PrescribeIT® Specification and Guide Version 5.0

An order for both supply of the medication and the instructions for administration of the medication to a patient. The resource is called "MedicationOrder" rather than "MedicationPrescription" to generalize the use across inpatient and outpatient settings as well as for care plans, etc.

For Task p170-m - Pharmacist Adapt, this conveys the adapted medication order.

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Usage Note: This will usually be a GUID and is assigned by the sending application.

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element as much as possible.

The base language in which the resource is written.

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative.

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Conformance Rule: This will be used to contain the Medication resource. No other resources should be 'contained'.

An Extension

• value @ url

Provides a textual description to convey any relevant reasons/rational related to the why the pharmacist adapted the prescription.

Conformance Rule: The Pharmacist must convey a reason for the adapted prescription.

Identifies the original Medication Order that is being adapted

Sub-categorizes medication prescriptions into drugs, devices, compounds, etc. May be used to apply sub-type-specific constraints

Conformance Rule: If no appropriate code exists, provide details using the 'text' component.

A free form textual specification generated from the input specifications as created by the provider.This is made up of either an 'Ad-hoc instruction' or 'Textual rendition of the structured dosage lines', plus route, dosage unit, and other pertinent administration information specified by the provider.

Allows the provider to verify the codified structured dosage information entered and ensure that the exploded instruction is consistent with the intended instructions. Also useful in bringing back administration instructions on query responses. This is mandatory as dosage instructions must always be available in rendered form.

Usage Note: This is intended to provide all dosage instructions to the Pharmacist in a clear human-readable format. This field will be displayed to the Pharmacist upon receipt of the prescription. Note: This must be as clear as possible and must include all instructions because the EMR may not provide individual/structured dosage instructions. When the Prescription cannot be delivered electronically, the rendered dosage instruction will be printed on the fax and will be the only source of dosage information.

It is recognized that very complex instructions may be conveyed as text only (not as structured data). Example: take 500 mg twice a day at breakfast and at lunch AND 250 mg once a day at bedtime - THEN (new dosage line)). If the EMR submits structured dosage instructions, this must be consistent with the textual instructions provided here. The PMS may ignore the structured frequency, or override it to align with the textual instructions.

Example: the EMR may enter frequency (multiplier of the dose) in their system like this (2 qam and 3 qhs ), in the structured frequency. The textual instructions could say Take 2 tablets in the morning and 3 at bedtime.

Conformance Rule: The rendered dosage instruction MUST contain ALL dosage instructions. This includes ALL child elements of dosage instruction, such as dosage quantity, dosage unit, frequency, etc) in human readable form and must be able to stand on its own. This field will include all of the information contained in the structured dosage as well as patient instructions (eg take with food, starting one day before dental appointment), assembled into one field and formatted as human-readable. Coded values codes should not be used (e.g. 'days' should be used instead of 'd', the code of PO as 'oral' )

Conformance Rule: MUST allow all printable characters and carriage return/line feeds.

Conformance Rule: If an EMR has discrete field for Pharmacy Notes (Dispenser Instructions), they should not be included here. If EMR's have both concepts combined into one field, they can both be included here.

Identifies the Protocol, Order set, Guideline or other definition that guided the creation of this prescription

FUTURE USE ONLY

Identifies whether this drug is for acute or chronic use

Conformance Rule: Must be populated if known

Additional information that relevant to the order. E.g. observations, allergies, etc.

Cardinality must be 0..1 for Shared Health List-Allergies and 0..2 for Shared Health Pharmacy-related Observation (i.e. 1 for height and 1 for weight).

Conformance Rule: All known patient allergies must be included in the Medication Order.

A set of managed and relevant detected issues that should be transmitted along with a prescription or order to provide context during the execution of that order.

Usage Note: This is a reference to the resource which is used to convey Managed Detected Issues (DUR)

Provides additional instructions from the prescriber to the pharmacy or other dispenser

Usage Note: To convey explicit instructions to the Pharmacist/dispenser related to this medication order.

Usage Note: If the PMS solution is unable to display the entire instructions, then it is expected that the current solution has a fail-over process and will create a printout of the prescription.

Conformance Rule: PMS solution must be able to print out the entire prescription with ALL dispensing instructions included on the printout. Minimum data elements can be based on the eFax model

Conformance Rule: When 'compliance pack' is indicated on the prescription within the EMR, populate the pharmacist instruction/dispenser instructions with 'COMPLIANCE PACK REQUESTED'

Usage Note: In the case where the prescriber indicates the concept of ‘do not adapt’ (meaning that the pharmacist should not alter the prescription based on the patient's weight as an example), this direction to the pharmacist should be conveyed in human language in this field.

Conformance Rule: If a prescriber wishes to indicate that there is no substitution it must be included as part of the pharmacy instructions.

Conformance Rule: LU Codes must be clearly conveyed as part of the Pharmacists Instructions. If vendors are programmitically mapping into this field, they should use a prefix of LU Code before the identifier.

Indicates that the total number of managed DURs associated with the prescription exceeds the reporting limit of 25

Conformance Rule: Set value = true when there are more than 25 warnings returned in the EMR DUR system

Allows prescribers to indicate that the prescription is for a 'Monitored Drug' (e.g. compound) value in the prescription message to the pharmacies

Conformance Rule: The prescriber should have the ability to set this flag when the medication is a compound. The absence of this extension means (i.e. value=”false”) that this is not a monitored substance.

Usage Note: Provinces may require prescribers to enter this value when a compound contains a monitored substance (e.g. narcotic) to support Prescription Drug Monitoring Programs (e.g. the Alberta Triplicate Prescription Program).

Indicates that the prescriber will not support renewals for this prescription

Conformance Rule: The PMS should present a warning to the dispenser if they create a renewal request for a prescription that has this flag set to indicate 'no renewals'. The PMS should allow the renewal to be submitted along with an explanation as there may be exceptional circumstances.

May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

A technical identifier - identifies some entity uniquely and unambiguously.

These are the identifiers assigned by the PMS and, in some cases, by the DIS.

• pattern @ type

A technical identifier - identifies some entity uniquely and unambiguously.

In the context of a Pharmacist Adapt (p170), this Prescription business identifier is generated by the PMS.

unique id for the element within a resource (for internal references).

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

The purpose of this identifier.

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Allows users to make use of identifiers when the identifier system is not known.

-

unique id for the element within a resource (for internal references).

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

A reference to a code defined by a terminology system.

Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labelled as UserSelected = true.

• value @ system
,
• value @ code

unique id for the element within a resource (for internal references).

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

The identification of the code system that defines the meaning of the symbol in the code.

Need to be unambiguous about the source of the definition of the symbol.

This is the URI that represents the coding system as defined within the binding.

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Need to refer to a particular code in the system.

This is the code as defined within the binding.

A representation of the meaning of the code in the system, following the rules of the system.

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

A reference to a code defined by a terminology system.

Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labelled as UserSelected = true.

unique id for the element within a resource (for internal references).

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

The identification of the code system that defines the meaning of the symbol in the code.

Need to be unambiguous about the source of the definition of the symbol.

Fixed value: http://hl7.org/fhir/identifier-type

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Need to refer to a particular code in the system.

Fixed value: PLAC

A representation of the meaning of the code in the system, following the rules of the system.

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Very often the text is the same as a displayName of one of the codings.

Establishes the namespace in which set of possible id values is unique.

There are many sequences of identifiers. To perform matching, we need to know what sequence we're dealing with. The system identifies a particular sequence or set of unique identifiers.

Conformance Rule: This must be an OID of the URI form [Vendor root].[Application instance node].2 (e.g. urn:oid:1.2.3.4). The branch, “.2” is appended to create a unique namespace for the Prescription Identifer

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

Usage Rule: The business identifier that uniquely identifies a prescription.

Time period during which identifier is/was valid for use.

Organization that issued/manages the identifier.

The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

External identifier - one that would be used by another non-FHIR system - for example a re-imbursement system might issue its own id for each prescription that is created. This is particularly important where FHIR only provides part of an entire workflow process where records have to be tracked through an entire system.

Conformance Rule: If the PMS has sent the adapted prescription to the jurisdiction they must include this identifier. If no identifier is present in the message instance, this is presumed to have NOT been sent to the DIS.

unique id for the element within a resource (for internal references).

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

The purpose of this identifier.

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Allows users to make use of identifiers when the identifier system is not known.

-

Establishes the namespace in which set of possible id values is unique.

There are many sequences of identifiers. To perform matching, we need to know what sequence we're dealing with. The system identifies a particular sequence or set of unique identifiers.

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension.

Time period during which identifier is/was valid for use.

Organization that issued/manages the identifier.

The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

A code specifying the state of the order. Generally this will be active or completed state.

Fixed value: active

Identifies the medication being administered. This is a link to a resource that represents the medication which may be the details of the medication or simply an attribute carrying a code that identifies the medication from a known list of medications.

If only a code is specified, then it needs to be a code for a specific product. If more information is required, then the use of the medication resource is recommended. Note: do not use Medication.name to describe the prescribed medication. When the only available information is a text description of the medication, Medication.code.text should be used.

• type @ $this

A reference from one resource to another.

Usage Note: this is populated with the reference to the Medication resource pertaining to this Medication Order. It will point to the 'contained' Medication resource. E.g. <reference value='#med'/>

A reference from one resource to another.

Usage Note: This must point to the patient associated with the message.

A link to a resource that identifies the particular occurrence of contact between patient and health care provider.

SubstanceAdministration->component->EncounterEvent.

The date (and perhaps time) when the prescription was written.

Conformance Rule: Must be either equal to or earlier then the MedicationOrder.dispenseRequest.validityPeriod.start element.

Conformance Rule: Must be either a full date (i.e. yyyy-mm-dd) or a full date and time with timezone (i.e. yyyy-mm-dd-HH:mm:ss.SSS-ZZZZZ).

Conformance Rule: Prescriptions sent within Alberta must support the full date time.

A reference from one resource to another.

Conformance Rule: When requesting that a prescription be filled or responding to a renewal request, this SHALL be the practitioner initiating the message.

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Conformance Rule: In the case where the prescriber wants to send an Indication for Use that is not included in the value set the prescriber must be able to send a text value without a code.

unique id for the element within a resource (for internal references).

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

A reference to a code defined by a terminology system.

Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labelled as UserSelected = true.

unique id for the element within a resource (for internal references).

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

The identification of the code system that defines the meaning of the symbol in the code.

Need to be unambiguous about the source of the definition of the symbol.

This is the URI that represents the coding system as defined within the binding.

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Need to refer to a particular code in the system.

This is the code as defined within the binding.

A representation of the meaning of the code in the system, following the rules of the system.

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Usage Note: When conveying the reason, this must be populated

Condition that supports why the prescription is being written.

The date (and perhaps time) when the prescription was stopped.

The reason why the prescription was stopped, if it was.

Codes indicating why the medication was terminated; e.g. Adverse reaction, medication change, issue resolved, etc.

Extra information about the prescription that could not be conveyed by the other attributes.

unique id for the element within a resource (for internal references).

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

The individual responsible for making the annotation.

Indicates when this particular annotation was made.

The text of the annotation.

Usage Note: This is used as an additional pharmacy note that is unrelated to the dispensing instructions. Eg. Do not fill immediately, Patient is coming in on July 12th for Booster shot.

Conformance Rule: PMS Vendors MUST display this to the pharmacist as it may contain important information. There could be Patient Instructions in here, inadvertently due to current prescribing behaviours.

Indicates how the medication is to be used by the patient.

Conformance Rule: For EMRs that can support structured dosage instruction, this element must be populated when the prescriber specifies any of structured dosage information. Anything that is populated as part of the structured dosage information must also be part of the RENDEREDDOSAGEINSTRUCTION element.

Usage Note: An Excel spreadsheet providing guidance on how to populate dosage instructions can be found under 'Scope and Usage'.

When the dose or rate is intended to change over the entire administration period, e.g. Tapering dose prescriptions, multiple instances of dosage instructions will need to be supplied to convey the different doses/rates. Another common example in institutional settings is 'titration' of an IV medication dose to maintain a specific stated hemodynamic value or range e.g. drug x to be administered to maintain AM (arterial mean) greater than 65.

unique id for the element within a resource (for internal references).

An Extension

• value @ url

Optional Extensions Element - found in all resources.

Conformance Rule: This must match the positional sequence of the dosageInstruction repetition. I.e. The first dosageInstruction repetition must have a 'sequence' value of 1, the second a 'sequence' value of 2, etc.

Optional Extensions Element - found in all resources.

Conformance Rule: As this will establish the relationship to the previous dosage lines (example: first and second dosage line, the second and third dosage line, etc.) this must be present for all dosage lines except for the FIRST dosage line.

Conformance Rule: ANDs and THENs should not be mixed due to ambiguity of meaning.

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Free text dosage instructions can be used for cases where the instructions are too complex to code. The content of this attribute does not include the name or description of the medication. When coded instructions are present, the free text instructions may still be present for display to humans taking or administering the medication. It is expected that the text instructions will always be populated. If the dosage.timing attribute is also populated, then the dosage.text should reflect the same information as the timing.

Conformance Rule: When providing multiple dosage lines can be expressed individually. All dosage lines (full text content) must be concatenated into MedicationOrder.extension(renderedDosageInstruction) as PMS will not be forced to support the receipt of individual lines.

Usage Note: This is a string composed of any available discrete MedicationOrder.dosageInstruction child elements such as timing, asNeeded[x], siteCodeableConcept, route, dose[x], rate[x], and maxDosePerPeriod for each repetition sequence line.

Example: Prednisone; variable dosage instruction, or concurrent instructions (1 pill morning and 1 pill before bed) or sequential dosages (1 pill for 2 days, then 2 pills).

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Codes identifying additional instructions such as "take with water" or "avoid operating heavy machinery".

Conformance Rule: When providing an additional instruction at the dosage line level (complex), this should be populated when appropriate.

Usage Note: It may be necessary for the EMR to parse instructions such as QHS (take at bedtime), into two data elements DOSAGETIMINGFREQUENCY = once a day and 'at bedtime' would be placed into this field.

unique id for the element within a resource (for internal references).

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

A reference to a code defined by a terminology system.

Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labelled as UserSelected = true.

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Conformance Rule: This is the text used to convey the exact word that was displayed to the practitioner

The timing schedule on how the patient is to take the medication. The timing schedules allows many different expressions to be expressed. For example: Every 8 hours, Three times a day, 1/2 an hour before breakfast for 10 days from 17 Oct 2017 to 27 Oct 2017

Conformance Rule: For EMRs that can support structured dosage instruction, this must be populated if prescriber specifies any of structured timing information. Anything that is populated as part of the structured timing information must also be part of the RENDEREDDOSAGEINSTRUCTION.

Usage Note: An Excel spreadsheet providing guidance on how to populate dosage instructions can be found under 'Scope and Usage'.

unique id for the element within a resource (for internal references).

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Identifies specific times when the event occurs.

In an MAR, for instance, you need to take a general specification, and turn it into a precise specification.

A set of rules that describe when the event should occur.

Many timing schedules are determined by regular repetitions.

Conformance Rule: If an EMR cannot send discrete elements in all cases for timing.repeat element, this is acceptable as long as RENDEREDDOSAGEINSTRUCTION captures the timing.

unique id for the element within a resource (for internal references).

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

boundsPeriod defines the start and/or end date of the period over which the specified instruction should take place for a given dosage line. For example, if the prescriber wants a patient to start taking the medication starting the day before surgery, and the surgery is scheduled for Feb 16th 2019, the start date within bounds period would be Feb 15 2019. The end date can be included if the prescriber wants the patient to stop medication after a certain number of days. In the example above lets say the prescriber wants to the patient to stop the medication after 10 days the end date would Feb 26 2019.

boundsQuantity defines the amount a time that the patient should be taking the specified instruction for a given dosage line. As an example, a prescription may call for taking 1-2 pills per day for 10 days. The boundsQuantity would be 10 days.

boundsRange defines a minimum and maximum amount of time that the patient should be taking the specified instruction for a given dosage line. As an example, a prescriber may indicate that a patient should apply a cream 2 times per day for a minimum of 10 days but if the rash persists, continue applying for up to 14 days. In this case the minimum for boundsRange would be 10 days and the maximum for boundsRange would be 14 days.

count defines how many time the dosing activities should be repeated across all periods. For example, if a prescriber wants a patient to take 1 pill morning and night every day for 10 days, the dose is 1 pill, the frequency is 2 per day, the period is one day, and the count is 20 doses (corresponding to 10 days times 2 doses per day).

Repetitions may be limited by end time or total occurrences.

If you have both bounds and count, then this should be understood as within the bounds period, until count times happens.

countMax defines the max number of doses that should be taken across all periods within a dosage line. countMax is only used when the count is expressed as a range of values. For example, if a prescriber wants a patient to take a dose of 2 pills per day for 7-10 days, the dose is 2 pills, the frequency is 1 dose per day, the period is 1 days, the count is 7 doses, and the countMax is 10 doses.

duration defines the amount of time it takes to provide a SINGLE dose of a medication to a patient. For most medications, duration is not relevant. However, one example that uses duration would be the application of a patch. The prescriber may instruct the patient to apply a patch for 10 hours each day for 10 days. In this case, the dose would be 1 patch, the duration would be 10 hours, the period would be 1 day, and the count would be 10 doses.

Some activities are not instantaneous and need to be maintained for a period of time.

For some events the duration is part of the definition of the event (e.g. IV infusions, where the duration is implicit in the specified quantity and rate). For others, it's part of the timing specification (e.g. exercise).

durationMax defines the maximum amount of time CAN/SHOULD take to provide a SINGLE dose of a medication to a patient. durationMax implies the usage of a range of values for the duration. For most medications, duration and durationMax is not relevant. However, one example that uses duration and durationMax would be the application of a patch for a range of time each day. The prescriber may instruct the patient to apply a patch for 10-12 hours each day for 10 days. In this case, the dose would be 1 patch, the duration would be 10 hours, the durationMax would be 12 hours, the period would be 1 day, and the count would be 10 doses.

Some activities are not instantaneous and need to be maintained for a period of time.

For some events the duration is part of the definition of the event (e.g. IV infusions, where the duration is implicit in the specified quantity and rate). For others, it's part of the timing specification (e.g. exercise).

The units of time for the duration, in UCUM units.

frequency defines the number of times to apply a single dose of a medication within a particular period. For example, the prescriber may instruct the patient to take 1 tablet 3 times per day for 10 days. In this cases, the dose would be 1 tablet, the frequency would be 3 times, the period would be 1 day, and the count would be 30 doses.

frequencyMax defines the maximum number of times to apply a single dose of a medication within a particular period. Using frequencyMax implies that the frequency is a range of values. For example, the prescriber may instruct the patient to take 1 tablet 3-4 times per day for 10 days. In this cases, the dose would be 1 tablet, the frequency would be 3 times, the frequencyMax would be 4 times, the period would be 1 day, and the count would be 30 doses.

The period defines the amount of time over which the frequency of doses should occur. For example, the prescriber may instruct the patient to take 1 tablet every day for 10 days. In this case, the period is 1 day.

The periodMax defines the maximum amount of time over which the frequency of doses should occur. For example, the prescriber may instruct the patient to apply one patch every 48 to 72 hours and leave the patch on for 12 hour and do this for 1 month. In this case, the dose would be one patch, the frequency would be 1, the duration would be 12 hours, the period would be 48 hours, the periodMax would be 72 hours, and the boundPeriod would be a start day of today and an end date of 2 months from now.

The units of time for the period in UCUM units.

A real world event that the occurrence of the event should be tied to.

Timings are frequently determined by occurrences such as waking, eating and sleep.

Use "additionalInstructions" instead

The number of minutes from the event. If the event code does not indicate whether the minutes is before or after the event, then the offset is assumed to be after the event.

Use "additionalInstructions" instead

A code for the timing pattern. Some codes such as BID are ubiquitous, but many institutions define their own additional codes. If a code is provided, the code is understood to be a complete statement of whatever is specified in the structured timing data, and either the code or the data may be used to interpret the Timing.

BID etc are defined as 'at institutionally specified times'. For example, an institution may choose that BID is "always at 7am and 6pm". If it is inappropriate for this choice to be made, the code BID should not be used. Instead, a distinct organization-specific code should be used in place of the HL7-defined BID code and/or the a structured representation should be used (in this case, specifying the two event times).

Indicates whether the Medication is only taken when needed within a specific dosing schedule (Boolean option), or it indicates the precondition for taking the Medication (CodeableConcept).

A coded concept identifying the precondition that should be met or evaluated prior to consuming or administering a medication dose. For example "pain", "30 minutes prior to sexual intercourse", "on flare-up" etc.

Conformance Rule: This is ONLY populated when the medication is prescribed on an as needed (i.e. PRN) basis.

Conformance Rule: Set value = true

Conformance Rule: When this is specified, it is not acceptable to express the quantity exclusively as a duration/DAYSSUPPLY. The DOSAGEQUANTITY must be provided.

The CodeableConcept should not be used at this time. If it is present, treat it as though the boolean value is set to true.

A coded specification of the anatomic site where the medication first enters the body.

• type @ $this

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Conformance Rule: When providing a structured SIG, this should be populated when appropriate. If not structured, this should be part of the SIG (RENDEREDDOSAGEINSTRUCTION)

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Conformance Rule: Coding should be populated if a code is available. However, text is always required.

A coded value indicating the method by which the medication is introduced into or onto the body. Most commonly used for injections. For examples, Slow Push; Deep IV.

A coded concept describing the technique by which the medicine is administered.

Terminologies used often pre-coordinate this term with the route and or form of administration.

The amount of therapeutic or other substance given at one administration event.

Conformance Rule: Could be sent as part of the dosage instruction. OR for those EMRs that can support it, this should be specified.

Identifies the speed with which the medication was or will be introduced into the patient. Typically the rate for an infusion e.g. 100 ml per 1 hour or 100 ml/hr. May also be expressed as a rate per unit of time e.g. 500 ml per 2 hours. Currently we do not specify a default of '1' in the denominator, but this is being discussed. Other examples: 200 mcg/min or 200 mcg/1 minute; 1 liter/8 hours.

It is possible to supply both a rate and a doseQuantity to provide full details about how the medication is to be administered and supplied. If the rate is intended to change over time, depending on local rules/regulations, each change should be captured as a new version of the MedicationOrder with an updated rate, or captured with a new MedicationOrder with the new rate.

• type @ $this

Identifies the speed with which the medication was or will be introduced into the patient. Typically the rate for an infusion e.g. 100 ml per 1 hour or 100 ml/hr. May also be expressed as a rate per unit of time e.g. 500 ml per 2 hours. Currently we do not specify a default of '1' in the denominator, but this is being discussed. Other examples: 200 mcg/min or 200 mcg/1 minute; 1 liter/8 hours.

It is possible to supply both a rate and a doseQuantity to provide full details about how the medication is to be administered and supplied. If the rate is intended to change over time, depending on local rules/regulations, each change should be captured as a new version of the MedicationOrder with an updated rate, or captured with a new MedicationOrder with the new rate.

unique id for the element within a resource (for internal references).

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

A measured or counted amount of a medication expressed as a value and human-readable string with optional coded units expressed in a local coding system

Usage Note: Quantity is used throughout the messages. It may be a drug form (e.g. TAB) an administrable drug (e.g. PUFF) form or a unit of measure (e.g. mg).

A measured amount (or an amount that can potentially be measured). Note that measured amounts include amounts that are not precisely quantified, including amounts involving arbitrary units and floating currencies.

This indicates the unit of time (e.g. per day, every 4 weeks, etc.)

The maximum total quantity of a therapeutic substance that may be administered to a subject over the period of time. For example, 1000mg in 24 hours.

Conformance Rule: When providing a structured SIG, this should be populated when appropriate.

unique id for the element within a resource (for internal references).

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

A measured or counted amount of a medication expressed as a value and human-readable string with optional coded units expressed in a local coding system

Conformance Rule: Quantity is used throughout the messages. It may be a drug form (e.g. TAB) an adminstratable drug (e.g. PUFF) for or a unit of measure (e.g. mg). If this is provided it is mandatory to send a value from the PrescribeIT® Drug Quantity.

A measured amount (or an amount that can potentially be measured). Note that measured amounts include amounts that are not precisely quantified, including amounts involving arbitrary units and floating currencies.

This indicates the unit of time (e.g. per day, every 4 weeks, etc.)

Indicates the specific details for the dispense or medication supply part of a medication order (also known as a Medication Prescription). Note that this information is NOT always sent with the order. There may be in some settings (e.g. hospitals) institutional or system support for completing the dispense details in the pharmacy department.

unique id for the element within a resource (for internal references).

An Extension

• value @ url

Indicates the minimum period of time that must pass between dispensing events as recorded against the dispense or prescription.

Example: A prescriber instructs a patient to take 3 Tylenol 3 tablets every day as needed for pain for 90 days. However, the prescriber does not wish the patient to have more than 30 days supply at any given time so the prescriber instructs the pharmacist that the dispenseInterval is 30 days. The pharmacist then does 3 partial fills of 90 tablets (or 30 days supply) over the 90 day period.

Optional Extensions Element - found in all resources.

Conformance Rule: If eligible for trial, this must be set to 'true' and presented to the Pharmacist.

Conformance Rule: This is ONLY populated if it is for trial, else it is assumed not to be eligble.

Note: Prescribers may include this information in notes.

Optional Extensions Element - found in all resources.

Conformance Rule: If this is supported within the EMR as a discrete data element, this must be populated. (e.g. this could map to 'Must be filled within')

Conformance Rule: First fill is only populated if required; if not populated, the general dispenseRequest instructions apply to all fills. You only specify an initial fill quantity if you have refills.

Usage Note: There are times when a patient's drug plan limits what can be dispensed (i.e. 7 days initially as a trial). In this situation, the patient is informed that their drug plan only pays for 7 days. The pharmacist will ask the patient to sign the Rx that they have been informed are ok with changing the quantity to 7 days and then dispense the 7 days. The patient's file is updated to note that 7 days was dispensed as a trial period. After the initial 7 days, the patient will still have 353 tablets to be used. (90 tabs x 4 authorized fills = 360 tabs - 7 tabs dispensed as trial.

Identifies the maximum quantity authorized to be dispensed at one time.

Conformance Rule: If this is supported within the EMR as a discrete data element, this must be populated.

Example: A prescriber instructs a patient to take 3 Tylenol 3 tablets every day as needed for pain for 90 days. However, the prescriber does not wish the patient to have more than 30 days supply at any given time so the prescriber instructs the pharmacist that the maxDispense is 90 tablets. The pharmacist then does 3 partial fills of 90 tablets (or 30 days supply) over the 90 day period.

Optional Extensions Element - found in all resources.

Conformance Rule: The Total Prescribed Quantity is not mandatory but must be supplied if the value is entered by the user or can be calculated by the system.

Optional Extensions Element - found in all resources.

Conformance Rule: Must be populated when the Total Days Supply is entered by the user or when the Total Days Supply can be calculated by the system.

Conformance Rule: Code must be 'd' and system must be 'http://unitsofmeasure.org'.

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Identifies the medication being administered. This is a link to a resource that represents the medication which may be the details of the medication or simply an attribute carrying a code that identifies the medication from a known list of medications.

If only a code is specified, then it needs to be a code for a specific product. If more information is required, then the use of the medication resource is recommended.

• type @ $this

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Conformance Rule: This element is used to represent the medication ordered. A 'code' (Canadian Clinical Drug Data Set, or DIN or NPN) must be accompanied by 'text' when prescribing. For compounds, a code is not used and the description will be sent as 'text'. A representative DIN or an NPN may also be used if a CCDD code is not available. This has an extensible binding meaning that the CCDD code system should be used but if a code is not available, vendors may also submit a code from the DIN or NPN code system. (Eventually CCDD will encompass all DINs and NPNs.)

     Code systems that are acceptable in the message are:
     CCDD - https://fhir.infoway-inforoute.ca/CodeSystem/canadianclinicaldrugdataset
     DIN - http://hl7.org/fhir/NamingSystem/ca-hc-din
     NPN - http://hl7.org/fhir/NamingSystem/ca-hc-npn

      EMRs must support sending and receiving all levels of drug terminology defined in the Canadian Clinical Drug Data (CCDD) Set including: Therapeutic Moiety (TM), Non-proprietary Therapeutic Product (NTP), Manufactured Product (MP) as well as Device NTP for devices. In cases where a Canadian Clinical Drug Data Set value is not available within the EMR, the EMR can send a DIN or Natural Product Number (NPN) or a DIN with the (isRepresentative) value set to 'true' (i.e. a representative DIN meaning that products by other manufacturers are acceptable).

     If no drug code (TM, NTP, MP, or DIN) is available in the EMR, only then should the EMR send the drug name as text without a code. The pharmacy system must always display the textual name of the medication or non-medication provided in the message to the user when displaying the prescription. This represents the name of the medication or non-medication (e.g. device) as seen by the prescriber at the time of prescribing.

     The pharmacy system may use the drug coding (TM, NTP, MP, DIN, NPN or representative DIN) to display to the user the list of products that can be dispensed.

This indicates the validity period of a prescription (stale dating the Prescription).

Indicates when the Prescription becomes valid, and when it ceases to be a dispensable Prescription.

Conformance Rule: Must be either equal to or later then the MedicationOrder.dateWritten element.

unique id for the element within a resource (for internal references).

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

The start of the period. The boundary is inclusive.

Conformance Rule: Must be either a full date (i.e. yyyy-mm-dd) or a full date and time with timezone (i.e. yyyy-mm-dd-HH:mm:ss.SSS-ZZZZZ).

The end of the period. If the end of the period is missing, it means that the period is ongoing. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time.

Conformance Rule: Must be either a full date (i.e. yyyy-mm-dd) or a full date and time with timezone (i.e. yyyy-mm-dd-HH:mm:ss.SSS-ZZZZZ).

An integer indicating the number of additional times (aka refills or repeats) the patient can receive the prescribed medication. Usage Notes: This integer does NOT include the original order dispense. This means that if an order indicates dispense 30 tablets plus "3 repeats", then the order can be dispensed a total of 4 times and the patient can receive a total of 120 tablets.

Conformance Rule: This must be populated when the number of repeats is 1 or more. As this field only allows a positive integer, this is not populated if there are no refills allowed.

Guidance: For narcotics, if this is incorrectly populated, the PMS could choose not to reject the message; rather they can adjust for the dispense.

A measured or counted amount of a medication expressed as a value and human-readable string with optional coded units expressed in a local coding system

Conformance Rule: If days supply is NOT present, this MUST be populated.

Identifies the period time over which the supplied product is expected to be used, or the length of time the dispense is expected to last.

Conformance Rule: This maps to 'duration' in some EMR's. Must be populated when this is a discrete data element in the EMR; else this is sent as part of the textual description.

Conformance Rule: If Fill Quantity is NOT populated, this must be present.

unique id for the element within a resource (for internal references).

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

The value of the measured amount. The value includes an implicit precision in the presentation of the value.

Precision is handled implicitly in almost all cases of measurement.

The implicit precision in the value should always be honored.

How the value should be understood and represented - whether the actual value is greater or less than the stated value due to measurement issues; e.g. if the comparator is "<" , then the real value is < stated value.

Need a framework for handling measures where the value is <5ug/L or >400mg/L due to the limitations of measuring methodology.

This is labeled as "Is Modifier" because the comparator modifies the interpretation of the value significantly. If there is no comparator, then there is no modification of the value.

A human-readable form of the unit.

There are many representations for units of measure and in many contexts, particular representations are fixed and required. I.e. mcg for micrograms.

The identification of the system that provides the coded form of the unit.

Need to know the system that defines the coded form of the unit.

Fixed value: http://unitsofmeasure.org

A computer processable form of the unit in some unit representation system.

Need a computable form of the unit that is fixed across all forms. UCUM provides this for quantities, but SNOMED CT provides many units of interest.

Fixed value: d

Indicates whether or not substitution can or should be part of the dispense. In some cases substitution must happen, in other cases substitution must not happen, and in others it does not matter. This block explains the prescriber's intent. If nothing is specified substitution may be done.

unique id for the element within a resource (for internal references).

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

A code signifying whether a different drug should be dispensed from what was prescribed.

Indicates the reason for the substitution, or why substitution must or must not be performed.

A link to a resource representing an earlier order or prescription that this order supersedes.

When present with a prescription identifier, this must be in the same form as was present on the original prescription. The system element will be an OID of the form [Vendor root].[Application instance node].2 expressed as a uri (e.g. urn:oid:1.2.3.4). The branch, “.2” is appended to create a unique namespace for the Prescription Identifer The value element will be the RX Number. Note that the system value must refer to the namespace of the system that created the original prescription, which may not always be the system performing the renewal.

In the context of Task e120: Conformance Rule: This is mandatory and MUST be populated with the EMR generated prescription identifier of the medication used as the basis for the new prescription for the same therapy. Its purpose is to identify the original prescription that drove the creation of this Renewal Fill Request. Note: This identifier may not be recognized by the PMS receiving this as it could have been a paper prescription or an ePrescription that was originally sent to another pharmacy.

For transition period, from paper to electronic, there would not be an EMR-assigned number. In this case, EMR MUST populate with a value of 'NA' in the Identifier.value and omit the system.

In the context of Task e140: This should include any prior prescription information that was included in the original prescription request from the EMR that is being cancelled. If the original EMR prescription request has this segment empty, then it should be empty for the e140.

In the context Tasks e162 and e163: Conformance Rule: This is mandatory and MUST be populated with the MedicationOrder.identifier as specified in the p160 being responded to.

In the context of Task p160: Conformance Rule: The MedicationOrder transmitted in a p160 is the prior order that is being asked to be renewed. If this came in as an e110, priorPrescription will be absent. If this came in as an e120, priorPrescription will be present. If it was entered into the PMS as a paper or fax prescription, priorPrescription may not be known (in which case it will be absent), or may be set to 'NA' if the prescription was known to be a renewal, but the prescription identifier of the prior request is unknown).

In the context of Tasks e161, e164, and p170: Conformance Rule: This is not required.

In the context of Task p190: This is not required but optionally can reference a previous prescription if the prescription being communicated is a continuation of an existing therapy.

unique id for the element within a resource (for internal references).

An Extension

• value @ url

Allows a reference to identify the target prescription, dispense or task by business identifier rather than URL

When this is present, the reference is typically omitted.

Usage Note: This provides the medication order identifier that the dispense is associated with

Usage Note: In the context of p160 and p200, PMS's will populate this identifier value with the appropriate value

Usage Note: In the context of p200, EMRs need to use this value to find the corresponding medication order in their local system in order to associate the incoming dispense it to.

Usage Note: In the context of p160, EMRs can use either this value or the MedicationOrder.identifier:EMR-id to find the corresponding medication order in their local system which is related to the medication order which is asking to be renewed.

Usage Note: The URL for this extension does not refer to an existing web-page as is a pre-adoption extension. Refer to the Shared Health implementation Guide for more information.

unique id for the element within a resource (for internal references).

An Extension

Source of the definition for the extension code - a logical name or a URL.

Fixed value: http://hl7.org/fhir/StructureDefinition/extension-Reference.identifier

A technical identifier - identifies some entity uniquely and unambiguously.

When this is present, the reference is typically omitted.

Comments:

In the context of a p200 this will represent the mediation order identifier of the original electronic prescription (e110, e120, e162, e163, e180) which the dispense is associated with.

In the context of a p160 this will represent either the mediation order identifier of the original electronic prescription (e110, e120, e162, e163, e180) which is the dispense is associated with or it will be the pharmacies own medication order identifier when the dispense is associated with a previous non-electronic order (i.e. paper or fax).

Usage: EMR's should use the identifier.system and identifier.value to determine whether medication order relates to an order within the local application. The identifier.system value represents the application (application instance id) that assigned the identifier and identifier.value represents the actual medication order value. When the system value does NOT match the local application then this identifier was assigned by another application and should be treated like a non-electronic (i.e. paper or fax) order. When the system value matches the local application then this identifier was assigned by this application and the system should then proceed to find the value. If the value cannot be found it should be treated like a non-electronic (i.e. paper or fax) order. Only when both the system and value match a local medication order can the application treat it as a electronic medication order.

• type @ $this

Value of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list).

A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

Plain text narrative that identifies the resource in addition to the resource reference.

This can be populated with the prescription identifier as a human-readable hint for downstream systems that don't recognize the extension. However, there is no known need for this element at present.