Hi, Yes this helps. Thank you.
Regards, Jos? Silva 2013/4/13 Heather Leslie <heather.leslie at oceaninformatics.com> > Hi Jose,**** > > ** ** > > The NEHTA archetypes are recent updates by the Australian/NEHTA community, > led by Sam as the original openEHR archetype author. So I?d endorse using > these as a preferred starting point.**** > > ** ** > > The Medication List COMPOSITION is intended for use as ?A persistent and > managed list of medications that are reasonably assumed to be taken by the > subject, and that may influence clinical decision-making and care provision. > ?**** > > ** ** > > So the Medication List is assumed to be a list of those items to be taken > on prescription or self-medicated. In a pure openEHR system the > prescribable list is likely to be predominantly INSTRUCTIONs that can then > be used as the ongoing order for these to be taken, perhaps with some > additional ACTIONS that record the ?over the counter? meds that are being > taken by the patient. All of these Medication-related ENTRYs can be used by > decision support to test for drug interactions prior to prescribing.**** > > ** ** > > The generation of a prescription from the INSTRUCTION will be stored as a > Prescription COMPOSITION and will also generate a matching ACTION that > could then be stored as part of a clinician?s consultation record to record > that Pill A was prescribed during the clinical visit. The administration > (by a clinician or self-administered) should generate ACTIONS that will > record that Pill ?A? was taken at 10 o?clock and may be stored as part of a > COMPOSITION such as a Progress Note.**** > > ** ** > > Does that help?**** > > ** ** > > Regards**** > > ** ** > > Heather**** > > ** ** > > *From:* openEHR-clinical [mailto: > openehr-clinical-bounces at lists.openehr.org] *On Behalf Of *Z? Silva > *Sent:* Saturday, 13 April 2013 1:24 AM > *To:* For openEHR clinical discussions > *Subject:* Re: Template for medication records**** > > ** ** > > Hi Sam, > > Thank you for your answer. > > I continued to study the existent archetypes and my result was: > > One template for prescriptions where I can plan the medication > administration. > This template will contain the following archetypes: > - openEHR-EHR-COMPOSITION.prescription.v1 > -- openEHR-EHR-INSTRUCTION.medication.v1 > --- openEHR-EHR-CLUSTER.timing.v1 > > One template to plan my self-medication administration. This medication is > not connected with any prescription. > This template will contain the following archetypes: > - openEHR-EHR-COMPOSITION.medication_list.v1 > -- openEHR-EHR-INSTRUCTION.medication.v1 > --- openEHR-EHR-CLUSTER.timing.v1 > > One last template for medication administration of the 2 templates above. > This template will contain the following archetypes: > - openEHR-EHR-COMPOSITION.medication_list.v1 > -- openEHR-EHR-ACTION.medication.v1**** > > ** ** > > If i understood well, each INSTRUCTION (represented by first 2 templates) > can have many Activities, each activity can lead to one (take this > medication at that date/time) or more (take this medication for 3 days at > that date/time) ACTIONS (represented by last template). This action could > not be the result of one INSTRUCTION (self-medication).**** > > **** > > All this archetypes are from http://dcm.nehta.org.au/ckm.**** > > ** ** > > If I'm missing or saying something wrong please correct me.**** > > ** ** > > > **** > > Regards, > Jos? Silva**** > > ** ** > > 2013/4/11 Sam Heard <sam.heard at oceaninformatics.com>**** > > Hi Jos?**** > > **** > > The answer to your question is that your medication order should be an > INSTRUCTION....this informs of what should take place in the future. > Administration is recorded with the ACTION class - and administration is > one of the ?pathway steps? that can be recorded. Have a look at the ACTION > and INSTRUCTION classes in the specifications (EHR) for more detail.**** > > **** > > I would go to http://dcm.nehta.org.au/ckm to look at the medication > instructions and actions there which inform the national messaging. There > is also a UK CKM coming along and they are working on a medication model > for the Scotland and the GP2GP project. Ian McNicoll ( > ian.mcnicoll at oceaninformatics.com) is involved.**** > > **** > > Cheers, Sam**** > > **** > > Sam Heard > FRACGP, MRCGP, DRCOG, FACHI > Consultant & Chairman, Ocean Informatics > Chairman, openEHR Foundation > Chairman, NTGPE > Senior Visiting Research Fellow, University College London**** > > **** > > *From:* Z? Silva > *Sent:* Thursday, 11 April 2013 7:46 PM > *To:* openehr-clinical at lists.openehr.org**** > > **** > > I'm trying to do a template to support medication records, having each > medication a person is taking. This medication can be prescribed by a > clinic or self-medicated (self-initiative). In both cases I want to save > the date/time of each medication administration. **** > > > For now i have from http://www.openehr.org/ckm/ :**** > > > - Medication List - openEHR-EHR-COMPOSITION.medication_list.v1 > -- Medication action - openEHR-EHR-ACTION.medication.v1 > --- Medication description - openEHR-EHR-ITEM_TREE.medication.v1 > > With this template I can save one list of medication that the person is > taking but I think I can't save the date/time of the administration.**** > > ** ** > > Can someone help me in this formulation?**** > > > Regards, > Jos? Silva**** > > **** > > > _______________________________________________ > openEHR-clinical mailing list > openEHR-clinical at lists.openehr.org > > http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org > **** > > ** ** > > _______________________________________________ > openEHR-clinical mailing list > openEHR-clinical at lists.openehr.org > > http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org > -------------- next part -------------- An HTML attachment was scrubbed... URL: <http://lists.openehr.org/pipermail/openehr-clinical_lists.openehr.org/attachments/20130415/5498860c/attachment.html>
