International Patient Summary Implementation Guide (Release 0.3.0 STU1 Ballot)

This page is part of the International Patient Summary Implementation Guide (v0.3.0: STU 1 (FHIR R4) Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions

SD.11 StructureDefinition-MedicationStatement-uv-ips

Note for balloters

There is an on-going discussion about what should be the most appropriate way to convey medication information within the IPS MedicationStatement.

  • In the previously balloted versions the medicationCodeableConcept was used only to provide information about the known absent/unknown medications; using the medicationReference to describe the actual medication.
  • To better support local implementations of patient summaries and align with the US Core appoach, both options (medicationCodeableConcept and medicationReference) have been made possible in this ballot version. We encourage, however, "to improve global interoperability (...) that the reference to a Medication resource is used, limiting the usage of the medicationCodeableConcept only to the cases in which no other information than a simple code is available."
  • Nevertheless, there are jurisdictions that impose a requirement that the medicationReference is always used.

Balloters are kindly asked to provide their feedback on this topic.

SD.11.1 Formal Views of Profile Content

Description of Profiles, Differentials, and Snapshots.

The official URL for this profile is: http://hl7.org/fhir/uv/ips/StructureDefinition/MedicationStatement-uv-ips

Published on Wed Feb 14 16:57:06 EST 2018 as a draft by HL7 International.

This profile builds on MedicationStatement

Summary

Mandatory: 2 elements
Must-Support: 17 elements
Fixed Value: 1 element

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. MedicationStatement SI0..*Record of medication being taken by a patient
... id SΣ0..1idLogical id of this artifact
... meta SΣ0..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated Σ0..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... profile SΣ0..*canonical(StructureDefinition)Profiles this resource claims to conform to

Fixed Value: http://hl7.org/fhir/uv/ips/StructureDefinition/MedicationStatement-uv-ips
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible)
.... tag Σ0..*CodingTags applied to this resource
Binding: CommonTags (example)
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text 0..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 | ServiceRequest)Fulfils plan, proposal or order
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Observation)Part of referenced event
... status ?!SΣ1..1codeactive | completed | entered-in-error | intended | stopped | on-hold | unknown | not-taken
Binding: Medication Status Codes (required)
... statusReason 0..*CodeableConceptReason for current status
Binding: SNOMEDCTDrugTherapyStatusCodes (example)
... category Σ0..1CodeableConceptType of medication usage
Binding: Medication Status Codes (preferred)
... medication[x] SΣ1..1What medication was taken
Binding: Absent or Unknown Medication (preferred)
.... medicationCodeableConceptCodeableConcept
.... medicationReferenceReference(StructureDefinition-Medication-uv-ips.html)
... subject SΣ1..1Reference(Patient (IPS))Who is/was taking the medication
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣI1..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... context Σ0..1Reference(Encounter | EpisodeOfCare)Encounter / Episode associated with MedicationStatement
... effective[x] SΣ1..1The date/time or interval when the medication is/was/will be taken
.... (All Types) Content/Rules for all Types
..... id 0..1stringUnique id for inter-element referencing
..... data-absent-reason S0..1codeeffective[x] absence reason
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
Slice: Unordered, Open by value:url
Binding: DataAbsentReason (required)
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... dateAsserted Σ0..1dateTimeWhen the statement was asserted?
... informationSource S0..1Reference(Patient | Practitioner | PractitionerRole | RelatedPerson | Organization)Person or organization that provided the information about the taking of this medication
... derivedFrom 0..*Reference(Resource)Additional supporting information
... reasonCode SI0..*CodeableConceptIPSConcept - reference to a terminology or just text
Binding: Condition/Problem/DiagnosisCodes (example)
... reasonReference S0..*Reference(Condition | Observation | DiagnosticReport)Condition or observation that supports why the medication is being/was taken
... note 0..*AnnotationFurther information about the statement
... dosage S0..*DosageDetails of how medication is/was taken or should be taken
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence Σ0..1integerThe order of the dosage instructions
.... text SΣ0..1stringFree text dosage instructions e.g. SIG
.... additionalInstruction Σ0..*CodeableConceptSupplemental instruction or warnings to the patient - e.g. "with meals", "may cause drowsiness"
Binding: SNOMEDCTAdditionalDosageInstructions (example)
.... patientInstruction Σ0..1stringPatient or consumer oriented instructions
.... timing SΣ0..1TimingWhen medication should be administered
.... asNeeded[x] Σ0..1Take "as needed" (for x)
Binding: SNOMEDCTMedicationAsNeededReasonCodes (example)
..... asNeededBooleanboolean
..... asNeededCodeableConceptCodeableConcept
.... site SI0..1CodeableConceptIPSConcept - reference to a terminology or just text
Binding: IPS Target Site (preferred)
.... route SI0..1CodeableConceptIPSConcept - reference to a terminology or just text
Binding: Medicine Route of Administration (required)
.... method Σ0..1CodeableConceptTechnique for administering medication
Binding: SNOMEDCTAdministrationMethodCodes (example)
.... doseAndRate ΣI0..*ElementAmount of medication administered
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... type Σ0..1CodeableConceptThe kind of dose or rate specified
Binding: DoseAndRateType (example)
..... dose[x] Σ0..1Amount of medication per dose
...... doseRangeRange
...... doseQuantityQuantity
..... rate[x] Σ0..1Amount of medication per unit of time
...... rateRatioRatio
...... rateRangeRange
...... rateQuantityQuantity
.... 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

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron