2nd DSTU Draft For Comment

This page is part of the FHIR Specification (v0.4.0: DSTU 2 Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

Profile Clinical Quality Framework (CQF) Medication Statement Profile - Definitions

Todo

Definitions for the cqf-medicationstatement-cqf-medicationstatement Profile.

MedicationStatement(cqf-medicationstatement)
Definition

Statement that a medication was given to a patient. The wasNotGiven and reasonNotGiven elements have been removed. See cqf-medicationstatement-notgiven to express the concept of nonoccurrence.

Control1..1
Requirements
Comments
MedicationStatement.id
Definition

The logical id of the resource, as used in the url for the resoure. Once assigned, this value never changes.

Control0..1
Typeid
Requirements
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Bundles always have an id, though it is usually a generated UUID.

MedicationStatement.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.

Control0..1
TypeMeta
Requirements
Comments
MedicationStatement.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.

Control0..1
Typeuri
Is Modifiertrue
Requirements
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element as much as possible.

MedicationStatement.language
Definition

The base language in which the resource is written.

Control0..1
BindingA human language
The codes SHALL be taken from http://tools.ietf.org/html/bcp47
Typecode
Requirements
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource

Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

MedicationStatement.text
Definition

A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Control0..1 This element is affected by the following invariants: dom-1
TypeNarrative
Requirements
Alternate Namesnarrative, html, xhtml, display
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative.

MedicationStatement.contained
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Control0..*
TypeResource
Requirements
Alternate Namesinline resources, anonymous resources, contained resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.

MedicationStatement.extension
Definition

May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Requirements
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

MedicationStatement.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Requirements
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

MedicationStatement.identifier
Definition

External identifier - FHIR will generate its own internal IDs (probably URLs) which do not need to be explicitly managed by the resource. The identifier here is one that would be used by another non-FHIR system - for example an automated medication pump would provide a record each time it operated; an administration while the patient was off the ward might be made with a different system and entered after the event. Particularly important if these records have to be updated.

Control0..*
TypeIdentifier
Requirements
Comments
MedicationStatement.patient
Definition

The person or animal who is /was taking the medication.

Control1..1
TypeReference(Profile = (Profile = http://hl7.org/fhir/Profile/Patient))
Must Supporttrue
Requirements
Comments
MedicationStatement.informationSource
Definition

The person who provided the information about the taking of this medication.

Control0..1
TypeChoice of: Reference(Profile = (Profile = http://hl7.org/fhir/Profile/Patient)), Reference(Profile = (Profile = http://hl7.org/fhir/Profile/Practitioner)), Reference(Profile = (Profile = http://hl7.org/fhir/Profile/RelatedPerson))
Requirements
Comments
MedicationStatement.dateAsserted
Definition

The date when the medication statement was asserted by the information source.

Control0..1
TypedateTime
Requirements
Comments
MedicationStatement.status
Definition

A code specifying the state of the statement. Generally this will be in-progress or completed state.

Control1..1
BindingA set of codes indicating the current status of a MedicationStatement
The codes SHALL be taken from MedicationStatementStatus
Typecode
Must Supporttrue
Requirements
Comments
MedicationStatement.wasNotGiven
Definition

Set this to true if the record is saying that the medication was NOT taken.

Control0..1
Typeboolean
Is Modifiertrue
Requirements
Comments
Fixed Valuefalse
MedicationStatement.reasonNotGiven
Definition

A code indicating why the medication was not taken.

Control0..* This element is affected by the following invariants: mst-1
BindingA set of codes indicating the reason why the MedicationAdministration is negated.
For example codes, see Reason Medication Not Given Codes
TypeCodeableConcept
Requirements
Comments
InvariantsDefined on this element
mst-1: Reason not given is only permitted if wasNotGiven is true (xpath: not(exists(f:reasonNotGiven) and f:wasNotGiven/@value='false'))
MedicationStatement.reasonForUse[x]
Definition

A reason for why the medication is being/was taken.

Control0..1
TypeChoice of: CodeableConcept, Reference(Profile = (Profile = http://hl7.org/fhir/Profile/Condition))
Must Supporttrue
Requirements
Comments
InvariantsDefined on this element
mst-2: Reason for use is only permitted if wasNotGiven is false (xpath: not(exists(f:reasonForUse[x]) and f:wasNotGiven/@value='true'))
MedicationStatement.effective[x]
Definition

The interval of time during which it is being asserted that the patient was taking the medication (or was not taking, when the 'wasNotGiven' attribute is true).

Control0..1
TypeChoice of: dateTime, Period
Must Supporttrue
Requirements
Comments

If the medication is still being taken at the time the statement is recorded, the "end" date will be omitted.

MedicationStatement.note
Definition

Provides extra information about the medication statement that is not conveyed by the other attributes.

Control0..1
Typestring
Requirements
Comments
MedicationStatement.medication
Definition

Identifies the medication being administered. This is either a link to a resource representing the details of the medication or a simple attribute carrying a code that identifies the medication from a known list of medications.

Control0..1
TypeReference(Profile = (Profile = http://hl7.org/fhir/Profile/Medication))
Must Supporttrue
Requirements
Comments

Note: do not use Medication.name to describe the medication this statement concerns. When the only available information is a text description of the medication, Medication.code.text should be used.

MedicationStatement.dosage
Definition

Indicates how the medication is/was used by the patient.

Control0..*
Must Supporttrue
Requirements
Comments
MedicationStatement.dosage.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Requirements
Comments
MedicationStatement.dosage.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Requirements
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

MedicationStatement.dosage.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Requirements
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

MedicationStatement.dosage.text
Definition

Free text dosage instructions can be used for cases where the instructions are too complex to code. When coded instructions are present, the free text instructions may still be present for display to humans taking or administering the medication.

Control0..1
Typestring
Requirements
Comments
MedicationStatement.dosage.schedule
Definition

The timing schedule for giving the medication to the patient. The Schedule data type allows many different expressions, for example. "Every 8 hours"; "Three times a day"; "1/2 an hour before breakfast for 10 days from 23-Dec 2011:"; "15 Oct 2013, 17 Oct 2013 and 1 Nov 2013".

Control0..1
TypeTiming
Must Supporttrue
Requirements
Comments
MedicationStatement.dosage.asNeeded[x]
Definition

If set to true or if specified as a CodeableConcept, indicates that the medication is only taken when needed within the specified schedule rather than at every scheduled dose. If a CodeableConcept is present, it indicates the pre-condition for taking the Medication.

Control0..1
BindingA coded concept identifying the pre-condition that should hold prior to consuming a medication dose. For example "pain", "30 minutes prior to sexual intercourse", "on flare-up", etc.
TypeChoice of: boolean, CodeableConcept
Must Supporttrue
Requirements
Comments
MedicationStatement.dosage.site
Definition

A coded specification of the anatomic site where the medication first enters the body.

Control0..1
BindingA coded concept describing the site location the medicine enters into or onto the body
For example codes, see SNOMED CT Anatomical Structure for Administration Site Codes
TypeCodeableConcept
Must Supporttrue
Requirements
Comments
MedicationStatement.dosage.route
Definition

A code specifying the route or physiological path of administration of a therapeutic agent into or onto a subject.

Control0..1
BindingA coded concept describing the route or physiological path of administration of a therapeutic agent into or onto the body of a subject.
For example codes, see SNOMED CT Route Codes
TypeCodeableConcept
Must Supporttrue
Requirements
Comments
MedicationStatement.dosage.method
Definition

A coded value indicating the method by which the medication is introduced into or onto the body. Most commonly used for injections. Examples: Slow Push; Deep IV.

Terminologies used often pre-coordinate this term with the route and or form of administration.

Control0..1
BindingA coded concept describing the technique by which the medicine is administered
For example codes, see SNOMED CT Introduction (procedure) for Administration Method Codes
TypeCodeableConcept
Must Supporttrue
Requirements
Comments
MedicationStatement.dosage.quantity
Definition

The amount of therapeutic or other substance given at one administration event.

Control0..1
TypeQuantity
Must Supporttrue
Requirements
Comments
MedicationStatement.dosage.rate
Definition

Identifies the speed with which the substance is introduced into the subject. Typically the rate for an infusion. 200ml in 2 hours.

Control0..1
TypeRatio
Must Supporttrue
Requirements
Comments
MedicationStatement.dosage.maxDosePerPeriod
Definition

The maximum total quantity of a therapeutic substance that may be administered to a subject over the period of time. E.g. 1000mg in 24 hours.

Control0..1
TypeRatio
Must Supporttrue
Requirements
Comments