DSTU2

This page is part of the FHIR Specification (v1.0.2: DSTU 2). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

4.16.6 Resource MedicationStatement - Detailed Descriptions

Detailed Descriptions for the elements in the MedicationStatement resource.

MedicationStatement
Definition

A record of a medication that is being consumed by a patient. A MedicationStatement may indicate that the patient may be taking the medication now, or has taken the medication in the past or will be taking the medication in the future. The source of this information can be the patient, significant other (such as a family member or spouse), or a clinician. A common scenario where this information is captured is during the history taking process during a patient visit or stay. The medication information may come from e.g. the patient's memory, from a prescription bottle, or from a list of medications the patient, clinician or other party maintains

The primary difference between a medication statement and a medication administration is that the medication administration has complete administration information and is based on actual administration information from the person who administered the medication. A medication statement is often, if not always, less specific. There is no required date/time when the medication was administered, in fact we only know that a source has reported the patient is taking this medication, where details such as time, quantity, or rate or even medication product may be incomplete or missing or less precise. As stated earlier, the medication statement information may come from the patient's memory, from a prescription bottle or from a list of medications the patient, clinician or other party maintains. Medication administration is more formal and is not missing detailed information.

Control1..1
Summarytrue
InvariantsDefined on this element
mst-1: Reason not taken is only permitted if wasNotTaken is true (xpath: not(exists(f:reasonNotTaken) and f:wasNotTaken/@value=false()))
mst-2: Reason for use is only permitted if wasNotTaken is false (xpath: not(exists(*[starts-with(local-name(.), 'reasonForUse')]) and f:wasNotTaken/@value=true()))
MedicationStatement.identifier
Definition

External identifier - FHIR will generate its own internal identifiers (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.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Summarytrue
MedicationStatement.patient
Definition

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

Control1..1
TypeReference(Patient)
Summarytrue
MedicationStatement.informationSource
Definition

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

Control0..1
TypeReference(Patient | Practitioner | RelatedPerson)
Summarytrue
MedicationStatement.dateAsserted
Definition

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

Control0..1
TypedateTime
Summarytrue
MedicationStatement.status
Definition

A code representing the patient or other source's judgment about the state of the medication used that this statement is about. Generally this will be active or completed.

Control1..1
BindingMedicationStatementStatus: A set of codes indicating the current status of a MedicationStatement. (Required)
Typecode
Is Modifiertrue
Summarytrue
MedicationStatement.wasNotTaken
Definition

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

Control0..1
Typeboolean
Is Modifiertrue
Meaning if MissingIf this is missing, then the medication was taken
Summarytrue
MedicationStatement.reasonNotTaken
Definition

A code indicating why the medication was not taken.

Control0..*
BindingReason Medication Not Given Codes: A set of codes indicating the reason why the MedicationAdministration is negated. (Example)
TypeCodeableConcept
Summarytrue
InvariantsAffect this element
mst-1: Reason not taken is only permitted if wasNotTaken is true (xpath: not(exists(f:reasonNotTaken) and f:wasNotTaken/@value=false()))
To DoIs this in the 80% for medication statement?
MedicationStatement.reasonForUse[x]
Definition

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

Control0..1
BindingCondition/Problem/Diagnosis Codes: Codes identifying why the medication is being taken. (Example)
TypeCodeableConcept|Reference(Condition)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
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 element is true).

Control0..1
TypedateTime|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
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
Summarytrue
MedicationStatement.supportingInformation
Definition

Allows linking the MedicationStatement to the underlying MedicationOrder, or to other information that supports the MedicationStatement.

Control0..*
TypeReference(Any)
Summarytrue
Comments

Likely references would be to MedicationOrder, MedicationDispense, Claim, Observation or QuestionnaireAnswers.

MedicationStatement.medication[x]
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.

Control1..1
TypeCodeableConcept|Reference(Medication)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Comments

If only a code is specified, then it needs to be a code for a specific product. If more information is required, then the use of the medication resource is recommended. 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..*
Summarytrue
MedicationStatement.dosage.text
Definition

Free text dosage information as reported about a patient's medication use. When coded dosage information is present, the free text may still be present for display to humans.

Control0..1
Typestring
Summarytrue
MedicationStatement.dosage.timing
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
Summarytrue
MedicationStatement.dosage.asNeeded[x]
Definition

Indicates whether the Medication is only taken when needed within a specific dosing schedule (Boolean option), or it indicates the precondition for taking the Medication (CodeableConcept).

Specifically if 'boolean' datatype is selected, then the following logic applies: If set to True, this indicates that the medication is only taken when needed, within the specified schedule.

Control0..1
BindingMedicationAsNeededReason: A coded concept identifying the precondition that should be met or evaluated prior to consuming or administering a medication dose. For example "pain", "30 minutes prior to sexual intercourse", "on flare-up" etc.
Typeboolean|CodeableConcept
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
MedicationStatement.dosage.site[x]
Definition

A coded specification of or a reference to the anatomic site where the medication first enters the body.

Control0..1
BindingSNOMED CT Anatomical Structure for Administration Site Codes: A coded concept describing the site location the medicine enters into or onto the body. (Example)
TypeCodeableConcept|Reference(BodySite)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
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
BindingSNOMED CT Route Codes: A coded concept describing the route or physiological path of administration of a therapeutic agent into or onto the body of a subject. (Example)
TypeCodeableConcept
Summarytrue
MedicationStatement.dosage.method
Definition

A coded value indicating the method by which the medication is intended to be or was introduced into or on the body. This attribute will most often NOT be populated. It is most commonly used for injections. For example, Slow Push, Deep IV.

Control0..1
BindingMedicationAdministrationMethod: A coded concept describing the technique by which the medicine is administered.
TypeCodeableConcept
Summarytrue
Comments

One of the reasons this attribute is not used often, is that the method is often pre-coordinated with the route and/or form of administration. This means the codes used in route or form may pre-coordinate the method in the route code or the form code. The implementation decision about what coding system to use for route or form code will determine how frequently the method code will be populated e.g. if route or form code pre-coordinate method code, then this attribute will not be populated often; if there is no pre-coordination then method code may be used frequently.

MedicationStatement.dosage.quantity[x]
Definition

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

Control0..1
TypeSimpleQuantity|Range
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
MedicationStatement.dosage.rate[x]
Definition

Identifies the speed with which the medication was or will be introduced into the patient. Typically the rate for an infusion e.g. 100 ml per 1 hour or 100 ml/hr. May also be expressed as a rate per unit of time e.g. 500 ml per 2 hours. Currently we do not specify a default of '1' in the denominator, but this is being discussed. Other examples: 200 mcg/min or 200 mcg/1 minute; 1 liter/8 hours.

Control0..1
TypeRatio|Range
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
MedicationStatement.dosage.maxDosePerPeriod
Definition

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

Control0..1
TypeRatio
Summarytrue
To DoIs this in the 80% for medication statement?