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|
|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.medicationReference.Medication.code|
|Form||E.g. 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||Required||MedicationStatement.medicationReference.Medication.form|
|Route||Medication administration description (oral, IM, IV, etc.): may include method of administration, (e.g., by infusion, via nebuliser, via NG tube).||0 TO MANY||• Coded text – constraint: NHS e-prescribing route of administration subset ID: 413001000001136 Original Id : 30201000001137 This is an extract from the SUBSET -BiAnnual-Drug-15.0.1-20130401: SnomedCT_GB1000001_20130401/Subsets/EPrescribing/NHS e-Prescribing route of administration subset. Constraint binding: [SNOMED-CT]subset=NHS e-Prescribing route of administration subset||Required||MedicationStatement.dosage.route|
|Indication||Reason for medication being prescribed, where known.||0 TO 1||This will be free text or SNOMED CT subset||Required||MedicationStatement.reasonCode|
|Dose directions description||A single plain text phrase describing the entire medication dosage and administration directions including dose quantity and medication frequency. Comment, e.g., “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||Free text||Required||MedicationStatement.dosage.text|
|Matters identified during the discussion||Matters identified during the service about the patient’s experience of using the medication. To include e.g., patient using/not using the medicine as prescribed, patient reports side effects, patient reports negative feelings about the medication etc.||1 TO MANY||Coded text using the following descriptors: a. patient not using a medicine as prescribed (non-adherence) b. problem with pharmaceutical form of a medicine or use of a device c. patient reports need for more information about a medicine or condition d. patient reports side effects or other concern about a medicine e. Potential drug interactions f. Potential side effects/adverse drug reaction preventing use of the medicine g. Patient reports not using the medicine any more h. Patient reports lack of efficacy i. Patient reports problem with dosage regimen j. Patient reports unresolved concern about the medicine k. other (free text information can be entered in the clinical record) l. No matters identified during medication review||Mandatory||Composition.section.text|
Example Medications and Medical Devices Section
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>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>injection</td> </tr> <tr> <th>Route</th> <td>IM</td> </tr> <tr> <th>Indication</th> <td>Reason for medication being prescribed, where known.</td> </tr> <tr> <th>Dose directions description</th> <td>I tablet at night" or "20mg at 10pm</td> </tr> <tr> <th>Matters identified during the discussion</th> <td>patient reports need for more information about the medicine</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>-->
This text section should be linked to the following FHIR Resources to provide the textual information in a coded format.
See constructing clinical coded structures - Medication Dispense List