TEMPLATE Medications list for 10041 (Medications list for 10041)

TEMPLATE ID

Medications list for 10041

Concept

Medications list for 10041

Description

Not Specified

Purpose

Not Specified

References

Other Details (Language Independent)

MetaDataSet:Sample Set : Template metadata sample set

Language used

Citeable Identifier

1013.26.545

Root archetype id

openEHR-EHR-COMPOSITION.medication_list_nehta.v1

Medication List to support HISO 10041.1

Medication List to support HISO 10041.1: A persistent and managed list of medications that are reasonably assumed to be taken by the subject, and that may influence clinical decision-making and care provision.

Annotations

CDA Mappings CDA.Implementation Guide: CDA Templates for Medications
CDA Mappings CDA.Template Name: medications section
CDA Mappings CDA.Template ID: @root = 2.16.840.1.113883.2.18.7.54
CDA Mappings Template Node.Name: title = "Medication List"
CDA Mappings Template Node.Path: component/text
CDA Mappings Template Node.Path CodedText: code[@code : LOINC = 18605-6][@displayName = "Medication list"]

Medication instruction for New Zealand

Medication instruction for New Zealand: Details of a medicine, vaccine or other therapeutic good with instructions for use.
This should normally be specialised from NEHTA archetype but Cardinality of structured dose breaks compatibility.

Annotations

CDA Mappings CDA.Template Name: medication list entry
CDA Mappings CDA.Template ID: @root = 2.16.840.1.113883.2.18.7.54.1
CDA Mappings Template Node.Path: entry/[@typeCode = DRIV]substanceAdministration/[@classCode = SBADM][@moodCode = INT]{interval of use}{timing}{route}{dose}{medicinal product}{prescriber}?{indication}*{patient instructions}?{last change}{last change reason}?{as required medicine}?

Order

Order: The instructions for a particular medicine, vaccine or other therapeutic good including dose and timing.

Description

Medicine

Medicine: The medicine, vaccine or other therapeutic good being ordered, administered to or used by the subject of care. This item should be coded if possible.

Text
Coded Text Value set: ac0001

Annotations

CDA Mappings CDA.Template Name: medicinal product
CDA Mappings CDA.Template ID: @root = 2.16.840.1.113883.2.18.7.5.25
CDA Mappings Template Node.Name: code
CDA Mappings Template Node.Path: consumable/manufacturedProduct/manufacturedMaterial/code
CDA Mappings Template Node.Name Valueset: @displayName (preferred name) : text
CDA Mappings Template Node.Value Valueset: @code : NZMT SCTID
CDA Mappings Template Node.Notes: This does not allow for entry of free text medicinal products; there are alternative drugs or others that are not included in NZMT yet.

Type

Type: Whether these are prescribed or other such as OTC, alternative, complementary or Rongoa

Normal
OTC
Alternative
Complementary
Rongoa medicine

Directions

Directions: A complete narrative description of how much, when and how to use the medicine, vaccine or other therapeutic good.

Annotations

CDA Mappings CDA.Template Name: patient instructions
CDA Mappings CDA.Template ID: @root = 2.16.840.1.113883.2.18.7.??
CDA Mappings Template Node.Name: instructions
CDA Mappings Template Node.Path: entryRelationship/[@typeCode = SUBJ][@inversionInd = true]act/[@classCode = ACT][@moodCode = INT]templateId/[@root = 2.16.840.1.113883.2.18.7.??]text/instruction
CDA Mappings Template Node.Path CodedText: Path entryRelationship/[@typeCode = SUBJ][@inversionInd = true]act/[@classCode = ACT][@moodCode = INT]templateId/[@root = 2.16.840.1.113883.2.18.7.??]code/[@code = PINSTRUCT][@displayName = "Patient instructions"][@codeSystem = 1.3.6.1.4.1.19376.1.5.3.2][@codeSystemName = "IHE Act Code"]

Used outside approved purpose

Used outside approved purpose: used to indicate of a medicine is deliberately used outside its approved use

Chemical Description of Medication

Chemical Description of Medication: The actual ingredients with strength and overall form of a chemical or medication.
Optional[{detail_docref=data_groups/NEHTA-16408-Chemical_Description_of_Medication-Data_Group.xml, spec_id=112}]

Active Ingredient

Active Ingredient: Information about an ingredient that is active.
The substance in the medication formulation that is pharmaceutically active and is responsible for the medication's therapeutic effect defined by its identifying name and the strength per dose unit.
Optional[{detail_docref=data_groups/NEHTA-10132-Active_Ingredient-Data_Group.xml}]

Name

Name: The name of the chemical or medication.
The identifying name of the active ingredient in the formulated medication.
Optional[{detail_docref=data_elements/NEHTA-10195-Active_Ingredient_Name-Data_Element.xml, fsn=Active Ingredient Name}]
Value set: ac0001

Compound

Compound: The detailed chemical name of the compound that is an active ingredient.
Optional[{detail_docref=data_elements/NEHTA-16409-Active_Ingredient_Compound-Data_Element.xml, fsn=Active Ingredient Compound}]

Strength

Strength: The amount or concentration of this ingredient.
Optional[{detail_docref=data_elements/NEHTA-16410-Active_Ingredient_Strength-Data_Element.xml, fsn=Active Ingredient Strength}]

Role

Role: The role of the ingredient.
Examples: 1. "Therapeutic". The chemical has a known and desired effect which is positive. 2. "Toxic". This chemical is toxic and has no therapeutic effect. 3. "Adjuvant". The chemical is active but aids the therapeutic effect of another ingredient.
Optional[{detail_docref=data_elements/NEHTA-16412-Active_Ingredient_Role-Data_Element.xml, fsn=Active Ingredient Role, value_domain_dc_id=16411, value_domain_name=Active Ingredient Role Values}]

Therapeutic
Toxic
Adjuvant
Other

Form

Form: The formulation or presentation of the overall substance.
It is preferred that this item be coded from the Medication Form Reference Set Value Domain. Examples: 1. Tablet. 2. Capsule. 3. Oral Drops. 4. Effervescent powder.
Optional[{coding_preferred=true, detail_docref=data_elements/NEHTA-10186-Form-Data_Element.xml, value_domain_dc_id=16618, value_domain_name=Medication Form Reference Set}]

Inactive Ingredient

Inactive Ingredient: Ingredients in the substance that are not active.
Optional[{detail_docref=data_groups/NEHTA-16413-Inactive_Ingredient-Data_Group.xml}]

Name

Name: The name of the inactive substance.
Optional[{detail_docref=data_elements/NEHTA-16415-Inactive_Ingredient_Name-Data_Element.xml, fsn=Inactive Ingredient Name}]
Value set: ac0002

Compound

Compound: The detailed chemical name of the compound which is an inactive ingredient.
Optional[{detail_docref=data_elements/NEHTA-16416-Inactive_Ingredient_Compound-Data_Element.xml, fsn=Inactive Ingredient Compound}]

Strength

Strength: The amount or concentration of this ingredient.
Optional[{detail_docref=data_elements/NEHTA-16417-Inactive_Ingredient_Strength-Data_Element.xml, fsn=Inactive Ingredient Strength}]

Role

Role: The role of the ingredient.
Examples: 1. "Additive". Inert additive. 2. "Dilutant". Inert dilutant. 3. "Propellent". Inert propellent. 4. "Preservative". The ingredient is present to prolong the life of the substance. 5. "Colouring". The ingredient is used to colour the substance.
Optional[{detail_docref=data_elements/NEHTA-16419-Inactive_Ingredient_Role-Data_Element.xml, fsn=Inactive Ingredient Role, value_domain_dc_id=16418, value_domain_name=Inactive Ingredient Role Values}]

Additive
Dilutant
Propellent
Preservative
Colouring

Dose description

Dose description: The amount and units of the medicine, vaccine or other therapeutic good to be used or administered at one time.

Dose (counted)

Dose (counted): The amount of a medication or substance for medication orders, administrations, dispensing etc.

Quantity

Quantity: The quantity, number or proportion.

Count>=1
Proportion

Annotations

CDA Mappings Template Node.Name: dose (counted)
CDA Mappings Template Node.Path: doseQuantity/[@value (numeric value) : decimal]

Quantity description

Quantity description: Free text description of the amount which may consist of the quantity and dose unit.

Dose (measured)

Dose (measured): The amount of a medication or substance for medication orders, administrations, dispensing etc.

Quantity

Quantity: The quantity, number or proportion.

Count>=1
Proportion

Annotations

CDA Mappings Template Node.Name: dose (measured)
CDA Mappings Template Node.Path: doseQuantity/[@unit : UCUM unit of measure (eg mL)]

Dose unit

Dose unit: The dose unit of this amount.
Value set: ac0001

Quantity description

Quantity description: Free text description of the amount which may consist of the quantity and dose unit.

Unusual quantity

Unusual quantity: Indicates if an unusual quantity has been prescribed deliberately.

Timing

Timing: Details of the timing of the use or administration of the medicine, vaccine or other therapeutic good.

Timing description

Timing description: The timing of the doses, which may include frequency and details such as relationship to food.

Annotations

CDA Mappings Template Node.Value Valueset: @code : HL7 event related timing code = PCM
CDA Mappings Template Node.Notes: can either have event list or free text; This needs consideration

Timing

Timing: Structured information about the timing (intended or actual) of administration or use of a medicine, other therapeutic good or other intervention that is given on a scheduled basis.

Daily count

Daily count: This is the actual or maximum number of doses or other interventions that are to be administered in a 24 hour period.

Frequency

Frequency: The frequency as number of times per time period that the intervention is to take place.
>=0; >=0; >=0; >=0; >=0; >=0; >=0
Units:

/d
/wk
/mo
/yr
/min
/s
/h

Annotations

CDA Mappings Template Node.Name: timing (period)
CDA Mappings Template Node.Path: effectiveTime/[@xsi:type = PIVL_TS][@institutionSpecified = true][@operator = A]/period/[@value (count)][@unit : UCUM time unit]

Interval

Interval: The length of time between doses or interventions. 8 Hourly is PT8H, monthly is P1M, every hour and a half is PT1H30M.

Annotations

CDA Mappings Template Node.Name: timing (period)
CDA Mappings Template Node.Path: effectiveTime/[@xsi:type = PIVL_TS][@institutionSpecified = true][@operator = A]/period/[@value (count)][@unit : UCUM time unit]

Variable frequency

Variable frequency: Details of variable upper and lower frequency e.g. 3-4 times a day.

Upper

Upper: The upper value of frequency.

Frequency

Frequency: The frequency as number of times per time period that the intervention is to take place.
>=0; >=0; >=0; >=0; >=0; >=0; >=0
Units:

/d
/wk
/mo
/yr
/min
/s
/h

Lower

Lower: The lower value of frequency.

Frequency

Frequency: The frequency as number of times per time period that the intervention is to take place.
>=0; >=0; >=0; >=0; >=0; >=0; >=0
Units:

/d
/wk
/mo
/yr
/min
/s
/h

Variable interval

Variable interval: Details of variable upper and lower intervals e.g. every 2-3 hours.

Upper

Upper: The upper value of the interval.

Interval

Interval: The length of time between doses or interventions. 8 Hourly is PT8H, monthly is P1M, every hour and a half is PT1H30M.

Lower

Lower: The lower value of the interval.

Interval

Interval: The length of time between doses or interventions. 8 Hourly is PT8H, monthly is P1M, every hour and a half is PT1H30M.

Specific time

Specific time: Specific time(s) during the day when the intervention should be applied.

Day of week

Day of week: The specific and repeating day(s) of the week.

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Day of month

Day of month: The specific and repeating day(s) of the month e.g. if it is required to give a dose on the 2nd day of each month then the value is 2.
1..31

Specific date

Specific date: A specific date when the intervention is to take place.

Parsable syntax

Parsable syntax: Complex intervention timing recorded as a parsable syntax.
Formalism

text/xml
text/plain

Start criterion

Start criterion: A condition which, when met, requires the start of administration or use.

Start date

Start date: The date and optional time to begin using the medicine, vaccine or other therapeutic good.

Stop criterion

Stop criterion: A condition which, when met, requires the cessation of administration or use.

Stop date

Stop date: The date and optional time to stop using the medicine, vaccine or other therapeutic good.

Interval of use

Interval of use: The length of time for which the medicine, vaccine or other therapeutic good should be used or administered (from the initial dose to the final dose).

Annotations

CDA Mappings Template Node.Name: interval of use
CDA Mappings Template Node.Path: effectiveTime/[@xsi:type = IVL_TS]low/@value (start date) : date; effectiveTime/[@xsi:type = IVL_TS]high/@value (finish date) : date

Number of administrations

Number of administrations: The total number of doses of the medicine, vaccine or other therapeutic good that are to be used or administered (from the initial dose to the final dose).

As-required medicine

As-required medicine: The timing is dependent within limits on the subject of care's condition or symptoms (e.g. 4hrly p.r.n. means the medicine can be taken as frequently as every four hours if necessary). "Pro re nata" in latin means as circumstances arise.

Annotations

CDA Mappings CDA.Template Name: As-required medicine
CDA Mappings CDA.Template ID: @root = 2.16.840.1.113883.2.18.7.27
CDA Mappings Template Node.Name: value
CDA Mappings Template Node.Path: precondition/criterion/value/[@xsi:type = CV][@code : SCTID]
CDA Mappings Template Node.Path CodedText: precondition/criterion/code/[@code = ASSERTION][@codeSystem = 2.16.840.1.113883.5.4]

Regular

Regular: Depicts regular medicines of patient

Once only

Once only: Once only medicines

Long-term

Long-term: It is anticipated that the medicine, vaccine or therapeutic good will be re-prescribed or re-dispensed over a period of time.

Additional instruction

Additional instruction: An additional statement on how to use the medicine, vaccine or other therapeutic good.

Clinical Indication

Clinical Indication: A reason for ordering the medicine, vaccine or other therapeutic good.

Annotations

CDA Mappings CDA.Template Name: indication
CDA Mappings CDA.Template ID: @root = 2.16.840.1.113883.2.18.7.22.4
CDA Mappings Template Node.Name: value
CDA Mappings Template Node.Path: entryRelationship/[@typeCode = RSON]observation/[@classCode = OBS][@moodCode = EVN]value/displayName
CDA Mappings Template Node.Value Valueset: [@xsi:type = CV][@code (problem) : SCTID][@displayName : text]
CDA Mappings Template Node.Path CodedText: code/[@code : LOINC][@displayName = "Indication"]

Medication administration

Medication administration: Information about the future or actual administration of medication.

Route

Route: The route by which the medication is administered (e.g. oral, sublingual etc).

Annotations

CDA Mappings Template Node.Name: routeCode
CDA Mappings Template Node.Path: routeCode/[@displayName : text (eg Oral)]
CDA Mappings Template Node.Value Valueset: routeCode/[@codeSystem = 2.16.840.1.113883.5.112][@codeSystemName = "Route of Administration"]
CDA Mappings Template Node.Path CodedText: routeCode/[@code : HL7 Route Of Administration (eg PO)]

Site

Site: A description of the site of administration.

Delivery method

Delivery method: The method of delivery if this should be specified (e.g. via a nebuliser or spacer).

Dose duration

Dose duration: The length of time over which to administer each dose (e.g. an intravenous administration may have to be over a period of 5 minutes).
>=P0Y

Reconciliation

Reconciliation: Capture detailed reconciliation information

Patient accounts

Patient accounts: Patient accounts of medication-related events e.g. missed doses or adverse events;

Discrepancy and resolution

Discrepancy and resolution: Discrepancies found and actions taken to amend

Own medication

Own medication: Medicine brought by patient

Comment

Comment: Comments about reconciliation

Information source

Information source: details of the sources of information used eg, the given and family name(s) of the person contacted and contact telephone number, email and/or address

Provider

Provider: Health provider as per NZ Health Practitioner Index (HPI) HISO 10005. Includes: provider person, organisation and facility

Annotations

CDA Mappings CDA.Template Name: health worker
CDA Mappings CDA.Template ID: @root = 2.16.840.1.113883.2.18.7.5.19; @extension : HPI Person Number
CDA Mappings Template Node.Name: prescriber
CDA Mappings Template Node.Path: performer/health worker

Provider Person

Provider Person: *

Common Person Number (CPN)

Common Person Number (CPN): A unique lifetime identifier for an individual, which takes precedence over all other identifiers (Practitioner and Health Worker) across the HPI.

Person Confidentiality Flag

Person Confidentiality Flag: Information about a person with this flag set to ‘Y’ (Yes) should not be accessible to the public or other users because of a risk of harm to the person, e.g. in accordance with the criteria and process described in sections 108 to 120 of the Domestic Violence Act 1995.

Person Identifier

Person Identifier: *

Source Person Identifier

Source Person Identifier: *

Assigning Source

Assigning Source: *

Identifier Type

Identifier Type: *

Person Name

Person Name: *

Person Name Type

Person Name Type: *

Name Prefix

Name Prefix: *

Given Name

Given Name: *

Second further given name(s) or initials thereof

Second further given name(s) or initials thereof: *

Surname Prefix

Surname Prefix: *

Surname

Surname: *

Suffix

Suffix: *

Service Type Details

Service Type Details: *

Job Role

Job Role: *

Job Title Description

Job Title Description: *

Practitioner Status

Practitioner Status: *

Practitioner Status Start Date

Practitioner Status Start Date: *

Practitioner Status Finish Date

Practitioner Status Finish Date: *

Health Worker Status

Health Worker Status: *

Practitioner Initial Registration Date

Practitioner Initial Registration Date: *

Practitioner Practising Certificate Start Date

Practitioner Practising Certificate Start Date: *

Practitioner Practising Certificate Finish Date

Practitioner Practising Certificate Finish Date: *

Demographic Detail

Demographic Detail: *

Sex

Sex: *

Ethnicity

Ethnicity: *

Date of Birth

Date of Birth: *

Language

Language: *

Language

Language: *

Ability

Ability: *

Proficiency

Proficiency: *

Practitioner Qualification

Practitioner Qualification: *

Qualification

Qualification: *

Granting Institution

Granting Institution: *

Granting Institution City

Granting Institution City: *

Granting Institution Country

Granting Institution Country: *

Qualification Year

Qualification Year: *

Practitioner Scope of Practice

Practitioner Scope of Practice: *

Practitioner Scope of Practice

Practitioner Scope of Practice: *

Practitioner Scope of Practice Start Date

Practitioner Scope of Practice Start Date: *

Practitioner Scope of Practice Finish Date

Practitioner Scope of Practice Finish Date: *

Conditions on Practice Description

Conditions on Practice Description: *

Conditions on Practice Description Start Date

Conditions on Practice Description Start Date: *

Conditions on Practice Description Finish Date

Conditions on Practice Description Finish Date: *

Additional Authorisations

Additional Authorisations: *

Additional Authorisations Start Date

Additional Authorisations Start Date: *

Additional Authorisations Finish Date

Additional Authorisations Finish Date: *

Address for Kiwis

Address for Kiwis: To record details of one or more personal addresses; extended for NZ

Address

Address: One or more adresses for an individual.

Address type

Address type: The type of address. Align with HL7 Table

Residential
Correspondence
Business
Temporary

Unstructured address

Unstructured address: A postal address expressed in an unstructured format. ENV 13606 - 4:2000 7.11.15.

Structured address

Structured address: The structure of a postal address representing the residence of a patient or the physical location of an organisation. ENV 13606-4:2000 7.11.1.

Unit

Unit: *

Property number

Property number: The number of the property.

Address line

Address line: A series of address lines.

Building name

Building name: *

Delivery

Delivery: *

Suburb

Suburb: *

Town

Town: *

Country

Country: *

Post code

Post code: Post code.

Geocode

Geocode: *

Domicile code

Domicile code: *

Meshblock ID

Meshblock ID: *

NZDeprivation index

NZDeprivation index: *

DHB catchment

DHB catchment: *

Northland
Waitemata
Auckland
Counties Manukau
Waikato
Lakes
Bay of Plenty
Tairawhiti
Hawkes Bay
Taranaki
MidCentral
Whanganui
Capital and Coast
Hutt
Wairarapa
Nelson Marlborough
West Coast
Canterbury
South Canterbury
Otago
Southland

AddressValid Period

AddressValid Period: The period during which the associated address is applicable to the person / organisation. ENV 13606 - 4:2000 7.11.11. This describes the actual period.

Valid from

Valid from: The start of the period for which this address is valid.

Valid to

Valid to: Date from which the Address is no longer valid.

Communication

Communication: data elements detailing the method used to contact a person by electronic means of communication. This is not about transmission of confidential data but the way in which a person is contacted.

Communication Usage

Communication Usage: The classification that specifies the way in which the communication medium is intended to be used, e.g. for business, in an emergency, etc.

Communication Medium

Communication Medium: The code representing the type of COMMUNICATION MEDIUM used, e.g. e-mail, telephone, pager, etc.

Communication Details

Communication Details: COMMUNICATION DETAILS may comprise an address or number.

Communication Confidentiality Flag

Communication Confidentiality Flag: Communication details with a NO flag may be made public; if the flag is YES this information is confidential.

Provider Organisation

Provider Organisation: *

Organisation Identifier

Organisation Identifier: *

Organisation Identifier

Organisation Identifier: *

Organisation Identifier Check Digit

Organisation Identifier Check Digit: *

Organisation Name

Organisation Name: *

Organisation Name Type

Organisation Name Type: *

Organisation Name

Organisation Name: *

Organisation Services

Organisation Services: *

Organisation Type

Organisation Type: *

Organisation Establishment Date

Organisation Establishment Date: *

Organisation Disestablishment Date

Organisation Disestablishment Date: *

Address for Kiwis

Address for Kiwis: To record details of one or more personal addresses; extended for NZ

Address

Address: One or more adresses for an individual.

Address type

Address type: The type of address. Align with HL7 Table

Residential
Correspondence
Business
Temporary

Unstructured address

Unstructured address: A postal address expressed in an unstructured format. ENV 13606 - 4:2000 7.11.15.

Structured address

Structured address: The structure of a postal address representing the residence of a patient or the physical location of an organisation. ENV 13606-4:2000 7.11.1.

Unit

Unit: *

Property number

Property number: The number of the property.

Address line

Address line: A series of address lines.

Building name

Building name: *

Delivery

Delivery: *

Suburb

Suburb: *

Town

Town: *

Country

Country: *

Post code

Post code: Post code.

Geocode

Geocode: *

Domicile code

Domicile code: *

Meshblock ID

Meshblock ID: *

NZDeprivation index

NZDeprivation index: *

DHB catchment

DHB catchment: *

Northland
Waitemata
Auckland
Counties Manukau
Waikato
Lakes
Bay of Plenty
Tairawhiti
Hawkes Bay
Taranaki
MidCentral
Whanganui
Capital and Coast
Hutt
Wairarapa
Nelson Marlborough
West Coast
Canterbury
South Canterbury
Otago
Southland

AddressValid Period

AddressValid Period: The period during which the associated address is applicable to the person / organisation. ENV 13606 - 4:2000 7.11.11. This describes the actual period.

Valid from

Valid from: The start of the period for which this address is valid.

Valid to

Valid to: Date from which the Address is no longer valid.

Communication

Communication Usage

Communication Usage: The classification that specifies the way in which the communication medium is intended to be used, e.g. for business, in an emergency, etc.

Communication Medium

Communication Medium: The code representing the type of COMMUNICATION MEDIUM used, e.g. e-mail, telephone, pager, etc.

Communication Details

Communication Details: COMMUNICATION DETAILS may comprise an address or number.

Communication Confidentiality Flag

Communication Confidentiality Flag: Communication details with a NO flag may be made public; if the flag is YES this information is confidential.

Provider Facility

Provider Facility: *

Facility Name

Facility Name: *

Facility Name Type

Facility Name Type: *

Facility Name

Facility Name: *

Facility Identifier

Facility Identifier: *

Facility Identifier

Facility Identifier: *

Facility Identifier Check Digit

Facility Identifier Check Digit: *

Facility Service

Facility Service: *

Facility Establishment Date

Facility Establishment Date: *

Facility Disestablishment Date

Facility Disestablishment Date: *

Address for Kiwis

Address for Kiwis: To record details of one or more personal addresses; extended for NZ

Address

Address: One or more adresses for an individual.

Address type

Address type: The type of address. Align with HL7 Table

Residential
Correspondence
Business
Temporary

Unstructured address

Unstructured address: A postal address expressed in an unstructured format. ENV 13606 - 4:2000 7.11.15.

Structured address

Structured address: The structure of a postal address representing the residence of a patient or the physical location of an organisation. ENV 13606-4:2000 7.11.1.

Unit

Unit: *

Property number

Property number: The number of the property.

Address line

Address line: A series of address lines.

Building name

Building name: *

Delivery

Delivery: *

Suburb

Suburb: *

Town

Town: *

Country

Country: *

Post code

Post code: Post code.

Geocode

Geocode: *

Domicile code

Domicile code: *

Meshblock ID

Meshblock ID: *

NZDeprivation index

NZDeprivation index: *

DHB catchment

DHB catchment: *

Northland
Waitemata
Auckland
Counties Manukau
Waikato
Lakes
Bay of Plenty
Tairawhiti
Hawkes Bay
Taranaki
MidCentral
Whanganui
Capital and Coast
Hutt
Wairarapa
Nelson Marlborough
West Coast
Canterbury
South Canterbury
Otago
Southland

AddressValid Period

AddressValid Period: The period during which the associated address is applicable to the person / organisation. ENV 13606 - 4:2000 7.11.11. This describes the actual period.

Valid from

Valid from: The start of the period for which this address is valid.

Valid to

Valid to: Date from which the Address is no longer valid.

Communication

Communication Usage

Communication Usage: The classification that specifies the way in which the communication medium is intended to be used, e.g. for business, in an emergency, etc.

Communication Medium

Communication Medium: The code representing the type of COMMUNICATION MEDIUM used, e.g. e-mail, telephone, pager, etc.

Communication Details

Communication Details: COMMUNICATION DETAILS may comprise an address or number.

Communication Confidentiality Flag

Communication Confidentiality Flag: Communication details with a NO flag may be made public; if the flag is YES this information is confidential.

Relationship

Relationship: *

Relationship Type

Relationship Type: *

Relationship Entity One

Relationship Entity One: *

Relationship Entity Two

Relationship Entity Two: *

Relationship Commencement Date

Relationship Commencement Date: *

Relationship Termination Date

Relationship Termination Date: *

Last change reason

Last change reason: reasons for any medicine change eg, form, dose, frequency, stops, starts

Annotations

CDA Mappings Template Node.Name: last change reason
CDA Mappings Template Node.Path: entryRelationship/[@typeCode = SPRT]act/[@classCode = INFRM][@moodCode = EVN]code/[@displayName]
CDA Mappings Template Node.Name Valueset: @code = CHGRSON
CDA Mappings Template Node.Value Valueset: [@codeSystem = 2.16.840.1.113883.2.18.38][@codeSystemName = "Prescription item property"]

Last change

Last change: All collected lists should account for any changes to medicines found within a minimum six-week period (start, stop, continue or change)

Started
Stopped
Continued
Changed

Annotations

CDA Mappings Template Node.Name: last change
CDA Mappings Template Node.Path: entryRelationship/[@typeCode = COMP]/observation/[@classCode = OBS][@moodCode = EVN]value/@displayName
CDA Mappings Template Node.Value Valueset: [@xsi:type = CV][@code = started | stopped | continued | changed][@displayName : text (eg started)][@codeSystem = 2.16.840.1.113883.2.18.37.3]
CDA Mappings Template Node.Path CodedText: entryRelationship/[@typeCode = COMP]/observation/[@classCode = OBS][@moodCode = EVN]code/[@code : LOINC = 33999-4?]

Dispensing

Dispensing: Information for the dispenser.

Deferred supply

Deferred supply: True if the supply of the medication has been deferred

Deferred supply reason

Deferred supply reason: Information relating to the reason for deferred supply

Amount of medication

Amount of medication: The amount of a medication or substance for medication orders, administrations, dispensing etc.

Quantity

Quantity: The quantity, number or proportion.

Count>=1
Proportion

Dose unit

Dose unit: The dose unit of this amount.
Value set: ac0001

Quantity description

Quantity description: Free text description of the amount which may consist of the quantity and dose unit.

Number of repeats

Number of repeats: The number of times the expressed quantity of medicine, vaccine or other therapeutic good may be refilled or redispensed without a new prescription.
>=0

Minimum interval between repeats

Minimum interval between repeats: The minimum time between repeat dispensing of the medicine, vaccine or therapeutic good. Note: This is specified by the ordering clinician for a specific reason such as safety or best practice.

Brand substitution permitted

Brand substitution permitted: Indicates whether or not the substitution of a prescribed medicine with a different brand name of the same medicine, vaccine or other therapeutic good, which has been determined as bioequivalent, is allowed when the medication is dispensed/supplied.

Dispensing instructions

Dispensing instructions: Additional instructions to the person dispensing the medicine, vaccine or other therapeutic good.

Comment

Comment: Any additional information that may be needed to ensure the continuity of supply, rationale for current dose and timing, or safe and appropriate use.

Protocol

Medication Instruction Id

Medication Instruction Id: An identifier used in an external system and associated with this medication instruction.

Restrictions

Restrictions: e.g. Section 29 medicines - not all included in NZMT

Endorsements

Endorsements: Any special endorsements by providers for subsidy

ID: Identifier for endorsement

Type

Type: Type of endorsement

Special authority
Specialist endorsement
Other endorsement

Expiry date

Expiry date: the date endorsement expires

Privacy

Privacy: Patient privacy related info

Private

Private: True if patient wants the item to be kept confidential

Patient view consent

Patient view consent: True if patient is consenting that their information be visible through a repository.

Comment

Comment: Comments about privacy related issues

Medication action for New Zealand

Medication action for New Zealand: Details of use, administration, dispensing or other care step relating to a medicine, vaccine or other therapeutic good which may arise from an instruction from a clinician.

Description

Medicine

Medicine: The medicine, vaccine or other therapeutic good which was the focus of the action.

Coded Text Value set: ac0001
Text

Instructions

Instructions: Any instructions given to the subject of care or carer at the time of the action.

Chemical Description of Medication

Active Ingredient

Name

Compound

Strength

Strength: The amount or concentration of this ingredient.
Optional[{detail_docref=data_elements/NEHTA-16410-Active_Ingredient_Strength-Data_Element.xml, fsn=Active Ingredient Strength}]

Role

Therapeutic
Toxic
Adjuvant
Other

Form

Inactive Ingredient

Inactive Ingredient: Ingredients in the substance that are not active.
Optional[{detail_docref=data_groups/NEHTA-16413-Inactive_Ingredient-Data_Group.xml}]

Name

Name: The name of the inactive substance.
Optional[{detail_docref=data_elements/NEHTA-16415-Inactive_Ingredient_Name-Data_Element.xml, fsn=Inactive Ingredient Name}]
Value set: ac0002

Compound

Strength

Strength: The amount or concentration of this ingredient.
Optional[{detail_docref=data_elements/NEHTA-16417-Inactive_Ingredient_Strength-Data_Element.xml, fsn=Inactive Ingredient Strength}]

Role

Additive
Dilutant
Propellent
Preservative
Colouring

Reason

Reason: The reason(s) the specific action or step was carried out. Note: This is not the reason for the medication instruction, rather the specific reason e.g. for administration or for ceasing the medication.

Dose (counted)

Dose (counted): The amount of a medication or substance for medication orders, administrations, dispensing etc.

Quantity

Quantity: The quantity, number or proportion.

Count>=1
Proportion

Quantity description

Quantity description: Free text description of the amount which may consist of the quantity and dose unit.

Dose (measured)

Dose (measured): The amount of a medication or substance for medication orders, administrations, dispensing etc.

Quantity

Quantity: The quantity, number or proportion.

Count>=1
Proportion

Dose unit

Dose unit: The dose unit of this amount.
Value set: ac0001

Quantity description

Quantity description: Free text description of the amount which may consist of the quantity and dose unit.

Comment

Comment: A comment on the action taken.

Sequence number

Sequence number: The sequence number specific to the action being recorded.

Medication administration

Medication administration: Information about the future or actual administration of medication.

Route

Route: The route by which the medication is administered (e.g. oral, sublingual etc).

Site

Site: A description of the site of administration.

Delivery method

Delivery method: The method of delivery if this should be specified (e.g. via a nebuliser or spacer).

Dose duration

Dose duration: The length of time over which to administer each dose (e.g. an intravenous administration may have to be over a period of 5 minutes).
>=P0Y

Brand substituted

Brand substituted: A different brand of the same medicine, vaccine or other therapeutic good was substituted for the one nominated in the order.

Protocol

BatchID

BatchID: Assigned by the manufacturer to identify the manufacturing batch of the item.

Expiry date

Expiry date: The expiry date of the medicine administered as documented by the manufacturer.

Dispensed to

Dispensed to: The name of the person to whom this was dispensed, if not the subject of care.

Number of times dispensed

Number of times dispensed: The number of times this order has been dispensed. The sum of this number minus one and the remaining repeats provides the number of repeats on the original order.

Remaining repeats

Remaining repeats: The number of times the medicine, vaccine or other therapeutic good may still be dispensed without re-issue of a prescription or order. Note: This is the information required by the subject of care and prescriber.
>=0

Claim category

Claim category: The category of reimbursement or subsidy sought for the item.

Exclusion Statement - Medications

Exclusion Statement - Medications: Statement to positively assert that the patient has not been prescribed or is not taking certain medication.
To positively record the absence or exclusion of any medication use within the health record.
Optional[{detail_docref=data_groups/NEHTA-16136-Exclusion_Statement_Medications-Data_Group.xml, spec_id=105}]

Data

Global Statement

Global Statement: The statement about the absence or exclusion of certain medication.
Use to capture any information that is needed to be explicitly recorded as being absent or excluded within the record.
Optional[{detail_docref=data_elements/NEHTA-16302-Global_Statement-Data_Element.xml}]
Value set: ac0.5

Not Currently Taking

Not Currently Taking: Positive statement about medications that are explicitly not being taken or used at the time of recording.
It is preferred that this item be coded from the Not Currently Taking Values Value Domain.
Optional[{coding_preferred=true, detail_docref=data_elements/NEHTA-16310-Not_Currently_Taking-Data_Element.xml, value_domain_dc_id=16310, value_domain_name=Not Currently Taking Values}]

Not Ever Taken

Not Ever Taken: Positive statement about medications that are explicitly known not to have ever been taken or used at the time of recording.
It is preferred that this item be coded from the Not Ever Taken Values Value Domain.
Optional[{coding_preferred=true, detail_docref=data_elements/NEHTA-16311-Not_Ever_Taken-Data_Element.xml, value_domain_dc_id=16311, value_domain_name=Not Ever Taken Values}]

Absence of Information

Absence of Information: Statement that there is no relevant information available, neither a positive presence nor a positive exclusion.

Data

Absence Statement

Absence Statement: Statement explicitly expressing the absence of available information.
Coding with a terminology is desirable, where possible. For example: "No information available about adverse reactions"; No information available about problems or diagnoses"; "No information available about previous procedures performed"; or "No information available about medications used".