QI-Core Implementation Guide: STU 3.2 (v3.2.0 for FHIR 3.0.1)

This page is part of the Quality Improvement Core Framework (v3.2.0: STU 3) 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

Profile of MedicationStatement for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

This profile builds on US Core Medication Statement Profile.

This profile was published on Wed Aug 22 00:00:00 AEST 2018 as a draft by Health Level Seven, Inc. - CQI WG.

Description of Profiles, Differentials, and Snapshots.

Summary

Mandatory: 1 element
Must-Support: 11 elements

Structures

This structure refers to these other structures:

NameFlagsCard.TypeDescription & Constraintsdoco
.. MedicationStatement I0..*US Core Medication Statement Profile
... 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)
Max Binding: All Languages
... 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 | CarePlan | ProcedureRequest | ReferralRequest)Fulfils plan, proposal or order
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Observation)Part of referenced event
... context Σ0..1Reference(Encounter | 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 | QICore-Practitioner | QICore-RelatedPerson)Person or organization that provided the information about the taking of this medication
... subject SΣ1..1Reference(QICore-Patient)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 | 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)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... 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

Summary

Mandatory: 1 element
Must-Support: 11 elements

Structures

This structure refers to these other structures:

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. MedicationStatement I0..*US Core Medication Statement Profile
... 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)
Max Binding: All Languages
... 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 | CarePlan | ProcedureRequest | ReferralRequest)Fulfils plan, proposal or order
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Observation)Part of referenced event
... context Σ0..1Reference(Encounter | 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 | QICore-Practitioner | QICore-RelatedPerson)Person or organization that provided the information about the taking of this medication
... subject SΣ1..1Reference(QICore-Patient)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 | 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)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... 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

PathConformanceValueSet
MedicationStatement.statusrequiredMedicationStatementStatus
MedicationStatement.medication[x]preferredMedication Clinical Drug (RxNorm)
MedicationStatement.takenrequiredMedicationStatementTaken
MedicationStatement.dosage.routeexampleSNOMED CT Route 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')