Be.en.hd.MedicationUse

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General

Name: be.en.hd.MedicationUse
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 2.16.840.1.113883.2.4.3.11.60.40.3.9.2
DCM::KeywordList Medicatie, Feitelijk Gebruik, Gebruik
DCM::LifecycleStatus Draft
DCM::ModelerList Clinical Building Blocks Expert Group & healthdata.be
DCM::Name be.en.hd.MedicationUse
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

MedicationUse describes taking or administering the medication, often in relation to a prescription, but also on the person’s own initiative. This describes the pattern of medication use, as reported by the patient themselves, a caregiver or healthcare provider. Documenting medication use provides insight into the use of prescribed medication as well as the use of medication at home.

Purpose

Recording medication information is a very important part of continuity in healthcare. It concerns the core of patient safety. Healthcare professionals in the collaborative branch must always have access to an up-to-date medication overview. Applying the building block will usually involve: • Recording the patient’s intake of self-medication or ‘drugs’. • Recording the medication used during a patient’s stay at the hospital. • Medication verification: recording the active medication profile.

Information model

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

rootconcept MedicationUse
Definition Root concept of the MedicationUse building block. This root concept contains all data elements of the MedicationUse building block.
Type Zib.png
data ProductUsed::Product
Definition The product used. This is usually medication. Food, blood products, aids and bandages do not strictly fall under the category of medication, but can be recorded as well.

In principle, this will be the prescribed product, but the product used may differ from the prescribed product.

Datatype Container.png
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 for the use of medication.
Datatype Container.png
DCM::ReferencedDefinitionCode NL-CM:9.5.1 Dit is een verwijzing naar concept MedicatieVoorschrift in de bouwsteen MedicatieVoorschrift.
data UsedDosage::Dosage
Definition When taking stock of medication use, the dosage describes the amount and the pattern of use as reported by the patient or a healthcare provider.

The used dosage is the reported dose used by the patient. The used dosage may differ in terms of the administering schedule of the prescribed dosage in the event that the patient makes different decisions on their use of the product and reports as such.

Datatype Container.png
DCM::ExampleValue 4x/dag 1 tablet via de mond voor de maaltijd en voor het slapen gaan.
DCM::ReferencedDefinitionCode NL-CM:9.5.4 Dit is een verwijzing naar concept Dosering in de bouwsteen MedicatieVoorschrift.
data Explanation
Definition Comments on the medication use.
Datatype ST.png
data MedicationUseStatus
Definition The status or status code is important in indicating the use schedule.

This attribute indicates whether the prescription is actively used, temporarily interrupted, or by now discontinued. Interrupting (home) use often occurs in the event of admittance to a healthcare facility, prior to a procedure and in response to monitoring (mirroring provisions, effect measurements, etc.).

When documenting this, the following interpretations are used:

  • Active: The product is used.
  • Interrupted: Use has (temporarily) been interrupted, because of a surgical procedure, for example. Later, the patient and/or doctor can decide whether or not to resume or discontinue use.
  • Discontinued: Use has been stopped for a specific reason.
  • Completed: Use has now been completed (according to the plan, prescription or agreement).]
  • Not started: The product was never used.
Datatype CD.png
DCM::ExampleValue Actief
DCM::ValueSet File:List.png MedicationUseStatusCodeList OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.2.1
data MedicationUseReasonForDiscontinuation
Definition Reason why the use of a certain medicine was discontinued.
Datatype CD.png
DCM::ValueSet File:List.png MedicationUseReasonForDiscontinuationCodeList OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.2.2
data MedicationUseReasonForInterruption
Definition Reason why the use of a certain medicine was interrupted. Here, you can choose to enter text or one of the codes.
Datatype CD.png
DCM::ValueSet File:List.png MedicationUseReasonForInterruptionCodeList OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.2.3

Code Lists

MedicationUseStatusCodeList

OID:2.16.840.1.113883.2.4.3.11.60.40.2.9.2.1

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

MedicationUseReasonForDiscontinuationCodeList

OID:2.16.840.1.113883.2.4.3.11.60.40.2.9.2.2

Concept Name Concept Code Coding Syst. Name Coding System OID Description
Intolerance SINTOL ActReason 2.16.840.1.113883.5.8 Bijwerking, allergie of intolerantie
Condition alert COND ActCode 2.16.840.1.113883.5.4 Contra-indicatie
Drug interacts with another drug SDDI ActReason 2.16.840.1.113883.5.8 Interactie met ander medicament
Dose change DOSECHG ActReason 2.16.840.1.113883.5.8 Dosiswijziging
No longer required for treatment NOREQ ActReason 2.16.840.1.113883.5.8 Niet langer vereist voor de behandeling
Ineffective INEFFECT ActReason 2.16.840.1.113883.5.8 Niet effectief
Formulary policy FP ActReason 2.16.840.1.113883.5.8 Ander voorschrijfbeleid
Product discontinued DISCONT ActReason 2.16.840.1.113883.5.8 Product niet meer leverbaar
Not covered NOTCOVER ActReason 2.16.840.1.113883.5.8 Product wordt niet vergoed
Patient refuse PREFUS ActReason 2.16.840.1.113883.5.8 Pati\'ebnt heeft geweigerd

MedicationUseReasonForInterruptionCodeList

OID:2.16.840.1.113883.2.4.3.11.60.40.2.9.2.3

Concept Name Concept Code Code System Name Code System OID Description
Drug level too high DRUGHIGH ActReason 2.16.840.1.113883.5.8 Te hoge geneesmiddel spiegel
Lab interference issues LABINT ActReason 2.16.840.1.113883.5.8 Interferentie met gepland labonderzoek
Patient is pregnant/breast feeding PREG ActReason 2.16.840.1.113883.5.8 Pati\'ebnt is zwangerschap of geeft borstvoeding
Patient not-available NON-AVAIL ActReason 2.16.840.1.113883.5.8 Pati\'ebnt is niet beschikbaar
Response to monitoring MONIT ActReason 2.16.840.1.113883.5.8 Reactie op monitoring
Drug interacts with another drug SDDI ActReason 2.16.840.1.113883.5.8 Interactie met ander medicament
Duplicate therapy SDUPTHER ActReason 2.16.840.1.113883.5.8 Een andere therapie maakt het gebruik tijdelijk overbodig
Patient scheduled for surgery SURG ActReason 2.16.840.1.113883.5.8 Patient is ingepland voor een ingreep
Waiting for old drug to wash out WASHOUT ActReason 2.16.840.1.113883.5.8 Tijdelijk onderbreken tot ander geneesmiddel geen werking meer uitoefent

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].[fr-BE]1. GROOT, E. (2011) Dataset medicatieproces 2011. [Online] Den Haag: Nictiz. Disponible sur : http://www.nictiz.nl/module/360/590/Dataset_Medicatieproces_2011.xlsx [Consulté le 23 juillet 2014].

2. HL7v3-implementatiehandleiding medicatieproces versie 6.1.0.0. [Online] Den Haag: Nictiz. Disponible sur : http://www.nictiz.nl/uploaded/FILES/html_cabinet/live/Zorgtoepassing/Medicatieproces/AORTA_Mp_IH_Medicatieproces_HL7.htm [Consulté le 23 juillet 2014].

3. Dossier Medicatieoverzicht. [Online] Disponible sur : Oria.nl. [Consulté le 23 juillet 2014].

4. G-standaard documentatie. [Online] Disponible sur : http://www.z-index.nl/ [Consulté le 23 juillet 2014].[\fr-BE]