ID

29620

Beskrivning

http://openehr.org/ckm/ Use to record a persistent and managed list of all medicines, both prescribed and 'over the counter', that are reasonably assumed to be taken by the individual or, alternatively, positive statements about known exclusions or actual absence of any information about medications; This list can be utilised as a source of medicines data as a current medication list, for exchange or as the basis for decision support. This list can be comprised of three types of archetype: - statements about the positive use of medications are recorded using the INSTRUCTION.medication and/or ACTION.medication archetypes; OR - a positive statement about the exclusion of medication use can be recorded using the specific EVALUATION.exclusion-medication archetype - for example: "Not currently taking any medications"; OR - a positive statement about no information being available - neither a positive known use of medication nor a positive exclusion - can be recorded using the EVALUATION.absence archetype. In order for a Medication list to be accurate and safe to use as the basis for decision support activities and for exchange, this Medication List should ideally be curated by a clinician responsible for the health record, rather than managed automatically by the clinical system through business rules alone. There can be a subtle but important difference between types of medication lists. Some examples include: 'Current Medication' or 'Regular Medication'. A 'Current Medication' list may be regarded as a list of all medicines that the individual would have in their body at a given time, including any stat or prn doses of a medicine that should be considered when prescribing to ensure that drug-drug interaction checking continues for the duration of it's physiological effect. A 'Regular Medication' list may only include those medicines that are taken by the individual on a regular and ongoing basis. In addition, it is common in clinical practice to create Medication Lists that have temporal constraints, including 'Admission Medication List' and 'Discharge Medication List', which will be relevant only at a specified point in time. It is probably better practice to record these contextual clinical constructs as the result of a query, rather than represent it within a COMPOSITION to prevent any incorrect assumption that this is an ongoing list of medications. This archetype is intended to be represented and managed as a persistent list, however there are situations where the list may be used within episodic care and require additional attributes such as context etc to enable accurate recording. The openEHR reference model currently only allows context to be recorded within Event-based COMPOSITION archetypes. As a result, this archetype has been modelled as an Event, rather than Persistent, COMPOSITION, to allow for flexibility so that some clinical systems can safely manage Medication lists for episodes of care, while others will choose to implement this COMPOSITION to act in a persistent manner.

Länk

http://openehr.org/ckm/

Nyckelord

Versioner (1)

1. 2018-04-10 2018-04-10 - Halim Ugurlu

Rättsinnehavare

openEHR Foundation

Uppladdad den

10 april 2018

DOI

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Licens