M4.1. Medication - Recommendations and Advice

The following table describes the use of medication statements and related classes to convey information about a recommendation for use of a particular medication without actually prescribing, supplying or administering it.

MedicationStatement (MedicationStatement)

A statement that represents the recommendation for administration of a therapeutic substance.

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

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

Indicates that this is a recommendation rather than an actual prescription.

[1..1] id (II)

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

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

If the recommendation record is valid (i.e. the recommendation was made as stated) 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 recommendation.

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

Relationship to the recommended dosage.

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

[1..1] MedicationDosage (MedicationDosage)

Details of the dosage.

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

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

If the recommendation is made by someone other than the EhrComposition/author of the containing EhrComposition the agent responsible for the recommendation is recorded here.

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

Identifies the related agent as the performer of the act of recommendation.

[1..1] time (TS)

The date and time of prescribing.

[1..1] AgentRef (AgentRef)

A reference to a role which contains detailed information about the person or other agent that made the recommendation..

[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 EhrFolder elements, the referenced role directory is in the same Folder as the component that refers to it.

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

Not applicable to recommendations.