This page is part of the FHIR Specification (v0.01: Historical Archive Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

Prescription

Directions provided by a prescribing practitioner for a specific medication to be administered to an individual.

The relative url is /prescriptions

Content

UML Image

<Prescription xmlns="http://www.hl7.org/fhir">
  <id> mand id Master Resource Id, always first in all resources</id>
  <identifier> mand Zero+ HumanId Prescription identification</identifier>
  <status> mand code Status: Active|Completed</status>
  <patient> mand (Patient) Patient receiving medicine</patient>
  <prescriber> mand (Agent) Prescribing doctor</prescriber>
  <prescribed> mand dateTime Date/time prescribed</prescribed>
  <dispense> opt  <!-- Details of included dispense request -->
   <repeats> opt integer Number of repeats</repeats>
   <quantity> mand Quantity Quantity per repeat</quantity>
   <dispenser> opt (Agent|Organization) Person to fullfil the requested dispense</dispenser>
  </dispense>
  <medicine> mand  <!-- Prescribed medicine -->
   <productCode> cond Coding Coded representation of medicine</productCode>
   <description> cond string Textual description of medicine</description>
   <activeIngredient> opt  <!-- Zero+ Active substance -->
    <productCode> mand Coding Coded representation of active ingredient</productCode>
    <quantity> opt Ratio Relative quantity of active ingredient</quantity>
   </activeIngredient>
   <inactiveIngredient> opt  <!-- Zero+ Inactive substance -->
    <productCode> mand Coding Coded representation of inactive ingredient</productCode>
    <quantity> opt Ratio Relative quantity of inactive ingredient</quantity>
   </inactiveIngredient>
  </medicine>
  <administrationRequest> mand  <!-- Instructions for use -->
   <description> opt string Textual instructions for use</description>
   <totalPeriodicDosis> opt Ratio Total periodic dosis</totalPeriodicDosis>
   <start> cond dateTime Startdate for administration</start>
   <end> cond dateTime Enddate for administration</end>
   <duration> cond Quantity Total duration of administration</duration>
   <numberOfAdministrations> cond integer Maximum number of separate administrations</numberOfAdministrations>
   <dosageInstruction> mand  <!-- One+ Dosage instruction -->
    <precondition> opt Zero+ CodeableConcept Precondition for starting administration</precondition>
    <prn> opt code Pro re nate: Yes|No</prn>
    <additionalInstruction> opt Zero+ CodeableConcept Additional instructions</additionalInstruction>
    <route> opt CodeableConcept Route of administration</route>
    <dose[x]> mand Quantity|Interval(Quantity) Dose per administration</dose[x]>
    <rate> opt Quantity Flow-rate for IV</rate>
    <schedule> mand One+ Schedule Schedule for administration</schedule>
   </dosageInstruction>
  </administrationRequest>
  <reason> opt CodeableConcept Reason for prescription</reason>
  <extensions> opt See Extensions   See Extensions </extensions>
  <text> mand Narrative Text summary of the prescription, for human interpretation</text>
</Prescription>

Schema for Prescription and an example (or formatted for browser)

Terminology Bindings

Notes:

RESTful Transactions

TODO

There is no content model for the response, except for an HTTP status code.

Searching Criteria

The following simple search/filter parameters are defined for prescription:

patient The identity of a patient to list prescriptions for
prescriber The identity of a prescriber to list prescriptions from
startdate Return only prescriptions made starting from this date
enddate Return only prescriptions made before this date
id search id in any prescription identifiers

The standard search parameters also apply (see Searching).

Formal Definitions

The formal definitions for the elements above. Also available as an XML file.

Prescription
DefinitionDirections provided by a prescribing practitioner for a specific medication to be administered to an individual
ControlMandatory, 1..1
RequirementsUsed to record details about the prescribed medication, administration schedule, dosage and dispensing.
RIM MappingSubstanceAdministration
Prescription.id
DefinitionMaster Resource Id, always first in all resources
ControlMandatory, 1..1
Typeid
Prescription.identifier
DefinitionA identifier used in an external system and associated with this medication
ControlMandatory, 0..*
TypeHumanId
Must Understandtrue
RequirementsPrescriptions are almost always assigned specific numerical identifiers
RIM Mapping.id
Prescription.status
DefinitionActual status of the prescription
ControlMandatory, 1..1
Typecode from PrescriptionStatus
Must Understandtrue
RIM Mapping.statusCode
Prescription.patient
DefinitionThe patient the prescription is prescribing medicine for
ControlMandatory, 1..1
TypeResource(Patient)
Must Understandtrue
Prescription.prescriber
DefinitionThe clinician or doctor prescribing the medication
ControlMandatory, 1..1
TypeResource(Agent)
Prescription.prescribed
DefinitionDate/time on which the prescription was written
ControlMandatory, 1..1
TypedateTime
Prescription.dispense
DefinitionDetails of the dispense as requested by the prescriber
ControlOptional, 0..1
Prescription.dispense.repeats
DefinitionRequested number of repeats
ControlOptional, 0..1
Typeinteger
CommentsDefault is "1"
Prescription.dispense.quantity
DefinitionRequested quantity per repeat
ControlMandatory, 1..1
TypeQuantity
Prescription.dispense.dispenser
DefinitionPerson to fullfil the requested dispense
ControlOptional, 0..1
TypeResource(Agent|Organization)
Prescription.medicine
DefinitionThe one single medicatine, vaccine or therapeutic good prescribed in this prescription.
ControlMandatory, 1..1
Prescription.medicine.productCode
DefinitionCoded representation of medicine
ControlConditional, 0..1: Can only be left empty if it cannot be coded
TypeCoding from MedicationKind
Must Understandtrue
To DoConformance should be "Required", not "Optional"
Prescription.medicine.description
DefinitionTextual description of medicine, including strength and ingredients
ControlConditional, 0..1: Mandatory when medication cannot be coded
Typestring
Prescription.medicine.activeIngredient
DefinitionThe substance in the medication formulation that is pharmaceutically active and is responsible for the medication's therapeutic effect
ControlOptional, 0..*
Prescription.medicine.activeIngredient.productCode
DefinitionCoded representation of active ingredient
ControlMandatory, 1..1
TypeCoding from MedicationKind
Prescription.medicine.activeIngredient.quantity
DefinitionQuantity of active ingredient expressed in relation to the whole of the prepared medicine
ControlOptional, 0..1
TypeRatio
Prescription.medicine.inactiveIngredient
DefinitionIngredients in the medication that are not active
ControlOptional, 0..*
Prescription.medicine.inactiveIngredient.productCode
DefinitionCoded representation of the inactive ingredient
ControlMandatory, 1..1
TypeCoding from MedicationKind
Prescription.medicine.inactiveIngredient.quantity
DefinitionQuantity of inactive ingredient expressed in relation to the whole of the prepared medicine
ControlOptional, 0..1
TypeRatio
Prescription.administrationRequest
DefinitionInstructions for the use of the medication. Includes details about the timing schedule, dosis amounts and additional usage instructions.
ControlMandatory, 1..1
Prescription.administrationRequest.description
DefinitionTextual description of the use of the medication.
ControlOptional, 0..1
Typestring
CommentsCan contain more details than the structured information under this element, but must be in accordance with it. May not contain information about the medicine itself.
Prescription.administrationRequest.totalPeriodicDosis
DefinitionTotal dose per day/week or other period when more specific information is missing or cannot be expressed using the timing specifications.
ControlOptional, 0..1
TypeRatio
RequirementsIt should be possible, as a last resort, to specify e.g. a daily dosis, even if more specific details are unknown
Prescription.administrationRequest.start
DefinitionFirst moment on which medication should be taken
ControlConditional, 0..1: Duration is given OR (Start is given AND (Duration OR End is given)) OR (Duration, Start and End are not given)
TypedateTime
Prescription.administrationRequest.end
DefinitionLast moment on which medication should be taken
ControlConditional, 0..1: Duration is given OR (Start is given AND (Duration OR End is given)) OR (Duration, Start and End are not given)
TypedateTime
Prescription.administrationRequest.duration
DefinitionTotal duration of administration
ControlConditional, 0..1: Duration is given OR (Start is given AND (Duration OR End is given)) OR (Duration, Start and End are not given)
TypeQuantity
Prescription.administrationRequest.numberOfAdministrations
DefinitionMaximum number of separate administrations before the instruction ends.
ControlConditional, 0..1: Can be given instead of Duration, as specified above
Typeinteger
Prescription.administrationRequest.dosageInstruction
DefinitionSpecification of dose and schedule for administration
ControlMandatory, 1..*
CommentsThe can be >1 dosage instruction to support administration of varying doses, resulting in 1 instruction per fixed dose.
Prescription.administrationRequest.dosageInstruction.precondition
DefinitionPrecondition for starting the administration specified in this instruction
ControlOptional, 0..*
TypeCodeableConcept from AdministrationPrecondition
Prescription.administrationRequest.dosageInstruction.prn
DefinitionPro re nate, "If necessary": Specifies whether administration depens on the state and symptoms of the patient
ControlOptional, 0..1
Typecode from BooleanYesNo
CommentsDefault is "false"
Prescription.administrationRequest.dosageInstruction.additionalInstruction
DefinitionAdditional details to guide administration. Especially relevant for medicine administered by patient
ControlOptional, 0..*
TypeCodeableConcept from AdministrationInstruction
Prescription.administrationRequest.dosageInstruction.route
DefinitionRoute of administration (oral, nasal, intravenous)
ControlOptional, 0..1
TypeCodeableConcept from AdministrationRoute
CommentsSince the route of administration is generally determined by the choice of medication, it is not necessary to provide a value in route
Prescription.administrationRequest.dosageInstruction.dose[x]
DefinitionDose per administration, expressed in units of the (prepared) product
ControlMandatory, 1..1
TypeQuantity|Interval(Quantity)
CommentsDose may be an interval, "2-3 tablets per 4 hours"
Prescription.administrationRequest.dosageInstruction.rate
DefinitionFlow-rate for IV
ControlOptional, 0..1
TypeQuantity
Prescription.administrationRequest.dosageInstruction.schedule
DefinitionSchedule for administration. If multiple are given, they are considered to be active in parrallel
ControlMandatory, 1..*
TypeSchedule
CommentsWill submit proposal to change Schedule type.
Prescription.reason
DefinitionDiagnosis which is the reason for prescribing this medicine
ControlOptional, 0..1
TypeCodeableConcept from PrescriptionReason
Prescription.extensions
DefinitionSee Extensions
ControlOptional, 0..1
Prescription.text
DefinitionText summary of the prescription, for human interpretation
ControlMandatory, 1..1
TypeNarrative

This is an old version of FHIR retained for archive purposes. Do not use for anything else
Implementers are welcome to experiment with the content defined here, but should note that the contents are subject to change without prior notice.
© HL7.org 2011 - 2012. FHIR v0.01 generated on Mon, May 14, 2012 09:48+1000.