OpenEHR Master CKM Mirror
Name
Medication management
Description
Any activity related to the planning, scheduling, prescription management, dispensing, administration, cessation and other use of a medication, vaccine, nutritional product or other therapeutic item.
Comment
This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication.
Keywords
medication
prescribe
dispense
administration
cessation
therapeutic good
supply
medicine
drug
preparation
medicinal
prescription
vaccine
vaccination
dosage
form
route
follow-up
Purpose
For recording details about any activity related to the planning, scheduling, prescription management, dispensing, administration, cessation and other use of a medication, vaccine, nutritional product or other therapeutic item.
Use
Use to record information about the activities required to support all aspects of medication management, including the planning, scheduling, suspension, cancellation and completion of medication orders, as well as the actual administration of medication items. This is done by the recording of data against specific activities, as defined by the 'Pathway' careflow steps in this archetype.
This archetype is intended to be used for any type of medication and related order, whether prescribed by a health professional or available for purchase 'over the counter'. The scope of this medication archetype also includes orders for vaccinations, parenteral fluids or other therapeutic goods, such as bandages, nutritional products or other items that are applied or administered to have a therapeutic effect and which have a common pattern for data recording. Within the context of a Medication or Vaccination List, this archetype will be used to record only what medication or vaccination has been prescribed or administered.
Additional structured and detailed information about the activity can be captured using purpose-specific archetypes inserted into the 'Preparations details', 'Amount', 'Structured body site', 'Administration device' or 'Additional details' SLOTs, where required.
Timings related to medication management can be managed in one of two ways:
- Using the reference model - the time for performance of any pathway step will use the ACTION time attribute for each step.
- Archetyped data elements - the 'Original scheduled date/time' data element is intended to record the time when the medication item was intended to be administered. Note: the corresponding ACTION time attribute for the Scheduled pathway step will record the time that the clinical activity was scheduled into a system, not the intended date/time on which the activity is intended to be carried out.
In practice, some medications (for example, during resuscitation in the emergency department) will be administered on the basis of a protocol or verbal order and not be ordered in advance. The details about the medication will be added against the pathway step 'Dose administered'. For an ongoing course of medication, data about the medication item will be recorded against the 'Dose administered' step at each administration, leaving the instruction in the active state. When the last occurrence is recorded the ‘Medication course completed' step is recorded showing that this order is now in the completed state.
In other situations, such as secondary care, there may be a formal order for a medication item using a corresponding INSTRUCTION.medication_order archetype. This ACTION archetype can then be used to record the workflow of when and how the order has been carried out.
Recording information using this ACTION archetype indicates that some sort of activity has actually occurred; this will most commonly be the administration of the medication item itself, but may be a delayed supply attempt or another activity such as suspending the medication item in preparation for a procedure. If there is a formal order for the medication item, the state of this order is represented by the Pathway step against which the data is recorded. For example, using this archetype the progressing state of a Paracetamol order may be recorded through separate entries in the EHR progress notes at each 'Pathway' step. When documenting the reason for why an activity was performed or a pathway step was chosen, for example why a dose was omitted or the medication was ceased, the element "Reason" may be used.
When this ACTION archetype is used with the corresponding INSTRUCTION.medication_order archetype, information which hasn't changed from the order to the management activity aren't generally repeated in the action. It's considered good practice, though not mandatory, to record the medication item in the ACTION.
The pathway steps make a distinction between those which relate directly to fulfillment of the order, such as authorisation, preparation and dose administration, and those which relate to handling of the prescription such as issue, re-authorisation, dispensing. In some jurisdictions these are regarded as a single pathway, in others it may be helpful to handle order fulfillment and prescription in separate templates.
The names of most of the pathway steps in this archetype start with either "Medication" or "Prescription" to make it easier to differentiate between the pathway steps that are associated with prescription handling and those that are associated with handling the medication order itself.
In some jurisdictions, a prescription can be re-authorised for the purpose of continuing an ongoing medication order, while in others an entirely new prescription must be issued in these circumstances. In the latter, the pathway step 'Prescription re-authorised' is not applicable.
This archetype is intended to be used for any type of medication and related order, whether prescribed by a health professional or available for purchase 'over the counter'. The scope of this medication archetype also includes orders for vaccinations, parenteral fluids or other therapeutic goods, such as bandages, nutritional products or other items that are applied or administered to have a therapeutic effect and which have a common pattern for data recording. Within the context of a Medication or Vaccination List, this archetype will be used to record only what medication or vaccination has been prescribed or administered.
Additional structured and detailed information about the activity can be captured using purpose-specific archetypes inserted into the 'Preparations details', 'Amount', 'Structured body site', 'Administration device' or 'Additional details' SLOTs, where required.
Timings related to medication management can be managed in one of two ways:
- Using the reference model - the time for performance of any pathway step will use the ACTION time attribute for each step.
- Archetyped data elements - the 'Original scheduled date/time' data element is intended to record the time when the medication item was intended to be administered. Note: the corresponding ACTION time attribute for the Scheduled pathway step will record the time that the clinical activity was scheduled into a system, not the intended date/time on which the activity is intended to be carried out.
In practice, some medications (for example, during resuscitation in the emergency department) will be administered on the basis of a protocol or verbal order and not be ordered in advance. The details about the medication will be added against the pathway step 'Dose administered'. For an ongoing course of medication, data about the medication item will be recorded against the 'Dose administered' step at each administration, leaving the instruction in the active state. When the last occurrence is recorded the ‘Medication course completed' step is recorded showing that this order is now in the completed state.
In other situations, such as secondary care, there may be a formal order for a medication item using a corresponding INSTRUCTION.medication_order archetype. This ACTION archetype can then be used to record the workflow of when and how the order has been carried out.
Recording information using this ACTION archetype indicates that some sort of activity has actually occurred; this will most commonly be the administration of the medication item itself, but may be a delayed supply attempt or another activity such as suspending the medication item in preparation for a procedure. If there is a formal order for the medication item, the state of this order is represented by the Pathway step against which the data is recorded. For example, using this archetype the progressing state of a Paracetamol order may be recorded through separate entries in the EHR progress notes at each 'Pathway' step. When documenting the reason for why an activity was performed or a pathway step was chosen, for example why a dose was omitted or the medication was ceased, the element "Reason" may be used.
When this ACTION archetype is used with the corresponding INSTRUCTION.medication_order archetype, information which hasn't changed from the order to the management activity aren't generally repeated in the action. It's considered good practice, though not mandatory, to record the medication item in the ACTION.
The pathway steps make a distinction between those which relate directly to fulfillment of the order, such as authorisation, preparation and dose administration, and those which relate to handling of the prescription such as issue, re-authorisation, dispensing. In some jurisdictions these are regarded as a single pathway, in others it may be helpful to handle order fulfillment and prescription in separate templates.
The names of most of the pathway steps in this archetype start with either "Medication" or "Prescription" to make it easier to differentiate between the pathway steps that are associated with prescription handling and those that are associated with handling the medication order itself.
In some jurisdictions, a prescription can be re-authorised for the purpose of continuing an ongoing medication order, while in others an entirely new prescription must be issued in these circumstances. In the latter, the pathway step 'Prescription re-authorised' is not applicable.
Misuse
Not to be used for recording a medication order or instruction. Use the INSTRUCTION.medication_order archetype for this purpose.
Not to be used to record the administration or dispensing of blood products, which involves a fundamentally different clinical process and is likely to require different supporting information. Use a different appropriate ACTION archetype for this purpose.
Not to be used for recording details about therapeutic adherence, secondary effects or toxicity. Use other archetypes for these purposes.
Not to be used for medication reconcilliation. Use other appropriate archetypes for this purpose.
Not to be used for a formal review of an entire medication list, for example by a pharmacist. Use other appropriate archetypes for this purpose.
Not to be used to record the administration or dispensing of blood products, which involves a fundamentally different clinical process and is likely to require different supporting information. Use a different appropriate ACTION archetype for this purpose.
Not to be used for recording details about therapeutic adherence, secondary effects or toxicity. Use other archetypes for these purposes.
Not to be used for medication reconcilliation. Use other appropriate archetypes for this purpose.
Not to be used for a formal review of an entire medication list, for example by a pharmacist. Use other appropriate archetypes for this purpose.
References
Based on Medication Action, Published Archetype [Internet]. Australian Digital Health Agency, Australian Digital Health Agency Clinical Knowledge Manager [cited: 2017-08-10]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.876
Medication statement, [Internet]. Intermountain Healthcare. Available from http://www.opencem.org/#/20170613/Intermountain/MedicationStatement
Messaging Implementation Manual (GP2GP messages) [Internet], NHS Digital England. Available from: https://data.developer.nhs.uk/dms/mim/6.3.01/Domains/GP2GP/Document%20files/GP2GP%20IM.htm#_Toc_Section_7.2
Standards for the clinical structure and content of patient records (Complete document) [Internet]. PRSB London. [cited 2017 Aug 29]. Available from: http://theprsb.org/download/document/7-standards-for-the-clinical-structure-and-content-of-patient-records
Norwegian regulations for medication management (Forskrift om legemiddelhåndtering for virksomheter og helsepersonell som yter helsehjelp) [Internet]. Government of Norway. [cited 2017-10-26]. Available from: https://lovdata.no/forskrift/2008-04-03-320
Archetype Id
openEHR-EHR-ACTION.medication.v1
Copyright
© openEHR Foundation
Licencing
This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/.
Original Author
Ian McNicoll
freshEHR Clinical Informatics UK
freshEHR Clinical Informatics UK
Date Originally Authored
2017-05-29
| Language | Details |
|---|---|
| German |
Ramona Wellmann, Natalia Strauch
Medizinische Hochschule Hannover
|
| Russian |
Art Latyp; Артур Латыпов
RusBITech; Русбитех, Москва
|
| Swedish |
Emma Malm
Karolinska Universitetssjukhuset
|
| Spanish (Argentina) |
Guillermo Palli
|
| Norwegian Bokmal |
Vebjørn Arntzen, Silje Ljosland Bakke, John Tore Valand
Oslo universitetssykehus HF, Helse Vest IKT AS, Norway
|
| Portuguese (Brazil) |
Débora Farage, Fernanda Maia, Adriana Kitajima, Ana Paula Andrade, Clóvis Puttini
Core Consulting
|
| Arabic (Syria) |
Mona Saleh
|
| Slovenian, Slovene |
Biljana Prinčič
Marand, Ljubljana
|
| Chinese (PRC) |
Lin Zhang
Freelancer
|
| Catalan, Valencian |
Manuel José Zafra Doménech
TRADCREA, S.L.
|
| Spanish, Castilian |
Julio de Sosa
Servei Català de la Salut
|
| Name | Card | Type | Description |
|---|---|---|---|
|
Medication item
|
0..1 | DV_TEXT |
Name of the medication, vaccine or other therapeutic/prescribable item which was the focus of the activity.
Comment
For example: 'Atenolol 100mg' or 'Tenormin tablets 100mg'.
It is strongly recommended that the 'Medication item' is coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple name of the medication item through to structured details about the actual medication pack used. Free text entry should only be used if there is no appropriate terminology available.
|
|
Medication details
|
0..1 | Slot (Cluster) |
Structured details about the medication including strength, form and constituent substances.
Comment
Use this SLOT where the detailed description of the dispensed, authorised or administered item needs to be explicitly stated. For example: the form, strength, any diluents or mixture of ingredients.
Slot
Slot
|
|
Amount
|
0..1 | Slot (Cluster) |
Specific details about the amount of the medication item.
Comment
CLUSTER.dosage is intended to carry details of medication order changes or dose administrations, whilst CLUSTER.medication_supply_amount is intended for details of dispensing-related activity.
Slot
Slot
|
|
Clinical indication
|
0..1 | DV_TEXT |
The clinical reason for the medication activity.
Comment
For example: 'Angina' or 'Pain'. Coding of the indication with a terminology is preferred, where possible. This data element allows multiple occurrences. If only an ACTION is used to record a medication indication, this data element can be used without additional consideration. However, if a clinical indication is recorded for both the Medication order INSTRUCTION and this Medication management ACTION, be aware that these indications might not be consistent."
|
|
Substitution
|
0..1 | DV_CODED_TEXT |
Subsitution action taken by the person administering or dispensing the drug.
Comment
In many jurisdictions, substitution of an ordered item as a generic form or with a different brand name, which has been determined as bioequivalent, is allowed at the point of dispense or supply. In other cases substitution is assumed and the clinician has to explicitly request non-substitution.
Constraint for DV_CODED_TEXT
|
|
Substitution reason
|
0..1 | DV_TEXT |
The reason or justification for the substitution action taken.
Comment
For example: "Generic alternative contains a substance that is not tolerated by the patient." May be coded with a terminology when clinically appropriate
|
|
Original scheduled date/time
|
0..1 | DV_DATE_TIME |
The datetime at which the medication action was scheduled to occur.
Comment
Used to compare variance from actual action time where this is not readily calculable from the original instruction.
|
|
Restart date/time
|
0..1 | DV_DATE_TIME |
The date/time on which the medication course is set to restart, as per the "Administrations suspended" pathway step.
Comment
For example: 2017-10-29
|
|
Restart criterion
|
0..1 | DV_TEXT |
The criterion which triggers the medication course to restart, as per the "Administrations suspended" pathway step.
Comment
For example: "On day 2 after surgery".
|
|
Reason
|
0..* | DV_TEXT |
Reason that the pathway step for the identified medication was carried out.
Comment
For example: 'Postponed - Patient not avalable at administration time', 'Cancelled - Adverse reaction'. Note: This is not the reason for the medication instruction, but rather the specific reason that a care step was carried out, and will often be used to document some variance from the original order.
|
Administration details
|
0..1 | CLUSTER |
Details of body site and administration of the medication.
CLUSTER
|
|
Route
|
0..1 | DV_TEXT |
The route by which the ordered item was, or is to be, administered into the subject's body.
Comment
Comment: For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible. Multiple potential routes may be specified.
|
|
Body site
|
0..1 | DV_TEXT |
Structured description of the site of administration of the ordered item.
Comment
For example: 'left upper arm', 'intravenous catheter right hand'.
Coding of the body site with a terminology is preferred, where possible.
|
|
Structured body site
|
0..1 | Slot (Cluster) |
Structured description of the site of administration of the medication, vaccine or therapeutic good.
Comment
For example: "On the medial skin surface of the left forearm, from 10 cm to 20 cm distally from the point of the elbow".
Slot
Slot
|
|
Administration method
|
0..* | DV_TEXT |
The technique or device by which the ordered item was, or is to be, administered.
Comment
Comment: For example: ' via Z-track injection'; 'via nebuliser'. Coding of the method with a terminology is preferred, where possible.
|
|
Administration device
|
0..* | Slot (Cluster) |
Details of the medical device used to assist administration of the medication.
Slot
Slot
|
|
Additional details
|
0..* | Slot (Cluster) |
Further structured details of the action, possibly specific to a pathway step.
Slot
Slot
|
|
Patient guidance
|
0..* | DV_TEXT |
Any guidance, instructions or advice given to the subject of care or personal carer at the time of the pathway step.
Comment
For example: 'Avoid grapefruit' , 'Take at least 2 hours before bedtime', 'Take with food'. May be coded with a terminology when clinically appropriate.
|
|
Double-checked?
|
0..1 | DV_BOOLEAN |
The pathway step has been checked by a separate individual.
Comment
Details of the individual performing the double-check can be carried in the Reference Model element "Participation".
|
|
Sequence number
|
0..1 | DV_COUNT |
The sequence number specific to the pathway step being recorded.
Comment
For example: Vaccine sequence number.
|
|
Comment
|
0..1 | DV_TEXT |
Additional narrative about the activity or pathway step not captured in other fields, including details of any variance between the intended action and the action actually performed.
Comment
For example: 'Patient was in radiology department', 'Accidental injection into blood vessel during IM administration'.
|
| Name | Card | Type | Description |
|---|---|---|---|
|
Order ID
|
0..* |
CHOICE OF
DV_IDENTIFIER
DV_TEXT
|
Unique identifier for the medication order.
Comment
Comment: This data element allows for multiple occurrences to be defined more explicitly at run-time, if required.
|
|
Extension
|
0..* | Slot (Cluster) |
Additional information required to capture local content or to align with other reference models/formalisms.
Comment
For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.
Slot
Slot
|
| Careflow Step | Description | Current State |
|---|---|---|
| Medication recommended | The medication has been recommended but no steps have been taken to initiate prescribing. | planned |
| Prescription awaiting authorisation | Draft prescription has been prepared and is awaiting confirmation from an authorised clinician. May be used where reauthorisations are performed as a batch. This careflow_step may have a status of 'planned' or 'active', reflecting the need to to handle new orders as well as re-authorised orders. | planned active |
| Medication course postponed | The scheduled medication course has been postponed prior to any administration. | postponed |
| Medication course cancelled | The planned course of medication has been cancelled prior to any administration. | cancelled |
| Prescription cancelled | The prescription was cancelled prior to being issued. | cancelled |
| Medication start date/condition set | The time to start the medication, or other starting condition, has been set. | scheduled |
| Medication authorised | The medication has been formally authorised for use. | scheduled |
| Prescription issued | A prescription has been issued for the medication. | active |
| Prescription dispensed | The ordered medication has been dispensed, for example from a pharmacy to the patient. | active |
| Prescription re-authorised | The original medication order has been re-authorised to allow repeat prescription or dispensing. In some jurisdictions an entirely new order must be issued in these circumstances. | active |
| Prescription re-issued | A prescription has been re-issued for an existing medication order. | active |
| Medication prepared | The medication has been physically prepared. | active |
| Medication double checked | The prepared medication has been double checked. | active |
| Medication course commenced | The medication has been taken by, or administered to, the patient for the first time. Although in some settings this significant date may be computable as the first of several administrations, in other settings, such as primary care, specific administration dates are not readily available. | active |
| Minor change to order | The medication order has been changed in a manner which does not require a new instruction/order to be issued, according to local clinical rules. | active |
| Medication reassessed | The individual medication has been reassessed, for example whether the medication should still be taken. This is not intended to capture review of the medication list. | active |
| Dose administered | A single administration of the medication has taken place. | active |
| Dose administration omitted | An administration of the medication has been withheld and not given. There is no expectation that it will be given later, though the next dose (if any) should be administered according to the original order. | active |
| Dose administration deferred | An administration of a dose of the medication has been delayed but is expected to be given as soon as possible. | active |
| Prescription supply delayed | The prescription has not been dispensed due to a technical or pharamaceutical supply issue. | suspended |
| Administrations suspended | The administration of the medication has been suspended until further notice. No further doses should be given until the restart date or conditions have been met. When setting the date/conditions for restart after suspending, a step from ‘Administrations suspended’ and back to 'Medication start date/condition set' should be performed. | suspended |
| Prescription re-authorisation pending | Issue of the prescription is awaiting re-authorisation by a clinician. | suspended |
| Medication course stopped | Administration of the medication has been ceased during the period of the intended course. | aborted |
| Major change to order | A major change to the order was required, resulting in this order being stopped and a replacement order being started. | aborted |
| Prescription invalid or expired | Prescription has been invalidated or has expired without being fulfilled. | aborted |
| Medication course completed | The medication course has been completed as planned. | completed |
| Prescription fulfilled | The prescription has been fulfilled successfully. | completed |
archetype (adl_version=1.4; uid=0033ab5c-cde0-4402-8b64-d30c188adf79) openEHR-EHR-ACTION.medication.v1 concept [at0000] -- Medication management language original_language = <[ISO_639-1::en]> translations = < ["de"] = < language = <[ISO_639-1::de]> author = < ["name"] = <"Ramona Wellmann, Natalia Strauch"> ["organisation"] = <"Medizinische Hochschule Hannover"> ["email"] = <"strauch.natalia@mh-hannover.de, Strauch.Natalia@mh-hannover.de"> > > ["ru"] = < language = <[ISO_639-1::ru]> author = < ["name"] = <"Art Latyp; Артур Латыпов"> ["organisation"] = <"RusBITech; Русбитех, Москва"> > accreditation = <"hmm"> > ["sv"] = < language = <[ISO_639-1::sv]> author = < ["name"] = <"Emma Malm"> ["organisation"] = <"Karolinska Universitetssjukhuset"> ["email"] = <"emma.malm@cambio.se"> > > ["es-ar"] = < language = <[ISO_639-1::es-ar]> author = < ["name"] = <"Guillermo Palli"> > > ["nb"] = < language = <[ISO_639-1::nb]> author = < ["name"] = <"Vebjørn Arntzen, Silje Ljosland Bakke, John Tore Valand"> ["organisation"] = <"Oslo universitetssykehus HF, Helse Vest IKT AS, Norway"> ["email"] = <"john.tore.valand@helse-vest-ikt.no, silje.ljosland.bakke@helse-vest-ikt.no"> > > ["pt-br"] = < language = <[ISO_639-1::pt-br]> author = < ["name"] = <"Débora Farage, Fernanda Maia, Adriana Kitajima, Ana Paula Andrade, Clóvis Puttini"> ["organisation"] = <"Core Consulting"> ["email"] = <"contato@coreconsulting.com.br"> > accreditation = <"Hospital Alemão Oswaldo Cruz"> > ["ar-sy"] = < language = <[ISO_639-1::ar-sy]> author = < ["name"] = <"Mona Saleh"> > > ["sl"] = < language = <[ISO_639-1::sl]> author = < ["name"] = <"Biljana Prinčič"> ["organisation"] = <"Marand, Ljubljana"> ["email"] = <"biljana.princic@marand.si"> > > ["zh-cn"] = < language = <[ISO_639-1::zh-cn]> author = < ["name"] = <"Lin Zhang"> ["organisation"] = <"Freelancer"> ["email"] = <"linforest@163.com"> > > ["ca"] = < language = <[ISO_639-1::ca]> author = < ["name"] = <"Manuel José Zafra Doménech"> ["organisation"] = <"TRADCREA, S.L."> ["email"] = <"mzafra@tradcrea.com"> > other_details = < ["other_contributors"] = <"Servei Català de la Salut"> > > ["es"] = < language = <[ISO_639-1::es]> author = < ["name"] = <"Julio de Sosa"> ["organisation"] = <"Servei Català de la Salut"> ["email"] = <"juliodesosa@catsalut.cat"> > > > description original_author = < ["name"] = <"Ian McNicoll"> ["organisation"] = <"freshEHR Clinical Informatics UK"> ["email"] = <"ian@freshehr.com"> ["date"] = <"2017-05-29"> > details = < ["de"] = < language = <[ISO_639-1::de]> purpose = <"Zur Darstellung von Angaben über alle Aktivitäten, die im Zusammenhang mit der Planung, Vorbereitung, Rezeptbearbeitung, Ausgabe, Verabreichung, Absetzung und sonstigen Verwendung von Medikamenten, Impfungen, Nahrungsergänzungsmitteln oder anderen therapeutischen Mitteln stehen."> use = <"Zur Darstellung von Informationen über Aktivitäten der Arzneimittelanwendung, einschließlich der Planung, Vorbereitung, Aussetzung, Absetzung und Beendigung von Arzneimittelverordnungen, sowie der aktuellen Verabreichung von Arzneimitteln. Die Erfassung der Daten bestimmter Aktivitäten erfolgt durch die im \"Pathway/Pfad\" des Archetyps definierten Arbeitsschritte. Dieser Archetyp ist für alle Arten von Arzneimitteln und die damit verbundene Verordnung bestimmt, unabhängig davon, ob sie von einem Arzt verschrieben werden oder ob sie \"rezeptfrei\" gekauft werden. Der Anwendungsbereich dieses Arzneimittel-Archetyps umfasst auch die Anwendung von Impfungen, parenteralen Lösungen oder anderen therapeutischen Produkten, wie Verbänden, Nahrungsergänzungs- oder anderen Mitteln, die zum Erzeugen einer therapeutischen Wirkung angewandt oder verabreicht werden und ein gemeinsames Muster für die Datenerfassung haben. Im Zusammenhang mit einer Medikamenten- oder Impfliste wird dieser Archetyp zur Darstellung von verschriebenen oder verabreichten Arzneimitteln oder Impfungen verwendet. Zusätzliche strukturierte und detaillierte Informationen über die Arzneimittel-Aktivität können über zweckgebundene Archetypen erfasst werden. Sie können in die SLOTs \"Arzneimitteldetails\", \"Dosis\", \"Lokalisation\", \"Verabreichungsmittel\" oder \"Zusätzliche Details\" eingefügt werden. Zeitliche Abläufe im Zusammenhang mit der Arzneimittelanwendung könnten auf zwei Arten gehandhabt werden: - unter Verwendung des Referenzmodells - die Zeit der Ausführung eines beliebigen Prozessschrittes wird über die Verwendung des ACTION-Time-Attributs aufgezeichnet. - mit dem Archetyp-Datenelement - das Datenelement \"Ursprünglich geplantes Datum/Uhrzeit\" soll die Zeit erfassen, zu der das Arzneimittel zur Verabreichung bestimmt war. Hinweis: Das entsprechende Attribut \"ACTION-Time\" für den geplanten Prozessschritt erfasst die Zeit, zu der die klinische Aktivität in einem System terminiert wurde, nicht jedoch das beabsichtigte Datum/Uhrzeit, zu dem die Aktivität ausgeführt werden sollte. In der Praxis werden einige Arzneimittel (z.B. bei Reanimation in der Notaufnahme) auf der Grundlage eines Protokolls oder einer mündlichen Anordnung verabreicht und nicht im Voraus verordnet. Die Details zu dem Arzneimittel werden zusammen mit dem Prozessschritt \"Dosis wurde verabreicht\" hinzugefügt. Für eine andauernde Arzneimittelbehandlung werden die Daten zum Arzneimittel zusammen mit dem Prozessschritt \"Dosis wurde verabreicht\" bei jeder Verabreichung erfasst. Die Verordnung bleibt dabei beim Status \"Aktiv\". Wenn das letzte Ereignis vermerkt wird, wird der Prozessschritt \"Arzneimittelbehandlung ist abgeschlossen\" erfasst. Die Verordnung des Arzneimittels erhält nun den Status \"abgeschlossen\". In anderen Situationen, wie z.B. in der Sekundärversorgung, kann es eine formale Verordnung für ein Arzneimittel mit einem entsprechenden Archetyp INSTRUCTION.medication_order geben. Dieser ACTION-Archetyp wird dann zur Darstellung des Workflows, also wann und wie die Verordnung ausgeführt wurde, verwendet. Die Darstellung von Informationen mit diesem ACTION-Archetyp zeigt an, dass eine bestimmte Aktivität tatsächlich stattgefunden hat; dies ist in den meisten Fällen die Verabreichung eines Arzneimittels, kann aber auch ein verzögerter Bereitstellungsversuch oder eine andere Aktivität sein, wie z.B. das Aussetzen einer Medikamentengabe zur Vorbereitung auf eine Operation. Gibt es eine offizielle Verordnung des Arzneimittels, wird der Status dieser Verordnung durch den Prozessschritt repräsentiert, in welchem die Daten registriert werden. Mit diesem Archetyp kann beispielsweise der weitere Verlauf einer Paracetamol-Verordnung in den EHR Prozessschritten dargestellt werden. Das Datenelement \"Begründung\" wird dabei verwendet, um den Grund zu dokumentieren, warum dieser Prozessschritt, z.B. das Weglassen einer Dosis oder das Einstellen einer Arzneimittelgabe, vorgenommen wurde. Wird dieser ACTION-Archetyp mit dem entsprechenden Archetyp INSTRUCTION.medication_order verwendet, werden die Informationen, die sich nicht von der Verordnung- zur Anwendungsaktivität geändert haben, in der Aktion im Allgemeinen nicht wiederholt. Es wird als gute Praxis angesehen, obwohl dies nicht obligatorisch ist, das Arzneimittel in der AKTION aufzuzeichnen. Die Prozessschritte unterscheiden sich zwischen denen, die sich direkt auf die Erfüllung der Verordnung beziehen, wie Autorisierung, Zubereitung und Verabreichung der Dosis, und denen, die sich auf die Handhabung des Rezeptes beziehen, wie Ausstellung, erneute Autorisierung und Abgabe. In einigen Ländern wird das als ein Prozessschritt angesehen. In anderen wird es als hilfreich erachtet, die Erfüllung der Verordnung und die Handhabung des Rezeptes in separaten Templates darzustellen. Die meisten Namen der Prozessschritte dieses Archetyps enthalten die Namen \"Arzneimittel\" oder \"Rezept\" bzw. \"Verordnung\". Dies soll die Unterscheidung der einzelnen Prozessschritte erleichtern. In einigen Ländern kann ein Rezept erneut genehmigt werden, um eine laufende Medikamentenverordnung fortzusetzen, während in anderen Ländern unter diesen Umständen ein völlig neues Rezept ausgestellt werden muss. In letzterem Fall ist der Prozessschritt \"Rezept ist re-autorisiert\" nicht anwendbar."> keywords = <"Arzneimittel", "Medikament", "verschreiben", "verordnen", "rezeptieren", "dosieren", "ausgeben", "Gabe", "Verabreichung", "Applikation", "Anwendung", "Medikation", "Beendigung", "Einstellen", "Absetzen", "Heilmittel", "therapeutisches Produkt", "Versorgung", "zubereiten", "Medizin", "Herstellung", "Präparat", "medizinisch", "medikamentös", "Verschreibung", "Rezept", "Impfstoff", "Impfung", "Dosierung", "Darreichungsform", "Applikationsform", "Applikationsart", "Verabreichungsweg", "Nachbeobachtung"> misuse = <"Nicht zur Repräsentation eines Arzneimittelrezeptes oder Verordnung verwenden. Für diesen Zweck muss der Archetyp INSTRUCTION.medication_order eingesetzt werden. Nicht zur Repräsentation der Verabreichung oder Abgabe von Blutprodukten verwenden. Sie haben meist einen vollkommen anderen klinischen Ablauf und erfordern meist andere unterstützende Informationen. Ein anderer geeigneter ACTION-Archetyp muss für diesen Zweck verwendet werden. Nicht zur Darstellung von Details über die Compliance/Therapietreue, Nebenwirkungen oder Toxizität verwenden. Für diesen Zweck muss ein anderer Archetyp verwendet werden. Nicht für den Medikamentenabgleich verwenden. Für diesen Zweck muss der passende Archetyp verwendet werden. Nicht für eine formelle Überprüfung einer ganzen Medikamentenliste, z.B. durch einen Apotheker, verwenden. Für diesen Zweck müssen andere geeignete Archetypen verwendet werden. "> > ["sv"] = < language = <[ISO_639-1::sv]> purpose = <"Att registrera information om aktiviteter relaterade till planering, schemaläggning, recepthantering, dosering, administrering, avbrott från eller användning av läkemedel, vaccinering, näringspreparat eller annan terapeutisk produkt."> use = <"Används för att registrera information om de aktiviteter som krävs för att stödja alla aspekter av läkemedelshantering inklusive planering, schemaläggning, avbrott, avbokning och slutförande av läkemedelsbeställningar, liksom den faktiska administreringen av läkemedelsartiklar. Detta görs genom registrering av data mot de specifika aktiviteterna, definierat som ”Pathway”-stegen. Den här arketypen är avsedd att användas för alla typer av läkemedel och relaterade ordrar, oavsett om de ordinerats av vårdpersonal eller är tillgängligt för köp \"över disk\". Omfattningen av denna arketyp inkluderar även beställning av vaccin, parenterala vätskor och andra terapeutiska varor, såsom bandage, näringspreparat eller andra föremål som appliceras eller administreras för att uppnå en terapeutisk effekt. För läkemedels- eller vaccinationslistor kommer denna arketyp att bara användas för att registrera vilken medicinering eller vaccination som har ordinerats eller administrerats. Ytterligare information om aktiviteterna kan fångas upp med hjälp av specifika arketyper. Dessa kan bifogas under följande SLOTs: ”Förberedelse av läkemedel”, ” Kvantitet”, ”Exakt anatomisk lokalisering”, \"Utrustning för administrering\" eller ”Övrig information”. Tidsenheter relaterat till läkemedelshantering kan hanteras på ett av följande sätt: - Med hjälp av referensmodellen. Använd tidsattributet ACTION vid utförandet av varje steg. - Med arketypiskt dataelement. Dataelementet ”Ursprungligt datum/tid” registrerar den tid då läkemedelsartikeln var avsedd att administreras. Obs! Motsvarande ACTION-attribut registrerar den tid då den kliniska aktiviteten inplanerades i ett system, och inte det datum/tid då aktiviteten var avsedd att faktiskt genomföras. I praktiken kommer vissa medicineringar (exempelvis de relaterade till återupplivningsförsök på akutmottagningen) att administreras baserat på ett protokoll eller en muntlig order, och därför inte beställas i förväg. Information om detta läkemedel läggs till under ”Administrerad dos”. För en pågående medicinering kommer data om läkemedelsartikeln att registreras under ”Administrerad dos” vid varje administrering, för att på så sätt hålla instruktionen aktiv. När den sista administreringen har registrerats och ordern är fullbordad, noteras detta i ”Fullföljd läkemedelsbehandling”. I andra situationer, till exempel vid sekundärvård, kan det finnas en formell beställning för en läkemedelsartikel med motsvarande INSTRUCTION.medication_order. Denna ACTION-arketyp kan sedan användas för att registrera arbetsflödet för när och hur ordern har genomförts. Registrering av information med denna ACTION-arketyp är en indikation på att någon form av aktivitet har inträffat. Detta utgörs ofta av administrering av själva läkemedelsartikeln, men kan även innebära försenad leverans eller avbrott i en läkemedelsbehandling. Om det finns en formell beställning av läkemedelsartikeln, representeras dess orderstatus av det ”Pathway”-steg mot vilken data registreras. Exempelvis kan ett fortskridande förlopp för en beställning av Paracetamol registreras genom separata noteringar i EHR vid varje ”Pathway”-steg. Vid dokumentation av orsak till utförd aktivitet eller vårdsteg, exempelvis varför en dos utelämnades eller att en medicinering upphörde, kan dataelemntet ”Orsak” användas. När denna ACTION-arketyp används med motsvarande INSTRUCTION.medication_order-arketyp, ska inte information som är oförändrad mellan order och tillhörande hanteringsaktivitet upprepas. God praxis avser dock registrering av läkemedelsartikeln i ACTION-arketypen, men detta är inte obligatoriskt. De olika vårdstegen utgör en åtskillnad mellan de som direkt hänför sig till uppfyllandet av ordern, såsom auktorisering, beredning och administrering av dos, samt de som avser hantering av receptet, såsom utfärdande, återauktorisering och dispensering. I vissa jurisdiktioner betraktas dessa som ett enda vårdsteg, medan det i andra fall är underlättande att behandla orderhantering och recept i separata mallar. Namn på de möjliga vårdstegen i denna arketyp börjar med antingen \"Läkemedel\" eller \"Ordination\" för att underlätta urskiljning mellan de vägval som är förknippade med recepthantering och de som är associerade med att hantera själva läkemedelsordern. I vissa jurisdiktioner kan en ordination godkännas på nytt för att få fortsätta en pågående läkemedelsorder, medan det i andra fall måste utfärdas en ny ordination. För det sistnämnda gäller inte vårdsteget \"Förnyelse av receptbeläggning\"."> keywords = <"medicinering", "ordinera", "dispensera", "administrering", "terapeutiska vara", "leverera", "medicin", "läkemedel", "preparat", "läkande", "ordination", "recept", "vaccin", "vaccination", "dosering", "administreringsväg", "uppföljning"> misuse = <"Ska inte användas för att registrera en läkemedelsorder eller föreskrift. Använd i stället arketypen INSTRUCTION.medication_order. Ska inte användas för att registrera administrering eller dispensering av blodprodukter, då denna aktivitet kräver annan klinisk process. Använd i stället annan lämplig ACTION-arketyp för detta ändamål. Ska inte användas för att registrera information om terapeutisk följsamhet, sekundära effekter eller toxicitet. Använd i stället andra lämpliga arketyper för dessa ändamål. Ska inte användas för förlikning av läkemedel. Använd i stället andra lämpliga arketyper för detta ändamål. Ska inte användas för formell granskning av en läkemedelslista. Använd i stället andra lämpliga arketyper för detta ändamål."> > ["ru"] = < language = <[ISO_639-1::ru]> purpose = <"этот архетип класса ДЕЙСТВИЕ позволяет записывать активность, связанную с введением лекарств или применением лечения. Обычно такая активность возникает в ответ на назначение лекарства врачом, но также может быть при самолечении или лечении по совету аптекаря. Информация о времени приема отсутствует, так как использование данного архетипа предполагает, что действие произведено в настоящий момент времени."> use = <"*For recording the planning, issuing of a prescription, dispensing, administration, cessation, suspension, completion of a medicine, vaccine or other therapeutic good . This will usually be in response to a medication order but may be administered immediately without an order at times, thus requiring recording of the administration alone (e.g. in an emergency situation). Such a record may be made to indicate the administration of a dose, dispensing of a certain quantity or as a record of ceasing a medication. The state of the medication instruction is altered by the action taken as indicated in the Pathway definition. There is a date and time at which this ACTION took place (as there is for all ACTIONs) and use of this archetype indicates that some action has actually occurred.(en)"> keywords = <"лекарство", "медикамент", "введение", "прием"> misuse = <"*Do not use when recording an instruction or order (use INSTRUCTION.medication).(en)"> copyright = <"© openEHR Foundation"> > ["es-ar"] = < language = <[ISO_639-1::es-ar]> purpose = <"Este ACTION permite la grabación de las ordenes de prescripciones. Esto será normalmente en respuesta a una orden de medicación o prescripción, pero puede ser autoadministrado o suministrada por una farmacia. No existe informacion sobre si el uso de este arquetipo implica que alguna accion haya efectivamente sido ejecutada"> use = <"*For recording the planning, issuing of a prescription, dispensing, administration, cessation, suspension, completion of a medicine, vaccine or other therapeutic good . This will usually be in response to a medication order but may be administered immediately without an order at times, thus requiring recording of the administration alone (e.g. in an emergency situation). Such a record may be made to indicate the administration of a dose, dispensing of a certain quantity or as a record of ceasing a medication. The state of the medication instruction is altered by the action taken as indicated in the Pathway definition. There is a date and time at which this ACTION took place (as there is for all ACTIONs) and use of this archetype indicates that some action has actually occurred.(en)"> keywords = <"*medication(en)", "*prescibe(en)", "*dispense(en)", "*administration(en)", "*cessation(en)", "*therapeutic good(en)", "*supply(en)", "*medicine(en)", "*drug(en)"> misuse = <"*Do not use when recording an instruction or order (use INSTRUCTION.medication).(en)"> copyright = <"© openEHR Foundation"> > ["nb"] = < language = <[ISO_639-1::nb]> purpose = <"For å registrere detaljer om enhver legemiddelrelatert oppgave som utføres fra et legemiddel er ordinert eller rekvirert til det er utdelt eller eventuelt kassert, for eksempel bestilling, istandgjøring, administrering, ekspedering eller seponering."> use = <"Brukes til å registrere detaljer om enhver legemiddelrelatert oppgave som utføres fra et legemiddel er ordinert eller rekvirert til det er utdelt eller eventuelt kassert, for eksempel bestilling, istandgjøring, administrering eller ekspedering. Dette gjøres ved å registrere data i sammenheng med spesifikke aktiviteter, som definert av \"Pathway\" prosesstrinnene i arketypen. Denne arketypen er ment for å brukes til en hvilken som helst type legemiddel og tilhørende ordinering, enten den er ordinert av en kliniker eller tilgjengelig uten resept. Den er ment å også dekke vaksiner, parenterale væsker, ernæringsprodukter eller medisinsk forbruksmateriell. Innenfor en legemiddelliste eller vaksinasjonsliste brukes denne arketypen for å registrere hva som er ordinert eller administrert. Ytterligere strukturerte detaljer om aktiviteten kan ved behov registreres ved hjelp av spesifikke arketyper som settes inn i SLOTene \"Legemiddeldetaljer\", \"Legemiddelmengde\", \"Strukturert anatomisk lokalisering\", \"Administreringsutstyr\" eller \"Ytterligere detaljer\". Timing i forbindelse med legemiddelhåndtering kan gjøres på to forskjellige måter: - Ved å bruke referansemodellen: Tidspunktet for utførelsen av en aktivitet bruker \"ACTION time\"-attributten for hvert prosesstrinn, for eksempel når en dose ble administrert eller når legemiddelet ble seponert. - Ved hjelp av informasjonselementer i arketyper: Elementet \"Opprinnelig planlagt tid\" er ment for å registrere tidspunktet da legemiddelet ifølge ordineringen skulle vært administrert. Merk: Den korresponderende \"ACTION time\"-attributten for prosesstrinn av typen \"scheduled\" vil registrere tidspunktet da planleggings-steget ble lagt inn i systemet, ikke tidspunktet når aktiviteten er planlagt å bli utført. I praksis vil noen legemidler, for eksempel under gjenoppliving, administreres på bakgrunn av en prosedyre eller verbal ordinering, og ikke bli registrert på forhånd. Detaljer om legemiddelet vil i disse tilfellene bli registrert i sammenheng med prosesstrinnet \"Legemiddel administrert\". Når det skal gjøres flere administreringer, blir informasjon om legemiddelet registrert i sammenheng med prosesstrinnet \"Legemiddel administrert\" for hver administrering, og instruksjonen beholder statusen \"active\". Når siste administrering er utført, settes prosesstrinnet \"Medisinering fullført\". I andre situasjoner, som for eksempel vanlig ordinering i sykehus, kan det eksistere en formell ordinering for hvert legemiddel i form av en \"INSTRUCTION.medication_order\"-arketype. Denne ACTION-arketypen kan da brukes for å registrere arbeidsflyten for når og hvordan ordineringen ble utført. Å registrere informasjon ved hjelp av denne ACTION-arketypen indikerer at en aktivitet faktisk har blitt utført. Dette vil vanligvis være administrering av legemiddelet, men kan også være forsinket levering fra apotek eller andre aktiviteter som å nulle ut legemiddelet i forkant av en operasjon. Dersom det finnes en formell ordinering av legemiddelet, representeres status for ordineringen ved prosesstrinnet informasjonen er registrert i sammenheng med. For eksempel kan arketypen brukes for å registrere den pågående statusen for en paracetamol-ordinering gjennom en serie registreringer i journalen som hver har sitt prosesstrinn. Man kan bruke elementet \"Årsak\" dersom man trenger å registrere begrunnelsen for at en aktivitet ble utført eller et prosesstrinn ble valgt, for eksempel hvorfor en enkeltdose ble nullet eller legemiddelet ble seponert. Når denne ACTION-arketypen brukes sammen med den korresponderende INSTRUCTION.medication_order-arketypen, vil man generelt ikke gjenta informasjon som ikke er endret fra ordineringen. Det regnes som god praksis, men ikke obligatorisk, å registrere legemiddelnavnet også i ACTION-arketypen. Navnene på prosesstrinnene skiller mellom dem som har direkte sammenheng med utførelse av ordineringen, som autorisering, istandgjøring eller administrering, og dem som har med resepthåndtering å gjøre, som utstedelse eller ekspedering. I noen myndighetsområder er dette regnet som én prosess, mens det i andre kan være nyttig å håndtere dem separat. I noen myndighetsområder kan en resept reautoriseres for å fortsette en pågående ordinering, mens det i andre må utstedes en helt ny resept. For sistnevnte områder er ikke prosesstrinnene \"Reautorisering av resept satt på vent\" eller \"Resept reautorisert\" relevante."> keywords = <"medikasjon", "utdeling", "administrasjon", "utsettelse", "seponering", "terapeutisk vare", "medisinsk vare", "tilførsel", "medisin", "apotekervare", "legemiddel", "legemiddellogistikk", "istandgjøring", "opptrekking", "utblanding", "apotekvare", "administrere", "gi", "preparat", "resept", "e-resept", "ekspedering"> misuse = <"Skal ikke brukes for å registrere ordinering av legemidler. Bruk arketypen INSTRUCTION.medication_order for dette formålet. Skal ikke brukes for å registrere administrering eller utlevering av blodkomponenter, da dette er en grunnleggende annerledes prosess som krever annen informasjon. Bruk en annen, passende ACTION-arketype til dette formålet. Skal ikke brukes for å registrere detaljer om adheranse, sekundæreffekter eller toksisitet. Bruk andre arketyper for disse formålene. Skal ikke brukes for legemiddelsamstemming. Bruk andre arketyper for dette formålet. Skal ikke brukes for en formell gjennomgang av en hel legemiddelliste, for eksempel av farmasøyt. Bruk andre arketyper for dette formålet."> copyright = <"© openEHR Foundation"> > ["pt-br"] = < language = <[ISO_639-1::pt-br]> purpose = <"Para registrar detalhes sobre qualquer atividade relacionada ao planejamento, agendamento, gestão da prescrição, dispensação, administração, término e outro uso de um medicamento, vacina, produto nutricional ou outro insumo terapêutico."> use = <"Usado para registrar informação sobre as atividades necessárias para suportar todos os aspectos da gestão de medicação, incluindo o planejamento, agendamento, suspensão, cancelamento e finalização de solicitação de medicação, assim como a administração de items de medicação. Isso é feito pela gravação de dados de atividades específicas, como definido pelo \"Fluxo\" das etapas do processo de cuidado neste arquétipo. Este arquétipo objetiva ser usado para qualquer tipo de medicação e solicitaçao relacionada, tanto prescrita por um profissional de saúde ou disponível para aquisição em venda livre. O escopo este arquétipo de medicação também inclui solicitações para vacinação, fluidos parenterais e outros insumos terapêuticos, como curativos, produtos nutricionais e outros items que são aplicados ou administraçõ para alcançar um efeito terapêutico e que têm padrões comuns de registro de dados. Dentro do contexto de uma lista de medicação ou vacinação, este arquétipo poderá ser usado para registrar a medicação ou vacinação que foi prescrita ou administrada. Informações adicionais estruturadas ou detalhadas sobre a atividade podem ser capturadas usando arquétipos específicos inseridos nos SLOTs \"Detalhes do preparo\", \"Quantidade\", \"Local do corpo estruturado\", \"Dispositivo de administração\" ou \"Detalhes adicionais\", quando necessário. Tempos relacionados à gestão de medicação podem ser geridos por uma das opções: - Usando o modelo de referência - o tempo da realização de qualquer etapa do processo usará o atributo do tempo da ACTION para cada etapa. - Elementos de dados arquetipados - o elemento de dado \"Data/hora original do agendamento\" pretende registrar o momento que o item de medicação foi marcado para ser administrado. Nota: o atributo ACTION de tempo correspondente para a etapa do processo agendada registrará o momento no qual a atividade clínica foi agendada no sistema, não sendo a data/hora na qual a atividade deve ser realizada. Na prática, algumas medicações (por exemplo, durante ressuscitação no departamento de emergência) serão administradas baseadas em um protocolo ou solicitação verbal e não serão solicitadas com antecedência. Os detalhes sobre a medicação serão adicionados na etapa \"Dose administrada\" do processo. Para um curso de medicação em andamento, dados sobre o item de medicação serão gravados na etapa \"Dose administrada\" para administração, deixando a instrução em estado ativo. Quando a última ocorrência é gravada a etapa \"Curso de medicação completo\" é registrada mostrando que esta solicitação está agora com estado completo. Em outras situações, como cuidado secundário, pode haver solicitação forma para um item de medicação usado o arquétipo correspondente INSTRUCTION.medication_order. Este arquétipo ACTION pode então ser usado para gravar o fluxo de trabalho de quando e como a solicitação foi realizada. O registro da informação usando este arquétipo ACTION indica que algum tipo de atividade realmente ocorreu; esta será mais frequentemente a administração de um medicamento em si, mas pode ser uma tentativa de suprimento adiada ou outra atividade como a suspensão de um item de medicação no preparo para um procedimento. Se há uma solicitação formal para o item de medicação, o estado desta solicitação é representado pela etapa do processo no qual o dado é gravado. Por exemplo, usando este arquétipo o estado progressivo de uma solicitação de paracetamol pode ser gravado em entradas diferentes nas notas do PEP em cada etapa do \"Processo\". Quando documentar o motivo pelo qual uma atividade foi realizada ou uma etapa do processo foi escolhida, por exemplo o por quê uma dose foi omitida ou a medicação terminada, o elemento \"Motivo\" pode ser usado. Quando este arquétipo ACTION é usado com o arquétipo correspondente NSTRUCTION.medication_order, a informação que não foi alterada na solicitação para a atividade de gestão não são geralmente repetidas na ação. É considerado boa prática, embora não obrigatória, gravar o item de medicação na ACTION. As etapas do processo distinguem entre aqueles que diretamente se relacionam a cumprir a solicitação, como uma autorização, preparo ou administração da dose, e aqueles que se relacionam ao manuseio da prescrição como um problema, reautorização, dispensação. Em algumas jurisdições, estes são considerados como um processo único, em outras pode ser útil a gestão de cumprimento de solicitações e prescrição em modelos separados. Os nomes da maioria das etapas do processo neste arquétipo começam ou com \"Medicação\" ou \"Prescrição\" para facilitar a diferenciação entre as etapas do processo associadas com o manuseio da prescrição e aqueles que são associados com o manuseio da solicitação de medicação em si. Em algumas jurisdições, a prescrição pode ser reautorizada para o propósito de continuar uma solicitação de medicação em curso, enquanto em outras uma prescrição inteiramente nova precisa ser emitida nestas circunstâncias. No último caso, a etapa do processo \"Prescrição reautorizada\" não se aplica."> keywords = <"medicamento", "prescrever", "dispensar", "administração", "término", "insumo terapêutico", "suprimento", "medicamento", "fármaco", "preparo", "medicinal", "prescrição", "vacina", "vacinação", "dose", "forma", "via", "seguimento"> misuse = <"Não deve ser usado para registrar uma solicitação de medicação ou instrução. Use o arquétipo INSTRUCTION.medication_order para este propósito. Não deve ser usado para gravar a administração ou dispensação de hemoderivados, que envolvem um processo clínico fundamentalmente diferente e é provável que requeira informação de suporte deiferentes. Use um arquétipo ACTION apropriado para este propósito. Não deve ser usado para gravar detalhes sobre aderência terapêutica, efeitos secundários ou toxicidade. Use outros arquétipos para estes propósitos. Não deve ser usado para reconciliação de medicamentos. Use arquétipos apropriados para este propósito. Não deve ser usado para uma revisão formal de uma lista inteira de medicameção, por exemplo por um farmacêutico. Use arquétipos apropriados para este propósito. "> copyright = <"© openEHR Foundation"> > ["ar-sy"] = < language = <[ISO_639-1::ar-sy]> purpose = <"يُمَكِّن هذا الفعل من تسجيل الأفعال التي يتم تنفيذها فيما يتعلق بالأدوية. و عادة ما يكون ذلك استجابة لأمر دوائي أو وصفة دوائية, و لكنه قد يكون إما قام المريض بتناوله بنفسه أو عن طريق الصيدلية. لا يوجد في هذا النموذج تفاصيل حول الوقت حيث إنه يشير إلى فعل تم في الواقع."> use = <"*For recording the planning, issuing of a prescription, dispensing, administration, cessation, suspension, completion of a medicine, vaccine or other therapeutic good . This will usually be in response to a medication order but may be administered immediately without an order at times, thus requiring recording of the administration alone (e.g. in an emergency situation). Such a record may be made to indicate the administration of a dose, dispensing of a certain quantity or as a record of ceasing a medication. The state of the medication instruction is altered by the action taken as indicated in the Pathway definition. There is a date and time at which this ACTION took place (as there is for all ACTIONs) and use of this archetype indicates that some action has actually occurred.(en)"> keywords = <"*medication(en)", "*prescibe(en)", "*dispense(en)", "*administration(en)", "*cessation(en)", "*therapeutic good(en)", "*supply(en)", "*medicine(en)", "*drug(en)"> misuse = <"*Do not use when recording an instruction or order (use INSTRUCTION.medication).(en)"> copyright = <"© openEHR Foundation"> > ["sl"] = < language = <[ISO_639-1::sl]> purpose = <"*The recording of activities undertaken with regard to a medicine, vaccine or other therapeutic good and linking to the instruction if appropriate."> use = <"*For recording the planning, issuing of a prescription, dispensing, administration, cessation, suspension, completion of a medicine, vaccine or other therapeutic good . This will usually be in response to a medication order but may be administered immediately without an order at times, thus requiring recording of the administration alone (e.g. in an emergency situation). Such a record may be made to indicate the administration of a dose, dispensing of a certain quantity or as a record of ceasing a medication. The state of the medication instruction is altered by the action taken as indicated in the Pathway definition. There is a date and time at which this ACTION took place (as there is for all ACTIONs) and use of this archetype indicates that some action has actually occurred."> keywords = <"*medication", "*prescibe", "*dispense", "*administration", "*cessation", "*therapeutic good", "*supply", "*medicine", "*drug"> misuse = <"*Do not use when recording an instruction or order (use INSTRUCTION.medication)."> copyright = <"© openEHR Foundation"> > ["en"] = < language = <[ISO_639-1::en]> purpose = <"For recording details about any activity related to the planning, scheduling, prescription management, dispensing, administration, cessation and other use of a medication, vaccine, nutritional product or other therapeutic item."> use = <"Use to record information about the activities required to support all aspects of medication management, including the planning, scheduling, suspension, cancellation and completion of medication orders, as well as the actual administration of medication items. This is done by the recording of data against specific activities, as defined by the 'Pathway' careflow steps in this archetype. This archetype is intended to be used for any type of medication and related order, whether prescribed by a health professional or available for purchase 'over the counter'. The scope of this medication archetype also includes orders for vaccinations, parenteral fluids or other therapeutic goods, such as bandages, nutritional products or other items that are applied or administered to have a therapeutic effect and which have a common pattern for data recording. Within the context of a Medication or Vaccination List, this archetype will be used to record only what medication or vaccination has been prescribed or administered. Additional structured and detailed information about the activity can be captured using purpose-specific archetypes inserted into the 'Preparations details', 'Amount', 'Structured body site', 'Administration device' or 'Additional details' SLOTs, where required. Timings related to medication management can be managed in one of two ways: - Using the reference model - the time for performance of any pathway step will use the ACTION time attribute for each step. - Archetyped data elements - the 'Original scheduled date/time' data element is intended to record the time when the medication item was intended to be administered. Note: the corresponding ACTION time attribute for the Scheduled pathway step will record the time that the clinical activity was scheduled into a system, not the intended date/time on which the activity is intended to be carried out. In practice, some medications (for example, during resuscitation in the emergency department) will be administered on the basis of a protocol or verbal order and not be ordered in advance. The details about the medication will be added against the pathway step 'Dose administered'. For an ongoing course of medication, data about the medication item will be recorded against the 'Dose administered' step at each administration, leaving the instruction in the active state. When the last occurrence is recorded the ‘Medication course completed' step is recorded showing that this order is now in the completed state. In other situations, such as secondary care, there may be a formal order for a medication item using a corresponding INSTRUCTION.medication_order archetype. This ACTION archetype can then be used to record the workflow of when and how the order has been carried out. Recording information using this ACTION archetype indicates that some sort of activity has actually occurred; this will most commonly be the administration of the medication item itself, but may be a delayed supply attempt or another activity such as suspending the medication item in preparation for a procedure. If there is a formal order for the medication item, the state of this order is represented by the Pathway step against which the data is recorded. For example, using this archetype the progressing state of a Paracetamol order may be recorded through separate entries in the EHR progress notes at each 'Pathway' step. When documenting the reason for why an activity was performed or a pathway step was chosen, for example why a dose was omitted or the medication was ceased, the element \"Reason\" may be used. When this ACTION archetype is used with the corresponding INSTRUCTION.medication_order archetype, information which hasn't changed from the order to the management activity aren't generally repeated in the action. It's considered good practice, though not mandatory, to record the medication item in the ACTION. The pathway steps make a distinction between those which relate directly to fulfillment of the order, such as authorisation, preparation and dose administration, and those which relate to handling of the prescription such as issue, re-authorisation, dispensing. In some jurisdictions these are regarded as a single pathway, in others it may be helpful to handle order fulfillment and prescription in separate templates. The names of most of the pathway steps in this archetype start with either \"Medication\" or \"Prescription\" to make it easier to differentiate between the pathway steps that are associated with prescription handling and those that are associated with handling the medication order itself. In some jurisdictions, a prescription can be re-authorised for the purpose of continuing an ongoing medication order, while in others an entirely new prescription must be issued in these circumstances. In the latter, the pathway step 'Prescription re-authorised' is not applicable."> keywords = <"medication", "prescribe", "dispense", "administration", "cessation", "therapeutic good", "supply", "medicine", "drug", "preparation", "medicinal", "prescription", "vaccine", "vaccination", "dosage", "form", "route", "follow-up"> misuse = <"Not to be used for recording a medication order or instruction. Use the INSTRUCTION.medication_order archetype for this purpose. Not to be used to record the administration or dispensing of blood products, which involves a fundamentally different clinical process and is likely to require different supporting information. Use a different appropriate ACTION archetype for this purpose. Not to be used for recording details about therapeutic adherence, secondary effects or toxicity. Use other archetypes for these purposes. Not to be used for medication reconcilliation. Use other appropriate archetypes for this purpose. Not to be used for a formal review of an entire medication list, for example by a pharmacist. Use other appropriate archetypes for this purpose."> copyright = <"© openEHR Foundation"> > ["zh-cn"] = < language = <[ISO_639-1::zh-cn]> purpose = <"用于记录关于任何与药物、疫苗、营养产品/制品或其他治疗类制剂（therapeutic item）的计划[编制]、排程/安排、处方管理、配发、施用/给药、停止/停用和其他使用情况相关的活动的详情。"> use = <"用于记录关于那些支持药物管理各个方面时所需活动的信息，而这些活动包括药物医嘱的计划[编制]、排程/安排、暂停、取消和完成，以及具体药物的实际施用/给药。方法就是按照本原始型之中的“路径”照护服务流程步骤的定义，来记录针对种种具体活动的数据。 本原始型旨在用于任何类型的药物医嘱和相关医嘱，无论是健康专业人员的处方所开具的药物还是可在“药房柜台”购买的非处方药。这一药物原始型的范围还包括关于疫苗接种、注射液或其他治疗类制剂/产品的医嘱。例如，绷带、营养产品/制品或其他应用或施用起来具有治疗效果的产品/制品/制剂；而且，此类的产品/制品/制剂在数据记录方面有着共同的模式。在药物或疫苗接种清单的背景下，本原始型将仅仅用于记录处方已开具或已施用的药物或疫苗[接种]。 如果需要，可以利用插入到“制剂详情”（Preparations details）、“数量”（Amount）、“结构化身体部位”（Structured body site）、“施用/给药设备”（Administration device）或“其他详情”（Additional details）槽位（SLOT）之中针对具体目的的原始型，来采集关于相应活动的其他结构化详情。 可以采用下列两种方式之一来管理与药物管理相关的时间特征（时机安排）信息： - 利用参考模型 - 任何路径步骤的执行时间将采用的是每个步骤的行动（ACTION）时间属性。 - 原始型数据元 - “原始预定日期/时间”（Original scheduled date/time）数据元旨在记录预定/打算施用相应药物的时间。注意：已排程/安排计划（Scheduled）路径步骤的相应行动（ACTION）时间属性将记录的是将相应的临床活动排程/安排到系统当中的时间，而不是预定/打算开展相应活动的预定日期/时间。 在实际工作中，一些药物（如急诊科复苏期间的用药）将根据特定的诊疗方案或口头医嘱来进行施用/给药，而不是提前开立医嘱。将会针对路径步骤“施用/给药剂量”（Dose administered），来添加关于药物的详情。对于正在进行之中的药物治疗过程，将会针对每次施用/给药时的步骤“施用/给药剂量”（Dose administered），来记录关于相应具体药物的数据，并使相应的医嘱指令保持有效状态。当记录最后一次施用/给药的情况时，将记录的步骤是“已完成的药物治疗过程”（Medication course completed），表明该医嘱现在处于已完成的状态。 在其他的情况下，如二级照护服务/医疗护理服务，则可能存在针对相应具体药物的正式医嘱，而此类的医嘱采用的是相应的药物医嘱原始型 INSTRUCTION.medication_order。这样，就可以利用当前的行动（ACTION）原始型来记录关于何时以及如何执行该医嘱的工作流。 采用当前这一行动（ACTION）原始型来记录信息表明，实际上已经发生了某种活动；此类活动最为常见的就是相应具体药物本身的施用/给药，但也可能是延迟供应的尝试，或者是其他活动，如为准备某项操作而暂停相应的具体药物。如果相应具体的药物有正式的医嘱，则采用据以记录相应数据的路径步骤来表达该医嘱的状态。例如，可以采用这一原始型，利用每个“路径”步骤时EHR病程记录之中的不同条目，来记录对乙酰氨基酚（扑热息痛）医嘱的进展状态。 在记录关于开展特定活动或选择特定路径步骤的原因时，如为何省略特定剂量的药物或停用相应的药物，则可以使用数据元“原因”（Reason）。 当这一行动（ACTION）原始型与相应的药物医嘱原始型INSTRUCTION.medication_order 一起使用时，一般并不会在相应的动作之中重复从医嘱到管理活动并未发生变化的信息。在行动（ACTION）中记录相应的具体药物属于是一种很好的做法，虽然并非强制性的要求。 路径步骤可以区分那些跟医嘱执行直接相关的步骤，如授权、准备和剂量施用，与那些跟处方处理相关的步骤，如签发、重新授权、配发。在某些司法管辖区域，会将这些步骤视为同一路径[的内容]，而在其他的司法管辖区域，可能会有所帮助的做法则是采用不同的模板来处理医嘱履行和处方。 本原始型之中大多数路径步骤的名称均以“药物”或“处方”开头，以便更易于区分那些跟处方处理相关的路径步骤与那些跟处理药物医嘱本身相关的路径步骤【中文名称的情况可能并非如此】。 在某些司法管辖区域，要继续沿用持续使用的药物医嘱，可以重新授权相应的处方，而在其他的司法管辖区域，在此类的情况下，则必须签发全新的处方。在后一种情况下，路径步骤“已重新授权的处方”（Prescription re-authorised）将不适用。"> keywords = <"药物", "药物治疗", "用药", "开立处方", "开具处方", "开处方", "配发", "调剂和发放", "施用", "给药", "停止", "停止施用", "停用", "治疗类产品", "供应", "供给", "药品", "药用", "医药", "处方", "疫苗", "疫苗接种", "接种疫苗", "免疫接种", "免疫", "剂量", "剂量药物", "剂型", "形式", "途径", "给药途径", "用药途径", "随访", "跟踪"> misuse = <"不得用于记录药物医嘱或说明。对于此类的用途，应当采用药物医嘱原始型INSTRUCTION.medication_order。 不得用于记录血液制品的施用或配发，因为其涉及的是截然不同的临床过程，且很可能需要不同的支持信息。 对于此类的用途，应当采用合适的行动（ACTION）原始型。 不得用于记录关于治疗依从性、继发反应或毒性的详情。对于此类的用途，应当采用其他的原始型。 不得用于药物汇整/核对协调。对于此类的用途，应当采用其他合适的原始型。 不得将其用于药师等对整个药物清单的正式审核。对于此类的用途，应当采用其他合适的原始型。"> > ["es"] = < language = <[ISO_639-1::es]> purpose = <"Registrar detalles sobre cualquier actividad relacionada con la planificación, programación, gestión de prescripciones, dispensación, administración, cese y otros usos de un medicamento, vacuna, producto nutricional u otro elemento terapéutico."> use = <"Se utiliza para registrar información sobre las actividades necesarias para respaldar todos los aspectos de la gestión de medicamentos, incluida la planificación, programación, suspensión, cancelación y finalización de órdenes de medicamentos, así como la administración real de los medicamentos. Esto se realiza mediante el registro de datos asociados a actividades específicas, según lo definido en las fases del 'Pathway' en este arquetipo. Este arquetipo está destinado a ser utilizado para cualquier tipo de medicamento y orden relacionada, ya sea recetada por un profesional sanitario o disponible para su compra 'sin receta médica'. El alcance de este arquetipo de medicación también incluye órdenes para vacunas, fluidos parenterales u otros productos terapéuticos, como vendajes, productos nutricionales u otros artículos que se apliquen o administren para tener un efecto terapéutico y que tengan un patrón común para el registro de datos. Dentro del contexto de una Lista de Medicamentos o Vacunas, este arquetipo se utilizará para registrar solo qué medicamento o vacuna ha sido recetado o administrado. Se puede capturar información adicional estructurada y detallada sobre la actividad utilizando arquetipos específicos para propósitos insertados en los SLOTs 'Detalles de preparación', 'Cantidad', 'Localización anatómica detallada', 'Dispositivo de administración' o 'Detalles adicionales', cuando sea necesario. Los tiempos relacionados con la gestión de la medicación se pueden gestionar de dos maneras: - Utilizando el modelo de referencia: el tiempo para la ejecución de cualquier fase del proceso usará el atributo de tiempo ACTION para cada fase. - Elementos de datos arquetipados: el elemento de datos 'Fecha/hora programada original' está destinado a registrar el momento en que se tenía previsto administrar el medicamento. Nota: el atributo de tiempo ACTION correspondiente a la fase del proceso programado registrará el momento en que la actividad clínica se programó en un sistema, no la fecha/hora prevista en la que se pretende realizar la actividad. En la práctica, algunos medicamentos (por ejemplo, durante una reanimación en Urgencias) se administrarán en base a un protocolo o una orden verbal y no se prescribirán con antelación. Los detalles sobre el medicamento se añadirán en la fase del proceso denominada 'Dosis administrada'. Para un curso de continuo de medicación, los datos sobre el medicamento se registrarán en la fase 'Dosis administrada' en cada administración, dejando la instrucción en estado activo. Cuando se registre la última ocurrencia, se anotará en la fase 'Curso de medicación completado', indicando que esta orden está ahora en estado completado. En otras situaciones, como en la atención secundaria, puede haber una orden formal para un medicamento utilizando un arquetipo INSTRUCTION.medication_order correspondiente. Este arquetipo de ACTION puede entonces utilizarse para registrar el flujo de trabajo de cuándo y cómo se ha llevado a cabo la orden. Registrar información utilizando este arquetipo de ACTION indica que algún tipo de actividad ha ocurrido realmente; lo más común será la administración del propio medicamento, pero puede ser un intento de suministro retrasado u otra actividad como suspender el medicamento en preparación para un procedimiento. Si existe una orden formal para el medicamento, el estado de esta orden se representa mediante la fase del proceso contra la cual se registran los datos. Por ejemplo, utilizando este arquetipo, el estado progresivo de una orden de Paracetamol puede registrarse a través de entradas separadas en las notas de progreso de la HCE en cada fase del proceso. Al documentar el motivo por el que se realizó una actividad o se escogió una fase, por ejemplo, por qué se omitió una dosis o se suspendió el medicamento, se puede usar el elemento 'Motivo'. Cuando este arquetipo ACTION se utiliza con el arquetipo INSTRUCTION.medication_order correspondiente, la información que no ha cambiado desde la orden hasta la actividad de gestión generalmente no se repite en la acción. Se considera una buena práctica, aunque no es obligatorio, registrar el medicamento en la ACTION. Las fases del proceso distinguen entre aquellas que se relacionan directamente con el cumplimiento de la orden, como la autorización, preparación y administración de la dosis, y aquellos que se relacionan con la gestión de la prescripción, como la emisión, re-autorización y dispensación. En algunas jurisdicciones, estos se consideran un solo proceso; en otras, puede ser útil manejar el cumplimiento de la orden y la prescripción en templates separadas. Los nombres de la mayoría de las fases en este arquetipo comienzan con \"Medicación\" o \"Prescripción\" para facilitar la diferenciación entre las fases asociadas con la gestión de la prescripción y aquellos asociados con la gestión de la orden de medicación en sí misma. En algunas jurisdicciones, una prescripción puede ser reautorizada con el propósito de continuar una orden de medicación en curso, mientras que en otras, se debe emitir una nueva prescripción en estas circunstancias. En el último caso, la fase 'Prescripción reautorizada' no es aplicable."> keywords = <"medicación", "prescribir", "dispensar", "administración", "cesación", "elemento terapéutico", "suministro", "medicina", "fármaco", "preparación", "medicinal", "prescripción", "vacuna", "vacunación", "dosificación", "formulario", "ruta", "seguimiento"> misuse = <"No debe utilizarse para registrar una orden o instrucción de medicación. Utilice el arquetipo INSTRUCTION.medication_order para este propósito. No debe utilizarse para registrar la administración o dispensación de productos sanguíneos, lo cual implica un proceso clínico fundamentalmente diferente y es probable que requiera de información de soporte distinta. Utilice un arquetipo de tipo ACTION diferente y apropiado para este propósito. No debe utilizarse para registrar detalles sobre la adherencia terapéutica, efectos secundarios o toxicidad. Utilice otros arquetipos para estos propósitos. No debe utilizarse para la reconciliación de medicamentos. Utilice otros arquetipos apropiados para este propósito. No debe utilizarse para una revisión formal de toda una lista de medicamentos, por ejemplo, por un farmacéutico. Utilice otros arquetipos apropiados para este propósito."> > ["ca"] = < language = <[ISO_639-1::ca]> purpose = <"Registrar dades sobre qualsevol activitat relacionada amb la planificació, programació, gestió de prescripció, dispensació, administració, cessació i l’ús alternatiu d’una medicació, vacuna, producte nutricional o altre element terapèutic."> use = <"Utilitzar per a registrar informació sobre les activitats necessàries per a donar suport a tots els aspectes de la gestió de la medicació, incloses la planificació, programació, suspensió, cancel·lació i finalització de les prescripcions, així com l’administració real dels elements de medicació. Això es fa mitjançant l’enregistrament de dades contra activitats específiques, com es defineix en les fases d'«Itinerari» de flux assistencial d’aquest arquetip. Aquest arquetip pretén utilitzar-se per a qualsevol mena de prescripció de medicació i prescripcions relacionades, ja estigui prescrita per un professional sanitari o disponible per a comprar «sense recepta». L’àmbit d’aplicació d’aquest arquetip de medicació també inclou prescripcions de vacunació, fluids parenterals o altres productes terapèutics, com ara benes, productes nutricionals o altres elements que s’apliquen o administren per a produir un efecte terapèutic i que tenen una pauta comuna per al registre de dades. En el context d’una Llista de Medicació o Vacunació aquest arquetip només s'utilitzarà per a registrar la medicació o vacunació que s'ha prescrit o administrat. Es pot recollir informació estructurada i detallada addicional sobre l’activitat utilitzant arquetips de finalitat específica inserits en els SLOT «Dades dels preparats», «Quantitat», «Zona del cos estructurada», «Dispositiu d’administració» o «Dades addicionals» quan sigui necessari. La temporalització relacionada amb la gestió de la medicació es pot gestionar de dues maneres: - Utilitzant el model de referència – el moment de la realització de qualsevol pas d’itinerari utilitzarà l’atribut de temps ACTION per a cada pas. - Elements de dades arquetipats – l’element de dades «Data/hora programada original» pretén registrar el moment en què es pretenia administrar l’element de medicació. Nota: l’atribut de temps ACTION corresponent per al pas d’itinerari Programat registrarà l’hora en què l’activitat clínica s’enregistrà en un sistema, no la data/hora en què l’activitat es pretén dur a terme. A la pràctica, algunes medicacions (per exemple, durant la reanimació al departament d’emergència) s’administraran partint de la base d’un protocol o ordre verbal i no es prescriuran amb antelació. Les dades sobre la medicació s’afegiran contra la fase d’itinerari «Dosi administrada». Per a un curs de medicació en procés, les dades sobre l’element de medicació s’enregistraran contra la fase «Dosi administrada» en cada administració, deixant la instrucció en estat actiu. Quan es registri l’últim esdeveniment, s’enregistrarà el pas «Curs de medicació completat», amb la qual cosa es demostrarà que aquesta prescripció ara està en estat complet. En altres situacions, com l'atenció secundària, hi pot haver una prescripció formal per a un element de medicació utilitzant un arquetip de INSTRUCTION.medication_order corresponent. Aquest arquetip de tipus ACTION es pot utilitzar aleshores per a registrar el flux de treball de quan i com s'ha dut a terme la prescripció. Registrar informació utilitzant aquest arquetip de tipus ACTION indica que un tipus d’activitat ha ocorregut en realitat; això serà generalment l’administració de l’element de medicació en si, però pot ser un intent d’abastiment d’acció retardada o altra activitat, com ara suspendre l’element de medicació com a preparació per a un procediment. Si hi ha una prescripció formal per a l’element de medicació, l’estat d’aquesta prescripció estarà representat pel pas d’Itinerari contra el qual es registren les dades. Per exemple, es pot registrar l’estat progressiu d’una prescripció de paracetamol utilitzant aquest arquetip a través d’entrades diferents en les notes de progrés de l’Expedient Clínic Electrònic (EHR per les sigles en anglès) en cada fase d'«Itinerari». Quan es documenti el motiu pel qual es dugué a terme una activitat o s’escollí un pas d’itinerari; per exemple, perquè es va ometre una dosi o cessà la medicació, es pot utilitzar l’element «Motiu». Quan aquest arquetip de tipus ACTION s'utilitzi amb l'arquetip INSTRUCTION.medication_order corresponent, la informació que no ha canviat de la prescripció a la gestió de l'activitat no es repetirà generalment en l'acció. Es considera una bona pràctica, encara que no obligatòria, registrar l'element de medicació en ACTION. Les fases d’itinerari fan una distinció entre aquelles que es refereixen directament al compliment de la prescripció, com l'autorització, preparació i administració de la dosi, i aquelles que es refereixen a la gestió de la prescripció com l'emissió, reautorització i dispensació. En algunes jurisdiccions aquestes es consideren un únic itinerari, i en altres pot ser útil gestionar el compliment de la prescripció i la prescripció en si en plantilles diferents. Els noms de la majoria de les fases d’itinerari d’aquest arquetip comencen amb «Medicació» o «Prescripció» per a facilitar la diferenciació entre les fases d’itinerari que estan associades amb la gestió de la prescripció i aquelles que estan associades amb la gestió de la prescripció de medicació en si. En algunes jurisdiccions, una prescripció es pot reautoritzar amb l’objectiu de continuar una prescripció de medicació en curs, mentre que en altres s'ha d'emetre una prescripció totalment nova en aquestes circumstàncies. Si aquest és el cas, no s'aplicarà la fase d’itinerari «Prescripció reautoritzada»."> keywords = <"medicació", "prescriure", "dispensar", "administració", "cessació", "producte terapèutic", "abastiment", "medicina", "medicament", "preparació", "medicinal", "prescripció", "vacuna", "vacunació", "dosificació", "formulari", "via", "seguiment"> misuse = <"No utilitzar per a registrar una prescripció o instrucció de medicació. Utilitzar l’arquetip INSTRUCTION.medication_order per a aquest objectiu. No utilitzar per a registrar l’administració i dispensació de productes sanguinis, la qual implica un procés clínic fonamentalment diferent i que probablement requereix informació auxiliar diferent. Utilitzar un arquetip adequat de tipus ACTION diferent per aquest objectiu. Not utilitzar per a registrar dades sobre adhesió terapèutica, efectes secundaris o toxicitat. Utilitzar altres arquetips per aquests objectius. No utilitzar per a la conciliació de la medicació. Utilitzar altres arquetips per aquest objectiu. No utilitzar per a una revisió formal d’una llista completa de medicació; per exemple, per part d’un farmacèutic. Utilitzar altres arquetips adequats per aquest objectiu."> > > lifecycle_state = <"published"> other_contributors = <"Morten Aas, Oslo Universitetssykehus, Norway", "Ole Andreas Bjordal, Webmed, Norway", "Erling Are Hole, Helse Bergen, Norway", "Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)", "Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor)", "SB Bhattacharyya, Bhattacharyyas Clinical Records Research & Informatics LLP, India", "Dionizio Brentano, UFRGS - Universidade Federal do Rio Grande do Sul, Brazil", "Laila Bruun, Oslo universitetssykehus HF, Norway", "Ady Angelica Castro Acosta, CIBERES-Hospital 12 de Octubre, Spain", "Ruth Caudwell, retired, United Kingdom", "Bjørn Christensen, Helse Bergen HF, Norway", "Stephen Chu, NEHTA, Australia (Editor)", "Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway", "Inderjit Daphu, Helse Bergen, Norway", "Samo Drnovšek, Marand, Slovenia (Editor)", "Robert Eager, Healthways, Australia", "Tone Engen, Norway", "Peter Fedorcsak, Oslo universitetssykehus, Norway", "Samuel Frade, Marand, Portugal", "Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom", "Jacquie Garton-Smith, Royal Perth Hospital and DoHWA, Australia", "Mikkel Gaup Grønmo, FSE, Helse Nord, Norway", "Heather Grain, Llewelyn Grain Informatics, Australia", "Sam Heard, Ocean Health Systems, Australia", "Geir Hoff, Sykehuset Telemark HF, Norway", "Annette Hole Sjøborg, DIPS ASA, Norway", "Hilde Hollås, DIPS AS, Norway", "Roar Holm, Helse Vest IKT A/S, Norway", "Alfred Honore, Haukeland, Norway", "Evelyn Hovenga, EJSH Consulting, Australia", "Lars Ivar Mehlum, Helse Bergen HF, Norway", "Tom Jarl Jakobsen, Helse Bergen, Norway", "Gunnar Jårvik, Nasjonal IKT HF, Norway", "Hilde Karen Ofte, Nordlandssykehuset HF, Norway", "Nils Kolstrup, Skansen Legekontor og Nasjonalt Senter for samhandling og telemedisin, Norway", "Harmony Kosola, Alberta Health Services, Canada", "Anne Kristin Strand, Sykehuspartner HF, Norway", "Robert L'egan, NEHTA, Australia", "Heather Leslie, Atomica Informatics, Australia (openEHR Editor)", "Marit Ludvigsen, St Olavs Hospital, Norway", "Colin Macfarlane, Elsevier, United Kingdom", "Siv Marie Lien, DIPS ASA, Norway", "James McClay, University of Nebraska Medical Center, United States", "Hildegard McNicoll, freshEHR Clinical Informatics Ltd., United Kingdom", "Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)", "Jude Michel, Queensland Health, Australia", "Chris Mitchell, RACGP, Australia", "Lars Morgan Karlsen, DIPS ASA, Norway", "Andrej Orel, Marand d.o.o., Slovenia", "Doug Pankoski, Alberta Health Services, Canada", "Vladimir Pizzo, Clínica Parente Pizzo, Finland", "Jodie Pycroft, Adelaide Northern Division of General Practice Ltd, Australia", "Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil", "Danielle Santos Alves, ARS Semantica, Brazil", "Anoop Shah, University College London, United Kingdom", "Line Silsand, Universitetssykehuset i Nord-Norge, Norway", "Sam Stokes, Citizen Scientist, United States", "Iztok Stotl, UKCLJ, Slovenia", "Norwegian Review Summary, Norwegian Public Hospitals, Norway", "Nyree Taylor, Ocean Health Systems, Australia", "Tesfay Teame, Folkehelseinstituttet, Norway", "Rowan Thomas, St. Vincent's Hospital Melbourne, Australia", "Anders Thurin, VGR, Sweden", "Gordon Tomes, Australian Institute of Health and Welfare, Australia", "Stian Torleif Varpe, Helse Bergen, Norway", "Richard Townley-O'Neill, NEHTA, Australia (Editor)", "Karl Trygve Kalleberg, Oslo Universitetssykehus, Norway", "Gro-Hilde Ulriksen, Norwegian center for ehealthresearch, Norway", "John Tore Valand, Helse Vest IKT, Norway (openEHR Editor)", "Ines Vaz, UFN, Portugal", "Kylie Young, The Royal Australian College of General Practitioners, Australia", "Iztok Štotl, UKCLJ, Slovenia"> other_details = < ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/."> ["custodian_organisation"] = <"openEHR Foundation"> ["references"] = <"Based on Medication Action, Published Archetype [Internet]. Australian Digital Health Agency, Australian Digital Health Agency Clinical Knowledge Manager [cited: 2017-08-10]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.876 Medication statement, [Internet]. Intermountain Healthcare. Available from http://www.opencem.org/#/20170613/Intermountain/MedicationStatement Messaging Implementation Manual (GP2GP messages) [Internet], NHS Digital England. Available from: https://data.developer.nhs.uk/dms/mim/6.3.01/Domains/GP2GP/Document%20files/GP2GP%20IM.htm#_Toc_Section_7.2 Standards for the clinical structure and content of patient records (Complete document) [Internet]. PRSB London. [cited 2017 Aug 29]. Available from: http://theprsb.org/download/document/7-standards-for-the-clinical-structure-and-content-of-patient-records Norwegian regulations for medication management (Forskrift om legemiddelhåndtering for virksomheter og helsepersonell som yter helsehjelp) [Internet]. Government of Norway. [cited 2017-10-26]. Available from: https://lovdata.no/forskrift/2008-04-03-320"> ["original_namespace"] = <"org.openehr"> ["original_publisher"] = <"openEHR Foundation"> ["custodian_namespace"] = <"org.openehr"> ["MD5-CAM-1.0.1"] = <"8BEC919844E82D2FCE2272FD3CDE7E12"> ["build_uid"] = <"310d3158-4100-4f1d-8b3f-100dce41edbd"> ["revision"] = <"1.4.0"> > definition ACTION[at0000] matches { -- Medication management ism_transition matches { ISM_TRANSITION[at0109] matches { -- Medication recommended current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::526] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0109] -- Medication recommended } } } } ISM_TRANSITION[at0145] matches { -- Prescription awaiting authorisation current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr:: 526, 245] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0145] -- Prescription awaiting authorisation } } } } ISM_TRANSITION[at0013] matches { -- Medication course postponed current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::527] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0013] -- Medication course postponed } } } } ISM_TRANSITION[at0012] matches { -- Medication course cancelled current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::528] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0012] -- Medication course cancelled } } } } ISM_TRANSITION[at0150] matches { -- Prescription cancelled current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::528] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0150] -- Prescription cancelled } } } } ISM_TRANSITION[at0016] matches { -- Medication start date/condition set current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::529] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0016] -- Medication start date/condition set } } } } ISM_TRANSITION[at0153] matches { -- Medication authorised current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::529] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0153] -- Medication authorised } } } } ISM_TRANSITION[at0002] matches { -- Prescription issued current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::245] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0002] -- Prescription issued } } } } ISM_TRANSITION[at0003] matches { -- Prescription dispensed current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::245] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0003] -- Prescription dispensed } } } } ISM_TRANSITION[at0106] matches { -- Prescription re-authorised current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::245] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0106] -- Prescription re-authorised } } } } ISM_TRANSITION[at0010] matches { -- Prescription re-issued current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::245] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0010] -- Prescription re-issued } } } } ISM_TRANSITION[at0148] matches { -- Medication prepared current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::245] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0148] -- Medication prepared } } } } ISM_TRANSITION[at0157] matches { -- Medication double checked current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::245] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0157] -- Medication double checked } } } } ISM_TRANSITION[at0004] matches { -- Medication course commenced current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::245] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0004] -- Medication course commenced } } } } ISM_TRANSITION[at0041] matches { -- Minor change to order current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::245] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0041] -- Minor change to order } } } } ISM_TRANSITION[at0005] matches { -- Medication reassessed current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::245] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0005] -- Medication reassessed } } } } ISM_TRANSITION[at0006] matches { -- Dose administered current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::245] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0006] -- Dose administered } } } } ISM_TRANSITION[at0018] matches { -- Dose administration omitted current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::245] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0018] -- Dose administration omitted } } } } ISM_TRANSITION[at0044] matches { -- Dose administration deferred current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::245] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0044] -- Dose administration deferred } } } } ISM_TRANSITION[at0008] matches { -- Prescription supply delayed current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::530] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0008] -- Prescription supply delayed } } } } ISM_TRANSITION[at0009] matches { -- Administrations suspended current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::530] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0009] -- Administrations suspended } } } } ISM_TRANSITION[at0011] matches { -- Prescription re-authorisation pending current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::530] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0011] -- Prescription re-authorisation pending } } } } ISM_TRANSITION[at0015] matches { -- Medication course stopped current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::531] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0015] -- Medication course stopped } } } } ISM_TRANSITION[at0039] matches { -- Major change to order current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::531] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0039] -- Major change to order } } } } ISM_TRANSITION[at0151] matches { -- Prescription invalid or expired current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::531] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0151] -- Prescription invalid or expired } } } } ISM_TRANSITION[at0007] matches { -- Medication course completed current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::532] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0007] -- Medication course completed } } } } ISM_TRANSITION[at0152] matches { -- Prescription fulfilled current_state matches { DV_CODED_TEXT matches { defining_code matches { [openehr::532] } } } careflow_step matches { DV_CODED_TEXT matches { defining_code matches { [local::at0152] -- Prescription fulfilled } } } } } description matches { ITEM_TREE[at0017] matches { -- Tree items cardinality matches {0..*; unordered} matches { ELEMENT[at0020] occurrences matches {0..1} matches { -- Medication item value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0104] occurrences matches {0..1} matches { -- Medication details include archetype_id/value matches {/openEHR-EHR-CLUSTER\.medication(-[a-zA-Z0-9_]+)*\.v2/} } allow_archetype CLUSTER[at0131] occurrences matches {0..1} matches { -- Amount include archetype_id/value matches {/openEHR-EHR-CLUSTER\.medication_supply_amount(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.medication_supply_amount(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.dosage(-[a-zA-Z0-9_]+)*\.v2/} } ELEMENT[at0156] occurrences matches {0..1} matches { -- Clinical indication value matches { DV_TEXT matches {*} } } ELEMENT[at0132] occurrences matches {0..1} matches { -- Substitution value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0138, -- Substitution performed at0139] -- Substitution not performed } } } } ELEMENT[at0133] occurrences matches {0..1} matches { -- Substitution reason value matches { DV_TEXT matches {*} } } ELEMENT[at0043] occurrences matches {0..1} matches { -- Original scheduled date/time value matches { DV_DATE_TIME matches {*} } } ELEMENT[at0154] occurrences matches {0..1} matches { -- Restart date/time value matches { DV_DATE_TIME matches {*} } } ELEMENT[at0155] occurrences matches {0..1} matches { -- Restart criterion value matches { DV_TEXT matches {*} } } ELEMENT[at0021] occurrences matches {0..*} matches { -- Reason value matches { DV_TEXT matches {*} } } CLUSTER[at0140] occurrences matches {0..1} matches { -- Administration details items cardinality matches {1..*; unordered} matches { ELEMENT[at0147] occurrences matches {0..1} matches { -- Route value matches { DV_TEXT matches {*} } } ELEMENT[at0141] occurrences matches {0..1} matches { -- Body site value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0142] occurrences matches {0..1} matches { -- Structured body site include archetype_id/value matches {/openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v2/} } ELEMENT[at0143] occurrences matches {0..*} matches { -- Administration method value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0144] occurrences matches {0..*} matches { -- Administration device include archetype_id/value matches {/openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1/} } } } allow_archetype CLUSTER[at0053] occurrences matches {0..*} matches { -- Additional details include archetype_id/value matches {/openEHR-EHR-CLUSTER\.medication_authorisation(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.medication_authorisation(-[a-zA-Z0-9_]+)*\.v1/} } ELEMENT[at0033] occurrences matches {0..*} matches { -- Patient guidance value matches { DV_TEXT matches {*} } } ELEMENT[at0149] occurrences matches {0..1} matches { -- Double-checked? value matches { DV_BOOLEAN matches {*} } } ELEMENT[at0025] occurrences matches {0..1} matches { -- Sequence number value matches { DV_COUNT matches {*} } } ELEMENT[at0024] occurrences matches {0..1} matches { -- Comment value matches { DV_TEXT matches {*} } } } } } protocol matches { ITEM_TREE[at0030] matches { -- Tree items cardinality matches {1..*; unordered} matches { ELEMENT[at0103] occurrences matches {0..*} matches { -- Order ID value matches { DV_IDENTIFIER matches {*} DV_TEXT matches {*} } } allow_archetype CLUSTER[at0085] occurrences matches {0..*} matches { -- Extension include archetype_id/value matches {/.*/} } } } } } ontology term_definitions = < ["ar-sy"] = < items = < ["at0000"] = < text = <"*Medication management(en)"> description = <"*Any activity related to the planning, scheduling, prescription management, dispensing, administration, cessation and other use of a medication, vaccine, nutritional product or other therapeutic item.(en)"> comment = <"*This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication.(en)"> > ["at0002"] = < text = <"*Prescription issued(en)"> description = <"*A prescription has been issued for the medication.(en)"> > ["at0003"] = < text = <"*Prescription dispensed(en)"> description = <"*The ordered medication has been dispensed, for example from a pharmacy to the patient.(en)"> > ["at0004"] = < text = <"*Medication course commenced(en)"> description = <"*The medication has been taken by, or administered to, the patient for the first time. Although in some settings this significant date may be computable as the first of several administrations, in other settings, such as primary care, specific administration dates are not readily available.(en)"> > ["at0005"] = < text = <"*Medication course reviewed(en)"> description = <"*The specific medication item has been reviewed, as planned. This is not intended to capture review of the whole medication list.(en)"> > ["at0006"] = < text = <"*Dose administered(en)"> description = <"*A single administration of the medication has taken place.(en)"> > ["at0007"] = < text = <"*Medication course completed(en)"> description = <"*The medication course has been completed as planned.(en)"> > ["at0008"] = < text = <"*Prescription supply delayed(en)"> description = <"*The prescription has not been dispensed due to a technical or pharamaceutical supply issue.(en)"> > ["at0009"] = < text = <"*Administrations suspended(en)"> description = <"*The administration of the medication has been suspended until further notice. No further doses should be given until the restart date or conditions have been met. When setting the date/conditions for restart after suspending, a step from ‘Administrations suspended’ and back to 'Medication start date/condition set' should be performed.(en)"> > ["at0010"] = < text = <"*Prescription re-issued(en)"> description = <"*A prescription token has been re-issued for an existing medication order.(en)"> > ["at0011"] = < text = <"*Prescription re-issue suspended(en)"> description = <"*Reissuing of this prescription is not available without some intervention.(en)"> > ["at0012"] = < text = <"*Medication course cancelled(en)"> description = <"*The planned course of medication has been cancelled prior to any administration.(en)"> > ["at0013"] = < text = <"*Medication course postponed(en)"> description = <"*The scheduled medication course has been postponed prior to any administration.(en)"> > ["at0015"] = < text = <"*Medication course stopped(en)"> description = <"*The administration of this medication has been ceased after the first dose has been administered, but before intended completion of the course. (en)"> > ["at0016"] = < text = <"*Medication start date/condition set(en)"> description = <"*The time to start this medication, or other starting condition, has been set.(en)"> > ["at0017"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0018"] = < text = <"*Dose administration omitted(en)"> description = <"*The administration of a medication has been withheld and not given. There is no expectation that it will be given later, though the next dose (if any) should be administered according to the original order.(en)"> > ["at0020"] = < text = <"*Medication item(en)"> description = <"*Name of the medication, vaccine or other therapeutic/prescribable item which was the focus of the activity.(en)"> comment = <"*For example: 'Atenolol 100mg' or 'Tenormin tablets 100mg'. It is strongly recommended that the 'Medication item' is coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple name of the medication item through to structured details about the actual medication pack used. Free text entry should only be used if there is no appropriate terminology available.(en)"> > ["at0021"] = < text = <"*Reason(en)"> description = <"*Reason that the pathway step for the identified medication was carried out.(en)"> comment = <"*For example: 'Postponed - Patient not avalable at administration time', 'Cancelled - Adverse reaction'. Note: This is not the reason for the medication instruction, but rather the specific reason that a care step was carried out, and will often be used to document some variance from the original order.(en)"> > ["at0024"] = < text = <"*Comment(en)"> description = <"*Additional narrative about the activity or care pathway step not captured in other fields, including details of any variance between the intended action and the action actually performed.(en)"> comment = <"*For example: 'Patient was in radiology department', 'Accidental injection into blood vessel during IM administration'.(en)"> > ["at0025"] = < text = <"*Sequence number(en)"> description = <"*The sequence number specific to the activity being recorded.(en)"> comment = <"*For example: Vaccine sequence number. (en)"> > ["at0030"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0033"] = < text = <"*Patient guidance(en)"> description = <"*Any guidance, instructions or advice given to the subject of care or personal carer at the time of the pathway step.(en)"> comment = <"*For example: 'Avoid grapefruit' , 'Take at least 2 hours before bedtime', 'Take with food'. May be coded with a terminology when clinically appropriate.(en)"> > ["at0039"] = < text = <"*Major change to order.(en)"> description = <"*A major change to the order was required, resulting in this order being stopped and a replacement order being started.(en)"> > ["at0041"] = < text = <"*Minor change to order(en)"> description = <"*The medication order has been changed in a manner which does not require a new instruction/order to be issued, according to local clinical rules.(en)"> > ["at0043"] = < text = <"*Original scheduled date/time(en)"> description = <"*The datetime at which the medication action was scheduled to occur.(en)"> comment = <"*Used to compare variance from actual action time where this is not readily calculable from the original instruction.(en)"> > ["at0044"] = < text = <"*Dose administration deferred(en)"> description = <"*Administration of a dose of mediciation has been delayed but is expected to be given as soon as possible.(en)"> > ["at0053"] = < text = <"*Additional details(en)"> description = <"*Further structured details of the action, possibly specific to a pathway step.(en)"> > ["at0085"] = < text = <"*Cluster(en)"> description = <"**(en)"> > ["at0103"] = < text = <"*Order ID(en)"> description = <"*Unique identifier for the medication order.(en)"> comment = <"*Comment: This data element allows for multiple occurrences to be defined more explicitly at run-time, if required.(en)"> > ["at0104"] = < text = <"*Medication details(en)"> description = <"*Structured details about the medication including strength, form and constituent substances.(en)"> comment = <"*Use this SLOT where the detailed description of the dispensed, authorised or administered item needs to be explicitly stated. For example: the form, strength, any diluents or mixture of ingredients.(en)"> > ["at0106"] = < text = <"*Prescription re-authorised(en)"> description = <"*The original medication order has been re-authorised to allow repeat prescription or dispensing. In some jurisdictions an entirely new order must be issued in these circumstances.(en)"> > ["at0109"] = < text = <"*Medication recommended(en)"> description = <"*The medication has been recommended but no steps have been taken to initiate prescribing.(en)"> > ["at0131"] = < text = <"*Amount(en)"> description = <"*Specific details about the amount of the medication item.(en)"> comment = <"*Dosage_administration is intended to carry details of medication order changes or dose administrations, whilst medication_supply_amount is intended for details of dispensing-related activity.(en)"> > ["at0132"] = < text = <"*Substitution(en)"> description = <"*Subsitution action taken by the person administering or dispensing the drug.(en)"> comment = <"*In many jurisdictions, substitution of an ordered item as a generic form or with a different brand name, which has been determined as bioequivalent, is allowed at the point of dispense or supply. In other cases substitution is assumed and the clinician has to explicitly request non-substitution.(en)"> > ["at0133"] = < text = <"*Substitution reason(en)"> description = <"*The reason or justification for the substitution action taken.(en)"> comment = <"*For example: \"Generic alternative contains a substance that is not tolerated by the patient.\" May be coded with a terminology when clinically appropriate(en)"> > ["at0138"] = < text = <"*Substitution performed(en)"> description = <"*A medication was substituted which is bioequivalent to that ordered.(en)"> > ["at0139"] = < text = <"*Substitution not performed(en)"> description = <"*Although allowed by the medication order a bioequvalent medication was not substituted.(en)"> > ["at0140"] = < text = <"*Administration details(en)"> description = <"*Details of body site and administration of the medication.(en)"> > ["at0141"] = < text = <"*Body site(en)"> description = <"*Structured description of the site of administration of the ordered item.(en)"> comment = <"*For example: 'left upper arm', 'intravenous catheter right hand'. Coding of the body site with a terminology is preferred, where possible.(en)"> > ["at0142"] = < text = <"*Structured body site(en)"> description = <"*Structured description of the site of administration of the medication, vaccine or therapeutic good.(en)"> comment = <"*For example: \"On the medial skin surface of the left forearm, from 10 cm to 20 cm distally from the point of the elbow\".(en)"> > ["at0143"] = < text = <"*Administration method(en)"> description = <"*The technique or device by which the ordered item was, or is to be, administered.(en)"> comment = <"*Comment: For example: ' via Z-track injection'; 'via nebuliser'. Coding of the method with a terminology is preferred, where possible.(en)"> > ["at0144"] = < text = <"*Administration device(en)"> description = <"*Details of the medical device used to assist administration of the medication.(en)"> > ["at0145"] = < text = <"*Prescription awaiting authorisation(en)"> description = <"*Draft prescription has been prepared and is awaiting confirmation from an authorised clinician. May be used where reauthorisations are performed as a batch. This careflow_step may have a status of 'planned' or 'active', reflecting the need to to handle new orders as well as re-authorised orders.(en)"> > ["at0147"] = < text = <"*Route(en)"> description = <"*The route by which the ordered item was, or is to be, administered into the subject's body.(en)"> comment = <"*Comment: For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible. Multiple potential routes may be specified.(en)"> > ["at0148"] = < text = <"*Medication prepared(en)"> description = <"*The medication has been physically prepared. (en)"> comment = <"*For example: preparation of an intravenous mixture. (en)"> > ["at0149"] = < text = <"*Double-checked?(en)"> description = <"*The action step has been checked by a separate individual.(en)"> comment = <"*Details of the individual performing the double-check can be carried in the Reference Model element \"Participation\".(en)"> > ["at0150"] = < text = <"*Prescription cancelled(en)"> description = <"*The prescription was cancelled prior to being issued.(en)"> > ["at0151"] = < text = <"*Prescription invalid or expired(en)"> description = <"*Prescription has been invalidated or has expired without being fulfilled.(en)"> > ["at0152"] = < text = <"*Prescription fulfilled(en)"> description = <"*The prescription has been fulfilled successfully.(en)"> > ["at0153"] = < text = <"*Medication authorised(en)"> description = <"*The medication has been formally authorised for use.(en)"> > ["at0154"] = < text = <"*Restart date/time(en)"> description = <"*The date/time on which the medication course is set to restart, as per the \"Medication restart date/condition set\" pathway step.(en)"> comment = <"*For example: 2017-10-29(en)"> > ["at0155"] = < text = <"*Restart criterion(en)"> description = <"*The criterion which triggers the medication course to restart, as per the \"Medication restart date/condition set\" pathway step.(en)"> comment = <"*For example: \"On day 2 after surgery\".(en)"> > ["at0156"] = < text = <"*Clinical indication (en)"> description = <"*The clinical reason for the medication activity. (en)"> comment = <"*For example: 'Angina' or 'Pain'. Coding of the indication with a terminology is preferred, where possible. This data element allows multiple occurrences. If only an ACTION is used to record a medication indication, this data element can be used without additional consideration. However, if a clinical indication is recorded for both the Medication order INSTRUCTION and this Medication management ACTION, be aware that these indications might not be consistent.\" (en)"> > ["at0157"] = < text = <"*Medication double checked (en)"> description = <"*The prepared medication has been double checked. (en)"> > > > ["sl"] = < items = < ["at0000"] = < text = <"*Medication management(en)"> description = <"*Any activity related to the planning, scheduling, prescription management, dispensing, administration, cessation and other use of a medication, vaccine, nutritional product or other therapeutic item.(en)"> comment = <"*This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication.(en)"> > ["at0002"] = < text = <"*Prescription issued(en)"> description = <"*A prescription has been issued for the medication.(en)"> > ["at0003"] = < text = <"*Prescription dispensed(en)"> description = <"*The ordered medication has been dispensed, for example from a pharmacy to the patient.(en)"> > ["at0004"] = < text = <"*Medication course commenced(en)"> description = <"*The medication has been taken by, or administered to, the patient for the first time. Although in some settings this significant date may be computable as the first of several administrations, in other settings, such as primary care, specific administration dates are not readily available.(en)"> > ["at0005"] = < text = <"*Medication course reviewed(en)"> description = <"*The specific medication item has been reviewed, as planned. This is not intended to capture review of the whole medication list.(en)"> > ["at0006"] = < text = <"*Dose administered(en)"> description = <"*A single administration of the medication has taken place.(en)"> > ["at0007"] = < text = <"*Medication course completed(en)"> description = <"*The medication course has been completed as planned.(en)"> > ["at0008"] = < text = <"*Prescription supply delayed(en)"> description = <"*The prescription has not been dispensed due to a technical or pharamaceutical supply issue.(en)"> > ["at0009"] = < text = <"*Administrations suspended(en)"> description = <"*The administration of the medication has been suspended until further notice. No further doses should be given until the restart date or conditions have been met. When setting the date/conditions for restart after suspending, a step from ‘Administrations suspended’ and back to 'Medication start date/condition set' should be performed.(en)"> > ["at0010"] = < text = <"*Prescription re-issued(en)"> description = <"*A prescription token has been re-issued for an existing medication order.(en)"> > ["at0011"] = < text = <"*Prescription re-issue suspended(en)"> description = <"*Reissuing of this prescription is not available without some intervention.(en)"> > ["at0012"] = < text = <"*Medication course cancelled(en)"> description = <"*The planned course of medication has been cancelled prior to any administration.(en)"> > ["at0013"] = < text = <"*Medication course postponed(en)"> description = <"*The scheduled medication course has been postponed prior to any administration.(en)"> > ["at0015"] = < text = <"*Medication course stopped(en)"> description = <"*The administration of this medication has been ceased after the first dose has been administered, but before intended completion of the course. (en)"> > ["at0016"] = < text = <"*Medication start date/condition set(en)"> description = <"*The time to start this medication, or other starting condition, has been set.(en)"> > ["at0017"] = < text = <"Tree"> description = <"@ internal @"> > ["at0018"] = < text = <"*Dose administration omitted(en)"> description = <"*The administration of a medication has been withheld and not given. There is no expectation that it will be given later, though the next dose (if any) should be administered according to the original order.(en)"> > ["at0020"] = < text = <"*Medication item(en)"> description = <"*Name of the medication, vaccine or other therapeutic/prescribable item which was the focus of the activity.(en)"> comment = <"*For example: 'Atenolol 100mg' or 'Tenormin tablets 100mg'. It is strongly recommended that the 'Medication item' is coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple name of the medication item through to structured details about the actual medication pack used. Free text entry should only be used if there is no appropriate terminology available.(en)"> > ["at0021"] = < text = <"*Reason(en)"> description = <"*Reason that the pathway step for the identified medication was carried out.(en)"> comment = <"*For example: 'Postponed - Patient not avalable at administration time', 'Cancelled - Adverse reaction'. Note: This is not the reason for the medication instruction, but rather the specific reason that a care step was carried out, and will often be used to document some variance from the original order.(en)"> > ["at0024"] = < text = <"*Comment(en)"> description = <"*Additional narrative about the activity or care pathway step not captured in other fields, including details of any variance between the intended action and the action actually performed.(en)"> comment = <"*For example: 'Patient was in radiology department', 'Accidental injection into blood vessel during IM administration'.(en)"> > ["at0025"] = < text = <"*Sequence number(en)"> description = <"*The sequence number specific to the activity being recorded.(en)"> comment = <"*For example: Vaccine sequence number. (en)"> > ["at0030"] = < text = <"Tree(en)"> description = <"@ internal @"> > ["at0033"] = < text = <"*Patient guidance(en)"> description = <"*Any guidance, instructions or advice given to the subject of care or personal carer at the time of the pathway step.(en)"> comment = <"*For example: 'Avoid grapefruit' , 'Take at least 2 hours before bedtime', 'Take with food'. May be coded with a terminology when clinically appropriate.(en)"> > ["at0039"] = < text = <"*Major change to order.(en)"> description = <"*A major change to the order was required, resulting in this order being stopped and a replacement order being started.(en)"> > ["at0041"] = < text = <"*Minor change to order(en)"> description = <"*The medication order has been changed in a manner which does not require a new instruction/order to be issued, according to local clinical rules.(en)"> > ["at0043"] = < text = <"*Original scheduled date/time(en)"> description = <"*The datetime at which the medication action was scheduled to occur.(en)"> comment = <"*Used to compare variance from actual action time where this is not readily calculable from the original instruction.(en)"> > ["at0044"] = < text = <"*Dose administration deferred(en)"> description = <"*Administration of a dose of mediciation has been delayed but is expected to be given as soon as possible.(en)"> > ["at0053"] = < text = <"*Additional details(en)"> description = <"*Further structured details of the action, possibly specific to a pathway step.(en)"> > ["at0085"] = < text = <"*Cluster(en)"> description = <"**(en)"> > ["at0103"] = < text = <"*Order ID(en)"> description = <"*Unique identifier for the medication order.(en)"> comment = <"*Comment: This data element allows for multiple occurrences to be defined more explicitly at run-time, if required.(en)"> > ["at0104"] = < text = <"*Medication details(en)"> description = <"*Structured details about the medication including strength, form and constituent substances.(en)"> comment = <"*Use this SLOT where the detailed description of the dispensed, authorised or administered item needs to be explicitly stated. For example: the form, strength, any diluents or mixture of ingredients.(en)"> > ["at0106"] = < text = <"*Prescription re-authorised(en)"> description = <"*The original medication order has been re-authorised to allow repeat prescription or dispensing. In some jurisdictions an entirely new order must be issued in these circumstances.(en)"> > ["at0109"] = < text = <"*Medication recommended(en)"> description = <"*The medication has been recommended but no steps have been taken to initiate prescribing.(en)"> > ["at0131"] = < text = <"*Amount(en)"> description = <"*Specific details about the amount of the medication item.(en)"> comment = <"*Dosage_administration is intended to carry details of medication order changes or dose administrations, whilst medication_supply_amount is intended for details of dispensing-related activity.(en)"> > ["at0132"] = < text = <"*Substitution(en)"> description = <"*Subsitution action taken by the person administering or dispensing the drug.(en)"> comment = <"*In many jurisdictions, substitution of an ordered item as a generic form or with a different brand name, which has been determined as bioequivalent, is allowed at the point of dispense or supply. In other cases substitution is assumed and the clinician has to explicitly request non-substitution.(en)"> > ["at0133"] = < text = <"*Substitution reason(en)"> description = <"*The reason or justification for the substitution action taken.(en)"> comment = <"*For example: \"Generic alternative contains a substance that is not tolerated by the patient.\" May be coded with a terminology when clinically appropriate(en)"> > ["at0138"] = < text = <"*Substitution performed(en)"> description = <"*A medication was substituted which is bioequivalent to that ordered.(en)"> > ["at0139"] = < text = <"*Substitution not performed(en)"> description = <"*Although allowed by the medication order a bioequvalent medication was not substituted.(en)"> > ["at0140"] = < text = <"*Administration details(en)"> description = <"*Details of body site and administration of the medication.(en)"> > ["at0141"] = < text = <"*Body site(en)"> description = <"*Structured description of the site of administration of the ordered item.(en)"> comment = <"*For example: 'left upper arm', 'intravenous catheter right hand'. Coding of the body site with a terminology is preferred, where possible.(en)"> > ["at0142"] = < text = <"*Structured body site(en)"> description = <"*Structured description of the site of administration of the medication, vaccine or therapeutic good.(en)"> comment = <"*For example: \"On the medial skin surface of the left forearm, from 10 cm to 20 cm distally from the point of the elbow\".(en)"> > ["at0143"] = < text = <"*Administration method(en)"> description = <"*The technique or device by which the ordered item was, or is to be, administered.(en)"> comment = <"*Comment: For example: ' via Z-track injection'; 'via nebuliser'. Coding of the method with a terminology is preferred, where possible.(en)"> > ["at0144"] = < text = <"*Administration device(en)"> description = <"*Details of the medical device used to assist administration of the medication.(en)"> > ["at0145"] = < text = <"*Prescription awaiting authorisation(en)"> description = <"*Draft prescription has been prepared and is awaiting confirmation from an authorised clinician. May be used where reauthorisations are performed as a batch. This careflow_step may have a status of 'planned' or 'active', reflecting the need to to handle new orders as well as re-authorised orders.(en)"> > ["at0147"] = < text = <"*Route(en)"> description = <"*The route by which the ordered item was, or is to be, administered into the subject's body.(en)"> comment = <"*Comment: For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible. Multiple potential routes may be specified.(en)"> > ["at0148"] = < text = <"*Medication prepared(en)"> description = <"*The medication has been physically prepared. (en)"> comment = <"*For example: preparation of an intravenous mixture. (en)"> > ["at0149"] = < text = <"*Double-checked?(en)"> description = <"*The action step has been checked by a separate individual.(en)"> comment = <"*Details of the individual performing the double-check can be carried in the Reference Model element \"Participation\".(en)"> > ["at0150"] = < text = <"*Prescription cancelled(en)"> description = <"*The prescription was cancelled prior to being issued.(en)"> > ["at0151"] = < text = <"*Prescription invalid or expired(en)"> description = <"*Prescription has been invalidated or has expired without being fulfilled.(en)"> > ["at0152"] = < text = <"*Prescription fulfilled(en)"> description = <"*The prescription has been fulfilled successfully.(en)"> > ["at0153"] = < text = <"*Medication authorised(en)"> description = <"*The medication has been formally authorised for use.(en)"> > ["at0154"] = < text = <"*Restart date/time(en)"> description = <"*The date/time on which the medication course is set to restart, as per the \"Medication restart date/condition set\" pathway step.(en)"> comment = <"*For example: 2017-10-29(en)"> > ["at0155"] = < text = <"*Restart criterion(en)"> description = <"*The criterion which triggers the medication course to restart, as per the \"Medication restart date/condition set\" pathway step.(en)"> comment = <"*For example: \"On day 2 after surgery\".(en)"> > ["at0156"] = < text = <"*Clinical indication (en)"> description = <"*The clinical reason for the medication activity. (en)"> comment = <"*For example: 'Angina' or 'Pain'. Coding of the indication with a terminology is preferred, where possible. This data element allows multiple occurrences. If only an ACTION is used to record a medication indication, this data element can be used without additional consideration. However, if a clinical indication is recorded for both the Medication order INSTRUCTION and this Medication management ACTION, be aware that these indications might not be consistent.\" (en)"> > ["at0157"] = < text = <"*Medication double checked (en)"> description = <"*The prepared medication has been double checked. (en)"> > > > ["es-ar"] = < items = < ["at0000"] = < text = <"*Medication management(en)"> description = <"*Any activity related to the planning, scheduling, prescription management, dispensing, administration, cessation and other use of a medication, vaccine, nutritional product or other therapeutic item.(en)"> comment = <"*This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication.(en)"> > ["at0002"] = < text = <"*Prescription issued(en)"> description = <"*A prescription has been issued for the medication.(en)"> > ["at0003"] = < text = <"*Prescription dispensed(en)"> description = <"*The ordered medication has been dispensed, for example from a pharmacy to the patient.(en)"> > ["at0004"] = < text = <"*Medication course commenced(en)"> description = <"*The medication has been taken by, or administered to, the patient for the first time. Although in some settings this significant date may be computable as the first of several administrations, in other settings, such as primary care, specific administration dates are not readily available.(en)"> > ["at0005"] = < text = <"*Medication course reviewed(en)"> description = <"*The specific medication item has been reviewed, as planned. This is not intended to capture review of the whole medication list.(en)"> > ["at0006"] = < text = <"*Dose administered(en)"> description = <"*A single administration of the medication has taken place.(en)"> > ["at0007"] = < text = <"*Medication course completed(en)"> description = <"*The medication course has been completed as planned.(en)"> > ["at0008"] = < text = <"*Prescription supply delayed(en)"> description = <"*The prescription has not been dispensed due to a technical or pharamaceutical supply issue.(en)"> > ["at0009"] = < text = <"*Administrations suspended(en)"> description = <"*The administration of the medication has been suspended until further notice. No further doses should be given until the restart date or conditions have been met. When setting the date/conditions for restart after suspending, a step from ‘Administrations suspended’ and back to 'Medication start date/condition set' should be performed.(en)"> > ["at0010"] = < text = <"*Prescription re-issued(en)"> description = <"*A prescription token has been re-issued for an existing medication order.(en)"> > ["at0011"] = < text = <"*Prescription re-issue suspended(en)"> description = <"*Reissuing of this prescription is not available without some intervention.(en)"> > ["at0012"] = < text = <"*Medication course cancelled(en)"> description = <"*The planned course of medication has been cancelled prior to any administration.(en)"> > ["at0013"] = < text = <"*Medication course postponed(en)"> description = <"*The scheduled medication course has been postponed prior to any administration.(en)"> > ["at0015"] = < text = <"*Medication course stopped(en)"> description = <"*The administration of this medication has been ceased after the first dose has been administered, but before intended completion of the course. (en)"> > ["at0016"] = < text = <"*Medication start date/condition set(en)"> description = <"*The time to start this medication, or other starting condition, has been set.(en)"> > ["at0017"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0018"] = < text = <"*Dose administration omitted(en)"> description = <"*The administration of a medication has been withheld and not given. There is no expectation that it will be given later, though the next dose (if any) should be administered according to the original order.(en)"> > ["at0020"] = < text = <"*Medication item(en)"> description = <"*Name of the medication, vaccine or other therapeutic/prescribable item which was the focus of the activity.(en)"> comment = <"*For example: 'Atenolol 100mg' or 'Tenormin tablets 100mg'. It is strongly recommended that the 'Medication item' is coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple name of the medication item through to structured details about the actual medication pack used. Free text entry should only be used if there is no appropriate terminology available.(en)"> > ["at0021"] = < text = <"*Reason(en)"> description = <"*Reason that the pathway step for the identified medication was carried out.(en)"> comment = <"*For example: 'Postponed - Patient not avalable at administration time', 'Cancelled - Adverse reaction'. Note: This is not the reason for the medication instruction, but rather the specific reason that a care step was carried out, and will often be used to document some variance from the original order.(en)"> > ["at0024"] = < text = <"*Comment(en)"> description = <"*Additional narrative about the activity or care pathway step not captured in other fields, including details of any variance between the intended action and the action actually performed.(en)"> comment = <"*For example: 'Patient was in radiology department', 'Accidental injection into blood vessel during IM administration'.(en)"> > ["at0025"] = < text = <"*Sequence number(en)"> description = <"*The sequence number specific to the activity being recorded.(en)"> comment = <"*For example: Vaccine sequence number. (en)"> > ["at0030"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0033"] = < text = <"*Patient guidance(en)"> description = <"*Any guidance, instructions or advice given to the subject of care or personal carer at the time of the pathway step.(en)"> comment = <"*For example: 'Avoid grapefruit' , 'Take at least 2 hours before bedtime', 'Take with food'. May be coded with a terminology when clinically appropriate.(en)"> > ["at0039"] = < text = <"*Major change to order.(en)"> description = <"*A major change to the order was required, resulting in this order being stopped and a replacement order being started.(en)"> > ["at0041"] = < text = <"*Minor change to order(en)"> description = <"*The medication order has been changed in a manner which does not require a new instruction/order to be issued, according to local clinical rules.(en)"> > ["at0043"] = < text = <"*Original scheduled date/time(en)"> description = <"*The datetime at which the medication action was scheduled to occur.(en)"> comment = <"*Used to compare variance from actual action time where this is not readily calculable from the original instruction.(en)"> > ["at0044"] = < text = <"*Dose administration deferred(en)"> description = <"*Administration of a dose of mediciation has been delayed but is expected to be given as soon as possible.(en)"> > ["at0053"] = < text = <"*Additional details(en)"> description = <"*Further structured details of the action, possibly specific to a pathway step.(en)"> > ["at0085"] = < text = <"*Cluster(en)"> description = <"**(en)"> > ["at0103"] = < text = <"*Order ID(en)"> description = <"*Unique identifier for the medication order.(en)"> comment = <"*Comment: This data element allows for multiple occurrences to be defined more explicitly at run-time, if required.(en)"> > ["at0104"] = < text = <"*Medication details(en)"> description = <"*Structured details about the medication including strength, form and constituent substances.(en)"> comment = <"*Use this SLOT where the detailed description of the dispensed, authorised or administered item needs to be explicitly stated. For example: the form, strength, any diluents or mixture of ingredients.(en)"> > ["at0106"] = < text = <"*Prescription re-authorised(en)"> description = <"*The original medication order has been re-authorised to allow repeat prescription or dispensing. In some jurisdictions an entirely new order must be issued in these circumstances.(en)"> > ["at0109"] = < text = <"*Medication recommended(en)"> description = <"*The medication has been recommended but no steps have been taken to initiate prescribing.(en)"> > ["at0131"] = < text = <"*Amount(en)"> description = <"*Specific details about the amount of the medication item.(en)"> comment = <"*Dosage_administration is intended to carry details of medication order changes or dose administrations, whilst medication_supply_amount is intended for details of dispensing-related activity.(en)"> > ["at0132"] = < text = <"*Substitution(en)"> description = <"*Subsitution action taken by the person administering or dispensing the drug.(en)"> comment = <"*In many jurisdictions, substitution of an ordered item as a generic form or with a different brand name, which has been determined as bioequivalent, is allowed at the point of dispense or supply. In other cases substitution is assumed and the clinician has to explicitly request non-substitution.(en)"> > ["at0133"] = < text = <"*Substitution reason(en)"> description = <"*The reason or justification for the substitution action taken.(en)"> comment = <"*For example: \"Generic alternative contains a substance that is not tolerated by the patient.\" May be coded with a terminology when clinically appropriate(en)"> > ["at0138"] = < text = <"*Substitution performed(en)"> description = <"*A medication was substituted which is bioequivalent to that ordered.(en)"> > ["at0139"] = < text = <"*Substitution not performed(en)"> description = <"*Although allowed by the medication order a bioequvalent medication was not substituted.(en)"> > ["at0140"] = < text = <"*Administration details(en)"> description = <"*Details of body site and administration of the medication.(en)"> > ["at0141"] = < text = <"*Body site(en)"> description = <"*Structured description of the site of administration of the ordered item.(en)"> comment = <"*For example: 'left upper arm', 'intravenous catheter right hand'. Coding of the body site with a terminology is preferred, where possible.(en)"> > ["at0142"] = < text = <"*Structured body site(en)"> description = <"*Structured description of the site of administration of the medication, vaccine or therapeutic good.(en)"> comment = <"*For example: \"On the medial skin surface of the left forearm, from 10 cm to 20 cm distally from the point of the elbow\".(en)"> > ["at0143"] = < text = <"*Administration method(en)"> description = <"*The technique or device by which the ordered item was, or is to be, administered.(en)"> comment = <"*Comment: For example: ' via Z-track injection'; 'via nebuliser'. Coding of the method with a terminology is preferred, where possible.(en)"> > ["at0144"] = < text = <"*Administration device(en)"> description = <"*Details of the medical device used to assist administration of the medication.(en)"> > ["at0145"] = < text = <"*Prescription awaiting authorisation(en)"> description = <"*Draft prescription has been prepared and is awaiting confirmation from an authorised clinician. May be used where reauthorisations are performed as a batch. This careflow_step may have a status of 'planned' or 'active', reflecting the need to to handle new orders as well as re-authorised orders.(en)"> > ["at0147"] = < text = <"*Route(en)"> description = <"*The route by which the ordered item was, or is to be, administered into the subject's body.(en)"> comment = <"*Comment: For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible. Multiple potential routes may be specified.(en)"> > ["at0148"] = < text = <"*Medication prepared(en)"> description = <"*The medication has been physically prepared. (en)"> comment = <"*For example: preparation of an intravenous mixture. (en)"> > ["at0149"] = < text = <"*Double-checked?(en)"> description = <"*The action step has been checked by a separate individual.(en)"> comment = <"*Details of the individual performing the double-check can be carried in the Reference Model element \"Participation\".(en)"> > ["at0150"] = < text = <"*Prescription cancelled(en)"> description = <"*The prescription was cancelled prior to being issued.(en)"> > ["at0151"] = < text = <"*Prescription invalid or expired(en)"> description = <"*Prescription has been invalidated or has expired without being fulfilled.(en)"> > ["at0152"] = < text = <"*Prescription fulfilled(en)"> description = <"*The prescription has been fulfilled successfully.(en)"> > ["at0153"] = < text = <"*Medication authorised(en)"> description = <"*The medication has been formally authorised for use.(en)"> > ["at0154"] = < text = <"*Restart date/time(en)"> description = <"*The date/time on which the medication course is set to restart, as per the \"Medication restart date/condition set\" pathway step.(en)"> comment = <"*For example: 2017-10-29(en)"> > ["at0155"] = < text = <"*Restart criterion(en)"> description = <"*The criterion which triggers the medication course to restart, as per the \"Medication restart date/condition set\" pathway step.(en)"> comment = <"*For example: \"On day 2 after surgery\".(en)"> > ["at0156"] = < text = <"*Clinical indication (en)"> description = <"*The clinical reason for the medication activity. (en)"> comment = <"*For example: 'Angina' or 'Pain'. Coding of the indication with a terminology is preferred, where possible. This data element allows multiple occurrences. If only an ACTION is used to record a medication indication, this data element can be used without additional consideration. However, if a clinical indication is recorded for both the Medication order INSTRUCTION and this Medication management ACTION, be aware that these indications might not be consistent.\" (en)"> > ["at0157"] = < text = <"*Medication double checked (en)"> description = <"*The prepared medication has been double checked. (en)"> > > > ["ru"] = < items = < ["at0000"] = < text = <"*Medication management(en)"> description = <"*Any activity related to the planning, scheduling, prescription management, dispensing, administration, cessation and other use of a medication, vaccine, nutritional product or other therapeutic item.(en)"> comment = <"*This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication.(en)"> > ["at0002"] = < text = <"*Prescription issued(en)"> description = <"*A prescription has been issued for the medication.(en)"> > ["at0003"] = < text = <"*Prescription dispensed(en)"> description = <"*The ordered medication has been dispensed, for example from a pharmacy to the patient.(en)"> > ["at0004"] = < text = <"*Medication course commenced(en)"> description = <"*The medication has been taken by, or administered to, the patient for the first time. Although in some settings this significant date may be computable as the first of several administrations, in other settings, such as primary care, specific administration dates are not readily available.(en)"> > ["at0005"] = < text = <"*Medication course reviewed(en)"> description = <"*The specific medication item has been reviewed, as planned. This is not intended to capture review of the whole medication list.(en)"> > ["at0006"] = < text = <"*Dose administered(en)"> description = <"*A single administration of the medication has taken place.(en)"> > ["at0007"] = < text = <"*Medication course completed(en)"> description = <"*The medication course has been completed as planned.(en)"> > ["at0008"] = < text = <"*Prescription supply delayed(en)"> description = <"*The prescription has not been dispensed due to a technical or pharamaceutical supply issue.(en)"> > ["at0009"] = < text = <"*Administrations suspended(en)"> description = <"*The administration of the medication has been suspended until further notice. No further doses should be given until the restart date or conditions have been met. When setting the date/conditions for restart after suspending, a step from ‘Administrations suspended’ and back to 'Medication start date/condition set' should be performed.(en)"> > ["at0010"] = < text = <"*Prescription re-issued(en)"> description = <"*A prescription token has been re-issued for an existing medication order.(en)"> > ["at0011"] = < text = <"*Prescription re-issue suspended(en)"> description = <"*Reissuing of this prescription is not available without some intervention.(en)"> > ["at0012"] = < text = <"*Medication course cancelled(en)"> description = <"*The planned course of medication has been cancelled prior to any administration.(en)"> > ["at0013"] = < text = <"*Medication course postponed(en)"> description = <"*The scheduled medication course has been postponed prior to any administration.(en)"> > ["at0015"] = < text = <"*Medication course stopped(en)"> description = <"*The administration of this medication has been ceased after the first dose has been administered, but before intended completion of the course. (en)"> > ["at0016"] = < text = <"*Medication start date/condition set(en)"> description = <"*The time to start this medication, or other starting condition, has been set.(en)"> > ["at0017"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0018"] = < text = <"*Dose administration omitted(en)"> description = <"*The administration of a medication has been withheld and not given. There is no expectation that it will be given later, though the next dose (if any) should be administered according to the original order.(en)"> > ["at0020"] = < text = <"*Medication item(en)"> description = <"*Name of the medication, vaccine or other therapeutic/prescribable item which was the focus of the activity.(en)"> comment = <"*For example: 'Atenolol 100mg' or 'Tenormin tablets 100mg'. It is strongly recommended that the 'Medication item' is coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple name of the medication item through to structured details about the actual medication pack used. Free text entry should only be used if there is no appropriate terminology available.(en)"> > ["at0021"] = < text = <"*Reason(en)"> description = <"*Reason that the pathway step for the identified medication was carried out.(en)"> comment = <"*For example: 'Postponed - Patient not avalable at administration time', 'Cancelled - Adverse reaction'. Note: This is not the reason for the medication instruction, but rather the specific reason that a care step was carried out, and will often be used to document some variance from the original order.(en)"> > ["at0024"] = < text = <"*Comment(en)"> description = <"*Additional narrative about the activity or care pathway step not captured in other fields, including details of any variance between the intended action and the action actually performed.(en)"> comment = <"*For example: 'Patient was in radiology department', 'Accidental injection into blood vessel during IM administration'.(en)"> > ["at0025"] = < text = <"*Sequence number(en)"> description = <"*The sequence number specific to the activity being recorded.(en)"> comment = <"*For example: Vaccine sequence number. (en)"> > ["at0030"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0033"] = < text = <"*Patient guidance(en)"> description = <"*Any guidance, instructions or advice given to the subject of care or personal carer at the time of the pathway step.(en)"> comment = <"*For example: 'Avoid grapefruit' , 'Take at least 2 hours before bedtime', 'Take with food'. May be coded with a terminology when clinically appropriate.(en)"> > ["at0039"] = < text = <"*Major change to order.(en)"> description = <"*A major change to the order was required, resulting in this order being stopped and a replacement order being started.(en)"> > ["at0041"] = < text = <"*Minor change to order(en)"> description = <"*The medication order has been changed in a manner which does not require a new instruction/order to be issued, according to local clinical rules.(en)"> > ["at0043"] = < text = <"*Original scheduled date/time(en)"> description = <"*The datetime at which the medication action was scheduled to occur.(en)"> comment = <"*Used to compare variance from actual action time where this is not readily calculable from the original instruction.(en)"> > ["at0044"] = < text = <"*Dose administration deferred(en)"> description = <"*Administration of a dose of mediciation has been delayed but is expected to be given as soon as possible.(en)"> > ["at0053"] = < text = <"*Additional details(en)"> description = <"*Further structured details of the action, possibly specific to a pathway step.(en)"> > ["at0085"] = < text = <"*Cluster(en)"> description = <"**(en)"> > ["at0103"] = < text = <"*Order ID(en)"> description = <"*Unique identifier for the medication order.(en)"> comment = <"*Comment: This data element allows for multiple occurrences to be defined more explicitly at run-time, if required.(en)"> > ["at0104"] = < text = <"*Medication details(en)"> description = <"*Structured details about the medication including strength, form and constituent substances.(en)"> comment = <"*Use this SLOT where the detailed description of the dispensed, authorised or administered item needs to be explicitly stated. For example: the form, strength, any diluents or mixture of ingredients.(en)"> > ["at0106"] = < text = <"*Prescription re-authorised(en)"> description = <"*The original medication order has been re-authorised to allow repeat prescription or dispensing. In some jurisdictions an entirely new order must be issued in these circumstances.(en)"> > ["at0109"] = < text = <"*Medication recommended(en)"> description = <"*The medication has been recommended but no steps have been taken to initiate prescribing.(en)"> > ["at0131"] = < text = <"*Amount(en)"> description = <"*Specific details about the amount of the medication item.(en)"> comment = <"*Dosage_administration is intended to carry details of medication order changes or dose administrations, whilst medication_supply_amount is intended for details of dispensing-related activity.(en)"> > ["at0132"] = < text = <"*Substitution(en)"> description = <"*Subsitution action taken by the person administering or dispensing the drug.(en)"> comment = <"*In many jurisdictions, substitution of an ordered item as a generic form or with a different brand name, which has been determined as bioequivalent, is allowed at the point of dispense or supply. In other cases substitution is assumed and the clinician has to explicitly request non-substitution.(en)"> > ["at0133"] = < text = <"*Substitution reason(en)"> description = <"*The reason or justification for the substitution action taken.(en)"> comment = <"*For example: \"Generic alternative contains a substance that is not tolerated by the patient.\" May be coded with a terminology when clinically appropriate(en)"> > ["at0138"] = < text = <"*Substitution performed(en)"> description = <"*A medication was substituted which is bioequivalent to that ordered.(en)"> > ["at0139"] = < text = <"*Substitution not performed(en)"> description = <"*Although allowed by the medication order a bioequvalent medication was not substituted.(en)"> > ["at0140"] = < text = <"*Administration details(en)"> description = <"*Details of body site and administration of the medication.(en)"> > ["at0141"] = < text = <"*Body site(en)"> description = <"*Structured description of the site of administration of the ordered item.(en)"> comment = <"*For example: 'left upper arm', 'intravenous catheter right hand'. Coding of the body site with a terminology is preferred, where possible.(en)"> > ["at0142"] = < text = <"*Structured body site(en)"> description = <"*Structured description of the site of administration of the medication, vaccine or therapeutic good.(en)"> comment = <"*For example: \"On the medial skin surface of the left forearm, from 10 cm to 20 cm distally from the point of the elbow\".(en)"> > ["at0143"] = < text = <"*Administration method(en)"> description = <"*The technique or device by which the ordered item was, or is to be, administered.(en)"> comment = <"*Comment: For example: ' via Z-track injection'; 'via nebuliser'. Coding of the method with a terminology is preferred, where possible.(en)"> > ["at0144"] = < text = <"*Administration device(en)"> description = <"*Details of the medical device used to assist administration of the medication.(en)"> > ["at0145"] = < text = <"*Prescription awaiting authorisation(en)"> description = <"*Draft prescription has been prepared and is awaiting confirmation from an authorised clinician. May be used where reauthorisations are performed as a batch. This careflow_step may have a status of 'planned' or 'active', reflecting the need to to handle new orders as well as re-authorised orders.(en)"> > ["at0147"] = < text = <"*Route(en)"> description = <"*The route by which the ordered item was, or is to be, administered into the subject's body.(en)"> comment = <"*Comment: For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible. Multiple potential routes may be specified.(en)"> > ["at0148"] = < text = <"*Medication prepared(en)"> description = <"*The medication has been physically prepared. (en)"> comment = <"*For example: preparation of an intravenous mixture. (en)"> > ["at0149"] = < text = <"*Double-checked?(en)"> description = <"*The action step has been checked by a separate individual.(en)"> comment = <"*Details of the individual performing the double-check can be carried in the Reference Model element \"Participation\".(en)"> > ["at0150"] = < text = <"*Prescription cancelled(en)"> description = <"*The prescription was cancelled prior to being issued.(en)"> > ["at0151"] = < text = <"*Prescription invalid or expired(en)"> description = <"*Prescription has been invalidated or has expired without being fulfilled.(en)"> > ["at0152"] = < text = <"*Prescription fulfilled(en)"> description = <"*The prescription has been fulfilled successfully.(en)"> > ["at0153"] = < text = <"*Medication authorised(en)"> description = <"*The medication has been formally authorised for use.(en)"> > ["at0154"] = < text = <"*Restart date/time(en)"> description = <"*The date/time on which the medication course is set to restart, as per the \"Medication restart date/condition set\" pathway step.(en)"> comment = <"*For example: 2017-10-29(en)"> > ["at0155"] = < text = <"*Restart criterion(en)"> description = <"*The criterion which triggers the medication course to restart, as per the \"Medication restart date/condition set\" pathway step.(en)"> comment = <"*For example: \"On day 2 after surgery\".(en)"> > ["at0156"] = < text = <"*Clinical indication (en)"> description = <"*The clinical reason for the medication activity. (en)"> comment = <"*For example: 'Angina' or 'Pain'. Coding of the indication with a terminology is preferred, where possible. This data element allows multiple occurrences. If only an ACTION is used to record a medication indication, this data element can be used without additional consideration. However, if a clinical indication is recorded for both the Medication order INSTRUCTION and this Medication management ACTION, be aware that these indications might not be consistent.\" (en)"> > ["at0157"] = < text = <"*Medication double checked (en)"> description = <"*The prepared medication has been double checked. (en)"> > > > ["en"] = < items = < ["at0000"] = < text = <"Medication management"> description = <"Any activity related to the planning, scheduling, prescription management, dispensing, administration, cessation and other use of a medication, vaccine, nutritional product or other therapeutic item."> comment = <"This is not limited to activities performed based on medication orders from clinicians, but could also include for example taking over the counter medication."> > ["at0002"] = < text = <"Prescription issued"> description = <"A prescription has been issued for the medication."> > ["at0003"] = < text = <"Prescription dispensed"> description = <"The ordered medication has been dispensed, for example from a pharmacy to the patient."> > ["at0004"] = < text = <"Medication course commenced"> description = <"The medication has been taken by, or administered to, the patient for the first time. Although in some settings this significant date may be computable as the first of several administrations, in other settings, such as primary care, specific administration dates are not readily available."> > ["at0005"] = < text = <"Medication reassessed"> description = <"The individual medication has been reassessed, for example whether the medication should still be taken. This is not intended to capture review of the medication list."> > ["at0006"] = < text = <"Dose administered"> description = <"A single administration of the medication has taken place."> > ["at0007"] = < text = <"Medication course completed"> description = <"The medication course has been completed as planned."> > ["at0008"] = < text = <"Prescription supply delayed"> description = <"The prescription has not been dispensed due to a technical or pharamaceutical supply issue."> > ["at0009"] = < text = <"Administrations suspended"> description = <"The administration of the medication has been suspended until further notice. No further doses should be given until the restart date or conditions have been met. When setting the date/conditions for restart after suspending, a step from ‘Administrations suspended’ and back to 'Medication start date/condition set' should be performed."> > ["at0010"] = < text = <"Prescription re-issued"> description = <"A prescription has been re-issued for an existing medication order."> > ["at0011"] = < text = <"Prescription re-authorisation pending"> description = <"Issue of the prescription is awaiting re-authorisation by a clinician."> > ["at0012"] = < text = <"Medication course cancelled"> description = <"The planned course of medication has been cancelled prior to any administration."> > ["at0013"] = < text = <"Medication course postponed"> description = <"The scheduled medication course has been postponed prior to any administration."> > ["at0015"] = < text = <"Medication course stopped"> description = <"Administration of the medication has been ceased during the period of the intended course."> > ["at0016"] = < text = <"Medication start date/condition set"> description = <"The time to start the medication, or other starting condition, has been set."> > ["at0017"] = < text = <"Tree"> description = <"@ internal @"> > ["at0018"] = < text = <"Dose administration omitted"> description = <"An administration of the medication has been withheld and not given. There is no expectation that it will be given later, though the next dose (if any) should be administered according to the original order."> > ["at0020"] = < text = <"Medication item"> description = <"Name of the medication, vaccine or other therapeutic/prescribable item which was the focus of the activity."> comment = <"For example: 'Atenolol 100mg' or 'Tenormin tablets 100mg'. It is strongly recommended that the 'Medication item' is coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple name of the medication item through to structured details about the actual medication pack used. Free text entry should only be used if there is no appropriate terminology available."> > ["at0021"] = < text = <"Reason"> description = <"Reason that the pathway step for the identified medication was carried out."> comment = <"For example: 'Postponed - Patient not avalable at administration time', 'Cancelled - Adverse reaction'. Note: This is not the reason for the medication instruction, but rather the specific reason that a care step was carried out, and will often be used to document some variance from the original order."> > ["at0024"] = < text = <"Comment"> description = <"Additional narrative about the activity or pathway step not captured in other fields, including details of any variance between the intended action and the action actually performed."> comment = <"For example: 'Patient was in radiology department', 'Accidental injection into blood vessel during IM administration'."> > ["at0025"] = < text = <"Sequence number"> description = <"The sequence number specific to the pathway step being recorded."> comment = <"For example: Vaccine sequence number."> > ["at0030"] = < text = <"Tree"> description = <"@ internal @"> > ["at0033"] = < text = <"Patient guidance"> description = <"Any guidance, instructions or advice given to the subject of care or personal carer at the time of the pathway step."> comment = <"For example: 'Avoid grapefruit' , 'Take at least 2 hours before bedtime', 'Take with food'. May be coded with a terminology when clinically appropriate."> > ["at0039"] = < text = <"Major change to order"> description = <"A major change to the order was required, resulting in this order being stopped and a replacement order being started."> > ["at0041"] = < text = <"Minor change to order"> description = <"The medication order has been changed in a manner which does not require a new instruction/order to be issued, according to local clinical rules."> > ["at0043"] = < text = <"Original scheduled date/time"> description = <"The datetime at which the medication action was scheduled to occur."> comment = <"Used to compare variance from actual action time where this is not readily calculable from the original instruction."> > ["at0044"] = < text = <"Dose administration deferred"> description = <"An administration of a dose of the medication has been delayed but is expected to be given as soon as possible."> > ["at0053"] = < text = <"Additional details"> description = <"Further structured details of the action, possibly specific to a pathway step."> > ["at0085"] = < text = <"Extension"> description = <"Additional information required to capture local content or to align with other reference models/formalisms."> comment = <"For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents."> > ["at0103"] = < text = <"Order ID"> description = <"Unique identifier for the medication order."> comment = <"Comment: This data element allows for multiple occurrences to be defined more explicitly at run-time, if required."> > ["at0104"] = < text = <"Medication details"> description = <"Structured details about the medication including strength, form and constituent substances."> comment = <"Use this SLOT where the detailed description of the dispensed, authorised or administered item needs to be explicitly stated. For example: the form, strength, any diluents or mixture of ingredients."> > ["at0106"] = < text = <"Prescription re-authorised"> description = <"The original medication order has been re-authorised to allow repeat prescription or dispensing. In some jurisdictions an entirely new order must be issued in these circumstances."> > ["at0109"] = < text = <"Medication recommended"> description = <"The medication has been recommended but no steps have been taken to initiate prescribing."> > ["at0131"] = < text = <"Amount"> description = <"Specific details about the amount of the medication item."> comment = <"CLUSTER.dosage is intended to carry details of medication order changes or dose administrations, whilst CLUSTER.medication_supply_amount is intended for details of dispensing-related activity."> > ["at0132"] = < text = <"Substitution"> description = <"Subsitution action taken by the person administering or dispensing the drug."> comment = <"In many jurisdictions, substitution of an ordered item as a generic form or with a different brand name, which has been determined as bioequivalent, is allowed at the point of dispense or supply. In other cases substitution is assumed and the clinician has to explicitly request non-substitution."> > ["at0133"] = < text = <"Substitution reason"> description = <"The reason or justification for the substitution action taken."> comment = <"For example: \"Generic alternative contains a substance that is not tolerated by the patient.\" May be coded with a terminology when clinically appropriate"> > ["at0138"] = < text = <"Substitution performed"> description = <"A medication was substituted which is bioequivalent to that ordered."> > ["at0139"] = < text = <"Substitution not performed"> description = <"Although allowed by the medication order a bioequvalent medication was not substituted."> > ["at0140"] = < text = <"Administration details"> description = <"Details of body site and administration of the medication."> > ["at0141"] = < text = <"Body site"> description = <"Structured description of the site of administration of the ordered item."> comment = <"For example: 'left upper arm', 'intravenous catheter right hand'. Coding of the body site with a terminology is preferred, where possible."> > ["at0142"] = < text = <"Structured body site"> description = <"Structured description of the site of administration of the medication, vaccine or therapeutic good."> comment = <"For example: \"On the medial skin surface of the left forearm, from 10 cm to 20 cm distally from the point of the elbow\"."> > ["at0143"] = < text = <"Administration method"> description = <"The technique or device by which the ordered item was, or is to be, administered."> comment = <"Comment: For example: ' via Z-track injection'; 'via nebuliser'. Coding of the method with a terminology is preferred, where possible."> > ["at0144"] = < text = <"Administration device"> description = <"Details of the medical device used to assist administration of the medication."> > ["at0145"] = < text = <"Prescription awaiting authorisation"> description = <"Draft prescription has been prepared and is awaiting confirmation from an authorised clinician. May be used where reauthorisations are performed as a batch. This careflow_step may have a status of 'planned' or 'active', reflecting the need to to handle new orders as well as re-authorised orders."> > ["at0147"] = < text = <"Route"> description = <"The route by which the ordered item was, or is to be, administered into the subject's body."> comment = <"Comment: For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible. Multiple potential routes may be specified."> > ["at0148"] = < text = <"Medication prepared"> description = <"The medication has been physically prepared."> comment = <"For example: preparation of an intravenous mixture."> > ["at0149"] = < text = <"Double-checked?"> description = <"The pathway step has been checked by a separate individual."> comment = <"Details of the individual performing the double-check can be carried in the Reference Model element \"Participation\"."> > ["at0150"] = < text = <"Prescription cancelled"> description = <"The prescription was cancelled prior to being issued."> > ["at0151"] = < text = <"Prescription invalid or expired"> description = <"Prescription has been invalidated or has expired without being fulfilled."> > ["at0152"] = < text = <"Prescription fulfilled"> description = <"The prescription has been fulfilled successfully."> > ["at0153"] = < text = <"Medication authorised"> description = <"The medication has been formally authorised for use."> > ["at0154"] = < text = <"Restart date/time"> description = <"The date/time on which the medication course is set to restart, as per the \"Administrations suspended\" pathway step."> comment = <"For example: 2017-10-29"> > ["at0155"] = < text = <"Restart criterion"> description = <"The criterion which triggers the medication course to restart, as per the \"Administrations suspended\" pathway step."> comment = <"For example: \"On day 2 after surgery\"."> > ["at0156"] = < text = <"Clinical indication"> description = <"The clinical reason for the medication activity."> comment = <"For example: 'Angina' or 'Pain'. Coding of the indication with a terminology is preferred, where possible. This data element allows multiple occurrences. If only an ACTION is used to record a medication indication, this data element can be used without additional consideration. However, if a clinical indication is recorded for both the Medication order INSTRUCTION and this Medication management ACTION, be aware that these indications might not be consistent.\""> > ["at0157"] = < text = <"Medication double checked"> description = <"The prepared medication has been double checked."> > > > ["nb"] = < items = < ["at0000"] = < text = <"Legemiddelhåndtering"> description = <"Detaljer om enhver legemiddelrelatert oppgave som utføres fra et legemiddel er ordinert eller rekvirert til det er utdelt eller eventuelt kassert, for eksempel bestilling, istandgjøring, administrering, ekspedering eller seponering."> comment = <"Dette er ikke begrenset til aktiviteter utført på bagrunn av legemiddelordineringer fra klinikere, men kan også omfatte å ta legemidler som ikke er reseptpliktige."> > ["at0002"] = < text = <"Resept utstedt"> description = <"Det er utstedt en resept for legemiddelet."> > ["at0003"] = < text = <"Resept ekspedert"> description = <"Legemiddelet er utdelt, for eksempel fra et apotek til pasienten."> > ["at0004"] = < text = <"Medisinering startet"> description = <"Legemiddelet er inntatt av eller administrert til pasienten for første gang. Selv om dette i noen bruksområder som f.eks. sykehus kan utledes fra den første av en rekke administreringer, må det i andre bruksområder som f.eks. allmennpraksis spesifiseres spesifikt siden administreringer ikke dokumenteres på samme måte."> > ["at0005"] = < text = <"Legemiddel revurdert"> description = <"Legemiddelet er revurdert, for eksempel for hvorvidt det fortsatt skal tas. Dette er ikke ment å omfatte gjennomgang av en legemiddelliste."> > ["at0006"] = < text = <"Legemiddel administrert"> description = <"En enkelt administrering av legemiddelet er utført."> > ["at0007"] = < text = <"Medisinering fullført"> description = <"Medisineringen er fullført som ordinert."> > ["at0008"] = < text = <"Forsinket levering"> description = <"Legemiddelet er ikke utdelt fordi det ikke er på lager enda."> > ["at0009"] = < text = <"Administrering satt på vent"> description = <"Administrering av legemiddelet er satt på vent inntil videre, ordinasjonen er \"nullet\". Ingen ytterligere doser gis før kriterium eller dato for å sette medisineringen i gang igjen er møtt. Når dato eller kriterium for å ny oppstart settes, bør det gjøres et 'suspend_step' tilbake til \"Oppstartsdato satt\"."> > ["at0010"] = < text = <"Resept fornyet"> description = <"Legemiddelet har fått en fornyet resept for den eksisterende ordineringen."> > ["at0011"] = < text = <"Reautorisering av resept satt på vent"> description = <"Utstedelse av resept avventer reautorisering av en kliniker. I noen myndighetsområder kan ikke resepter reautoriseres, og det må i disse tilfellene utstedes en helt ny resept."> > ["at0012"] = < text = <"Planlagt medisinering avbrutt"> description = <"Den planlagte medisineringen er avbrutt før den første dosen er administrert."> > ["at0013"] = < text = <"Planlagt medisinering satt på vent"> description = <"Den planlagte medisineringen er satt på vent før den første dosen er administrert."> > ["at0015"] = < text = <"Legemiddel seponert"> description = <"Legemiddelet er seponert etter at første dose er administrert, men før planlagt fullførelse av ordineringen."> > ["at0016"] = < text = <"Oppstartsdato satt"> description = <"Tidspunktet eller vilkår for å starte medisineringen er satt."> > ["at0017"] = < text = <"Tree"> description = <"@ internal @"> > ["at0018"] = < text = <"Enkeltdose ikke administrert"> description = <"En enkeltdose er holdt tilbake og ikke administrert (\"nullet\"). Det er ingen forventing om at den aktuelle dosen skal gis på et senere tidspunkt, men neste dose administreres i henhold til ordineringen."> > ["at0020"] = < text = <"Legemiddel"> description = <"Navnet på legemiddelet, vaksinen eller det medisinske forbruksmateriellet som var fokus for aktiviteten."> comment = <"For eksempel: 'Atenolol 100mg' eller 'Tenormin 100mg tabletter'. Det anbefales sterkt at \"Legemiddel\" kodes med en terminologi som understøtter beslutningsstøtte der dette er mulig, f.eks. FEST. Nivå av koding kan variere fra legemiddelnavn til strukturerte detaljer om den aktuelle legemiddelforpakningen som skal brukes. Fritekst bør bare brukes om ingen passende terminologi er tilgjengelig."> > ["at0021"] = < text = <"Årsak"> description = <"Årsak til at det aktuelle prosesstrinnet ble utført."> comment = <"For eksempel: Dersom administrering er utsatt pga pasienten ikke er tilgjengelig, velges prosesstrinnet \"Utsatt administrering\", og \"Pasienten er ikke tilgjengelig ved administreringstidspunktet\" dokumenteres i dette elementet. Dersom legemiddelet seponeres pga legemiddelreaksjon, velges prosesstrinnet \"Seponert\", og \"Legemiddelreaksjon\" dokumenteres i dette elementet. NB: Dette er ikke årsaken til legemiddelordineringen, men de spesifikke årsakene til at det aktuelle prosesstrinnet ble utført. Dette vil som regel brukes for å dokumentere varians fra den opprinnelige ordineringen."> > ["at0024"] = < text = <"Kommentar"> description = <"Ytterligere fritekstdetaljer om aktiviteten eller prosesstrinnet som ikke representeres i andre elementer, inkludert detaljer om varians mellom den planlagte handlingen og handlingen som faktisk ble utført."> comment = <"For eksempel \"Pasienten var på røntgenavdelingen\" eller \"Utilsiktet intravenøs injeksjon under intramuskulær administrering\"."> > ["at0025"] = < text = <"Sekvensnummer"> description = <"Sekvensnummeret for den spesifikke handlingen som blir registrert."> comment = <"For eksempel: En vaksines sekvensnummer/ nummer i en rekkefølge."> > ["at0030"] = < text = <"Tree"> description = <"@ internal @"> > ["at0033"] = < text = <"Pasientinstruksjoner"> description = <"Enhver instruksjon som gis til pasienten eller en omsorgsperson når prosesstrinnet utføres."> comment = <"For eksempel \"unngå grapefrukt\", \"ta minst 2 timer før sengetid\" eller \"ta med mat\". Kan kodes med en terminologi der det er klinisk passende."> > ["at0039"] = < text = <"Omfattende endring av ordinering"> description = <"Det er utført en større endring i ordineringen, denne ordineringen er stoppet og en ny ordinering er igangsatt."> > ["at0041"] = < text = <"Mindre endring av ordinering"> description = <"Legemiddelordineringen er endret på en slik måte at det etter lokale retningslinjer ikke er behov for en ny ordinering. For eksempel endring av produkt fra tabletter til kapsler."> > ["at0043"] = < text = <"Opprinnelig planlagt tid"> description = <"Dato/tid for når legemiddelaktiviteten var planlagt å skulle skje."> comment = <"Brukes til å sammenligne varians fra faktisk tidspunkt for en aktivitet, der dette ikke er mulig å beregne ut fra den opprinnelige ordineringen."> > ["at0044"] = < text = <"Administrering utsatt"> description = <"Administrering av legemiddelet er utsatt/forsinket, men legemiddelet forventes administrert så raskt som mulig."> > ["at0053"] = < text = <"Ytterligere detaljer"> description = <"Ytterligere strukturerte detaljer om handlingen, for eksempel spesifikk informasjon for det aktuelle prosesstrinnet."> > ["at0085"] = < text = <"Tilleggsinformasjon"> description = <"Ytterligere informasjon som er nødvendig for å sammenstille med andre referansemodeller/formalismer."> comment = <"F.eks. lokale informasjonskrav eller ekstra metadata for å samsvare med FHIR eller CIMI ekvivalenter."> > ["at0103"] = < text = <"OrdineringsID"> description = <"Identifikatoren for den opprinnelige ordineringen."> comment = <"Dette dataelementet tillater flere forekomster som kan defineres mer eksplisitt ved behov."> > ["at0104"] = < text = <"Legemiddeldetaljer"> description = <"Strukturerte detaljer om legemiddelet, blant annet styrke, form og virkestoffene det består av."> comment = <"Bruk dette SLOTet til å spesifisere en detaljert beskrivelse av det bestilte, istandgjorte, administrerte, ekspederte eller seponerte produktet. For eksempel form, styrke, fortynningsmiddel eller blandinger av ingredienser."> > ["at0106"] = < text = <"Resept reautorisert"> description = <"En repeterende resept har blitt reautorisert. I noen myndighetsområder må det i disse tilfellene utstedes en helt ny resept."> > ["at0109"] = < text = <"Anbefalt medisinering"> description = <"Medisineringen er anbefalt, men ordinering er ikke iverksatt."> > ["at0131"] = < text = <"Mengde"> description = <"Spesifikke detaljer om mengden legemiddel."> comment = <"Arketypen CLUSTER.dosage er ment å inneholde detaljer om endringer i legemiddelordinering eller i administrert dose, mens CLUSTER.medication_supply_amount er ment for detaljer rundt ekspedering."> > ["at0132"] = < text = <"Generisk bytte"> description = <"Generisk bytte utført ved administrering eller ekspedering."> comment = <"I mange myndighetsområder er generisk bytte av et ordinert produkt mot et bioekvivalent produkt fra en annen produsent tillatt. I andre områder er bytte forutsatt, og ordinerende kliniker må eksplisitt avslå bytte."> > ["at0133"] = < text = <"Årsak for bytte/ikke bytte"> description = <"Årsak eller begrunnelse for at generisk bytte er utført eller ikke utført."> comment = <"For eksempel \"Generiske alternativer inneholder et hjelpestoff som ikke tolereres av pasienten\". Kan kodes med en terminologi der det er klinisk passende."> > ["at0138"] = < text = <"Generisk bytte utført"> description = <"Det ordinerte produktet ble byttet til et bioekvivalent produkt."> > ["at0139"] = < text = <"Generisk bytte ikke utført"> description = <"Det ordinerte produktet ble ikke byttet til et bioekvivalent produkt, til tross for at dette var tillatt i ordineringen."> > ["at0140"] = < text = <"Administreringsdetaljer"> description = <"Detaljer om administrering av legemiddelet."> > ["at0141"] = < text = <"Anatomisk lokalisering"> description = <"Strukturert beskrivelse av hvor i kroppen det ordinerte produktet skal administreres eller ble administrert."> comment = <"For eksempel \"venstre overarm\", \"intravenøst kateter høyre hånd\". Det bør om mulig benyttes terminologi, f.eks. SNOMED CT eller EDQM standardtermer, for å kode anatomisk lokalisering."> > ["at0142"] = < text = <"Strukturert anatomisk lokalisering"> description = <"Strukturert beskrivelse av administreringsstedet for legemiddelet eller vaksinen."> comment = <"For eksempel \"på hudoverflaten medialt på venstre underarm, fra 10 cm til 20 cm distalt fra albuspissen\"."> > ["at0143"] = < text = <"Administreringsmetode"> description = <"Metoden legemiddelet ble administrert eller skal administreres ved."> comment = <"For eksempel \"via Z-trackinjeksjon\", \"via forstøver\". Koding av administreringsmetoden med en terminologi er anbefalt, der det er mulig."> > ["at0144"] = < text = <"Administreringsutstyr"> description = <"Detaljer om utstyret som ble brukt for å administrere legemiddelet."> > ["at0145"] = < text = <"Resept avventer autorisering"> description = <"Det er forberedt et utkast for en resept, og denne avventer godkjenning av en autorisert kliniker. Kan brukes der reseptutstedelse utføres satsvis. Dette prosesstrinnet kan brukes enten med status \"planned\" eller \"active\", for å underbygge behovet for å håndtere både nye og reautoriserte ordinasjoner."> > ["at0147"] = < text = <"Administreringsvei"> description = <"Administreringsveien som skal eller ble brukt for legemiddelet."> comment = <"For eksempel \"oral bruk\", \"intravenøst\" eller \"på huden\". Det bør om mulig benyttes terminologi, f.eks. FEST, for å angi administreringsvei. Det kan spesifiseres flere mulige administreringsveier."> > ["at0148"] = < text = <"Legemiddel istandgjort"> description = <"Legemiddelet er fysisk istandgjort"> comment = <"For eksempel istandgjøring av en intravenøs blanding."> > ["at0149"] = < text = <"Dobbeltkontrollert?"> description = <"Prosesstrinnet har blitt kontrollert av en annen person enn den som primært utfører det."> comment = <"Detaljer om individet som utfører dobbeltkontrollen kan registreres som \"Participation\" i referansemodellen."> > ["at0150"] = < text = <"Resept avbrutt"> description = <"Resepten ble avbrutt før den ble utstedt."> > ["at0151"] = < text = <"Resept ugyldig eller utgått"> description = <"Resepten er ugyldiggjort eller har utgått før den er ferdig ekspedert."> > ["at0152"] = < text = <"Resept ferdig ekspedert"> description = <"Resepten er ferdig ekspedert."> > ["at0153"] = < text = <"Legemiddel autorisert"> description = <"Legemiddelet er formelt autorisert for bruk."> > ["at0154"] = < text = <"Dato/tid for ny oppstart"> description = <"Datoen eller tidspunktet når medisineringen skal startes opp igjen, i sammenheng med prosesstrinnet \"Vilkår satt for å sette medisineringen i gang igjen\"."> comment = <"For eksempel \"2017-10-29\"."> > ["at0155"] = < text = <"Kriterium for ny oppstart"> description = <"Kriterium for når medisineringen skal startes opp igjen, i sammenheng med prosesstrinnet \"Vilkår satt for å sette medisineringen i gang igjen\"."> comment = <"For eksempel \"på dag 2 etter kirurgi\"."> > ["at0156"] = < text = <"Klinisk indikasjon"> description = <"Den kliniske årsaken til legemiddeladministrasjonen."> comment = <"For eksempel: \"Angina\" eller \"Smerte\". Koding av indikasjonen med en terminologi er foretrukket, om mulig. Dette dataelementet er repeterbart. Dersom bare denne arketypen blir brukt for å dokumentere legemiddeladministeringen, kan dette dataelementet brukes uten å tenke noe mer på det. Men dersom \"Klinisk indikasjon\" er registrert i både Legemiddelordinering (INSTRUCTION.medication_order) og denne Legemiddelhåndtering (ACTION.medication), må man være oppmerksom på at det kan være forskjell i registrert indikasjonen. "> > ["at0157"] = < text = <"Legemiddel dobbeltkontrollert"> description = <"Det istandgjorte legemiddelet har blitt dobbeltkontrollert."> > > > ["pt-br"] = < items = < ["at0000"] = < text = <"Gestão de medicação"> description = <"Qualquer atividade relacionada ao planejamento, agendamento, gestão da prescrição, dispensação, administração, término e outro uso de um medicamento, vacina, produto nutricional ou outro item terapêutico."> comment = <"Este não é limitado a atividades realizadas sobre solicitação de medicação de clínicos, mas também inclui por exemplo a adquisição de medicamentos de venda livre."> > ["at0002"] = < text = <"Prescrição emitida"> description = <"Uma prescrição foi emitida para a medicação."> > ["at0003"] = < text = <"Prescrição aviada"> description = <"Uma prescrição de medicação foi aviada, por exemplo de uma farmácia ao paciente."> > ["at0004"] = < text = <"Curso da medicação iniciado"> description = <"A medicação foi adquirida, ou administrada, ao paciente pela primeira vez. Embora em algumas situações esta data significativa pode ser computada como a primeira de muitas administrações, em outras, como na atenção primária, datas de administração específicas não estão prontamente disponíveis. "> > ["at0005"] = < text = <"Curso da medicação revisado"> description = <"O item de medicação específico foi revisado, conforme planejado. Este não pretende capturar uma revisão da lista completa de medicação."> > ["at0006"] = < text = <"Dose administrada"> description = <"Dose do medicamento foi administrada."> > ["at0007"] = < text = <"Final do tratamento medicamentoso"> description = <"O tratamento medicamentoso foi finalizado conforme previsto."> > ["at0008"] = < text = <"Suprimento da prescrição atrasado"> description = <"A prescrição não foi aviada devido a um problema técnico ou de suprimento farmacêutico."> > ["at0009"] = < text = <"Administração suspensa"> description = <"A administração do medicamento foi suspensa até nova ordem. Doses adicionais não devem ser administradas até que a data de reinício ou condições forem alcançadas. Na configuração de nova data/condições para reinício após a suspensão, deve-se realizar a etapa de suspensão de Administrações suspensas e voltar a Data do início/ Condição de início."> > ["at0010"] = < text = <"Nova liberação de prescrição"> description = <"Nova liberação de prescrição já existente."> > ["at0011"] = < text = <"Reemissão da prescrição suspensa"> description = <"Reemissão da prescrição não está disponível sem alguma intervenção."> > ["at0012"] = < text = <"Curso da medicação cancelado"> description = <"O curso planejado da medicação foi cancelado antes de qualquer administração."> > ["at0013"] = < text = <"Curso da medicação adiado"> description = <"O curso planejado da medicação foi adiado antes de qualquer administração."> > ["at0015"] = < text = <"Curso da medicação interrompido"> description = <"A administração desta medicação foi interrompida após administração da primeira dose, mas antes de completar o curso pretendido."> > ["at0016"] = < text = <"Data do início/ Condição de início"> description = <"A hora de começar a medicação, ou outra condição para iniciar o tratamento foi estabelecida."> > ["at0017"] = < text = <"Tree"> description = <"@ internal @"> > ["at0018"] = < text = <"Omissão da administração da dose"> description = <"A administração de um medicamento foi suspensa e não realizada. Não há expectativa de que será dada mais tarde, embora a próxima dose (se houver) deva ser administrada conforme a prescrição original."> > ["at0020"] = < text = <"Item de medicação"> description = <"Nome do medicamento, vacina ou outro item terapêutico que foi o foco da atividade."> comment = <"Por exemplo: \"Atenolol 100mg\" ou \"Tenormin comprimidos 100mg\". É altamente recomendável que o \"Item de medicação\" seja codificado com uma terminologia capaz de desencadear suporte à decisão, quando possível. A extensão da codificação pode variar de um simple nome do item de medicação até detalhes estruturados sobre a embalagem de medicamento usada. Entradas em texto livre devem ser usadas apenas e não houver terminologia apropriada disponível."> > ["at0021"] = < text = <"Motivo"> description = <"Motivo pelo qual a etapa para determinada medicação foi realizada."> comment = <"Por exemplo: \"Adiado - paciente indisponível na hora da administração\", \"Cancelado - reação adversa\". Nota: Esta não é a razão para a instrução da medicação, mas sim o motivo específico para a realização de determinada etapa no processo de cuidado, e será frequentemente usado para documentar alguma variação da solicitação original."> > ["at0024"] = < text = <"Comentário"> description = <"Narrativa adicional sobre a atividade ou etapa do fluxo de cuidado não capturada em outros campos, incluindo detalhes de quaisquer variáveis entre a ação pretendida e a ação realmente realizada."> comment = <"Por exemplo: \"Paciente estava no departamento de radiologia\", \"Injeção intravenosa acidental durante a administração IM\"."> > ["at0025"] = < text = <"Número sequencial"> description = <"O número sequencial específico da atividade registrada."> comment = <"*For example: Vaccine sequence number. (en)"> > ["at0030"] = < text = <"Tree"> description = <"@ internal @"> > ["at0033"] = < text = <"Orientação ao paciente"> description = <"Quaisquer orientações, instruções ou conselhos dados ao sujeito do cuidado ou cuidador no momento"> comment = <"Por exemplo: \"Evitar toranja\", \"Tomar pelo menos 2 horas antes de deitar\", \"Tomar com alimento\". Pode ser codificado com uma terminologia quando clinicamente apropriado."> > ["at0039"] = < text = <"Alteração significativa na prescrição"> description = <"Foi necessário realizar uma alteração significativa na prescrição, resultando no cancelamento da atual e a substituição por uma nova prescrição."> > ["at0041"] = < text = <"Prescrição com mínimas mudanças"> description = <"A prescrição foi alterada de uma forma que não exige uma nova liberação da prescrição, de acordo com as regras clínicas locais."> > ["at0043"] = < text = <"Data/hora original do agendamento"> description = <"Data/hora na qual a foi agendada ação da medicação."> comment = <"Usado para comparar a variação do tempo real de ação onde este não é prontamente calculado da instrução original."> > ["at0044"] = < text = <"Administração da dose adiada"> description = <"A administração de uma dose de medicamento foi adiada, mas espera-se que seja administrada o mais rápido possível."> > ["at0053"] = < text = <"Detalhes adicionais"> description = <"Demais detalhes estruturados da ação, possivelmente específicos à etapa do processo."> > ["at0085"] = < text = <"Extensão"> description = <"Informações adicionais necessárias para capturar o conteúdo local ou para se alinhar com outros modelos de referência / formalismos."> comment = <"Por exemplo: requisitos locais de informação ou metadados adicionais para alinhar com os modelos equivalente em FHIR e CIMI."> > ["at0103"] = < text = <"Identificação da solicitação"> description = <"Identificador único para a solicitação de medicação."> comment = <"Comentário: este elemento de dado permite a definição de múltiplas ocorrências mais explicitamente em tempo de execução, caso necessário."> > ["at0104"] = < text = <"Detalhes da medicação"> description = <"Detalhes estruturados sobre a medicação incluindo concentração, forma e componentes."> comment = <"Use este SLOT quando descrições detalhadas sobre o item dispensado, autorizado ou administrado precisam ser explicitamente citadas. Por exemplo: a forma, concentração, quaisquer diluentes ou mistura de ingredientes."> > ["at0106"] = < text = <"Prescrição reautorizada"> description = <"A solicitação original da medicação foi reautorização para permitir prescrição ou dispensação repetida. Em algumas jurisdições uma nova solicitação deve ser emitida nestas circunstâncias."> > ["at0109"] = < text = <"Medicamento recomendado"> description = <"Medicamento foi recomendado mas nenhuma ação foi realizada para iniciar a prescrição."> > ["at0131"] = < text = <"Quantidade"> description = <"Detalhes específicos sobre a quantidade do item de medicação."> comment = <"CLUSTER.dosage pretende carregar detalhes da solicitação de mudanças da medicação ou administrações da dose, enquanto CLUSTER.medication_supply_amount registra os detalhes da atividade relacionada à dispensação."> > ["at0132"] = < text = <"Substituição"> description = <"Ação de substituição realizada pela pessoa que administrou ou dispensou o medicamento."> comment = <"Em muitas jurisdições, a substituição de um item prescrito como uma forma genérica ou com um nome comercial diferente, que foi determinado como bioequivalente, é permitida no momento da dispensação ou suprimento. Em outros casos assume-se a substituição e o clínico deve requisitar explicitamente a não-substituição."> > ["at0133"] = < text = <"Motivo da substituição"> description = <"O motivo ou justificativa para a ação de substituição realizada."> comment = <"Por exemplo: \"Alternativa genérica contém uma substância não tolerada pelo paciente\". Pode ser codificado com uma terminologia quando clinicamente apropriado."> > ["at0138"] = < text = <"Substituição realizada"> description = <"A medicação substituída é bioequivalente àquela prescrita."> > ["at0139"] = < text = <"Substituição não realizada"> description = <"Embora permitido pela prescrição da medicação a substituição por um medicamento bioequivalente não foi realizada."> > ["at0140"] = < text = <"Detalhes da administração"> description = <"Detalhes do local do corpo e administração da medicação."> > ["at0141"] = < text = <"Local do corpo"> description = <"Descrição estruturada do local de administração do item prescrito."> comment = <"Por exemplo: \"braço esquerdo superior\", \"cateter intravenoso na mão direita\". A codificação do local do corpo com uma terminologia é preferível, quando possível."> > ["at0142"] = < text = <"Local do corpo estruturado"> description = <"Descrição estruturada do local de administração do medicamento, vacina ou insumo terapêutico."> comment = <"Por exemplo: \"Na superfície medial da pele do antebraço esquerdo, de 10 cm a 20 cm distante da ponta do cotovelo\"."> > ["at0143"] = < text = <"Método de administração"> description = <"A técnica ou dispositivo pelo qual o item foi, ou deve ser, administrado."> comment = <"Comentário: Por exemplo: \"injeção com técnica em Z\"; \"via nebulizador\". A codificação do método com uma terminologia é preferível, quando possível."> > ["at0144"] = < text = <"Dispositivo de administração"> description = <"Detalhes do dispositivo médico usado para auxiliar a administração do medicamento."> > ["at0145"] = < text = <"Prescrição no aguardo de autorização"> description = <"Rascunho da prescrição foi preparado e está aguardando confirmação de um clínico autorizado. Pode ser usado quando reautorizações são realizadas em lote. Esta etapa do processo de cuidado pode ter um estado de \"planejado\" ou \"ativo\", refletindo a necessidade de gerir novas solicitações assim como solicitações reautorizadas."> > ["at0147"] = < text = <"Via"> description = <"A via pela qual o item prescrito foi, ou deve ser, administrado no corpo do indivíduo."> comment = <"Comentário: Por exemplo: \"oral\", \"intravenoso\", ou \"tópico\". Codificar a via com uma terminologia é preferível, quando possível. Múltiplas vias potenciais podem ser especificadas."> > ["at0148"] = < text = <"Medicamento preparado"> description = <"*The medication has been physically prepared. (en)"> comment = <"*For example: preparation of an intravenous mixture. (en)"> > ["at0149"] = < text = <"Dupla checagem?"> description = <"Uma ação que foi checada por outro indivíduo."> comment = <"Detalhes do indivíduo que realiza a dupla checagem pode ser registrado no elemento \"Participação\" do Modelo de Referência."> > ["at0150"] = < text = <"Prescrição cancelada"> description = <"A prescrição foi cancelada antes de ser emitida."> > ["at0151"] = < text = <"Prescrição inválida ou cancelada"> description = <"A prescrição foi invalidada ou expirou sem ser aviada."> > ["at0152"] = < text = <"Prescrição aviada"> description = <"A prescrição foi aviada com sucesso."> > ["at0153"] = < text = <"Medicação autorizada"> description = <"A medicação foi formalmente autorizada para uso."> > ["at0154"] = < text = <"Data/hora do reinício"> description = <"A data/hora na qual o curso da medicação está configurado para reiniciar, como a etapa \"Conjunto de condições para reinício da medicação\" do processo."> comment = <"Por exemplo: 2017-10-29"> > ["at0155"] = < text = <"Critério do reinício"> description = <"O critério que desencadeia o reinício do curso da medicação, como uma etapa \"Conjunto de condições para reinício da medicação\" do processo."> comment = <"Por exemplo: \"No segundo dia após a cirurgia\"."> > ["at0156"] = < text = <"*Clinical indication (en)"> description = <"*The clinical reason for the medication activity. (en)"> comment = <"*For example: 'Angina' or 'Pain'. Coding of the indication with a terminology is preferred, where possible. This data element allows multiple occurrences. If only an ACTION is used to record a medication indication, this data element can be used without additional consideration. However, if a clinical indication is recorded for both the Medication order INSTRUCTION and this Medication management ACTION, be aware that these indications might not be consistent.\" (en)"> > ["at0157"] = < text = <"*Medication double checked (en)"> description = <"*The prepared medication has been double checked. (en)"> > > > ["de"] = < items = < ["at0000"] = < text = <"Arzneimittelanwendung"> description = <"Jede Aktivität in Bezug auf die Planung, Vorbereitung, Rezeptverwaltung, Ausgabe, Verabreichung, Einnahme, Absetzung und anderer Verwendung von Arzneimitteln, Impfstoffen, Nahrungsergänzungsmitteln und anderen therapeutischen Mitteln."> comment = <"Dies beschränkt sich nicht nur auf Aktivitäten, die auf der Grundlage von Arzneimittelverordnungen von Ärzten durchgeführt werden, sondern kann sich auch z.B. auf die Einnahme von freiverkäuflichen Medikamenten beziehen."> > ["at0002"] = < text = <"Rezept ausgestellt"> description = <"Für das Arzneimittel wurde ein Rezept ausgestellt."> > ["at0003"] = < text = <"Rezept wurde ausgegeben/eingelöst"> description = <"Das verordnete Arzneimittel ist an einen Patienten ausgegeben worden, z.B. von einer Apotheke."> > ["at0004"] = < text = <"Arzneimittelbehandlung hat begonnen"> description = <"Das Arzneimittel wurde zum ersten Mal von dem Patienten eingenommen oder ihm verabreicht. Obwohl in einigen Situationen das relevante Datum als erste von mehreren Anwendungen errechenbar ist, kann es in der Grundversorgung sein, dass genaue Verabreichungszeit nicht ohne weiteres verfügbar ist."> > ["at0005"] = < text = <"Arzneimittel wurde neu bewertet"> description = <"Das individuelle Arzneimittel wurde neu bewertet, beispielsweise ob das Arzneimittel noch angewendet werden soll. Eine Überprüfung der Arzneimittelliste soll nicht durchgeführt werden."> > ["at0006"] = < text = <"Dosis wurde verabreicht"> description = <"Eine einzelne Verabreichung des Arzneimittels ist erfolgt."> > ["at0007"] = < text = <"Arzneimittelbehandlung ist abgeschlossen"> description = <"Die medikamentöse Behandlung wurde, wie geplant, beendet."> > ["at0008"] = < text = <"Verzögerung der Rezeptabgabe"> description = <"Das Rezept wurde aufgrund einer technischen oder pharmazeutischen Störung nicht ausgegeben."> > ["at0009"] = < text = <"Verabreichung wurde ausgesetzt"> description = <"Die Verabreichung des Arzneimittels wurde bis zum Erhalt weiterer Informationen ausgesetzt. Es sollten keine weiteren Dosen, bis zur Bekanntgabe des neuen Startdatums oder bis die Bedingungen erfüllt sind, verabreicht werden. Wenn Sie das Datum/ die Voraussetzungen für den Neustart nach dem Aussetzen festlegen, sollte ein Schritt von \"Verabreichung wurde ausgesetzt\" und zurück zu \"Arzneimittel Startdatum/Voraussetzung\" ausgeführt werden."> > ["at0010"] = < text = <"Rezept neu ausgestellt"> description = <"Ein Rezept wurde für eine vorhandene Arzneimittelverordnung neu ausgestellt."> > ["at0011"] = < text = <"Re-Autorisierug des Rezepts ausstehend"> description = <"Die Ausstellung des Rezeptes wartet auf die erneute Autorisierung durch einen Arzt."> > ["at0012"] = < text = <"Arzneimittelbehandlung wurde abgesagt"> description = <"Die geplante Arzneimittelbehandlung wurde vor der Verabreichung abgesagt."> > ["at0013"] = < text = <"Arzneimittelbehandlung wurde verschoben"> description = <"Die geplante Arzneimittelbehandlung wurde vor der Verabreichung verschoben."> > ["at0015"] = < text = <"Arzneimittelbehandlung gestoppt"> description = <"Die Verabreichung des Arzneimittels wurde während der Dauer der geplanten Behandlung eingestellt."> > ["at0016"] = < text = <"Arzneimittel Startdatum/Voraussetzung"> description = <"Das Startdatum der Arzneimittelanwendung oder andere Startbedingungen wurden festgelegt."> > ["at0017"] = < text = <"Tree"> description = <"@ internal @"> > ["at0018"] = < text = <"Verabreichung einer Dosis wurde ausgelassen"> description = <"Eine Gabe des Arzneimittels wurde zurückgehalten und nicht gegeben. Es besteht keine Erwartung, dass sie später verabreicht wird, obwohl die nächste Dosis (falls es eine gibt) gemäß der ursprünglichen Verordnung verabreicht werden sollte."> > ["at0020"] = < text = <"Arzneimittel"> description = <"Name des Arzneimittels, eines Impfstoffs oder eines anderen therapeutischen Mittels, welches im Mittelpunkt der Aktivität steht."> comment = <"Zum Beispiel: \"Atenolol 100 mg\" oder \"Tenormin Tabletten 100 mg\". Es wird dringend empfohlen, dass das Element \"Arzneimittel\" mit einer Terminologie kodiert wird, die nach Möglichkeit eine Entscheidungsunterstützung auslösen kann. Der Umfang der Kodierung kann vom einfachen Namen des Arzneimittels bis hin zu strukturierten Details über die tatsächlich verwendete Medikamentenpackung variieren. Die Freitext-Eingabe sollte nur dann verwendet werden, wenn keine entsprechende Terminologie vorhanden ist."> > ["at0021"] = < text = <"Begründung"> description = <"Begründung, warum der Prozessschritt für das identifizierte Arzneimittel durchgeführt wurde."> comment = <"Zum Beispiel: \"Verschoben - Patient zur Verabreichungszeit nicht verfügbar\", \"abgesagt - Nebenwirkung\". Merke: Dies ist nicht der Grund für die Verordnung von Arzneimittel, sondern der spezifische Grund, warum ein Prozessschritt durchgeführt wurde. Wird oft verwendet, um Abweichungen von der ursprünglichen Verordnung zu dokumentieren."> > ["at0024"] = < text = <"Kommentar"> description = <"Zur Dokumentation von zusätzlichen Schilderungen über die Aktivitäten oder den Prozessschritt, wenn sie noch nicht in anderen Feldern erfasst wurden. Dabei sollen Einzelheiten zu Abweichungen zwischen durchzuführender Aktion und tatsächlich durchgeführter Aktion erfasst werden."> comment = <"Zum Beispiel: \"Patient war in der Radiologie.\", \"Versehentliche Punktion der Vene während der i.m. Verabreichung.\""> > ["at0025"] = < text = <"Sequenznummer"> description = <"Die spezifische Sequenznummer des Prozessschritts wird erfasst."> comment = <"Zum Beispiel: Impfsequenznummer."> > ["at0030"] = < text = <"Tree"> description = <"@ internal @"> > ["at0033"] = < text = <"Patientenanweisung"> description = <"Jede Anweisung, Anleitung oder Empfehlung, die dem Patienten oder der Pflegekraft zum Zeitpunkt eines Prozessschrittes übermittelt wird."> comment = <"Zum Beispiel: \"Vermeiden Sie den Konsum von Grapefruits oder grapefruithaltigen Lebensmitteln.\", \"Die Einnahme sollte mindestens 2 Stunden vor dem Zubettgehen erfolgen.\", \"Bitte zusammen mit Nahrung einnehmen.\" Wenn es klinisch zutreffend ist, kann für dieses Item eine Terminologie hinterlegt werden."> > ["at0039"] = < text = <"Größere Änderung der Verordnung"> description = <"Eine große Änderung der Verordnung war erforderlich, die dazu führte, dass diese Verordnung gestoppt und eine Ersatzverordnung gestartet wurde."> > ["at0041"] = < text = <"Geringfügige Änderung der Verordnung"> description = <"Die Arzneimittelverordnung wurde so geändert, dass keine neue Verordnung/neues Rezept nach den lokalen klinischen Regeln ausgestellt werden muss."> > ["at0043"] = < text = <"Ursprünglich geplantes Datum/Uhrzeit"> description = <"Das Datum/die Uhrzeit, an dem die Aktion mit dem Arzneimittel eingeplant war."> comment = <"Wird verwendet, um die Abweichung von der tatsächlichen Aktionszeit zu vergleichen, wenn diese aus der ursprünglichen Verordnung nicht leicht berechenbar ist."> > ["at0044"] = < text = <"Verabreichung einer Dosis wurde verschoben"> description = <"Die Verabreichung einer Dosis hat sich verzögert, wird aber so schnell wie möglich erfolgen."> > ["at0053"] = < text = <"Zusätzliche Details"> description = <"Weitere strukturierte Details zu der Aktivität, möglicherweise speziell zu einem Prozessschritt."> > ["at0085"] = < text = <"Erweiterung"> description = <"Zusätzliche Informationen zur Erfassung lokaler Inhalte oder Anpassung an andere Referenzmodelle/Formalismen."> comment = <"Zum Beispiel: Lokaler Informationsbedarf oder zusätzliche Metadaten zur Anpassung an FHIR-Ressourcen oder CIMI-Modelle."> > ["at0103"] = < text = <"ID der Verordnung"> description = <"Eindeutige ID der Arzneimittelverordnung."> comment = <"Kommentar: Dieses Datenelement ermöglicht zur Laufzeit einer Anwendung eine genauere Spezifikation von Mehrfach-Auftreten, wenn notwendig."> > ["at0104"] = < text = <"Arzneimitteldetails"> description = <"Strukturierte Informationen über das Arzneimittel inklusive Stärke, Form und Inhaltsstoffe."> comment = <"Verwenden Sie diesen SLOT, wenn die detaillierte Beschreibung des ausgegebenen, autorisierten oder verabreichten Arzneimittels ausdrücklich angegeben werden muss. Zum Beispiel: die Form, Stärke, alle Verdünner oder Mischung von Inhaltsstoffen."> > ["at0106"] = < text = <"Rezept ist re-autorisiert"> description = <"Die ursprüngliche Verordnung des Arzneimittels wurde erneut genehmigt, um eine wiederholte Verschreibung oder Abgabe zu ermöglichen. In einigen Ländern, wie z.B. Deutschland, muss unter diesen Umständen ein völlig neues Rezept ausgestellt werden."> > ["at0109"] = < text = <"Arzneimittel empfohlen"> description = <"Das Arzneimittel wurde empfohlen, aber es wurden keine Schritte unternommen, um die Verschreibung/Verordnung einzuleiten."> > ["at0131"] = < text = <"Dosis"> description = <"Spezifische Angaben zur Dosis des Arzneimittels."> comment = <"Der CLUSTER.dosage soll Details zu Änderungen der Arzneimittelverordnung oder der Dosisverabreichungen enthalten, während CLUSTER.medication_supply_amount ist für Details zu Aktivitäten im Zusammenhang mit der Abgabe bestimmt."> > ["at0132"] = < text = <"Substitution"> description = <"Substitutionsmaßnahmen, die von der Person ergriffen werden, die das Medikament verabreicht oder ausgibt."> comment = <"In vielen Rechtssystemen ist die Substitution eines verordneten Arzneimittels in generischer Form oder mit einem anderen Markennamen, welcher als bioäquivalent bestimmt wurde, zum Zeitpunkt der Ausgabe oder Verabreichung erlaubt. In anderen Fällen wird eine Substitution erwartet und der Arzt muss ausdrücklich die Nicht-Substitution verlangen."> > ["at0133"] = < text = <"Grund für die Substitution"> description = <"Die Ursache oder die Begründung für die durchgeführte Substitution."> comment = <"Zum Beispiel: \"Generische Alternative beinhaltet eine Substanz, die vom Patient nicht vertragen wird.\" Kann bei klinischer Eignung mit einer Terminologie codiert werden."> > ["at0138"] = < text = <"Substitution wurde durchgeführt"> description = <"Ein Arzneimittel wurde substituiert, welches bioäquivalent zu dem Angeforderten ist."> > ["at0139"] = < text = <"Substitution wurde nicht durchgeführt"> description = <"Obwohl es nach der Arzneimittelverordnung erlaubt gewesen wäre, wurde nicht mit einem bioäquivalenten Arzneimittel substituiert."> > ["at0140"] = < text = <"Details zur Verabreichung"> description = <"Details über die Körperstelle und über die Verabreichung des Arzneimittels."> > ["at0141"] = < text = <"Körperstelle"> description = <"Strukturierte Beschreibung der Körperstelle, an der das Arzneimittel angewendet wird."> comment = <"Zum Beispiel: \"linker Oberarm\", \"intravenöser Katheter rechte Hand\". Die Codierung der Körperstelle mit einer Terminologie, wenn möglich, wird bevorzugt."> > ["at0142"] = < text = <"Lokalisation"> description = <"Genaue Beschreibung der Körperstelle, an der das Arzneimittel, der Impfstoff oder ein therapeutisches Produkt angewendet wird."> comment = <"Zum Beispiel: \"Auf der medialen Hautoberfläche des linken Unterarms, 10 cm bis 20 cm distal von der Spitze des Ellbogens entfernt.\""> > ["at0143"] = < text = <"Methode der Verabreichung"> description = <"Die Technik oder das Gerät mit dem das verschriebene Arzneimittel verabreicht wird oder werden soll."> comment = <"Kommentar: Zum Beispiel: \"via Z-track Injektion\"; \"via Vernebler\". Die Codierung der Methode mit einer Terminologie, wenn möglich, wird bevorzugt."> > ["at0144"] = < text = <"Verabreichungsmittel"> description = <"Details zu der Vorrichtung mit dem das Arzneimittel verabreicht wird."> > ["at0145"] = < text = <"Rezept wartet auf Genehmigung"> description = <"Der Rezeptentwurf wurde erstellt und wartet auf die Bestätigung durch einen autorisierten Arzt. Kann auch verwendet werden, wenn die Re-autorisierung gebündelt erfolgt. Dieser \"careflow_step\" hat den Status \"geplant\" oder \"aktiv\", was die Notwendigkeit widerspiegelt, sowohl Neuaufträge als auch erneut autorisierte Aufträge zu bearbeiten."> > ["at0147"] = < text = <"Verabreichungsweg"> description = <"Die Angabe darüber, auf welche Art das verordnete Arzneimittel am Körper des Patienten angewendet wird."> comment = <"Kommentar: Zum Beispiel: \"oral\", \"intravenös\" oder \"topisch\". Die Codierung des Verabreichungswegs wird bevorzugt, wenn möglich. Mehrere potentielle Anwendungsformen können spezifiziert werden."> > ["at0148"] = < text = <"Arzneimittel wurde vorbereitet"> description = <"*The medication has been physically prepared. (en)"> comment = <"*For example: preparation of an intravenous mixture. (en)"> > ["at0149"] = < text = <"Nachkontrolliert?"> description = <"Der Prozessschritt wurde durch eine unabhängige Person überprüft."> comment = <"Details zu der Person, die die Überprüfung vornimmt, können in das Referenzmodell \"Participations\" übertragen werden."> > ["at0150"] = < text = <"Rezept wurde widerrufen"> description = <"Das Rezept wurde vor der Ausstellung widerrufen."> > ["at0151"] = < text = <"Rezept ist ungültig oder abgelaufen"> description = <"Das Rezept ist ungültig geworden oder ist abgelaufen, ohne das es eingelöst wurde."> > ["at0152"] = < text = <"Rezept wurde ausgeführt"> description = <"Das Rezept wurde erfolgreich ausgeführt/eingehalten."> > ["at0153"] = < text = <"Arzneimittel wurde genehmigt"> description = <"Das Arzneimittel ist offiziell zur Anwendung genehmigt."> > ["at0154"] = < text = <"Datum/Uhrzeit des Neustarts"> description = <"Das Datum/die Uhrzeit an dem die Arzneimittelbehandlung wieder begonnen wird, gemäß dem \"Verabreichung wurde ausgesetzt\"- Schritt."> comment = <"Zum Beispiel: 29.10.2017"> > ["at0155"] = < text = <"Kriterium des Neustarts"> description = <"Das Kriterium, das den Neustart der Arzneimittelbehandlung auslöst, gemäß dem Schritt \"Verabreichung wurde ausgesetzt\"."> comment = <"Zum Beispiel: \"Am Tag 2 nach der OP.\""> > ["at0156"] = < text = <"Klinische Indikation"> description = <"Der klinische Grund für die Aktivität mit dem Arzneimittel."> comment = <"Zum Beispiel: \"Angina\" oder \"Schmerz\". Die Codierung der Indikation mit einer Terminologie wird nach Möglichkeit bevorzugt. Dieses Datenelement ermöglicht mehrere Vorkommen. Wenn nur ein AKTION-Archetyp zur Aufzeichnung einer Medikamentenindikation verwendet wird, kann dieses Datenelement ohne zusätzliche Überlegungen verwendet werden. Wenn jedoch eine klinische Indikation sowohl im INSTRUCTION-Archetyp zur Verordnung von Arzneimittel als auch im AKTION-Archetyp zur Medikamentenanwendung aufgezeichnet wird, beachten Sie, dass diese Indikationen möglicherweise nicht konsistent sind."> > ["at0157"] = < text = <"*Medication double checked (en)"> description = <"*The prepared medication has been double checked. (en)"> > > > ["sv"] = < items = < ["at0000"] = < text = <"Hantering av läkemedelsregim"> description = <"Aktiviteter relaterade till planering, schemaläggning, recepthantering, dosering, administrering, avbrott från eller användning av läkemedel, vaccinering, näringspreparat eller annan terapeutisk produkt."> comment = <"Ej begränsat till aktiviteter som utförs baserat på läkemedelsbeställningar från kliniker, utan kan även inkludera exempelvis övertagande av läkemedel."> > ["at0002"] = < text = <"Utfärdad ordination"> description = <"En ordination av läkemedlet har utfärdats."> > ["at0003"] = < text = <"Utdelad ordination"> description = <"Det ordinerade läkemedlet har dispenserats, exempelvis från ett apotek till patienten."> > ["at0004"] = < text = <"Påbörjad läkemedelsbehandling"> description = <"Läkemedlet har tagits av eller administrerats till patienten för första gången. I vissa fall kan startdatum för varje administrationstillfälle finnas tillgängligt, medan det i andra fall (såsom i primärvården) inte gör det."> > ["at0005"] = < text = <"Omprövning av läkemedel"> description = <"Omprövning av det enskilda läkemedlet, exempelvis huruvida medicineringen ska fortskrida. Syftet är inte att skapa en översyn av läkemedelslistan."> > ["at0006"] = < text = <"Administrerad dos"> description = <"Engångsadministrering av läkemedlet."> > ["at0007"] = < text = <"Fullföljd läkemedelsbehandling"> description = <"Läkemedelsbehandlingen har slutförts som planerat."> > ["at0008"] = < text = <"Försenad receptleverans"> description = <"Ordinationen har inte delats ut på grund av ett teknisk eller faramaceutiskt leveransproblem."> > ["at0009"] = < text = <"Indragen administrering"> description = <"Administreringen av läkemedlet har avbrutits tills vidare. Inga ytterligare doser ska ges förrän ett nytt startdatum har angivits eller villkoren har uppfyllts. Vid inställning av in datum/villkor för omstart, ska stegen från \"Läkemedlets startdatum/fastställda villkor\" till \"Indragen administrering\" utföras på nytt."> > ["at0010"] = < text = <"Förnyelse av ordination"> description = <"En ordination har utfärdats på nytt för en befintlig läkemedelsorder."> > ["at0011"] = < text = <"Återauktorisering av recept inväntas"> description = <"Inväntar återauktorisering för ordination av en läkare."> > ["at0012"] = < text = <"Avbruten läkemedelsbehandling"> description = <"Schemalagd läkemedelsbehandling som har avbrutits före administrering."> > ["at0013"] = < text = <"Uppskjuten läkemedelsbehandling"> description = <"Schemalagd läkemedelsbehandling som har blivit uppskjuten före administrering."> > ["at0015"] = < text = <"Avbruten läkemedelsbehandling"> description = <"Administreringen av läkemedlet har avbrutits under det planerade förloppet."> > ["at0016"] = < text = <"Läkemedlets startdatum/fastställda villkor"> description = <"Tid då medicinering startar, eller vid annat startvillkor."> > ["at0017"] = < text = <"Tree"> description = <"@ internal @"> > ["at0018"] = < text = <"Utelämnad dos"> description = <"Nekad administrering av läkemedlet. Denna dos förväntas inte att ges vid senare tillfälle, även om en eventuellt nästa dos ska administreras enligt planerat."> > ["at0020"] = < text = <"Läkemedelsartikel"> description = <"Benämning på läkemedlet, vaccinet eller annan terapeutisk/ordinationsbar artikel som aktiviteten gäller."> comment = <"Till exempel: \"Atenolol 100mg\" eller \"Tenormin 100mg\". Om möjligt, benämn läkemedelsartikeln med en terminologi som kan utlösa beslutsstöd. Omfattningen av denna angivelse kan variera från namnet på läkemedelsartikeln till detaljer om det läkemedelspaketet som används. Fri textinmatning bör endast användas om det inte finns någon lämplig terminologi tillgänglig."> > ["at0021"] = < text = <"Orsak"> description = <"Anledningen till att steget för det aktuella läkemedlet utfördes."> comment = <"Till exempel: \"Uppskjutning - Patient inte tillgänglig vid administreringstillfälle\", \"Avbrott - Biverkning\". Obs! Detta utgör inte orsaken bakom själva medicineringsanvisningen, utan snarare anledningen till att ett vårdsteg genomförs. Detta användas generellt för att dokumentera avvikelser från den ursprungliga ordern."> > ["at0024"] = < text = <"Kommentar"> description = <"Kommentarer avseende den aktivitet eller det vårdsteg som inte beskrivs i övriga fält, inklusive detaljer om eventuell avvikelse mellan den avsedda åtgärden och den faktiska utförda åtgärden."> comment = <"Till exempel: \"Patienten befann sig på röntgenavdelning\", \"Oavsiktlig injektion i blodkärlet under IM-administrering\"."> > ["at0025"] = < text = <"Sekvensnummer"> description = <"Det specifika sekvensnumret för det aktuella vårdsteget."> comment = <"Exempelvis dosnummer för vaccinering."> > ["at0030"] = < text = <"Tree"> description = <"@ internal @"> > ["at0033"] = < text = <"Patientvägledning"> description = <"Vägledning, instruktioner eller råd som ges till patienten eller dennes personliga vårdgivare vid tidpunkten för vårdsteget."> comment = <"Till exempel: \"Undvik grapefrukt\", \"Ta minst 2 timmar före sänggåendet\", \"Ta tillsammans med mat\". Om kliniskt lämpligt, benämn med en terminologi."> > ["at0039"] = < text = <"Större orderändring"> description = <"Då en större ändring av ordern krävdes, resulterade detta i att denna order stoppades och en ersättningsorder påbörjades."> > ["at0041"] = < text = <"Mindre orderändring"> description = <"Läkemedelsordern har ändrats på ett sätt som inte kräver att en ny order ska utfärdas, enligt lokala kliniska regler."> > ["at0043"] = < text = <"Ursprungligt datum/tid"> description = <"Tidpunkt då hantering av läkemedelsregim var schemalagd."> comment = <"Används för att jämföra avvikelse från faktisk åtgärdstid."> > ["at0044"] = < text = <"Uppskjuten dos"> description = <"En dos av läkemedlet har försenats men förväntas administreras så snart som möjligt."> > ["at0053"] = < text = <"Övrig information"> description = <"Ytterligare information om åtgärden, eventuellt specifikt för ett särskilt vårdsteg."> > ["at0085"] = < text = <"Tilläggsinformation"> description = <"Plats för att infoga tilläggsinformation som krävs för lokala anpassningar eller anpassning till andra referensmodeller eller formella krav."> comment = <"Exempelvis lokala informationskrav eller metadata för anpassning till FHIR- eller CIMI-motsvarigheter."> > ["at0103"] = < text = <"Beställnings-ID"> description = <"Unik identifikator för läkemedelsbeställningen."> comment = <"Detta dataelement möjliggör exakt identifiering av flera ordrar samtidigt."> > ["at0104"] = < text = <"Läkemedelsinformation"> description = <"Information om läkemedlet inklusive dess styrka, form och beståndsdelar."> comment = <"Använd denna SLOT när detaljerad beskrivning av den dispenserade, auktoriserade eller administrerade artikeln måste anges explicit. Till exempel: form, styrka, eventuella utspädningsmedel eller blandning av ingredienser."> > ["at0106"] = < text = <"Förnyelse av receptbeläggning"> description = <"Den ursprungliga läkemedelsorden har godkänts på nytt för att möjliggöra fortsatt dosering. I vissa jurisdiktioner måste en helt ny order utfärdas."> > ["at0109"] = < text = <"Rekommenderat läkemedel"> description = <"Rekommenderat läkemedel, ej påbörjad ordination."> > ["at0131"] = < text = <"Kvantitet"> description = <"Kvantitet av läkemedelsartikeln."> comment = <"CLUSTER.dosage är avsedd för information om ändringar av läkemedelsbeställningar eller administrerad dos och CLUSTER.medication_supply_amount är avsedd för information om doseringsrelaterad aktivitet."> > ["at0132"] = < text = <"Substitution"> description = <"Substitutionsåtgärder vidtagna av den person som administrerar eller dispenserar läkemedlet."> comment = <"I många jurisdiktioner är det möjligt att vid dispenseringstillfället ersätta en beställd artikel med en generisk sort eller med ett annat varumärke, förutsatt att bioekvivalens är uppnått. I andra fall antas substitution vara tillåtet, såvida en kliniker explicit inte begär annat."> > ["at0133"] = < text = <"Orsak för substitution"> description = <"Anledning eller motivering till den vidtagna substitutionsåtgärden."> comment = <"Till exempel: \"Generiskt alternativ innehåller ett ämne som inte tolereras av patienten.\" Om kliniskt lämpligt, benämn med en terminologi."> > ["at0138"] = < text = <"Utförd substitution"> description = <"Ersättning av läkemedel som är bioekvivalent med det som beställts."> > ["at0139"] = < text = <"Ej utförd substitution"> description = <"Trots tillåtelse av läkemedelsordern, ersattes inte ett bioekvivalent läkemedel."> > ["at0140"] = < text = <"Administreringsinformation"> description = <"Information om atomisk lokalisering och administrering av läkemedlet."> > ["at0141"] = < text = <"Anatomisk lokalisering"> description = <"Beskrivning av administrationsstället för den beställda artikeln."> comment = <"Till exempel: \"vänster överarm\", \"intravenös kateter, höger hand\". Om möjligt, benämn den anatomiska lokaliseringen med en terminologi."> > ["at0142"] = < text = <"Exakt anatomisk lokalisering"> description = <"Närmare beskrivning av administrationsstället för läkemedlet, vaccinet eller annan terapeutisk produkt."> comment = <"Till exempel: \"På den mediala hudytan på vänster underarm, från 10 cm till 20 cm distalt från armbågens punkt\"."> > ["at0143"] = < text = <"Administreringsmetod"> description = <"Den teknik eller utrustning med vilken den beställda artikeln administrerades eller ska administreras."> comment = <"Till exempel: \"via Z-teknik\"; \"via nebulisator\". Om möjligt, benämn metoden med en terminologi."> > ["at0144"] = < text = <"Utrustning för administrering"> description = <"Information om den medicinska utrustning som används vid administrering av läkemedlet."> > ["at0145"] = < text = <"Ordination som inväntar tillstånd"> description = <"Förslag på ordination har utarbetats och inväntar bekräftelse från en auktoriserad läkare. Kan användas där återauktorisering utförs som en batch. Detta flödessteg kan ha statusen \"planerad\" eller \"aktiv\", vilket återspeglar behovet av att hantera nya beställningar såväl som återauktoriserade ordrar."> > ["at0147"] = < text = <"Administreringsväg"> description = <"Sättet genom vilken den beställda artikeln administrerades eller ska administreras i patientens kropp."> comment = <"Till exempel: \"oralt\", \"intravenöst\" eller \"lokalt\". Om möjligt, benämn administreringsvägen med en terminologi. Flera potentiella administreringsvägar kan specificeras."> > ["at0148"] = < text = <"Förberedelse av läkemedel"> description = <"*The medication has been physically prepared. (en)"> comment = <"*For example: preparation of an intravenous mixture. (en)"> > ["at0149"] = < text = <"Dubbelkontrollerat?"> description = <"Vårdsteget har dubbelkontrollerats av annan individ."> comment = <"Information om den person som utför dubbelkontrollen kan anges i referensmodells-elementet \"Deltagande\"."> > ["at0150"] = < text = <"Avbruten ordination"> description = <"Ordinationen avbröts innan det utfärdades."> > ["at0151"] = < text = <"Ogiltigt eller utgånget recept"> description = <"Receptet har ogiltigförklarats eller upphört att gälla."> > ["at0152"] = < text = <"Uppfyllt recept"> description = <"Receptet har framgångsrikt uppfyllts."> > ["at0153"] = < text = <"Godkännande av läkemedel"> description = <"Läkemedlet har formellt godkänts för användning."> > ["at0154"] = < text = <"Datum/tid för omstart"> description = <"Datum/tid för omstart av läkemedelsbehandling, enligt \"Indragen administrering\"."> comment = <"Till exempel: 2017-10-29"> > ["at0155"] = < text = <"Omstartskriterium"> description = <"Kriteriet för omstart av läkemedelsbehandling, enligt \"Indragen administrering\"."> comment = <"Till exempel: \"Dag 2 efter operation\"."> > ["at0156"] = < text = <"Klinisk indikation"> description = <"Klinisk orsak till läkemedelsbehandling."> comment = <"Exempelvis \"Angina pectoris\" eller \"Smärta\". Om möjligt, benämn den kliniska indikationen med en terminologi. Detta dataelement kan förekomma upprepade gånger. Om endast ACTION används för att registrera en klinisk indikation, kan detta dataelement användas utan någon särskild aktning. Om en klinisk indikation i stället registreras för både INSTRUCTION och ACTION, var uppmärksam på att dessa angivelser kanske inte är konsekventa."> > ["at0157"] = < text = <"*Medication double checked (en)"> description = <"*The prepared medication has been double checked. (en)"> > > > ["zh-cn"] = < items = < ["at0000"] = < text = <"药物管理"> description = <"任何与药物、疫苗、营养产品/制品或其他治疗类制剂（therapeutic item）的计划[编制]、排程/安排、处方管理、配发、施用/给药、停止/停用和其他使用情况相关的活动。又称为用药管理。"> comment = <"这不仅限于根据临床医生的药物医嘱所执行/开展的活动，还可以包括服用非处方药物之类的情况。"> > ["at0002"] = < text = <"已签发的处方"> description = <"已经签发/开出了相应药物的处方。"> > ["at0003"] = < text = <"已配发的处方"> description = <"已经配发医嘱所开立的药物；例如，由药房配发给了相应的患者。"> > ["at0004"] = < text = <"已开始的药物治疗过程"> description = <"患者已经首次服用相应的药物，或者说已经对其进行了首次的施用/给药。 尽管在某些场所环境下，这一重要的日期可以作为多次施用/给药之中的第一次而用于计算，而在其他的场所环境下，如初级照护服务（基层医疗服务），具体的施用/给药日期并不容易获得。"> > ["at0005"] = < text = <"已重新评估的药物"> description = <"已经重新评估了相应的具体药物，如是否仍然应当服用该药物。 这一节点并非旨在用于采集药物清单的审核情况。"> > ["at0006"] = < text = <"已施用/给药的剂量"> description = <"已经进行了单独一次的药物施用/给药。"> > ["at0007"] = < text = <"已完成的药物治疗过程"> description = <"已经按计划完成了相应的药物治疗过程。"> > ["at0008"] = < text = <"已延迟的处方供应"> description = <"由于技术或药品供应问题，目前尚未配发相应的处方[药物]。"> > ["at0009"] = < text = <"已暂停的施用/给药"> description = <"已经暂停了相应药物的施用/给药，直至另行通知。 在重新开始日期之前或满足种种条件之前，不应再进行给予更多的剂量药物。 在设置暂停之后的重新开始日期/条件时，应当执行从“已暂停的施用/给药”（Administrations suspended）返回到“已设定的用药开始日期/条件”（Medication start date/condition set）的步骤。"> > ["at0010"] = < text = <"已重新签发的处方"> description = <"已经为现有的药物医嘱重新签发/开出了相应的处方。"> > ["at0011"] = < text = <"待处理的处方重新授权"> description = <"处方的签发正在等待临床医务人员的重新授权。"> > ["at0012"] = < text = <"已取消的药物治疗过程"> description = <"在任何的施用/给药之前，已经取消了已计划的药物治疗过程。"> > ["at0013"] = < text = <"已推迟的药物治疗过程"> description = <"在任何的施用/给药之前，已经推迟了已排程/安排的药物治疗过程。"> > ["at0015"] = < text = <"已停止的药物治疗过程"> description = <"在预定的治疗过程（疗程）期间，已经停止了相应药物的施用/给药。"> > ["at0016"] = < text = <"已设定的用药开始日期/条件"> description = <"已经设定开始用药的时间或其他的起始/开始条件。"> > ["at0017"] = < text = <"Tree"> description = <"@ internal @"> > ["at0018"] = < text = <"已省略的剂量管理"> description = <"已经予以省略/扣除而并未给予的施用/给药。 虽说应该按照原始的医嘱来施用/给予下次剂量的药物（如果有的话），但并不期望后续会再施用/给予所省略/扣除的剂量。"> > ["at0020"] = < text = <"用药项"> description = <"作为活动关注焦点的药物、疫苗或其他治疗项/处方项的名称。"> comment = <"例如：“阿替洛尔 100mg”或“特诺明片 100mg”。 强烈建议尽可能采用能够触发决策支持手段的术语集来编码“用药项”（Medication item）。编码的程度/范围可能各不相同，包括从用药项简称到关于实际使用的药物包装的结构化详情。只有在没有合适的术语集可用的情况下才应当采用自由文本录入的方式。"> > ["at0021"] = < text = <"原因"> description = <"关于执行所标识用药/药物治疗路径步骤的原因。"> comment = <"例如：“已推迟 - 患者在施用/给药时不在场”，“已取消 - 不良反应”。 注意：这不是关于用药医嘱/指令的原因，而是关于执行特定照护服务步骤的具体原因，且往往用于记录相对于原始医嘱的一些偏差。"> > ["at0024"] = < text = <"备注"> description = <"额外关于其他字段之中并未采集的，关于相应活动或路径步骤的文本叙述型说明，包括关于预期行动与实际所执行的行动之间的任何差异的详情。"> comment = <"例如：“患者当时在放射科”、“在肌肉注射给药期间意外注射到了血管内”。"> > ["at0025"] = < text = <"顺序编号"> description = <"专门针对当前所记录的路径步骤的顺序编号/序列号/序号。"> comment = <"例如：疫苗序列号。"> > ["at0030"] = < text = <"Tree"> description = <"@ internal @"> > ["at0033"] = < text = <"患者指导"> description = <"为照护服务对象（患者）或具体照护人员所提供的任何关于特定路径步骤时的指导[意见]、操作指南/使用说明/指示或建议/忠告。"> comment = <"例如：“避免吃葡萄柚”、“睡前至少2小时服用”、“随食物一同服用”。 在临床上合适的情况下，可以采用术语集来编码。"> > ["at0039"] = < text = <"医嘱的重大变更"> description = <"需要对医嘱进行重大变更，导致该医嘱遭到停止并开始启用替代的医嘱。"> > ["at0041"] = < text = <"医嘱的微小变更"> description = <"根据本地的临床规则，采取并不需要签发新的指令/医嘱的方式，对药物医嘱进行了变更。"> > ["at0043"] = < text = <"原始排程/安排的日期/时间"> description = <"当初所排程/安排的开展药物治疗行动的日期时间。"> comment = <"用于在并不容易获得原始排程/安排日期/时间的情况下，比较它与实际行动日期/时间之间的差异。"> > ["at0044"] = < text = <"已延期的施用/给药"> description = <"已经推迟一剂药物的施用/给药，但预计会尽快施用/给药。"> > ["at0053"] = < text = <"其他详情"> description = <"进一步关于当前行动的结构化细节，且有可能针对的是特定的路径步骤。"> > ["at0085"] = < text = <"扩展"> description = <"采集本地语境/上下文背景或者是与其他的参考模型/形式化体系进行协调统一时所需的其他信息。"> comment = <"例如：本地信息需求/要求或者是其他旨在与FHIR或CIMI等价元素/结构进行协调统一时所需的元数据。"> > ["at0103"] = < text = <"医嘱标识符"> description = <"药物/用药医嘱的唯一性标识符。"> comment = <"备注：如果需要，此数据元允许在运行时更为明确地定义其多次的重复出现。"> > ["at0104"] = < text = <"药物详情"> description = <"关于相应药物的结构化详情，包括规格、剂型/形式和组成物质。"> comment = <"在需要明确说明所配发、授权或施用/给予的用药项的详细描述时，应当采用这一槽位（SLOT）。 例如：剂型/形式、规格、任何稀释剂或若干成分的混合物。"> > ["at0106"] = < text = <"已重新授权的处方"> description = <"已经对原始的药物医嘱进行了重新授权，以便能够重复利用处方或配发药物。在某些司法管辖区域，在此类的情况下，必须签发/开出全新的医嘱。"> > ["at0109"] = < text = <"已推荐的药物"> description = <"已经推荐了相应的药物，但尚未采取任何的措施/步骤来启动处方开立的过程。"> > ["at0131"] = < text = <"数量"> description = <"关于用药项数量的具体详情。"> comment = <"剂量群簇CLUSTER.dosage旨在承载关于药物医嘱变更或剂量施用/给药的详情，而 药物供应数量群簇CLUSTER.medication_supply_amount则旨在用于记录关于配发相关的活动的详情。"> > ["at0132"] = < text = <"替换"> description = <"负责施用/给药或配发药物的人员所采取的替换行动。"> comment = <"在许多的司法管辖区域，在配发或供应药物时，允许将医嘱所开立的用药项替换为已确定具有生物等效性的通用形式/剂型或不同商品名的产品。在其他的情况下，则假定默认可以予以替换，而如果希望不得替换，临床医务人员则必须做出明确的要求。"> > ["at0133"] = < text = <"替换原因"> description = <"关于所采取的替代行动的原因或理由。"> comment = <"例如：“非专利/通用替代药物含有患者不能耐受的物质。” 在临床上合适的情况下，可以采用术语集来编码。"> > ["at0138"] = < text = <"已执行的替换"> description = <"已经将医嘱所开立的药物替换成了与之生物等效的药物。"> > ["at0139"] = < text = <"未执行的替换"> description = <"尽管药物医嘱允许替换，但并未将医嘱所开立的药物替换成生物等效药物。"> > ["at0140"] = < text = <"施用/给药详情"> description = <"关于当前药物治疗的身体部位和施用/给药情况的详情。"> > ["at0141"] = < text = <"身体部位"> description = <"关于医嘱所开立用药项的施用/给药部位的结构化描述。"> comment = <"例如：“左上臂”、“右手静脉导管”。 最好采用术语集来编码身体部位。"> > ["at0142"] = < text = <"结构化身体部位"> description = <"关于药物、疫苗或治疗类产品施用/给药部位的结构化描述。"> comment = <"例如：“左前臂内侧皮肤表面，从肘尖远侧10厘米到20厘米”。"> > ["at0143"] = < text = <"施用/给药方法"> description = <"已经或预定施用医嘱所开立的用药项时所采用的技术方法或装置/器械/设备。"> comment = <"备注：例如，“采用Z型注射法”（Z径路肌肉注射法）； '采用雾化器'。 最好采用术语集来编码施用/给药方法。"> > ["at0144"] = < text = <"施用/给药装置"> description = <"关于用来协助施用/给药的医疗装置/器械/设备的详情。"> > ["at0145"] = < text = <"等待授权的处方"> description = <"已经准备/书写好了处方草稿，正在等待授权临床医务人员的确认。可以用于批量执行重新授权的情况。照护服务流程步骤（careflow_step）的状态可能是“已计划”或“有效”，反映的则是需要处理新的医嘱以及重新授权的医嘱。"> > ["at0147"] = < text = <"途径"> description = <"已经或预定将医嘱所开立的用药项施用于服务对象身体时所采用的途径。又称为施用途径或用药途径。"> comment = <"备注：例如，“口服”、“静脉注射”或“局部/外用”。 最好尽可能采用术语集来编码途径。 可以指定多个潜在的途径。"> > ["at0148"] = < text = <"已准备好的药物"> description = <"已经实际上/物质上准备/制备好了相应的药物。"> comment = <"例如：静脉注射混合液的准备/制备。"> > ["at0149"] = < text = <"复核情况"> description = <"另一不同的人员已经检查核对了这一路径步骤。"> comment = <"可以在参考模型的参与元素“Participation”之中记录关于执行复核的个人的详情。"> > ["at0150"] = < text = <"已取消的处方"> description = <"在签发/开出之前取消了处方。"> > ["at0151"] = < text = <"无效或过期的处方"> description = <"处方已经失效或过期且并未获得执行。"> > ["at0152"] = < text = <"已执行的处方"> description = <"已经成功地执行了相应的处方。"> > ["at0153"] = < text = <"已授权的药物"> description = <"已经正式授权使用相应的药物。"> > ["at0154"] = < text = <"重新开始日期/时间"> description = <"根据“已暂停的施用/给药”（Administrations suspended）路径步骤，设置重新开始药物治疗过程的日期/时间。"> comment = <"例如：2017-10-29"> > ["at0155"] = < text = <"重新开始的评判准则"> description = <"根据“已暂停的施用/给药”（Administrations suspended）路径步骤，用于触发药物治疗过程重新开始的评判准则/标准。"> comment = <"例如：“术后第2天”。"> > ["at0156"] = < text = <"临床适应证"> description = <"用药活性的临床原因。"> comment = <"例如：“心绞痛”或“疼痛”。 最好尽可能采用术语集来编码适应证。此数据元允许多次重复出现。 如果仅仅利用行动（ACTION）来记录药物适应证，则可直接采用这一数据元，而无需做其他的考虑。不过，如果药物医嘱指令（INSTRUCTION）和当前药物管理行动（ACTION）同时都记录了临床适应证，则应当注意两处的适应证可能并不一致。"> > ["at0157"] = < text = <"已复核的药物"> description = <"已经复核了所准备/制备好的相应药物。"> > > > ["ca"] = < items = < ["at0000"] = < text = <"Gestió de la medicació"> description = <"Qualsevol activitat relacionada amb la planificació, programació, gestió de prescripció, dispensació, administració, cessació i l’ús alternatiu d’una medicació, vacuna, producte nutricional o altre element terapèutic."> comment = <"Això no es limita a activitats dutes a terme basades en prescripcions de medicacions per part de metges, sinó que també pot incloure, per exemple, prendre medicació sense recepta."> > ["at0002"] = < text = <"Prescripció emesa"> description = <"S’ha emès una prescripció per a la medicació."> > ["at0003"] = < text = <"Prescripció dispensada"> description = <"S’ha dispensat la medicació prescrita; per exemple, des d’una farmàcia al pacient."> > ["at0004"] = < text = <"Curs de la medicació iniciat"> description = <"El pacient ha pres o se li ha administrat la medicació per primera vegada. Encara que en alguns entorns es pugui computar aquesta data significativa com la primera de diverses administracions, en altres entorns, com atenció primària, les dates d’administració específiques no són fàcilment accessibles."> > ["at0005"] = < text = <"Medicació reavaluada"> description = <"S’ha reavaluat la medicació concreta; per exemple, si s’ha de continuar prenent. Això no pretén recollir una revisió de la llista de medicació."> > ["at0006"] = < text = <"Dosi administrada"> description = <"S’ha realitzat una única administració de la medicació."> > ["at0007"] = < text = <"Curs de la medicació completat"> description = <"El curs de medicació s'ha completat segons allò previst."> > ["at0008"] = < text = <"Abastiment retardat de la prescripció"> description = <"No s’ha dispensat la prescripció a causa d'un problema d’abastiment tècnic o farmacèutic."> > ["at0009"] = < text = <"Administració suspesa"> description = <"S’ha suspès l’administració de la medicació fins a nou avís. No s’han d’administrar més dosis fins que no es compleixin la data o les condicions de reinici. Quan s’estableixin les condicions/data de reinici després de la suspensió, cal realitzar una fase des d'«Administració suspesa» i tornar a «Data d’inici de la medicació/condicions establertes»."> > ["at0010"] = < text = <"Prescripció reemesa"> description = <"S’ha reemès una prescripció per a una prescripció existent."> > ["at0011"] = < text = <"Reautorització de la prescripció pendent"> description = <"L'expedició de la prescripció està pendent d'una reautorització per part d'un metge."> > ["at0012"] = < text = <"Curs de la medicació cancel·lat"> description = <"S'ha cancel·lat el curs de la medicació previst abans de qualsevol administració."> > ["at0013"] = < text = <"Curs de la medicació posposat"> description = <"S'ha posposat el curs de la medicació programat abans de qualsevol administració."> > ["at0015"] = < text = <"Interrupció de la medicació"> description = <"S'ha interromput l'administració de la medicació durant el període del curs previst."> > ["at0016"] = < text = <"Data d’inici de la medicació/condició establerta"> description = <"S'ha fixat l'hora d'inici de la medicació o una altra condició d'inici."> > ["at0017"] = < text = <"Tree"> description = <"@ internal @"> > ["at0018"] = < text = <"Administració de dosi omesa"> description = <"S’ha retingut i no s’ha administrat un torn d’administració de la medicació. No s’espera que s’administri més tard, encara que la dosi següent (si n’hi hagués) s’ha d’administrar d’acord amb l’ordre original."> > ["at0020"] = < text = <"Medicament"> description = <"Nom del medicament, vacuna o altre element terapèutic/prescriptible en què es va centrar l'activitat."> comment = <"Per exemple: «Atenolol 100 mg» o «Tenormin comprimits 100 mg». Es recomana encaridament que l'«Element terapèutic» es programi amb una terminologia capaç d'activar el suport de la presa de decisions, sempre que sigui possible. L'extensió del codi pot variar des del nom del medicament fins a les dades estructurades sobre l’envàs de la medicació utilitzat. L'entrada de text lliure només caldrà utilitzar-la si no es disposa de la terminologia adequada."> > ["at0021"] = < text = <"Motiu"> description = <"Motiu pel qual es va realitzar la fase de l’itinerari per a la medicació identificada."> comment = <"Per exemple: «Posposat - Pacient no disponible al moment de l'administració», «Cancel·lat - Reacció adversa». Nota: aquest no és el motiu de la instrucció de la medicació, sinó del motiu específic pel qual es va fer una fase de cuidats, i sovint s'utilitzarà per a documentar alguna variació de la prescripció original."> > ["at0024"] = < text = <"Observacions"> description = <"Informació addicional sobre l'activitat o la fase d’itinerari no recollida en altres caselles, inclosos els detalls de qualsevol variació entre l'acció prevista i l'acció que es va realitzar realment."> comment = <"Per exemple: «El pacient estava al servei de radiologia», «Injecció accidental en un vas sanguini durant l'administració d'un IM»."> > ["at0025"] = < text = <"Nombre de la seqüència"> description = <"El nombre de la seqüència específic de la fase d’itinerari que s'està registrant."> comment = <"Per exemple: Nombre de la seqüència de la vacuna."> > ["at0030"] = < text = <"Tree"> description = <"@ internal @"> > ["at0033"] = < text = <"Orientació al pacient"> description = <"Qualsevol orientació, instrucció o consell que s’ha donat al subjecte d'assistència o al cuidador personal al moment de la fase d’itinerari."> comment = <"Per exemple: «Evitar menjar pomelo», «Prendre almenys 2 hores abans d'anar al llit», «Prendre amb menjar». Es pot programar amb una terminologia quan sigui clínicament apropiat."> > ["at0039"] = < text = <"Canvi important a la prescripció"> description = <"Es va requerir un canvi important en la prescripció, raó per la qual es va interrompre aquesta prescripció i es va iniciar una prescripció substituta."> > ["at0041"] = < text = <"Canvi menor a la prescripció"> description = <"La prescripció s’ha modificat de manera que no requereixi l’emissió d’una nova prescripció/instrucció, d’acord amb les normes clíniques locals."> > ["at0043"] = < text = <"Data/hora programada original"> description = <"La data o hora en què estava programat que ocorreguera l’acció de medicació."> comment = <"Utilitzar per a comparar la diferència del temps real d’acció quan no es pot calcular fàcilment a partir de les instruccions originals."> > ["at0044"] = < text = <"Administració de dosi ajornada"> description = <"S’ha ajornat l’administració d’una dosi de la medicació, però s’espera que s’administri com més aviat millor."> > ["at0053"] = < text = <"Dades addicionals"> description = <"Dades estructurades complementàries de l'acció, específics possiblement d'una fase d’itinerari."> > ["at0085"] = < text = <"Extensió"> description = <"Informació addicional necessària per a recollir el contingut local o per alinear-se amb altres models/formalismes de referència."> comment = <"Per exemple: requisits locals d'informació o metadades addicionals per alinear-se amb equivalents de FHIR o CIMI."> > ["at0103"] = < text = <"Identificació de la prescripció"> description = <"Identificador únic per a la prescripció."> comment = <"Observació: Aquest element de dades permet definir diversos esdeveniments de manera més explícita en el temps d'execució, si cal."> > ["at0104"] = < text = <"Dades de la medicació"> description = <"Dades estructurades sobre la medicació, incloses la concentració, forma i substàncies que la componen."> comment = <"Utilitzar aquest SLOT quan s'hagi d'explicitar la descripció detallada del producte dispensat, autoritzat o administrat. Per exemple: la forma, la concentració, qualsevol diluent o la mescla d'ingredients."> > ["at0106"] = < text = <"Prescripció reautoritzada"> description = <"S’ha reautoritzat la prescripció original per a permetre que es repeteixin tant la prescripció com la dispensació. En algunes jurisdiccions, s’ha d’emetre una prescripció nova en aquestes circumstàncies."> > ["at0109"] = < text = <"Medicació recomanada"> description = <"S’ha recomanat la medicació, però no s’ha iniciat cap procés per a començar la prescripció."> > ["at0131"] = < text = <"Quantitat"> description = <"Dades específiques sobre la quantitat de l’element de medicació."> comment = <"CLUSTER.dosage pretén recollir dades de canvis en les prescripcions o administracions de dosis, mentre que CLUSTER.medication_supply_amount pretén recollir dades de l'activitat relacionada amb la dispensació."> > ["at0132"] = < text = <"Substitució"> description = <"Acció de substitució adoptada per la persona que administra o dispensa el medicament."> comment = <"En moltes jurisdiccions, es permet la substitució d'un element prescrit com a forma genèrica o amb una marca diferent, que s'hagi determinat com a bioequivalent, al punt de dispensació o abastiment. En altres casos, la substitució s’assumeix i el metge ha de sol·licitar explícitament que no es substitueixi."> > ["at0133"] = < text = <"Motiu de la substitució"> description = <"Motiu o justificació de l'acció de substitució adoptada."> comment = <"Per exemple: «L'alternativa genèrica conté una substància que el pacient no tolera». Es pot programar amb una terminologia quan sigui clínicament apropiat."> > ["at0138"] = < text = <"Substitució realitzada"> description = <"Una medicació es va substituir per una altra bioequivalent a la prescrita."> > ["at0139"] = < text = <"Substitució no realitzada"> description = <"Encara que la prescripció ho permetia, no es va substituir una medicació bioequivalent."> > ["at0140"] = < text = <"Dades de l'administració"> description = <"Dades sobre la zona del cos i l'administració de la medicació."> > ["at0141"] = < text = <"Zona del cos"> description = <"Descripció estructurada de la zona d'administració de l’element prescrit."> comment = <"Per exemple: «part superior del braç esquerre», «catèter intravenós a la mà dreta». Es recomana programar la zona del cos amb una terminologia, sempre que sigui possible."> > ["at0142"] = < text = <"Zona del cos estructurada"> description = <"Descripció estructurada de la zona d'administració de la medicació, vacuna o producte terapèutic."> comment = <"Per exemple: «En la superfície cutània medial de l'avantbraç esquerre, de 10 cm a 20 cm de manera distal des de la punta del colze». "> > ["at0143"] = < text = <"Mètode d'administració"> description = <"Tècnica o dispositiu mitjançant el qual es va administrar o administrarà l’element prescrit."> comment = <"Observació. Per exemple: «mitjançant la tècnica d’injecció Z»; «mitjançant un nebulitzador». Es recomana programar el mètode amb una terminologia, sempre que sigui possible."> > ["at0144"] = < text = <"Dispositiu d'administració"> description = <"Dades del dispositiu mèdic utilitzat per ajudar a administrar la medicació."> > ["at0145"] = < text = <"Prescripció en espera per autorització"> description = <"S’ha preparat un esborrany de la prescripció i està pendent de confirmació per part d’un metge autoritzat. Es pot utilitzar quan les reautoritzacions es fan per lots. Aquest careflow_step pot tenir un estat «planificat» o «actiu», cosa que reflecteix la necessitat de gestionar tant prescripcions noves com prescripcions reautoritzades."> > ["at0147"] = < text = <"Via d'administració"> description = <"Via per la qual l’element prescrit s'ha administrat o s'administrarà en el cos del subjecte."> comment = <"Observació. Per exemple: «oral», «intravenosa» o «tòpica». Es recomana programar la via amb una terminologia sempre que sigui possible. Es poden especificar múltiples vies possibles."> > ["at0148"] = < text = <"Medicació preparada"> description = <"S’ha preparat la medicació físicament."> comment = <"Per exemple: la preparació d’una mescla intravenosa."> > ["at0149"] = < text = <"Verificació"> description = <"La fase d’itinerari s'ha comprovat per una persona diferent."> comment = <"Dades de la persona que realitza la verificació es poden recollir a l'element de Model de Referència «Participació»."> > ["at0150"] = < text = <"Prescripció cancel·lada"> description = <"La prescripció es cancel·là abans de ser emesa."> > ["at0151"] = < text = <"Prescripció no vàlida o caducada"> description = <"S’ha invalidat la prescripció o ha caducat sense completar-se."> > ["at0152"] = < text = <"Prescripció finalitzada"> description = <"La prescripció s'ha finalitzat correctament."> > ["at0153"] = < text = <"Medicació autoritzada"> description = <"S’ha autoritzat formalment l’ús de la medicació."> > ["at0154"] = < text = <"Data/hora de reinici"> description = <"Data/hora en què el curs de medicació està programat per reiniciar-se, segons la fase de l’itinerari «Administració suspesa»."> comment = <"Per exemple: 29-10-2017."> > ["at0155"] = < text = <"Criteri de reinici"> description = <"El criteri que provoca el reinici del curs de la medicació, segons la fase de l’itinerari «Administració suspesa»."> comment = <"Per exemple: «El segon dia després de l'operació»."> > ["at0156"] = < text = <"Indicació clínica"> description = <"Motiu clínic de l'activitat de medicació."> comment = <"Per exemple: «Angina» o «Dolor». Es recomana programar la indicació clínica amb una terminologia quan sigui possible. Aquest element de dades permet múltiples esdeveniments. Si només s'utilitza una ACTION per a registrar una indicació de medicació, aquest element de dades es pot registrar sense més consideració. No obstant això, si una indicació clínica es registra tant per a la INSTRUCTION de Prescripció com per a aquesta ACTION de la Gestió de medicació, s'ha de tindre en compte que aquestes indicacions poden no ser congruents."> > ["at0157"] = < text = <"Medicació verificada"> description = <"S’ha comprovat la medicació preparada amb minuciositat."> > > > ["es"] = < items = < ["at0000"] = < text = <"Gestión de la medicación"> description = <"Cualquier actividad relacionada con la planificación, programación, gestión de prescripciones, dispensación, administración, cese y otro uso de un medicamento, vacuna, producto nutricional u otro elemento terapéutico."> comment = <"No se limita a actividades realizadas en base a órdenes de medicación de los clínicos, sino que también podría incluir, por ejemplo, el uso de medicamentos de venta libre."> > ["at0002"] = < text = <"Prescripción emitida"> description = <"Se ha emitido una receta médica para el medicamento."> > ["at0003"] = < text = <"Prescripción dispensada"> description = <"Se ha dispensado la medicación solicitada, por ejemplo, desde una farmacia al paciente."> > ["at0004"] = < text = <"Curso de medicación iniciado"> description = <"El paciente ha tomado o se le ha administrado el medicamento por primera vez. Aunque en algunos entornos esta fecha significativa puede ser calculada como la primera de varias administraciones, en otros contextos, como la atención primaria, las fechas específicas de administración no están fácilmente disponibles."> > ["at0005"] = < text = <"Medicación reevaluada"> description = <"Se ha reevaluado la medicación individual, por ejemplo, si debe seguir tomándose. No se trata de revisar la lista de medicamentos."> > ["at0006"] = < text = <"Dosis administrada"> description = <"Se ha realizado una única administración del medicamento."> > ["at0007"] = < text = <"Curso de medicación completado"> description = <"El curso de medicación se ha completado según lo previsto."> > ["at0008"] = < text = <"Retraso en el suministro de prescripciones"> description = <"La receta no se ha dispensado debido a un problema técnico o de suministro farmacéutico."> > ["at0009"] = < text = <"Administración suspendida"> description = <"La administración del medicamento ha sido suspendida hasta nuevo aviso. No deben administrarse más dosis hasta que se haya restablecido la fecha de reinicio o se hayan cumplido las condiciones necesarias. Al establecer la fecha/condiciones de reinicio tras la suspensión, debe realizarse un paso desde 'Administración suspendida' y volver a 'Fecha de inicio de la medicación/condición establecida'."> > ["at0010"] = < text = <"Prescripción reexpedida"> description = <"Se ha vuelto a emitir una receta para una orden de medicación existente."> > ["at0011"] = < text = <"Reautorización de prescripción pendiente"> description = <"La emisión de la receta médica está pendiente de reautorización por parte de un clínico."> > ["at0012"] = < text = <"Curso de medicación cancelado"> description = <"Se ha cancelado la medicación prevista antes de su administración."> > ["at0013"] = < text = <"Curso de medicación pospuesto"> description = <"Se ha pospuesto el curso de medicación programado antes de cualquier administración."> > ["at0015"] = < text = <"Interrupción de la medicación"> description = <"Se ha interrumpido la administración del medicamento durante el período del curso previsto."> > ["at0016"] = < text = <"Fecha de inicio de la medicación/condición establecida"> description = <"Se ha establecido el momento para comenzar la medicación, o cualquier otra condición de inicio."> > ["at0017"] = < text = <"Tree"> description = <"@ internal @"> > ["at0018"] = < text = <"Administración de dosis omitida"> description = <"Se ha retenido y no administrado una dosis del medicamento. No se espera que se administre más tarde, aunque la siguiente dosis (si la hubiera) debe administrarse de acuerdo con la orden original."> > ["at0020"] = < text = <"Medicamento"> description = <"Nombre del medicamento, vacuna u otro elemento terapéutico/prescribible foco de la actividad."> comment = <"Por ejemplo: \"Atenolol 100 mg\" o \"Tenormin comprimidos 100 mg\". Se recomienda encarecidamente que 'Medicamento' se codifique con una terminología capaz de activar el apoyo a la toma de decisiones, siempre que sea posible. El grado de codificación puede variar desde el simple nombre del medicamento hasta detalles estructurados sobre el envase utilizado. La entrada de texto libre sólo debe utilizarse si no se dispone de la terminología adecuada."> > ["at0021"] = < text = <"Motivo"> description = <"Motivo por el que se llevó a cabo la fase de la ruta para el medicamento identificado."> comment = <"Por ejemplo: \"Aplazado - Paciente no disponible en el momento de la administración\", \"Cancelado - Reacción adversa\". Nota: No se trata del motivo de la instrucción de medicación, sino de la razón específica por la que se llevó a cabo un paso asistencial, y a menudo se utilizará para documentar alguna desviación de la orden original."> > ["at0024"] = < text = <"Comentarios"> description = <"Información adicional sobre la actividad o fase del proceso no recogida en otros campos, incluidos los detalles de cualquier variación entre la acción prevista y la acción realmente realizada."> comment = <"Por ejemplo: \"El paciente estaba en el servicio de radiología\", \"Inyección accidental en un vaso sanguíneo durante la administración de IM\"."> > ["at0025"] = < text = <"Secuencia numérica"> description = <"La secuencia numérica específica de la fase del proceso que se está registrando."> comment = <"Por ejemplo: Número de secuencia de la vacuna."> > ["at0030"] = < text = <"Tree"> description = <"@ internal @"> > ["at0033"] = < text = <"Orientación al paciente"> description = <"Cualquier orientación, instrucción o consejo que se haya dado al sujeto de asistencia o al cuidador personal en el momento de la fase del proceso."> comment = <"Por ejemplo: \"Evitar el pomelo\", \"Tomar al menos 2 horas antes de acostarse\", \"Tomar con comida\". Puede codificarse con una terminología cuando sea clínicamente apropiado."> > ["at0039"] = < text = <"Cambio importante en la orden médica"> description = <"Fue necesario introducir un cambio importante en la orden, lo que obligó a interrumpirlo e iniciar una orden de reemplazo."> > ["at0041"] = < text = <"Cambio menor en la orden"> description = <"La orden de medicación se ha modificado de manera que no requiere emitir una nueva instrucción/orden, de acuerdo con las normas clínicas locales."> > ["at0043"] = < text = <"Fecha/hora programada original"> description = <"La fecha en la que estaba programada la acción de medicación."> comment = <"Se utiliza para comparar la desviación del tiempo de acción real cuando no se puede calcular fácilmente a partir de la instrucción original."> > ["at0044"] = < text = <"Administración de dosis aplazada"> description = <"Se ha retrasado la administración de una dosis del medicamento, pero se espera que se administre lo antes posible."> > ["at0053"] = < text = <"Detalles adicionales"> description = <"Detalles más estructurados de la acción, posiblemente específicos de una etapa del proceso."> > ["at0085"] = < text = <"Ampliación"> description = <"Información adicional necesaria para registrar el contenido local o para alinearse con otros modelos/formalismos de referencia."> comment = <"Por ejemplo: requisitos de información local o metadatos adicionales para alinearse con los equivalentes de FHIR o CIMI."> > ["at0103"] = < text = <"ID de la orden"> description = <"Identificador único de la orden de medicación."> comment = <"Este elemento de datos permite definir múltiples ocurrencias de forma más explícita en tiempo de ejecución, si es necesario."> > ["at0104"] = < text = <"Detalles del medicamento"> description = <"Detalles estructurados sobre el medicamento, incluida la concentración, la forma y las sustancias que lo componen."> comment = <"Utilice este SLOT donde se requiera una descripción detallada del producto dispensado, autorizado o administrado de forma explícita. Por ejemplo: la forma, concentración, diluyentes o mezcla de ingredientes, entre otros detalles."> > ["at0106"] = < text = <"Prescripción reautorizada"> description = <"La orden de medicación original ha sido reautorizada para permitir la repetición de la prescripción o dispensación. En algunas jurisdicciones, en estas circunstancias debe emitirse una orden completamente nueva."> > ["at0109"] = < text = <"Medicación recomendada"> description = <"La medicación ha sido recomendada, pero no se han tomado medidas para iniciar la prescripción."> > ["at0131"] = < text = <"Cantidad"> description = <"Detalles específicos sobre la cantidad de medicamento."> comment = <"CLUSTER.dosage está pensado para llevar detalles de cambios en la orden de medicación o administraciones de dosis, mientras que CLUSTER.medication_supply_amount está pensado para detalles de actividad relacionada con la dispensación."> > ["at0132"] = < text = <"Sustitución"> description = <"Medidas de sustitución adoptadas por la persona que administra o dispensa el medicamento."> comment = <"En muchas jurisdicciones, se permite la sustitución de un artículo solicitado como forma genérica o con una marca diferente, que se haya determinado como bioequivalente, en el punto de dispensación o suministro. En otros casos, la sustitución se da por supuesta y el médico debe solicitar explícitamente que no se sustituya."> > ["at0133"] = < text = <"Motivo de la sustitución"> description = <"Motivo o justificación de la medida de sustitución adoptada."> comment = <"Por ejemplo: \"La alternativa genérica contiene una sustancia que el paciente no tolera\". Puede codificarse con una terminología cuando sea clínicamente apropiado."> > ["at0138"] = < text = <"Sustitución realizada"> description = <"Se sustituyó por un medicamento bioequivalente al solicitado."> > ["at0139"] = < text = <"Sustitución no realizada"> description = <"Aunque la orden de medicación lo permitía, no se sustituyó por un medicamento bioequivalente."> > ["at0140"] = < text = <"Detalles de la administración"> description = <"Datos sobre la localización corporal y la administración de la medicación."> > ["at0141"] = < text = <"Zona corporal"> description = <"Descripción estructurada del lugar de administración del producto solicitado."> comment = <"Por ejemplo: \"brazo izquierdo\", \"catéter intravenoso mano derecha\". Siempre que sea posible, es preferible codificar el lugar del cuerpo con una terminología."> > ["at0142"] = < text = <"Zona corporal estructurada"> description = <"Descripción estructurada del lugar de administración del medicamento, vacuna o bien terapéutico."> comment = <"Por ejemplo: \"En la superficie cutánea medial del antebrazo izquierdo, de 10 cm a 20 cm distalmente desde la punta del codo\"."> > ["at0143"] = < text = <"Método de administración"> description = <"La técnica o el dispositivo mediante el cual se administró o se administrará el artículo solicitado."> comment = <"Por ejemplo: 'mediante inyección de vía Z'; 'a través de nebulizador'. Es preferible codificar el método con una terminología, siempre que sea posible."> > ["at0144"] = < text = <"Dispositivo de administración"> description = <"Detalles del dispositivo médico utilizado para ayudar a la administración de la medicación."> > ["at0145"] = < text = <"Prescripción pendiente de autorización"> description = <"Se ha preparado una receta provisional y está pendiente de confirmación por parte de un clínico autorizado. Puede ser utilizada cuando se realicen reautorizaciones de forma conjunta. Este careflow_step puede tener un estado de \"planificado\" o \"activo\", reflejando la necesidad de manejar tanto órdenes nuevas como órdenes reautorizadas."> > ["at0147"] = < text = <"Vía de administración"> description = <"La vía por la que se ha administrado o se va a administrar el producto solicitado al cuerpo del sujeto."> comment = <"Por ejemplo: \"oral\", \"intravenosa\" o \"tópica\". Es preferible codificar la vía con una terminología, siempre que sea posible. Pueden especificarse múltiples vías potenciales."> > ["at0148"] = < text = <"Medicación preparada"> description = <"*The medication has been physically prepared. (en)"> comment = <"*For example: preparation of an intravenous mixture. (en)"> > ["at0149"] = < text = <"¿Doble comprobación?"> description = <"La fase del proceso ha sido comprobada por otra persona."> comment = <"Los datos de la persona que realiza el doble control pueden figurar en el elemento \"Participación\" del Modelo de Referencia."> > ["at0150"] = < text = <"Prescripción anulada"> description = <"La receta fue anulada antes de ser emitida."> > ["at0151"] = < text = <"Prescripción no válida o caducada"> description = <"La receta ha sido invalidada o ha caducado sin ser cumplida."> > ["at0152"] = < text = <"Prescripción cumplida"> description = <"La prescripción ha sido cumplida con éxito."> > ["at0153"] = < text = <"Medicación autorizada"> description = <"Se ha autorizado formalmente el uso del medicamento."> > ["at0154"] = < text = <"Fecha/hora de reinicio"> description = <"La fecha/hora en la que el curso de medicación está programado para reiniciarse, según la fase del proceso \"Administración suspendida\"."> comment = <"Por ejemplo: 29/10/2017"> > ["at0155"] = < text = <"Criterio de reinicio"> description = <"El criterio que desencadena el reinicio del curso de medicación, según la fase del proceso \"Administración suspendida\"."> comment = <"Por ejemplo: \"El día 2 después de la operación\"."> > ["at0156"] = < text = <"Indicación clínica"> description = <"Motivo clínico de la actividad medicamentosa."> comment = <"Por ejemplo: \"Angina\" o \"Dolor\". Siempre que sea posible, se prefiere codificar la indicación con una terminología. Este dato permite múltiples ocurrencias. Si sólo se utiliza una ACTION para registrar una indicación de medicación, este elemento de datos puede utilizarse sin consideración adicional. Sin embargo, si se registra una indicación clínica tanto para la INSTRUCTION de orden de medicación como para esta ACTION de gestión de la medicación, tenga en cuenta que estas indicaciones podrían no ser coherentes."> > ["at0157"] = < text = <"*Medication double checked (en)"> description = <"*The prepared medication has been double checked. (en)"> > > > >