Qi-Core Implementation Guide (Release 2.1 Trial-Use Ballot)

This page is part of the Quality Improvement Core Framework (v2.1.0: STU 3 Ballot 1) based on FHIR R3. The current version which supercedes this version is 4.1.1. For a full list of available versions, see the Directory of published versions

D.4.1 StructureDefinition: qicore-medicationstatement

Examples:

Penicillin MedicationStatement Example

D.4.1.1 Formal Views of Profile Content

The official URL for this profile is: 

http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-medicationstatement

This profile builds on US Core Medication Statement Profile.

This profile was published on Mon Aug 21 16:00:00 AEST 2017 as a draft by Health Level Seven International (Clinical Quality Information - QICore).

Description of Profiles, Differentials, and Snapshots.

NameFlagsCard.TypeDescription & Constraintsdoco
.. MedicationStatement I0..*Record of medication being taken by a patient
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal identifier
... basedOn Σ0..*Reference(MedicationRequest), Reference(CarePlan), Reference(ProcedureRequest), Reference(ReferralRequest)Fulfils plan, proposal or order
... partOf Σ0..*Reference(MedicationAdministration), Reference(MedicationDispense), Reference(MedicationStatement), Reference(Procedure), Reference(Observation)Part of referenced event
... context Σ0..1Reference(Encounter), Reference(EpisodeOfCare)Encounter / Episode associated with MedicationStatement
... status ?!SΣ1..1codeactive | completed | entered-in-error | intended | stopped | on-hold
Binding: MedicationStatementStatus (required)
... category Σ0..1CodeableConceptType of medication usage
Binding: MedicationStatementCategory (preferred)
... medication[x] SΣ1..1CodeableConcept, Reference(QICore-Medication)What medication was taken
Binding: Medication Clinical Drug (RxNorm) (preferred)
... effective[x] SΣ0..1dateTime, PeriodThe date/time or interval when the medication was taken
... dateAsserted SΣ1..1dateTimeWhen the statement was asserted?
... informationSource S0..1Reference(QICore-Patient), Reference(QICore-Practitioner), Reference(QICore-RelatedPerson)Person or organization that provided the information about the taking of this medication
... subject SΣ1..1Reference(QICore-Patient), Reference(Group)Who is/was taking the medication
... derivedFrom S0..*Reference(Resource)Additional supporting information
... taken ?!SΣ1..1codey | n | unk | na
Binding: MedicationStatementTaken (required)
... reasonNotTaken I0..*CodeableConceptTrue if asserting medication was not given
Binding: SNOMED CT Drugs not taken/completed Codes (example)
... reasonCode 0..*CodeableConceptReason for why the medication is being/was taken
Binding: Condition/Problem/Diagnosis Codes (example)
... reasonReference 0..*Reference(Condition), Reference(Observation)Condition or observation that supports why the medication is being/was taken
... note 0..*AnnotationFurther information about the statement
... dosage 0..*DosageDetails of how medication is/was taken or should be taken
.... id 0..1stringxml:id (or equivalent in JSON)
.... sequence Σ0..1integerThe order of the dosage instructions
.... text Σ0..1stringFree text dosage instructions e.g. SIG
.... additionalInstruction Σ0..*CodeableConceptSupplemental instruction - e.g. "with meals"
Binding: SNOMED CT Additional Dosage Instructions (example)
.... patientInstruction Σ0..1stringPatient or consumer oriented instructions
.... timing SΣ0..1TimingWhen medication should be administered
.... asNeeded[x] Σ0..1boolean, CodeableConceptTake "as needed" (for x)
Binding: SNOMED CT Medication As Needed Reason Codes (example)
.... site Σ0..1CodeableConceptBody site to administer to
Binding: SNOMED CT Anatomical Structure for Administration Site Codes (example)
.... route SΣ0..1CodeableConceptHow drug should enter body
Binding: SNOMED CT Route Codes (example)
.... method Σ0..1CodeableConceptTechnique for administering medication
Binding: SNOMED CT Administration Method Codes (example)
.... dose[x] SΣ0..1Range, SimpleQuantityAmount of medication per dose
.... maxDosePerPeriod Σ0..1RatioUpper limit on medication per unit of time
.... maxDosePerAdministration Σ0..1SimpleQuantityUpper limit on medication per administration
.... maxDosePerLifetime Σ0..1SimpleQuantityUpper limit on medication per lifetime of the patient
.... rate[x] Σ0..1Ratio, Range, SimpleQuantityAmount of medication per unit of time

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. MedicationStatement I0..*Record of medication being taken by a patient
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal identifier
... basedOn Σ0..*Reference(MedicationRequest), Reference(CarePlan), Reference(ProcedureRequest), Reference(ReferralRequest)Fulfils plan, proposal or order
... partOf Σ0..*Reference(MedicationAdministration), Reference(MedicationDispense), Reference(MedicationStatement), Reference(Procedure), Reference(Observation)Part of referenced event
... context Σ0..1Reference(Encounter), Reference(EpisodeOfCare)Encounter / Episode associated with MedicationStatement
... status ?!SΣ1..1codeactive | completed | entered-in-error | intended | stopped | on-hold
Binding: MedicationStatementStatus (required)
... category Σ0..1CodeableConceptType of medication usage
Binding: MedicationStatementCategory (preferred)
... medication[x] SΣ1..1CodeableConcept, Reference(QICore-Medication)What medication was taken
Binding: Medication Clinical Drug (RxNorm) (preferred)
... effective[x] SΣ0..1dateTime, PeriodThe date/time or interval when the medication was taken
... dateAsserted SΣ1..1dateTimeWhen the statement was asserted?
... informationSource S0..1Reference(QICore-Patient), Reference(QICore-Practitioner), Reference(QICore-RelatedPerson)Person or organization that provided the information about the taking of this medication
... subject SΣ1..1Reference(QICore-Patient), Reference(Group)Who is/was taking the medication
... derivedFrom S0..*Reference(Resource)Additional supporting information
... taken ?!SΣ1..1codey | n | unk | na
Binding: MedicationStatementTaken (required)
... reasonNotTaken I0..*CodeableConceptTrue if asserting medication was not given
Binding: SNOMED CT Drugs not taken/completed Codes (example)
... reasonCode 0..*CodeableConceptReason for why the medication is being/was taken
Binding: Condition/Problem/Diagnosis Codes (example)
... reasonReference 0..*Reference(Condition), Reference(Observation)Condition or observation that supports why the medication is being/was taken
... note 0..*AnnotationFurther information about the statement
... dosage 0..*DosageDetails of how medication is/was taken or should be taken
.... id 0..1stringxml:id (or equivalent in JSON)
.... sequence Σ0..1integerThe order of the dosage instructions
.... text Σ0..1stringFree text dosage instructions e.g. SIG
.... additionalInstruction Σ0..*CodeableConceptSupplemental instruction - e.g. "with meals"
Binding: SNOMED CT Additional Dosage Instructions (example)
.... patientInstruction Σ0..1stringPatient or consumer oriented instructions
.... timing SΣ0..1TimingWhen medication should be administered
.... asNeeded[x] Σ0..1boolean, CodeableConceptTake "as needed" (for x)
Binding: SNOMED CT Medication As Needed Reason Codes (example)
.... site Σ0..1CodeableConceptBody site to administer to
Binding: SNOMED CT Anatomical Structure for Administration Site Codes (example)
.... route SΣ0..1CodeableConceptHow drug should enter body
Binding: SNOMED CT Route Codes (example)
.... method Σ0..1CodeableConceptTechnique for administering medication
Binding: SNOMED CT Administration Method Codes (example)
.... dose[x] SΣ0..1Range, SimpleQuantityAmount of medication per dose
.... maxDosePerPeriod Σ0..1RatioUpper limit on medication per unit of time
.... maxDosePerAdministration Σ0..1SimpleQuantityUpper limit on medication per administration
.... maxDosePerLifetime Σ0..1SimpleQuantityUpper limit on medication per lifetime of the patient
.... rate[x] Σ0..1Ratio, Range, SimpleQuantityAmount of medication per unit of time

doco Documentation for this format

 

D.4.1.2 Terminology Bindings

Terminology Bindings

PathNameConformanceValueSet
MedicationStatement.languageCommon LanguagesextensibleCommon Languages
MedicationStatement.statusMedicationStatementStatusrequiredMedicationStatementStatus
MedicationStatement.categoryMedicationStatementCategorypreferredMedicationStatementCategory
MedicationStatement.medication[x]Medication Clinical Drug (RxNorm)preferredMedication Clinical Drug (RxNorm)
MedicationStatement.takenMedicationStatementTakenrequiredMedicationStatementTaken
MedicationStatement.reasonNotTakenSNOMED CT Drugs not taken/completed CodesexampleSNOMED CT Drugs not taken/completed Codes
MedicationStatement.reasonCodeCondition/Problem/Diagnosis CodesexampleCondition/Problem/Diagnosis Codes
MedicationStatement.dosage.additionalInstructionSNOMED CT Additional Dosage InstructionsexampleSNOMED CT Additional Dosage Instructions
MedicationStatement.dosage.asNeeded[x]SNOMED CT Medication As Needed Reason CodesexampleSNOMED CT Medication As Needed Reason Codes
MedicationStatement.dosage.siteSNOMED CT Anatomical Structure for Administration Site CodesexampleSNOMED CT Anatomical Structure for Administration Site Codes
MedicationStatement.dosage.routeSNOMED CT Route CodesexampleSNOMED CT Route Codes
MedicationStatement.dosage.methodSNOMED CT Administration Method CodesexampleSNOMED CT Administration Method Codes

D.4.1.3 Constraints

Constraints

IdPathDetailsRequirements
dom-2MedicationStatementIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-1MedicationStatementIf the resource is contained in another resource, it SHALL NOT contain any narrative
: contained.text.empty()
dom-4MedicationStatementIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-3MedicationStatementIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
: contained.where(('#'+id in %resource.descendants().reference).not()).empty()
mst-1MedicationStatementReason not taken is only permitted if Taken is No
: reasonNotTaken.exists().not() or (taken = 'n')