MedicationUse-v3.0(2016EN): verschil tussen versies

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This information model is also available as [[Media:nl.zorg.MedicationUse-v3.0(2016EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.zorg.MedicationUse-v3.0(2016EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]]
This information model is also available as [[Media:nl.zorg.MedicationUse-v3.0(2016EN).pdf|pdf file]] [[File:PDF.png|link=]] or as [[Media:nl.zorg.MedicationUse-v3.0(2016EN).xlsx|spreadsheet]] [[File:xlsx.png|link=]]

Versie van 20 feb 2018 10:06

General information

Name: nl.zorg.MedicationUse NL.png
Version: 3.0
HCIM Status:Final
Release: 2016
Release status: Published
Release date: 1-5-2016

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Metadata

DCM::CoderList Kerngroep Registratie aan de Bron
DCM::ContactInformation.Address
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom
DCM::ContentAuthorList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::CreationDate 19-12-2013
DCM::DeprecatedDate
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name PM
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.9.2
DCM::KeywordList Medicatie, Feitelijk Gebruik, Gebruik
DCM::LifecycleStatus Final
DCM::ModelerList Kerngroep Registratie aan de Bron
DCM::Name nl.zorg.MedicatieGebruik
DCM::PublicationDate 1-5-2016
DCM::PublicationStatus Published
DCM::ReviewerList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 22-5-2015
DCM::Superseeds nl.nfu.MedicatieGebruik-v1.0.1
DCM::Version 3.0
HCIM::PublicationLanguage EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (01-04-2015)

ZIB-56 RFC Bouwsteen Medicatie
ZIB-308 Prefix Overdracht weggehaald bij de generieke bouwstenen

Incl. algemene wijzigingsverzoeken:

ZIB-94 Aanpassen tekst van Disclaimer, Terms of Use & Copyrights
ZIB-154 Consequenties opsplitsing Medicatie bouwstenen voor overige bouwstenen.
ZIB-200 Naamgeving SNOMED CT in tagged values klinische bouwstenen gelijk getrokken.
ZIB-201 Naamgeving OID: in tagged value notes van klinische bouwstenen gelijk getrokken.
ZIB-309 EOI aangepast
ZIB-324 Codelijsten Name en Description beginnen met een Hoofdletter
ZIB-326 Tekstuele aanpassingen conform de kwaliteitsreview kerngroep 2015

Publicatieversie 1.0.1 (22-05-2015)

ZIB-381 Onterecht een spatie achter "OID :" in tagged value notes van tagged value DCM::ValueSet MedicatieGebruikRedenVanStoppenCodelijst van concept MedicatieGebruikRedenVanStoppen.

Publicatieversie 3.0 (01-05-2016)

.

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 information model 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


MedicationPrescription-v3.0(2016EN)MedicationPrescription-v3.0(2016EN)#11150#MedicationUseReasonForInterruptionCodelist#11158#MedicationUseReasonForDiscontinuationCodelist#11159#MedicationUseStatusCodelistMedicationPrescription-v3.0(2016EN)#11154#11863MedicationUse-v3.0Model(EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:9.2.1 Arrowdown.pngMedicationUse Root concept of the MedicationUse information model. This root concept contains all data elements of the MedicationUse information model.
Verwijzing.png NL-CM:9.2.2 Arrowright.pngProductUsed::Product 1 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.

Block.png MedicationPrescription
Verwijzing.png NL-CM:9.2.3 Arrowright.pngPrescription 0..* The agreement or order for the use of medication.
Block.png MedicationPrescription
Verwijzing.png NL-CM:9.2.4 Arrowright.pngUsedDosage::Dosage 0..* 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.

Block.png MedicationPrescription
CD.png NL-CM:9.2.5 Arrowright.pngMedicationUseStatus 1 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.
List2.png MedicationUseStatusCodelist
CD.png NL-CM:9.2.6 Arrowright.pngMedicationUseReasonForDiscontinuation 0..1 Reason why the use of a certain medicine was discontinued.
List2.png MedicationUseReasonForDiscontinuationCodelist
CD.png NL-CM:9.2.7 Arrowright.pngMedicationUseReasonForInterruption 0..1 Reason why the use of a certain medicine was interrupted. Here, you can choose to enter text or one of the codes.
List2.png MedicationUseReasonForInterruptionCodelist
ST.png NL-CM:9.2.8 Arrowright.pngComment 0..1 Comments on the medication use.

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

GebruiksProduct GebruiksDosering MedicatieGebruikStatus Voorschrift
ProductNaam StartDatum EindDatum Keerdosis | Toedieningsschema ToedieningsWeg Reden van Voorschrijven
Probleem
Paracetamol tablet 500 mg 05-2012 Zo nodig 500mg (=1st), max. 4x/dag Oraal Actief Hoofdpijn
GebruiksProduct GebruiksDosering MedicatieGebruikStatus Voorschrift
ProductNaam StartDatum EindDatum Keerdosis | Toedieningsschema ToedieningsWeg Reden van Voorschrijven
Probleem
Pantoprazol injpdr 40mg fl 11-09-2012 17:21 1x/dag(8u) 40mg (=1st) iv Actief Ulcusprofylaxe
GebruiksProduct GebruiksDosering MedicatieGebruikStatus Voorschrift
ProductNaam StartDatum EindDatum Keerdosis | Toedieningsschema ToedieningsWeg Reden van Voorschrijven
Probleem
Dalteparine 2500 injvlst 12.500 ie/ml wwsp 0,2ml 19-09-2012 1x/dag(18u) 2500ie(=0,2ml) Subcutaan Actief Thrombose-
profylaxe

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].

Valuesets

MedicationUseReasonForDiscontinuationCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.9.2.2
Conceptname Conceptcode Codesystem name Codesystem 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 Patiënt heeft geweigerd

MedicationUseReasonForInterruptionCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.9.2.3
Conceptname Conceptcode Codesystem name Codesystem 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 Patiënt is zwangerschap of geeft borstvoeding
Patient not-available NON-AVAIL ActReason 2.16.840.1.113883.5.8 Patiënt 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

MedicationUseStatusCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.9.2.1
Conceptname Conceptcode Codesystem name Codesystem 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


This information model in other releases

More on this information model

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

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 summer 2016
Conditions for use are located on the mainpage List2.png
This page is generated on 24/01/2018 23:30:14

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