| TEMPLATE ID | *CL 7.3 Medication List |
|---|---|
| Concept | *CL 7.3 Medication List |
| Description | Not Specified |
| Purpose | Not Specified |
| References | |
| Other Details (Language Independent) |
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| Language used | en |
| Citeable Identifier | 1013.26.805 |
| Root archetype id | openEHR-EHR-COMPOSITION.medication_list.v0 |
| Medication list | Medication list: A persistent and managed list of medications that are reasonably assumed to be taken by the individual and that may influence clinical decision-making and care provision. |
| Medication order | Medication order: Instructions for use of a medication, vaccine or other therapeutic item. |
| Order | Order: Order. |
| Description | |
| Medication item | Medication item: Identification of the medication, vaccine or other therapeutic item being ordered. 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. Annotations
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| Route | Route: The route of administration. For example: 'oral', 'intravenous', or 'topical'. |
| Dose directions description | Dose directions description: Complete narrative description about how the medication is to be used. Including the amount, when to take it and 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 dosage directions fully in computable form, partial representation is not recommended, and the directions should be only recorded in narrative form using this data element. |
| Medication safety | Medication safety: Details about medication safety for the medication, vaccine or other therapeutic item. |
| Maximum dose | Maximum dose: Details about the maximum dose allowed over a defined period. 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. |
| Maximum amount | Maximum amount: The maximum amount of medication allowed in the allowed period. For example: 1, 1.5, 0.125. >=0 |
| Maximum amount dose unit | Maximum amount dose unit: The dose unit for the maximum amount allowed. For example: 'tablet','mg'. Coding of the dose unit with a terminology is preferred, where possible. |
| Maximum class amount | Maximum class amount: The maximum amount of this medication item, expressed as a percentage of the total dose for this class of medication during the allowed period. Where diferent drugs of the same class are used, such as anti-pschotics, each drug may be allocated a nominal percentage figure which represents its contribution to a maximal 100% dose (usually per day). In some circumstances the ordering clinician may want to override the 100% limit to a greater or smaller amount.
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| Allowed period | Allowed period: The allowed period of time. >=P0Y |
| Exceptional dose override? | Exceptional dose override?: Confirmation by the prescriber that the normal dose has been overridden due to exceptional circumstances? |
| Cumulative maximum dose | Cumulative maximum dose: Details about the maximum total dose allowed over a lifetime. |
| Maximum amount | Maximum amount: The maximum amount of medication allowed in the allowed period. For example: 1, 1.5, 0.125. >=0 |
| Maximum amount dose unit | Maximum amount dose unit: The dose unit for the maximum amount allowed. For example: 'tablet','mg'. Coding of the dose unit with a terminology is preferred, where possible. |
| Dose goal | Dose goal: Details about the proposed total daily amount of medication. The dose goal will record the expected effective dose, and thus support titration of an initial low dose towards the effective dose over a period of time. |
| Total daily dose amount | Total daily dose amount: The amount of medication which is intended to be taken each day if the medication is administered as intended. >=0 |
| Total daily dose unit | Total daily dose unit: The dose unit associated with the total daily dose amount. The dose units are normally scientific units such as mg, ml rather than 'tablets'. |
| Additional instruction | Additional instruction: An additional instruction on how to use the medication, vaccine or other therapeutic good. For example: 'take with food'. This data element allows multiple occurrences. |
| Patient guidance | Patient guidance: An additional instruction directed primarily at the patient or carers. For example: 'To reduce your blood pressure', 'To thin your blood', 'Avoid grapefruit'. This data element allows multiple occurrences. |
| Monitoring instruction | Monitoring instruction: An additional instruction which gives advice on appropriate monitoring of the medication. For example: 'Please check renal function in 2 weeks'. This data element allows multiple occurrences. |
| Clinical indication | Clinical indication: The clinical reason for ordering the medication, vaccine or other therapeutic good. For example: 'Angina'. Coding of the clinical indication with a terminology is preferred, where possible. This data element allows multiple occurrences. |
| Therapeutic intent | Therapeutic intent: The overall theraputic intent of the medication. For example: 'palliative', 'low-dose propylaxis'. |
| Course details | Course details: Details about the intended course of the medication. |
| Order start date/time | Order start date/time: The date and optional time to commence use of the medication, vaccine or other therapeutic good. |
| Order stop date/time | Order stop date/time: The date and optional time to cease use of the medication, vaccine or other therapeutic good. |
| Order start criterion | Order start criterion: A condition which, when met, requires the commencement of administration or use. For example: 'Start if symptoms recur'. |
| Order stop criterion | Order stop criterion: A condition which, when met, requires the cessation of administration or use. For example: 'Stop after symptoms disappear''. |
| Duration of course already complete | Duration of course already complete: The time period during which the patient has already been using the medication, vaccine or other therapeutic good, as a part of the proposed overall course but prior to the issue of this order. 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. >=PT0H Units:
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| Administrations already complete | Administrations already complete: The number of administrations of the medication, vaccine or other therapeutic good that have been completed, as part of the proposed overall course but prior to the issue of this order. For example: To record that the patient had been taking antibiotics three days prior to hospital admission, in the context of a 7-day course. |
| Administration directions | Administration directions: Details about the administration of the medication, vaccine or other therapeutic good. |
| Body site | Body site: Identification of the site of administration of the medication, vaccine or therapeutic good. For example: 'left upper arm', 'intravenous catheter right hand'. |
| Dispense directions | Dispense directions: Details about the dispensing of the medication, vaccine or other therapeutic good. |
| Dispense instruction | Dispense instruction: An additional instruction directed primarily at the person dispensing the medication, vaccine or therapeutic good. |
| Dispense supply | Dispense supply: Details about the amount of medication to be supplied by the dispenser. |
| Dispense description | Dispense description: Narrative description of amount of medication to be dispensed. For example: '30 tablets'. This data element is intended for use in clinical situations where dispensingthis cannot be handled by a structured expression. Where the dispensing 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 dosage directions fully in computable form, partial representation is not recommended, and the directions should be only recorded in narrative form using this data element. |
| Dispense amount | Dispense amount: The amount of medication, vaccine or therapeutic good to be dispensed. For example: 1, 1.5, or 0.125. >=0 |
| Dispense unit | Dispense unit: The dose unit or pack unit associated with the dispense amount. For example: 'tablets', 'packs', ml'. |
| Duration of supply | Duration of supply: The period of time for which the medication should be dispensed. The dispenser is asked to supply sufficient quantity of medication to cover the defined period. >=P0Y Units:
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| Start date | Start date: The date after which the medication is permitted to be dispensed for the first time. May be used to control the time of dispensing of medications with potential for abuse. For example: benzodiazepines or analgesics. |
| Substitution permitted | Substitution permitted: Indicates if substitution of a bioequivalent medication, vaccine or therapeutic good during dispensing is acceptable to the prescribing clinician. In many jurisdictions, substitution of a prescribed medication, vaccine or other therapeutic good 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. |
| Substitution reason | Substitution reason: The reason for a substitution or non-substitution decision. |
| Priority | Priority: An indicator of the urgency with which the medication should be dispensed. |
| Protocol | Protocol: The amount and units of the medication, vaccine or other therapeutic good to be used or administered at one time. |
| Order identifier | Order identifier: Unique identifier for the medication order. |
| Dosage formula | Dosage formula: The formula used to calculate the Dose amount or administration rate where this is dependent on some other factor such as patient weight. For example: 10mg/kg/day. |
| Exclusion of a Medication | Exclusion of a Medication: Statement/s about use of medication that needs to be positively recorded as clinically excluded from the health record ata a specific point in time. |
| Data | |
| Exclusion Statement | Exclusion Statement: A statement about exclusion of use of medication in the health record. The statement can support recording that no medications are being taken or that one or more specified medications are not being taken. For example: "Not currently taking any medications"; "Never taken any medications" or "Not currently taking corticosteroids".
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| Protocol | |
| Date Last Updated | Date Last Updated: The date at which the exclusion was last clinically asserted, affirmed or confirmed. |
| Absence of Information | Absence of Information: Statement that specified health information is not available for inclusion in the health record or extract at the time of recording. |
| Data | |
| Absence statement | Absence statement: Positive statement that no information is available. 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".
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| Protocol | |
| Last updated | Last updated: The date at which the absence was last updated. |