Pharmacy Administration Issues and thoughts Jürgen Brandstätter

Can we confirm this? A Pharmacy Administration documents one single administration event – E.g. the taking of a pill – E.g. applying a creme – E.g. get an injection – E.g. get an infusion A Pharmacy Administration is related to a DIS – Q: Should it be possible to reference a PRE item instead of a DIS (means: we jump over the step of dispensing)? A Pharmacy Administration does not need to be „managed“ by PADVs (what happened that happened) – But PADVs might refer to ADMs in case of issues -> will be extended by a CP Pharmacy Administration Items shall be able to be part of the PML document Additional sections – The usual ones as in all documents: Authorization, Patient Contacts, Payers – Coded Vital Signs [O] The Coded Vital Signs section should contain at least the height and weight of the patient. – Allergies [R] Allergies, Intolerances and Adverse reactions observed as a consequence of the recorded administration SHALL be documented in this section. If no such issues have been observed, the section shall remain empty or contain a narrative description declaring that no such issue has been observed.

Hierarchy PRE item Injection 2 times a day for 1 week 5 injections in a package 3 packages to dispense DIS item 1 package with 5 injections ADM item (1 inj) DIS item 1 package with 5 injections DIS item 1 package with 5 injections ADM item (1 inj) :

Data-elements Right HL7 structure: substanceAdministration with moodCode=EVN – Not „supply“ as it is in DIS -> that means, we derive the structure from PRE Data-Elements – Medicine All as in PRE, except Packaging and Generic Equivalent – Administration item (derived from PRE-item) Rename – Dosage Instructions -> Dosage administered – Prescriber -> Administering person – Fulfillment Instructions -> Administering Notes – Amount of units of the consumable to dispense -> Quantity administered Delete – Number of repeats – Patient Medication Instructions – Substitution Handling – Precondition Add – Reference to DIS item – Other data-elements to add?

Other thoughts Which data-container to use for the use-case „Patient tells the physician that he takes this or that medication“? – It is not really a PRE, because a PRE is an order – It is not really a DIS, because a DIS documents what the patient got dispensed. This is usually taken piece-per-piece for a longer period of time – It is not really an ADM, because an ADM documents on single administration event – Is it a „Medication Statement“? How does a Medication Statement look like? Do we need another profile for that or can we use the standard PCC Medication template?