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11.4 Resource MedicationStatement - Content

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

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.

11.4.1 Scope and Usage

Common usage includes:

  • the recording of non-prescription and/or recreational drugs
  • the recording of an intake medication list upon admission to hospital
  • the summarization of a patient's "active medications" in a patient profile

A MedicationStatement SHALL NOT be used to record substance abuse or the use of other agents such as tobacco or alcohol UNLESS those agents have been prescribed, e.g. nicotine patches or gum, long term care alcohol, etc. These should recorded as Social History Observations.

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 includes an adherence element. Note that this adherence is specific to that instance of MedicationStatement. If MedicationStatement.adherence is being tracked over time, then instances of MedicationStatement would report adherence for the interval noted in effectivePeriod.

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

11.4.2 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.

To indicate the link between a MedicationStatement instance and the Medication Request, Dispense, or Administration that was used to derive the MedicationStatement, the reference should be placed in the MedicationStatement.derivedFrom element.

11.4.3 References to this Resource

11.4.4 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. MedicationStatement TU DomainResource Record of medication being taken by a patient

Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier Σ 0..* Identifier External identifier

... partOf 0..* Reference(Procedure | MedicationStatement) Part of referenced event

... status ?!Σ 1..1 code recorded | entered-in-error | draft
Binding: MedicationStatement Status Codes (Required)
... medication Σ 1..1 CodeableReference(Medication) What medication was taken
Binding: SNOMED CT Medication Codes (Example)
... subject Σ 1..1 Reference(Patient | Group) Who is/was taking the medication
... encounter Σ 0..1 Reference(Encounter) Encounter associated with MedicationStatement
... effective[x] Σ 0..1 The date/time or interval when the medication is/was/will be taken
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effectiveTiming Timing
... dateAsserted Σ 0..1 dateTime When the usage was asserted?
... author Σ 0..1 Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) Who/What authored the statement
... informationSource 0..* Reference(Device | Patient | Practitioner | PractitionerRole | RelatedPerson | Organization | Group) Person or organization that provided the information about the taking of this medication

... derivedFrom 0..* Reference(Any) Link to information used to derive the MedicationStatement

... reason 0..* CodeableReference(Condition | Observation | DiagnosticReport | Procedure) Reason for why the medication is being/was taken
Binding: Condition/Problem/Diagnosis Codes (Example)

... note 0..* Annotation Further information about the usage

... relatedClinicalInformation 0..* Reference(Observation | Condition) Link to information relevant to the usage of a medication

... renderedDosageInstruction 0..1 markdown Full representation of the dosage instructions
... dosage 0..* Dosage Details of how medication is/was taken or should be taken

... adherence Σ 0..1 BackboneElement Indicates whether the medication is or is not being consumed or administered
.... code Σ 1..1 CodeableConcept Type of adherence
Binding: MedicationStatement Adherence Codes (Example)
.... reason 0..1 CodeableConcept Details of the reason for the current use of the medication
Binding: SNOMED CT Drug Therapy Status codes (Example)

doco Documentation for this format icon

See the Extensions for this resource

 

Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis

11.4.4.1 Terminology Bindings

Path ValueSet Type Documentation
MedicationStatement.status MedicationStatementStatusCodes Required

MedicationStatement Status Codes
MedicationStatement.category MedicationRequestAdministrationLocationCodes Example

MedicationRequest Administration Location Codes
MedicationStatement.medication SNOMEDCTMedicationCodes Example

This value set includes all drug or medicament substance codes and all pharmaceutical/biologic products from SNOMED CT - provided as an exemplar value set.
MedicationStatement.reason ConditionProblemDiagnosisCodes Example

Example value set for Condition/Problem/Diagnosis codes.
MedicationStatement.adherence.code MedicationStatementAdherenceCodes Example

MedicationStatement Adherence Codes
MedicationStatement.adherence.reason SNOMEDCTDrugTherapyStatusCodes Example

This value set includes some taken and not taken reason codes from SNOMED CT - provided as an exemplar

11.4.5 Search Parameters

Search parameters for this resource. See also the full list of search parameters for this resource, and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
adherence token Returns statements based on adherence or compliance MedicationStatement.adherence.code
category token Returns statements of this category of MedicationStatement MedicationStatement.category
code token Return statements of this medication code MedicationStatement.medication.concept 21 Resources
effective date Date when patient was taking (or not taking) the medication MedicationStatement.effective.ofType(dateTime) | MedicationStatement.effective.ofType(Period)
encounter reference Returns statements for a specific encounter MedicationStatement.encounter
(Encounter)		 29 Resources
identifier token Return statements with this external identifier MedicationStatement.identifier 65 Resources
medication reference Return statements of this medication reference MedicationStatement.medication.reference 4 Resources
patient reference Returns statements for a specific patient. MedicationStatement.subject.where(resolve() is Patient)
(Patient)		 65 Resources
source reference Who or where the information in the statement came from MedicationStatement.informationSource
(Practitioner, Group, Organization, Device, Patient, PractitionerRole, RelatedPerson)
status token Return statements that match the given status MedicationStatement.status 4 Resources
subject reference The identity of a patient, animal or group to list statements for MedicationStatement.subject
(Group, Patient)