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Version: 3.1

Medication Statement

A medication statement is a record of what a patient is actually taking, has taken, or intends to take — as reported, not as ordered by your facility. It captures the real-world medication picture: drugs started at another hospital, over-the-counter products, and what a patient or relative tells you during a visit.

What it represents​

In Care's FHIR-aligned model, a medication statement maps to the MedicationStatement resource. The key distinction is its source of truth: a statement is a snapshot of reality, not an instruction. It does not order, supply, or administer anything.

So every statement carries two things a prescription does not: a single coded drug taken from a SNOMED CT value set rather than free text, and an explicit account of who said so — the patient, a relative, or a clinician. Around that core it records the status, the period the drug is or was taken, free-text dosage instructions, and the encounter it was recorded in.

If your facility is actively prescribing a drug, that belongs in a medication request. Reach for a statement when the source of truth lives outside that order — a home medication list, a drug started elsewhere, or a patient's own account of what they take.

Lifecycle​

A statement carries a single current status that reflects the patient's relationship to the medication. It is not a running log — updating the status replaces the previous value, and only the status, period, and notes can change after creation.

intended → active → on_hold → completed / stopped
                              not_taken / unknown / entered_in_error
  • intended — the patient plans to take the medication but has not started
  • active — the medication is currently being taken
  • on_hold — taking has been paused
  • completed — the course has finished as expected
  • stopped — the medication was stopped before completion
  • not_taken — the patient is not taking the medication
  • unknown — the status could not be determined
  • entered_in_error — the record was created by mistake and should be disregarded

Information source​

Because a statement is reported rather than ordered, it always names its source. This is what separates a self-reported or second-hand account from a managed prescription, and it tells a clinician how much to trust the entry.

SourceMeaning
PatientThe patient self-reported it
Related personA relative or carer reported it
PractitionerA clinician recorded it on the patient's behalf

How it connects​

  • Patient — every statement is about one patient. The patient is derived automatically from the encounter, so it is never set by hand.
  • Encounter — a statement is recorded within an encounter, anchoring it to a specific visit and clinician.
  • Medication request — the active-order counterpart. Use a medication request when your facility is the one prescribing; use a statement to capture everything else.

Permissions​

Access to medication statements is governed by the clinical-data permissions on the encounter and patient. Creating, updating, and deleting a statement all require write access to the encounter's clinical data, while listing and reading require view access to the patient's clinical data (or, when filtered by encounter, read access to that encounter's clinical data).

PermissionDescriptionSystem Roles
can_write_encounter_clinical_dataCreate, update, or delete a medication statement on an open encounterAdmin, Doctor, Nurse, Facility Admin
can_view_clinical_dataView a patient's clinical data, the primary gate for listing and reading statementsStaff, Doctor, Nurse, Admin, Facility Admin
can_read_encounter_clinical_dataRead an encounter's clinical data, the fallback gate when results are filtered to a specific encounterAdmin, Doctor, Nurse, Facility Admin

Roles are granted through a user's organization and facility memberships, and permissions cascade down the organization tree — a role held at a parent organization applies to the facilities and patients beneath it.