Medicatieafspraak-v1.0.1(2018EN)

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General information

Name: nl.zorg.Medicatieafspraak
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

Type	Id	Concept						Card.	Definition	DefinitionCode	Reference
	NL-CM:9.6.9580	Medicatieafspraak							Root concept of the MedicationAgreement information model. This root concept contains all data elements of the MedicationAgreement information model.
	NL-CM:9.6.1030		Voorschrijver::Zorgverlener					0..1	The health professional that entered the medication agreement with the patient.		HealthProfessional
	NL-CM:9.6.23133		RedenVanVoorschrijven::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”.		Problem
	NL-CM:9.6.23028		Lichaamsgewicht					0..1	Weight the dose is based on, relevant to this agreement.		BodyWeight
	NL-CM:9.6.23023		Lichaamslengte					0..1	Height the dose is based on, relevant to this agreement.		BodyHeight
	NL-CM:9.6.19925		Afgesprokengeneesmiddel::FarmaceutischProduct					1	The medicine agreed upon to be used.		PharmaceuticalProduct
	NL-CM:9.6.23240		Gebruiksinstructie					0..1	Instructions for the use of the medication, e.g. dose and route of administration.		InstructionsForUse
	NL-CM:9.6.19757		MedicatieafspraakDatumTijd					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		Gebruiksperiode::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.		TimeInterval
	NL-CM:9.6.23033		GeannuleerdIndicator					0..1	In the event of an error correction of the medication agreement, this indicator is to be put on for the incorrect agreement.
	NL-CM:9.6.19954		MedicatieafspraakStopType					0..1	Stop type, the manner in which this medication is discontinued (temporary or definitive).		MedicatieafspraakStopTypeCodelijst
	NL-CM:9.6.22094		RedenMedicatieafspraak					0..1	Reason for this agreement. This can be the reason to start, change or stop the medication treatment.		RedenMedicatieafspraakCodelijst
	NL-CM:9.6.23283		MedicatieafspraakAanvullendeInformatie					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.		MedicatieafspraakAanvullendeInformatieCodelijst
	NL-CM:9.6.22273		Toelichting					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	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

This information model in other releases

• Release 2017, (Version 1.0.1)
• Prerelease 2019-2, (Version 1.1)
• Release 2020, (Version 1.2)
• Prerelease 2021-2, (Version 1.3)
• Prerelease 2022-1, (Version 2.0)
• Prerelease 2023-1, (Version 2.1)
• Prerelease 2024-1, (Version 3.0)

Information model references

This information model refers to

• BodyHeight-v3.1
• BodyWeight-v3.1
• HealthProfessional-v3.2
• InstructionsForUse-v1.1.1
• PharmaceuticalProduct-v2.0
• Problem-v4.1.1
• TimeInterval-v1.0

This information model is used in

• AdministrationAgreement-v1.0.1
• MedicationAdministration2-v1.0.1

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 00:47:45 with ZibExtraction v. 3.0.6929.24609

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