MedicationAgreement-v1.2(2020EN): verschil tussen versies

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Geen bewerkingssamenvatting
Regel 527: Regel 527:
|Indicatie vervallen(DEPRECATED)
|Indicatie vervallen(DEPRECATED)
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "(situation)">Drug treatment not indicated</span>
|<span title = "Geen indicatie voor medicamenteuze behandeling (situation)">Drug treatment not indicated</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=183966005 183966005]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=183966005 183966005]
|SNOMED CT
|SNOMED CT
Regel 557: Regel 557:
|Wens patiënt(DEPRECATED)
|Wens patiënt(DEPRECATED)
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "(situation)">Patient requested treatment</span>
|<span title = "Verzoek van zorgafnemer om behandeling (situation)">Patient requested treatment</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=184003006 184003006]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=184003006 184003006]
|SNOMED CT
|SNOMED CT
Regel 661: Regel 661:
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:<!--ftReferenceIntro-->
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:<!--ftReferenceIntro-->
<ul>
<ul>
<li>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment<!--ftArtDecorReference--> [http://decor.nictiz.nl/art-decor/decor-scenarios--zib2020bbr-?id=2.16.840.1.113883.2.4.3.11.60.10.4.2.9.6&effectiveDate=2020-09-01T00:00:00&language=en-US&scenariotree=false [[File:artdecor.jpg|16px|link=]]]</li>
<li>HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment<!--ftArtDecorReference--> [http://decor.nictiz.nl/art-decor/decor-scenarios--zib2020bbr-?id=2.16.840.1.113883.2.4.3.11.60.121.4.2.9.6&effectiveDate=2020-09-01T00:00:00&language=en-US&scenariotree=false [[File:artdecor.jpg|16px|link=]]]</li>
<li>HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR<!--ftSimplifierReference--> {{SimplefierLinks|2020}}</li>
<li>HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR<!--ftSimplifierReference--> {{SimplefierLinks|2020}}</li>
</ul>
</ul>
Regel 670: Regel 670:
SNOMED CT and LOINC codes are based on:
SNOMED CT and LOINC codes are based on:
<ul>
<ul>
<li>SNOMED Clinical Terms version: 20200309 [R] (March 2020 Interim Release)</li>
<li>SNOMED Clinical Terms version: 20200731 [R] (July 2020 Release)</li>
<li>LOINC version 2.67</li>
<li>LOINC version 2.67</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>
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This page is generated on 29/09/2020 21:34:19 with ZibExtraction v. 4.0.7577.31095<!--ftDate--> <BR>
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Versie van 29 sep 2020 21:19


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: 1.2
HCIM Status:Final
Release: 2020
Release status: Published
Release date: 01-09-2020

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 01-09-2020
DCM::PublicationStatus Published
DCM::ReviewerList Projectgroep Medicatieproces & Architectuurgroep Registratie aan de Bron
DCM::RevisionDate 15-06-2020
DCM::Supersedes nl.zorg.Medicatieafspraak-v1.1
DCM::Version 1.2
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

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-v4.4(2020EN)PharmaceuticalProduct-v2.1.2(2020EN)#MedicationAgreementStopTypeCodeList#MedicationAgreementReasonCodeListHealthProfessional-v3.5(2020EN)#13318#13305#13314TimeInterval-v1.0(2020EN)InstructionsForUse-v1.2.1(2020EN)#13312#13317MedicationAgreement-v1.2Model(2020EN).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.
16076005 Prescription
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 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 to', 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.pngReasonMedicationAgreement 0..1 Reason for this agreement. This can be the reason to start, change or stop the medication treatment.
112241000146101 Reason for 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)

Instructions

MedicationAgreementAdditionalInformation: When choosing a medicine, you can deviate from what is expected or from what the standard is. For example, when the hospital uses a different formulary than the community pharmacy. For reasons of efficiency, for example, one gastric acid inhibitor has been chosen in the hospital: pantoprazole.
Upon admission, a patient with omeprazole is converted to pantoprazole for the duration of the stay. When discharged, the patient goes back to omeprazole.
It is clear that something can go wrong here and that the patient takes both omeprazole and pantoprazole when there is no intervention. In the hospital's medication agreement for pantoprazole a remark can be made about the deviation so that it is clear that pantoprazole is the substitute for omeprazole or that it should be used in addition to omeprazole.
Another example are the half strengths. The hospital sometimes stocks tablets with half the strength of the normal trade preparation (own production). Where the patient enters the hospital on 25 mg chlortalidone, half a tablet once a day, he receives 12.5 mg intramural chlortalidone, one tablet once a day. Then the nursing does not have to break tablets in this case. Here there is a risk that the patient will use the 25 mg again at home, but then a whole tablet at a time in stead of half a tablet. By means of an explanation in the medication agreement (Additional information) of the last chlortalidone 25 mg, it can be indicated whether this has been a intended increase.

Valuesets

MedicationAgreementAdditionalInformationCodeList

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.6.3 Binding: Required
Conceptname Conceptcode Codesystem name Codesystem OID Description
Bewust hoge dosering 1 Voorlopige G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.3.2050 Bewust hoge dosering
Bewust lage dosering 2 Voorlopige G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.3.2050 Bewust lage dosering
Bewust afwijkende toedieningsweg 3 Voorlopige G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.3.2050 Bewust afwijkende toedieningsweg
Medische noodzaak 4 Voorlopige G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.3.2050 Medische noodzaak
Profylaxe 5 Voorlopige G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.3.2050 Profylaxe
Wijziging in GDS per direct 6 Voorlopige G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.3.2050 Wijziging in GDS per direct
Wijziging in GDS per rolwissel 7 Voorlopige G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.3.2050 Wijziging in GDS per rolwissel

MedicationAgreementReasonCodeList

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.6.2 Binding: Required
Conceptname Conceptcode Codesystem name Codesystem OID Description
Medication commenced 266709005 SNOMED CT 2.16.840.1.113883.6.96 Starten medicamenteuze behandeling
Administration of medication contraindicated 438833006 SNOMED CT 2.16.840.1.113883.6.96 Contra-indicatie
Medication interaction 79899007 SNOMED CT 2.16.840.1.113883.6.96 Interactie
Hypersensitivity condition 473010000 SNOMED CT 2.16.840.1.113883.6.96 Overgevoeligheid
Geen of onvoldoende effect 5 Medicatieafspraak Reden 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.2 Geen of onvoldoende effect(DEPRECATED)
Lack of drug action 58848006 SNOMED CT 2.16.840.1.113883.6.96 Geen of onvoldoende effect
Te sterk effect 6 Medicatieafspraak Reden 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.2 Te sterk effect(DEPRECATED)
Drug action too strong 112251000146103 SNOMED CT 2.16.840.1.113883.6.96 Te sterk effect
(Mogelijke) bijwerking 7 Medicatieafspraak Reden 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.2 (Mogelijke) bijwerking(DEPRECATED)
At risk of medication side effect 704417003 SNOMED CT 2.16.840.1.113883.6.96 (Mogelijke) bijwerking
Toedieningsweg voldoet niet 8 Medicatieafspraak Reden 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.2 Toedieningsweg voldoet niet (DEPRECATED)
Insufficient route of drug administration 112191000146101 SNOMED CT 2.16.840.1.113883.6.96 Toedieningsweg voldoet niet
Indicatie vervallen 9 Medicatieafspraak Reden 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.2 Indicatie vervallen(DEPRECATED)
Drug treatment not indicated 183966005 SNOMED CT 2.16.840.1.113883.6.96 Indicatie vervallen
Beleidswijziging 10 Medicatieafspraak Reden 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.2 Beleidswijziging(DEPRECATED)
Medication management changed (situation) 112751000146109 Medicatieafspraak Reden 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.2 Beleidswijziging
Admission to establishment 305335007 SNOMED CT 2.16.840.1.113883.6.96 Opname
Wens patiënt 12 Medicatieafspraak Reden 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.2 Wens patiënt(DEPRECATED)
Patient requested treatment 184003006 SNOMED CT 2.16.840.1.113883.6.96 Wens patiënt
Volgens afspraak 13 Medicatieafspraak Reden 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.2 Volgens afspraak(DEPRECATED)
Patient agreed with treatment 112211000146102 SNOMED CT 2.16.840.1.113883.6.96 Volgens afspraak
Hervatten beleid vorige voorschrijver 14 Medicatieafspraak Reden 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.2 Hervatten beleid vorige voorschrijver(DEPRECATED)
Treatment previous prescriber continued 112261000146100 SNOMED CT 2.16.840.1.113883.6.96 Hervatten beleid vorige voorschrijver
Geplande procedure 15 Medicatieafspraak Reden 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.2 Procedure waaronder ingreep, interferentie met gepland labonderzoek, etc.(DEPRECATED)
Planned procedure 405613005 SNOMED CT 2.16.840.1.113883.6.96 Procedure waaronder ingreep, interferentie met gepland labonderzoek, etc.
Overig OTH NullFlavour 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: Required
Conceptname Conceptcode Codesystem name Codesystem OID Description
Tijdelijk 1 StopType 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.1 Tijdelijke onderbreking van medicamenteuze behandeling (bijvoorbeeld tijdelijk stoppen gebruik vanwege operatie). (DEPRECATED)
Drug therapy temporarily stopped (finding) 112171000146100 SNOMED CT 2.16.840.1.113883.6.96 Tijdelijke onderbreking van medicamenteuze behandeling (bijvoorbeeld tijdelijk stoppen gebruik vanwege operatie).
Definitief 2 StopType 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.1 Het staken van een bestaande medicamenteuze behandeling. (DEPRECATED)
Drug therapy definitively stopped (finding) 112161000146106 SNOMED CT 2.16.840.1.113883.6.96 Het staken van een bestaande medicamenteuze behandeling.

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Information model references

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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 Release 2020
SNOMED CT and LOINC codes are based on:

  • SNOMED Clinical Terms version: 20200731 [R] (July 2020 Release)
  • LOINC version 2.67

Conditions for use are located on the mainpage List2.png
This page is generated on 29/09/2020 21:34:19 with ZibExtraction v. 4.0.7577.31095

Back 16.png Back to HCIM list
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