Overview of the Digital Medicines headings

Overview

This section provides a list of the PRSB headings used for text sections in the ITK3 FHIR Digital Medicines Vaccinations notification based on the “Standards for the clinical structure and content of patient records” documentation.

This section lists the following

  • The headings used
  • An overview of the type of information carried within the text section
  • An example of a text section instance
  • A list of the coded resources which may be used to give the text carried in the section in a coded format.

Typical Text Section Content

This diagram shows the elements of a typical text section which is found in the FHIR Composition Resource. Note: the examples of section HTML in this specification show only example HTML format such as tables. This is an exemplar format. There is no mandated format for the section HTML.

Must Support Property

Some elements in the Composition Resource used within ITK3 Digital Medicines documents have the “mustSupport” property set to “true”.
These are :

  • Composition.encounter
  • Composition.custodian
  • Composition.section(slice) sections: Attendance details, Consent, Referrer details

The “mustSupport” property has been added to all the elements that must be supported regardless of cardinality. Whether the conformance of the element is mandatory or optional has no relevance for the “mustSupport” property. This means that for sending or receiving systems to claim conformance to any ITK3 Digital Medicines Composition Profile the following MUST be true:

  • The sending system MUST support the creation and sending of all the elements in the list above.
  • The sending system MUST support the creation and sending of all Composition.section slices with the specified sub-elements and narrative.* See Note 2.
  • The receiving system MUST support the processing of all the elements in the list above.
  • The receiving system MUST support the display of all Composition.section slices with the specified sub-elements and narrative.

Note 2 - There are rules around when sections are sent or not sent in a document. These are specified in the document headings sections.

Headings used by Common Headings

These headings are common across all the Digital Medicines document types, so are documented once under the Common Headings menu.

Each document may have specific requirements around common headings, for example Attendance Details has an additional “Person collecting the medicine” header when used for Emergency Supply & Digital Minor Illness Referral Service. These specific requirements are documented on each common header.

Each document type may have supplementary headers that are found under the specific document types listed below

Headings Used By Vaccinations Administration Document

Section Name SNOMED Concept Cardinality Conformance Associated Coded Profiles
Allergies and adverse reactions 886921000000105 0..1 Optional 1
Attendance details 1077881000000105 0..1 Required 1
Consent 61861000000100 0..1 Required 0
Distribution list 887261000000109 0..1 Required 7
Eligibility criteria 61871000000107 0..1 Optional 1
GP practice 886711000000101 1..1 Mandatory 1
History 717121000000105 0..1 Optional 0
Information and advice given 1052951000000105 0..1 Optional 0
Patient demographics 886731000000109 1..1 Mandatory 1
Referral details 886721000000107 0..1 Required 0
Vaccinations 1102181000000102 1..* Mandatory 0

Headings Used By Emergency Supply Document

Section Name SNOMED Concept Cardinality Conformance Associated Coded Profiles
Allergies and adverse reactions 886921000000105 0..1 Optional 1
Attendance details 1077881000000105 0..1 Required 1
Consent 61861000000100 0..1 Required 0
Distribution list 887261000000109 0..1 Required 7
GP practice 886711000000101 1..1 Mandatory 1
History 717121000000105 0..1 Required 0
Information and advice given 1052951000000105 0..1 Required 0
Medications and medical devices 933361000000108 1..1 Mandatory 2
Patient demographics 886731000000109 1..1 Mandatory 1
Plan and requested actions 887201000000105 0..1 Required 0
Referral details 886721000000107 0..1 Required 0

Headings Used By New Medicine Service Document

Section Name SNOMED Concept Cardinality Conformance Associated Coded Profiles
Allergies and adverse reactions 886921000000105 0..1 Optional 1
Attendance details 1077881000000105 0..1 Required 1
Consent 61861000000100 0..1 Required 0
Distribution list 887261000000109 0..1 Required 7
Eligibility criteria 61871000000107 0..1 Optional 1
GP practice 886711000000101 1..1 Mandatory 1
History 717121000000105 0..1 Required 0
Medications and medical devices 933361000000108 1..1 Mandatory 2
Patient demographics 886731000000109 1..1 Mandatory 1
Plan and requested actions 887201000000105 0..1 Required 0

Headings Used By Medication Review Headings Document

Section Name SNOMED Concept Cardinality Conformance Associated Coded Profiles
Allergies and adverse reactions 886921000000105 0..1 Optional 1
Attendance details 1077881000000105 0..1 Required 1
Consent 61861000000100 0..1 Required 0
Distribution list 887261000000109 0..1 Required 7
Eligibility criteria 61871000000107 0..1 Optional 1
GP practice 886711000000101 1..1 Mandatory 1
History 717121000000105 0..1 Required 0
Information and advice given 1052951000000105 0..1 Required 0
Medications and medical devices 933361000000108 1..1 Mandatory 2
Patient demographics 886731000000109 1..1 Mandatory 1
Plan and requested actions 887201000000105 0..1 Required 0
Referral details 886721000000107 0..1 Required 0

Headings Used By DMIRS Headings Document

Section Name SNOMED Concept Cardinality Conformance Associated Coded Profiles
Allergies and adverse reactions 886921000000105 0..1 Optional 1
Attendance details 1077881000000105 0..1 Required 1
Clinical narrative 1077901000000108 0..1 Required 0
Consent 61861000000100 0..1 Required 0
Distribution list 887261000000109 0..1 Required 7
GP practice 886711000000101 1..1 Mandatory 1
History 717121000000105 0..1 Required 0
Information and advice given 1052951000000105 0..1 Required 0
Medications and medical devices 933361000000108 1..1 Mandatory 2
Patient demographics 886731000000109 1..1 Mandatory 1
Plan and requested actions 887201000000105 0..1 Required 0
Presenting complaint or issue 886891000000102 0..1 Required 0
Referral details 886721000000107 0..1 Required 0

Headings Used By Appliance Use Review Document

Section Name SNOMED Concept Cardinality Conformance Associated Coded Profiles
Allergies and adverse reactions 886921000000105 0..1 Optional 1
Appliances 334251007 1..1 Mandatory 1
Attendance details 1077881000000105 0..1 Required 1
Consent 61861000000100 0..1 Required 0
Distribution list 887261000000109 0..1 Required 7
GP practice 886711000000101 1..1 Mandatory 1
History 717121000000105 0..1 Required 0
Information and advice given 1052951000000105 0..1 Required 0
Patient demographics 886731000000109 1..1 Mandatory 1
Plan and requested actions 887201000000105 0..1 Required 0
Referral details 886721000000107 0..1 Required 0
Tags: fhir