Huidige versie van 24 dec 2018 om 11:57
Attention!! This is not the most recent version of this information model. You can find the most recent version
''here''.
General information
Name: nl.zorg.MedicatieToediening2 
Version: 1.0.1
HCIM Status:Final
Release: 2018
Release status: Prepublished
Release date: 01-10-2018
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 |
01-10-2018
|
| DCM::PublicationStatus |
Prepublished
|
| DCM::ReviewerList |
Projectgroep Medicatieproces & Architectuurgroep Registratie aan de Bron
|
| DCM::RevisionDate |
31-12-2017
|
| DCM::Superseeds |
nl.zorg.MedicatieToediening-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
|
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
| Type |
Id |
Concept |
Card. |
Definition |
DefinitionCode |
Reference
|
|
NL-CM:9.13.20928
|
 MedicatieToediening
|
|
Root concept of the MedicationAdministration information model. This root concept contains all data elements of the MedicationAdministration information model.
|
|
|
|
NL-CM:9.13.20929
|
|
 ToedieningsProduct::FarmaceutischProduct
|
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.
|
|
|
|
|
NL-CM:9.13.23159
|
|
Toedieningssnelheid::Bereik
|
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
Optionally a translation to NHG table Gebruiksvoorschriften(Table 25) is also allowed.
|
|
|
|
NL-CM:9.13.21193
|
|
ToedieningsDatumTijd
|
1
|
The date and time at which the medication was administered.
|
|
|
|
|
NL-CM:9.13.23171
|
|
AfgesprokenDatumTijd
|
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
|
|
ToegediendeHoeveelheid
|
1
|
Amount of the administered product.
|
|
|
|
NL-CM:9.13.23167
|
|
AfwijkendeToediening
|
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
|
|
Toedieningsweg
|
1
|
The route through which the medication is administered (oral, nasal, intravenous,...).
|
|
|
|
|
NL-CM:9.13.23168
|
|
DubbeleControleUitgevoerd
|
0..1
|
Was a double check performed prior to the administration? This is only legally required for certain medication.
|
|
|
|
|
NL-CM:9.13.23170
|
|
|
Medicatieafspraak
|
(0..1)
|
Medication agreement on which this administration.is based.
|
|
|
|
|
NL-CM:9.13.23237
|
|
|
Toedieningsafspraak
|
(0..1)
|
Administration agreement on which this administration is based.
|
|
|
|
NL-CM:9.13.23169
|
|
GerelateerdeAfspraak
|
0..1
|
Medication or administration agreement on which this administration.is based.
|
|
|
|
|
NL-CM:9.13.21196
|
|
Toediener
|
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
|
|
|
Patiënt
|
(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.
|
|
|
|
|
NL-CM:9.13.23172
|
|
|
Zorgverlener
|
(0..1)
|
The concept describes the person who administered the product. This is a professional authorised administrator.
|
|
|
|
|
NL-CM:9.13.23355
|
|
|
Mantelzorger::Contactpersoon
|
(0..1)
|
Information on the patient’s personal relative or contact that administered the medication.
|
|
|
|
|
NL-CM:9.13.23166
|
|
MedicatieToedieningRedenVanAfwijken
|
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.
|
|
|
|
|
NL-CM:9.13.21191
|
|
MedicatieToedieningStatus
|
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.
|
|
|
|
NL-CM:9.13.21337
|
|
Toelichting
|
0..1
|
Comments on administering the medication.
|
| 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
| 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
MedicatieToedieningRedenVanAfwijkenCodelijst
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.13.3
|
Binding: Extensible
|
| 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
|
MedicatieToedieningStatusCodelijst
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.13.1
|
Binding: Extensible
|
| 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
|
MedicatieToedieningToedieningswegCodelijst
| Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.13.2
|
Binding: Extensible
|
| Conceptname
|
Codesystem name |
Codesystem OID
|
| Alle waarden
|
G-Standaard Toedieningswegen
|
2.16.840.1.113883.2.4.4.9
|
This information model in other releases
Information model references
This information model refers to
This information model is used in
Technical specifications in HL7v3 CDA and HL7 FHIR
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
- HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR
Downloads
This information model is also available as pdf file 
or as spreadsheet 
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
This page is generated on 23/12/2018 00:48:00 with ZibExtraction v. 3.0.6929.24609
