MedicationPrescription-v3.0(2016EN)

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General information

Name: nl.zorg.MedicationPrescription NL.png
Version: 3.0
HCIM Status:Final
Release: 2016
Release status: Published
Release date: 1-5-2016


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Metadata

DCM::CoderList Kerngroep Registratie aan de Bron
DCM::ContactInformation.Address
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom
DCM::ContentAuthorList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::CreationDate 19-12-2013
DCM::DeprecatedDate
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name PM
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.9.5
DCM::KeywordList Medicatie, Voorschrift
DCM::LifecycleStatus Final
DCM::ModelerList Kerngroep Registratie aan de Bron
DCM::Name nl.zorg.MedicatieVoorschrift
DCM::PublicationDate 1-5-2016
DCM::PublicationStatus Published
DCM::ReviewerList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 22-5-2015
DCM::Superseeds nl.nfu.MedicatieVoorschrift-v1.0.1
DCM::Version 3.0
HCIM::PublicationLanguage EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (01-04-2015)

ZIB-56 RFC Bouwsteen Medicatie
ZIB-78 Medicatie, diverse issues
ZIB-80 OverdrachtMedicatie v1.1
ZIB-144 Aanpassingen in SNOMED CT codes en omschrijvingen voor codelijst DagdeelCodelijst n.a.v. review terminologie expert.
ZIB-145 Aanpassingen in SNOMED CT codes en omschrijvingen voor codelijst WeekdagenCodelijst n.a.v. review terminologie expert.
ZIB-308 Prefix Overdracht weggehaald bij de generieke bouwstenen
ZIB-353 Tagged values DCM::CodeSystem aanpassen naar DCM::ValueSet incl. gekoppelde codelijst.

Incl. algemene wijzigingsverzoeken:

ZIB-94 Aanpassen tekst van Disclaimer, Terms of Use & Copyrights
ZIB-154 Consequenties opsplitsing Medicatie bouwstenen voor overige bouwstenen.
ZIB-200 Naamgeving SNOMED CT in tagged values klinische bouwstenen gelijk getrokken.
ZIB-201 Naamgeving OID: in tagged value notes van klinische bouwstenen gelijk getrokken.
ZIB-309 EOI aangepast
ZIB-324 Codelijsten Name en Description beginnen met een Hoofdletter
ZIB-326 Tekstuele aanpassingen conform de kwaliteitsreview kerngroep 2015

Publicatieversie 1.0.1 (22-05-2015)

ZIB-393 Tagged value DCM::LifecycleStatus bevat waarde Draft.
ZIB-390 De OID van de codelijst WeekdagenCodelijst van het concept Weekdagen is onjuist in de onderliggende codelijst.
ZIB-377 Source/Destination van MaximumAantalPertijd en Criterium richting ZoNodig aanpassen.
ZIB-376 Inconsistent gebruik van naamgeving Ing(r)edientCodeGTINCodelijst.
ZIB-372 Concepten Mantelzorger::Contactpersoon en Toelichting uit nl.nfu.Voorschrift-v1.0 hebben hetzelfde ID.

Publicatieversie 3.0 (01-05-2016)

.

Concept

A medication prescription is an agreement or order for the use of medication in which the following are described: the prescribed product, instructions for use or administration and (optionally) a request for delivery.
The dose information is given for every prescribed product: the start date and time, and if possible stop date and time or total number of administrations, administering schedule (frequency or interval, administering times, link with meals etc.), the number of doses, administering speed or time (for drips), and the route of administration.
An indication can also be included of whether the medication is only to be administered ‘as needed’ and under which conditions the product is to be used, and how high the agreed maximum dose is in a certain period.
If possible, the reason or indication of starting/stopping/changes in use is to be included.
Medication that has been discontinued temporarily can be included as well.
If the prescription also contains the order to provide a product to a patient or to an administerer, it can officially be referred to as a prescription.

Purpose

The goal of the medication prescription is to provide insight in the therapeutic intention of the healthcare provider in terms of treatment with medicines. Furthermore, it offers the option to record any requests asking the provider of the medication to provide medication to the patient.

Evidence Base

Content-wise, the information model was made to support the national medication transfer guidelines (www.medicatieoverdracht.nl). The appendices to the guidelines describe how the structure can depend on the healthcare providers involved, the local situation and the existing preconditions. The concept guidelines provide sufficient space for this. That means that the collaborating healthcare providers draw up their own protocol, applicable to their specific situation. In other words, information details in transfers within the second line may differ from those in transfers between the first and second line, or between healthcare providers and pharmacies.

Where possible, coding within the Medication domain is based on the G standard (managed by the firm Z-index). This is because in the Netherlands, almost all software packages for electronic prescriptions, pharmacy management and medication monitoring are based on this standard. The content of the G standard is very precisely updated under the direction of the KNMP in consultation with stakeholders, including the software suppliers.

The following were taken into account in determining restrictions and instructions on information domains (value sets) to be used:
- Implementation Guidelines HL7 v3 medication information
- Data set Medication process

The results of the ‘G standard platform’ consultations between users and developers of the G standard and content experts were taken into account as well.

The information model for medication is very extensive. In simple implementations, the following are of primary importance:

  • the correct product name and coding
  • medication use (patient information)
  • the instructions, which can take the form of a prescription (with agreements on use and requests to supply the medication) or a medication order (only administering instructions)
  • dosage instructions with the route of administration, dose per administration, period of use (start and stop date), dose schedule and other administering instructions
  • the reason for prescription (prescriber information) or reason for use (patient information)
  • the status (active, interrupted, discontinued or completed)

Information Model


ContactPerson-v3.0(2016EN)Patient-v3.0(2016EN)#11004#11000#11021#11035#MedicationPrescriptionInterruptionReasonCodelist#11011#MedicationPrescriptionDiscontinuationReasonCodelist#11002#MedicationPrescriptionStatusCodelistHealthProfessional-v3.0(2016EN)#11008ConcernForTransfer-v3.0(2016EN)#11053#11006#11866MedicationPrescription-v3.0Model(2016EN).png
#PrescriptionCodeGPKCodelist#PrescriptionCodeHPKCodelist#PrescriptionCodePRKCodelist#PrescriptionCodeGTINCodelist#PrescriptionCodeZICodelist#IngredientCodeGPKCodelist#IngredientCodeHPKCodelist#IngredientCodePRKCodelist#IngredientCodezICodelist#IngredientCodeSNKCodelist#PharmaceuticalFormCodelist#IngredientCodeATCCodelist#IngredientCodeSSKCodelist#PrescriptionCodeATCCodelist#IngredientCodeGTINCodelist#11026#11024#11018#11019#11022#11020#11023#11027#11021Product-v3.0Model(2016EN).png
#PrescriptionAdministrationRouteCodelist#11048#DaysOfTheWeekCodelist#11034#TimeOfDayCodelist#11045#11042#11043#11036#11030#11046#11051#11047#11039#11044#11041#11033#11049#11038#11029#11032#11035Dosering-v3.0Model(2016EN).png
HealthProfessional-v3.0(2016EN)#11056#11052#11053Afleververzoek-v3.0Model(2016EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:9.5.1 Arrowdown.pngPrescription Root concept of the MedicationPrescription information model. This root concept contains all data elements of the MedicationPrescription information model.
Folder.png NL-CM:9.5.5 Arrowdown.pngSupplyRequest 0..1 Container of the SupplyRequest concept. This container contains all data elements of the SupplyRequest concept.

The supply request is the order placed with the supplier to supply medication. The number of refills can be indicated as well.

PQ.png NL-CM:9.5.30 Arrowright.pngAmount 0..1 The amount to be supplied defines the number of units of the ordered product that have to be supplied. The amount is given in the unit of the ordered product. The amount to be supplied is always the amount per partial supply. The number of refills indicates how often this amount is allowed to be supplied.
INT.png NL-CM:9.5.31 Arrowright.pngNumberOfRefills 0..1 Maximum number of partial supplies (refills) allowed to be given for this prescription.
Verwijzing.png NL-CM:9.5.32 Arrowright.pngIntendedSupplier::HealthcareProvider 0..1 In almost all cases, the intended supplier will be a registered pharmacist.
Block.png HealthProfessional
Folder.png NL-CM:9.5.4 Arrowdown.pngDosage 1..* Container of the Dosage concept. This container contains all data elements of the Dosage concept.

Instructions for the administerer to administer the medication (the patient themselves, a nurse or other aid). When taking stock of medication use, the dosage describes the pattern of use established by the patient.

If the dose schedule (distribution of doses over time) and the dose per administration have been determined, there will be a single instruction for use.

Multiple parallel instructions for use can be included in the event of a changing dose within one day and in the event of a variable frequency of use.

Multiple sequential instructions for use can be included in the event of changing doses within one period and/or in the event of a changing dose schedule.

TS.png NL-CM:9.5.11 Arrowright.pngStartDateTime 0..1 The date (and time) at which use of the product started or will start according to the dose information.
TS.png NL-CM:9.5.12 Arrowright.pngENdDateTime 0..1 The end date of a dose (specification of use). This can be an agreed date, but also the date on which use of the product was discontinued (stop date, discontinuation date).
PQ.png NL-CM:9.5.13 Arrowright.pngDurationOfUse 0..1 In some cases, it may be necessary to indicate the intended duration of use, which cannot be calculated from the start date, end date and/or total number of doses. This could for example be the case with temporary sleep medication to be taken as needed.
INT.png NL-CM:9.5.14 Arrowright.pngNumberOfDoses 0..1 In many cases, the total number of doses indicates the desired duration of use.
PQ.png NL-CM:9.5.15 Arrowright.pngDose 0..1 The administration dose indicates the dose amount per administration.

The dosage is described in the unit accompanying the product; usually, this is just a number of units or doses. Liquids and other divisible products will usually include a unit of volume (preferably "ml").

In many cases, the prescriber will want to indicate the dose in units of weight of the active substance.

If only the substance is included and not the product, the amount of that substance will be given. Paracetamol 1000mg is equivalent to 2 Paracetamol 500mg tablets (or units).

The dosage is sometimes given as a calculation, in which the patient’s body weight or body surface area is often used as a parameter. The calculation is however no more than an aid in reaching a decision.

In the event of constant administration, sometimes the dose per administration (e.g. 20ml in a syringe or 500ml in a bag) is given in addition to the administration speed (rate of infusion), but it is often also omitted.

A general dosage recommendation such as ‘Use according to protocol’ or ‘See instructions’ can be sufficient. In that case, no dose per administration is given either.

CD.png NL-CM:9.5.16 Arrowright.pngRouteOfAdministration 1 The route through which the medication is to be administered (oral, nasal, intravenous,...).
List2.png PrescriptionAdministrationRouteCodelist
PQ.png NL-CM:9.5.17 Arrowright.pngInfusionRate 0..1 The rate of infusion is used in slow administration of liquids. In practice, the measuring unit is almost always ml/hour.

Entering an interval (such as 0-10 ml/hour) is also a commonly used option.

PQ.png NL-CM:9.5.18 Arrowright.pngDuration 0..1 The duration of administration indicates how long the medication is to be administered and used in the event of slow administration of liquids.
ST.png NL-CM:9.5.19 Arrowright.pngAdditionalExplanation 0..1 The additional explanation contains extra information on the use of or considerations for the current prescription.

This can also include all instructions for use. The text can come from the original "paper" medication prescription, but can also be generated from the coded information.

This concept may contain more information than what is structurally coded in the information below, but may not conflict with it. The instructions may not conflict with other components of the request for administration.

The instructions can also refer to an existing protocol.

The G standard contains many texts that can support this attribute, in for example G standard table 362, which contains texts from the general practitioners’ standard WCIA table 25. If desired, these texts can be used to structure this concept.

ST.png NL-CM:9.5.20 Arrowright.pngCondition 0..1 The condition for administering medication can be:
  • a physiological measurement value (plasma glucose concentration, body temperature, blood pressure);
  • a symptom or other circumstance (in the event of a headache, or itch).

Such a criterion will be entered in correspondence with the AsNeeded indicator.

PQ.png NL-CM:9.5.21 Arrowright.pngMaximumDosePerTimeUnit 0..1 The MaximumAmountPerPeriod concept indicates the maximum duration a product can be used with an 'as needed' prescription.
BL.png NL-CM:9.5.22 Arrowright.pngAsNeeded 0..1 Indicates whether the dose is only to be administered under certain conditions.
Folder.png NL-CM:9.5.23 Arrowdown.pngAdministeringSchedule 0..1 Container of the AdministeringSchedule concept. This container contains all data elements of the AdministeringSchedule concept.

Specifications of the times at which the medication is administered/is to be administered. This is indicated as follows:

  • Time(s) (16:00) or indications ("before meals") at which the medication is to be taken each day.
  • A specific number of times the medication is to be taken each day ("3x a day"), indicated with the frequency
  • A time interval between consecutive doses ("Every 2 hours", "every 3 days"), indicated with the word Interval.
  • Combined periods with an interval and duration ("1 daily for three out of four weeks: the pill schedule")

If a certain medication is not to be taken daily, the aforementioned can be combined with daily indications:

  • One or more days of the week on which the medication is to be administered (e.g. "Monday, Wednesday, Friday")
  • "3x a week", "2x a month".

The specified administration "infinite" will automatically be repeated until:

  • The end date and time has been reached
  • The total administration duration has been reached (for 14 days)
  • A specific amount of administrations has been reached ("20 doses", "one-time only"), to be entered in the NumberOfDoses concept.
PQ.png NL-CM:9.5.24 Arrowright.pngFrequency 0..1 The frequency indicates the number of dose moments per time unit, usually per day. If this frequency is included, then the Interval will not have been included.

In that case, a reasonable distribution throughout the day is expected, but exact times are not given. This is left to the patient. It is the most common type of extramural prescription. In the case of Baxter packs and intramural care, such a prescription is used to draw up a (location-specific) outline for distribution times (logistics).

PQ.png NL-CM:9.5.25 Arrowright.pngInterval 0..1 Interval indicates the time between dose times. If this is included, the Frequency will not have been included.

Examples: every 4 hours, every 3 weeks.

The times can now be chosen freely, but distribution throughout the day is more precise, and the interval between times is important (e.g. in the case of antibiotics) In the case of Baxter packs and intramural care, such a prescription is used to draw up a (location-specific) outline for distribution times (logistics).

TS.png NL-CM:9.5.26 Arrowright.pngAdministrationTime 0..* The time of administration is a specific time of day (on the clock). This time usually isn’t (intended to be) exact. There can be multiple administering times in one day.

The intended time of administration can also be entered as a time of day (morning, afternoon, evening, night-time). The administration time is then to be left empty, and the time of day can be entered in the TimeOfDay concept.

CD.png NL-CM:9.5.27 Arrowright.pngDaysOfTheWeek 0..* DaysOfTheWeek indicates a pattern of doses on fixed days of the week.
List2.png DaysOfTheWeekCodelist
CD.png NL-CM:9.5.28 Arrowright.pngTimeOfDay 0..* To make prescriptions easier for the patient and to facilitate transfers between first and second line, it is best to indicate a time of day instead of a set time.

To code a time of day in the administering schedule, agreements were made between the first and second line to be able to clearly translate the first-line WCIA 21 code to standard times of day in clinical second-line medication assignments. In this process, the following times of day apply:

WCIA Second line morning 6:00am - 12:00pm afternoon 12:00pm - 6:00pm evening 6:00pm - 12:00am night-time 12:00am - 6:00am

List2.png TimeOfDayCodelist
Folder.png NL-CM:9.5.6 Arrowdown.pngMedication 1 Container of the Product concept. This container contains all data elements of the Product concept.

The prescribed product is usually a medicine. However, medical aids and bandages can also be prescribed and supplied via the pharmacy. Strictly speaking, food and blood products do not belong in the medication category, but can be prescribed and supplied by a pharmacy as well.

A type of medication can be indicated with a single code. That code can be chosen from several possible coding systems (concretely: GPK, PRK, HPK or article numbers). Correct use of these codes in the software systems will sufficiently record the composition of the product used, making a complete product specification unnecessary.

In addition to a primary code, alternative codes from other coding systems can also be entered (so that the GPK can be sent along in the event that the patient was registered based on PRK, for example).

Entering multiple ingredients will enable you to display a compound product. If one of the composite parts is liquid, the dosage will be given in milliliters; otherwise it will be given in ‘units’.

In that case, the composition of the medication can be specified implicitly (with the use of a medication code) or explicitly, for example by listing the (active) substance(s) of the medication.

Prescriptions to be prepared by the pharmacy can be entered as well. This can be done by means of the option listed above to enter coded ingredients and/or by entering the composition and preparation method as free text.

CD.png NL-CM:9.5.33 Arrowright.pngMedicationCode 0..* Coding medication in the Netherlands is done on the basis of the G standard (issued by Z-index), which is filled under the direction of KNMP.

The coded medication can be expressed as:

  • GTIN International Article Number
  • KNMP article number = ATKODE (2.16.840.1.113883.2.4.4.8)
  • Trade product code (HPK)
  • Prescription code (PRK)
  • Generic product code (GPK)
  • Anatomic Therapeutic Classification code (ATC)
  • SNOMED CT code
  • 90.000.000 number (individual code setting) (or similar from the facility)

The GTIN enables identification of the product including its origin with a barcode. The ATKODE is the number with which wholesalers link the article to pharmacy systems (e.g. a box with 3 strips of 10 tablets). The HPK is the code for the trade product (with the brand name) as used per dose/per time the medication is taken (1 pill, 1 puff, 1ml) The PRK codes for the same product as the HPK does, but is not linked to a manufacturer (no brand name, no characteristics such as color, geometrical shape etc.). This code will enable a generic prescription, while still defining which trade product can be taken (e.g. a 200ml bag). The generic product code defines the composition of a product, and is sufficient for recording the prescription, but not the order.

The prescription code (PRK) was developed and added to the older generic (GPK) and supplier-specific (HPK, ATKODE) coding to enable a generic product to be entered without listing a specific brand on the one hand, and to enable providing enough information to support the pharmacy supplying it on the other.

The GTIN coding is used for the implementation of a barcode scanning standard and to be able to trace the origin of the product.

The 90.000.000 number is used in accordance with national agreements.

List2.png PrescriptionCodeATCCodelist
List2.png PrescriptionCodeGPKCodelist
List2.png PrescriptionCodeGTINCodelist
List2.png PrescriptionCodeHPKCodelist
List2.png PrescriptionCodePRKCodelist
List2.png PrescriptionCodeZICodelist
Folder.png NL-CM:9.5.34 Arrowdown.pngProductSpecifications 0..1 Container of the ProductSpecifications concept. This container contains all data elements of the ProductSpecifications concept.

Product specifications are required if the product code is not sufficient to ascertain the active substances and strength.

ST.png NL-CM:9.5.35 Arrowright.pngMedication 0..1 There is no code for medication entered in free text. In these cases, enter the complete description.
ST.png NL-CM:9.5.36 Arrowright.pngBrandName 0..1 If the ProductCode does not contain a brand name, the brand name can be entered in this concept.
CD.png NL-CM:9.5.37 Arrowright.pngPharmaceuticalForm 0..1 The pharmaceutical form indicates the form of the medication in accordance with the route of administration. Examples include: tablet, suppository, infusion liquid, ointment. If the product has a generic code in the G standard, the form will be known in the G standard. For products without a code (free text, preparation by the pharmacy), the means of administration can be entered.
List2.png PharmaceuticalFormCodelist
Folder.png NL-CM:9.5.38 Arrowdown.pngIngredient 0..* Container of the Ingredient concept. This container contains all data elements of the Ingredient concept.

A product contains one or more active substances and excipients. These are usually determined by the product code. For medication prepared or compounded by the local pharmacy, each ingredient must be entered separately.

The active substances play an important role, as they: a) determine the pharmacotherapeutic effect of the medication and b) serve as the basis for the indication of the strength of the medication (e.g. 200mg).

PQ.png NL-CM:9.5.39 Arrowright.pngStrength 1 The amount of absorbed active substance or addition per unit of product. This could be a concentration if the medication is dissolved in liquid, for example.
CD.png NL-CM:9.5.40 Arrowright.pngIngredientCode 1 Active substance or excipient.

Here, the same codes can be used as for the ProductCode (for dilutions and compounds in particular), but now, the ATC, SSK and SNK codes can also be used to indicate a substance (to list ingredients of local products prepared by the pharmacy).

  • GTIN International Article Number
  • KNMP article number
  • Trade product code (HPK)
  • Prescription code (PRK)
  • Generic product code (GPK)
  • ATC (anatomic therapeutic classification)
  • SSK (substance name code with route of administration)
  • SNK (substance name code)

The ATC is an international classification of pharmaceutical substances without a reference to specific products on the market. Therefore, the ATC code of a generic product will not contain a reference to a certain dose, pharmaceutical form or route of administration; it will only contain a reference to the ingredients (not the amount/concentration/strength).

List2.png IngredientCodeATCCodelist
List2.png IngredientCodeGPKCodelist
List2.png IngredientCodeGTINCodelist
List2.png IngredientCodeHPKCodelist
List2.png IngredientCodePRKCodelist
List2.png IngredientCodeSNKCodelist
List2.png IngredientCodeSSKCodelist
List2.png IngredientCodezICodelist
CD.png NL-CM:9.5.7 Arrowright.pngMedicationPrescriptionStatus 1 The MedicationPrescriptionStatus indicates whether the prescription is actively used, temporarily interrupted, or by now discontinued. The status describes the consecutive stages of the prescription process and is important for the indication of the schedule for use.

Interrupting (home) use often occurs in the event of admittance to a healthcare facility, prior to a procedure and in response to monitoring (level determination, effect measurements, etc.).

When documenting this, the following interpretations are used:

  • Active: The product is used.
  • Interrupted: Use has (temporarily) been interrupted, because of a surgical procedure, for example. Later, the patient and/or doctor can decide whether or not to resume or discontinue use.
  • Discontinued: There is an assignment or agreement to discontinue use.
  • Completed: The prescription has now been completed (according to the plan, prescription or agreement).
List2.png MedicationPrescriptionStatusCodelist
CD.png NL-CM:9.5.8 Arrowright.pngMedicationPrescriptionDiscontinuationReason 0..1 Reason for discontinuing the use of a certain medicine.
List2.png MedicationPrescriptionDiscontinuationReasonCodelist
CD.png NL-CM:9.5.9 Arrowright.pngMedicationPrescriptionInterruptionReason 0..1 Reason for interrupting the use of a certain medicine.
List2.png MedicationPrescriptionInterruptionReasonCodelist
TS.png NL-CM:9.5.10 Arrowright.pngMedicationPrescriptionDate 1 Date on which the prescription was issued.
Verwijzing.png NL-CM:9.5.2 Arrowright.pngReasonForPrescription 0..1 The medical reason for the prescription or for use of the medication. This can be used to enter a medical indication which was the direct cause for prescription or for use of the medication in question.

It can concern every type of problem (or condition) of the patient, almost always a diagnosis, complaint or symptom.

Please note: The BST401T file of the G standard contains a "special reference" to indicate that "exchange of the reason for prescription is essential".

Block.png ConcernForTransfer
Folder.png NL-CM:9.5.41 Arrowdown.pngPrescriber 1 Container of the Prescriber concept. This container contains all data elements of the Prescriber concept.

The person who prescribed the prescription.

Verwijzing.png NL-CM:9.5.3 Arrowright.pngHealthcareProvider (0..1) The healthcare provider responsible for the prescription.
Block.png HealthProfessional
Verwijzing.png NL-CM:9.5.42 Arrowright.pngPatient (0..1) The patient who prescribed their own product.
Block.png Patient
Verwijzing.png NL-CM:9.5.43 Arrowright.pngCaregiver::Contact (0..1) The caregiver who prescribed the product.
Block.png ContactPerson
ST.png NL-CM:9.5.44 Arrowright.pngExplanation 0..1 Comments on the medication prescription.

Columns Concept and DefinitionCode: hover over the values for more information
For explanation of the symbols, please see the legend page List2.png

Example Instances

Only available in Dutch

DatumMedicatieVoorschrift Product Dosering Voorschrijver Medicatie
VoorschriftStatus
MedicatieReden
VanOnderbreken
ProductNaam StartDatum Toedieningsschema ToedieningsWeg Keerdosis Zorgverlener
Frequentie Naamgegevens
18-09-2012 Carbasalaatcalcium poeder 100mg 18-09-2012 1x/dag Oraal 100mg (=1st) C. Dols Onderbroken Geplande ingreep
DatumMedicatieVoorschrift Product Dosering Voorschrijver Medicatie
VoorschriftStatus
RedenVan
Voorschrijven
ProductNaam StartDatum Toedieningsschema ToedieningsWeg Keerdosis Zorgverlener ProbleemNaam
Frequentie | Weekdagen | Toedientijd Naamgegevens
01-03-2012 Methotrexaat invlst 25mg/ml amp 2ml 01-03-2012 1x/wk op maandag(14u) iv 50mg (=2ml) B. Takken Actief Autoimmuunziekte

References

1. GROOT, E. (2011) Dataset medicatieproces 2011. [Online] Den Haag: Nictiz. Beschikbaar op: http://www.nictiz.nl/module/360/590/Dataset_Medicatieproces_2011.xlsx [Geraadpleegd: 23 juli 2014].

2. HL7v3-implementatiehandleiding medicatieproces versie 6.1.0.0. [Online] Den Haag: Nictiz. Beschikbaar op: http://www.nictiz.nl/uploaded/FILES/html_cabinet/live/Zorgtoepassing/Medicatieproces/AORTA_Mp_IH_Medicatieproces_HL7.htm [Geraadpleegd: 23 juli 2014].

3. Dossier Medicatieoverzicht. [Online] Beschikbaar op: Oria.nl. [Geraadpleegd: 23 juli 2014].

4. G-standaard documentatie. [Online] Beschikbaar op: http://www.z-index.nl/ [Geraadpleegd: 23 juli 2014].

Valuesets

DaysOfTheWeekCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.5.4 Binding:
Conceptname Conceptcode Codesystem name Codesystem OID Description
Monday 307145004 SNOMED CT 2.16.840.1.113883.6.96 maandag
Tuesday 307147007 SNOMED CT 2.16.840.1.113883.6.96 dinsdag
Wednesday 307148002 SNOMED CT 2.16.840.1.113883.6.96 woensdag
Thursday 307149005 SNOMED CT 2.16.840.1.113883.6.96 donderdag
Friday 307150005 SNOMED CT 2.16.840.1.113883.6.96 vrijdag
Saturday 307151009 SNOMED CT 2.16.840.1.113883.6.96 zaterdag
Sunday 307146003 SNOMED CT 2.16.840.1.113883.6.96 zondag

IngredientCodeATCCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.5.14 Binding:
Conceptname Codesystem name Codesystem OID
Alle waarden Anatomic Therapeutic Classification (ATC) 2.16.840.1.113883.6.73

IngredientCodeGPKCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.5.16 Binding:
Conceptname Codesystem name Codesystem OID
Alle waarden G-Standaard Generieke Product Kode (GPK) 2.16.840.1.113883.2.4.4.1

IngredientCodeGTINCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.5.21 Binding:
Conceptname Codesystem name Codesystem OID
Alle waarden Global Trade Item Number (GTIN) 1.3.160

IngredientCodeHPKCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.5.17 Binding:
Conceptname Codesystem name Codesystem OID
Alle waarden G-Standaard Handels Product Kode (HPK) 2.16.840.1.113883.2.4.4.7

IngredientCodePRKCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.5.18 Binding:
Conceptname Codesystem name Codesystem OID
Alle waarden G-Standaard Voorschrijfproducten (PRK) 2.16.840.1.113883.2.4.4.10

IngredientCodeSNKCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.5.15 Binding:
Conceptname Codesystem name Codesystem OID
Alle waarden G-standaard Stofnaamcode (SNK) 2.16.840.1.113883.2.4.4.1.750

IngredientCodeSSKCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.5.19 Binding:
Conceptname Codesystem name Codesystem OID
Alle waarden G-standaard Stofnaamcode i.c.m. toedieningsweg (SSK) 2.16.840.1.113883.2.4.4.1.725

IngredientCodezICodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.5.12 Binding:
Conceptname Codesystem name Codesystem OID
Alle waarden G-Standaard Artikelen (ook KNMP-nummer, ATKODE) 2.16.840.1.113883.2.4.4.8

MedicationPrescriptionDiscontinuationReasonCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.5.2 Binding:
Conceptname Conceptcode Codesystem name Codesystem OID Description
Intolerance SINTOL ActReason 2.16.840.1.113883.5.8 Bijwerking, allergie of intolerantie
Condition alert [Proposed therapy may be inappropriate or contraindicated due to an existing/recent patient condition or diagnosis] COND ActCode 2.16.840.1.113883.5.4 Contra-indicatie [comorbiditeit, diagnose]
Drug interacts with another drug SDDI ActReason 2.16.840.1.113883.5.8 Interactie [interactie met ander medicament met hogere urgentie]
Dose change DOSECHG ActReason 2.16.840.1.113883.5.8 Dosiswijziging
No longer required for treatment NOREQ ActReason 2.16.840.1.113883.5.8 Niet langer vereist voor de behandeling [indicatie vervallen]
Ineffective INEFFECT ActReason 2.16.840.1.113883.5.8 Niet effectief
Formulary policy FP ActReason 2.16.840.1.113883.5.8 Ander voorschrijfbeleid
Product discontinued DISCONT ActReason 2.16.840.1.113883.5.8 Product niet meer leverbaar
Not covered NOTCOVER ActReason 2.16.840.1.113883.5.8 Product wordt niet vergoed
Patient request PAT ActReason 2.16.840.1.113883.5.8 Informatie of wens patiënt

MedicationPrescriptionInterruptionReasonCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.5.3 Binding:
Conceptname Conceptcode Codesystem name Codesystem OID Description
Drug level too high DRUGHIGH ActReason 2.16.840.1.113883.5.8 Te hoge geneesmiddel spiegel
Lab interference issues LABINT ActReason 2.16.840.1.113883.5.8 Interferentie met gepland labonderzoek
Parent is pregnant/breast feeding PREG ActReason 2.16.840.1.113883.5.8 Zwangerschap of borstvoeding
Patient not-available NON-AVAIL ActReason 2.16.840.1.113883.5.8 Patiënt is tijdelijk afwezig of ondergaat ingreep
Response to monitoring MONIT ActReason 2.16.840.1.113883.5.8 Reactie op monitoring
Drug interacts with another drug SDDI ActReason 2.16.840.1.113883.5.8 Interactie met ander medicament met hogere urgentie
Duplicate therapy SDUPTHER ActReason 2.16.840.1.113883.5.8 Een andere therapie maakt het gebruik tijdelijk overbodig
Patient scheduled for surgery SURG ActReason 2.16.840.1.113883.5.8 Geplande ingreep
Waiting for old drug to wash out WASHOUT ActReason 2.16.840.1.113883.5.8 Tijdelijk onderbreken tot ander geneesmiddel geen werking meer uitoefent

MedicationPrescriptionStatusCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.5.1 Binding:
Conceptname Conceptcode Codesystem name Codesystem OID Description
Active active ActStatus 2.16.840.1.113883.5.14 Actief
Suspended suspended ActStatus 2.16.840.1.113883.5.14 Onderbroken
Aborted aborted ActStatus 2.16.840.1.113883.5.14 Afgebroken
Completed completed ActStatus 2.16.840.1.113883.5.14 Voltooid

PharmaceuticalFormCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.5.7 Binding:
Conceptname Codesystem name Codesystem OID
Alle waarden G-Standaard Farmaceutische vormen 2.16.840.1.113883.2.4.4.11

PrescriptionAdministrationRouteCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.5.6 Binding:
Conceptname Codesystem name Codesystem OID
Alle waarden G-Standaard Toedieningswegen 2.16.840.1.113883.2.4.4.9

PrescriptionCodeATCCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.5.20 Binding:
Conceptname Codesystem name Codesystem OID
Alle waarden Anatomic Therapeutic Classification (ATC) 2.16.840.1.113883.6.73

PrescriptionCodeGPKCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.5.8 Binding:
Conceptname Codesystem name Codesystem OID
Alle waarden G-Standaard Generieke Product Kode (GPK) 2.16.840.1.113883.2.4.4.1

PrescriptionCodeGTINCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.5.11 Binding:
Conceptname Codesystem name Codesystem OID
Alle waarden Global Trade Item Number (GTIN) 1.3.160

PrescriptionCodeHPKCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.5.9 Binding:
Conceptname Codesystem name Codesystem OID
Alle waarden G-Standaard Handels Product Kode (HPK) 2.16.840.1.113883.2.4.4.7

PrescriptionCodePRKCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.5.10 Binding:
Conceptname Codesystem name Codesystem OID
Alle waarden G-Standaard Voorschrijfproducten (PRK) 2.16.840.1.113883.2.4.4.10

PrescriptionCodeZICodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.5.13 Binding:
Conceptname Codesystem name Codesystem OID
Alle waarden G-Standaard Artikelen (ook KNMP-nummer, ATKODE) 2.16.840.1.113883.2.4.4.8

TimeOfDayCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.9.5.5 Binding:
Conceptname Conceptcode Codesystem name Codesystem OID Description
During the morning 73775008 SNOMED CT 2.16.840.1.113883.6.96 s ochtends
During the afternoon 255213009 SNOMED CT 2.16.840.1.113883.6.96 s middags
During the evening 3157002 SNOMED CT 2.16.840.1.113883.6.96 s avonds
During the night 2546009 SNOMED CT 2.16.840.1.113883.6.96 s nachts

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The information in this wikipage is based on Release summer 2016
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This page is generated on 21/12/2018 15:40:02 with ZibExtraction v. 3.0.6929.24609


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