MedicationUse-v3.0(2016EN)

General information

Name: nl.zorg.MedicationUse
Version: 3.0
HCIM Status:Final
Release: 2016
Release status: Published
Release date: 1-5-2016

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Metadata

DCM::CoderList	Kerngroep Registratie aan de Bron
DCM::ContactInformation.Address
DCM::ContactInformation.Name	*
DCM::ContactInformation.Telecom
DCM::ContentAuthorList	Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::CreationDate	19-12-2013
DCM::DeprecatedDate
DCM::DescriptionLanguage	nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name	PM
DCM::EndorsingAuthority.Telecom
DCM::Id	2.16.840.1.113883.2.4.3.11.60.40.3.9.2
DCM::KeywordList	Medicatie, Feitelijk Gebruik, Gebruik
DCM::LifecycleStatus	Final
DCM::ModelerList	Kerngroep Registratie aan de Bron
DCM::Name	nl.zorg.MedicatieGebruik
DCM::PublicationDate	1-5-2016
DCM::PublicationStatus	Published
DCM::ReviewerList	Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate	22-5-2015
DCM::Superseeds	nl.nfu.MedicatieGebruik-v1.0.1
DCM::Version	3.0
HCIM::PublicationLanguage	EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (01-04-2015)

ZIB-56	RFC Bouwsteen Medicatie
ZIB-308	Prefix Overdracht weggehaald bij de generieke bouwstenen

Incl. algemene wijzigingsverzoeken:

ZIB-94	Aanpassen tekst van Disclaimer, Terms of Use & Copyrights
ZIB-154	Consequenties opsplitsing Medicatie bouwstenen voor overige bouwstenen.
ZIB-200	Naamgeving SNOMED CT in tagged values klinische bouwstenen gelijk getrokken.
ZIB-201	Naamgeving OID: in tagged value notes van klinische bouwstenen gelijk getrokken.
ZIB-309	EOI aangepast
ZIB-324	Codelijsten Name en Description beginnen met een Hoofdletter
ZIB-326	Tekstuele aanpassingen conform de kwaliteitsreview kerngroep 2015

Publicatieversie 1.0.1 (22-05-2015)

ZIB-381

Onterecht een spatie achter "OID :" in tagged value notes van tagged value DCM::ValueSet MedicatieGebruikRedenVanStoppenCodelijst van concept MedicatieGebruikRedenVanStoppen.

Publicatieversie 3.0 (01-05-2016)

.

Concept

MedicationUse describes taking or administering the medication, often in relation to a prescription, but also on the person’s own initiative. This describes the pattern of medication use, as reported by the patient themselves, a caregiver or healthcare provider. Documenting medication use provides insight into the use of prescribed medication as well as the use of medication at home.

Purpose

Recording medication information is a very important part of continuity in healthcare. It concerns the core of patient safety. Healthcare professionals in the collaborative branch must always have access to an up-to-date medication overview. Applying the information model will usually involve:
• Recording the patient’s intake of self-medication or ‘drugs’.
• Recording the medication used during a patient’s stay at the hospital.
• Medication verification: recording the active medication profile.

Information Model

Type	Id	Concept						Card.	Definition	DefinitionCode	Reference
	NL-CM:9.2.1	MedicationUse							Root concept of the MedicationUse information model. This root concept contains all data elements of the MedicationUse information model.
	NL-CM:9.2.2		ProductUsed::Product					1	The product used. This is usually medication. Food, blood products, aids and bandages do not strictly fall under the category of medication, but can be recorded as well. In principle, this will be the prescribed product, but the product used may differ from the prescribed product.		MedicationPrescription
	NL-CM:9.2.3		Prescription					0..*	The agreement or order for the use of medication.		MedicationPrescription
	NL-CM:9.2.4		UsedDosage::Dosage					0..*	When taking stock of medication use, the dosage describes the amount and the pattern of use as reported by the patient or a healthcare provider. The used dosage is the reported dose used by the patient. The used dosage may differ in terms of the administering schedule of the prescribed dosage in the event that the patient makes different decisions on their use of the product and reports as such.		MedicationPrescription
	NL-CM:9.2.5		MedicationUseStatus					1	The status or status code is important in indicating the use schedule. This attribute indicates whether the prescription is actively used, temporarily interrupted, or by now discontinued. Interrupting (home) use often occurs in the event of admittance to a healthcare facility, prior to a procedure and in response to monitoring (mirroring provisions, effect measurements, etc.). When documenting this, the following interpretations are used: Active: The product is used. Interrupted: Use has (temporarily) been interrupted, because of a surgical procedure, for example. Later, the patient and/or doctor can decide whether or not to resume or discontinue use. Discontinued: Use has been stopped for a specific reason. Completed: Use has now been completed (according to the plan, prescription or agreement).] Not started: The product was never used.		MedicationUseStatusCodelist
	NL-CM:9.2.6		MedicationUseReasonForDiscontinuation					0..1	Reason why the use of a certain medicine was discontinued.		MedicationUseReasonForDiscontinuationCodelist
	NL-CM:9.2.7		MedicationUseReasonForInterruption					0..1	Reason why the use of a certain medicine was interrupted. Here, you can choose to enter text or one of the codes.		MedicationUseReasonForInterruptionCodelist
	NL-CM:9.2.8		Comment					0..1	Comments on the medication use.

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

GebruiksProduct	GebruiksDosering				MedicatieGebruikStatus	Voorschrift
ProductNaam	StartDatum	EindDatum	Keerdosis | Toedieningsschema	ToedieningsWeg		Reden van Voorschrijven
						Probleem
Paracetamol tablet 500 mg	05-2012		Zo nodig 500mg (=1st), max. 4x/dag	Oraal	Actief	Hoofdpijn

GebruiksProduct	GebruiksDosering				MedicatieGebruikStatus	Voorschrift
ProductNaam	StartDatum	EindDatum	Keerdosis | Toedieningsschema	ToedieningsWeg		Reden van Voorschrijven
						Probleem
Pantoprazol injpdr 40mg fl	11-09-2012 17:21		1x/dag(8u) 40mg (=1st)	iv	Actief	Ulcusprofylaxe

GebruiksProduct	GebruiksDosering				MedicatieGebruikStatus	Voorschrift
ProductNaam	StartDatum	EindDatum	Keerdosis | Toedieningsschema	ToedieningsWeg		Reden van Voorschrijven
						Probleem
Dalteparine 2500 injvlst 12.500 ie/ml wwsp 0,2ml	19-09-2012		1x/dag(18u) 2500ie(=0,2ml)	Subcutaan	Actief	Thrombose- profylaxe

References

1. GROOT, E. (2011) Dataset medicatieproces 2011. [Online] Den Haag: Nictiz. Beschikbaar op: http://www.nictiz.nl/module/360/590/Dataset_Medicatieproces_2011.xlsx [Geraadpleegd: 23 juli 2014].

2. HL7v3-implementatiehandleiding medicatieproces versie 6.1.0.0. [Online] Den Haag: Nictiz. Beschikbaar op: http://www.nictiz.nl/uploaded/FILES/html_cabinet/live/Zorgtoepassing/Medicatieproces/AORTA_Mp_IH_Medicatieproces_HL7.htm [Geraadpleegd: 23 juli 2014].

3. Dossier Medicatieoverzicht. [Online] Beschikbaar op: Oria.nl. [Geraadpleegd: 23 juli 2014].

4. G-standaard documentatie. [Online] Beschikbaar op: http://www.z-index.nl/ [Geraadpleegd: 23 juli 2014].

Valuesets

MedicationUseReasonForDiscontinuationCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.2.2

Binding:

Conceptname	Conceptcode	Codesystem name	Codesystem OID	Description
Intolerance	SINTOL	ActReason	2.16.840.1.113883.5.8	Bijwerking, allergie of intolerantie
Condition alert	COND	ActCode	2.16.840.1.113883.5.4	Contra-indicatie
Drug interacts with another drug	SDDI	ActReason	2.16.840.1.113883.5.8	Interactie met ander medicament
Dose change	DOSECHG	ActReason	2.16.840.1.113883.5.8	Dosiswijziging
No longer required for treatment	NOREQ	ActReason	2.16.840.1.113883.5.8	Niet langer vereist voor de behandeling
Ineffective	INEFFECT	ActReason	2.16.840.1.113883.5.8	Niet effectief
Formulary policy	FP	ActReason	2.16.840.1.113883.5.8	Ander voorschrijfbeleid
Product discontinued	DISCONT	ActReason	2.16.840.1.113883.5.8	Product niet meer leverbaar
Not covered	NOTCOVER	ActReason	2.16.840.1.113883.5.8	Product wordt niet vergoed
Patient refuse	PREFUS	ActReason	2.16.840.1.113883.5.8	Patiënt heeft geweigerd

MedicationUseReasonForInterruptionCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.2.3

Binding:

Conceptname	Conceptcode	Codesystem name	Codesystem OID	Description
Drug level too high	DRUGHIGH	ActReason	2.16.840.1.113883.5.8	Te hoge geneesmiddel spiegel
Lab interference issues	LABINT	ActReason	2.16.840.1.113883.5.8	Interferentie met gepland labonderzoek
Patient is pregnant/breast feeding	PREG	ActReason	2.16.840.1.113883.5.8	Patiënt is zwangerschap of geeft borstvoeding
Patient not-available	NON-AVAIL	ActReason	2.16.840.1.113883.5.8	Patiënt is niet beschikbaar
Response to monitoring	MONIT	ActReason	2.16.840.1.113883.5.8	Reactie op monitoring
Drug interacts with another drug	SDDI	ActReason	2.16.840.1.113883.5.8	Interactie met ander medicament
Duplicate therapy	SDUPTHER	ActReason	2.16.840.1.113883.5.8	Een andere therapie maakt het gebruik tijdelijk overbodig
Patient scheduled for surgery	SURG	ActReason	2.16.840.1.113883.5.8	Patient is ingepland voor een ingreep
Waiting for old drug to wash out	WASHOUT	ActReason	2.16.840.1.113883.5.8	Tijdelijk onderbreken tot ander geneesmiddel geen werking meer uitoefent

MedicationUseStatusCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.2.1

Binding:

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

• Release 2015, (Version 1.0.1)

Information model references

This information model refers to

• MedicationPrescription-v3.0

This information model is used in

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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
• 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 Release summer 2016
Conditions for use are located on the mainpage
This page is generated on 21/12/2018 15:39:25 with ZibExtraction v. 3.0.6929.24609

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