Be.en.hd.MedicationAdministration.Review

From Clinical Building Blocks
Jump to: navigation, search


General

Name: be.en.hd.MedicationAdministration
Version: 0.0.1
Status: Draft

Metadata

DCM::CoderList healthdata.be
DCM::ContactInformation.Address
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom
DCM::ContentAuthorList Clinical Building Blocks Expert Group & healthdata.be
DCM::CreationDate 19-12-2013
DCM::DeprecatedDate
DCM::DescriptionLanguage en
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name healthdata.be
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.9.3
DCM::KeywordList Medicatie, Toediening
DCM::LifecycleStatus Draft
DCM::ModelerList Clinical Building Blocks Expert Group & healthdata.be
DCM::Name be.en.hd.MedicationAdministration
DCM::PublicationDate
DCM::PublicationStatus
DCM::ReviewerList Clinical Building Blocks Expert Group & healthdata.be
DCM::RevisionDate 05-01-2016
DCM::Superseeds
DCM::Version 0.0.1

Revision History

Concept

Administration of medication describes the actual administration of the medication. This can be simply swallowing a tablet, applying ointment or paste, or an infusion that takes a considerable amount of time. The administration can refer to a medication prescription, but can also refer to home medication.

Purpose

To precisely plan the medication to be administered in a chain of collaborating healthcare professionals, it is often best to have information on the most recent administrations of medication, food or blood products.

Information model

Be.en.hd.MedicationAdministrationModel.png
Refer to the legend page for more information about the used types and data types

rootconcept MedicationAdministration
Definition Root concept of the MedicationAdministration building block. This root concept contains all data elements of the MedicationAdministration building block.
Type Zib.png
DCM::DefinitionCode NL-CM:9.3.1
data ProductToBeAdministered::Product
Definition The product taken or administered. This is usually medication. Food, blood products, aids and bandages do not strictly fall under the category of medication, but can be reported as well.

In principle, this will be the prescribed product, but the administrator may substitute it by replacing the product with an equivalent product. For example: two 50mg tablets can be administered instead of one 100mg tablet.

Datatype Container.png
DCM::DefinitionCode NL-CM:9.3.2
DCM::ReferencedDefinitionCode NL-CM:9.5.6 Dit is een verwijzing naar concept Product in de bouwsteen MedicatieVoorschrift.
data Prescription::MedicationPrescription
Definition The agreement or order mandating the administration.
Datatype Container.png
DCM::DefinitionCode NL-CM:9.3.3
DCM::ReferencedDefinitionCode NL-CM:9.5.1 Dit is een verwijzing naar concept MedicatieVoorschrift in de bouwsteen MedicatieVoorschrift.
data AdministrationDateTime
Definition The date and time at which the medication was taken or administered.
Datatype TS.png
DCM::DefinitionCode NL-CM:9.3.6
DCM::ExampleValue 09-07-2011 07:50
data AdministeredAmount
Definition Amount of the product that was administered.
Datatype PQ.png
DCM::DefinitionCode NL-CM:9.3.7
DCM::ExampleValue 2 st
container Administrator
Definition Container of the Administrator concept. This container contains all data elements of the Administrator concept. The concept describes the person who administered the product.
Datatype Container.png
DCM::DefinitionCode NL-CM:9.3.9
data Explanation
Definition Comments on administering the medication.
Datatype ST.png
DCM::DefinitionCode NL-CM:9.3.13
DCM::ExampleValue Toediening onderbroken wegens verstopt infuus.
data Status
Definition The status of the administration, as a description of the stage within the administration process. For indivisible products (such as tablets or suppositories) only the status codes ‘completed’ and ‘cancelled’ apply. For divisible products (such as infusions), administration can also be ‘suspended’ or ‘aborted’.

When documenting this, the following interpretations are used:

  • Active: The product is administered.
  • Interrupted: Use has (temporarily) been interrupted, because of a side effect, for example. Later, the patient and/or doctor can decide whether or not to resume or discontinue use.
  • Discontinued: Administration has stopped.
  • Completed: The administration has now been completed (according to the plan, prescription or agreement).
  • Not started: The product was never administered.
Datatype CD.png
DCM::DefinitionCode NL-CM:9.3.4
DCM::ExampleValue Actief
DCM::ValueSet File:List.png MedicationAdministrationStatusCodeList OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.3.1
data MedicationAdministrationReasonForNoAdministration
Definition Reason why the medication was not taken or administered. Here, you can choose to enter text or one of the codes.
Datatype CD.png
DCM::DefinitionCode NL-CM:9.3.5
DCM::ValueSet File:List.png MedicationAdministrationReasonForNoAdministrationCodeList OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.3.2
data RouteOfAdministration
Definition The route through which the medication is administered (oral, nasal, intravenous,...).
Datatype CD.png
DCM::DefinitionCode NL-CM:9.3.8
DCM::ExampleValue Oraal
DCM::ValueSet File:List.png RouteOfAdministrationCodeList OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.3.3

Code Lists

RouteOfAdministrationCodeList

OID:2.16.840.1.113883.2.4.3.11.60.40.2.9.3.3

Codes Coding Syst. Name Coding System OID
Alle waarden G-Standaard Toedieningswegen 2.16.840.1.113883.2.4.4.9

MedicationAdministrationStatusCodeList

OID:2.16.840.1.113883.2.4.3.11.60.40.2.9.3.1

Concept Name Concept Code Code System Name Code System OID Description
Active active ActStatus 2.16.840.1.113883.5.14 Actief
Suspended suspended ActStatus 2.16.840.1.113883.5.14 Onderbroken
Aborted aborted ActStatus 2.16.840.1.113883.5.14 Afgebroken
Completed completed ActStatus 2.16.840.1.113883.5.14 Voltooid
Cancelled cancelled ActStatus 2.16.840.1.113883.5.14 Niet gestart

MedicationAdministrationReasonForNoAdministrationCodeList

OID:2.16.840.1.113883.2.4.3.11.60.40.2.9.3.2

Concept Name Concept Code Code System Name Code System OID Description
Product discontinued DISCONT ActReason 2.16.840.1.113883.5.8 Product niet meer leverbaar
Patient not available NON-AVAIL ActReason 2.16.840.1.113883.5.8 Pati\'ebnt niet beschikbaar
Patient refuse PREFUS ActReason 2.16.840.1.113883.5.8 Pati\'ebnt heeft geweigerd
Unable to use UNABLE ActReason 2.16.840.1.113883.5.8 Toediening volgens voorschrift niet mogelijk
Order aborted FOABORT ActReason 2.16.840.1.113883.5.8 Voorschrift is gestopt
Forgotten to administer FORGOT NL-CM-CS 2.16.840.1.113883.2.4.3.11.60.40.4 Vergeten toe te dienen
Administration performer not available APNA NL-CM-CS 2.16.840.1.113883.2.4.3.11.60.40.4 Toediener niet aanwezig
No information NI NullFlavor 2.16.840.1.113883.5.1008 Geen informatie

References

1. GROOT, E. (2011) Dataset medicatieproces 2011. [Online] Den Haag: Nictiz. Beschikbaar op: http://www.nictiz.nl/module/360/590/Dataset_Medicatieproces_2011.xlsx [Geraadpleegd: 23 juli 2014].

2. HL7v3-implementatiehandleiding medicatieproces versie 6.1.0.0. [Online] Den Haag: Nictiz. Beschikbaar op: http://www.nictiz.nl/uploaded/FILES/html_cabinet/live/Zorgtoepassing/Medicatieproces/AORTA_Mp_IH_Medicatieproces_HL7.htm [Geraadpleegd: 23 juli 2014].

3. Dossier Medicatieoverzicht. [Online] Beschikbaar op: Oria.nl. [Geraadpleegd: 23 juli 2014].

4. G-standaard documentatie. [Online] Beschikbaar op: http://www.z-index.nl/ [Geraadpleegd: 23 juli 2014].