupply)
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Optional third instance of MedicationStatement/component
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MedicationStatement/component (MedicationStatement/component)
Relationship to details of the authorisation
associated with a repeat prescription.
This is included only if the authorisation and prescribing actions
are recorded together. Otherwise the authorisation is referenced from Prescribe by the Prescribe/inFulfillmentOf
relationship.
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[1..1] typeCode
(CS){
Fixed="COMP " }
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[1..1] Authorise
(EhrSupply)
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