Resource type: medicationstatement

Description

A record of a medication that is being consumed by a patient. A MedicationStatement may indicate that the patient may be taking the medication now, or has taken the medication in the past or will be taking the medication in the future. The source of this information can be the patient, significant other (such as a family member or spouse), or a clinician. A common scenario where this information is captured is during the history taking process during a patient visit or stay. The medication information may come from sources such as the patient's memory, from a prescription bottle, or from a list of medications the patient, clinician or other party maintains. The primary difference between a medication statement and a medication administration is that the medication administration has complete administration information and is based on actual administration information from the person who administered the medication. A medication statement is often, if not always, less specific. There is no required date/time when the medication was administered, in fact we only know that a source has reported the patient is taking this medication, where details such as time, quantity, or rate or even medication product may be incomplete or missing or less precise. As stated earlier, the medication statement information may come from the patient's memory, from a prescription bottle or from a list of medications the patient, clinician or other party maintains. Medication administration is more formal and is not missing detailed information.

Elements

PathShortDefinitionComments
Record of medication being taken by a patientA record of a medication that is being consumed by a patient. A MedicationStatement may indicate that the patient may be taking the medication now, or has taken the medication in the past or will be taking the medication in the future. The source of this information can be the patient, significant other (such as a family member or spouse), or a clinician. A common scenario where this information is captured is during the history taking process during a patient visit or stay. The medication information may come from sources such as the patient's memory, from a prescription bottle, or from a list of medications the patient, clinician or other party maintains. The primary difference between a medication statement and a medication administration is that the medication administration has complete administration information and is based on actual administration information from the person who administered the medication. A medication statement is often, if not always, less specific. There is no required date/time when the medication was administered, in fact we only know that a source has reported the patient is taking this medication, where details such as time, quantity, or rate or even medication product may be incomplete or missing or less precise. As stated earlier, the medication statement information may come from the patient's memory, from a prescription bottle or from a list of medications the patient, clinician or other party maintains. Medication administration is more formal and is not missing detailed information.When interpreting a medicationStatement, the value of the status and NotTaken needed to be considered: MedicationStatement.status + MedicationStatement.wasNotTaken Status=Active + NotTaken=T = Not currently taking Status=Completed + NotTaken=T = Not taken in the past Status=Intended + NotTaken=T = No intention of taking Status=Active + NotTaken=F = Taking, but not as prescribed Status=Active + NotTaken=F = Taking Status=Intended +NotTaken= F = Will be taking (not started) Status=Completed + NotTaken=F = Taken in past Status=In Error + NotTaken=N/A = In Error.
identifierExternal identifierIdentifiers associated with this Medication Statement that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate. They are business identifiers assigned to this resource by the performer or other systems and remain constant as the resource is updated and propagates from server to server.This is a business identifier, not a resource identifier.
basedOnFulfils plan, proposal or orderA plan, proposal or order that is fulfilled in whole or in part by this event.
partOfPart of referenced eventA larger event of which this particular event is a component or step.
statusactive | completed | entered-in-error | intended | stopped | on-hold | unknown | not-takenA code representing the patient or other source's judgment about the state of the medication used that this statement is about. Generally this will be active or completed.MedicationStatement is a statement at a point in time. The status is only representative at the point when it was asserted. The value set for MedicationStatement.status contains codes that assert the status of the use of the medication by the patient (for example, stopped or on hold) as well as codes that assert the status of the medication statement itself (for example, entered in error). This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
statusReasonReason for current statusCaptures the reason for the current state of the MedicationStatement.This is generally only used for "exception" statuses such as "not-taken", "on-hold", "cancelled" or "entered-in-error". The reason for performing the event at all is captured in reasonCode, not here.
categoryType of medication usageIndicates where the medication is expected to be consumed or administered.
medication[x]What medication was takenIdentifies the medication being administered. This is either a link to a resource representing the details of the medication or a simple attribute carrying a code that identifies the medication from a known list of medications.If only a code is specified, then it needs to be a code for a specific product. If more information is required, then the use of the medication resource is recommended. For example if you require form or lot number, then you must reference the Medication resource.
subjectWho is/was taking the medicationThe person, animal or group who is/was taking the medication.
contextEncounter / Episode associated with MedicationStatementThe encounter or episode of care that establishes the context for this MedicationStatement.
effective[x]The date/time or interval when the medication is/was/will takenThe interval of time during which it is being asserted that the patient is/was/will be taking the medication ( or was not taking, when the MedicationStatement.taken element is No).This attribute reflects the period over which the patient consumed the medication and is expected to be populated on the majority of Medication Statements. If the medication is still being taken at the time the statement is recorded, the "end" date will be omitted. The date/time attribute supports a variety of dates - year, year/month and exact date. If something more than this is required, this should be conveyed as text.
dateAssertedWhen the statement was asserted?The date when the medication statement was asserted by the information source.
informationSourcePerson or organization that provided the information about the taking of this medicationThe person or organization that provided the information about the taking of this medication. Note: Use derivedFrom when a MedicationStatement is derived from other resources, e.g. Claim or MedicationRequest.
derivedFromAdditional supporting informationAllows linking the MedicationStatement to the underlying MedicationRequest, or to other information that supports or is used to derive the MedicationStatement.Likely references would be to MedicationRequest, MedicationDispense, Claim, Observation or QuestionnaireAnswers. The most common use cases for deriving a MedicationStatement comes from creating a MedicationStatement from a MedicationRequest or from a lab observation or a claim. it should be noted that the amount of information that is available varies from the type resource that you derive the MedicationStatement from.
reasonCodeReason for why the medication is being/was takenA reason for why the medication is being/was taken.This could be a diagnosis code. If a full condition record exists or additional detail is needed, use reasonForUseReference.
reasonReferenceCondition or observation that supports why the medication is being/was takenCondition or observation that supports why the medication is being/was taken.This is a reference to a condition that is the reason why the medication is being/was taken. If only a code exists, use reasonForUseCode.
noteFurther information about the statementProvides extra information about the medication statement that is not conveyed by the other attributes.
dosageDetails of how medication is/was taken or should be takenIndicates how the medication is/was or should be taken by the patient.The dates included in the dosage on a Medication Statement reflect the dates for a given dose. For example, "from November 1, 2016 to November 3, 2016, take one tablet daily and from November 4, 2016 to November 7, 2016, take two tablets daily." It is expected that this specificity may only be populated where the patient brings in their labeled container or where the Medication Statement is derived from a MedicationRequest.

Scope and Usage

Common usage includes:

A MedicationStatement may be used to record substance abuse or the use of other agents such as tobacco or alcohol. This would typically be done if these substances are intended to be included in clinical decision support checking (for example, interaction checking) and as part of an active medication list. If the intent is to populate social history and/or to include additional information (for example, desire to quit, amount per day, negative health effects), then it is better to record as an Observation that could then be used to populate Social History.

This resource does not produce a medication list, but it does produce individual medication statements that may be used in the List resource to construct various types of medication lists. Note that other medication lists can also be constructed from the other Pharmacy resources (e.g., MedicationRequest, MedicationAdministration).

A medication statement is not a part of the prescribe -> dispense -> administer sequence, but is a report by a patient, significant other or a clinician that one or more of the prescribe, dispense or administer actions has occurred, resulting is a belief that the patient is, has, or will be using a particular medication.

MedicationStatement is an event resource from a FHIR workflow perspective - see Workflow Event

Boundaries and Relationships

The MedicationStatement resource is used to record a medications or substances that the patient reports as being taken, not taking, have taken in the past or may take in the future. It can also be used to record medication use that is derived from other records such as a MedicationRequest. The statement is not used to request or order a medication, supply or device. When requesting medication, supplies or devices when there is a patient focus or instructions regarding their use, a MedicationRequest, SupplyRequest or DeviceRequest should be used instead

The Medication domain includes a number of related resources

MedicationRequest An order for both supply of the medication and the instructions for administration of the medicine to a patient.
MedicationDispense Provision of a supply of a medication with the intention that it is subsequently consumed by a patient (usually in response to a prescription).
MedicationAdministration When a patient actually consumes a medicine, or it is otherwise administered to them
MedicationStatement This is a record of a medication being taken by a patient or that a medication has been given to a patient, where the record is the result of a report from the patient or another clinician, or derived from supporting information (for example, Claim, Observation or MedicationRequest). A medication statement is not a part of the prescribe->dispense->administer sequence, but is a report that such a sequence (or at least a part of it) did take place, resulting in a belief that the patient has received a particular medication.

This resource is distinct from MedicationRequest, MedicationDispense and MedicationAdministration. Each of those resources refers to specific events - an individual order, an individual provisioning of medication or an individual dosing. MedicationStatement is a broader assertion covering a wider timespan and is independent of specific events. The existence of resource instances of any of the preceding three types may be used to infer a medication statement. However, medication statements can also be captured on the basis of other information, including an assertion by the patient or a care-giver, the results of a lab test, etc.

Search Parameters

categoryReturns statements of this category of medicationstatementMedicationStatement.category
contextReturns statements for a specific context (episode or episode of Care).MedicationStatement.context
effectiveDate when patient was taking (or not taking) the medicationMedicationStatement.effective
part-ofReturns statements that are part of another event.MedicationStatement.partOf
patientReturns statements for a specific patient.MedicationStatement.subject.where(resolve() is Patient)
sourceWho or where the information in the statement came fromMedicationStatement.informationSource
subjectThe identity of a patient, animal or group to list statements forMedicationStatement.subject

Extension Definitions

These are extension definitions for this resource defined by the spec