Jenni Syed (mmoseman@cerner.com;

Jenni.Syed@Cerner.com)

Existing Wording: informationSource = The person who provided the information about the taking of this medication

dateAsserted = The date when the medication statement was asserted by the information source

reasonNotGiven = A code indicating why the medication was not taken

Scope = the summarization of a patient's "active medications" in a patient profile

Comment:

MedicationStatement scope implies a summarization of all active medications (which could be either inpatient or outpatient medications). The reasonNotGiven is most relevant for inpatient (medicationadministration) medications, which supports the scope of the MedicationStatement including inpatient (administered) medications. However, the EMR is generally only asking the patient about compliance (wasNotGiven) for outpatient/home prescriptions due to the lack of visibility to patient compliance with those home medications. In the inpatient setting, when clinicians are administering medications, there is no need to ask the patient for their compliance statement (since the medication administration record serves as evidence that the medication was given). Thus, many inpatient (administered) medications won't have an explicit informationSource and dateAsserted, but rather inpatient orders will have an actual medicationprescription and corresponding medicationadministrations. The scope implies the MedicationStatement resource is intended to cover inpatient medication orders that were administered by the provider, which means there is some ambiguity in the informationSource and dateAsserted. EMRs will track the medicationprescription and medicationadministration, but do EMRs generally document compliance beyond that? Will there be an informationSource and/or dateAsserted or will it be implied through MedStatement.informationSource = MedPrescription.prescriber and MedStatement.dateAsserted = MedPrescription.dateWritten? I want the ability to convey the full list of active medications, but I would like to decouple this from medication compliance (wasNotGiven, reasonNotGiven, etc).