Gives information about the Medications and medical devices section

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.

Section Description Card. MRO* FHIR Target and Guidance
Medications and Medical Devices The details of and instructions for medications and medical equipment the patient is using. 0 to 1 O Carried in the CodeableConcept of Composition.section.code FHIR element.
PRSB Element Description Card. MRO* FHIR Target and Guidance
Medication item cluster        
Medication name May be generic name or brand name (as appropriate). Mandatory medication name coded using a SNOMED CT/dm+d term where possible, allowing plain text for historical/patient reported items , extemporaneous preparations or those not registered in dm+d. Comment: e.g. "Citalopram tab 20mg", "Trimethoprim". 1 only M Text and a SNOMED CT concept carried in the CodeableConcept of the FHIR element MedicationStatement.medication[x].
medicationReference.Medication.Name
. See medication.code for further guidance.
Form Form of the medicinal substance e.g. capsules, tablets, liquid. Not normally required unless a specific form has been requested by the prescriber.  Comment: e.g. "Modified Release Capsules". 0 to 1 O Text and a SNOMED CT concept carried in the CodeableConcept of the FHIR element MedicationStatement.medication[x].
medicationReference.Medication.form
. See medication.form for further guidance.
Route Medication administration description (oral, IM, IV, etc.): may include method of administration, (e.g., by infusion, via nebuliser, via NG tube). Optional medication route, using SNOMED CT terms where possible. Not generally applicable to product-based medication. Should not be used to specify a specific administration site, for which a separate archetype is used e.g. The Route is 'intraocular' the Site may be 'Left eye'.   Comment: e.g. "Oral", "Intraocular". Note that this element supports multiple Routes to allow a choice to be specified by the prescriber. 0 to many O Text and a SNOMED CT concept carried in the CodeableConcept of the FHIR element MedicationStatement.dosage.route. See medicationStatement.dosage.route for further guidance.
Site The anatomical site at which the medication is to be administered.  Comment: e.g. "Left eye". 0 to 1 O Text and a SNOMED CT concept carried in the CodeableConcept of the FHIR element MedicationStatement.dosage.site. See medicationStatement.dosage.site for further guidance.
Method The technique or method by which the medication is to be administered. 0 to 1 O Text Only.
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. "I tablet at night" or "20mg at 10pm" This is the form of dosage direction text normally available from UK GP systems. 0 to 1 O Text within the section.narrative.text and text repeated in the FHIR element MedicationStatement.dosage.text.
Dose amount description A plain text description of medication single dose amount, as described in the AoMRC medication headings.  Comment: e.g. "30 mg" or "2 tabs". UK Secondary care clinicians and systems normally minimally structure their dose directions, separating Dose amount and Dose timing (often referred to as Dose and Frequency). This format is not normally used in GP systems, which will always import Dose and Frequency descriptions concatenated into the single Dose directions description. 0 to 1 O Text should be part of Dose directions description PRSB element and will be included as part of the FHIR element MedicationStatement.dosage.text.
Dose timing description A plain text description of medication dose frequency, as described in the PRSB medication headings.  Comment: e.g. "Twice a day", "At 8am 2pm and 10pm". UK Secondary care clinicians and systems normally minimally structure their dose directions, separating Dose amount and Dose timing (often referred to as Dose and Frequency). This format is not normally used in GP systems, which will always import Dose and Frequency descriptions concatenated into the single Dose directions description. 0 to 1 O Text should be part of Dose directions description PRSB element and will be included as part of the FHIR element MedicationStatement.dosage.text.
Text Parsable dose directions A parsable 'dose syntax' which carries dose strength, dose timing, dose duration and maximum dose information.  Comment: e.g. "20-30mg ^4/6h prn [180mg /24h]" = 20 to 30 mgs, up to 4-6 hourly as required. Maximum 180mg in 24 hours. The 'as required reason' e.g. 'for pain' should be carried in the Additional Instruction element. Note that this is generally a symptom and is not the same as the Indication which will usually describe a diagnosis or condition. Where supported, this would generally be used to exchange dosage information between systems, while Structured dose directions are likely to be used only within openEHR-based systems. 0 to 1 O DO NOT USE Data items acting as placeholders for future 'advanced' structured dose syntax solution. Insufficient information to detail these further at present.
Structured dose direction cluster A structural representation of the elements carried by the dose syntax in 'Parsable doseStrength / timing' i.e. dose strength, dose timing, dose duration and maximum dose. 0 to many O Where supported (these values)
  • Continue indefinitely [The medication should be continued indefinitely.]
  • Do not discontinue [The medication should be continued indefinitely and the prescriber highly recommends that it should never be discontinued. This is an AoMRC Clinical Headings recommendation.]
  • Stop when course complete. [The medication should be stopped when the currently prescribed course has been completed.]
  • Duration: Allowed values: years, months, weeks, days, hours >=0 days
For coded information use the FHIR element MedicationStatement.dosage.additionalInstruction.
If no codes exist use the FHIR element MedicationStatement.dosage.additionalInstruction CodeableConcept.text
Duration goes in the FHIR element MedicationStatement.effective[x].effectivePeriod
Implementation guidance: FHIR element MedicationStatement.additionalInstruction to be used as a string element for "Continue Indefinitely"; "Do not discontinue" and "Stop when course complete".
Any Duration instructions in the FHIR element MedicationStatement.effective[x].effectivePeriod or in FHIR element MedicationStatement.note as a degrade to text.
Structured dose amount cluster A structural representation of dose amount.  Comment: e.g. 20mg or 2 tablets This element will generally only be used when persisting data within systems with 'Parsable dose directions' being used to exchange the same information between systems.   O DO NOT USE - Data items acting as placeholders for future 'advanced' structured dose syntax solution. Insufficient information to detail these further at present.
Structured dose timing cluster A slot containing a structural, computable representation of dose timing and maximum dose.  Comment: This element will generally only be used when persisting data within systems with 'Parsable dose directions' being used to exchange the same information between systems.   O DO NOT USE - Data items acting as placeholders for future 'advanced' structured dose syntax solution. Insufficient information to detail these further at present.
Dose direction duration Recommendation of the time period for which the medication should be continued, including direction not to discontinue. 0 to 1 O Text in the section.narrative.text - Continue indefinitely [The medication should be continued indefinitely.]
Do not discontinue [The medication should be continued indefinitely and the prescriber highly recommends that it should never be discontinued. This is an AoMRC Clinical Headings recommendation.]
Stop when course complete. [The medication should be stopped when the currently prescribed course has been completed.]
Duration: Allowed values: years, months, weeks, days, hours >=0 days". Duration goes in the FHIR element MedicationStatement.effective[x].effectivePeriod and should be repeated in the FHIR element MedicationStatement.dosage.additionalInstruction.
Additional instruction Additional multiple dosage or administration instructions as plain text. This may include guidance to the prescriber, patient or person administering the medication. In some settings, specific Administration Instructions may be re-labelled as "Patient advice' or 'Dispensing Instruction' to capture these flavours of instruction.  Comment: e.g. "Omit morning dose on day of procedure", "for pain or fever", "Dispense weekly". 0 to many O Additional instruction [Additional multiple dosage or administration instructions as plain text. This may include guidance to the prescriber, patient or person administering the medication. In some settings, specific Administration Instructions may be re-labelled as "Patient advice' or 'Dispensing Instruction' to capture these flavours of instruction.]
Dispensing instruction [Multiple plain text to record complex dispensing arrangements, particularly for Controlled Drug instalment dispensing. 'Dispensing instructions' may be used as a specific label to overwrite 'Additional instructions' to align with legacy GP system behaviour.]
Patient advice [Multiple plain text instructions intended for patient or carer. 'Patient advice' may be used as a specific label to overwrite 'Additional instructions' to align with legacy GP system behaviour.]
Monitoring [Special instructions related to monitoring of medication, such as lab tests.]. This information is carried as text in section.narrative.text and repeated in the FHIR elements MedicationStatement.dosage.patientInstruction for specific patient instruction use and MedicationStatement.note For narrative instructions (e.g. monitoring, pain, prevention).
Medication item cluster end
Course details cluster Details of the overall course of medication. 0 to 1 O Not to be used for Hospital to GP discharge summary.
Course status The status of this prescription in an ambulatory (outpatient/GP/community) context. 0 to 1 O Choice of Coded text:
Active [This is an active medication.]
Discontinued [This is a medication that has been issued. dispensed or administered but has now been discontinued.]
Never active [A medication which was ordered or authorised but has been cancelled prior to being issued, dispensed or administered.]
Completed [The medication course has been completed.]
Obsolete [This medication order has been superseded by another.] Data items not relevant to Hospital to GP discharge summary and SHOULD NOT be used.
Start date/time The date and/or time that the medication course should begin. 0 to 1 O Date/time - Data items not relevant to Hospital to GP discharge summary and SHOULD NOT be used.
End date/time The date and/or time that the medication course should finish. 0 to 1 O Date/time. Data items not relevant to Hospital to GP discharge summary and SHOULD NOT be used.
Indication Reason for medication being prescribed, where known. 0 to 1 O A free text or code derived text term giving the clinical indication or reason for ordering the medication. Coded terms are preferable.
Comment: e.g. "Angina". The Indication generally describes a condition or diagnosis. Data items not relevant to Hospital to GP discharge summary and SHOULD NOT be used.
Link to indication record A link to the record which contains the Indication for this medication order. 0 to 1 O URL. Data items not relevant to Hospital to GP discharge summary and SHOULD NOT be used.
Comment/recommendation Suggestions about duration and/or review, ongoing monitoring requirements, advice on starting, discontinuing or changing medication. 0 to 1 O Free text. Additional comment or recommendation about the medication course e.g. 'Patient named supply', 'unlicensed medication', 'Foreign brand' or monitoring recommendations. Data items not relevant to Hospital to GP discharge summary and SHOULD NOT be used.
End of course details cluster
Medication change summary cluster Records the changes made to medication since admission 0 to 1 O  
Status The nature of any change made to the medication since admission. 0 to 1 O Text containing the strings associated with the codes as below
Continued [Medicine present on both admission and discharge with no amendments.]
Added [Medicine present on discharge but not on admission]
Amended [Medicine present on both admission and discharge but with amendment(s) since admission.] and coded using the FHIR elements in MedicationStatement.Extension
-CareConnect-MedicationChangeSummary
, These will use the status element.
Indication Reason for change in medication, e.g. sub-therapeutic dose, patient intolerant. 0 to 1 O Text is carried using the FHIR elements in MedicationStatement.Extension
-CareConnect-MedicationChangeSummary
, this will use the indicationForChange element.
Date of latest change The date of the latest change - addition, or amendment 0 to 1 O Text and carried using the FHIR elements in MedicationStatement.Extension
-CareConnect-MedicationChangeSummary
, this will use the dateChanged element.
Description of amendment Where a change is made to the medication i.e. one drug stopped and another started or e.g. dose, frequency or route is changed. 0 to 1 O Text and carried using the FHIR elements in MedicationStatement.Extension
-CareConnect-MedicationChangeSummary
, this will use the detailsOfAmendment element.
Comment Any additional comment about the medication change 0 to 1 O This heading is no longer used and comments should be included in the Description of amendment heading.
Total dose daily quantity cluster The total daily dose of this medication. This is helpful for estimating optimal adherence to dosing guidance. It may be computed from product/dose strength and frequency or entered manually. 0 to 1 O Data item not relevant to Hospital to GP discharge summary and MUST NOT be used.
Medical devices entry Any therapeutic medical device of relevance that does not have representation in the NHS dictionary of medicines and medical devices (dm+d). 0 to many O Text only.
Medication discontinued entry        
Name of discontinued medication May be generic name or brand name (as appropriate).Mandatory medication name coded using a SNOMED CT/dm+d term where possible, allowing plain text for historical/patient reported items , extemporaneous preparations or those not registered in dm+d. Comment: e.g."Citalopram tab 20mg", "Trimethoprim" 1 only M Text and a SNOMED CT concept carried in the CodeableConcept of the FHIR element MedicationStatement.medication[x].
medicationReference.Medication.Name
. See medication.code for further guidance.
Status The nature of any change made to the medication since admission. 1 M Text and carried in the FHIR element MedicationStatement.status which MUST contain the value of "stopped"
Indication The clinical indication for any changes in medication status 0 to 1 O Text and carried in the FHIR element MedicationStatement.reasonCode.
Date of latest change The date of the discontinuation 0 to 1 O Text and carried in the FHIR element MedicationStatement.effectiveDateTime.
Description of amendment A description of any amendment 0 to 1 O Text and carried in the FHIR element MedicationStatement.note.
Comment Any additional comment about the medication change. 0 to 1 O Text and may also be carried in the FHIR element "MedicationStatement.note.
* M=Mandatory R=Required O=Optional

Example Medications and Medical Devices Section

Coded Resources

This text section should be linked to the following FHIR Resources to provide the textual information in a coded format.

  • List
  • MedicationStatement
  • Medication
  • MedicationDispense

See constructing clinical coded structures - Medication Lists

Tags: fhir