MedicationAdministration2-v1.0(2017EN)

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General information

Name: nl.zorg.MedicationAdministration2
Version: 1.0
HCIM Status:Final
Release: 2017
Release status: Prepublished
Release date: 04-09-2017

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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 2.16.840.1.113883.2.4.3.11.60.40.3.9.13
DCM::KeywordList Medicatie, Toediening
DCM::LifecycleStatus Final
DCM::ModelerList Architectuurgroep Registratie aan de Bron
DCM::Name nl.zorg.MedicatieToediening2
DCM::PublicationDate 04-09-2017
DCM::PublicationStatus Prepublished
DCM::ReviewerList Projectgroep Medicatieproces & Architectuurgroep Registratie aan de Bron
DCM::RevisionDate 04-09-2017
DCM::Superseeds nl.zorg.MedicatieToediening-v3.0
DCM::Version 1.0
HCIM::PublicationLanguage EN

Revision History

Concept

Medication administration is the registration of the individual administrations of the medicine on the patient by the administrator (e.g. a nurse or patient themselves), in relation to the entered agreements.

Purpose

The goal of administering the medication is to provide insight into the actual administered products.

Information Model


AdministrationAgreement-v1.0(2017EN)MedicationAgreement-v1.0(2017EN)#13486#13491ContactPerson-v3.1(2017EN)Patient-v3.1(2017EN)Range-v1.0(2017EN)#13482HealthProfessional-v3.1(2017EN)#13498#13481#13495#13484#13493#13500#13488Product-v1.0(2017EN)#13489#13483#MedicationAdministrationRouteOfAdministration#MedicationAdministrationReasonForDeviationCodeLis#MedicationAdministrationStatusCodeList


Type Id Concept Card. Definition DefinitionCode Reference
NL-CM:9.13.20928 MedicationAdministration Root concept of the MedicationAdministration information model. This root concept contains all data elements of the MedicationAdministration information model.
18629005 Administration of drug or medicament
NL-CM:9.13.20929 AdministrationProduct::Product 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.

Product
NL-CM:9.13.23159 AdministeringSpeed::Range 0..1 The administering speed is used in slow administration of liquid. In practice, the measuring unit is almost always ml/hour.

Entering an interval (such as 0-10 ml/hour) is also a commonly used option.

For example, with an administering speed of 10ml/hour:

  • amount = 10,
  • dose unit = ml
  • time unit = hour
Range
NL-CM:9.13.21193 AdministrationDateTime 1 The date and time at which the medication was administered.
NL-CM:9.13.23171 AgreedDateTime 0..1 Date and time in the medication or administration agreement to which this administration pertains. Since multiple times can be indicated in one medication/administration agreement, this can be used to identify the agreed time in the event of e.g. early administration or a late administration.
NL-CM:9.13.21194 AdministeredAmount 1 Amount of the administered product.
NL-CM:9.13.23167 DeviatingAdministration 0..1 In the administration, was there a deviation from the medication or administration agreement? This can be a deviation in product, time, amount, route of administration or administering speed or foregoing administration altogether.
NL-CM:9.13.21195 RouteOfAdministration 1 The route through which the medication is administered (oral, nasal, intravenous,...).
410675002 Route of administration
MedicationAdministrationRouteOfAdministration
NL-CM:9.13.23168 DoubleCheckPerformed 0..1 Was a double check performed prior to the administration? This is only legally required for certain medication.
NL-CM:9.13.23170 MedicationAgreement (0..1) Medication agreement on which this administration.is based.
MedicationAgreement
NL-CM:9.13.23237 AdministrationAgreement (0..1) Administration agreement on which this administration is based.
AdministrationAgreement
NL-CM:9.13.23169 RelatedAgreement 0..1 Medication or administration agreement on which this administration.is based.
NL-CM:9.13.21196 Administrator 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. This is a professional authorised administrator, the patient themselves or the caregiver, for example.
NL-CM:9.13.23380 Patient (0..1) If the patient administered the medication themselves, indicate that here. If the medication is administered by a health professional or caregiver/family member/etc., the health professional is entered in the ‘Healthcare provider’ element or the caregiver/family member/etc. is entered in the ‘Contact’ element respectively.
Patient
NL-CM:9.13.23172 HealthProfessional (0..1) The concept describes the person who administered the product. This is a professional authorised administrator.
HealthProfessional
NL-CM:9.13.23355 Caregiver::Contact (0..1) Information on the patient’s personal relative or contact that administered the medication.
ContactPerson
NL-CM:9.13.23166 MedicationAdministrationReasonForDeviation 0..1 Reason why the medication was not taken or administered or was taken or administered differently. Here, you can choose to enter text or one of the codes.
MedicationAdministrationReasonForDeviationCodeLis
NL-CM:9.13.21191 MedicationAdministrationStatus 1 The status of the administration, as a description of the stage within the administering process. Only the status codes ‘completed’ and ‘cancelled’ apply to indivisible products (such as tablets or suppositories). For divisible products (such as infusions), doses 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: Administration has been completed.
  • Not started: The product was never administered.
MedicationAdministrationStatusCodeList
NL-CM:9.13.21337 Comment 0..1 Comments on administering the medication.
48767-8 Annotation comment

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

Example Instances

Only available in Dutch

MedicatieToedieningDatumTijd Toedieningsproduct AfwijkendeToediening MedicatieToedieningStatus Toedieningsweg Toegediende Hoeveelheid AfgesprokenDatumTijd MedicatieToedieningRedenVanAfwijken MedicatieAfspraak
ProductCode GebruiksInstructie
Doseerinstructie|Dosering|Keerdosis
3-6-2014 16:19:07
 Pantoprazol mylan tablet msr 20mg Nee Gereed Oraal 1 stuk
Bumetanide pch tablet 2 mg Ja Afgebroken Oraal 1 stuk Patiënt heeft geweigerd
 2 stuks
19-9-2014 14:12:11 Novorapid Flexpen Injvlst 100e/Ml Pen 3ml Ja Uitgesteld Subcutaan 22 eenheden 19-9-2014 9:00:00
 Vergeten toe te dienen 22 elementen

Valuesets

MedicationAdministrationReasonForDeviationCodeLis

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.9.13.3
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 Medicatieafspraak 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

MedicationAdministrationRouteOfAdministration

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.9.13.2
Conceptname Codesystem name Codesystem OID
Alle waarden G-Standaard Toedieningswegen 2.16.840.1.113883.2.4.4.9

MedicationAdministrationStatusCodeList

Valueset OID 2.16.840.1.113883.2.4.3.11.60.40.2.9.13.1
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

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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
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This information model is also available as pdf file or as spreadsheet

About this information

The information in this wikipage is based on Prerelease 2017 #1
Conditions for use are located on the mainpage
This page is generated on 30/11/2017 13:37:39

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