ARCHETYPE Medication order 2 KSP (openEHR-EHR-INSTRUCTION.medication_test_order2.v0)

ARCHETYPE IDopenEHR-EHR-INSTRUCTION.medication_test_order2.v0
ConceptMedication order 2 KSP
DescriptionAn order for a medication, vaccine, nutritional product or other therapeutic item for an identified individual.
UseUse to record all aspects of an order of a medication, vaccine, nutritional product or other therapeutic item for an identified individual. It is intended to be used for any type of medication and related order, whether prescribed by a health professional or available for purchase 'over the counter'. The scope of this medication archetype also includes orders for vaccinations, parenteral fluids or other therapeutic goods, such as bandages, nutritional products or other items that are applied or administered to have a therapeutic effect and which have a common pattern for data recording. This archetype is designed to be used in a number of clinical contexts, including but not limited to: - a record in a clinical consultation (COMPOSITION.encounter); - a written prescription by a physician, dentist, nurse practitioner, or other designated health professional for a medication or nutritional product to be dispensed and administered (within a COMPOSITION.prescription); - an item in a current medication list, prescription or drug chart (within COMPOSITION.medication_list); and - an item in a summary document such as transfer of care (COMPOSITION.transfer_summary) or a referral (COMPOSITION.request). In many cases a medication order will be simple – typically for a single medication item with uncomplicated instructions for dispensing and administration. However this archetype is also designed to allow for more complex therapeutic orders. For example: - a reducing dose of prednisolone over a period of weeks; - titration of insulin, with dosing dependent on test results; - multiple medications prescribed simultaneously as part of a single drug regimen, such as a triple therapy for peptic ulcer; and - intravenous administration of medications or nutrition supplements, including parenteral nutrition. The archetype has therefore been designed to allow for a range of complexity, from: - simple narrative instructions for orders like 'furosemide 40mg two tablets in the morning and one at lunch' to ensure compatibility with existing systems; and - the amount of medication is usually represented in terms of a number and corresponding dose unit, however there can alternatively be a narrative statement to ensure compatibility with existing systems and coverage of all clinical scenarios; through to - structured detail for dose, route and timing to represent a fully computable specification. It has also been designed so that a single medication order structure can represent: - complex sequential medication orders using the same preparation strength to be supported within a single order structure; and - multiple medication orders can be chained in circumstances where different medications or preparations need to be given sequentially. This archetype is also suitable for ordering parenteral fluids, in care settings where it is normal practice to make these 'prescribable' items. In other settings a separate 'parenteral fluid order' may be appropriate. SLOTs containing CLUSTER archetypes have been used to represent some of the content for three reasons: - To ensure a core archetype that can be used for all the above use cases, yet allow flexibility where it is required, for example the ‘Preparation details’ SLOT where additional structured detail can be added. A candidate archetype has been suggested for Medications. It is possible that other CLUSTER archetypes may be required in future for other purposes such as complex parenteral nutrition orders; - to support archetype re-use in situations where the content has been identified as being also used in other clinical contexts, in particular the paired ACTION.medication archetype for recording actual dispensing, administration etc; and - to remove less commonly used content from the core archetype framework. Multiple orders can be represented as separate activities within this single archetype instance to carry tightly bound orders of different medications, for example, H. pylori therapy when this is not prescribed as a single pack. It should be noted that these uses subsume both the FHIR Medication Order and Medication Statement use cases. i.e this archetype is a match for both FHIR resources, used in the appropriate context.
MisuseNot to be used to record the activities related to carrying out the order for medication, vaccine, nutritional product or therapeutic item, such as details about actual administration or dispensing. Use the ACTION.medication for this purpose. Not to be used to record the ordering of blood products, which involves a fundamentally different clinical process and is likely to require different supporting information Use the INSTRUCTION.transfusion for this purpose. Not to be used to record the order for insertion of implants or medical devices such as pacemakers and defibrillators. Use the INSTRUCTION.procedure for this purpose.
PurposeTo record all aspects of an order of a medication, vaccine, nutritional product or other therapeutic item for an identified individual.
ReferencesDerived from: <testing>
Derived from: Medication order, Published archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2017-12-05]. Available from: http://openehr.org/ckm/#showArchetype_1013.1.1445
Medication instruction, Draft Archetype [Internet]. nehta, Australia, nehta Clinical Knowledge Manager [cited: 2015-12-15]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.838

Intermountain Healthcare Medication order model, Personal Communication to Sam Heard by Dr Stan Huff.

Royal Australian College of General Practitioners. Fact Sheet: Medicines List. 2010.

NHS HSCIC Messaging Implementation Manual (GP2GP messages) http://www.uktcregistration.nss.cfh.nhs.uk/trud3

Standards for medication and medical device records – technical annex [Internet]. RCP London. [cited 2015 Dec 15]. Available from: https://www.rcplondon.ac.uk/projects/outputs/standards-medication-and-medical-device-records-technical-annex
Copyright© openEHR Foundation, Alberta Health Services (Canada), openEHR Foundation, openEHR Foundation, openEHR Foundation
AuthorsAuthor name: Ian McNicoll
Organisation: freshEHR Clinical Informatics
Email: ian@freshehr.com
Date originally authored: 2015-10-21
Other Details LanguageAuthor name: Ian McNicoll
Organisation: freshEHR Clinical Informatics
Email: ian@freshehr.com
Date originally authored: 2015-10-21
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=Ocean Informatics, references=Derived from: Derived from: Medication order, Published archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2017-12-05]. Available from: http://openehr.org/ckm/#showArchetype_1013.1.1445 Medication instruction, Draft Archetype [Internet]. nehta, Australia, nehta Clinical Knowledge Manager [cited: 2015-12-15]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.838 Intermountain Healthcare Medication order model, Personal Communication to Sam Heard by Dr Stan Huff. Royal Australian College of General Practitioners. Fact Sheet: Medicines List. 2010. NHS HSCIC Messaging Implementation Manual (GP2GP messages) http://www.uktcregistration.nss.cfh.nhs.uk/trud3 Standards for medication and medical device records – technical annex [Internet]. RCP London. [cited 2015 Dec 15]. Available from: https://www.rcplondon.ac.uk/projects/outputs/standards-medication-and-medical-device-records-technical-annex, current_contact=Doug Pankowski, Alberta Health Services, Canada, original_namespace=com.oceaninformatics, original_publisher=Ocean Informatics, custodian_namespace=com.oceaninformatics, MD5-CAM-1.0.1=B87EBF4D87104184EEFE0F2AA87FA07E, build_uid=7331c6f9-aeac-4e3a-a14b-1528cbede223, revision=0.0.1-alpha}
Keywordsmedication, order, prescribe, therapy, substance, drug, therapeutic, otc, therapeutic good, pharmaceutical, product, posology, treatment, fluid, nutrition, CPOE
Lifecyclein_development
UID0d1610dc-9416-4661-b89a-6c2a36851d95
Language useden
Citeable Identifier1013.1.1930
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=An order for a medication, vaccine, nutritional product or other therapeutic item for an identified individual., archetypeConceptComment=null, otherContributors=Morten Aas, Oslo Universitetssykehus, Norway
Tomas Alme, DIPS, Norway
Ole Andreas Bjordal, Webmed, Norway
Erling Are Hole, Helse Bergen, Norway
Vebjørn Arntzen, Oslo University Hospital, Norway
Koray Atalag, University of Auckland, New Zealand
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)
Marcus Baw, openGPSoC / BawMedical Ltd, United Kingdom
John Bennett, NEHTA, Australia
Kristian Berg, Universitetssykehuset Nord Norge, Norway (Nasjonal IKT redaktør)
SumanBhusan Bhattacharyya, Sudisa Consultancy Services, India
Sharmila Biswas, Australia
Lars Bitsch-Larsen, Haukeland University hospital, Norway
Laila Bruun, Oslo universitetssykehus HF, Norway
Bjørn Christensen, Helse Bergen HF, Norway
Stephen Chu, NEHTA, Australia (Editor)
Matthew Cordell, NEHTA, Australia
Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway
Inderjit Daphu, Helse Bergen, Norway
Gail Easterbrook, Flinders Medical Centre, Australia
Gunn Elin Blakkisrud, DIPS ASA, Norway
Stig Erik Hegrestad, Helse Førde, Norway
David Evans, Queensland Health, Australia
Samuel Frade, Marand, Portugal
Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom
Sarah Gaunt, NEHTA, Australia
Heather Grain, Llewelyn Grain Informatics, Australia
Cecilie Graver, Oslo universitetssykehus HF, Norway
Trina Gregory, cpc, Australia
Bjørn Grøva, Diretoratet for e-helse, Norway
Robert Hausam, Hausam Consulting LLC, United States
Sam Heard, Ocean Informatics, Australia (Editor)
Kristian Heldal, Telemark Hospital Trust, Norway
Annette Hole Sjøborg, DIPS ASA, Norway
Hilde Hollås, DIPS ASA, Norway
Roar Holm, Helse Vest IKT A/S, Norway
Evelyn Hovenga, EJSH Consulting, Australia
Gunnar Jårvik, Nasjonal IKT HF, Norway
Lars Morgan Karlsen, DIPS ASA, Norway
Mary Kelaher, NEHTA, Australia
Nils Kolstrup, Skansen Legekontor og Nasjonalt Senter for samhandling og telemedisin, Norway
Ole Kristian Losvik, Losol AS, Norway
Robert L'egan, NEHTA, Australia
Russell Leftwich, Russell B Leftwich MD, United States
Fest Legemiddelverket, Statens Legemiddelverk, Norway
Øygunn Leite Kallevik, Helse Bergen, Norway
Heather Leslie, Ocean Health Systems, Australia (openEHR Editor)
Colin Macfarlane, Elsevier, United Kingdom
Alan March, Hospital Universitario Austral, Argentina
Siv Marie Lien, DIPS ASA, Norway
Susan McIndoe, Royal District Nursing Service, Australia
David McKillop, NEHTA, Australia
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)
Chris Mitchell, RACGP, Australia
Stewart Morrison, NEHTA, Australia
Bjørn Næss, DIPS ASA, Norway
Andrej Orel, Marand d.o.o., Slovenia
Anne Pauline Anderssen, Helse Nord RHF, Norway
Martin Paulson, Sykehuset i Vestfold, Norway
Chris Pearce, Melbourne East GP Network, Australia
Kristian Pedersen, Nordlandssykehuset HF, Norway
Rune Pedersen, Universitetssykehuset i Nord Norge, Norway
Vladimir Pizzo, Hospital Sírio Libanês, Brazil
Camilla Preeston, Royal Australian College of General Practitioners, Australia
Margaret Prichard, NEHTA, Australia
Cathy Richardson, NEHTA, Australia
Robyn Richards, NEHTA - Clinical Terminology, Australia
Tanja Riise, Nasjonal IKT HF, Norway
Anoop Shah, University College London, United Kingdom
Line Silsand, Universitetssykehuset i Nord-Norge, Norway
Raymond Simkus, Brookswood Family Practice, Canada
Iztok Stotl, UKCLJ, Slovenia
John Taylor, NEHTA, Australia
Nyree Taylor, Ocean Informatics, Australia
Tesfay Teame, Folkehelseinstituttet, Norway
Richard Townley-O'Neill, Australian Digital Health Agency, Australia
John Tore Valand, Helse Bergen, Norway (openEHR Editor)
Ines Vaz, UFN, Portugal
Nils Widnes, Helse-Bergen, Norway
Kylie Young, The Royal Australian College of General Practitioners, Australia, originalLanguage=en, translators=Norwegian Bokmål: John Tore Valand/Silje Ljosland Bakke, Helse Bergen HF/Nasjonal IKT HF
Portuguese (Brazil): Osmeire Chamelette Sanzovo, Hospital Sírio Libanês - SP, osmeire.acsanzovo@hsl.org.br, R.N.
, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={source=[], provider=[], ism_transition=[], other_participations=[], activities=[ResourceSimplifiedHierarchyItem [path=/activities[at0001], code=at0001, itemType=ACTIVITY, level=1, text=Order, description=Details of the requested order., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTIVITY, bindings=null, values=null, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0070], code=at0070, itemType=ELEMENT, level=2, text=Medication item, description=Name of the medication, vaccine or other therapeutic/prescribable item being ordered., comment=Depending on the prescribing context this field could be used for either generic- or product-based prescribing. This data field can be used to record tightly bound orders of different medications when they are prescribed as a single pack. It is strongly recommended that the 'Medication item' be coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple name of the medication item through to structured details about the actual medication pack to be used. Free text entry should only be used if there is no appropriate terminology available., uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0143], code=at0143, itemType=SLOT, level=2, text=Preparation details, description=Structured details about the overall preparation including strength, form and constituent substances., comment=Use this SLOT where the detailed description of the ordered item needs to be explicitly stated. For example: the form, strength, any diluents or mixture of ingredients., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.medication_substance.v0 and specialisations Or
openEHR-EHR-CLUSTER.medication_substance.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0091], code=at0091, itemType=ELEMENT, level=2, text=Route, description=The route by which the ordered item is to be administered into the subject's body., comment=For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible. Multiple potential routes may be specified., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • PO [.]
  • IM [.]
  • IV [.]
  • SC [.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0092], code=at0092, itemType=ELEMENT, level=2, text=Body site, description=Name of the site of administration of the ordered item., comment=For example: 'left upper arm', 'intravenous catheter right hand'. Coding of the body site with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0093], code=at0093, itemType=SLOT, level=2, text=Structured body site, description=Structured description of the site of administration of the ordered item., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.anatomical_location.v1 and specialisations Or
openEHR-EHR-CLUSTER.anatomical_location_clock.v0 and specialisations Or
openEHR-EHR-CLUSTER.anatomical_location_relative.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0094], code=at0094, itemType=ELEMENT, level=2, text=Delivery method, description=The technique or device by which the ordered item is to be delivered., comment=For example: ' via Z-track injection'; 'via nebuliser'. Coding of the method with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0095], code=at0095, itemType=SLOT, level=2, text=Delivery device details, description=Details of the medical device used to assist delivery of the ordered item., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.device.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0009], code=at0009, itemType=ELEMENT, level=2, text=Overall directions description, description=Complete narrative description about how the ordered item is to be used., comment=This narrative should normally subsume data captured in 'Dose amount', 'Dose timing' and any additional instructions for use. Where the medication dose directions are fully carried by the structured, computable dose directions, this element should carry the narrative equivalent, generally auto-generated. If it is not possible to represent the intended 'Dose direction' fully in computable form, partial representation is not recommended, and the directions should be only recorded in narrative form using this data element., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0047], code=at0047, itemType=ELEMENT, level=2, text=Parsable directions, description=A parsable, computable text representation of the directions., comment=Generally this is only used when passing information between legacy systems. For example: '10mg bd; 20mg n' as used by the NHS Dose syntax (in development)., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PARSABLE, bindings=null, values=Formalism: text/html, text/plain, text/xml
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0173], code=at0173, itemType=ELEMENT, level=2, text=Specific directions description, description=A narrative description of a specific part of overall directions., comment=In some settings, it is common to split overall narrative directions into more specific segments of narrative. For example in hospital settings, it can be common to split the overall directions into 'Dose amount' and 'Dose timing', both as narrative text. These terms can be applied at template or run-time., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0174], code=at0174, itemType=ELEMENT, level=2, text=Dosage justification, description=A description of the justification used to calculate a dose amount or administration rate where this is dependent on some other factor., comment=For example: 'Adjusted for amputation'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0177], code=at0177, itemType=SLOT, level=2, text=Structured dose and timing directions, description=Details of structured dose and timing directions., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.therapeutic_direction.v0 and specialisations Or
openEHR-EHR-CLUSTER.therapeutic_direction.v1 and specialisations
Exclude:
All not explicitly included archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0062], code=at0062, itemType=CLUSTER, level=2, text=Medication safety, description=Details about medication safety for the ordered item., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0062]/items[at0051], code=at0051, itemType=CLUSTER, level=3, text=Maximum dose, description=Details about the maximum, cumulative dose allowed over a defined period for the ordered item., comment=For example: 'up to 1gram per day'. This cluster allows multiple occurrences to enable representation of multiple maximum doses that apply to different time periods. Lifetime maximum dose should not be carried here as it refers to multiple orders over time., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0062]/items[at0051]/items[at0130], code=at0130, itemType=ELEMENT, level=4, text=Maximum amount, description=The maximum, cumulative amount of medication which should be administered within the allowed period. The unit for this amount is carried in Maximum amount unit., comment=For example: 1, 1.5, 0.125., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Qualified real
Units:
  • >=0.0 1
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0062]/items[at0051]/items[at0146], code=at0146, itemType=ELEMENT, level=4, text=Maximum amount unit, description=The unit for the maximum amount allowed., comment=For example: 'tablet','mg'. Coding of the dose unit with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0062]/items[at0051]/items[at0053], code=at0053, itemType=ELEMENT, level=4, text=Allowed period, description=The period of time during which the maximum dose is calculated., comment=Example: 24 hours., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=>=0 seconds
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0062]/items[at0171], code=at0171, itemType=ELEMENT, level=3, text=Overriden safety advice, description=A known or recognised safety issue which applies to this subject and the ordered item, such as an allergy, drug duplication warning or contraindication. This element is normally only recorded when this safety advice is overridden., comment=For example: 'Allergic to penicillin', 'Atenolol duplicated'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0062]/items[at0064], code=at0064, itemType=ELEMENT, level=3, text=Exceptional safety override?, description=Confirmation by the prescriber that the normal dose or other safety limit has been overridden due to exceptional circumstances., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0062]/items[at0162], code=at0162, itemType=ELEMENT, level=3, text=Override reason, description=The reason for a clinical safety or maximum dose override., comment=For example: 'Not responsive at maximum recommended dose. Critical situation.', 'Peniciilin is only valid treatment, likelihood of true penicillin allergy is low'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Clinically applicable to patient [.]
  • Palliative dosing [.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0062]/items[at0150], code=at0150, itemType=CLUSTER, level=3, text=Total daily effective dose, description=Details about the total daily amount of the ordered item expected to be administered., comment=The total daily dose records the expected effective dose, and thus support titration of an initial low dose towards the effective dose over a period of time. This is not itself the target dose or goal but the actual effective daily dose against that goal. In some circumstances the Total daily dose will be calcuable from computable directions, in others it may need to be manually entered., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0062]/items[at0150]/items[at0165], code=at0165, itemType=ELEMENT, level=4, text=Purpose, description=Description of the reason for recording a total daily effective dose., comment=For example: 'Hypertension control', 'Target dose 20mg daily'. The description could be used to identify a name, phrase or paragraph about the purpose for recording total daily effective dose, commonly to allow to titration towards a specific target dose. The goal or target dose might be recorded here or more commonly as part of a linked EVALUATION 'Goal' archetype., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0062]/items[at0150]/items[at0151], code=at0151, itemType=ELEMENT, level=4, text=Total daily amount, description=The amount of ordered item which will be taken each day if administered as intended., comment=For example '20mg'., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Qualified real
Units:
  • >=0.0 1
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0062]/items[at0150]/items[at0152], code=at0152, itemType=ELEMENT, level=4, text=Total daily amount unit, description=The dose unit associated with the total daily amount., comment=The dose units are normally scientific units such as mg, ml rather than 'tablets'., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0044], code=at0044, itemType=ELEMENT, level=2, text=Additional instruction, description=An additional instruction on how to use or store the ordered item., comment=For example: precautions as 'take with food', 'Avoid grapefruit', 'Dissolve in water', 'store in a cool, dry place'. This data element allows multiple occurrences and should be coded with a reference terminology, where possible., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0105], code=at0105, itemType=ELEMENT, level=2, text=Patient information, description=An additional instruction directed primarily at the individual/patient or carers., comment=For example: 'To reduce your blood pressure', 'To thin your blood'. This data element allows multiple occurrences and should be coded with a reference terminology, where possible. If required it is possible to use a LINK attribute to associate this element with, for example, the 'original diagnosis' in a separate Problem list composition but the indication should be explicitly recorded here, as the link target may change over time., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0107], code=at0107, itemType=ELEMENT, level=2, text=Monitoring instruction, description=An additional instruction which gives advice on recommended or required monitoring of the ordered item., comment=For example: 'Please check renal function in 2 weeks'. This data element allows multiple occurrences., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0018], code=at0018, itemType=ELEMENT, level=2, text=Clinical indication, description=The clinical reason for use of the ordered item., comment=For example: 'Angina'. Coding of the clinical indication with a terminology is preferred, where possible. This data element allows multiple occurrences. It is not intended to carry an indication for administrative authorisation purposes., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0148], code=at0148, itemType=ELEMENT, level=2, text=Therapeutic intent, description=The overall therapeutic intent of the ordered item., comment=For example: 'pain relief'; 'palliative care'; 'low-dose prophylaxis'; 'rehydration'; 'nutritional infusion'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0113], code=at0113, itemType=CLUSTER, level=2, text=Order details, description=Details about the whole medication order., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0113]/items[at0012], code=at0012, itemType=ELEMENT, level=3, text=Order start date/time, description=The date and optional time to commence use of the ordered item., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0113]/items[at0013], code=at0013, itemType=ELEMENT, level=3, text=Order stop date/time, description=The date and optional time when it is planned to cease use of the ordered item., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0113]/items[at0011], code=at0011, itemType=ELEMENT, level=3, text=Order start criterion, description=A condition which, when met, requires the commencement of administration or use., comment=For example: 'Start if symptoms recur'. This is intended for a general pre-condition which should trigger the whole medication course to be started, and not for 'as required' administrations of an ongoing order., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0113]/items[at0016], code=at0016, itemType=ELEMENT, level=3, text=Order stop criterion, description=A condition which, when met, requires the cessation of administration or use., comment=For example: 'Stop after symptoms disappear''., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0113]/items[at0060], code=at0060, itemType=ELEMENT, level=3, text=Administrations completed, description=The number of administrations of the ordered item that have been completed, as part of the intended whole order but prior to the issuance of this order., comment=For example: To record that the patient has taken the two first antibiotic tablets of a three day course, prior to discharge from the hospital to a nursing home., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=0

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0113]/items[at0050], code=at0050, itemType=ELEMENT, level=3, text=Duration of order completed, description=The time period during which the individual/patient has already been using the ordered item as a part of the intended whole order but prior to the issuance of this order., comment=For example: To record that the patient had been taking antibiotics 3 days prior to hospital admission, in the context of a 7 day course., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=Allowed values: weeks, days, hours
>=0 hours
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0113]/items[at0112], code=at0112, itemType=SLOT, level=3, text=Order summary, description=Summary information about use of the ordered item, such as current status or key dates, generally used in non-prescription contexts., comment=Course summary may be required when transmitting medication information between systems or representing a FHIR Medication statement. For example: as part of a referral, emergency patient summary or discharge communication., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.medication_order_summary.v0 and specialisations Or
openEHR-EHR-CLUSTER.medication_order_summary.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0069], code=at0069, itemType=SLOT, level=2, text=Authorisation directions, description=Details of authorisation of the ordered item, including supporting local self-administration, issue and endorsement policies., comment=For example: details of repeat/refill supply. This SLOT allows for local variation in the different jurisdictions regarding medication authorisation and re-authorisation to be managed., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.medication_authorisation.v0 and specialisations Or
openEHR-EHR-CLUSTER.medication_authorisation.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0129], code=at0129, itemType=CLUSTER, level=2, text=Dispense directions, description=Directions about the dispensing of the ordered item., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0129]/items[at0106], code=at0106, itemType=ELEMENT, level=3, text=Dispense instruction, description=An additional instruction directed primarily at the person dispensing the ordered item., comment=Example: Detailed instructions for phased dispensing of opiates., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0129]/items[at0065], code=at0065, itemType=SLOT, level=3, text=Dispense amount, description=Details about the amount of the ordered item to be dispensed., comment=This SLOT allows for local variation in the different jurisdictions regarding medication dispensing amount to be managed., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.medication_supply_amount.v0 and specialisations Or
openEHR-EHR-CLUSTER.medication_supply_amount.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0129]/items[at0132], code=at0132, itemType=ELEMENT, level=3, text=Substitution direction, description=Permission for substitution with a bioequivalent item., comment=In many jurisdictions, substitution of an ordered item as a generic form or with a different brand name, which has been determined as bioequivalent, is allowed at the point of dispense or supply. In other cases substitution is assumed and the clinician has to explicitly request non-substitution., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Permitted [Substitution of the medication with a bioequivalent medication is allowed.]
  • Not permitted [Substitution of the medication with a bioequivalent medication is not allowed.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0129]/items[at0154], code=at0154, itemType=ELEMENT, level=3, text=Non-substitution reason, description=The reason why an ordered item should not be substituted at dispense., comment=For example 'Generic preparation not bio-equivalent'., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0129]/items[at0139], code=at0139, itemType=ELEMENT, level=3, text=Priority, description=An indicator of the urgency with which the ordered item should be dispensed., comment=For example 'Urgent'. This is left to be templated or specialised according to local valuesets. Some jurisdictions allow instructions to dispense to be marked as 'urgent' so that the dispensary handles them quickly., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0129]/items[at0155], code=at0155, itemType=ELEMENT, level=3, text=Dispensing start date, description=The date from which the ordered item is permitted to be dispensed for the first time., comment=May be used to control the time of dispensing of medications with potential for abuse. For example: benzodiazepines or analgesics., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0129]/items[at0161], code=at0161, itemType=ELEMENT, level=3, text=Dispensing expiry date, description=The date after which the ordered item is no longer valid to be legally dispensed., comment=In some jurisdictions, orders to dispense may have an expiry date after which the prescription may not be dispensed., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0129]/items[at0170], code=at0170, itemType=SLOT, level=3, text=Dispense details, description=Further details related to dispense directions., comment=This SLOT allows for local variation in the different jurisdictions regarding medication dispensing., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0166], code=at0166, itemType=SLOT, level=2, text=Additional details, description=Additional structured details about the ordered item not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0002]/items[at0167], code=at0167, itemType=ELEMENT, level=2, text=Comment, description=Additional narrative about the medication order not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], protocol=[ResourceSimplifiedHierarchyItem [path=/protocol[at0005]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Order identifier, description=Unique identifier for the medication order., comment=This data element allows for multiple occurrences to be defined more explicitly at run-time, if required., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0005]/items[at0008], code=at0008, itemType=SLOT, level=2, text=Extension, description=Additional information required to capture local content or to align with other reference models/formalisms., comment=For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null]], content=[], state=[], description=[], identities=[], data=[], credentials=[], target=[], capabilities=[], items=[], contacts=[], relationships=[], context=[], events=[], details=[]}, topLevelItems={activities=ResourceSimplifiedHierarchyItem [path=ROOT_/activities[at0001], code=at0001, itemType=ACTIVITY, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=0..*, cardinalityText=Minimum of 0 items, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTIVITY, bindings=null, values=null, extendedValues=null], protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0005], code=at0005, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=1..1, cardinalityText=mandatory, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0005]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Order identifier, description=Unique identifier for the medication order., comment=This data element allows for multiple occurrences to be defined more explicitly at run-time, if required., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0005]/items[at0008], code=at0008, itemType=SLOT, level=2, text=Extension, description=Additional information required to capture local content or to align with other reference models/formalisms., comment=For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]