The medication information may come from sources such as the patient’s memory, from a prescription bottle, or from a list of medications the patient, clinician or other party maintains. The primary difference between a medication statement and a medication administration is that the medication administration has complete administration information and is based on actual administration information from the person who administered the medication. A medication statement is often, if not always, less specific. There is no required date/time when the medication was administered, in fact we only know that a source has reported the patient is taking this medication, where details such as time, quantity, or rate or even medication product may be incomplete or missing or less precise. Medication administration is more formal and is not missing detailed information.
Common usage includes:
– the recording of non-prescription and/or recreational drugs
– the recording of an intake medication list upon admission to hospital
– the summarization of a patient’s “active medications” in a patient profile
A Medication Statement may be used to record substance abuse or the use of other agents such as tobacco or alcohol. This would typically be done if these substances are intended to be included in clinical decision support checking (for example, interaction checking) and as part of an active medication list. If the intent is to populate social history and/or to include additional information (for example, desire to quit, amount per day, negative health effects), then it is better to record as an Observation that could then be used to populate Social History.
This resource does not produce a medication list, but it does produce individual medication statements that may be used in the List resource to construct various types of medication lists. Note that other medication lists can also be constructed from the other Pharmacy resources (e.g., Medication Request, Medication Administration).
A medication statement is not a part of the prescribe -> dispense -> administer sequence, but is a report by a patient, significant other or a clinician that one or more of the prescribe, dispense or administer actions has occurred, resulting is a belief that the patient is, has, or will be using a particular medication. Medication Statement is an event resource from a Fast Healthcare Interoperability Resources (FHIR) workflow perspective.
The Medication Statement resource is used to record a medications or substances that the patient reports as being taken, not taking, have taken in the past or may take in the future. It can also be used to record medication use that is derived from other records such as a Medication Request. The statement is not used to request or order a medication, supply or device. When requesting medication, supplies or devices when there is a patient focus or instructions regarding their use, a Medication Request, Supply Request or Device Request should be used instead.