PrescribeIT® Specification and Guide Version 5.0

Indicates that a medication product is to be or has been dispensed for a named person/patient. This includes a description of the medication product (supply) provided and the instructions for administering the medication. The medication dispense is the result of a pharmacy system responding to a 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.

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.

An Extension

• value @ url

This represents the complete instruction on how the medication is to be taken by the patient as entered by the pharmacy on the dispense or prescription.

Usage Note: This will be populated by the PMS and will reflect the directions as presented to the patient on the label. The rendered dosage instruction will contain all dosage instructions such as dosage quantity, dosage unit, frequency, frequency period administration start/end date, route etc. as well as any additional instructions (e.g. take with food, starting one day before dental appointment) that are provided to the patient on the label.

Conformance Rule: This field must contain all the dosage information assembled into one field, this includes any overflow or supplemental directions that do not get included on the label as they are too long but are still are provided to the patient. The dosage information must be in a clear readable format, meaning that codes should not be used (e.g. 'days' should be used instead of 'd', 'oral' should be used instead of 'PO') unless this is how it is presented on the patients label.

Usage Note: Allows the provider to verify and compare the directions for use with the original directions of use that was provided on the original prescription. This is particularly helpful when the pharmacy split the original order into multiple dispensed products.

The total authorized quantity outstanding after the fill issued as part of this dispense record

Should be specified even if 0. When there are unlimited refills on a prescription the PMS should send the maximum value that is supported by their system otherwise can send 999,999 and the applicable unit

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.

This is the identifier assigned by the pharmacy to a specific dispense. The system element will be an OID of the form [Vendor root].[Application instance node].4 expressed as a uri (e.g. urn:oid:1.2.3.4). The value element will be the pharmacy-assigned dispense identifier.

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 coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

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

This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

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].4 (e.g. urn:oid:1.2.3.4). The branch, “.4” is appended to create a unique namespace for the Pharmacy-assigned dispense identifier.

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 set of dispense events.

Fixed value: completed

Identifies the medication being administered. This is either a link to a resource representing the details of the medication or a simple 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 dispensed medication. When the only available information is a text description of the medication, Medication.code.text should be used.

• 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 dispensed A 'code' (Canadian Clinical Drug Data Set, or DIN or NPN) must be accompanied by 'text' when dispensing. For compounds, a code is not used and the description will be sent as 'text'. A DIN or an NPN may also be used if an appropriate CCDD code is not yet 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

      When sending CCDD codes, only the Manufactured Product (MP) or Device NTP codes should be used. In cases where a Canadian Clinical Drug Data Set value is not available within the PMS, the PMS can send a DIN or Natural Product Number (NPN).

     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 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.

A link to a resource representing the person to whom the medication will be given.

SubstanceAdministration->subject->Patient.

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 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.

This must point to the patient associated with the message

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

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

The individual responsible for dispensing the medication.

Only organization (conveyed by the extension) is needed. No need to send the actual dispensing practitioner

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

An Extension

• value @ url

Allows capturing the organization responsible for an action instead of or in addition to identifying the responsible practitioner

For Shared Health purposes, only the pharmacy is relevant, not the dispensing pharmacist or technician. In the future, this should be supported directly by the resource.

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 is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Indicates the medication order that is being dispensed against.

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

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

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, EMR's 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 in the context of p160, EMR's 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.

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.

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 Note: 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.

If the MedicationOrder is included in the bundle (e.g. p160 Renewal Request when sending the most recent dispense), this reference can be provide which points to the medication order resource found in the same bundle. This reference is optional and can be omitted.

Conformance Rule: When providing this reference it must be the same as the Task.subject reference value.

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

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

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

Usage note: For future use

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 administrable drug (e.g. PUFF) form or a unit of measure (e.g. mg). You must send the coding system and code.

The number of days that the quantity is expected to last.

Useful in monitoring patient compliance. May also be useful in determining and managing certain contraindications ('Fill-Too-Soon', 'Fill-Too-Late', and 'Duration of Therapy'). Because 'Days Supply' may be necessary to compute total dispensed quantity, it is made a"populated field.

Usage Note: In the context of the Dispense resource this must always be provided as a dispense must always have a days supply value.

In the context of the PMS Rx Dispense resource that is used within the p160 message the value as recorded on the last dispense that is associated to the prescription must be sent and if the prescription has never been dispensed the value as recorded on the prescription must be sent.

In the scenario where the pharmacy system not require a days supply value to be recorded on the prescription when not dispensing and putting the prescription on file for future dispensing or posting it as a reference prescription a value of 0 must be sent, given the field is mandatory.

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.

Not allowed to be used in this context

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.

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

The time when the dispensed product was packaged and reviewed.

This represents the date the medication was dispensed.

The time the dispensed product was provided to the patient or their representative.

Identification of the facility/location where the medication was shipped to, as part of the dispense event.

Identifies the person who picked up the medication. This will usually be a patient or their caregiver, but some cases exist where it can be a healthcare professional.

Extra information about the dispense that could not be conveyed in the other attributes.

Indicates how the medication is to be used by the patient. The pharmacist reviews the medication order prior to dispense and updates the dosageInstruction based on the actual product being dispensed.

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. Conformance Rule:  If PMS is able to support the structured dosage, they may do so but this is not mandatory

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

An Extension

• value @ url

Indicates the sequence of a particular dosage line within all dosage lines - equivalent to the repetition number of the dosage instruction element this extension is on.

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.

Indicates how the timing of this dosage instruction relates to the preceding dosage instruction. Specifically, is it concurrent (AND) or sequential (THEN).

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

Usage Note: ANDs are instructions lines that are done together and THENs are instructions that are sequential and are done following the previous line. ANDs and THENs can be used individually or mixed together depending on the specific instructions.

Example using just AND: Take 1 tablet every morning and 2 tablets every evening.

Example using just THEN: Take 1 tablet every morning for 1 week THEN take 2 tablets every morning for 1 week.

Example using both: Take 1 tablet every morning AND 2 tablets every evening for 1 week THEN take 2 tablets every morning AND 3 tablets every evening for 1 week.

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 free form description of how the dispensed medication is to be administered to the patient.

Conformance Rule: If supported by the PMS, multiple dosage lines can be expressed individually. However, they must be concatenated into the RENDEREDDOSAGEINSTRUCTION as PMS will not be forced to support the receipt of individual lines.

Usage Note: This is a string that is typically composed of the route, duration, dose, frequency, per line.

Examples are: 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 free form textual description of extended instruction regarding the administration of the drug.

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.

HL7 MAPPING - ADDITIONALDOSAGEINSTRUCTION (Business Name Change).

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

A structure describing the frequency (how often the drug is to be administered), offset (elapse time between administrations) represented by one line of dosage administration instruction. Includes the overall time-period the dosage instruction applies.

Conformance Rule: For EMRs that can support it, this should be specified. Must also be part of the COMPLEXDOSAGEINSTRUCTION

Conformance Rule: A start date may optionally be included. Refer to the Timing data type page for guidance on its use.

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.

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.

boundsDuration defines the amount of 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 boundsDuration 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.

A total count of the desired number of repetitions.

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.

A maximum value for the count of the desired repetitions (e.g. do something 6-8 times).

How long this thing happens for when it happens.

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 upper limit of how long this thing happens for when it happens.

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.

The number of times to repeat the action within the specified period / period range (i.e. both period and periodMax provided).

If present, indicates that the frequency is a range - so repeat between [frequency] and [frequencyMax] times within the period or period range.

Indicates the duration of time over which repetitions are to occur; e.g. to express "3 times per day", 3 would be the frequency and "1 day" would be the period.

If present, indicates that the period is a range from [period] to [periodMax], allowing expressing concepts such as "do this once every 3-5 days.

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). Specifically if 'boolean' datatype is selected, then the following logic applies: If set to True, this indicates that the medication is only taken when needed, within the specified schedule.

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: 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 set.

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).

Also can be specified for COMPLEX

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 intended to be or was introduced into or on the body.

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

This attribute will most often NOT be populated. It is most commonly used for injections. For example, Slow Push, Deep IV. One of the reasons this attribute is not used often, is that the method is often pre-coordinated with the route and/or form of administration. This means the codes used in route or form may pre-coordinate the method in the route code or the form code. The implementation decision about what coding system to use for route or form code will determine how frequently the method code will be populated e.g. if route or form code pre-coordinate method code, then this attribute will not be populated often; if there is no pre-coordination then method code may be used frequently.

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.

• 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.

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

Needed when the dosage unit is not expressed as part of the dose quantity (mg, mL) or implicit as part of the drug form (capsules, tablets). Examples are Puffs, Actuations, etc.

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

Also can be specified for COMPLEX

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.

The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.

Indicates whether or not substitution was made as part of the dispense. In some cases substitution will be expected but does not happen, in other cases substitution is not expected but does happen. This block explains what substitution did or did not happen and why.

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 was dispensed from what was prescribed.

Indicates the reason for the substitution of (or lack of substitution) from what was prescribed.

The person or organization that has primary responsibility for the substitution.