Gives information about the Medications and Medical Devices section
Important: This specification is based on the Professional Records Standards Body's Pharmacy information flows standard which provides further information on document headings and content: https://theprsb.org/standards/pharmacyinformationflows1and2/
Medications and Medical Devices Section Content
The Medications and medical devices section carries information about the patient’s medication. PRSB Elements should be formatted as subheadings in any HTML sent. For more information on constructing medication lists see constructing clinical coded structures.
MEDICATIONS AND MEDICAL DEVICES | |||||
---|---|---|---|---|---|
Data Item | Description | Cardinality | Values | Mandatory/required/ optional | FHIR Target |
Supply type | A description of the type of supply (e.g. emergency supply, over the counter medication, patient group direction etc) | 0 TO 1 | Emergency supply Minor ailments scheme Over the counter Patient group direction Prescription dispensing Private prescription dispensing Self declared | Required | Composition.section.text |
Medication name | May be generic name or brand name (as appropriate). | 1 ONLY | Choice of • Text • Coded text (needs to be GS1 code mapped to DM+D)– constraint: MedicationName. Any AMP/VMP/VTM/AMPP/VMPP subsets from the dm+d terminology. NHS dm+d AMP ::352201000001139 NHS dm+d AMPP ::352401000001135 NHS dm+d VMP ::352701000001133 NHS dm+d VMPP ::352601000001138. Constraint binding: [dm+d]subset=NHS_dm+d | Mandatory | MedicationStatement.medication[x]. medicationReference.Medication.Name |
Form | Eg capsule, drops, tablet, lotion etc. | 0 TO 1 | Choice of • Text • Coded text – constraint: DrugDoseForm. SNOMED CT CfH DoseForm termset. Any descendant of 421967003 drug dose form. Constraint binding: [SNOMED CT]subset=CfH DoseForm | Optional | MedicationStatement.medication[x]. medicationReference.Medication.form |
Site | The anatomical site at which the medication is to be used, including laterality. | 0 TO 1 | Choice of • Text • Coded text – constraint: SiteOfMedicationAdministration. Any valid site for the administration of a medication. Constraint binding: [SNOMED-CT]subset= SiteOfMedicationAdministration | Optional | MedicationStatement.dosage.site |
Indication | Reason for medication being supplied, where known. | 0 TO 1 | This will be free text or SNOMED CT subset | Required | Composition.section.text |
Total amount of medication supplied | A description of the total amount of medication supplied e.g 30 tablets, 100ml etc. | 1 ONLY | Recorded in a structured format i.e. a unit (eg ml, tablet, etc.) and a value (eg 100, 1, 0.5 etc.) . | Required | Composition.section.text |
Dose directions description | A single plain text phrase describing the entire medication dosage and administration directions including dose quantity and medication frequency. Comment, eg, “1 tablet at night or “2mg at 10pm”. This is the form of dosage direction text normally available from UK GP Systems. | 0 TO 1 | This will be free text. | Optional | MedicationStatement.dosage.text |
Additional instructions | Allows for: * requirements for adherence support, e.g., compliance aids, prompts and packaging requirements * additional information about specific person requirements, e.g., unable to swallow tablets.medicines, e.g., where specific brand required | 0 TO MANY | This will be free text | Optional | Composition.section.text |
Date/time | The date/time on which the medication was supplied to the patient. | 0 TO 1 | The date/time as recorded by the pharmacy system. | Required | MedicationStatement.effective |
Example Medications and Medical Devices Section
Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.
Examples are illustrative only.
<!--<xml>-->
<section>
<title value="Medications and medical devices"/>
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="933361000000108"/>
<display value="Medications and medical devices"/>
</coding>
</code>
<text>
<status value="additional"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table width="100%">
<tbody>
<tr>
<th>Supply type</th>
<td>A description of the type of medication being supplied (e.g. emergency supply, over the counter medication, patient group direction etc.).</td>
</tr>
<tr>
<th>Medication name</th>
<td>BD Viva hypodermic insulin needles for pre-filled / reusable pen injectors screw on 5mm/31gauge (Becton, Dickinson UK Ltd)</td>
</tr>
<tr>
<th>Form</th>
<td>capsule</td>
</tr>
<tr>
<th>Site</th>
<td>"Mouth"</td>
</tr>
<tr>
<th>Indication</th>
<td>Reason for medication being prescribed, where known.</td>
</tr>
<tr>
<th>Total amount of medication supplied</th>
<td>30 tablets</td>
</tr>
<tr>
<th>Dose directions description</th>
<td>I tablet at night" or "20mg at 10pm"</td>
</tr>
<tr>
<th>Additional instructions</th>
<td>Allows for: <br> - requirements for adherence support, e.g., compliance aids, prompts and packaging requirements <br> - additional information about specific person requirements, e.g., unable to swallow tablets.medicines, e.g., where specific brand required</td>
</tr>
<tr>
<th>Date/time</th>
<td>The date/time on which the medication was supplied to the patient.</td>
</tr>
</tbody>
</table>
</div>
</text>
<!--reference to further information carried in the medication dispense list resource-->
<entry>
<reference value="urn:uuid:4bc7faea-5974-407a-b658-d6ed1d4c9187"/>
</entry>
</section>
<!--</xml>-->
Coded Resources
This text section should be linked to the following FHIR Resources to provide the textual information in a coded format.
- List
- MedicationDispense
- Medication
See constructing clinical coded structures - Medication Dispense List