TEMPLATE KDS_Medikationseintrag (KDS_Medikationseintrag)

TEMPLATE ID	KDS_Medikationseintrag
Concept	KDS_Medikationseintrag
Description	Zur Repräsentation der Medikation, die für eine Person verordnet oder durch die Person angewendet wird. Das Template stellt Medikamente dar, die der Patient zurzeit einnimmt, in der Vergangenheit genommen hat oder in Zukunft einnehmen wird. Dabei kann es sich sowohl um verschreibungspflichtige Medikamente handeln, wie auch um OTC-Präparate, welche ein Patient in Eigenverantwortung einnimmt.
Use	Zur Repräsentation der Anwendung von Medikamenten, die für eine Person verordnet oder durch die Person angewendet werden. Es kann sich dabei um eine aktuelle, frühere oder geplante Anwendung handeln. Das Template hat eher den Charakter eines Medikationsplans. Es ist nicht klar, ob der Patient diese Arzneimittel tatsächlich eingenommen hat oder diese verabreicht wurden. Wenn ein Fallbezug oder eine Verbindung zu anderen Compositions (z.B. Prozeduren, Diagnose-Templates) hergestellt werden soll, bitte die LINK class aus dem Referenzmodell nutzen.
Misuse	Nicht zur Repräsentation spezifischer Medikamententherapie oder Medikamentenklassen, die weitere Angaben erfordern (z. B. Protokoll bei Chemotherapie). Dafür bitte eigene Templates anlegen. Nicht für die Darstellung der eigentlichen Medikamentenverabreichung, die auf vollständige Verabreichungsinformationen basieren, geeignet. Dafür wird das Template Medikamentenverabreichungen verwendet.
Purpose	Zur Repräsentation der Medikation, die für eine Person verordnet oder durch die Person angewendet wird. Das Template stellt Medikamente dar, die der Patient zurzeit einnimmt, in der Vergangenheit genommen hat oder in Zukunft einnehmen wird. Dabei kann es sich sowohl um verschreibungspflichtige Medikamente handeln, wie auch um OTC-Präparate, welche ein Patient in Eigenverantwortung einnimmt.
References
Authors	date: 2020-01-16
Other Details Language	date: 2020-01-16
Other Details (Language Independent)	MetaDataSet:Sample Set : Template metadata sample set MD5-CAM-1.0.1: 72d53e2020bd26266ec2b5afa22497db PARENT:MD5-CAM-1.0.1: 006E9F209FD9F3691A5B9EFF0BAC3B5B Original Language: ISO_639-1::de Sem Ver: 16.0.0
Keywords	Medikation; Medikamentöse Behandlung; Arzneiliste; Medikamentenverordnung; Arzneiverordnung; Medikamentenanwendung; Arzneimittel; Medikamentenanamnese; Medikationsliste; Medikamentenliste; Arzneimittelverordnung; Medikationseintrag, Medikamentenplan, Medikationseintrag, Kerndatensatz, Medication Statement
Language used	en
Citeable Identifier	1246.169.438
Root archetype id	openEHR-EHR-COMPOSITION.medication_list.v1
Medication list	Medication list: A persistent and versioned list of medicines for an individual.
Other Context
Case identification	Case identification: To record case identification details for public health purposes.
Case identifier	Case identifier: The identifier of this case.
Status	Status: The status of the case. A status of completed means the patient has been associated with the given case number. A status of aborted means the patient was associated with the case number in error. Terminology: http://hl7.org/fhir/CodeSystem/medication-statement-status Das Medikament wird noch angewendet. Das Medikament wird nicht mehr angewendet. Einige der Aktionen, die im Medikation Statement enthalten sind, können bereits stattgefunden haben. Beispielsweise kann der Patient einen Teil der Medikamente eingenommen haben. Die Medikation kann irgendwann in der Zukunft angewendet werden. Die im Medikation Statement implizierten Aktionen wurden dauerhaft gestoppt, bevor alle von ihnen eingetreten sind. Dies sollte nicht verwendet werden, wenn Medikation Statement versehentlich eingegeben wurde. Die im Medikation Statement implizierten Aktionen wurden vorübergehend gestoppt, werden aber voraussichtlich später fortgesetzt. Kann auch als "ausgesetzt" bezeichnet werden. Der Status des Medikaments ist derzeit nicht bekannt. Das Medikament wurde vom Patienten nicht angewendet.
Medication use statement	Medication use statement: An assertion about the current use of a single medication by an individual.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Medication details	Medication details: Details about a medication or component of a medication, including strength, form and details of any specific constituents.
Arzneimittel-Name	Arzneimittel-Name: The name of the medication or medication component. 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'.
Form	Form: The formulation or presentation of the medication or medication component. 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. Terminology: http://standardterms.edqm.eu Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://hl7.org/fhir/uv/ips/ValueSet/medicine-doseform 12102000 \| Anticoagulant and preservative solution for blood 10501000 \| Bath additive 11502000 \| Bladder irrigation 31030 \| Blood fraction modifier 10314011 \| Buccal film 10320000 \| Buccal tablet 10209000 \| Cachet 12100 \| Capsule 10210000 \| Capsule, hard 10211000 \| Capsule, soft 10214000 \| Chewable capsule, soft 10228000 \| Chewable tablet 50001000 \| Chewable/dispersible tablet 13046000 \| Coated granules 50001250 \| Coated granules in sachet 10220000 \| Coated tablet 10520000 \| Collodion 10322000 \| Compressed lozenge 50002000 \| Concentrate and solvent for concentrate for solution for infusion 50003000 \| Concentrate and solvent for cutaneous solution 13143000 \| Concentrate and solvent for dispersion for injection 13153000 \| Concentrate and solvent for emulsion for injection 13144000 \| Concentrate and solvent for intravesical solution 13160000 \| Concentrate and solvent for oral solution 50006000 \| Concentrate and solvent for solution for infusion ... +602
Wirkstärke (Konzentration)	Wirkstärke (Konzentration): The strength of the medication or medication component, as a concentration. 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.
Bestandteil	Bestandteil: Details about a medication or component of a medication, including strength, form and details of any specific constituents.
Bestandteil	Bestandteil: The name of the medication or medication component. 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'.
Wirkstofftyp	Wirkstofftyp: The category of the medication or medication component, with regard to manufacturing or preparation, and the number of ingredients. 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. Coded Text Ad-hoc mixture Ingredient Multi-ingredient product Single-ingredient product Combination product Text
Bestandteil-Menge	Bestandteil-Menge: The strength of the medication or medication component, expressed as a ratio. 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.
Zähler	Zähler: The numerator of the strength fraction. 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'.
Nenner	Nenner: The denominator of the strength fraction. 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'.
Ist aktiver Bestandteil?	Ist aktiver Bestandteil?: The role of the medication or medication component within a mixture. Ja Nein
Wirkstoffrelation	Wirkstoffrelation: Details about a medication or component of a medication, including strength, form and details of any specific constituents.
Allgemeiner Wirkstoff	Allgemeiner Wirkstoff: The name of the medication or medication component. 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'.
Wirkstoffmenge	Wirkstoffmenge: The strength of the medication or medication component, expressed as a ratio. 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.
Zähler	Zähler: The numerator of the strength fraction. 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'.
Nenner	Nenner: The denominator of the strength fraction. 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'.
Strength (concentration)	Strength (concentration): The strength of the medication or medication component, as a concentration. 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.
Manufacturer	Manufacturer: The manufacturer of the medication or medication component. For example: 'Abbott'.
Batch ID	Batch ID: The identifier assigned to the production batch by the manufacturer during production. Text Identifier
Expiry	Expiry: The expiry date and/or time of the medication or medication component, as given by the manufacturer or individual preparing the mixture. Any other form of expiry date, such as time from production or depending on storage environment, can be inserted using a specific CLUSTER archetype in the Substance Details slot or added as part of the Description. For example: '2017-05-23'.
Amount	Amount: The amount of medication or medication component. For example: '1 ml', '1.5 mg', '1000 ml'.
Alternate amount	Alternate amount: An equivalent representation of the amount of the medication or medication component. For example: for a medication with a strength of '5 mg/ml' and where the Amount is '1 ml', and the value recorded in this data element would be '5 mg'.
Role	Role: The role of the medication or medication component within a mixture. Coded Text Therapeutic Adjuvant Excipient Text
Description	Description: Narrative description of the medication or medication component where it is not possible to describe this fully using structured elements.
Rezeptur Freitextzeile	Rezeptur Freitextzeile: Narrative description of the medication or medication component where it is not possible to describe this fully using structured elements.
Dosage	Dosage: The combination of a medication amount and administration timing for a single day, in the context of a medication order or medication management. 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.
Dosage sequence	Dosage sequence: The intended position of this dosage within the overall sequence of dosages. For example: '1', '2', '3'. Where multiple dosages are expressed, the 'Pattern sequence' makes the order in which they should be executed explicit. For example: (1) 1 tab in the morning, (2) 2 tab at 2pm, (3) 1 tab at night. >=1
Dose	Dose: The amount of medication administered at one time. For example: 1 mg, 1.5 ml, 0.125 g; or 1-2 ml, 12.5-20.5 mg. Quantity Interval of Quantity
Dosierung Freitext	Dosierung Freitext: Text description of the dose. 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.
Tägliche Dosierung	Tägliche Dosierung: Structured information about the intended timing of a therapeutic or diagnostic activity within any 24 hour period.
Periode	Periode: The time interval or minimum and maximum range of an interval between each scheduled activity. For example: "Every 4 hours" or "Every 4 to 6 hours". PT0H..PT24H Units: Hour Minute Second
Zeitpunkt	Zeitpunkt: A specific time or interval of time when the activity should occur. For example: "08:00" or "15:00-16:00".
Timing description	Timing description: Text description of the daily timing. This element is intended to allow implementers to use the structures for different timings without necessarily specifying the timings in a structured way. For example: "Take morning and evening".
As required	As required: Record as True if the activity should only occur when the "'As required' criterion" is met. Termed 'PRN' ("pro re nata", latin: "as the situation arises") or 'PN' ("per necessare", latin: "when required") in some cultures.
Specific event	Specific event: A specific, named time event that the activity should occur in relation to.
Ereignis	Ereignis: The name of the event that triggers the activity to take place. For example: "Before each meal", "at bedtime", "in the morning". It is understood that these event names may not equate to the same exact times in different cultures. Coding with a terminology, for example HL7 FHIR Named events, is recommended where appropriate.
Offset	Offset: The period of time before or after the named event when the activity should take place. Negative durations can be used to signify that the activity should take place before the event. For example: '30 minutes after meal = meal + 30 minutes', '2 hours before bedtime = bedtime -2 hours'. -PT24H..PT24H Units: Hour Minute Second
Nicht tägliche Dosierung	Nicht tägliche Dosierung: Structured information about the intended timing pattern for a therapeutic or diagnostic activity occurring over days, weeks, months or years.
Periode	Periode: The interval between repetitions of the activity. For example: 'Every 3 weeks'. If necessary, this element can be used to explicity specify that an activity is to take place every single day, by setting it to "1 day". >P0D Units: Year Month Week Day
Zeitpunkt	Zeitpunkt: The activity should take place on a specific date or a specific range of dates. For example: 'on 12 Jan 2017' or 'on 30 Oct 2017 to 6 Nov 2017'. Date Interval
Timing description	Timing description: Text description of the timing. For example: 'Use for one week, then stop for two weeks, then repeat'. This element is intended to allow implementers to use the structures for daily timings without necessarily specifying the non-daily timings in a structured way.
Specific event	Specific event: The activity should take place in relation to a specific named event.
Ereignis	Ereignis: The name of the event that triggers the activity to take place. This element is intended for events that can occur at variable dates, such as onset of menstruation, and not for doses or activities that are conditional on a different varable. If required, the event name can be coded using a terminology, which could potentially be used to trigger an application to set a concrete date for the activity.
Offset	Offset: The period of time before or after the named event when the activity should take place. Negative durations can be used to signify that the activity should be taken before a known event. For example: '3 days after onset of menstruation = menstrual onset + 3 days', '2 weeks prior to admission= admission -2 weeks'. Units: Year Month Week Day
Route of administration	Route of administration: The route by which the medication is administrated into the body. For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible. 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 20089000 \| Cardioplegic 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 20087000 \| Extrapleural 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 ... +60
Description	Description: Narrative description of the use of the medication.
Behandlungsgrund	Behandlungsgrund: The clinical symptom, sign or diagnosis that necessitates the use of the medication. For example: 'Angina' or 'Migraine'. Coding of the clinical indication with a terminology is preferred, where possible. This data element has multiple occurrences to allow recording of more than one clinical indication per medication.
Hinweis	Hinweis: Additional narrative about the medication statement not captured in other fields.
Protocol
Kategorie des Eintrags	Kategorie des Eintrags: Kategorie, Art oder Typ der Information.
Kategorie der Medikation	Kategorie der Medikation: Kategorie des Eintrags. Belassen Sie als Freitext oder beschränken Sie sich auf eine interne oder externe Codeliste. Terminology: http://terminology.hl7.org/CodeSystem/medication-statement-category Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://hl7.org/fhir/ValueSet/medication-statement-category community \| Community inpatient \| Inpatient outpatient \| Outpatient patientspecified \| Patient Specified
Kommentar	Kommentar: Kommentar zu der Kategorie, oder Erläuterung.