MedicationAdministration-v3.0(2016EN)

Uit Zorginformatiebouwstenen
Naar navigatie springen Naar zoeken springen

General information

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


Back 16.png Back to HCIM list

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 2.16.840.1.113883.2.4.3.11.60.40.3.9.3
DCM::KeywordList Medicatie, Toediening
DCM::LifecycleStatus Final
DCM::ModelerList Kerngroep Registratie aan de Bron
DCM::Name nl.zorg.MedicatieToediening
DCM::PublicationDate 1-5-2016
DCM::PublicationStatus Published
DCM::ReviewerList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 1-4-2015
DCM::Superseeds nl.nfu.MedicatieToediening-v1.0
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
ZIB-353 Tagged values DCM::CodeSystem aanpassen naar DCM::ValueSet incl. gekoppelde codelijst.

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 3.0 (01-05-2016)

.

Concept

Administration of medication describes the actual administration of the medication. This can be simply swallowing a tablet, applying ointment or paste, or an infusion that takes a considerable amount of time.
The administration can refer to a medication prescription, but can also refer to home medication.

Purpose

To precisely plan the medication to be administered in a chain of collaborating healthcare professionals, it is often best to have information on the most recent administrations of medication, food or blood products.

Information Model


#AdministrationRouteOfAdministrationCodelistContactPerson-v3.0(2016EN)#11117Patient-v3.0(2016EN)#MedicationAdministrationReasonForNoAdministrationCodelist#11118#11116MedicationPrescription-v3.0(2016EN)MedicationPrescription-v3.0(2016EN)HealthProfessional-v3.0(2016EN)#11115#11125#11120#MedicationAdministrationStatusCodelist#11114#11864MedicationAdministration-v3.0Model(EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:9.3.1 Arrowdown.pngMedicationAdministration Root concept of the MedicationAdministration information model. This root concept contains all data elements of the MedicationAdministration information model.
Verwijzing.png NL-CM:9.3.2 Arrowright.pngMedicationUseStatusCodelist 1 The product taken or administered. This is usually medication. Food, blood products, aids and bandages do not strictly fall under the category of medication, but can be reported as well.

In principle, this will be the prescribed product, but the administrator may substitute it by replacing the product with an equivalent product. For example: two 50mg tablets can be administered instead of one 100mg tablet.

Block.png MedicationPrescription
Verwijzing.png NL-CM:9.3.3 Arrowright.pngPrescription::MedicationPrescription 0..1 The agreement or order mandating the administration.
Block.png MedicationPrescription
CD.png NL-CM:9.3.4 Arrowright.pngMedicationAdministrationStatus 1 The status of the administration, as a description of the stage within the administration process. For indivisible products (such as tablets or suppositories) only the status codes ‘completed’ and ‘cancelled’ apply. For divisible products (such as infusions), administration can also be ‘suspended’ or ‘aborted’.

When documenting this, the following interpretations are used:

  • Active: The product is administered.
  • Interrupted: Use has (temporarily) been interrupted, because of a side effect, for example. Later, the patient and/or doctor can decide whether or not to resume or discontinue use.
  • Discontinued: Administration has stopped.
  • Completed: The administration has now been completed (according to the plan, prescription or agreement).
  • Not started: The product was never administered.
List2.png MedicationAdministrationStatusCodelist
CD.png NL-CM:9.3.5 Arrowright.pngMedicationAdministrationReasonForNoAdministration 0..1 Reason why the medication was not taken or administered. Here, you can choose to enter text or one of the codes.
List2.png MedicationAdministrationReasonForNoAdministrationCodelist
TS.png NL-CM:9.3.6 Arrowright.pngAdministrationDateTime 1 The date and time at which the medication was taken or administered.
PQ.png NL-CM:9.3.7 Arrowright.pngAdministeredAmount 1 Amount of the administered product.
CD.png NL-CM:9.3.8 Arrowright.pngRouteOfAdministration 0..1 The route through which the medication is administered (oral, nasal, intravenous,...).
List2.png AdministrationRouteOfAdministrationCodelist
Folder.png NL-CM:9.3.9 Arrowdown.pngAdministrator 0..1 Container of the Administrator concept. This container contains all data elements of the Administrator concept. The concept describes the person who administered the product.
Verwijzing.png NL-CM:9.3.10 Arrowright.pngHealthcareProvider (0..1) The healthcare provider who administered the product.
Block.png HealthProfessional
Verwijzing.png NL-CM:9.3.11 Arrowright.pngPatient (0..1) The patient who administered the product.
Block.png Patient
Verwijzing.png NL-CM:9.3.12 Arrowright.pngCaregiver::Contact (0..1) The caregiver who administered the product.
Block.png ContactPerson
ST.png NL-CM:9.3.13 Arrowright.pngComment 0..1 Comments on administering the medication.

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

ToedieningsProduct Toedieningsweg ToegediendeHoeveelheid ToedieningsTijdstip Medicatie
ToedieningStatus
MedicatieToediening
RedenVanNietToedienen
Voorschrift
ProductNaam RedenVanVoorschrijven
Probleem
Paracetamol tablet 500 mg Oraal 1 tablet 3-5-2014 10:00 Het product is niet toegediend. Patiënt heeft geweigerd Pijn
ToedieningsProduct Toedieningsweg ToegediendeHoeveelheid ToedieningsTijdstip Medicatie
ToedieningStatus
MedicatieToediening
RedenVanNietToedienen
Voorschrift
ProductNaam RedenVanVoorschrijven
Probleem
Glucose/NaCl 2,5/0,45% infvlst zak 500ml iv 500ml 3-5-2014 12:00 Onderbroken Ondervulling

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

AdministrationRouteOfAdministrationCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.9.3.3
Conceptname Codesystem name Codesystem OID
Alle waarden G-Standaard Toedieningswegen 2.16.840.1.113883.2.4.4.9

MedicationAdministrationReasonForNoAdministrationCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.9.3.2
Conceptname Conceptcode Codesystem name Codesystem OID Description
Product discontinued DISCONT ActReason 2.16.840.1.113883.5.8 Product niet meer leverbaar
Patient not available NON-AVAIL ActReason 2.16.840.1.113883.5.8 Patiënt niet beschikbaar
Patient refuse PREFUS ActReason 2.16.840.1.113883.5.8 Patiënt heeft geweigerd
Unable to use UNABLE ActReason 2.16.840.1.113883.5.8 Toediening volgens voorschrift niet mogelijk
Order aborted FOABORT ActReason 2.16.840.1.113883.5.8 Voorschrift is gestopt
Forgotten to administer FORGOT NL-CM-CS 2.16.840.1.113883.2.4.3.11.60.40.4 Vergeten toe te dienen
Administration performer not available APNA NL-CM-CS 2.16.840.1.113883.2.4.3.11.60.40.4 Toediener niet aanwezig
No information NI NullFlavor 2.16.840.1.113883.5.1008 Geen informatie

MedicationAdministrationStatusCodelist

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.9.3.1
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 23:30:21


Back 16.png Back to HCIM list