Medicatieafspraak-v1.0.1(2018EN)

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General information

Name: nl.zorg.Medicatieafspraak NL.png
Version: 1.0.1
HCIM Status:Final
Release: 2018
Release status: Prepublished
Release date: 01-10-2018

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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 01-10-2018
DCM::PublicationStatus Prepublished
DCM::ReviewerList Projectgroep Medicatieproces & Architectuurgroep Registratie aan de Bron
DCM::RevisionDate 31-12-2017
DCM::Superseeds nl.zorg.Medicatieafspraak-v1.0
DCM::Version 1.0.1
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

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


#MedicatieafspraakAanvullendeInformatieCodelijst#13304Problem-v4.1.1(2018EN)PharmaceuticalProduct-v2.0(2018EN)#MedicatieafspraakStopTypeCodelijst#RedenMedicatieafspraakCodelijstHealthProfessional-v3.2(2018EN)BodyWeight-v3.1(2018EN)BodyHeight-v3.1(2018EN)#13318#13305#13314#13306TimeInterval-v1.0(2018EN)InstructionsForUse-v1.1.1(2018EN)#13312#13317Medicatieafspraak-v1.0.1Model(2018EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:9.6.9580 Arrowdown.pngMedicatieafspraak Root concept of the MedicationAgreement information model. This root concept contains all data elements of the MedicationAgreement information model.
Verwijzing.png NL-CM:9.6.1030 Arrowright.pngVoorschrijver::Zorgverlener 0..1 The health professional that entered the medication agreement with the patient.
Block.png HealthProfessional
Verwijzing.png NL-CM:9.6.23133 Arrowright.pngRedenVanVoorschrijven::Probleem 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”.

Block.png Problem
Verwijzing.png NL-CM:9.6.23028 Arrowright.pngLichaamsgewicht 0..1 Weight the dose is based on, relevant to this agreement.
Block.png BodyWeight
Verwijzing.png NL-CM:9.6.23023 Arrowright.pngLichaamslengte 0..1 Height the dose is based on, relevant to this agreement.
Block.png BodyHeight
Verwijzing.png NL-CM:9.6.19925 Arrowright.pngAfgesprokengeneesmiddel::FarmaceutischProduct 1 The medicine agreed upon to be used.
Block.png PharmaceuticalProduct
Verwijzing.png NL-CM:9.6.23240 Arrowright.pngGebruiksinstructie 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.pngMedicatieafspraakDatumTijd 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.pngGebruiksperiode::TijdsInterval 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
BL.png NL-CM:9.6.23033 Arrowright.pngGeannuleerdIndicator 0..1 In the event of an error correction of the medication agreement, this indicator is to be put on for the incorrect agreement.
CD.png NL-CM:9.6.19954 Arrowright.pngMedicatieafspraakStopType 0..1 Stop type, the manner in which this medication is discontinued (temporary or definitive).
List2.png MedicatieafspraakStopTypeCodelijst
CD.png NL-CM:9.6.22094 Arrowright.pngRedenMedicatieafspraak 0..1 Reason for this agreement. This can be the reason to start, change or stop the medication treatment.
List2.png RedenMedicatieafspraakCodelijst
CD.png NL-CM:9.6.23283 Arrowright.pngMedicatieafspraakAanvullendeInformatie 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 MedicatieafspraakAanvullendeInformatieCodelijst
ST.png NL-CM:9.6.22273 Arrowright.pngToelichting 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 Geannuleerd Indicator 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 Nee Definitief Geen of onvoldoende effect
6-3-2016 9:12:30 06-03-2016 Methotrexaat injvlst 25mg/ml 0,6 ml R. Jansen Nee 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

MedicatieafspraakAanvullendeInformatieCodelijst

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 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

MedicatieafspraakStopTypeCodelijst

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
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).
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.

RedenMedicatieafspraakCodelijst

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
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
Te sterk effect 6 Medicatieafspraak Reden 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.2 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
Toedieningsweg voldoet niet 8 Medicatieafspraak Reden 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.2 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
Beleidswijziging 10 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
Volgens afspraak 13 Medicatieafspraak Reden 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.2 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
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.
Overig OTH NullFlavour 2.16.840.1.113883.5.1008 Overig

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About this information

The information in this wikipage is based on Prerelease 2018 #1
SNOMED CT and LOINC codes are based on:

  • SNOMED Clinical Terms version: 20180731 [R] (July 2018 Release)
  • LOINC version 2.64

Conditions for use are located on the mainpage List2.png
This page is generated on 23/12/2018 00:47:45 with ZibExtraction v. 3.0.6929.24609

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