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Responsible Owner: Pharmacy icon Work Group Maturity Level : 3   Trial Use Security Category : Patient Compartments : Encounter , Group , Patient , Practitioner , RelatedPerson

Detailed Descriptions for the elements in the MedicationStatement resource.

SNOMED CT Drug Therapy Status codes ( Example )
Element Id 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 sources such as 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 medicationstatement and a medication administration medicationadministration 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 medicationstatement 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 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.

Short Display Record of medication being taken by a patient
Cardinality 0..*
Type DomainResource
Alternate Names Comments MedicationStatement
When interpreting a medicationStatement, the value of the status and NotTaken needed to be considered: MedicationStatement.status + MedicationStatement.wasNotTaken Status=Active + NotTaken=T = Not currently taking Status=Completed + NotTaken=T = Not taken in the past Status=Intended + NotTaken=T = No intention of taking Status=Active + NotTaken=F = Taking, but not as prescribed Status=Active + NotTaken=F = Taking Status=Intended +NotTaken= F = Will be taking (not started) Status=Completed + NotTaken=F = Taken in past Status=In Error + NotTaken=N/A = In Error. Summary false
Element Id MedicationStatement.identifier
Definition

Identifiers associated with this Medication Statement that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate. They are business identifiers assigned to this resource by the performer or other systems and remain constant as the resource is updated and propagates from server to server.

Note Short Display External identifier
Note This is a business identifier, not a resource identifier (see discussion )
Cardinality 0..*
Type Identifier
Summary true
Comments

This is a business identifier, not a resource identifier.

Element Id MedicationStatement.partOf
Definition

A larger event of which this particular event MedicationStatement is a component or step.

Short Display Part of referenced event
Cardinality 0..*
Type Reference ( MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Observation MedicationStatement )
Requirements Hierarchy This should not be used when indicating which resource a MedicationStatement has been derived from. If that reference is the use case, then MedicationStatement.derivedFrom should be used. part of a strict Hierarchy
Summary true false
Element Id MedicationStatement.status
Definition

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

Short Display recorded | entered-in-error | draft
Cardinality 1..1
Terminology Binding Medication status codes MedicationStatement Status Codes ( Required )
Type code
Is Modifier true (Reason: This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
Summary true
Comments

MedicationStatement is a statement at a point in time. The status is only representative at the point when it was asserted. The value set for MedicationStatement.status contains codes that assert the This status of concerns just the use recording of the medication by the patient (for example, stopped or on hold) as well as codes that assert statement. MedicationStatement.adherence should be used for indicating a patient's adherence to the status of information in this resource. Note, the medication statement itself (for example, entered statuses are different than in error). previous releases for MedicationStatement or MedicationStatement.

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Type Element Id CodeableConcept MedicationStatement.category
Comments Definition

This is generally only used for "exception" statuses such as "not-taken", "on-hold", "cancelled" or "entered-in-error". The reason for performing the event at all is captured in reasonCode, not here. Type of medication statement.

MedicationStatement.category Element Id

The committee will revisit these codes, expecting to use a codesystem from terminology.hl7.org icon MedicationStatement.category .

Definition Short Display Indicates where the Type of medication is expected to be consumed or administered. statement
Cardinality 0..1 0..*
Terminology Binding Medication usage category codes MedicationRequest Category Codes ( Preferred Example )
Type CodeableConcept
Summary true
Element Id MedicationStatement.medication[x] 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.

Short Display What medication was taken
Cardinality 1..1
Terminology Binding SNOMED CT Medication Codes ( Example )
Type CodeableConcept | Reference CodeableReference ( Medication )
[x] Note See Choice of Data Types for further information about how to use [x] Summary true
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. For example, if you require form or lot number, then you must reference the Medication resource.

Element Id MedicationStatement.subject
Definition

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

Short Display Who is/was taking the medication
Cardinality 1..1
Type Reference ( Patient | Group )
Summary true
Element Id MedicationStatement.context MedicationStatement.encounter
Definition

The encounter or episode of care that establishes the context for this MedicationStatement.

Short Display Encounter associated with MedicationStatement
Cardinality 0..1
Type Reference ( Encounter | EpisodeOfCare )
Summary true
Element Id MedicationStatement.effective[x]
Definition

The interval of time during which it is being asserted that the patient is/was/will be taking the medication (or was not taking, when the MedicationStatement.taken MedicationStatement.adherence element is No). Not Taking).

Short Display The date/time or interval when the medication is/was/will be taken
Cardinality 0..1
Type dateTime | Period | Timing
[x] Note See Choice of Data Types Datatypes for further information about how to use [x]
Summary true
Comments

This attribute reflects the period over which the patient consumed the medication and is expected to be populated on the majority of Medication Statements. If the medication is still being taken and is expected to continue indefinitely at the time the statement usage is recorded, the "end" date will be omitted. If the end date is known, then it is included as the "end date". The date/time attribute supports a variety of dates - year, year/month and exact date. If something more than this is required, this should be conveyed as text.

Element Id MedicationStatement.dateAsserted
Definition

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

Short Display When the usage was asserted?
Cardinality 0..1
Type dateTime
Summary true
Element Id MedicationStatement.author
Definition

The individual, organization, or device that created the statement and has responsibility for its content.

Short Display Who/What authored the statement
Cardinality 0..1
Type Reference ( Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device )
Summary true
Element Id MedicationStatement.informationSource
Definition

The person or organization that provided the information about the taking of this medication. Note: Use derivedFrom when a MedicationStatement is derived from other resources, e.g. Claim or MedicationRequest.

Short Display Person or organization that provided the information about the taking of this medication
Cardinality 0..1 0..*
Type Reference ( Device | Patient | Practitioner | PractitionerRole | RelatedPerson | Organization | Group )
Summary false
Element Id MedicationStatement.derivedFrom
Definition

Allows linking the MedicationStatement to the underlying MedicationRequest, or to other information that supports or is used to derive the MedicationStatement.

Short Display Link to information used to derive the MedicationStatement
Cardinality 0..*
Type Reference ( Any )
Comments Summary false
Comments

Likely references would be to MedicationRequest, MedicationDispense, Claim, Observation or QuestionnaireAnswers. The most common use cases for deriving a MedicationStatement comes from creating a MedicationStatement from a MedicationRequest or from a lab observation or a claim. it should be noted that the amount of information that is available varies from the type resource that you derive the MedicationStatement from.

Element Id MedicationStatement.reasonCode MedicationStatement.reason
Definition

A reason for concept, Condition or observation that supports why the medication is being/was taken.

Short Display Reason for why the medication is being/was taken
Cardinality 0..*
Terminology Binding Condition/Problem/Diagnosis Codes ( Example )
Type CodeableReference ( Condition | Observation | DiagnosticReport | Procedure )
CodeableConcept Summary false
Comments

This could be a diagnosis code. If a full condition record exists or additional detail is needed, use reasonForUseReference.

Element Id MedicationStatement.reasonReference MedicationStatement.note
Definition

Condition or observation that supports why Provides extra information about the medication Medication Statement that is being/was taken. not conveyed by the other attributes.

Short Display Further information about the usage
Cardinality 0..*
Type Reference Annotation ( Condition
Summary | Observation false
Comments Element Id MedicationStatement.relatedClinicalInformation
Definition

This is a reference Link to a condition information that is the reason why the medication is being/was taken. If only relevant to a code exists, use reasonForUseCode. medication statement, for example, illicit drug use, gestational age, etc.

Short Display Link to information relevant to the usage of a medication
Cardinality 0..*
Type Reference ( Observation | Condition )
Summary false
Element Id MedicationStatement.note MedicationStatement.renderedDosageInstruction
Definition

Provides extra information about The full representation of the medication statement that is not conveyed by dose of the other attributes. medication included in all dosage instructions. To be used when multiple dosage instructions are included to represent complex dosing such as increasing or tapering doses.

Short Display Full representation of the dosage instructions
Cardinality 0..* 0..1
Type markdown
Requirements Annotation

The content of the renderedDosageInstructions must not be different than the dose represented in the dosageInstruction content.

Summary false
Element Id MedicationStatement.dosage
Definition

Indicates how the medication is/was or should be taken by the patient.

Short Display Details of how medication is/was taken or should be taken
Cardinality 0..*
Type Dosage
Comments Summary false
Comments

The dates included in the dosage on a Medication Statement reflect the dates for a given dose. For example, "from November 1, 2016 to November 3, 2016, take one tablet daily and from November 4, 2016 to November 7, 2016, take two tablets daily." It is expected that this specificity may only be populated where the patient brings in their labeled container or where the Medication Statement is derived from a MedicationRequest.

Element Id MedicationStatement.adherence
Definition

Indicates whether the medication is or is not being consumed or administered.

Short Display Indicates whether the medication is or is not being consumed or administered
Cardinality 0..1
Summary true
Comments

This element can be used to indicate whether a patient is following a course of treatment as instructed/prescribed or whether they are taking medications of their own volition. It can also be used to indicate that a patient is not taking a medication, either because they were told not to or because they decided on their own.

Element Id MedicationStatement.adherence.code
Definition

Type of the adherence for the medication.

Short Display Type of adherence
Cardinality 1..1
Terminology Binding MedicationStatement Adherence Codes ( Example )
Type CodeableConcept
Summary true
Element Id MedicationStatement.adherence.reason
Definition

Captures the reason for the current use or adherence of a medication.

Short Display Details of the reason for the current use of the medication
Cardinality 0..1
Terminology Binding SNOMED CT Drug Therapy Status codes ( Example )
Type CodeableConcept
Summary false
Comments

This is generally only used for "exception" statuses such as "entered-in-error". The reason for performing the event at all is captured in reasonCode, not here.