Medications
Pharmacologic agent used in the diagnosis, cure, mitigation, treatment, or prevention of disease.
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- RxNorm® Full Monthly Release, July 1, 2024
Optional: - National Drug Code (NDC), July 16, 2024
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Dose
Amount of a medication for each administration.
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Dose Unit of Measure
Unit of measure of a medication. Examples include but are not limited to milligram (mg) and milliliter (mL).
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- The Unified Code for Units of Measure, Revision 2.1
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Route of Administration
Physiological administration path of a therapeutic agent into or onto a patient. Examples include but are not limited to oral, topical, and intravenous.
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- SNOMED Clinical Terms® (SNOMED CT®) U.S. Edition, March 2024 Release
- National Cancer Institute Thesaurus (NCIt) v24.04e, FDA Structured Product Labeling (SPL) Terminology
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Indication
Sign, symptom, or medical condition that is the reason for giving or taking a medication.
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- SNOMED Clinical Terms® (SNOMED CT®) U.S. Edition, March 2024 Release
- International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) 2024
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Fill Status
State of a medication with regards to dispensing or other activity. Examples include but are not limited to dispensed, partially dispensed, and not dispensed.
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Medication Instructions
Directions for administering or taking a medication. Usage note: May include route, quantity, timing/frequency, and special instructions (PRN, sliding scale, taper). Examples include but are not limited to prescription directions for taking a medication, and package instructions for over-the-counter medications.
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Medication Adherence
Statement of whether a medication has been consumed according to instructions. Examples include but are not limited to taking as directed, taking less than directed, and not taking.
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- SNOMED Clinical Terms® (SNOMED CT®) U.S. Edition, March 2024 Release
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Submitted by aphillips@imoh… on
Data Class: Medications
IMO would like to note while many the proposed Level 2 data elements for the Medication data class are collected and exchanged by ONC certified HIT, not all the proposed Level 2 data elements meet ONC criteria for inclusion in USCDI V3. We have categorized our review of the proposed data elements by these criteria.
Data Elements for Medications: Meet Level 2 Critiera
These data elements are incorporated in eCQMs reported in CMS quality programs, represented in implemented terminology specifications, and incorporated in requirements for ONC Certified HIT.
Data Elements for Medications: Do Not Meet Level 2 Critiera
The following technical specifications are cited in support of proposed Level 2 data elements. These technical specifications vary in maturity and do not yet have widespread implementation in ONC Certified Health IT. Specifications include:
As the technical specifications that include these proposed data elements mature and are implemented in production environments these data elements could be reconsidered in future versions of USCDI.