MedicationAgreement-v2.0(2022EN): verschil tussen versies

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Regel 296: Regel 296:
{|
{|
|-
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|<span title = "Codesystem: SNOMED CT&#xA;Unknown code" style = "color:red">160111000146106 reden voor wijzigen van voorschrift</span>
|<span title = "Codesystem: SNOMED CT; Reden voor wijzigen van voorschrift (observable entity)" >[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=160111000146106 160111000146106] Reason for change of prescription</span>
|}
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Regel 327: Regel 327:
{|
{|
|-
|-
|<span title = "Codesystem: LOINC (Nar)" >[https://terminologie.nictiz.nl/art-decor/loinc?conceptId=48767-8 48767-8] Annotation comment [Interpretation] Narrative</span>
|<span title = "Codesystem: LOINC; Verklarend commentaar [interpretatie] in {systeem} (Nar)" >[https://terminologie.nictiz.nl/art-decor/loinc?conceptId=48767-8 48767-8] Annotation comment [Interpretation] Narrative</span>
|}
|}
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Regel 600: Regel 600:
|Verrichting gepland
|Verrichting gepland
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Foutieve registratie medicatie (finding)">Incorrect registration of medication</span>
|<span title = "Foutieve registratie van medicatie (finding)">Incorrect registration of medication</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=159691000146109 159691000146109]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=159691000146109 159691000146109]
|SNOMED CT
|SNOMED CT
|2.16.840.1.113883.6.1
|2.16.840.1.113883.6.96
|Foutieve registratie
|Foutieve registratie
|-style="vertical-align:top; "
|-style="vertical-align:top; "
Regel 612: Regel 612:
|Geneesmiddel niet voorradig
|Geneesmiddel niet voorradig
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Unknown code" style = "color:red">Change in lab value</span>
|<span title = "Verandering in uitslag van laboratoriumonderzoek (finding)">Change in laboratory test finding</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=160131000146104 160131000146104]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=160131000146104 160131000146104]
|SNOMED CT
|SNOMED CT
Regel 618: Regel 618:
|Verandering in labwaarde
|Verandering in labwaarde
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Unknown code" style = "color:red">Duplicate registration of medication treatment</span>
|<span title = "Patiëntvriendelijk-Nederlandse taalreferentieset op leesniveau B1 (foundation metadata concept)">Patient-friendly Dutch at B1 reading level language reference set</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=160161000146108 160161000146108]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=160161000146108 160161000146108]
|SNOMED CT
|SNOMED CT
Regel 624: Regel 624:
|Dubbele registratie van medicamenteuze behandeling
|Dubbele registratie van medicamenteuze behandeling
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Inname van medicatie door patiënt volgens afspraak (finding)">Patient takes medication as prescribed</span>
|<span title = "Medicatiegebruik van patiënt volgens afspraak (finding)">Patient takes medication as prescribed</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=112221000146107 112221000146107]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=112221000146107 112221000146107]
|SNOMED CT
|SNOMED CT
Regel 636: Regel 636:
|Overig
|Overig
|}
|}
=== MedicationAgreementStopTypeCodeList===
=== MedicationAgreementStopTypeCodeList===
{| class="wikitable" width="60%"  
{| class="wikitable" width="60%"  
Regel 690: Regel 689:
SNOMED CT and LOINC codes are based on:
SNOMED CT and LOINC codes are based on:
<ul>
<ul>
<li>SNOMED Clinical Terms version: 20220131 [R] (January 2022 Release)</li>
<li>SNOMED Clinical Terms versie: 20220930 [R] (september 2022-editie)</li>
<li>LOINC version 2.67</li>
<li>LOINC version 2.72</li>
</ul>
</ul>
Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR>
Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR>
This page is generated on 10/06/2022 12:42:06 with ZibExtraction v. 8.0.8196.20371<!--ftDate--> <BR>
This page is generated on 17/10/2022 23:18:43 with ZibExtraction v. 8.1.8325.41206<!--ftDate--> <BR>
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Huidige versie van 17 okt 2022 om 22:29


Attention!! This is not the most recent version of this information model. You can find the most recent version ''here''.

General information

Name: nl.zorg.MedicationAgreement NL.png
Version: 2.0
HCIM Status:Final
Release: 2022
Release status: Prepublished
Release date: 10-06-2022

Attention!! For this HCIM an erratum exists. You can find it in the Errata section of the prerelease.

Back 16.png Back to HCIM list

Metadata

DCM::CoderList Projectgroep Medicatieproces
DCM::ContactInformation.Address
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom
DCM::ContentAuthorList Projectgroep Medicatieproces
DCM::CreationDate 1-2-2017
DCM::DeprecatedDate
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name PM
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.9.6
DCM::KeywordList Medicatie, Afspraak
DCM::LifecycleStatus Final
DCM::ModelerList Kerngroep Registratie aan de Bron
DCM::Name nl.zorg.Medicatieafspraak
DCM::PublicationDate 10-06-2022
DCM::PublicationStatus Prepublished
DCM::ReviewerList Projectgroep Medicatieproces & Architectuurgroep Registratie aan de Bron
DCM::RevisionDate 06-05-2022
DCM::Supersedes nl.zorg.Medicatieafspraak-v1.3
DCM::Version 2.0
HCIM::PublicationLanguage EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (04-09-2017)

Publicatieversie 1.0.1 (31-12-2017)

ZIB-618 Hernoemen Verstrekking naar Medicatieverstrekking
ZIB-643 Kleine tekstuele verbeteringen

Publicatieversie 1.1 (31-01-2020)

ZIB-888 terminologie reden voor stoppen medicatie verbeteren en SNOMED coderingen zibs met meditatieproces gelijktrekken

Publicatieversie 1.2 (01-09-2020)

ZIB-911 Correction English "Farmaceutical"
ZIB-1020 Zib Gewicht en Zib Lengte uit Zib Medicatieafspraak halen
ZIB-1021 Element 'Geannuleerd indicator' uit MA verwijderen

Publicatieversie 1.3 (01-12-2021)

ZIB-1261 Medicatieafspraak waardelijst MedicatieafspraakStopTypeCodelijst bevat vervallen SNOMED CT codes
ZIB-1454 Onduidelijkheid codes bij StopType codelijsten
ZIB-1457 Verwijderen woord 'voorlopig'
ZIB-1458 Verwijderen sectie 'Instructions' bij MedicationAgreement
ZIB-1575 Deprecated termen en waardelijsten uit de prepublicatie halen

Publicatieversie 2.0 (10-06-2022)

ZIB-1659 Aanpassen terminologiecodering MA in zibMA
ZIB-1685 Medicatiebouwstenen MA, TA, MGB - engelse vertaling van 'tot en met'
ZIB-1696 MedicatieafspraakAanvullendeInformatieCodelijst heeft 'verkeerde' oid voor codesysteem
ZIB-1720 Verzameling errata bouwsteen Medicatieafspraak

Concept

A medication agreement is a prescriber’s proposal for a patient to use medication. An agreement to discontinue the use of medication is also a medication agreement.

Purpose

The goal of the medication agreement is to provide insight into the agreements reached between the prescriber and the patient on the use of medication.

Information Model


#MedicationAgreementAdditionalInformationCodeList#13304Problem-v4.6(2022EN)PharmaceuticalProduct-v2.2(2022EN)#MedicationAgreementStopTypeCodeList#MedicationAgreementReasonCodeListHealthProfessional-v3.5.2(2022EN)#13318#13305#13314TimeInterval-v1.1.1(2022EN)InstructionsForUse-v2.0(2022EN)#13312#13317MedicationAgreement-v2.0Model(2022EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:9.6.9580 Arrowdown.pngMedicationAgreement Root concept of the MedicationAgreement information model. This root concept contains all data elements of the MedicationAgreement information model.
33633005 Prescription of drug
Verwijzing.png NL-CM:9.6.1030 Arrowright.pngPrescriber::HealthProfessional 0..1 The health professional that entered the medication agreement with the patient.
Block.png HealthProfessional
Verwijzing.png NL-CM:9.6.23133 Arrowright.pngPrescriptionReason::Problem 0..1 The medical reason for the prescription or for use of the medication. This can be used to enter a medical indication which was the direct cause for prescription or for use of the medication in question.

It can concern every type of problem (or condition) of the patient, almost all diagnoses, complaints or symptoms.

Please note: The BST401T file of the G standard contains a “special reference” to indicate that “exchange of the reason for prescription is essential”.

112201000146104 Medical reason for prescription
Block.png Problem
Verwijzing.png NL-CM:9.6.19925 Arrowright.pngAgreedMedicine::PharmaceuticalProduct 1 The medicine agreed upon to be used.
Block.png PharmaceuticalProduct
Verwijzing.png NL-CM:9.6.23240 Arrowright.pngInstructionsForUse 0..1 Instructions for the use of the medication, e.g. dose and route of administration.
Block.png InstructionsForUse
TS.png NL-CM:9.6.19757 Arrowright.pngMedicationAgreementDateTime 1 The time at which the agreement was made.

Appointment date + time are required (order of the appointments must be clear in cases with multiple appointments on one day)

Verwijzing.png NL-CM:9.6.19936 Arrowright.pngPeriodOfUse::TimeInterval 0..1 Start date: This is the time at which the agreement was to take effect (or took effect or will take effect). This is the time at which the instructions for use in this agreement start. In the case of an agreement to discontinue use, this is the start date of the original medication agreement. The end date indicates from when the medication is to be discontinued.

Duration: The intended duration of use. E.g. 5 days or 8 weeks. It is not allowed to indicate the duration in months, because different months have a variable duration in days.

End date: The time at which the period of use ends (or ended or will end). In the case of an agreement to discontinue use, this is the time at which the medication is to be discontinued. To avoid confusion between 'to' and 'up until and including', the submission of time is always mandatory for the end date.

With medication for an indefinite period only a start date is indicated.

Block.png TimeInterval
CD.png NL-CM:9.6.19954 Arrowright.pngMedicationAgreementStopType 0..1 Stop type, the manner in which this medication is discontinued (temporary or definitive).
274512008 Medication discontinued
List2.png MedicationAgreementStopTypeCodeList
CD.png NL-CM:9.6.22094 Arrowright.pngReasonModificationOrDiscontinuation 0..1 Reason for modification or discontinuation of the medication agreement.
160111000146106 Reason for change of prescription
List2.png MedicationAgreementReasonCodeList
CD.png NL-CM:9.6.23283 Arrowright.pngMedicationAgreementAdditionalInformation 0..* Additional information includes details on the structure of the agreement made that are relevant for pharmacovigilance and fulfillment by the pharmacist. This can be used e.g. to indicate that there was a conscious decision to deviate from the norm or that the agreement is to be structured in a certain way.

See also the Instructions section for more information about use of the element.

List2.png MedicationAgreementAdditionalInformationCodeList
ST.png NL-CM:9.6.22273 Arrowright.pngComment 0..1 Comments regarding to the medication agreement. For example: in consultation with the medical specialist.
48767-8 Annotation comment [Interpretation] Narrative

Columns Concept and DefinitionCode: hover over the values for more information
For explanation of the symbols, please see the legend page List2.png

Example Instances

Only available in Dutch

MedicatieAfspraak DatumTijd Gebruiksperiode Afgesproken geneesmiddel Voorschrijver MedicatieAfspraak Stoptype MedicatieAfspraak.Reden
Ingangsdatum Einddatum Duur FarmaceutischProduct Zorgverlener
Naamgegevens
18-9-2016 18:00:00 08-09-16 18-09-16 Lisinopril tablet 10mg D. Bakker Definitief Geen of onvoldoende effect
6-3-2016 9:12:30 06-03-2016 Methotrexaat injvlst 25mg/ml 0,6 ml R. Jansen Starten medicamenteuze behandeling
RedenVan Voorschrijven Gebruiksinstructie
Probleem Omschrijving Doseerinstructie
Doseerduur Dosering |Keerdosis Toedieningsschema |Frequentie |Interval |Toedientijd |Weekdag |Dagdeel
Van 8-9-2017 tot 18-9-2017 1x per dag 1 stuk. Vanaf 18-9-2017 staken. 1 stuk 1x per dag
Reumatoïde Artritis Vanaf 6 maart 2016 1x per week op maandag om 14uur 15 mg (=0,6 ml) 15 mg (=0,6 ml) 1x per week op maandag (14u)

Valuesets

MedicationAgreementAdditionalInformationCodeList

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.6.3 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Bewust hoge dosering 1 G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.14.2050 Bewust hoge dosering
Bewust lage dosering 2 G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.14.2050 Bewust lage dosering
Bewust afwijkende toedieningsweg 3 G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.14.2050 Bewust afwijkende toedieningsweg
Medische noodzaak 4 G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.14.2050 Medische noodzaak
Profylaxe 5 G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.14.2050 Profylaxe
Wijziging in GDS per direct 6 G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.14.2050 Wijziging in GDS per direct
Wijziging in GDS per rolwissel 7 G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.14.2050 Wijziging in GDS per rolwissel
Bewust afwijken van leeftijdsgrenzen 8 G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.14.2050 Bewust afwijken van leeftijdsgrenzen
Bewust van te lage nierfunctie voor deze dosering 9 G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.14.2050 Bewust van te lage nierfunctie voor deze dosering
Bewust van eerder gemelde overgevoeligheid 10 G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.14.2050 Bewust van eerder gemelde overgevoeligheid

MedicationAgreementReasonCodeList

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.6.2 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Medication commenced 266709005 SNOMED CT 2.16.840.1.113883.6.96 Starten medicamenteuze behandeling [DEPRECATED]
Administration of medication contraindicated 438833006 SNOMED CT 2.16.840.1.113883.6.96 Toedienen van medicatie gecontra-indiceerd
Medication interaction 79899007 SNOMED CT 2.16.840.1.113883.6.96 Geneesmiddelinteractie
Adverse reaction to drug 62014003 SNOMED CT 2.16.840.1.113883.6.96 Ongewenste reactie op medicatie en/of drugs
Hypersensitivity condition 473010000 SNOMED CT 2.16.840.1.113883.6.96 Overgevoeligheid [DEPRECATED]
Lack of drug action 58848006 SNOMED CT 2.16.840.1.113883.6.96 Gebrek aan geneesmiddeleffect
Drug action too strong 112251000146103 SNOMED CT 2.16.840.1.113883.6.96 Te sterk effect van medicatie
At risk of medication side effect 704417003 SNOMED CT 2.16.840.1.113883.6.96 (Mogelijke) bijwerking [DEPRECATED]
Insufficient route of drug administration 112191000146101 SNOMED CT 2.16.840.1.113883.6.96 Medicatietoedieningsweg voldoet niet
Drug treatment not indicated 183966005 SNOMED CT 2.16.840.1.113883.6.96 Geen indicatie voor medicamenteuze behandeling
Medication management changed 112751000146109 SNOMED CT 2.16.840.1.113883.6.96 Medicatiebeleids veranderd
Admission to establishment 305335007 SNOMED CT 2.16.840.1.113883.6.96 Opname in instelling
Patient requested modification of treatment 159711000146106 SNOMED CT 2.16.840.1.113883.6.96 Verzoek van zorgafnemer om behandeling te wijzigen
Patient requested treatment 184003006 SNOMED CT 2.16.840.1.113883.6.96 Wens patiënt [DEPRECATED]
Patient agreed with treatment 112211000146102 SNOMED CT 2.16.840.1.113883.6.96 Volgens afspraak [DEPRECATED]
Treatment previous prescriber continued 112261000146100 SNOMED CT 2.16.840.1.113883.6.96 Hervatten beleid vorige voorschrijver
Planned procedure 405613005 SNOMED CT 2.16.840.1.113883.6.96 Verrichting gepland
Incorrect registration of medication 159691000146109 SNOMED CT 2.16.840.1.113883.6.96 Foutieve registratie
Drug not available - out of stock 182856006 SNOMED CT 2.16.840.1.113883.6.96 Geneesmiddel niet voorradig
Change in laboratory test finding 160131000146104 SNOMED CT 2.16.840.1.113883.6.96 Verandering in labwaarde
Patient-friendly Dutch at B1 reading level language reference set 160161000146108 SNOMED CT 2.16.840.1.113883.6.96 Dubbele registratie van medicamenteuze behandeling
Patient takes medication as prescribed 112221000146107 SNOMED CT 2.16.840.1.113883.6.96 Medicatiegebruik van patient volgens afspraak
Overig OTH NullFlavor 2.16.840.1.113883.5.1008 Overig

MedicationAgreementStopTypeCodeList

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.6.1 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Drug therapy temporarily stopped 113381000146106 SNOMED CT 2.16.840.1.113883.6.96 Tijdelijke onderbreking van medicamenteuze behandeling (bijvoorbeeld tijdelijk stoppen gebruik vanwege operatie).
Drug therapy definitely stopped 113371000146109 SNOMED CT 2.16.840.1.113883.6.96 Het staken van een bestaande medicamenteuze behandeling.

This information model in other releases

Information model references

This information model refers to

This information model is used in

Technical specifications in HL7v3 CDA and HL7 FHIR

To exchange information based on health and care information models, additional, more technical specifications are required.
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:

  • HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment Artdecor.jpg
  • HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR Fhir.png

Downloads

This information model is also available as pdf file PDF.png or as spreadsheet Xlsx.png

About this information

The information in this wikipage is based on Pre-release 2022-1
SNOMED CT and LOINC codes are based on:

  • SNOMED Clinical Terms versie: 20220930 [R] (september 2022-editie)
  • LOINC version 2.72

Conditions for use are located on the mainpage List2.png
This page is generated on 17/10/2022 23:18:43 with ZibExtraction v. 8.1.8325.41206

Back 16.png Back to HCIM list
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