MedicationAdministration2-v1.0.1(2018EN)

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General information

Name: nl.zorg.MedicationAdministration2 NL.png
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 2.16.840.1.113883.2.4.3.11.60.40.3.9.13
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


AdministrationAgreement-v1.0.1(2018EN)MedicationAgreement-v1.0.1(2018EN)#13486#13491ContactPerson-v3.2(2018EN)Patient-v3.1.1(2018EN)Range-v1.0(2018EN)#13482HealthProfessional-v3.2(2018EN)#13498#13481#13495#13484#13493#13500#13488PharmaceuticalProduct-v2.0(2018EN)#13489#13483#MedicationAdministrationRouteOfAdministration#MedicationAdministrationReasonForDeviationCodeLis#MedicationAdministrationStatusCodeListMedicationAdministration2-v1.0.1Model(EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:9.13.20928 Arrowdown.pngMedicationAdministration Root concept of the MedicationAdministration information model. This root concept contains all data elements of the MedicationAdministration information model.
18629005 Administration of medication
Verwijzing.png NL-CM:9.13.20929 Arrowright.pngAdministrationProduct::FarmaceuticalProduct 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 PharmaceuticalProduct
Verwijzing.png NL-CM:9.13.23159 Arrowright.pngAdministeringSpeed::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

Optionally a translation to NHG table Gebruiksvoorschriften(Table 25) is also allowed.

Block.png Range
TS.png NL-CM:9.13.21193 Arrowright.pngAdministrationDateTime 1 The date and time at which the medication was administered.
TS.png NL-CM:9.13.23171 Arrowright.pngAgreedDateTime 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.
PQ.png NL-CM:9.13.21194 Arrowright.pngAdministeredAmount 1 Amount of the administered product.
BL.png NL-CM:9.13.23167 Arrowright.pngDeviatingAdministration 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.
CD.png NL-CM:9.13.21195 Arrowright.pngRouteOfAdministration 1 The route through which the medication is administered (oral, nasal, intravenous,...).
410675002 Route of administration
List2.png MedicationAdministrationRouteOfAdministration
BL.png NL-CM:9.13.23168 Arrowright.pngDoubleCheckPerformed 0..1 Was a double check performed prior to the administration? This is only legally required for certain medication.
Verwijzing.png NL-CM:9.13.23170 Arrowright.pngMedicationAgreement (0..1) Medication agreement on which this administration.is based.
Block.png MedicationAgreement
Verwijzing.png NL-CM:9.13.23237 Arrowright.pngAdministrationAgreement (0..1) Administration agreement on which this administration is based.
Block.png AdministrationAgreement
Folder.png NL-CM:9.13.23169 Arrowdown.pngRelatedAgreement 0..1 Medication or administration agreement on which this administration.is based.
Folder.png NL-CM:9.13.21196 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. This is a professional authorised administrator, the patient themselves or the caregiver, for example.
Verwijzing.png NL-CM:9.13.23380 Arrowright.pngPatient (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.
Block.png Patient
Verwijzing.png NL-CM:9.13.23172 Arrowright.pngHealthProfessional (0..1) The concept describes the person who administered the product. This is a professional authorised administrator.
Block.png HealthProfessional
Verwijzing.png NL-CM:9.13.23355 Arrowright.pngCaregiver::Contact (0..1) Information on the patient’s personal relative or contact that administered the medication.
Block.png ContactPerson
CD.png NL-CM:9.13.23166 Arrowright.pngMedicationAdministrationReasonForDeviation 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.
List2.png MedicationAdministrationReasonForDeviationCodeLis
CD.png NL-CM:9.13.21191 Arrowright.pngMedicationAdministrationStatus 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.
List2.png MedicationAdministrationStatusCodeList
ST.png NL-CM:9.13.21337 Arrowright.pngComment 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 List2.png

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 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

MedicationAdministrationRouteOfAdministration

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

MedicationAdministrationStatusCodeList

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

This information model in other releases

Information model references

This information model refers to

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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 Artdecor.jpg
  • HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR Fhir.png

Downloads

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 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 List2.png
This page is generated on 01/11/2018 17:36:32 with ZibExtraction v. 2.0.6879.31307


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