DSTU2 STU 3 Candidate
This page is part of the FHIR Specification (v1.0.2: DSTU 2). The current version which supercedes this version is

This page is part of the FHIR Specification (v1.4.0: STU 3 Ballot 3). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . For a full list of available versions, see the Directory of published versions . Page versions: . Page versions: R5 R4B R4 R3 R2

4.16 4.27 Resource MedicationStatement - Content Resource MedicationStatement - Content

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.
Pharmacy Pharmacy Work Group Work Group Maturity Level : 1 Maturity Level : 1 Compartments : : Patient , , Practitioner , , RelatedPerson

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.

4.16.1 Scope and Usage 4.27.1 Scope and Usage Common usage includes: the recording of non-prescription and/or recreational drugs the recording of an intake medication list upon admission to hospital the summarization of a patient's "active medications" in a patient profile This resource does not produce a medication list, but it does produce individual medication statements that may be used in the List resource to construct various types of medication lists. Note that other medication lists can also be constructed from the other Pharmacy resources (e.g., MedicationOrder, MedicationAdministration).

Common usage includes:

  • the recording of non-prescription and/or recreational drugs
  • the recording of an intake medication list upon admission to hospital
  • the summarization of a patient's "active medications" in a patient profile

This resource does not produce a medication list, but it does produce individual medication statements that may be used in the List resource to construct various types of medication lists. Note that other medication lists can also be constructed from the other Pharmacy resources (e.g., MedicationOrder, MedicationAdministration).

A medication statement is not a part of the prescribe -> dispense -> administer sequence, but is a report by a patient, significant other or a clinician that one or more of the prescribe, dispense or administer actions has occurred, resulting is a belief that the patient is, has, or will be using a particular medication.

A medication statement is not a part of the prescribe -> dispense -> administer sequence, but is a report by a patient, significant other or a clinician that one or more of the prescribe, dispense or administer actions has occurred, resulting is a belief that the patient is, has, or will be using a particular medication.

4.16.2 Boundaries and Relationships 4.27.2 Boundaries and Relationships The Medication domain includes a number of related resources

The Medication domain includes a number of related resources

MedicationOrder An order for both supply of the medication and the instructions for administration of the medicine to a patient. An order for both supply of the medication and the instructions for administration of the medicine to a patient.
MedicationDispense Provision of a supply of a medication with the intention that it is subsequently consumed by a patient (usually in response to a prescription). Provision of a supply of a medication with the intention that it is subsequently consumed by a patient (usually in response to a prescription).
MedicationAdministration When a patient actually consumes a medicine, or it is otherwise administered to them When a patient actually consumes a medicine, or it is otherwise administered to them
MedicationStatement This is a record of a medication being taken by a patient or that a medication has been given to a patient, where the record is the result of a report from the patient or another clinician. A medication statement is not a part of the prescribe->dispense->administer sequence, but is a report that such a sequence (or at least a part of it) did take place, resulting in a belief that the patient has received a particular medication. This resource is distinct from This is a record of a medication being taken by a patient or that a medication has been given to a patient, where the record is the result of a report from the patient or another clinician. A medication statement is not a part of the prescribe->dispense->administer sequence, but is a report that such a sequence (or at least a part of it) did take place, resulting in a belief that the patient has received a particular medication.

This resource is distinct from MedicationOrder , , MedicationDispense and and MedicationAdministration . Each of those resources refer to specific events - an individual order, an individual provisioning of medication or an individual dosing. MedicationStatement is a broader assertion covering a wider timespan and is independent of specific events. The existence of resource instances of any of the preceding three types may be used to infer a medication statement. However, medication statements can also be captured on the basis of other information, including an assertion by the patient or a care-giver, the results of a lab test, etc. This resource is referenced by . Each of those resources refer to specific events - an individual order, an individual provisioning of medication or an individual dosing. MedicationStatement is a broader assertion covering a wider timespan and is independent of specific events. The existence of resource instances of any of the preceding three types may be used to infer a medication statement. However, medication statements can also be captured on the basis of other information, including an assertion by the patient or a care-giver, the results of a lab test, etc.

This resource is referenced by goal

4.16.3 Resource Content 4.27.3 Resource Content

Structure

dateTime 1..1 active | completed | entered-in-error | intended MedicationStatementStatus ( Required ) ?! Σ True if medication is/was not being taken dateTime Period
Name Flags Card. Type Description & Constraints Description & Constraints doco
. . MedicationStatement Σ Σ I DomainResource Record of medication being taken by a patient Record of medication being taken by a patient
Reason for use is only permitted if wasNotTaken is false Reason for use is only permitted if wasNotTaken is false
Reason not taken is only permitted if wasNotTaken is true Reason not taken is only permitted if wasNotTaken is true
. . . identifier Σ 0..* Identifier External identifier External identifier
. . patient . status ?! Σ 1..1 Reference ( Patient ) Who is/was taking the medication informationSource code active | completed | entered-in-error | intended
Σ 0..1 Reference ( Patient | Practitioner | RelatedPerson MedicationStatementStatus ( Required )
. . dateAsserted . medication[x] Σ 0..1 1..1 When the statement was asserted? What medication was taken
. status . ?! . Σ . medicationCodeableConcept code CodeableConcept
. wasNotTaken . . . medicationReference 0..1 boolean Reference ( Medication )
. . reasonNotTaken . patient Σ I 0..* CodeableConcept 1..1 True if asserting medication was not given Reason Medication Not Given Codes Reference ( Example Patient ) Who is/was taking the medication
. . reasonForUse[x] . effective[x] Σ 0..1 Condition/Problem/Diagnosis Codes ( Example ) Over what period was medication consumed?
. . . reasonForUseCodeableConcept . effectiveDateTime CodeableConcept dateTime
. . . reasonForUseReference . effectivePeriod Reference ( Condition Period )
. . effective[x] . informationSource Σ 0..1 Reference ( Patient | Practitioner | RelatedPerson ) Over what period was medication consumed? Person who provided the information about the taking of this medication
. . effectiveDateTime . supportingInformation Σ 0..* Reference ( Any ) Additional supporting information
. . . dateAsserted effectivePeriod Σ 0..1 dateTime When the statement was asserted?
. . note . wasNotTaken ?! Σ 0..1 string boolean Further information about the statement True if medication is/was not being taken
. . supportingInformation . reasonNotTaken Σ Σ I 0..* Reference ( Any CodeableConcept ) Additional supporting information True if asserting medication was not given
Reason Medication Not Given Codes ( Example )
. . medication[x] . reasonForUse[x] Σ 1..1 0..1 What medication was taken
Condition/Problem/Diagnosis Codes ( Example )
. . . medicationCodeableConcept . reasonForUseCodeableConcept CodeableConcept
. . . medicationReference . reasonForUseReference Reference ( Medication Condition )
. . . note Σ 0..* Annotation Further information about the statement
. . . dosage Σ 0..* BackboneElement Details of how medication was taken Details of how medication was taken
. . . . text Σ 0..1 string Reported dosage information Free text dosage instructions as reported by the information source
. . . . timing Σ 0..1 Timing When/how often was medication taken When/how often was medication taken
. . . . asNeeded[x] Σ 0..1 Take "as needed" (for x) Take "as needed" (for x)
. . . . . asNeededBoolean boolean
. . . . . asNeededCodeableConcept CodeableConcept
. . . . site[x] Σ 0..1 Where (on body) medication is/was administered Where (on body) medication is/was administered
SNOMED CT Anatomical Structure for Administration Site Codes ( SNOMED CT Anatomical Structure for Administration Site Codes ( Example )
. . . . . siteCodeableConcept CodeableConcept
. . . . siteReference . siteReference Reference ( BodySite )
. . . . route Σ 0..1 CodeableConcept How the medication entered the body How the medication entered the body
SNOMED CT Route Codes ( SNOMED CT Route Codes ( Example )
. . . . method Σ 0..1 CodeableConcept Technique used to administer medication Technique used to administer medication
. . . . quantity[x] Σ 0..1 Amount administered in one dose Amount administered in one dose
. . . . quantityQuantity . quantityQuantity SimpleQuantity
. . . . . quantityRange Range
. . . . rate[x] Σ 0..1 Dose quantity per unit of time Dose quantity per unit of time
. . . . . rateRatio Ratio
. . . . . rateRange Range
. . . . maxDosePerPeriod Σ 0..1 Ratio Maximum dose that was consumed per unit of time Maximum dose that was consumed per unit of time

Documentation for this format doco Documentation for this format

UML Diagram UML Diagram

MedicationStatement ( ( DomainResource ) 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 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 identifier : : Identifier [0..*] [0..*] The person or animal who is/was taking the medication 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 (this element modifies the meaning of other elements) patient status : code [1..1] « A set of codes indicating the current status of a MedicationStatement. (Strength=Required) MedicationStatementStatus ! » 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 medication[x] : Type [1..1] « CodeableConcept : | Reference [1..1] « ( Medication ) » The person or animal who is/was taking the medication patient : Reference [1..1] « Patient » 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) effective[x] : Type [0..1] « dateTime » | Period » The person who provided the information about the taking of this medication The person who provided the information about the taking of this medication. Note: A MedicationStatement may be derived from supportingInformation e.g claims or medicationOrder informationSource : : Reference [0..1] « [0..1] « Patient | Practitioner | RelatedPerson » » The date when the medication statement was asserted by the information source Allows linking the MedicationStatement to the underlying MedicationOrder, or to other information that supports or is used to derive the MedicationStatement dateAsserted : dateTime [0..1] supportingInformation : Reference [0..*] « Any » 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 (this element modifies the meaning of other elements) status : code [1..1] « A set of codes indicating the current status of a MedicationStatement. (Strength=Required) The date when the medication statement was asserted by the information source MedicationStatementStatus ! » dateAsserted : dateTime [0..1] Set this to true if the record is saying that the medication was NOT taken (this element modifies the meaning of other elements) Set this to true if the record is saying that the medication was NOT taken (this element modifies the meaning of other elements) wasNotTaken : : boolean [0..1] [0..1] A code indicating why the medication was not taken A code indicating why the medication was not taken reasonNotTaken : : CodeableConcept [0..*] « [0..*] « A set of codes indicating the reason why the MedicationAdministration is negated. (Strength=Example) A set of codes indicating the reason why the MedicationAdministration is negated. (Strength=Example) Reason Medication Not Reason Medication Not Given ?? » Given ?? » A reason for why the medication is being/was taken A reason for why the medication is being/was taken reasonForUse[x] : : Type [0..1] « [0..1] « CodeableConcept | Reference ( Condition ); ); Codes identifying why the medication is being taken. (Strength=Example) Codes identifying why the medication is being taken. (Strength=Example) Condition/Problem/Diagnosis ?? » 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) effective[x] : Type [0..1] « dateTime | Period » Condition/Problem/Diagnosis ?? » Provides extra information about the medication statement that is not conveyed by the other attributes Provides extra information about the medication statement that is not conveyed by the other attributes note : string [0..1] Allows linking the MedicationStatement to the underlying MedicationOrder, or to other information that supports the MedicationStatement supportingInformation : Reference [0..*] « Any » 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 medication[x] : Type [1..1] « CodeableConcept | Reference ( Medication ) » : Annotation [0..*] Dosage 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 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 text : : string [0..1] [0..1] 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" 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" timing : : Timing [0..1] [0..1] 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 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 asNeeded[x] : : Type [0..1] « [0..1] « boolean | CodeableConcept » » A coded specification of or a reference to the anatomic site where the medication first enters the body A coded specification of or a reference to the anatomic site where the medication first enters the body site[x] : : Type [0..1] « [0..1] « CodeableConcept | Reference ( BodySite ); ); A coded concept describing the site location the medicine enters into or onto the body. (Strength=Example) A coded concept describing the site location the medicine enters into or onto the body. (Strength=Example) SNOMED CT Anatomical Structur... CT Anatomical Structur... ?? » ?? » A code specifying the route or physiological path of administration of a therapeutic agent into or onto a subject A code specifying the route or physiological path of administration of a therapeutic agent into or onto a subject route : : CodeableConcept [0..1] « [0..1] « A coded concept describing the route or physiological path of administration of a therapeutic agent into or onto the body of a subject. (Strength=Example) A coded concept describing the route or physiological path of administration of a therapeutic agent into or onto the body of a subject. (Strength=Example) SNOMED CT Route ?? » SNOMED CT Route ?? » 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 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 method : : CodeableConcept [0..1] [0..1] The amount of therapeutic or other substance given at one administration event The amount of therapeutic or other substance given at one administration event quantity[x] : : Type [0..1] « [0..1] « Quantity ( SimpleQuantity )| Range » » 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 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 rate[x] : : Type [0..1] « [0..1] « Ratio | Range » » 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 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 maxDosePerPeriod : : Ratio [0..1] [0..1] Indicates how the medication is/was used by the patient Indicates how the medication is/was used by the patient dosage [0..*]

XML Template XML Template 

<MedicationStatement xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier External identifier --></identifier>
 <status value="[code]"/><!-- 1..1 active | completed | entered-in-error | intended -->
 <medication[x]><!-- 1..1 CodeableConcept|Reference(Medication) What medication was taken --></medication[x]>

 <patient><!-- 1..1 Reference(Patient) Who is/was taking  the medication --></patient>
 <</informationSource>

 <effective[x]><!-- 0..1 dateTime|Period Over what period was medication consumed? --></effective[x]>
 <informationSource><!-- 0..1 Reference(Patient|Practitioner|RelatedPerson) Person who provided the information about the taking of this medication --></informationSource>
 <supportingInformation><!-- 0..* Reference(Any) Additional supporting information --></supportingInformation>

 <dateAsserted value="[dateTime]"/><!-- 0..1 When the statement was asserted? -->
 <

 <wasNotTaken value="[boolean]"/><!-- 0..1 True if medication is/was not being taken -->
 <reasonNotTaken><!-- ?? 0..* CodeableConcept True if asserting medication was not given --></reasonNotTaken>
 <reasonForUse[x]><!-- 0..1 CodeableConcept|Reference(Condition)  --></reasonForUse[x]>
 <</effective[x]>
 <
 <</supportingInformation>
 <</medication[x]>

 <note><!-- 0..* Annotation Further information about the statement --></note>

 <dosage>  <!-- 0..* Details of how medication was taken -->
  <

  <text value="[string]"/><!-- 0..1 Free text dosage instructions as reported by the information source -->

  <timing><!-- 0..1 Timing When/how often was medication taken --></timing>
  <asNeeded[x]><!-- 0..1 boolean|CodeableConcept Take "as needed" (for x) --></asNeeded[x]>
  <site[x]><!-- 0..1 CodeableConcept|Reference(BodySite) Where (on body) medication is/was administered --></site[x]>
  <route><!-- 0..1 CodeableConcept How the medication entered the body --></route>
  <method><!-- 0..1 CodeableConcept Technique used to administer medication --></method>
  <quantity[x]><!-- 0..1 Quantity(SimpleQuantity)|Range Amount administered in one dose --></quantity[x]>
  <rate[x]><!-- 0..1 Ratio|Range Dose quantity per unit of time --></rate[x]>
  <maxDosePerPeriod><!-- 0..1 Ratio Maximum dose that was consumed per unit of time --></maxDosePerPeriod>
 </dosage>
</MedicationStatement>

JSON Template JSON Template 

{doco
  "resourceType" : "MedicationStatement",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // External identifier
  "status" : "<code>", // R!  active | completed | entered-in-error | intended
  // medication[x]: What medication was taken. One of these 2:

  "medicationCodeableConcept" : { CodeableConcept },
  "medicationReference" : { Reference(Medication) },

  "patient" : { Reference(Patient) }, // R!  Who is/was taking  the medication
  "

  // effective[x]: Over what period was medication consumed?. One of these 2:
  "effectiveDateTime" : "<dateTime>",
  "effectivePeriod" : { Period },
  "informationSource" : { Reference(Patient|Practitioner|RelatedPerson) }, // Person who provided the information about the taking of this medication
  "supportingInformation" : [{ Reference(Any) }], // Additional supporting information

  "dateAsserted" : "<dateTime>", // When the statement was asserted?
  "

  "wasNotTaken" : <boolean>, // True if medication is/was not being taken
  "reasonNotTaken" : [{ CodeableConcept }], // C? True if asserting medication was not given
  // reasonForUse[x]: . One of these 2:
  "reasonForUseCodeableConcept" : { CodeableConcept },
  "reasonForUseReference" : { Reference(Condition) },
  
  ">",
  " },
  "
  "
  
  " },
  " },

  "note" : [{ Annotation }], // Further information about the statement

  "dosage" : [{ // Details of how medication was taken
    "

    "text" : "<string>", // Free text dosage instructions as reported by the information source

    "timing" : { Timing }, // When/how often was medication taken
    // asNeeded[x]: Take "as needed" (for x). One of these 2:
    "asNeededBoolean" : <boolean>,
    "asNeededCodeableConcept" : { CodeableConcept },
    // site[x]: Where (on body) medication is/was administered. One of these 2:
    "siteCodeableConcept" : { CodeableConcept },
    "siteReference" : { Reference(BodySite) },
    "route" : { CodeableConcept }, // How the medication entered the body
    "method" : { CodeableConcept }, // Technique used to administer medication
    // quantity[x]: Amount administered in one dose. One of these 2:
    "quantityQuantity" : { Quantity(SimpleQuantity) },
    "quantityRange" : { Range },
    // rate[x]: Dose quantity per unit of time. One of these 2:
    "rateRatio" : { Ratio },
    "rateRange" : { Range },
    "maxDosePerPeriod" : { Ratio } // Maximum dose that was consumed per unit of time
  }]
}

Structure

dateTime 1..1 active | completed | entered-in-error | intended MedicationStatementStatus ( Required ) ?! Σ True if medication is/was not being taken Period
Name Flags Card. Type Description & Constraints Description & Constraints doco
. . MedicationStatement Σ Σ I DomainResource Record of medication being taken by a patient Record of medication being taken by a patient
Reason for use is only permitted if wasNotTaken is false Reason for use is only permitted if wasNotTaken is false
Reason not taken is only permitted if wasNotTaken is true Reason not taken is only permitted if wasNotTaken is true
. . . identifier Σ 0..* Identifier External identifier External identifier
. . patient . status ?! Σ 1..1 Reference ( Patient ) Who is/was taking the medication informationSource code active | completed | entered-in-error | intended
Σ 0..1 Reference ( Patient | Practitioner | RelatedPerson MedicationStatementStatus ( Required )
. . dateAsserted . medication[x] Σ 0..1 1..1 When the statement was asserted? What medication was taken
. status . ?! . Σ . medicationCodeableConcept code CodeableConcept
. wasNotTaken . . . medicationReference 0..1 boolean Reference ( Medication )
. . reasonNotTaken . patient Σ I 0..* CodeableConcept 1..1 True if asserting medication was not given Reason Medication Not Given Codes Reference ( Example Patient ) Who is/was taking the medication
. . reasonForUse[x] . effective[x] Σ 0..1 Condition/Problem/Diagnosis Codes ( Example ) Over what period was medication consumed?
. . . reasonForUseCodeableConcept . effectiveDateTime CodeableConcept dateTime
. . . reasonForUseReference . effectivePeriod Reference ( Condition Period )
. . effective[x] . informationSource Σ 0..1 Reference ( Patient | Practitioner | RelatedPerson ) Over what period was medication consumed? Person who provided the information about the taking of this medication
. . effectiveDateTime . supportingInformation Σ 0..* dateTime Reference ( Any ) Additional supporting information
. . . dateAsserted effectivePeriod Σ 0..1 dateTime When the statement was asserted?
. . note . wasNotTaken ?! Σ 0..1 string boolean Further information about the statement True if medication is/was not being taken
. . supportingInformation . reasonNotTaken Σ Σ I 0..* Reference ( Any CodeableConcept ) Additional supporting information True if asserting medication was not given
Reason Medication Not Given Codes ( Example )
. . medication[x] . reasonForUse[x] Σ 1..1 0..1 What medication was taken
Condition/Problem/Diagnosis Codes ( Example )
. . . medicationCodeableConcept . reasonForUseCodeableConcept CodeableConcept
. . . medicationReference . reasonForUseReference Reference ( Medication Condition )
. . . note Σ 0..* Annotation Further information about the statement
. . . dosage Σ 0..* BackboneElement Details of how medication was taken Details of how medication was taken
. . . . text Σ 0..1 string Reported dosage information Free text dosage instructions as reported by the information source
. . . . timing Σ 0..1 Timing When/how often was medication taken When/how often was medication taken
. . . . asNeeded[x] Σ 0..1 Take "as needed" (for x) Take "as needed" (for x)
. . . . . asNeededBoolean boolean
. . . . . asNeededCodeableConcept CodeableConcept
. . . . site[x] Σ 0..1 Where (on body) medication is/was administered Where (on body) medication is/was administered
SNOMED CT Anatomical Structure for Administration Site Codes ( SNOMED CT Anatomical Structure for Administration Site Codes ( Example )
. . . . . siteCodeableConcept CodeableConcept
. . . . siteReference . siteReference Reference ( BodySite )
. . . . route Σ 0..1 CodeableConcept How the medication entered the body How the medication entered the body
SNOMED CT Route Codes ( SNOMED CT Route Codes ( Example )
. . . . method Σ 0..1 CodeableConcept Technique used to administer medication Technique used to administer medication
. . . . quantity[x] Σ 0..1 Amount administered in one dose Amount administered in one dose
. . . . quantityQuantity . quantityQuantity SimpleQuantity
. . . . . quantityRange Range
. . . . rate[x] Σ 0..1 Dose quantity per unit of time Dose quantity per unit of time
. . . . . rateRatio Ratio
. . . . . rateRange Range
. . . . maxDosePerPeriod Σ 0..1 Ratio Maximum dose that was consumed per unit of time Maximum dose that was consumed per unit of time

Documentation for this format doco Documentation for this format

UML Diagram UML Diagram

MedicationStatement ( ( DomainResource ) 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 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 identifier : : Identifier [0..*] [0..*] The person or animal who is/was taking the medication 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 (this element modifies the meaning of other elements) patient status : code [1..1] « A set of codes indicating the current status of a MedicationStatement. (Strength=Required) MedicationStatementStatus ! » 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 medication[x] : Type [1..1] « CodeableConcept : | Reference [1..1] « ( Medication ) » The person or animal who is/was taking the medication patient : Reference [1..1] « Patient » 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) effective[x] : Type [0..1] « dateTime » | Period » The person who provided the information about the taking of this medication The person who provided the information about the taking of this medication. Note: A MedicationStatement may be derived from supportingInformation e.g claims or medicationOrder informationSource : : Reference [0..1] « [0..1] « Patient | Practitioner | RelatedPerson » » The date when the medication statement was asserted by the information source Allows linking the MedicationStatement to the underlying MedicationOrder, or to other information that supports or is used to derive the MedicationStatement dateAsserted : dateTime [0..1] supportingInformation : Reference [0..*] « Any » 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 (this element modifies the meaning of other elements) status : code [1..1] « A set of codes indicating the current status of a MedicationStatement. (Strength=Required) The date when the medication statement was asserted by the information source MedicationStatementStatus ! » dateAsserted : dateTime [0..1] Set this to true if the record is saying that the medication was NOT taken (this element modifies the meaning of other elements) Set this to true if the record is saying that the medication was NOT taken (this element modifies the meaning of other elements) wasNotTaken : : boolean [0..1] [0..1] A code indicating why the medication was not taken A code indicating why the medication was not taken reasonNotTaken : : CodeableConcept [0..*] « [0..*] « A set of codes indicating the reason why the MedicationAdministration is negated. (Strength=Example) A set of codes indicating the reason why the MedicationAdministration is negated. (Strength=Example) Reason Medication Not Reason Medication Not Given ?? » Given ?? » A reason for why the medication is being/was taken A reason for why the medication is being/was taken reasonForUse[x] : : Type [0..1] « [0..1] « CodeableConcept | Reference ( Condition ); ); Codes identifying why the medication is being taken. (Strength=Example) Codes identifying why the medication is being taken. (Strength=Example) Condition/Problem/Diagnosis ?? » 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) effective[x] : Type [0..1] « dateTime | Period » Condition/Problem/Diagnosis ?? » Provides extra information about the medication statement that is not conveyed by the other attributes Provides extra information about the medication statement that is not conveyed by the other attributes note : string [0..1] Allows linking the MedicationStatement to the underlying MedicationOrder, or to other information that supports the MedicationStatement supportingInformation : Reference [0..*] « Any » 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 medication[x] : Type [1..1] « CodeableConcept | Reference ( Medication ) » : Annotation [0..*] Dosage 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 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 text : : string [0..1] [0..1] 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" 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" timing : : Timing [0..1] [0..1] 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 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 asNeeded[x] : : Type [0..1] « [0..1] « boolean | CodeableConcept » » A coded specification of or a reference to the anatomic site where the medication first enters the body A coded specification of or a reference to the anatomic site where the medication first enters the body site[x] : : Type [0..1] « [0..1] « CodeableConcept | Reference ( BodySite ); ); A coded concept describing the site location the medicine enters into or onto the body. (Strength=Example) A coded concept describing the site location the medicine enters into or onto the body. (Strength=Example) SNOMED CT Anatomical Structur... CT Anatomical Structur... ?? » ?? » A code specifying the route or physiological path of administration of a therapeutic agent into or onto a subject A code specifying the route or physiological path of administration of a therapeutic agent into or onto a subject route : : CodeableConcept [0..1] « [0..1] « A coded concept describing the route or physiological path of administration of a therapeutic agent into or onto the body of a subject. (Strength=Example) A coded concept describing the route or physiological path of administration of a therapeutic agent into or onto the body of a subject. (Strength=Example) SNOMED CT Route ?? » SNOMED CT Route ?? » 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 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 method : : CodeableConcept [0..1] [0..1] The amount of therapeutic or other substance given at one administration event The amount of therapeutic or other substance given at one administration event quantity[x] : : Type [0..1] « [0..1] « Quantity ( SimpleQuantity )| Range » » 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 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 rate[x] : : Type [0..1] « [0..1] « Ratio | Range » » 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 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 maxDosePerPeriod : : Ratio [0..1] [0..1] Indicates how the medication is/was used by the patient Indicates how the medication is/was used by the patient dosage [0..*]

XML Template XML Template 

<MedicationStatement xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier External identifier --></identifier>
 <status value="[code]"/><!-- 1..1 active | completed | entered-in-error | intended -->
 <medication[x]><!-- 1..1 CodeableConcept|Reference(Medication) What medication was taken --></medication[x]>

 <patient><!-- 1..1 Reference(Patient) Who is/was taking  the medication --></patient>
 <</informationSource>

 <effective[x]><!-- 0..1 dateTime|Period Over what period was medication consumed? --></effective[x]>
 <informationSource><!-- 0..1 Reference(Patient|Practitioner|RelatedPerson) Person who provided the information about the taking of this medication --></informationSource>
 <supportingInformation><!-- 0..* Reference(Any) Additional supporting information --></supportingInformation>

 <dateAsserted value="[dateTime]"/><!-- 0..1 When the statement was asserted? -->
 <

 <wasNotTaken value="[boolean]"/><!-- 0..1 True if medication is/was not being taken -->
 <reasonNotTaken><!-- ?? 0..* CodeableConcept True if asserting medication was not given --></reasonNotTaken>
 <reasonForUse[x]><!-- 0..1 CodeableConcept|Reference(Condition)  --></reasonForUse[x]>
 <</effective[x]>
 <
 <</supportingInformation>
 <</medication[x]>

 <note><!-- 0..* Annotation Further information about the statement --></note>

 <dosage>  <!-- 0..* Details of how medication was taken -->
  <

  <text value="[string]"/><!-- 0..1 Free text dosage instructions as reported by the information source -->

  <timing><!-- 0..1 Timing When/how often was medication taken --></timing>
  <asNeeded[x]><!-- 0..1 boolean|CodeableConcept Take "as needed" (for x) --></asNeeded[x]>
  <site[x]><!-- 0..1 CodeableConcept|Reference(BodySite) Where (on body) medication is/was administered --></site[x]>
  <route><!-- 0..1 CodeableConcept How the medication entered the body --></route>
  <method><!-- 0..1 CodeableConcept Technique used to administer medication --></method>
  <quantity[x]><!-- 0..1 Quantity(SimpleQuantity)|Range Amount administered in one dose --></quantity[x]>
  <rate[x]><!-- 0..1 Ratio|Range Dose quantity per unit of time --></rate[x]>
  <maxDosePerPeriod><!-- 0..1 Ratio Maximum dose that was consumed per unit of time --></maxDosePerPeriod>
 </dosage>
</MedicationStatement>

JSON Template JSON Template 

{doco
  "resourceType" : "MedicationStatement",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // External identifier
  "status" : "<code>", // R!  active | completed | entered-in-error | intended
  // medication[x]: What medication was taken. One of these 2:

  "medicationCodeableConcept" : { CodeableConcept },
  "medicationReference" : { Reference(Medication) },

  "patient" : { Reference(Patient) }, // R!  Who is/was taking  the medication
  "

  // effective[x]: Over what period was medication consumed?. One of these 2:
  "effectiveDateTime" : "<dateTime>",
  "effectivePeriod" : { Period },
  "informationSource" : { Reference(Patient|Practitioner|RelatedPerson) }, // Person who provided the information about the taking of this medication
  "supportingInformation" : [{ Reference(Any) }], // Additional supporting information

  "dateAsserted" : "<dateTime>", // When the statement was asserted?
  "

  "wasNotTaken" : <boolean>, // True if medication is/was not being taken
  "reasonNotTaken" : [{ CodeableConcept }], // C? True if asserting medication was not given
  // reasonForUse[x]: . One of these 2:
  "reasonForUseCodeableConcept" : { CodeableConcept },
  "reasonForUseReference" : { Reference(Condition) },
  
  ">",
  " },
  "
  "
  
  " },
  " },

  "note" : [{ Annotation }], // Further information about the statement

  "dosage" : [{ // Details of how medication was taken
    "

    "text" : "<string>", // Free text dosage instructions as reported by the information source

    "timing" : { Timing }, // When/how often was medication taken
    // asNeeded[x]: Take "as needed" (for x). One of these 2:
    "asNeededBoolean" : <boolean>,
    "asNeededCodeableConcept" : { CodeableConcept },
    // site[x]: Where (on body) medication is/was administered. One of these 2:
    "siteCodeableConcept" : { CodeableConcept },
    "siteReference" : { Reference(BodySite) },
    "route" : { CodeableConcept }, // How the medication entered the body
    "method" : { CodeableConcept }, // Technique used to administer medication
    // quantity[x]: Amount administered in one dose. One of these 2:
    "quantityQuantity" : { Quantity(SimpleQuantity) },
    "quantityRange" : { Range },
    // rate[x]: Dose quantity per unit of time. One of these 2:
    "rateRatio" : { Ratio },
    "rateRange" : { Range },
    "maxDosePerPeriod" : { Ratio } // Maximum dose that was consumed per unit of time
  }]
}

  Alternate definitions:

Alternate definitions: Schema / Schematron , Resource Profile ( , Resource Profile ( XML , , JSON ), ), Questionnaire

4.16.3.1 Terminology Bindings 4.27.3.1 Terminology Bindings

Path Definition Type Reference
MedicationStatement.status MedicationStatement.status A set of codes indicating the current status of a MedicationStatement. A set of codes indicating the current status of a MedicationStatement. Required MedicationStatementStatus
MedicationStatement.reasonNotTaken MedicationStatement.reasonNotTaken A set of codes indicating the reason why the MedicationAdministration is negated. A set of codes indicating the reason why the MedicationAdministration is negated. Example Reason Medication Not Given Codes Reason Medication Not Given Codes
MedicationStatement.reasonForUse[x] MedicationStatement.reasonForUse[x] Codes identifying why the medication is being taken. Codes identifying why the medication is being taken. Example Condition/Problem/Diagnosis Codes Condition/Problem/Diagnosis Codes
MedicationStatement.dosage.asNeeded[x] MedicationStatement.dosage.asNeeded[x] 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. 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. Unknown No details provided yet No details provided yet
MedicationStatement.dosage.site[x] MedicationStatement.dosage.site[x] A coded concept describing the site location the medicine enters into or onto the body. A coded concept describing the site location the medicine enters into or onto the body. Example SNOMED CT Anatomical Structure for Administration Site Codes SNOMED CT Anatomical Structure for Administration Site Codes
MedicationStatement.dosage.route MedicationStatement.dosage.route A coded concept describing the route or physiological path of administration of a therapeutic agent into or onto the body of a subject. A coded concept describing the route or physiological path of administration of a therapeutic agent into or onto the body of a subject. Example SNOMED CT Route Codes SNOMED CT Route Codes
MedicationStatement.dosage.method MedicationStatement.dosage.method A coded concept describing the technique by which the medicine is administered. A coded concept describing the technique by which the medicine is administered. Unknown No details provided yet No details provided yet

4.16.3.2 Constraints 4.27.3.2 Constraints

  • mst-1 : Reason not taken is only permitted if wasNotTaken is true (xpath: not(exists(f:reasonNotTaken) and f:wasNotTaken/@value=false()) : Reason not taken is only permitted if wasNotTaken is true ( expression : reasonNotTaken.empty() or wasNotTaken = true )
  • 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()) : Reason for use is only permitted if wasNotTaken is false ( expression : reasonForUse.empty() or wasNotTaken = false )

4.16.4 Search Parameters 4.27.4 Search Parameters Search parameters for this resource. The common parameters also apply. See

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services. for more information about searching in REST, messaging, and services.

© HL7.org 2011+. FHIR DSTU2 (v1.0.2-7202) generated on Sat, Oct 24, 2015 07:43+1100. Links: Search
Name Type Description Paths
code token Return administrations of this medication code Return administrations of this medication code MedicationStatement.medicationCodeableConcept
effectivedate effective date Date when patient was taking (or not taking) the medication Date when patient was taking (or not taking) the medication MedicationStatement.effective[x]
identifier token Return statements with this external identifier Return statements with this external identifier MedicationStatement.identifier
medication reference Return administrations of this medication reference Return administrations of this medication reference MedicationStatement.medicationReference
( Medication )
patient reference The identity of a patient to list statements for The identity of a patient to list statements for MedicationStatement.patient
( Patient )
source reference Who the information in the statement came from Who the information in the statement came from MedicationStatement.informationSource
( Patient , , Practitioner , , RelatedPerson )
status token Return statements that match the given status Return statements that match the given status MedicationStatement.status