Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02

The content of this release is not comprehensive and is not fully validated and must not be used in live system implementations.

ENTRY Constrained Domain Model: StoppedMedicationActivity

A constrained ENTRY containing a collection of data items required to represent stopped medications. Stopped medications represents a list of medications that were discontinued during this admission. Comprises a required

  • single coded Stopped Medication Activity item, and
  • an association with a current medication activity item which represents the details of the medication being stopped such as the indication for the medication, medicinal product, dose quantity, dose frequency, dosage instructions, course timing, , devices used, review details, amongst others.
It may also optionally comprise of
  • any coded representation(s) of the indication for stopping the medication.
  • a textual description of the indication for stopping the medication if it cannot be coded.
  • a coded representation of the reconciliation status of the stopped medication
  • a textual representation of any other additional instructions forming part of the medication activity that cannot be coded.
Recommended guidelines to follow for the coding and constraining of relevant SCT expression constraints for stopped medications as per the reconciliation status requirements are listed below:
  1. Reconciliation Status Requirement -suspended
  • Record artefact -Ended medication
  • Stopped Medication Activity focus concept constraint -( 432102000 | administration of substance | )
OR ( 433590000 | administration of substance via specific route | )
  • Context Value Attribute constraint -385655000 | Suspended |
2. Reconciliation Status Requirement -stopped (completed/discontinued)
  • Record artefact -Ended medication
  • Stopped Medication Activity focus concept constraint -( 432102000 | administration of substance | )
OR ( 433590000 | administration of substance via specific route | )
  • Context Value Attribute constraint -(385658003 | Done |) OR(410546004 | Discontinued |)

Specializes

ProductOrSubstanceRelatedActivity

Attributes

Name Data type Occurs Description Value constraints
name SC 1..1 The name, expressed as a coded value or as plain text, specifies the clinical or administrative concept to which this EHR node corresponds, as labelled in the EHR system in which it was first committed.
value
Literal value(s): ENTRY
rc_id II 1..1 The globally-unique identifier by which this node in the EHR hierarchy is referenced in the EHR system to which the data were first committed. This identifier shall be retained by the EHR Recipient and re-used whenever this RECORD_COMPONENT is subsequently included in another EHR_EXTRACT.
synthesised BL 1..1 This attribute value shall be TRUE if this RECORD_COMPONENT has been created in order to comply with this standard , but this point in the EHR hierarchy has no corresponding node in the EHR from which it was extracted.
value
Default value: false
uncertainty_expressed BL 1..1 This attribute is set to TRUE to advise the EHR Recipient that this ENTRY contains data that indicates some degree of uncertainty, and that care should be taken when using these data within automated processes and systems.
nullFlavor
Literal value(s): NA


Contained ELEMENTs



Graphical Representation

Subject ELEMENT class Related object classes
Name ELEMENT Class Occurs Description Relationship Occurs Class Dependency
items StoppedMedicationActivity 1 HasRecordRole 0..* StoppedMedicationReconciliationStatus

INDEPENDENT
HasAnnotation 0..* Text

INDEPENDENT
HasTemporalContext 0..* StoppedMedicationActivity

INDEPENDENT
IsComponentActionOf 0..* StoppedMedicationActivity

TreatmentActivity

INDEPENDENT
HasPredecessor 1..* CurrentMedicationActivity

INDEPENDENT
HasIndication 0..* ReasonForStoppingMedicationText

ProcedureActivity

FindingObservation

PropertyObservation

AllergiesOrAdverseReactionEvent

StoppedMedicationActivity

InvestigationActivity

Diagnosis

CareIssues

TreatmentActivity

INDEPENDENT
items ProcedureActivity 0 .. * IsComplicatedBy 0..* ProcedureActivity

FindingObservation

INDEPENDENT
HasIndication 0..* Diagnosis

FindingObservation

CareIssues

INDEPENDENT
IsIndicationOf 0..* StoppedMedicationActivity

CurrentMedicationActivity

INDEPENDENT
HasAnnotation 0..* Text

INDEPENDENT
Complicates 0..* Diagnosis

INDEPENDENT
items CareIssues 0 .. * IsClinicalContextOf 0..* AdmissionEvent

INDEPENDENT
HasRecordRole 0..* ProblemsAndComplaintsTag

INDEPENDENT
HasClinicalContext 0..* ProcedureActivity

Diagnosis

FindingObservation

INDEPENDENT
IsIndicationOf 0..* StoppedMedicationActivity

CurrentMedicationActivity

INDEPENDENT
IsMotivationOf 0..* ProcedureActivity

AdmissionEvent

INDEPENDENT
HasAnnotation 0..* Text

INDEPENDENT
items ReasonForStoppingMedicationText 0 .. *
items InvestigationActivity 0 .. *
items PropertyObservation 0 .. * IsIndicationOf CurrentMedicationActivity

StoppedMedicationActivity

INDEPENDENT
HasAnnotation 0..* Text

INDEPENDENT
items CurrentMedicationActivity 1 .. * HasTemporalContext 0..* MedicationFutureCourseTiming

MedicationCourseTiming

INDEPENDENT
HasRecordRole 0..* CurrentMedicationReconciliationStatus

INDEPENDENT
HasTemporalContext 0..* CurrentMedicationActivity

INDEPENDENT
HasParameterSetting 0..* DoseQuantity

INDEPENDENT
AssertsTiming 0..* EventDoseFrequency

MeasuredDoseFrequency

MedicationReviewText

INDEPENDENT
Consumes 1..* MedicinalProductOrSubstance

INDEPENDENT
HasAnnotation 0..* DosageInstructions

INDEPENDENT
UsesDevice 0..* MedicinalDevice

ComplianceDevice

INDEPENDENT
IsProspectOf 1..* MedicationRecommendationActivity

INDEPENDENT
IsPrecedentOf 1..* StoppedMedicationActivity

INDEPENDENT
HasAnnotation 0..* DosageInstructions

AdditionalInstructions

INDEPENDENT
HasIndication 0..* AllergiesOrAdverseReactionEvent

TreatmentActivity

InvestigationActivity

FindingObservation

CurrentMedicationActivity

ReasonForMedicationText

PropertyObservation

ProcedureActivity

CareIssues

Diagnosis

INDEPENDENT
IsComponentActionOf 0..* CurrentMedicationActivity

TreatmentActivity

INDEPENDENT
HasComponentAction 0..* MedicationReviewActivity

INDEPENDENT
items Diagnosis 0 .. * IsComplicatedBy 0..* Diagnosis

ProcedureActivity

INDEPENDENT
IsClinicalContextOf 0..* CareIssues

INDEPENDENT
IsIndicationOf 0..* CurrentMedicationActivity

StoppedMedicationActivity

INDEPENDENT
HasRecordRole 0..1 DiagnosisStatus

INDEPENDENT
HasAnnotation 0..* Text

INDEPENDENT
items Text 0 .. *
items StoppedMedicationReconciliationStatus 0 .. 1
items TreatmentActivity 0 .. *
items AllergiesOrAdverseReactionEvent 0 .. * IsMotivationOf 0..* AdmissionEvent

INDEPENDENT
IsIndicationOf 0..* CurrentMedicationActivity

StoppedMedicationActivity

INDEPENDENT
HasAnnotation 0..* Text

INDEPENDENT
IsInterpretationOf 0..* AllergiesOrAdverseReactionPropensity

INDEPENDENT
items FindingObservation 0 .. * IsClinicalContextOf 0..* CareIssues

INDEPENDENT
IsIndicationOf 0..* StoppedMedicationActivity

CurrentMedicationActivity

ProcedureActivity

INDEPENDENT
HasAnnotation 0..* Text

INDEPENDENT

Content of COMPOSITION Models

DischargeSummary

Reference Model Type

ENTRY