M3.1. Medication - Third Party Prescriptions

The following table describes the use of medication statements and related classes to convey information about medication prescription or supplied by a third party such as a hospital out patient department or GP in another practice.

MedicationStatement (MedicationStatement)

A statement that represents the a record of a prescription for a therapeutic substance or appliance.

[1..1] classCode (CS){ Fixed="SBADM " }

[1..1] moodCode (CS) {CNE:ORD or EVN}

[1..1] id (II)

An instance identifier of this statement represented using the Identifier Global flavour of the II data type.

[1..1] statusCode (CS) {CNE:EhrMedicationState}

If the prescription/supply record is valid (i.e. believed to be accurate) the status is "complete".

The other possible values ("obsolete" and "nullified") are only used if the record was subsequently corrected or deleted due an error.

[1..1] availabilityTime (TS)

The date and time of recording this prescribing action.

[0..1] pertinentInformation (MedicationStatement/pertinentInformation)

Relationship to the prescribed dosage.

[1..1] typeCode (CS){ Fixed="PERT " }

[1..1] MedicationDosage (MedicationDosage)

Details of the dosage.

[1..1] classCode (CS){ Fixed="SBADM " }

 Indicates that this is a substance administration action.

[1..1] moodCode (CS) {CNE:RMD}

Indicates that this is a dosage recommendation..

[1..1] text (ED)

A textual description of the dosage instructions.

Note

• At present there is no provision for structured representation of dosage. This information is not available on the sending systems and is not included in current UK electronic prescribing. However, should structured data be required this could be supported by adding the doseQuantity and effectiveTime to represent the quantity and frequency of individual doses. If necessary routeCode could also be added.

[1..1] consumable (MedicationStatement/consumable)

Include this to identify the nature of the product.

[1..1] typeCode (CS){ Fixed="CSM " }

[1..1] manufacturedProduct (ManufacturedProduct)

Details of the medicinal product prescribed.

• May include, drugs, nutritional supplements, devices used to administer drugs, dressing, appliances, diagnostic reagents, etc.

[1..1] classCode (CS){ Fixed="MANU " }

 Indicates that this is a manufactured product.

[1..1] manufacturedMaterial (Material)

Information about the material or substance that forms the medicinal product.

[1..1] Material

The details of a medicinal product.

[1..1] classCode (CS){ Fixed="MMAT " }

Indicates that this is a manufactured material.

[1..1] determinerCode (CS) {CNE:KIND}

Indicates that this represents a kind of material.

[1..1] code (CE)

The code representing the nature of the product as one of the following:

• virtual medicinal product
• virtual medicinal product pack
• actual medicinal product
• actual medicinal product pack.

If the native coding scheme for medicinal product is the Read Codes then the appropriate code is represented using the Coded with Original Text flavour of the data type CE. Otherwise the Coded Translated flavour should be used with the medicinal product represented in the coding system used  in the sending system with a translation to an appropriate (possibly more generalised) Read Code.

Note

• The source of these codes should eventually be an agreed UK medicinal product dictionary.

[0..1] quantity (PQ)

The quantity of the product.

• Express simple quantities such as "100 ml" or "3 grams" using Quantity in Standard Units.
• Express numbers of tablets, capsules, etc. where the item is explicit elsewhere using Quantity in Standard Units with the unit "1" (unity).
• Express quantities that cannot be represented adequately using standard units using Quantity in Arbitrary Units.

[0..*] participant (EhrStatement/participant)

Refers to the third party (person or organisation) who prescribed or supplied the product.

[1..1] typeCode (CS) {CNE:PRF}

Identifies that this agent performed the associated action..

[1..1] time (TS)

The date and time of prescribing or supply to the level of accuracy known.

[1..1] AgentRef (AgentRef)

A reference to a role which contains detailed information about the third party prescriber/supplier.

[1..1] classCode (CS){ Fixed="AGNT " }

Indicates that this is a reference to a related agent.

[1..1] id (II)

The unique instance identifier of the referenced role as specified in the role directory.

• If a message contains several Folders, the referenced role directory is in the same Folder as the component that refers to it.

[0..1] component (MedicationStatement/component)

For third party prescription or supplies an instance of MedicationStatement/component containing a minimal instance of the Prescribe or Dispense class may be included to the record the quantity prescribed or supplied (if known).

Relationship to details of the prescribing or supply action.

This is included only if the dispensing and prescribing actions are recorded together. Otherwise the prescription is referenced by the Dispense/inFulfillmentOf relationship.

[1..1] typeCode (CS){ Fixed="COMP " }

[1..1] EhrSupply (EhrSupply)

EITHER

Prescribe

Details of the prescription see Supply - Prescribe

OR

Dispense

Details of dispensing see Supply - Dispense.