OpenEHR Apperta Mirror
Name
Admission medication reconciliation
Description
Information about admission reconciliation of a single medication entry.
Keywords
medication medicine drug admission
Purpose
To record the result of an admission medicines reconciliation process for a single medication item.
Use
Use to record additional data captured during the process of medicines reconciliation on admission.
References
NHS National Prescribing Centre, Medicines Reconciliation, A guide to implementation.
Available from http://www.npc.nhs.uk/improving_safety/medicines_reconciliation/resources/reconciliation_guide.pdf
Health Quality and Safety Commission New Zealand, Medicine Reconciliation Standard V3, September 2012
Available from: http://ithealthboard.health.nz/system/files/documents/publications/medication-reconciliation-standard-v3.pdf
Archetype Id
openEHR-EHR-CLUSTER.medication_reconciliation_admit_uk.v0
Copyright
© Clinical Models UK, Apperta Foundation
Licencing
This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/.
Original Author
Ian McNicoll
freshEHR Clinical Informatics
Date Originally Authored
2014-03-15
Name Card Type Description
Reconciliation action
0..1 DV_CODED_TEXT The recommendation for ongoing continuation of a medication entry within the current care setting.
Constraint for DV_CODED_TEXT
  • Add medication
    [A new medication has been added.]
  • Change medication
    [The medication was changed, generally a dose change.]
  • Stop medication
    [The medication was stopped.]
  • Withhold medication
    [The medication has been temprarily withheld.]
  • No change to medication
    [The medication has not been changed.]
Date reconciled
0..1 DV_DATE_TIME The date at which the reconciliation decision was made or updated.
Discrepancy intentional?
0..1 DV_CODED_TEXT Is the discrepancy was a result of a deliberate decision.
Constraint for DV_CODED_TEXT
  • Intentional
    [The discrepancy was the result of a deliberate decision.]
  • Unintentional
    [The discrepancy was not result of a deliberate decision.]
Target medication record updated?
0..1 DV_BOOLEAN The target medication has neen updated.
Source of information
0..1 DV_TEXT The source of information about the reconciled medication. Coded terms preferred.
Source contact details
0..1 DV_TEXT Contact details for the person supplying source information e.g carer.
Link to source medication entry
0..1 DV_URI Link to the associated source medication entry to which the reconciliation recommendation refers.
Link to target medication entry
0..1 DV_URI A link to the target medication record.
archetype (adl_version=1.4; uid=c66ad879-9992-4e66-9fba-413fc91f6c38)
	openEHR-EHR-CLUSTER.medication_reconciliation_admit_uk.v0

concept
	[at0000]	-- Admission medication reconciliation
language
	original_language = <[ISO_639-1::en]>
description
	original_author = <
		["name"] = <"Ian McNicoll">
		["organisation"] = <"freshEHR Clinical Informatics">
		["email"] = <"ian@freshehr.com">
		["date"] = <"2014-03-15">
	>
	details = <
		["en"] = <
			language = <[ISO_639-1::en]>
			purpose = <"To record the result of an admission medicines reconciliation process for a single medication item.">
			use = <"Use to record additional data captured during the process of medicines reconciliation on admission.">
			keywords = <"medication", "medicine", "drug", "admission">
			misuse = <"">
			copyright = <"© Clinical Models UK, Apperta Foundation">
		>
	>
	lifecycle_state = <"in_development">
	other_contributors = <>
	other_details = <
		["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/.">
		["custodian_organisation"] = <"Apperta UK">
		["references"] = <"NHS National Prescribing Centre, Medicines Reconciliation, A guide to implementation. 
Available from http://www.npc.nhs.uk/improving_safety/medicines_reconciliation/resources/reconciliation_guide.pdf

Health Quality and Safety Commission New Zealand, Medicine Reconciliation Standard V3, September 2012
Available from: http://ithealthboard.health.nz/system/files/documents/publications/medication-reconciliation-standard-v3.pdf">
		["original_namespace"] = <"uk.org.clinicalmodels">
		["original_publisher"] = <"Apperta UK">
		["custodian_namespace"] = <"uk.org.clinicalmodels">
		["MD5-CAM-1.0.1"] = <"EB44A2D9B688C4E8B9F66C5508630DF6">
		["build_uid"] = <"77b3f92a-597c-417b-a2a9-85962733543c">
		["revision"] = <"0.0.1-alpha">
	>

definition
	CLUSTER[at0000] matches {    -- Admission medication reconciliation
		items cardinality matches {1..*; unordered} matches {
			ELEMENT[at0003] occurrences matches {0..1} matches {    -- Reconciliation action
				value matches {
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::
							at0023,    -- Add medication
							at0019,    -- Change medication
							at0020,    -- Stop medication
							at0021,    -- Withhold medication
							at0031]    -- No change to medication
						}
					}
				}
			}
			ELEMENT[at0006] occurrences matches {0..1} matches {    -- Date reconciled
				value matches {
					DV_DATE_TIME matches {*}
				}
			}
			ELEMENT[at0014] occurrences matches {0..1} matches {    -- Discrepancy intentional?
				value matches {
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::
							at0016,    -- Intentional
							at0017]    -- Unintentional
						}
					}
				}
			}
			ELEMENT[at0028] occurrences matches {0..1} matches {    -- Target medication record updated?
				value matches {
					DV_BOOLEAN matches {*}
				}
			}
			ELEMENT[at0026] occurrences matches {0..1} matches {    -- Source of information
				value matches {
					DV_TEXT matches {*}
				}
			}
			ELEMENT[at0027] occurrences matches {0..1} matches {    -- Source contact details
				value matches {
					DV_TEXT matches {*}
				}
			}
			ELEMENT[at0007] occurrences matches {0..1} matches {    -- Link to source medication entry
				value matches {
					DV_URI matches {*}
				}
			}
			ELEMENT[at0029] occurrences matches {0..1} matches {    -- Link to target medication entry
				value matches {
					DV_URI matches {*}
				}
			}
		}
	}


ontology
	term_definitions = <
		["en"] = <
			items = <
				["at0000"] = <
					text = <"Admission medication reconciliation">
					description = <"Information about admission reconciliation of a single medication entry.">
				>
				["at0003"] = <
					text = <"Reconciliation action">
					description = <"The recommendation for ongoing continuation of a medication entry within the current care setting.">
				>
				["at0006"] = <
					text = <"Date reconciled">
					description = <"The date at which the reconciliation decision was made or updated.">
				>
				["at0007"] = <
					text = <"Link to source medication entry">
					description = <"Link to the associated source medication entry to which the reconciliation recommendation refers.">
				>
				["at0014"] = <
					text = <"Discrepancy intentional?">
					description = <"Is the discrepancy was a result of a deliberate decision.">
				>
				["at0016"] = <
					text = <"Intentional">
					description = <"The discrepancy was the result of a deliberate decision.">
				>
				["at0017"] = <
					text = <"Unintentional">
					description = <"The discrepancy was not result of a deliberate decision.">
				>
				["at0019"] = <
					text = <"Change medication">
					description = <"The medication was changed, generally a dose change.">
				>
				["at0020"] = <
					text = <"Stop medication">
					description = <"The medication was stopped.">
				>
				["at0021"] = <
					text = <"Withhold medication">
					description = <"The medication has been temprarily withheld.">
				>
				["at0023"] = <
					text = <"Add medication">
					description = <"A new medication has been added.">
				>
				["at0026"] = <
					text = <"Source of information">
					description = <"The source of information about the reconciled medication. Coded terms preferred.">
				>
				["at0027"] = <
					text = <"Source contact details">
					description = <"Contact details for the person supplying source information e.g carer.">
				>
				["at0028"] = <
					text = <"Target medication record updated?">
					description = <"The target medication has neen updated.">
				>
				["at0029"] = <
					text = <"Link to target medication entry">
					description = <"A link to the target medication record.">
				>
				["at0031"] = <
					text = <"No change to medication">
					description = <"The medication has not been changed.">
				>
			>
		>
	>