Canonical URL: http://fhir.de/StructureDefinition/medicationstatement-de-basis/0.2
| MedicationStatement | 0..* | MedicationStatement | Short description Record of medication being taken by a patient DefinitionA 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.
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| identifier | Σ | 0..* | Identifier | Short description External identifier DefinitionExternal identifier - FHIR will generate its own internal identifiers (probably URLs) which do not need to be explicitly managed by the resource. The identifier here is one that would be used by another non-FHIR system - for example an automated medication pump would provide a record each time it operated; an administration while the patient was off the ward might be made with a different system and entered after the event. Particularly important if these records have to be updated.
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| basedOn | Σ | 0..* | Reference(MedicationRequest | CarePlan | ProcedureRequest | ReferralRequest) | Short description Fulfils plan, proposal or order DefinitionA plan, proposal or order that is fulfilled in whole or in part by this event. Allows tracing of authorization for the event and tracking whether proposals/recommendations were acted upon. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(MedicationRequest | CarePlan | ProcedureRequest | ReferralRequest) Constraints
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| partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Observation | MedicationStatement, deutsches Basisprofil (Version 0.2)) | Short description Part of referenced event DefinitionA larger event of which this particular event is a component or step. This should not be used when indicating which resource a MedicationStatement has been derived from. If that is the use case, then MedicationStatement.derivedFrom should be used. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Observation | MedicationStatement, deutsches Basisprofil (Version 0.2)) Constraints
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| context | Σ | 0..1 | Reference(Encounter | EpisodeOfCare) | Short description Encounter / Episode associated with MedicationStatement DefinitionThe encounter or episode of care that establishes the context for this MedicationStatement. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Encounter | EpisodeOfCare) Constraints
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| status | Σ ?! | 1..1 | codeBinding | Short description active | completed | entered-in-error | intended | stopped | on-hold DefinitionA 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. medication-statement-status (required) Constraints
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| category | Σ | 0..1 | CodeableConceptBinding | Short description Type of medication usage DefinitionIndicates where type of medication statement and where the medication is expected to be consumed or administered. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. medication-statement-category (preferred) Constraints
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| medication[x] | Σ | 1..1 | Short description What medication was taken DefinitionIdentifies 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. .
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| medicationCodeableConcept | CodeableConcept | Data Type | ||
| medicationReference | Reference(Medication | Medication, deutsches Basisprofil (Version 0.2)) | Data Type Reference(Medication | Medication, deutsches Basisprofil (Version 0.2)) | ||
| effective[x] | Σ | 0..1 | Short description The date/time or interval when the medication was taken DefinitionThe interval of time during which it is being asserted that the patient was taking the medication (or was not taking, when the wasNotGiven element is true). 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.
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| effectiveDateTime | dateTime | Data Type | ||
| effectivePeriod | Period | Data Type | ||
| dateAsserted | Σ | 0..1 | dateTime | Short description When the statement was asserted? DefinitionThe date when the medication statement was asserted by the information source.
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| informationSource | 0..1 | Reference(Patient | Practitioner | RelatedPerson | Organization | Patient, deutsches Basisprofil (Version 0.2) | Practitioner, deutsches Basisprofil (Version 0.2)) | Short description Person or organization that provided the information about the taking of this medication DefinitionThe 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. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Patient | Practitioner | RelatedPerson | Organization | Patient, deutsches Basisprofil (Version 0.2) | Practitioner, deutsches Basisprofil (Version 0.2)) Constraints
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| subject | Σ | 1..1 | Reference(Patient | Group | Patient, deutsches Basisprofil (Version 0.2)) | Short description Who is/was taking the medication DefinitionThe person, animal or group who is/was taking the medication. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Patient | Group | Patient, deutsches Basisprofil (Version 0.2)) Constraints
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| derivedFrom | 0..* | Reference(Resource) | Short description Additional supporting information DefinitionAllows 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.
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| taken | Σ ?! | 1..1 | codeBinding | Short description y | n | unk | na DefinitionIndicator of the certainty of whether the medication was taken by the patient. This element is labeled as a modifier because it indicates that the medication was not taken. medication-statement-taken (required) Constraints
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| reasonNotTaken | 0..* | CodeableConcept | Short description True if asserting medication was not given DefinitionA code indicating why the medication was not taken. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. reason-medication-not-taken-codes (example) Constraints
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| reasonCode | 0..* | CodeableConcept | Short description Reason for why the medication is being/was taken DefinitionA 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.
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| reasonReference | 0..* | Reference(Condition | Observation | Deutsches Basisprofil einer Condition (Version 0.2) | Observation, deutsches Basisprofil (Version 0.2)) | Short description Condition or observation that supports why the medication is being/was taken DefinitionCondition 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. Reference(Condition | Observation | Deutsches Basisprofil einer Condition (Version 0.2) | Observation, deutsches Basisprofil (Version 0.2)) Constraints
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| note | 0..* | Annotation | Short description Further information about the statement DefinitionProvides extra information about the medication statement that is not conveyed by the other attributes. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
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| dosage | 0..* | Dosage | Short description Details of how medication is/was taken or should be taken DefinitionIndicates 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.
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| sequence | Σ | 0..1 | integer | Short description The order of the dosage instructions DefinitionIndicates the order in which the dosage instructions should be applied or interpreted. If the sequence number of multiple Dosages is the same, then it is implied that the instructions are to be treated as concurrent. If the sequence number is different, then the Dosages are intended to be sequential. 32 bit number; for values larger than this, use decimal
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| text | Σ | 0..1 | string | Short description Free text dosage instructions e.g. SIG DefinitionFree text dosage instructions e.g. SIG. Free text dosage instructions can be used for cases where the instructions are too complex to code. The content of this attribute does not include the name or description of the medication. When coded instructions are present, the free text instructions may still be present for display to humans taking or administering the medication. It is expected that the text instructions will always be populated. If the dosage.timing attribute is also populated, then the dosage.text should reflect the same information as the timing. Note that FHIR strings may not exceed 1MB in size
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| additionalInstruction | Σ | 0..* | CodeableConcept | Short description Supplemental instruction - e.g. "with meals" DefinitionSupplemental instruction - e.g. "with meals". Additional instruction such as "Swallow with plenty of water" which may or may not be coded. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. additional-instruction-codes (example) Constraints
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| patientInstruction | Σ | 0..1 | string | Short description Patient or consumer oriented instructions DefinitionInstructions in terms that are understood by the patient or consumer. Note that FHIR strings may not exceed 1MB in size
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| timing | Σ | 0..1 | Timing | Short description When medication should be administered DefinitionWhen medication should be administered. The timing schedule for giving the medication to the patient. The Schedule data type allows many different expressions. For example: "Every 8 hours"; "Three times a day"; "1/2 an hour before breakfast for 10 days from 23-Dec 2011:"; "15 Oct 2013, 17 Oct 2013 and 1 Nov 2013". Sometimes, a rate can imply duration when expressed as total volume / duration (e.g. 500mL/2 hours implies a duration of 2 hours). However, when rate doesn't imply duration (e.g. 250mL/hour), then the timing.repeat.duration is needed to convey the infuse over time period. This attribute may not always be populated while the Dosage.text is expected to be populated. If both are populated, then the Dosage.text should reflect the content of the Dosage.timing.
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| event | Σ | 0..* | dateTime | Short description When the event occurs DefinitionIdentifies specific times when the event occurs. In an MAR, for instance, you need to take a general specification, and turn it into a precise specification.
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| repeat | Σ | 0..1 | Element | Short description When the event is to occur DefinitionA set of rules that describe when the event is scheduled. Many timing schedules are determined by regular repetitions.
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| bounds[x] | Σ | 0..1 | Short description Length/Range of lengths, or (Start and/or end) limits DefinitionEither a duration for the length of the timing schedule, a range of possible length, or outer bounds for start and/or end limits of the timing schedule. The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.
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| boundsDuration | Duration | Data Type | ||
| boundsRange | Range | Data Type | ||
| boundsPeriod | Period | Data Type | ||
| count | Σ | 0..1 | integer | Short description Number of times to repeat DefinitionA total count of the desired number of repetitions. Repetitions may be limited by end time or total occurrences. If you have both bounds and count, then this should be understood as within the bounds period, until count times happens.
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| countMax | Σ | 0..1 | integer | Short description Maximum number of times to repeat DefinitionA maximum value for the count of the desired repetitions (e.g. do something 6-8 times). 32 bit number; for values larger than this, use decimal
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| duration | Σ | 0..1 | decimal | Short description How long when it happens DefinitionHow long this thing happens for when it happens. Some activities are not instantaneous and need to be maintained for a period of time. For some events the duration is part of the definition of the event (e.g. IV infusions, where the duration is implicit in the specified quantity and rate). For others, it's part of the timing specification (e.g. exercise).
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| durationMax | Σ | 0..1 | decimal | Short description How long when it happens (Max) DefinitionThe upper limit of how long this thing happens for when it happens. Some activities are not instantaneous and need to be maintained for a period of time. For some events the duration is part of the definition of the event (e.g. IV infusions, where the duration is implicit in the specified quantity and rate). For others, it's part of the timing specification (e.g. exercise).
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| durationUnit | Σ | 0..1 | codeBinding | Short description s | min | h | d | wk | mo | a - unit of time (UCUM) DefinitionThe units of time for the duration, in UCUM units. Note that FHIR strings may not exceed 1MB in size
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| frequency | Σ | 0..1 | integer | Short description Event occurs frequency times per period DefinitionThe number of times to repeat the action within the specified period / period range (i.e. both period and periodMax provided). 32 bit number; for values larger than this, use decimal
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| frequencyMax | Σ | 0..1 | integer | Short description Event occurs up to frequencyMax times per period DefinitionIf present, indicates that the frequency is a range - so to repeat between [frequency] and [frequencyMax] times within the period or period range. 32 bit number; for values larger than this, use decimal
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| period | Σ | 0..1 | decimal | Short description Event occurs frequency times per period DefinitionIndicates the duration of time over which repetitions are to occur; e.g. to express "3 times per day", 3 would be the frequency and "1 day" would be the period. Do not use a IEEE type floating point type, instead use something that works like a true decimal, with inbuilt precision (e.g. Java BigInteger)
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| periodMax | Σ | 0..1 | decimal | Short description Upper limit of period (3-4 hours) DefinitionIf present, indicates that the period is a range from [period] to [periodMax], allowing expressing concepts such as "do this once every 3-5 days. Do not use a IEEE type floating point type, instead use something that works like a true decimal, with inbuilt precision (e.g. Java BigInteger)
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| periodUnit | Σ | 0..1 | codeBinding | Short description s | min | h | d | wk | mo | a - unit of time (UCUM) DefinitionThe units of time for the period in UCUM units. Note that FHIR strings may not exceed 1MB in size
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| dayOfWeek | Σ | 0..* | codeBinding | Short description mon | tue | wed | thu | fri | sat | sun DefinitionIf one or more days of week is provided, then the action happens only on the specified day(s). If no days are specified, the action is assumed to happen every day as otherwise specified. The elements frequency and period cannot be used as well as dayOfWeek.
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| timeOfDay | Σ | 0..* | time | Short description Time of day for action DefinitionSpecified time of day for action to take place. When time of day is specified, it is inferred that the action happens every day (as filtered by dayofWeek) on the specified times. The elements when, frequency and period cannot be used as well as timeOfDay.
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| when | Σ | 0..* | codeBinding | Short description Regular life events the event is tied to DefinitionReal world events that the occurrence of the event should be tied to. Timings are frequently determined by occurrences such as waking, eating and sleep. When more than one event is listed, the event is tied to the union of the specified events.
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| offset | Σ | 0..1 | unsignedInt | Short description Minutes from event (before or after) DefinitionThe number of minutes from the event. If the event code does not indicate whether the minutes is before or after the event, then the offset is assumed to be after the event. 32 bit number; for values larger than this, use decimal
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| code | Σ | 0..1 | CodeableConceptBinding | Short description Einnahmezeitpunkt DefinitionEinnahmezeitpunkt (morgens, mittags, ...) BID etc are defined as 'at institutionally specified times'. For example, an institution may choose that BID is "always at 7am and 6pm". If it is inappropriate for this choice to be made, the code BID should not be used. Instead, a distinct organization-specific code should be used in place of the HL7-defined BID code and/or the a structured representation should be used (in this case, specifying the two event times). einnahmezeitpunkte (extensible) Constraints
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| asNeeded[x] | Σ | 0..1 | Short description Take "as needed" (for x) DefinitionIndicates whether the Medication is only taken when needed within a specific dosing schedule (Boolean option), or it indicates the precondition for taking the Medication (CodeableConcept). Can express "as needed" without a reason by setting the Boolean = True. In this case the CodeableConcept is not populated. Or you can express "as needed" with a reason by including the CodeableConcept. In this case the Boolean is assumed to be True. If you set the Boolean to False, then the dose is given according to the schedule and is not "prn" or "as needed". medication-as-needed-reason (example) Constraints
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| asNeededBoolean | boolean | Data Type | ||
| asNeededCodeableConcept | CodeableConcept | Data Type | ||
| site | Σ | 0..1 | CodeableConcept | Short description Body site to administer to DefinitionBody site to administer to. A coded specification of the anatomic site where the medication first enters the body. If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension body-site-instance. May be a summary code, or a reference to a very precise definition of the location, or both.
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| route | Σ | 0..1 | CodeableConcept | Short description How drug should enter body DefinitionHow drug should enter body. A code specifying the route or physiological path of administration of a therapeutic agent into or onto a patient's body. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
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| method | Σ | 0..1 | CodeableConcept | Short description Technique for administering medication DefinitionTechnique for administering medication. A coded value indicating the method by which the medication is introduced into or onto the body. Most commonly used for injections. For examples, Slow Push; Deep IV. Terminologies used often pre-coordinate this term with the route and or form of administration. administration-method-codes (example) Constraints
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| dose[x] | Σ | 0..1 | Short description Amount of medication per dose DefinitionAmount of medication per dose. The amount of therapeutic or other substance given at one administration event. Note that this specifies the quantity of the specified medication, not the quantity for each active ingredient(s). Each ingredient amount can be communicated in the Medication resource. For example, if one wants to communicate that a tablet was 375 mg, where the dose was one tablet, you can use the Medication resource to document that the tablet was comprised of 375 mg of drug XYZ. Alternatively if the dose was 375 mg, then you may only need to use the Medication resource to indicate this was a tablet. If the example were an IV such as dopamine and you wanted to communicate that 400mg of dopamine was mixed in 500 ml of some IV solution, then this would all be communicated in the Medication resource. If the administration is not intended to be instantaneous (rate is present or timing has a duration), this can be specified to convey the total amount to be administered over the period of time as indicated by the schedule e.g. 500 ml in dose, with timing used to convey that this should be done over 4 hours.
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| doseRange | Range | Data Type | ||
| doseQuantity | SimpleQuantity | Data Type | ||
| maxDosePerPeriod | Σ | 0..1 | Ratio | Short description Upper limit on medication per unit of time DefinitionUpper limit on medication per unit of time. The maximum total quantity of a therapeutic substance that may be administered to a subject over the period of time. For example, 1000mg in 24 hours. This is intended for use as an adjunct to the dosage when there is an upper cap. For example "2 tablets every 4 hours to a maximum of 8/day".
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| maxDosePerAdministration | Σ | 0..1 | SimpleQuantity | Short description Upper limit on medication per administration DefinitionUpper limit on medication per administration. The maximum total quantity of a therapeutic substance that may be administered to a subject per administration. This is intended for use as an adjunct to the dosage when there is an upper cap. For example, a body surface area related dose with a maximum amount, such as 1.5 mg/m2 (maximum 2 mg) IV over 5 – 10 minutes would have doseQuantity of 1.5 mg/m2 and maxDosePerAdministration of 2 mg.
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| maxDosePerLifetime | Σ | 0..1 | SimpleQuantity | Short description Upper limit on medication per lifetime of the patient DefinitionUpper limit on medication per lifetime of the patient. The maximum total quantity of a therapeutic substance that may be administered per lifetime of the subject. The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.
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| rate[x] | Σ | 0..1 | Short description Amount of medication per unit of time DefinitionAmount of medication per unit of time. Identifies the speed with which the medication was or will be introduced into the patient. Typically the rate for an infusion e.g. 100 ml per 1 hour or 100 ml/hr. May also be expressed as a rate per unit of time e.g. 500 ml per 2 hours. Other examples: 200 mcg/min or 200 mcg/1 minute; 1 liter/8 hours. Sometimes, a rate can imply duration when expressed as total volume / duration (e.g. 500mL/2 hours implies a duration of 2 hours). However, when rate doesn't imply duration (e.g. 250mL/hour), then the timing.repeat.duration is needed to convey the infuse over time period. It is possible to supply both a rate and a doseQuantity to provide full details about how the medication is to be administered and supplied. If the rate is intended to change over time, depending on local rules/regulations, each change should be captured as a new version of the MedicationRequest with an updated rate, or captured with a new MedicationRequest with the new rate.
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| rateRatio | Ratio | Data Type | ||
| rateRange | Range | Data Type | ||
| rateQuantity | SimpleQuantity | Data Type |
<MedicationStatement> <meta> <profile value="http://fhir.de/StructureDefinition/medicationstatement-de-basis/0.2" /> </meta> <status value="active" /> <medicationReference> <reference value="/Medication/987654" /> </medicationReference> <effectivePeriod> <start value="2017-08-08" /> </effectivePeriod> <dateAsserted value="2017-08-01" /> <subject> <reference value="Patient/13345" /> </subject> <taken value="y" /> <dosage> <timing> <code> <coding> <system value="http://hl7.org/fhir/v3/TimingEvent" /> <code value="CV" /> </coding> </code> </timing> <doseQuantity> <value value="1" /> <system value="http://fhir.de/CodeSystem/kbv/s-bmp-dosiereinheit" /> <code value="1" /> </doseQuantity> </dosage> </MedicationStatement>
{ "resourceType":"MedicationStatement", "meta":{ "profile": [ "http://fhir.de/StructureDefinition/medicationstatement-de-basis/0.2" ] }, "status":"active", "medicationReference":{ "reference":"/Medication/987654" }, "effectivePeriod":{ "start":"2017-08-08" }, "dateAsserted":"2017-08-01", "subject":{ "reference":"Patient/13345" }, "taken":"y", "dosage": [ { "timing":{ "code":{ "coding": [ { "system":"http://hl7.org/fhir/v3/TimingEvent", "code":"CV" } ] } }, "doseQuantity":{ "value":"1", "system":"http://fhir.de/CodeSystem/kbv/s-bmp-dosiereinheit", "code":"1" } } ] }
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