This
page
is
part
of
the
FHIR
Specification
(v3.0.2:
STU
3).
(v3.5.0:
R4
Ballot
#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
Pharmacy
Work
Group
|
Maturity Level : 3 | Trial Use | Compartments : Patient , Practitioner , RelatedPerson |
Detailed Descriptions for the elements in the MedicationStatement resource.
| MedicationStatement | |
| 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
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. |
| Control | 1..1 |
| Type | DomainResource |
| Comments |
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. |
|
|
|
| Element Id | 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. |
| Note | This is a business identifer, not a resource identifier (see discussion ) |
| Control | 0..* |
| Type | Identifier |
| Summary | true |
| MedicationStatement.basedOn | |
| Element Id | MedicationStatement.basedOn |
| Definition |
A plan, proposal or order that is fulfilled in whole or in part by this event. |
| Control | 0..* |
| Type |
Reference
(
MedicationRequest
|
CarePlan
|
|
| Requirements |
Allows tracing of authorization for the event and tracking whether proposals/recommendations were acted upon. |
| Summary | true |
| MedicationStatement.partOf | |
| Element Id | MedicationStatement.partOf |
| Definition |
A larger event of which this particular event is a component or step. |
| Control | 0..* |
| Type | Reference ( MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Observation ) |
| Requirements |
This should not be used when indicating which resource a MedicationStatement has been derived from. If that is the use case, then MedicationStatement.derivedFrom should be used. |
| Summary | true |
|
|
|
|
|
|
| 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. |
| Control | 1..1 |
| Terminology Binding | MedicationStatementStatus ( 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 status of the use of the medication by the patient (for example, stopped or on hold) as well as codes that assert the status of the medication statement itself (for example, entered in error). This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. |
| MedicationStatement.statusReason | |
| Element Id | MedicationStatement.statusReason |
| Definition | Captures the reason for the current state of the MedicationStatement. |
| Control | 0..* |
| Terminology Binding | SNOMED CT Drug Therapy Status codes ( Example ) |
| Type | CodeableConcept |
| Comments | 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. |
| MedicationStatement.category | |
| Element Id | MedicationStatement.category |
| Definition |
Indicates
where
|
| Control | 0..1 |
| Terminology Binding | MedicationStatementCategory ( Preferred ) |
| Type | CodeableConcept |
| Summary | true |
| MedicationStatement.medication[x] | |
| Element Id | 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. |
| Control | 1..1 |
| Terminology Binding | SNOMED CT Medication Codes ( Example ) |
| Type | CodeableConcept | Reference ( 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
|
| MedicationStatement.subject | |
| Element Id | MedicationStatement.subject |
| Definition | The person, animal or group who is/was taking the medication. |
| Control | 1..1 |
| Type | Reference ( Patient | Group ) |
| Summary | true |
| MedicationStatement.context | |
| Element Id | MedicationStatement.context |
| Definition | The encounter or episode of care that establishes the context for this MedicationStatement. |
| Control | 0..1 |
| Type | Reference ( Encounter | EpisodeOfCare ) |
| Summary | true |
| MedicationStatement.effective[x] | |
| Element Id | MedicationStatement.effective[x] |
| Definition |
The
interval
of
time
during
which
it
is
being
asserted
that
the
patient
|
| Control | 0..1 |
| Type | dateTime | Period |
| [x] Note | See Choice of Data Types 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
at
the
time
the
statement
is
recorded,
the
|
| MedicationStatement.dateAsserted | |
| Element Id | MedicationStatement.dateAsserted |
| Definition |
The date when the medication statement was asserted by the information source. |
| Control | 0..1 |
| Type | dateTime |
| Summary | true |
| MedicationStatement.informationSource | |
| 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,
|
| Control | 0..1 |
| Type | Reference ( Patient | Practitioner | RelatedPerson | Organization ) |
|
|
|
|
|
|
| Definition |
Allows linking the MedicationStatement to the underlying MedicationRequest, or to other information that supports or is used to derive the MedicationStatement. |
| Control | 0..* |
| Type | Reference ( Any ) |
| 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. |
|
|
|
|
|
|
| Definition |
A reason for why the medication is being/was taken. |
| Control | 0..* |
| Terminology Binding | Condition/Problem/Diagnosis Codes ( Example ) |
| Type | CodeableConcept |
| Comments |
This could be a diagnosis code. If a full condition record exists or additional detail is needed, use reasonForUseReference. |
| MedicationStatement.reasonReference | |
| Element Id | MedicationStatement.reasonReference |
| Definition |
Condition or observation that supports why the medication is being/was taken. |
| Control | 0..* |
| Type | Reference ( Condition | Observation | DiagnosticReport ) |
| Comments |
This is a reference to a condition that is the reason why the medication is being/was taken. If only a code exists, use reasonForUseCode. |
| MedicationStatement.note | |
| Element Id | MedicationStatement.note |
| Definition |
Provides extra information about the medication statement that is not conveyed by the other attributes. |
| Control | 0..* |
| Type | Annotation |
| MedicationStatement.dosage | |
| Element Id | MedicationStatement.dosage |
| Definition |
Indicates how the medication is/was or should be taken by the patient. |
| Control | 0..* |
| Type | Dosage |
| Comments |
The
dates
included
in
the
dosage
on
a
Medication
Statement
reflect
the
dates
for
a
given
dose.
For
example,
|