# Template for medication records **Category:** [Clinical (archive)](https://discourse.openehr.org/c/clinical-archive/153) **Created:** 2013-04-11 10:15 UTC **Views:** 10 **Replies:** 4 **URL:** https://discourse.openehr.org/t/template-for-medication-records/15251 --- ## Post #1 by @Ze_Silva Hi 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/](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, José Silva --- ## Post #2 by @system Hi José 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](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@oceaninformatics.com](mailto:ian.mcnicoll@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 --- ## Post #3 by @Ze_Silva 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](http://dcm.nehta.org.au/ckm). If I'm missing or saying something wrong please correct me. --- ## Post #4 by @heather.leslie 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 --- ## Post #5 by @Ze_Silva Hi, Yes this helps. Thank you. --- **Canonical:** https://discourse.openehr.org/t/template-for-medication-records/15251 **Original content:** https://discourse.openehr.org/t/template-for-medication-records/15251