OpenEHR Apperta Mirror
Name
Medication and medical devices
Description
Medication and medical devices heading (AoMRC).
Purpose
To organise Medication and medical devices details within a standardised record heading as recommended by the UK Academy of Royal Colleges (AoMRC).
Suggested 'subheading' content includes ...
Medication name:
May be generic name or brand name (as appropriate).
Medication form:
Eg capsule, drops, tablet, lotion etc.
Route:
(intravenous), etc): may include method of administration, (eg, by
infusion, via nebuliser, via NG (nasogastric) tube) and/or site of use (eg, ‘to wound’, 'to left eye', etc).
Dose:
This is a record of the total amount of the active ingredient(s) to be
given at each administration.
It should include, eg, units of measurement, number of tablets,
volume/concentration of liquid, number of drops, etc.
Medication frequency:
Frequency of taking or administration of the therapeutic agent or
medication.
Additional instructions:
Allows for:
* requirements for adherence support, eg, compliance aids, prompts and packaging requirements
* additional information about specific medicines, eg where specific brand required
* patient requirements, eg, unable to swallow tablets.
Do not discontinue warning:
To be used on a case-by-case basis if it is vital not to discontinue a medicine in a specific patient scenario.
Reason for medication:
Reason for medication being prescribed, where known.
Medication recommendations:
Suggestions about duration and/or review, ongoing monitoring
requirements, advice on starting, discontinuing or changing medication.
Medication change:
Where a change is made to the medication, ie one drug stopped and
another started or, eg, dose, frequency or route is changed.
Reason for medication change:
Reason for change in medication, eg sub-therapeutic dose, patient
intolerant.
Medicine administered:
Record of administration to the patient, including self-administration.
Reason for non-administration:
Reason why drug not administered, (eg, patient refused, patient
unavailable, drug not available).
Relevant previous medications:
Record of relevant previous medications.
Medical devices:
Record of dietary supplements, dressings and equipment that the patient is currently taking or using.
Use
References
Health and Social Care Information Centre, Academy of Medical Royal Colleges (2013) Standards for the Clinical Structure and Content of Patient Records. HSCIC, Leeds.
Available from: https://www.rcplondon.ac.uk/sites/default/files/standards-for-the-clinical-structure-and-content-of-patient-records.pdf [Accessed July 22, 2014]
Archetype Id
openEHR-EHR-SECTION.medication_medical_devices_rcp.v1
Copyright
© Clinical Models UK
Licencing
Original Author
Ian McNicoll
Ocean Informatics UK
Ocean Informatics UK
Date Originally Authored
2014-06-08
archetype (adl_version=1.4) openEHR-EHR-SECTION.medication_medical_devices_rcp.v1 concept [at0000] -- Medication and medical devices language original_language = <[ISO_639-1::en]> description original_author = < ["name"] = <"Ian McNicoll"> ["organisation"] = <"Ocean Informatics UK"> ["email"] = <"ian.mcnicoll@oceaninformatics.com"> ["date"] = <"2014-06-08"> > details = < ["en"] = < language = <[ISO_639-1::en]> purpose = <"To organise Medication and medical devices details within a standardised record heading as recommended by the UK Academy of Royal Colleges (AoMRC). Suggested 'subheading' content includes ... Medication name: May be generic name or brand name (as appropriate). Medication form: Eg capsule, drops, tablet, lotion etc. Route: (intravenous), etc): may include method of administration, (eg, by infusion, via nebuliser, via NG (nasogastric) tube) and/or site of use (eg, ‘to wound’, 'to left eye', etc). Dose: This is a record of the total amount of the active ingredient(s) to be given at each administration. It should include, eg, units of measurement, number of tablets, volume/concentration of liquid, number of drops, etc. Medication frequency: Frequency of taking or administration of the therapeutic agent or medication. Additional instructions: Allows for: * requirements for adherence support, eg, compliance aids, prompts and packaging requirements * additional information about specific medicines, eg where specific brand required * patient requirements, eg, unable to swallow tablets. Do not discontinue warning: To be used on a case-by-case basis if it is vital not to discontinue a medicine in a specific patient scenario. Reason for medication: Reason for medication being prescribed, where known. Medication recommendations: Suggestions about duration and/or review, ongoing monitoring requirements, advice on starting, discontinuing or changing medication. Medication change: Where a change is made to the medication, ie one drug stopped and another started or, eg, dose, frequency or route is changed. Reason for medication change: Reason for change in medication, eg sub-therapeutic dose, patient intolerant. Medicine administered: Record of administration to the patient, including self-administration. Reason for non-administration: Reason why drug not administered, (eg, patient refused, patient unavailable, drug not available). Relevant previous medications: Record of relevant previous medications. Medical devices: Record of dietary supplements, dressings and equipment that the patient is currently taking or using. "> use = <""> misuse = <""> copyright = <"© Clinical Models UK"> > > lifecycle_state = <"AuthorDraft"> other_contributors = <> other_details = < ["references"] = <"Health and Social Care Information Centre, Academy of Medical Royal Colleges (2013) Standards for the Clinical Structure and Content of Patient Records. HSCIC, Leeds. Available from: https://www.rcplondon.ac.uk/sites/default/files/standards-for-the-clinical-structure-and-content-of-patient-records.pdf [Accessed July 22, 2014]"> ["MD5-CAM-1.0.1"] = <"BA8A4CAF4F969BDC67687A8EF75D3523"> > definition SECTION[at0000] matches {*} ontology term_definitions = < ["en"] = < items = < ["at0000"] = < text = <"Medication and medical devices"> description = <"Medication and medical devices heading (AoMRC)."> > > > >