M8.1. Medication - Personal Administration of Medication

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.

MedicationStatement (MedicationStatement)

A statement that represents the supply and administration a substance.

[1..1] classCode (CS){ Fixed="SBADM " }

[1..1] moodCode (CS) {CNE:EVN}

[1..1] id (II)

An instance identifier of this statement represented using the Identifier Global flavour of the II data type.

[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.

[1..1] effectiveTime (IVL<TS>)

The clinically relevant date/time or period of administration. E.g. for an infusion or injection.

[1..1] availabilityTime (TS)

The date and time of recording this substance administration action.

[0..1] pertinentInformation (MedicationStatement/pertinentInformation)

Relationship to the administered dosage.

[1..1] typeCode (CS){ Fixed="COMP " }

[1..1] MedicationDosage (MedicationDosage)

Details of the dosage.

[1..1] classCode (CS){ Fixed="SBADM " }

[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..

[1..1] text (ED)

A textual description of the dosage administration.

[1..1] consumable (MedicationStatement/consumable)

Include this to identify the nature of the product.

[1..1] typeCode (CS){ Fixed="CSM " }

[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.

[1..1] classCode (CS){ Fixed="MANU " }

 Indicates that this is a manufactured product.

[1..1] manufacturedMaterial (Material)

Information about the material or substance that forms the medicinal product.

[1..1] Material

The details of a medicinal product.

[1..1] classCode (CS){ Fixed="MMAT " }

Indicates that this is a manufactured material.

[1..1] determinerCode (CS) {CNE:INSTANCE}

Indicates that this represents a specific instance of a material.

[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.

[0..1] quantity (PQ)

The quantity of the product.

[0..*] participant (EhrStatement/participant)

Refers to the third party (person or organisation) who administered the medication if this is not the EhrComposition/author of the containing EhrComposition.

[1..1] typeCode (CS) {CNE:PRF}

Identifies that this agent performed the associated action (i.e. in this case administering the medication).

[1..1] AgentRef (AgentRef)

A reference to a role which contains detailed information about the person who administered the medication.

[1..1] classCode (CS){ Fixed="AGNT " }

Indicates that this is a reference to a related agent.

[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.

[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.

[1..1] typeCode (CS){ Fixed="COMP " }

[1..1] Dispense  (EhrSupply)

A record of the actual supply of a medicinal product.

[1..1] classCode (CS){ Fixed="SPLY" }

[1..1] moodCode (CS){ Fixed="EVN" }

[1..1] id (II)

An identifier of the prescription.

[1..1] code (CV) {CNE:EhrSupplyType}

A code representing the type of prescription.

[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.

[1..1] availabilityTime (TS)

The date and time that the supply action was recorded.

[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".

[0..1] pertinentInformation (EhrSupply/pertinentInformation)

[1..1] typeCode (CS){ Fixed="PERT " }

[1..1] pertinentSupplyAnnotation (SupplyAnnotation)

Details of the annotation.

[1..1] classCode (CS){ Fixed="OBS " }

Indicates that this is an Observation.

[1..1] moodCode (CS){ Fixed="EVN " }

Indicates that this is an actual event.

[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.

[0..1] performer (EhrSupply/performer)

Include this only if the dispenser is not the the EhrComposition/author of the containing EhrComposition.

[1..1] typeCode (CS){ Fixed="PRF " }

[1..1] AgentRef (AgentRef)

Refers to the person (or other agent) responsible for supplying the administered product..

[1..1] classCode (CS){ Fixed="AGNT " }

Indicates that this is a reference to a related agent.

[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.

[0..1] consumable  (EhrSupply/consumable)

Include this only where necessary to provide more detailed information about the prescribed product.

[1..1] typeCode (CS){ Fixed="CSM " }

[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.

[1..1] classCode (CS){ Fixed="MANU " }

[1..1] manufacturedMaterial (Material)

Information about the material or substance that forms the medicinal product.

[1..1] Material

The details of a medicinal product.

[1..1] classCode (CS){ Fixed="MMAT " }

Indicates that this is a manufactured material.

[1..1] determinerCode (CS) {CNE:INSTANCE}

Indicates that this represents a specific instance of a material.

[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.

[0..1] quantity (PQ)

The quantity of the product.

[0..1] inFulfillmentOf (Dispense/inFulfillmentOf)

Include if this fulfils a prescription issue.

Refers to  the prescription fulfilled by this supply actions.

[1..1] typeCode (CS){ Fixed="FLFS" }

[1..1] MedicationRef (MedicationRef) 

A reference to a previously recorded MedicationStatement statement associated with the prescription fulfilled by this supply.

[1..1] classCode (CS){ Fixed="SBADM" }

Indicates that the referenced class is based on the Substance Administration class.

[1..1] id (II)

Refers to the id of the referenced medication statement.

Optional second instance of MedicationStatement/component

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.

[1..1] typeCode (CS){ Fixed="COMP " }

[1..1] Prescribe (EhrSupply)

Details of the prescription see Prescribe.

Optional third instance of MedicationStatement/component

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.

[1..1] typeCode (CS){ Fixed="COMP " }

[1..1] Authorise  (EhrSupply)

Details of the prescription see Supply Authorisation.