type: resource-definitionsresource: MedicationStatement

MedicationStatement Definitions

MedicationStatement

Record of medication being taken by a patient

Definition: A record of a medication that is being consumed by a patient. A MedicationStatement may indicate that the patient may be taking the medication now or has taken the medication in the past or will be taking the medication in the future. The source of this information can be the patient, significant other (such as a family member or spouse), or a clinician. A common scenario where this information is captured is during the history taking process during a patient visit or stay. The medication information may come from sources such as the patient's memory, from a prescription bottle, or from a list of medications the patient, clinician or other party maintains.

The primary difference between a medicationstatement and a medicationadministration is that the medication administration has complete administration information and is based on actual administration information from the person who administered the medication. A medicationstatement is often, if not always, less specific. There is no required date/time when the medication was administered, in fact we only know that a source has reported the patient is taking this medication, where details such as time, quantity, or rate or even medication product may be incomplete or missing or less precise. As stated earlier, the Medication Statement information may come from the patient's memory, from a prescription bottle or from a list of medications the patient, clinician or other party maintains. Medication administration is more formal and is not missing detailed information.

Aliases: MedicationStatement

Cardinality: 0..*

Mappings: workflow=Event; rim=SubstanceAdministration; w5=clinical.medication

MedicationStatement.identifier

External identifier

Definition: Identifiers associated with this Medication Statement that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate. They are business identifiers assigned to this resource by the performer or other systems and remain constant as the resource is updated and propagates from server to server.

Comments: This is a business identifier, not a resource identifier.

Cardinality: 0..*

Type: Identifier

Summary: true

Mappings: workflow=Event.identifier; w5=FiveWs.identifier; rim=.id

MedicationStatement.partOf

Part of referenced event

Definition: A larger event of which this particular MedicationStatement is a component or step.

Cardinality: 0..*

Type: Reference(Procedure, MedicationStatement)

Mappings: rim=.outboundRelationship[typeCode=COMP]/target[classCode=SPLY or SBADM or PROC or OBS,moodCode=EVN]

MedicationStatement.status

recorded | entered-in-error | draft

Definition: A code representing the status of recording the medication statement.

Comments: This status concerns just the recording of the medication statement. MedicationStatement.adherence should be used for indicating a patient's adherence to the information in this resource. Note, the statuses are different than in previous releases for MedicationStatement or MedicationStatement.

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Cardinality: 1..1

Type: code

Binding: required:medication-statement-status

Summary: true

Is Modifier: true (Reason: This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)

Mappings: workflow=Event.status; w5=FiveWs.status; rim=.statusCode

MedicationStatement.category

Type of medication statement

Definition: Type of medication statement.

The committee will revisit these codes, expecting to use a codesystem from terminology.hl7.org.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:medicationrequest-category

Summary: true

Mappings: w5=FiveWs.class; rim=.inboundRelationship[typeCode=COMP].source[classCode=OBS, moodCode=EVN, code="type of medication statement"].value

MedicationStatement.medication

The medication that is/was taken (or not taken)

Definition: Identifies the medication taken (or not taken). This is either a link to a resource representing the details of the medication or a simple attribute carrying a code that identifies the medication from a known list of medications.

Comments: If only a code is specified, then it should be a code for a product. If more information is required, then the use of the medication resource is recommended. For example, if dose form or lot number are required, this is done using a reference to a Medication resource. In cases where the statement is for 'no known medications', this element can contain a code indicating that situation.

Cardinality: 1..1

Type: CodeableReference

Binding: example:medication-statement-medication-codes

Summary: true

Mappings: workflow=Event.code; w5=FiveWs.what[x]; rim=.participation[typeCode=CSM].role[classCode=ADMM or MANU]

MedicationStatement.subject

Who is/was taking the medication

Definition: The person, animal or group who is/was taking the medication.

Cardinality: 1..1

Type: Reference(Patient, Group)

Summary: true

Mappings: workflow=Event.subject; w5=FiveWs.subject; v2=PID-3 Patient ID List; rim=.participation[typeCode=SBJ].role[classCode=PAT]

MedicationStatement.encounter

Encounter associated with MedicationStatement

Definition: The encounter that establishes the context for this MedicationStatement.

Cardinality: 0..1

Type: Reference(Encounter)

Summary: true

Mappings: workflow=Event.encounter; rim=.inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN, code="type of encounter or episode"]

MedicationStatement.effective[x]

The date/time or interval when the medication is/was/will be taken

Definition: The interval of time during which it is being asserted that the patient is/was/will be taking the medication (or was not taking, when the MedicationStatement.adherence element is Not Taking).

Comments: This attribute reflects the period over which the patient consumed the medication and is expected to be populated on the majority of Medication Statements. If the medication is still being taken and is expected to continue indefinitely at the time the usage is recorded, the "end" date will be omitted. If the end date is known, then it is included as the "end date". The date/time attribute supports a variety of dates - year, year/month and exact date. If something more than this is required, this should be conveyed as text.

Cardinality: 0..1

Type: dateTime, Period, Timing

Summary: true

Mappings: workflow=Event.occurrence[x]; w5=FiveWs.done[x]; rim=.effectiveTime

MedicationStatement.dateAsserted

When the usage was asserted?

Definition: The date when the Medication Statement was asserted by the information source.

Cardinality: 0..1

Type: dateTime

Summary: true

Mappings: w5=FiveWs.recorded; rim=.participation[typeCode=AUT].time

MedicationStatement.author

Who/What authored the statement

Definition: The individual, organization, or device that created the statement and has responsibility for its content.

Cardinality: 0..1

Type: Reference(Practitioner, PractitionerRole, Organization, Patient, RelatedPerson, Device)

Summary: true

Mappings: w5=FiveWs.author; rim=.participation[typeCode=AUT].role

MedicationStatement.informationSource

Person or organization that provided the information about the taking of this medication

Definition: The person or organization that provided the information about the taking of this medication. Note: Use derivedFrom when a MedicationStatement is derived from other resources, e.g. Claim or MedicationRequest.

Cardinality: 0..*

Type: Reference(Device, Patient, Practitioner, PractitionerRole, RelatedPerson, Organization, Group)

Mappings: w5=FiveWs.source; rim=.participation[typeCode=INF].role[classCode=PAT, or codes for Practitioner or Related Person (if PAT is the informer, then syntax for self-reported =true)

MedicationStatement.derivedFrom

Link to information used to derive the MedicationStatement

Definition: Allows linking the MedicationStatement to the underlying MedicationRequest, or to other information that supports or is used to derive the MedicationStatement.

Comments: Likely references would be to MedicationRequest, MedicationDispense, Claim, Observation or QuestionnaireAnswers. The most common use cases for deriving a MedicationStatement comes from creating a MedicationStatement from a MedicationRequest or from a lab observation or a claim. it should be noted that the amount of information that is available varies from the type resource that you derive the MedicationStatement from.

Cardinality: 0..*

Type: Reference(Resource)

Mappings: rim=.outboundRelationship[typeCode=SPRT]/target[classCode=ACT,moodCode=EVN]

MedicationStatement.reason

Reason for why the medication is being/was taken

Definition: A concept, Condition or observation that supports why the medication is being/was taken.

Comments: This could be a diagnosis code. If a full condition record exists or additional detail is needed, use reasonForUseReference.

Cardinality: 0..*

Type: CodeableReference

Binding: example:condition-code

Mappings: workflow=Event.reason; w5=FiveWs.why[x]; rim=.reasonCode

MedicationStatement.note

Further information about the usage

Definition: Provides extra information about the Medication Statement that is not conveyed by the other attributes.

Cardinality: 0..*

Type: Annotation

Mappings: workflow=Event.note; rim=.inboundRelationship[typeCode=SUBJ]/source[classCode=OBS,moodCode=EVN,code="annotation"].value

MedicationStatement.relatedClinicalInformation

Link to information relevant to the usage of a medication

Definition: Link to information that is relevant to a medication statement, for example, illicit drug use, gestational age, etc.

Cardinality: 0..*

Type: Reference(Observation, Condition)

Mappings: rim=TBD

MedicationStatement.dosage

Details of how medication is/was taken or should be taken

Definition: Indicates how the medication is/was or should be taken by the patient.

Comments: The dates included in the dosage on a Medication Statement reflect the dates for a given dose. For example, "from November 1, 2016 to November 3, 2016, take one tablet daily and from November 4, 2016 to November 7, 2016, take two tablets daily." It is expected that this specificity may only be populated where the patient brings in their labeled container or where the Medication Statement is derived from a MedicationRequest.

Cardinality: 0..1

Type: DosageDetails

MedicationStatement.adherence

Indicates whether the medication is or is not being consumed or administered

Definition: Indicates whether the medication is or is not being consumed or administered.

Comments: This element can be used to indicate whether a patient is following a course of treatment as instructed/prescribed or whether they are taking medications of their own volition. It can also be used to indicate that a patient is not taking a medication, either because they were told not to or because they decided on their own.

Cardinality: 0..1

Type: BackboneElement

Summary: true

Mappings: rim=outboundRelationship[typeCode=PERT].target[classCode=OBV,moodCode=EVN].value[xsi:type=CD]

MedicationStatement.adherence.code

Type of adherence

Definition: Type of the adherence for the medication.

Cardinality: 1..1

Type: CodeableConcept

Binding: example:medication-statement-adherence

Summary: true

Mappings: rim=outboundRelationship[typeCode=PERT].target[classCode=OBV,moodCode=EVN].value[xsi:type=CD]

MedicationStatement.adherence.reason

Details of the reason for the current use of the medication

Definition: Captures the reason for the current use or adherence of a medication.

Comments: This is generally only used for "exception" statuses such as "entered-in-error". The reason for performing the event at all is captured in reasonCode, not here.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:reason-medication-status-codes

Mappings: rim=.inboundRelationship[typeCode=SUBJ].source[classCode=CACT, moodCode=EVN].reasonCode