A Medication Statement is concerned with stating information about medication use. The medications in the statements may or may not have been prescribed. Medication statements may include "negative" statements. The source of this information is obtained in the form of one or more statements from:
- patient self reporting
- patient and non-patient narratives gathered by health care professionals (physicians, pharmacists, nurses, etc.)
The above definition implies that there is an exchange of information between two persons: a patient – clinician, non-patient – clinician. In the case of a patient self reporting, this is in effect a patient – clinician interaction with the system that stores the data in the middle
All of the following are NOT Medication Statements:
- Medication Orders (may contain prescriptions)
- Medication Administrations – these are documented events that describe the medication, the time of administration and other related administration information. These specific documented events are NOT the same as Medication Statements.
- Medication Dispenses – these represent the dispensed medication supply to a patient or other representative.
- Medication Reconciliation – this process uses Medication Orders, Medication Administrations, Medication Dispenses and Medication Statements to inform the clinicians’ judgment about the current status of the patient’s medications. Often this is done when there is a change of care delivery setting – admission to hospital or other healthcare setting, transfer from one type of care setting to another e.g. from hospital to LTC or Rehab. This process may result in new Medication Statements.
- Medication statement - need to add distinguish from med administration
Both are about actual use but one is single record and the other is an aggregation
- Need to say a machine generated summary is also a medication statement
- Medication statements are not actionable - they have a null mood code.