MedicationAgreement-v2.1(2023EN)

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General information

Name: nl.zorg.MedicationAgreement
Version: 2.1
HCIM Status:Final
Release: 2023
Release status: Prepublished
Release date: 15-10-2023


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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 15-10-2023
DCM::PublicationStatus Prepublished
DCM::ReviewerList Projectgroep Medicatieproces & Architectuurgroep Registratie aan de Bron
DCM::RevisionDate 17-07-2023
DCM::Supersedes nl.zorg.Medicatieafspraak-v2.0
DCM::Version 2.1
HCIM::PublicationLanguage EN

Revision History

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#688Problem-v4.6.1(2023EN)PharmaceuticalProduct-v2.2.1(2023EN)#MedicationAgreementStopTypeCodeList#ReasonModificationOrDiscontinuationCodeListHealthProfessional-v4.0(2023EN)#1474#689#697TimeInterval-v1.2(2023EN)InstructionsForUse-v2.0.1(2023EN)#695#1473


Type Id Concept Card. Definition DefinitionCode Reference
NL-CM:9.6.9580 MedicationAgreement Root concept of the MedicationAgreement information model. This root concept contains all data elements of the MedicationAgreement information model.
33633005 Prescription of drug
NL-CM:9.6.1030 Prescriber::HealthProfessional 0..1 The health professional that entered the medication agreement with the patient.
HealthProfessional
NL-CM:9.6.23133 PrescriptionReason::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
Problem
NL-CM:9.6.19925 AgreedMedicine::PharmaceuticalProduct 1 The medicine agreed upon to be used.
PharmaceuticalProduct
NL-CM:9.6.23240 InstructionsForUse 0..1 Instructions for the use of the medication, e.g. dose and route of administration.
InstructionsForUse
NL-CM:9.6.19757 MedicationAgreementDateTime 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)

NL-CM:9.6.19936 PeriodOfUse::TimeInterval 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 until and including', the submission of time is always mandatory for the end date.

With medication for an indefinite period only a start date is indicated.

TimeInterval
NL-CM:9.6.19954 MedicationAgreementStopType 0..1 Stop type, the manner in which this medication is discontinued (temporary or definitive).
274512008 Medication discontinued
MedicationAgreementStopTypeCodeList
NL-CM:9.6.22094 ReasonModificationOrDiscontinuation 0..1 Reason for modification or discontinuation of the medication agreement.
160111000146106 Reason for change of prescription
ReasonModificationOrDiscontinuationCodeList
NL-CM:9.6.23283 MedicationAgreementAdditionalInformation 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.

MedicationAgreementAdditionalInformationCodeList
NL-CM:9.6.22273 Comment 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

Example Instances

Only available in Dutch

MedicatieAfspraak DatumTijd Gebruiksperiode Afgesproken geneesmiddel Voorschrijver MedicatieAfspraak Stoptype MedicatieAfspraakRedenWijzigenOfStaken
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
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)

Valuesets

MedicationAgreementAdditionalInformationCodeList

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 G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.14.2050 Bewust hoge dosering
Bewust lage dosering 2 G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.14.2050 Bewust lage dosering
Bewust afwijkende toedieningsweg 3 G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.14.2050 Bewust afwijkende toedieningsweg
Medische noodzaak 4 G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.14.2050 Medische noodzaak
Profylaxe 5 G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.14.2050 Profylaxe
Wijziging in GDS per direct 6 G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.14.2050 Wijziging in GDS per direct
Wijziging in GDS per rolwissel 7 G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.14.2050 Wijziging in GDS per rolwissel
Bewust afwijken van leeftijdsgrenzen 8 G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.14.2050 Bewust afwijken van leeftijdsgrenzen
Bewust van te lage nierfunctie voor deze dosering 9 G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.14.2050 Bewust van te lage nierfunctie voor deze dosering
Bewust van eerder gemelde overgevoeligheid 10 G-std thesaurus 2050 2.16.840.1.113883.2.4.3.11.60.20.77.5.2.14.2050 Bewust van eerder gemelde overgevoeligheid

MedicationAgreementStopTypeCodeList

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
Drug therapy temporarily stopped 113381000146106 SNOMED CT 2.16.840.1.113883.6.96 Tijdelijke onderbreking van medicamenteuze behandeling (bijvoorbeeld tijdelijk stoppen gebruik vanwege operatie).
Drug therapy definitely stopped 113371000146109 SNOMED CT 2.16.840.1.113883.6.96 Het staken van een bestaande medicamenteuze behandeling.

ReasonModificationOrDiscontinuationCodeList

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 [DEPRECATED]
Administration of medication contraindicated 438833006 SNOMED CT 2.16.840.1.113883.6.96 Toedienen van medicatie gecontra-indiceerd
Medication interaction 79899007 SNOMED CT 2.16.840.1.113883.6.96 Geneesmiddelinteractie
Adverse reaction to drug 62014003 SNOMED CT 2.16.840.1.113883.6.96 Ongewenste reactie op medicatie en/of drugs
Hypersensitivity condition 473010000 SNOMED CT 2.16.840.1.113883.6.96 Overgevoeligheid [DEPRECATED]
Lack of drug action 58848006 SNOMED CT 2.16.840.1.113883.6.96 Gebrek aan geneesmiddeleffect
Drug action too strong 112251000146103 SNOMED CT 2.16.840.1.113883.6.96 Te sterk effect van medicatie
At increased risk of medication side effect 704417003 SNOMED CT 2.16.840.1.113883.6.96 (Mogelijke) bijwerking [DEPRECATED]
Insufficient route of drug administration 112191000146101 SNOMED CT 2.16.840.1.113883.6.96 Medicatietoedieningsweg voldoet niet
Drug treatment not indicated 183966005 SNOMED CT 2.16.840.1.113883.6.96 Geen indicatie voor medicamenteuze behandeling
Medication management changed 112751000146109 SNOMED CT 2.16.840.1.113883.6.96 Medicatiebeleids veranderd
Admission to establishment 305335007 SNOMED CT 2.16.840.1.113883.6.96 Opname in instelling
Patient requested modification of treatment 159711000146106 SNOMED CT 2.16.840.1.113883.6.96 Verzoek van zorgafnemer om behandeling te wijzigen
Patient requested treatment 184003006 SNOMED CT 2.16.840.1.113883.6.96 Wens patiënt [DEPRECATED]
Patient agreed with treatment 112211000146102 SNOMED CT 2.16.840.1.113883.6.96 Volgens afspraak [DEPRECATED]
Treatment previous prescriber continued 112261000146100 SNOMED CT 2.16.840.1.113883.6.96 Hervatten beleid vorige voorschrijver
Planned procedure 405613005 SNOMED CT 2.16.840.1.113883.6.96 Verrichting gepland
Incorrect registration of medication 159691000146109 SNOMED CT 2.16.840.1.113883.6.96 Foutieve registratie van medicatie
Drug not available - out of stock 182856006 SNOMED CT 2.16.840.1.113883.6.96 Geneesmiddel niet voorradig
Change in laboratory test finding 160131000146104 SNOMED CT 2.16.840.1.113883.6.96 Verandering in labwaarde
Patient-friendly Dutch at B1 reading level language reference set 160161000146108 SNOMED CT 2.16.840.1.113883.6.96 Dubbele registratie van medicamenteuze behandeling
Patient takes medication as prescribed 112221000146107 SNOMED CT 2.16.840.1.113883.6.96 Medicatiegebruik van patient volgens afspraak
Overig OTH NullFlavor 2.16.840.1.113883.5.1008 Overig

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About this information

The information in this wikipage is based on Prerelease 2023-1
SNOMED CT and LOINC codes are based on:

  • SNOMED Clinical Terms versie: 20230930 [R] (september 2023-editie)
  • LOINC version 2.76

Conditions for use are located on the mainpage
This page is generated on 31/10/2023 18:34:54 with ZibExtraction v. 9.3.8704.31782


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