Medication Administration and Statement Topic Scope

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Scope Statement

This topic provides interactions for exchanging information about medication use by patients between community and institutional health care systems . The specific types of interactions will include notification, request/response and query/response interactions. The content in the messages includes medication information constructed from:

• patient self reporting
• patient narratives gathered by health care professionals (physicians, pharmacists, nurses, etc.)
• institutional administration records

The business process being modelled is only concerned with recording of medication information; it does NOT cover any processes of medication order fulfilment (these are dealth with in other topics).

Example sources of information:

• Pharmacy records of Over The Counter (OTC) purchases
• Patient entering medication profile by means of a web or other portal
• Health care professional taking a patient history
• Institutional (e.g. hospital, clinic, ER) medication administration records
• Insurance (claims) records

Definitions

Medication List – A list of medications and associated information, pertaining to a specific patient, constructed for a specific purpose. There is more than one type of medication list, for example:

• Active medication orders in an institutional setting.
• A list of all historical medication orders, some may be active and some may no longer be active.
• A list of patient reported current medications. This list may include prescribed and over the counter medications the patient is currently taking.
• Admission Medication List – the list of medications the patient is using just before admission to a healthcare institution.
• Discharge Medications list – the list of medications the patient will be taking after discharge from a healthcare institution.
• The Medication Administration Record list – this is a list of all medications the patient has been administered during an institutional visit, including details about dose, route, time of administration and who administered the medication. This list may also include the schedule for future medication administrations.
• A list of medications that have been dispensed from a specific pharmacy, or perhaps the list of all medications that have been dispensed from multiple pharmacies.
• The list of medications that a health care professional has documented during a patient history session .

Medication History – An organization of historical medication information. Medication History can also be presented as a list of medication information.