{ "resourceType": "StructureDefinition", "url": "https://unicas-fhir.sanidad.gob.es/StructureDefinition/UNICASMedicationAdministration", "name": "UNICASMedicationAdministration", "title": "MedicationAdministration Prescripción ÚNICAS", "status": "draft", "description": "Este profile define las restricciones del recurso MedicationAdministration para representar el registro del consumo de medicamento en el hospital, en el contexto del caso de uso de ÚNICAS.", "fhirVersion": "5.0.0", "kind": "resource", "abstract": false, "type": "MedicationAdministration", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/MedicationAdministration", "derivation": "constraint", "differential": { "element": [ { "id": "MedicationAdministration.identifier", "path": "MedicationAdministration.identifier", "short": "Identificador único", "definition": "External identifier. Identifiers associated with this Medication Administration that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate. They are business identifiers assigned to this resource by the performer or other systems and remain constant as the resource is updated and propagates from server to server.", "min": 1 }, { "id": "MedicationAdministration.identifier.system", "path": "MedicationAdministration.identifier.system", "short": "Sistema para identificar el origen", "definition": "Formato: urn:regcess:[CódigoREGCESS]\r\nDebe incluir el código REGCESS después de urn:regcess:", "min": 1, "constraint": [ { "key": "regcess-system", "severity": "warning", "human": "system debe comenzar por urn:regcess: seguido del identificador del sistema.", "expression": "matches('^urn:regcess:[A-Za-z0-9]+$')" } ] }, { "id": "MedicationAdministration.identifier.value", "path": "MedicationAdministration.identifier.value", "short": "Identificador interno del sistema para el consumo de medicamento en el hospital", "definition": "Debe indicar el ID interno del sistema de origen utilizado para el consumo de medicamento en el hospital.", "min": 1 }, { "id": "MedicationAdministration.medication", "path": "MedicationAdministration.medication", "short": "Medicación", "definition": "What was administered. Identifies the medication that was administered. This is either a link to a resource representing the details of the medication or a simple attribute carrying a code that identifies the medication from a known list of medications.", "type": [ { "code": "CodeableReference", "targetProfile": [ "https://unicas-fhir.sanidad.gob.es/StructureDefinition/UNICASMedication" ] } ], "binding": { "strength": "extensible", "description": "Value set de Fármacos", "valueSet": "https://unicas-fhir.sanidad.gob.es/ValueSet/Farmacos" } }, { "id": "MedicationAdministration.medication.concept", "path": "MedicationAdministration.medication.concept", "short": "Fármaco", "definition": "Reference to a concept (by class). A reference to a concept - e.g. the information is identified by its general class to the degree of precision found in the terminology.", "min": 1 }, { "id": "MedicationAdministration.medication.concept.coding.system", "path": "MedicationAdministration.medication.concept.coding.system", "short": "URL del SNOMED CT. Extensión para España del SNS | OID del ATC | OID del DCSA", "definition": "Posibles URLs y/o OIDs de terminología utilizada para indicar el fármaco y su descripción correspondiente:\r\n\r\n- SNOMED CT. Extensión para España del SNS con filtro aplicado al eje producto: http://snomed.info/sct/900000001000122104\r\n- ATC: urn:oid:2.16.724.4.21.5.15.1\r\n- DCSA: urn:oid:2.16.724.4.21.5.14.3", "min": 1 }, { "id": "MedicationAdministration.medication.concept.coding.code", "path": "MedicationAdministration.medication.concept.coding.code", "short": "Código del fármaco", "min": 1 }, { "id": "MedicationAdministration.medication.concept.coding.display", "path": "MedicationAdministration.medication.concept.coding.display", "short": "Descripción del fármaco", "definition": "Representation defined by the system. A representation of the meaning of the code in the system, following the rules of the system.", "min": 1 }, { "id": "MedicationAdministration.medication.concept.text", "path": "MedicationAdministration.medication.concept.text", "short": "Nombre comercial", "definition": "Plain text representation of the concept. A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user." }, { "id": "MedicationAdministration.medication.reference", "path": "MedicationAdministration.medication.reference", "short": "Referencia al fármaco", "definition": "Reference to a resource (by instance). A reference to a resource the provides exact details about the information being referenced." }, { "id": "MedicationAdministration.medication.reference.reference", "path": "MedicationAdministration.medication.reference.reference", "short": "Referencia recurso FHIR", "definition": "Formato: [base]/Medication?code=[URL del SNOMED CT. Extensión para España del SNS o urn:oid del ATC o DCSA]|[Código del fármaco]" }, { "id": "MedicationAdministration.medication.reference.type", "path": "MedicationAdministration.medication.reference.type", "short": "Tipo de recurso FHIR", "definition": "Type the reference refers to (e.g. \"Patient\") - must be a resource in resources. The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.\n\nThe type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. \"Patient\" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources)." }, { "id": "MedicationAdministration.medication.reference.display", "path": "MedicationAdministration.medication.reference.display", "short": "Nombre comercial", "definition": "Text alternative for the resource. Plain text narrative that identifies the resource in addition to the resource reference." }, { "id": "MedicationAdministration.subject", "path": "MedicationAdministration.subject", "short": "Referencia al paciente", "definition": "Who received medication. The person or animal or group receiving the medication.", "type": [ { "code": "Reference", "targetProfile": [ "https://unicas-fhir.sanidad.gob.es/StructureDefinition/UNICASPatient" ] } ] }, { "id": "MedicationAdministration.subject.reference", "path": "MedicationAdministration.subject.reference", "short": "Referencia recurso FHIR. Identificador de la referencia del recurso FHIR asociado cuando exista/creamos un recurso en el mismo servidor FHIR", "definition": "Formato: [base]/Patient?identifier=[OID registro de número de CIP-SNS]|[Número CIP-SNS]" }, { "id": "MedicationAdministration.subject.type", "path": "MedicationAdministration.subject.type", "short": "Tipo de recurso FHIR", "definition": "Type the reference refers to (e.g. \"Patient\") - must be a resource in resources. The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.\n\nThe type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. \"Patient\" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).", "min": 1 }, { "id": "MedicationAdministration.subject.identifier", "path": "MedicationAdministration.subject.identifier", "short": "Identificador de paciente CIP-SNS. Cuando no tengamos recurso Patient, se debera informar el identificador de paciente mediante CIP-SNS", "definition": "Logical reference, when literal reference is not known. An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.", "min": 1 }, { "id": "MedicationAdministration.subject.identifier.type", "path": "MedicationAdministration.subject.identifier.type", "short": "Tipos de documentos de identificación para persona ÚNICAS", "definition": "Description of identifier. A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.", "binding": { "strength": "extensible", "description": "Value set de Tipos de documentos de identificación para persona ÚNICAS", "valueSet": "https://unicas-fhir.sanidad.gob.es/ValueSet/TiposDocumentosIdentificacionPersona" } }, { "id": "MedicationAdministration.subject.identifier.type.coding.system", "path": "MedicationAdministration.subject.identifier.type.coding.system", "short": "URL del SNOMED CT. Extensión para España del SNS", "definition": "Posible URL de terminología utilizada para indicar el tipo de documentos de identificación y su descripción correspondiente:\r\n\r\n- SNOMED CT. Extensión para España del SNS: http://snomed.info/sct/900000001000122104" }, { "id": "MedicationAdministration.subject.identifier.type.coding.code", "path": "MedicationAdministration.subject.identifier.type.coding.code", "short": "Código del identificador" }, { "id": "MedicationAdministration.subject.identifier.type.coding.display", "path": "MedicationAdministration.subject.identifier.type.coding.display", "short": "Decripción del identificador", "definition": "Representation defined by the system. A representation of the meaning of the code in the system, following the rules of the system." }, { "id": "MedicationAdministration.subject.identifier.system", "path": "MedicationAdministration.subject.identifier.system", "short": "OID registro de número de CIP-SNS", "definition": "The namespace for the identifier value. Establishes the namespace for the value - that is, an absolute URL that describes a set values that are unique." }, { "id": "MedicationAdministration.subject.identifier.value", "path": "MedicationAdministration.subject.identifier.value", "short": "Número CIP-SNS", "definition": "The value that is unique. The portion of the identifier typically relevant to the user and which is unique within the context of the system." }, { "id": "MedicationAdministration.subject.display", "path": "MedicationAdministration.subject.display", "short": "Nombre completo del paciente", "definition": "Text alternative for the resource. Plain text narrative that identifies the resource in addition to the resource reference." }, { "id": "MedicationAdministration.encounter", "path": "MedicationAdministration.encounter", "short": "Referencia a la interacción clínica", "definition": "Encounter administered as part of. The visit, admission, or other contact between patient and health care provider during which the medication administration was performed.", "type": [ { "code": "Reference", "targetProfile": [ "https://unicas-fhir.sanidad.gob.es/StructureDefinition/UNICASEncounter" ] } ] }, { "id": "MedicationAdministration.encounter.reference", "path": "MedicationAdministration.encounter.reference", "short": "Referencia recurso FHIR", "definition": "Formato: [base]/Encounter?identifier=urn:regcess:[CódigoREGCESS]|[Id interno del sistema para la interacción clínica]" }, { "id": "MedicationAdministration.encounter.type", "path": "MedicationAdministration.encounter.type", "short": "Tipo de recurso FHIR", "definition": "Type the reference refers to (e.g. \"Patient\") - must be a resource in resources. The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.\r\n\r\nThe type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. \"Patient\" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources)." }, { "id": "MedicationAdministration.encounter.identifier", "path": "MedicationAdministration.encounter.identifier", "short": "Identificador del recurso FHIR", "definition": "Logical reference, when literal reference is not known. An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference." }, { "id": "MedicationAdministration.encounter.identifier.system", "path": "MedicationAdministration.encounter.identifier.system", "short": "Sistema para identificar el origen", "definition": "Formato: urn:regcess:[CódigoREGCESS]\r\nDebe incluir el código REGCESS después de urn:regcess:" }, { "id": "MedicationAdministration.encounter.identifier.value", "path": "MedicationAdministration.encounter.identifier.value", "short": "Identificador interno del sistema para la interacción clínica", "definition": "Debe indicar el ID interno del sistema de origen utilizado para la interacción clínica" }, { "id": "MedicationAdministration.occurence[x]", "path": "MedicationAdministration.occurence[x]", "short": "Fecha de inicio del tratamiento y/o Fecha de fin del tratamiento (Duración del tratamiento)", "type": [ { "code": "Period" } ] }, { "id": "MedicationAdministration.occurence[x].start", "path": "MedicationAdministration.occurence[x].start", "short": "Fecha de inicio del tratamiento", "definition": "Starting time with inclusive boundary. The start of the period. The boundary is inclusive.", "min": 1 }, { "id": "MedicationAdministration.occurence[x].end", "path": "MedicationAdministration.occurence[x].end", "short": "Fecha de fin del tratamiento", "definition": "End time with inclusive boundary, if not ongoing. The end of the period. If the end of the period is missing, it means no end was known or planned at the time the instance was created. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time." }, { "id": "MedicationAdministration.recorded", "path": "MedicationAdministration.recorded", "short": "Fecha de la prescripción", "definition": "When the MedicationAdministration was first captured in the subject's record. The date the occurrence of the MedicationAdministration was first captured in the record - potentially significantly after the occurrence of the event." }, { "id": "MedicationAdministration.performer", "path": "MedicationAdministration.performer", "short": "Profesional sanitario que realizó la prescripción", "definition": "Who or what performed the medication administration and what type of performance they did. The performer of the medication treatment. For devices this is the device that performed the administration of the medication. An IV Pump would be an example of a device that is performing the administration. Both the IV Pump and the practitioner that set the rate or bolus on the pump can be listed as performers.", "min": 1 }, { "id": "MedicationAdministration.performer.actor", "path": "MedicationAdministration.performer.actor", "short": "Referencia al profesional sanitario", "definition": "Who or what performed the medication administration. Indicates who or what performed the medication administration.", "type": [ { "code": "CodeableReference", "targetProfile": [ "https://unicas-fhir.sanidad.gob.es/StructureDefinition/UNICASPractitionerRole", "https://unicas-fhir.sanidad.gob.es/StructureDefinition/UNICASPractitioner" ] } ] }, { "id": "MedicationAdministration.performer.actor.reference", "path": "MedicationAdministration.performer.actor.reference", "short": "Referencia al profesional sanitario", "definition": "Reference to a resource (by instance). A reference to a resource the provides exact details about the information being referenced." }, { "id": "MedicationAdministration.performer.actor.reference.reference", "path": "MedicationAdministration.performer.actor.reference.reference", "short": "Referencia recurso FHIR. Identificador de la referencia del recurso FHIR asociado cuando exista/creamos un recurso en el mismo servidor FHIR", "definition": "Formato: [base]/Practitioner?identifier=[OID registro de DNI]|[Número DNI]" }, { "id": "MedicationAdministration.performer.actor.reference.type", "path": "MedicationAdministration.performer.actor.reference.type", "short": "Tipo de recurso FHIR", "definition": "Type the reference refers to (e.g. \"Patient\") - must be a resource in resources. The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.\n\nThe type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. \"Patient\" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).", "min": 1 }, { "id": "MedicationAdministration.performer.actor.reference.identifier", "path": "MedicationAdministration.performer.actor.reference.identifier", "short": "Identificadores del profesional sanitario. Cuando no tengamos recurso Practitioner, se debera informar el identificador del profesional sanitario mediante DNI como dato mínimo. Adicionalmente, se puede informar el número colegiado del profesional sanitario como dato recomendado", "definition": "Logical reference, when literal reference is not known. An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.", "min": 1 }, { "id": "MedicationAdministration.performer.actor.reference.identifier.extension:numeroColegiadoProfesionalSanitario", "path": "MedicationAdministration.performer.actor.reference.identifier.extension", "sliceName": "numeroColegiadoProfesionalSanitario", "type": [ { "code": "Extension", "profile": [ "https://unicas-fhir.sanidad.gob.es/StructureDefinition/NumeroColegiadoProfesionalSanitario" ] } ], "isModifier": false }, { "id": "MedicationAdministration.performer.actor.reference.identifier.type", "path": "MedicationAdministration.performer.actor.reference.identifier.type", "short": "Tipos de documentos de identificación para persona ÚNICAS", "definition": "Description of identifier. A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.", "binding": { "strength": "extensible", "description": "Value set de Tipos de documentos de identificación para persona ÚNICAS", "valueSet": "https://unicas-fhir.sanidad.gob.es/ValueSet/TiposDocumentosIdentificacionPersona" } }, { "id": "MedicationAdministration.performer.actor.reference.identifier.type.coding.system", "path": "MedicationAdministration.performer.actor.reference.identifier.type.coding.system", "short": "URL del refset Tipos de documento para identificación personal de SNOMED CT. Extensión para España del SNS", "definition": "Posible URL de terminología utilizada para indicar el tipo de documentos de identificación y su descripción correspondiente:\r\n\r\n- Refset Tipos de documento para identificación personal del SNOMED CT. Extensión para España del SNS: http://snomed.info/sct/900000001000122104?fhir_vs-refset/900000251000122107" }, { "id": "MedicationAdministration.performer.actor.reference.identifier.type.coding.code", "path": "MedicationAdministration.performer.actor.reference.identifier.type.coding.code", "short": "Código del identificador" }, { "id": "MedicationAdministration.performer.actor.reference.identifier.type.coding.display", "path": "MedicationAdministration.performer.actor.reference.identifier.type.coding.display", "short": "Decripción del identificador", "definition": "Representation defined by the system. A representation of the meaning of the code in the system, following the rules of the system." }, { "id": "MedicationAdministration.performer.actor.reference.identifier.system", "path": "MedicationAdministration.performer.actor.reference.identifier.system", "short": "OID registro de DNI", "definition": "The namespace for the identifier value. Establishes the namespace for the value - that is, an absolute URL that describes a set values that are unique." }, { "id": "MedicationAdministration.performer.actor.reference.identifier.value", "path": "MedicationAdministration.performer.actor.reference.identifier.value", "short": "Número del DNI", "definition": "The value that is unique. The portion of the identifier typically relevant to the user and which is unique within the context of the system." }, { "id": "MedicationAdministration.performer.actor.reference.display", "path": "MedicationAdministration.performer.actor.reference.display", "short": "Nombre completo del profesional sanitario", "definition": "Text alternative for the resource. Plain text narrative that identifies the resource in addition to the resource reference." }, { "id": "MedicationAdministration.dosage", "path": "MedicationAdministration.dosage", "min": 1 }, { "id": "MedicationAdministration.dosage.text", "path": "MedicationAdministration.dosage.text", "short": "Comentarios para el farmacéutico", "definition": "Free text dosage instructions e.g. SIG. Free text dosage can be used for cases where the dosage administered is too complex to code. When coded dosage is present, the free text dosage may still be present for display to humans.\r\rThe dosage instructions should reflect the dosage of the medication that was administered." }, { "id": "MedicationAdministration.dosage.route", "path": "MedicationAdministration.dosage.route", "short": "Vía de administración", "definition": "Path of substance into body. A code specifying the route or physiological path of administration of a therapeutic agent into or onto the patient. For example, topical, intravenous, etc.", "binding": { "strength": "extensible", "description": "Value set de Vías de administración farmacológica", "valueSet": "https://unicas-fhir.sanidad.gob.es/ValueSet/ViasAdministracionFarmacologica" } }, { "id": "MedicationAdministration.dosage.route.coding.system", "path": "MedicationAdministration.dosage.route.coding.system", "short": "OID del Nomenclátor de Prescripción AEMPS. Vía de administración", "definition": "Posible OID de catálogo utilizado para indicar la vía de administración farmacológica y su descripción correspondiente:\r\n\r\n- Nomenclátor de Prescripción AEMPS. Vía de administración: urn:oid:2.16.724.4.21.5.14.2" }, { "id": "MedicationAdministration.dosage.route.coding.code", "path": "MedicationAdministration.dosage.route.coding.code", "short": "Código de la vía de administración farmacológica" }, { "id": "MedicationAdministration.dosage.route.coding.display", "path": "MedicationAdministration.dosage.route.coding.display", "short": "Descripción de la vía de administración farmacológica", "definition": "Representation defined by the system. A representation of the meaning of the code in the system, following the rules of the system." }, { "id": "MedicationAdministration.dosage.dose", "path": "MedicationAdministration.dosage.dose", "short": "Dosis del medicamento", "definition": "Amount of medication per dose. The amount of the medication given at one administration event. Use this value when the administration is essentially an instantaneous event such as a swallowing a tablet or giving an injection.", "min": 1 }, { "id": "MedicationAdministration.dosage.dose.value", "path": "MedicationAdministration.dosage.dose.value", "short": "Número de dosis", "definition": "Numerical value (with implicit precision). The value of the measured amount. The value includes an implicit precision in the presentation of the value." }, { "id": "MedicationAdministration.dosage.dose.unit", "path": "MedicationAdministration.dosage.dose.unit", "short": "Unidad de dosis", "definition": "Unit representation. A human-readable form of the unit." }, { "id": "MedicationAdministration.dosage.dose.system", "path": "MedicationAdministration.dosage.dose.system", "short": "URL del catálogo UCUM", "definition": "- Unified Code for Units of Measure (UCUM): http://unitsofmeasure.org" }, { "id": "MedicationAdministration.dosage.dose.code", "path": "MedicationAdministration.dosage.dose.code", "short": "Código de la unidad de la dosis", "definition": "Coded form of the unit. A computer processable form of the unit in some unit representation system." }, { "id": "MedicationAdministration.dosage.rate[x]", "path": "MedicationAdministration.dosage.rate[x]", "short": "Frecuencia de tomas (Posología)", "definition": "Dose quantity per unit of time. Identifies the speed with which the medication was or will be introduced into the patient. Typically, the rate for an infusion e.g. 100 ml per 1 hour or 100 ml/hr. May also be expressed as a rate per unit of time, e.g. 500 ml per 2 hours. Other examples: 200 mcg/min or 200 mcg/1 minute; 1 liter/8 hours.", "min": 1, "type": [ { "code": "Quantity" } ] }, { "id": "MedicationAdministration.dosage.rate[x].value", "path": "MedicationAdministration.dosage.rate[x].value", "short": "Frecuencia de la toma durante el período", "definition": "Numerical value (with implicit precision). The value of the measured amount. The value includes an implicit precision in the presentation of the value." }, { "id": "MedicationAdministration.dosage.rate[x].unit", "path": "MedicationAdministration.dosage.rate[x].unit", "short": "Unidad de frecuencia de la toma durante el período", "definition": "Unit representation. A human-readable form of the unit." }, { "id": "MedicationAdministration.dosage.rate[x].system", "path": "MedicationAdministration.dosage.rate[x].system", "short": "URL del catálogo UCUM", "definition": "- Unified Code for Units of Measure (UCUM): http://unitsofmeasure.org" }, { "id": "MedicationAdministration.dosage.rate[x].code", "path": "MedicationAdministration.dosage.rate[x].code", "short": "Código de la unidad de frecuencia de la toma durante el período", "definition": "Coded form of the unit. A computer processable form of the unit in some unit representation system." } ] } }