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Pharmacy icon Work GroupMaturity Level: 4 Trial UseSecurity Category: Patient Compartments: Encounter, Patient, Practitioner, RelatedPerson

Detailed Descriptions for the elements in the MedicationStatement resource.

MedicationStatement
Element Id MedicationStatement
Definition

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 medicationstatement and a medicationadministration is that the medication administration has complete administration information and is based on actual administration information from the person who administered the medication. A medicationstatement 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.

Short Display Record of medication being taken by a patient
Cardinality 0..*
Type DomainResource
Alternate Names MedicationStatement
Summary false
MedicationStatement.identifier
Element Id MedicationStatement.identifier
Definition

Identifiers 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.

Short Display External identifier
Note This is a business identifier, not a resource identifier (see discussion)
Cardinality 0..*
Type Identifier
Summary true
Comments

This is a business identifier, not a resource identifier.

MedicationStatement.partOf
Element Id MedicationStatement.partOf
Definition

A larger event of which this particular MedicationStatement is a component or step.

Short Display Part of referenced event
Cardinality 0..*
Type Reference(Procedure | MedicationStatement)
Hierarchy This reference is part of a strict Hierarchy
Summary false
MedicationStatement.status
Element Id MedicationStatement.status
Definition

A code representing the status of recording the medication statement.

Short Display recorded | entered-in-error | draft
Cardinality 1..1
Terminology Binding MedicationStatement Status Codes (Required)
Type code
Is Modifier true (Reason: This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
Summary true
Comments

This status concerns just the recording of the medication statement. MedicationStatement.adherence should be used for indicating a patient's adherence to the information in this resource. Note, the statuses are different than in previous releases for MedicationStatement or MedicationStatement.

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

MedicationStatement.category
Element Id MedicationStatement.category
Definition

Type of medication statement (for example, drug classification like ATC, where meds would be administered, legal category of the medication.).

Short Display Type of medication statement
Cardinality 0..*
Terminology Binding medicationRequest Administration Location Codes (Example)
Type CodeableConcept
Summary true
MedicationStatement.medication
Element Id MedicationStatement.medication
Definition

Identifies 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.

Short Display What medication was taken
Cardinality 1..1
Terminology Binding SNOMED CT Medication Codes (Example)
Type CodeableReference(Medication)
Summary true
Comments

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.

MedicationStatement.subject
Element Id MedicationStatement.subject
Definition

The person, animal or group who is/was taking the medication.

Short Display Who is/was taking the medication
Cardinality 1..1
Type Reference(Patient | Group)
Summary true
MedicationStatement.encounter
Element Id MedicationStatement.encounter
Definition

The encounter that establishes the context for this MedicationStatement.

Short Display Encounter associated with MedicationStatement
Cardinality 0..1
Type Reference(Encounter)
Summary true
MedicationStatement.effective[x]
Element Id MedicationStatement.effective[x]
Definition

The 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.adherence element is Not Taking).

Short Display The date/time or interval when the medication is/was/will be taken
Cardinality 0..1
Type dateTime|Period|Timing
[x] Note See Choice of Datatypes for further information about how to use [x]
Summary true
Comments

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 and is expected to continue indefinitely at the time the usage is recorded, the "end" date will be omitted. If the end date is known, then it is included as the "end date". 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.

MedicationStatement.dateAsserted
Element Id MedicationStatement.dateAsserted
Definition

The date when the Medication Statement was asserted by the information source.

Short Display When the usage was asserted?
Cardinality 0..1
Type dateTime
Summary true
MedicationStatement.informationSource
Element Id MedicationStatement.informationSource
Definition

The 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.

Short Display Person or organization that provided the information about the taking of this medication
Cardinality 0..*
Type Reference(Device | Patient | Practitioner | PractitionerRole | RelatedPerson | Organization)
Summary false
MedicationStatement.derivedFrom
Element Id MedicationStatement.derivedFrom
Definition

Allows linking the MedicationStatement to the underlying MedicationRequest, or to other information that supports or is used to derive the MedicationStatement.

Short Display Link to information used to derive the MedicationStatement
Cardinality 0..*
Type Reference(Any)
Summary false
Comments

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.

MedicationStatement.reason
Element Id MedicationStatement.reason
Definition

A concept, Condition or observation that supports why the medication is being/was taken.

Short Display Reason for why the medication is being/was taken
Cardinality 0..*
Terminology Binding Condition/Problem/Diagnosis Codes (Example)
Type CodeableReference(Condition | Observation | DiagnosticReport | Procedure)
Summary false
Comments

This could be a diagnosis code. If a full condition record exists or additional detail is needed, use reasonForUseReference.

MedicationStatement.note
Element Id MedicationStatement.note
Definition

Provides extra information about the Medication Statement that is not conveyed by the other attributes.

Short Display Further information about the usage
Cardinality 0..*
Type Annotation
Summary false
MedicationStatement.relatedClinicalInformation
Element Id MedicationStatement.relatedClinicalInformation
Definition

Link to information that is relevant to a medication statement, for example, illicit drug use, gestational age, etc.

Short Display Link to information relevant to the usage of a medication
Cardinality 0..*
Type Reference(Observation | Condition)
Summary false
MedicationStatement.renderedDosageInstruction
Element Id MedicationStatement.renderedDosageInstruction
Definition

The full representation of the dose of the medication included in all dosage instructions. To be used when multiple dosage instructions are included to represent complex dosing such as increasing or tapering doses.

Short Display Full representation of the dosage instructions
Cardinality 0..1
Type markdown
Requirements

The content of the renderedDosageInstructions must not be different than the dose represented in the dosageInstruction content.

Summary false
MedicationStatement.dosage
Element Id MedicationStatement.dosage
Definition

Indicates how the medication is/was or should be taken by the patient.

Short Display Details of how medication is/was taken or should be taken
Cardinality 0..*
Type Dosage
Summary false
Comments

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.

MedicationStatement.adherence
Element Id MedicationStatement.adherence
Definition

Indicates whether the medication is or is not being consumed or administered.

Short Display Indicates whether the medication is or is not being consumed or administered
Cardinality 0..1
Summary true
Comments

This element can be used to indicate whether a patient is following a course of treatment as instructed/prescribed or whether they are taking medications of their own volition. It can also be used to indicate that a patient is not taking a medication, either because they were told not to or because they decided on their own.

MedicationStatement.adherence.code
Element Id MedicationStatement.adherence.code
Definition

Type of the adherence for the medication.

Short Display Type of adherence
Cardinality 1..1
Terminology Binding MedicationStatement Adherence Codes (Example)
Type CodeableConcept
Summary true
MedicationStatement.adherence.reason
Element Id MedicationStatement.adherence.reason
Definition

Captures the reason for the current use or adherence of a medication.

Short Display Details of the reason for the current use of the medication
Cardinality 0..1
Terminology Binding SNOMED CT Drug Therapy Status codes (Example)
Type CodeableConcept
Summary false
Comments

This is generally only used for "exception" statuses such as "entered-in-error". The reason for performing the event at all is captured in reasonCode, not here.