| ARCHETYPE ID | openEHR-EHR-INSTRUCTION.medication_order_gr1.v3 |
| Concept | Medication order |
| Description | An order for a medication, vaccine, nutritional product or other therapeutic item for an identified individual. |
| Use | Use 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. |
| Misuse | Not 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. |
| Purpose | To record all aspects of an order of a medication, vaccine, nutritional product or other therapeutic item for an identified individual. |
| References | Derived from: <Add reference to original resource here> 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, HiGHmed |
| Authors | Author name: Ian McNicoll Organisation: freshEHR Clinical Informatics Email: ian@freshehr.com Date originally authored: 2015-10-21 |
| Other Details Language | Author 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 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=HiGHmed, references=Derived from: |
| Keywords | medication, order, prescribe, therapy, substance, drug, therapeutic, otc, therapeutic good, pharmaceutical, product, posology, treatment, fluid, nutrition, CPOE, medicine |
| Lifecycle | in_development |
| UID | 4173ce20-8ed6-4acd-a7f0-5e65a937041c |
| Language used | en |
| Citeable Identifier | 1246.145.1886 |
| Revision Number | 3.0.0-alpha |
| All | Archetype [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 (openEHR Editor) Koray Atalag, University of Auckland, New Zealand Silje Ljosland Bakke, Helse Vest IKT AS, 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 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, Atomica Informatics, 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 Lars Morgan Karlsen, DIPS ASA, Norway 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=
openEHR-EHR-CLUSTER.medication.v1 and specialisations or openEHR-EHR-CLUSTER.medication.v2 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_TEXT, bindings=null, values=, 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_ openEHR-EHR-CLUSTER.anatomical_ openEHR-EHR-CLUSTER.anatomical_ 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=This SLOT has been designed to be used with the CLUSTER.therapeutic_direction archetype to enable recording of a complex set of dosage and timing directions. While it's possible to use other CLUSTER archetypes within this SLOT, it's strongly advised to do so only when predictable queryability is not a priority., 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_ , 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[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_ openEHR-EHR-CLUSTER.medication_ All not explicitly excluded archetypes, extendedValues=null]]}, 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=0..1, cardinalityText=optional, 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] |