TEMPLATE KDS_Medikamentenverabreichungen (KDS_Medikamentenverabreichungen)

TEMPLATE IDKDS_Medikamentenverabreichungen
ConceptKDS_Medikamentenverabreichungen
DescriptionZur Repräsentation der Medikation, die eine Person eingenommen oder angewendet hat bzw. die einer Person verabreicht wurde. Das Template stellt die erfolgte Einnahme, Anwendung oder Verabreichung für einzelne Medikamenten dar. Dabei kann es sich sowohl um verschreibungspflichtige Medikamente, als auch um OTC-Präparate handeln, welche eine Person in Eigenverantwortung verwendet. Hierbei muss die Information über die erfolgte Einnahme, Anwendung oder Verabreichung bzw. die entsprechende Dokumentation aus gesicherter Quelle kommen.
UseZur Repräsentation von Medikamenten, die einer Person verabreicht wurden oder die eine Person eingenommen bzw. angewendet hat. Das Template dient nur zum Erfassen einzelner Einnahmen, Anwendungen oder Verabreichungen, die tatsächlich erfolgt sind.
MisuseNicht zur Repräsentation spezifischer Medikamententherapie oder Medikamentenklassen, die weitere Angaben erfordern (z. B. Protokoll bei Chemotherapie). Dafür bitte eigene Templates anlegen. Nicht für die Darstellung von Medikationsplänen, unvollständigen Verabreichungsinformation, nicht gesicherter Verabreichungsinformation oder zukünftiger Verabreichungen. Dafür wird das Template KDS_Medikationseintrag verwendet.
PurposeZur Repräsentation der Medikation, die eine Person eingenommen oder angewendet hat bzw. die einer Person verabreicht wurde. Das Template stellt die erfolgte Einnahme, Anwendung oder Verabreichung für einzelne Medikamenten dar. Dabei kann es sich sowohl um verschreibungspflichtige Medikamente, als auch um OTC-Präparate handeln, welche eine Person in Eigenverantwortung verwendet. Hierbei muss die Information über die erfolgte Einnahme, Anwendung oder Verabreichung bzw. die entsprechende Dokumentation aus gesicherter Quelle kommen.
References
Authorsdate: 2021-03-17; name: Shilpa Aguduri; organisation: University Clinic Heidelberg; email: shilpa.aguduri@med.uni-heidelberg.de
Other Details Languagedate: 2021-03-17; name: Shilpa Aguduri; organisation: University Clinic Heidelberg; email: shilpa.aguduri@med.uni-heidelberg.de
OtherDetails Language Independent{original_language=ISO_639-1::de, PARENT:MD5-CAM-1.0.1=005501C1FA493A4838F5F1121F2870EC, MD5-CAM-1.0.1=2299c71ea512c752f1cb54fce27284af, sem_ver=5.0.1, build_uid=92e58be7-b4b5-48f7-890f-9c3f3f267f40}
KeywordsMedikation; Medikamentenanwendung; Arzneimittel; Arzneimittelverabreichungen, Medikamentenverabreichungen, Kerndatensatz, Medication Administration
Language useden
Citeable Identifier1246.169.1638
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.report.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1], code=at0000, itemType=COMPOSITION, level=0, text=KDS_Medikamentenverabreichungen, description=Document to communicate information to others, commonly in response to a request from another party., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=COMPOSITION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=null, code=null, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=1, text=Other Context, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Report ID, description=Identification information about the report., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=2, text=Status, description=The status of the entire report. Note: This is not the status of any of the report components., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminology: http://terminology.hl7.org/CodeSystem/medication-admin-status
  • In Progress 
  • Not Done 
  • On Hold 
  • Completed 
  • Entered in Error 
  • Stopped 
  • Unknown 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.case_identification.v0], code=at0000, itemType=CLUSTER, level=2, text=Case identification, description=To record case identification details for public health purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.case_identification.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=3, text=Case identifier, description=The identifier of this case., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1], code=at0000, itemType=ACTION, level=1, text=Medication management, description=Any activity related to the planning, scheduling, prescription management, dispensing, administration, cessation and other use of a medication, vaccine, nutritional product or other therapeutic item., comment=This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017], code=at0017, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Description, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2], code=at0000, itemType=CLUSTER, level=3, text=Medication details, description=Details about a medication or component of a medication, including strength, form and details of any specific constituents., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[at0132], code=at0132, itemType=ELEMENT, level=4, text=Arzneimittel-Name, description=The name of the medication or medication component., comment=For example: 'Zinacef 750 mg powder' or 'cefuroxim'. This item should be coded if possible, using for example, RxNorm, DM+D, Australian Medicines Terminology or FEST. Usage of this element will vary according to context of use. This element may be omitted where the name of the medication is recorded in the parent INSTRUCTION or ACTION archetype, and this archetype is only used to record that the form must be or was 'liquid'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[at0071], code=at0071, itemType=ELEMENT, level=4, text=Form, description=The formulation or presentation of the medication or medication component., comment=For example: 'tablet', 'capsule', 'cream', 'infusion fluid' or 'inhalation powder'. Coding of the form with a terminology is preferred, where possible. Medicines catalogues may differentiate between administrable form 'solution for injection' and product form 'powder for solution for injection'. The recorded form will depend on the exact context of use but administrable form is likely to be used in most instances., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminology: https://fhir.kbv.de/CodeSystem/KBV_CS_SFHIR_BMP_DARREICHUNGSFORM
  • Öl 
  • Amp 
  • Amp 
  • Salbe 
  • Salbe 
  • Tropf 
  • AuTropf 
  • AuBad 
  • AuCreme 
  • AuGel 
  • AuSalbe 
  • Bad 
  • Balsam 
  • Bandage 
  • Beutel 
  • Binden 
  • Bonbons 
  • Platte 
  • Brei 
  • BrTabl 
  • Creme 
  • Flasche 
  • Dilut 
  • DIS 
  • Dragees 
  • Spray 
  • Dragees 
  • Dragees 
  • Schaum 
  • Spray 
  • Pipette 
  • Einreib 
  • Elektr 
  • Elixier 
  • Emul 
  • Essenz 
  • Supp 
  • Extrakt 
  • Beutel 
  • Einreib 
  • Drag 
  • Spritze 
  • Salbe 
  • Flasche 
  • Flüss 
  • Flüss 
  • Tabl 
  • Folie 
  • FRB 
  • Seife 
  • Tabl 
  • Gel 
  • GLI 
  • Globuli 
  • Gran 
  • Platte 
  • Gran 
  • Saft 
  • Lösung 
  • Handsch 
  • Kaps 
  • Kaps 
  • InhKaps 
  • Kaps 
  • Amp 
  • Beutel 
  • Flasche 
  • Lösung 
  • Flasche 
  • Set 
  • InhAmp 
  • InhPulv 
  • Lösung 
  • InhKaps 
  • Lösung 
  • Impl 
  • Lösung 
  • Inhalat 
  • Flasche 
  • InhLös 
  • Tee 
  • Instill 
  • Susp 
  • Spirale 
  • Kanüle 
  • Kaps 
  • KAT 
  • KauDrag 
  • Kegel 
  • Kerne 
  • Kaug 
  • Konz 
  • Supp 
  • Klist 
  • KlisTbl 
  • Kaps 
  • Kaps 
  • Kondom 
  • Kompr 
  • Konz 
  • KombiPg 
  • KRI 
  • Supp 
  • Supp 
  • KauTabl 
  • Lanz 
  • Lösung 
  • Flüss 
  • Lösung 
  • Lotion 
  • LOV 
  • Lösung 
  • Tabl 
  • LUP 
  • LuTabl 
  • Milch 
  • Mixtur 
  • RetGran 
  • Pellets 
  • Tabl 
  • MUW 
  • NasGel 
  • NasÖl 
  • NasSpr 
  • NAW 
  • NasSpr 
  • NSalbe 
  • NTropf 
  • OCU 
  • Öl 
  • OTropf 
  • Ovula 
  • Pastill 
  • Pellets 
  • Pen 
  • Perlen 
  • Pflast 
  • Pflast 
  • Pulver 
  • Lösung 
  • Pulver 
  • Pulver 
  • Pulver 
  • PIV 
  • Pulver 
  • PLF 
  • PLG 
  • PLH 
  • PLI 
  • PLK 
  • PLV 
  • Lösung 
  • PRS 
  • Saft 
  • Paste 
  • Puder 
  • Pulver 
  • RetDrag 
  • RetKaps 
  • RetTabl 
  • RetGran 
  • RekKaps 
  • Schaum 
  • RetTabl 
  • Saft 
  • Salbe 
  • Salbe 
  • Schaum 
  • Seife 
  • Shampoo 
  • Sirup 
  • SMF 
  • SMT 
  • Supp 
  • Amp 
  • Flasche 
  • Lösung 
  • Spray 
  • Spritze 
  • Supp 
  • Amp 
  • Stäbch 
  • Stifte 
  • Streif 
  • Subst 
  • Susp 
  • Supp 
  • Susp 
  • SubTabl 
  • Susp 
  • Schwamm 
  • Tabl 
  • Tafel 
  • Amp 
  • Tee 
  • Tropfen 
  • Test 
  • Tinktur 
  • Tabl 
  • Tabl 
  • Tonikum 
  • Tampon 
  • Tamp 
  • TrAmp 
  • TRI 
  • Tropfen 
  • TRS 
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  • Saft 
  • TSD 
  • TSS 
  • Test 
  • TSY 
  • Test 
  • Tube 
  • Tücher 
  • Tupfer 
  • Tabl 
  • VagLös 
  • VagRing 
  • VagCrem 
  • Verband 
  • VagGel 
  • VagKaps 
  • Vlies 
  • VagOvul 
  • VagStäb 
  • VagSupp 
  • VagTabl 
  • Watte 
  • Gaze 
  • Kaps 
  • Kaps 
  • Würfel 
  • Gel 
  • Spray 
  • Festig. 
  • Maske 
  • Spül. 
  • Creme 
  • Pflege 
  • Creme 
  • Amp 
  • Bürste 
  • Zahncr. 
  • Zahngel 
  • ZerbKps 
  • Zahnp 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[at0115], code=at0115, itemType=ELEMENT, level=4, text=Wirkstärke (Konzentration), description=The strength of the medication or medication component, as a concentration., comment=This element is used for liquid or semisolid medications, or medications intended to be diluted in a liquid before administration. For example: '10 mg/ml', '20 mg/g', '5 %', '10,000 SQ-U/ml'. If the 'Strength (presentation)' cluster is used, this element becomes redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[openEHR-EHR-CLUSTER.medication.v2], code=at0000, itemType=CLUSTER, level=4, text=Wirkstoff, description=Details about a medication or component of a medication, including strength, form and details of any specific constituents., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[openEHR-EHR-CLUSTER.medication.v2]/items[at0132], code=at0132, itemType=ELEMENT, level=5, text=Wirkstoff-Name, description=The name of the medication or medication component., comment=For example: 'Zinacef 750 mg powder' or 'cefuroxim'. This item should be coded if possible, using for example, RxNorm, DM+D, Australian Medicines Terminology or FEST. Usage of this element will vary according to context of use. This element may be omitted where the name of the medication is recorded in the parent INSTRUCTION or ACTION archetype, and this archetype is only used to record that the form must be or was 'liquid'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[openEHR-EHR-CLUSTER.medication.v2]/items[at0142], code=at0142, itemType=ELEMENT, level=5, text=Wirkstofftyp, description=The category of the medication or medication component, with regard to manufacturing or preparation, and the number of ingredients., comment=For example: 'Paracetamol/codeine' is a Multi-ingredient product, while 'Morphine 60 mg + Haloperidol 2 mg + Midazolam 5 mg' is an Ad-hoc mixture, whose composition is fully specified within the order., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Active
  • Common
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[openEHR-EHR-CLUSTER.medication.v2]/items[at0152], code=at0152, itemType=CLUSTER, level=5, text=Wirkstoffmenge, description=The strength of the medication or medication component, expressed as a ratio., comment=In some cases, as for liquid or semisolid medications, the denominator of the strength ratio is a physical quantity, for example 2 mg/5 ml. In some of these cases the denominator also reflects the actual volume of the component: 5 ml in the previous example. In this case the 'Strength (concentration)' would be 0.4 mg/ml. In other cases, where the strength involves a denominator which is not a physical quantity, for example 4 mg/tablet, the denominator is expressed as a unitary value '1' with a unit of 'tablet'. This arrangement was chosen to align with the approach adopted by the ISO IDMP standard for medication catalogues. If the 'Strength (concentration)' element is used, this cluster becomes redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[openEHR-EHR-CLUSTER.medication.v2]/items[at0152]/items[at0153], code=at0153, itemType=ELEMENT, level=6, text=Zähler, description=The numerator of the strength fraction., comment=For example: For a presentation strength of '300 µg/0.3 ml', the strength numerator is '300 µg'. For a presentation strength of '100 mg/tablet', the strength numerator value is '100 mg'., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[openEHR-EHR-CLUSTER.medication.v2]/items[at0152]/items[at0157], code=at0157, itemType=ELEMENT, level=6, text=Nenner, description=The denominator of the strength fraction., comment=For example: For a presentation strength of '300 µg/0.3 ml', the strength denominator value is '0.3 ml'. For a presentation strength of '100 mg/tablet', the strength denominator value is '1 tablet'., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[openEHR-EHR-CLUSTER.medication.v2]/items[openEHR-EHR-CLUSTER.drug_class.v0], code=at0000, itemType=CLUSTER, level=5, text=Wirkstoff-Code (ASK, SNOMED CT, UNII, CAS), description=Zur Einordnung eines Arzneimittels in eine Gruppe, Klasse oder Kategorie., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[openEHR-EHR-CLUSTER.medication.v2]/items[openEHR-EHR-CLUSTER.drug_class.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Wirkstoff-Code, description=Name der Arzneimittelgruppe., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[openEHR-EHR-CLUSTER.medication.v2]/items[openEHR-EHR-CLUSTER.drug_class.v0]/items[at0004], code=at0004, itemType=CLUSTER, level=6, text=Katalog, description=Hier können Arzneimittelverzeichnisse, sowie intern verwendete Kataloge angegeben werden., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[openEHR-EHR-CLUSTER.medication.v2]/items[openEHR-EHR-CLUSTER.drug_class.v0]/items[at0004]/items[at0002], code=at0002, itemType=ELEMENT, level=7, text=Katalogname, description=Name des verwendeten Katalogs oder Verzeichnisses., comment=Bekannte Arzneimittelverzeichnisse in Deutschland sind u.a. die Rote Liste, die Gelbe Liste oder die Lauer-Taxe., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • ASK
  • UNII
  • CAS
  • SNOMED CT
  • [...]
Default value: ASK, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[openEHR-EHR-CLUSTER.medication.v2]/items[openEHR-EHR-CLUSTER.drug_class.v0]/items[at0004]/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Version, description=Versionsnummer des verwendeten Katalogs oder Verzeichnisses., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[at0133], code=at0133, itemType=ELEMENT, level=4, text=Rezeptur Freitextzeile, description=Narrative description of the medication or medication component where it is not possible to describe this fully using structured elements., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[openEHR-EHR-CLUSTER.drug_class.v0], code=at0000, itemType=CLUSTER, level=4, text=Arzneimittelgruppe, description=Zur Einordnung eines Arzneimittels in eine Gruppe, Klasse oder Kategorie., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[openEHR-EHR-CLUSTER.drug_class.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=5, text=Arzneimittel-Code, description=Name der Arzneimittelgruppe., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[openEHR-EHR-CLUSTER.drug_class.v0]/items[at0004], code=at0004, itemType=CLUSTER, level=5, text=Katalog, description=Hier können Arzneimittelverzeichnisse, sowie intern verwendete Kataloge angegeben werden., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[openEHR-EHR-CLUSTER.drug_class.v0]/items[at0004]/items[at0002], code=at0002, itemType=ELEMENT, level=6, text=Katalogname, description=Name des verwendeten Katalogs oder Verzeichnisses., comment=Bekannte Arzneimittelverzeichnisse in Deutschland sind u.a. die Rote Liste, die Gelbe Liste oder die Lauer-Taxe., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • RxNorm
  • SNOMED CT
  • IDMP
  • PZN
  • ATC
  • [...]
Default value: RxNorm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.medication.v2]/items[openEHR-EHR-CLUSTER.drug_class.v0]/items[at0004]/items[at0005], code=at0005, itemType=ELEMENT, level=6, text=Version, description=Versionsnummer des verwendeten Katalogs oder Verzeichnisses., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v2], code=at0000, itemType=CLUSTER, level=3, text=Dosage, description=The combination of a medication amount and administration timing for a single day, in the context of a medication order or medication management., comment=For example: '2 tablets at 6pm' or '20 mg three times per day'. Please note: this cluster allows multiple occurrences to enable representation of a complete set of dose patterns for a single dose direction., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v2]/items[at0144], code=at0144, itemType=ELEMENT, level=4, text=Dosis, description=The amount of medication administered at one time., comment=For example: 1 mg, 1.5 ml, 0.125 g; or 1-2 ml, 12.5-20.5 mg., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v2]/items[at0178], code=at0178, itemType=ELEMENT, level=4, text=Dosierung Freitext, description=Text description of the dose., comment=For example: "Apply ointment to affected area until it glistens". This element is intended to allow implementers to use the structures for increasing/tapering dosages without necessarily specifying the doses in a structured way., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v2]/items[openEHR-EHR-CLUSTER.timing_daily.v1], code=at0000, itemType=CLUSTER, level=4, text=Timing - daily, description=Structured information about the intended timing of a therapeutic or diagnostic activity within any 24 hour period., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v2]/items[openEHR-EHR-CLUSTER.timing_daily.v1]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Verabreichungszeitpunkt /-intervall, description=A specific time or interval of time when the activity should occur., comment=For example: "08:00" or "15:00-16:00"., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Time
  •  Interval
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[openEHR-EHR-CLUSTER.dosage.v2]/items[at0134], code=at0134, itemType=ELEMENT, level=4, text=Administration rate, description=The rate at which the medication, such as an infusion, is to be administered., comment=For example: '200 ml/h'. Use the text data type to record non- or semi-quantifiable instructions., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Quantity>=0; >=0; >=0; >=0
    Units:
    • l/h
    • ml/min
    • ml/s
    • ml/h
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0156], code=at0156, itemType=ELEMENT, level=3, text=Clinical indication, description=The clinical reason for the medication activity., comment=For example: 'Angina' or 'Pain'. Coding of the indication with a terminology is preferred, where possible. This data element allows multiple occurrences. If only an ACTION is used to record a medication indication, this data element can be used without additional consideration. However, if a clinical indication is recorded for both the Medication order INSTRUCTION and this Medication management ACTION, be aware that these indications might not be consistent.", uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0140], code=at0140, itemType=CLUSTER, level=3, text=Administration details, description=Details of body site and administration of the medication., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0140]/items[at0147], code=at0147, itemType=ELEMENT, level=4, text=Route, description=The route by which the ordered item was, or is to be, administered into the subject's body., comment=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=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Terminology: http://standardterms.edqm.eu
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://hl7.org/fhir/uv/ips/ValueSet/medicine-route-of-administration
  • 20001000 | Auricular use 
  • 20002500 | Buccal use 
  • 20003000 | Cutaneous use 
  • 20004000 | Dental use 
  • 20006000 | Endocervical use 
  • 20007000 | Endosinusial use 
  • 20008000 | Endotracheopulmonary use 
  • 20009000 | Epidural use 
  • 20010000 | Epilesional use 
  • 20011000 | Extraamniotic use 
  • 20011500 | Extracorporeal use 
  • 20013500 | Gastric use 
  • 20013000 | Gastroenteral use 
  • 20014000 | Gingival use 
  • 20015000 | Haemodialysis 
  • 20015500 | Implantation 
  • 20019500 | Infiltration 
  • 20020000 | Inhalation use 
  • 20021000 | Intestinal use 
  • 20022000 | Intraamniotic use 
  • 20023000 | Intraarterial use 
  • 20024000 | Intraarticular use 
  • 20025000 | Intrabursal use 
  • 20025500 | Intracameral use 
  • 20026000 | Intracardiac use 
  • ... +54 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0140]/items[at0141], code=at0141, itemType=ELEMENT, level=4, text=Body site, description=Structured description 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=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Value set: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0140]/items[at0143], code=at0143, itemType=ELEMENT, level=4, text=Administration method, description=The technique or device by which the ordered item was, or is to be, administered., comment=Comment: For example: ' via Z-track injection'; 'via nebuliser'. Coding of the method with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= Value set: external, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/description[at0017]/items[at0024], code=at0024, itemType=ELEMENT, level=3, text=Comment, description=Additional narrative about the activity or pathway step not captured in other fields, including details of any variance between the intended action and the action actually performed., comment=For example: 'Patient was in radiology department', 'Accidental injection into blood vessel during IM administration'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/protocol[at0030], code=at0030, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report.v1]/content[openEHR-EHR-ACTION.medication.v1]/protocol[at0030]/items[at0103], code=at0103, itemType=ELEMENT, level=3, text=Order ID, description=Unique identifier for the medication order., comment=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]], templateType=normal]