1. STU3 Limitation - Combination pack instructions
Workaround: Use a free-text `Dosage.additionalInstruction`.
It is common practice to provide a dosage instruction for the combination pack “Migraleve tablets” with instructions for when to take the pink tablets and when to take the yellow tablets. With the current STU3 Dosage structure, these instructions would have to be conveyed in free-text using the Dosage.patientInstructions
.
In secondary care the individual components of the pack should be prescribed as separate items.
In primary care the combination pack is prescribed and therefore the medication request must reference the medication resource for the dm+d code of the combination product. The medication request then links to 2 dosing instructions which describe how each tablet should be taken.
<MedicationRequest xmlns="http://hl7.org/fhir"> <id value="859e5d8a-391a-4b2a-8f29-15e8c75180bb" /> <contained> <Medication> <id value="internalMedicationIdentifer123abc" /> <code> <coding> <system value="http://snomed.info/sct" /> <code value="3363411000001108" /> <display value="Migraleve tablets (McNeil Products Ltd)" /> </coding> </code> </Medication> </contained> <status value="active" /> <intent value="order" /> <medicationReference> <reference value="#internalMedicationIdentifer123abc" /> <display value="Migraleve tablets (McNeil Products Ltd)" /> </medicationReference> <subject> <identifier> <system value="https://fhir.nhs.uk/Id/nhs-number" /> <value value="9999999999" /> </identifier> </subject> <dosageInstruction> <sequence value="1" /> <text value="2 tablets - take once - as required when migraine occurs - Max dose 2 tablets in 24 hours - Pink tablet" /> <additionalInstruction> <text value="Pink tablets" /> </additionalInstruction> <timing> <repeat> <count value="1" /> </repeat> </timing> <asNeededCodeableConcept> <coding> <system value="http://snomed.info/sct" /> <code value="37796009" /> <display value="Migraine" /> </coding> </asNeededCodeableConcept> <doseQuantity> <value value="2" /> <unit value="tablet" /> <system value="http://snomed.info/sct" /> <code value="428673006" /> </doseQuantity> <maxDosePerPeriod> <numerator> <value value="2" /> <unit value="tablet" /> <system value="http://snomed.info/sct" /> <code value="428673006" /> </numerator> <denominator> <value value="24" /> <unit value="hour" /> <system value="http://unitsofmeasure.org" /> <code value="h" /> </denominator> </maxDosePerPeriod> </dosageInstruction> <dosageInstruction> <sequence value="2" /> <text value="2 tablets - every 4 hours - as required - max dose 6 tablets in 24 hours - Yellow tablets" /> <additionalInstruction> <text value="Yellow tablets" /> </additionalInstruction> <timing> <repeat> <frequency value="1" /> <period value="4" /> <periodUnit value="h" /> </repeat> </timing> <asNeededBoolean value="true" /> <doseQuantity> <value value="2" /> <unit value="tablet" /> <system value="http://snomed.info/sct" /> <code value="428673006" /> </doseQuantity> <maxDosePerPeriod> <numerator> <value value="6" /> <unit value="tablet" /> <system value="http://snomed.info/sct" /> <code value="428673006" /> </numerator> <denominator> <value value="24" /> <unit value="hour" /> <system value="http://unitsofmeasure.org" /> <code value="h" /> </denominator> </maxDosePerPeriod> </dosageInstruction> </MedicationRequest>
{ "resourceType": "MedicationRequest", "id": "859e5d8a-391a-4b2a-8f29-15e8c75180bb", "contained": [ { "resourceType": "Medication", "id": "internalMedicationIdentifer123abc", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "3363411000001108", "display": "Migraleve tablets (McNeil Products Ltd)" } ] } } ], "status": "active", "intent": "order", "medicationReference": { "reference": "#internalMedicationIdentifer123abc", "display": "Migraleve tablets (McNeil Products Ltd)" }, "subject": { "identifier": { "system": "https://fhir.nhs.uk/Id/nhs-number", "value": "9999999999" } }, "dosageInstruction": [ { "sequence": 1, "text": "2 tablets - take once - as required when migraine occurs - Max dose 2 tablets in 24 hours - Pink tablet", "additionalInstruction": [ { "text": "Pink tablets" } ], "timing": { "repeat": { "count": 1 } }, "asNeededCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "37796009", "display": "Migraine" } ] }, "doseQuantity": { "value": 2, "unit": "tablet", "system": "http://snomed.info/sct", "code": "428673006" }, "maxDosePerPeriod": { "numerator": { "value": 2, "unit": "tablet", "system": "http://snomed.info/sct", "code": "428673006" }, "denominator": { "value": 24, "unit": "hour", "system": "http://unitsofmeasure.org", "code": "h" } } }, { "sequence": 2, "text": "2 tablets - every 4 hours - as required - max dose 6 tablets in 24 hours - Yellow tablets", "additionalInstruction": [ { "text": "Yellow tablets" } ], "timing": { "repeat": { "frequency": 1, "period": 4, "periodUnit": "h" } }, "asNeededBoolean": true, "doseQuantity": { "value": 2, "unit": "tablet", "system": "http://snomed.info/sct", "code": "428673006" }, "maxDosePerPeriod": { "numerator": { "value": 6, "unit": "tablet", "system": "http://snomed.info/sct", "code": "428673006" }, "denominator": { "value": 24, "unit": "hour", "system": "http://unitsofmeasure.org", "code": "h" } } } ] }
MedicationRequest.id[0] | 859e5d8a-391a-4b2a-8f29-15e8c75180bb |
MedicationRequest.contained[0].id[0] | internalMedicationIdentifer123abc |
MedicationRequest.contained[0].code[0].coding[0].system[0] | http://snomed.info/sct |
MedicationRequest.contained[0].code[0].coding[0].code[0] | 3363411000001108 |
MedicationRequest.contained[0].code[0].coding[0].display[0] | Migraleve tablets (McNeil Products Ltd) |
MedicationRequest.status[0] | active |
MedicationRequest.intent[0] | order |
MedicationRequest.medication[0].reference[0] | #internalMedicationIdentifer123abc |
MedicationRequest.medication[0].display[0] | Migraleve tablets (McNeil Products Ltd) |
MedicationRequest.subject[0].identifier[0].system[0] | https://fhir.nhs.uk/Id/nhs-number |
MedicationRequest.subject[0].identifier[0].value[0] | 9999999999 |
MedicationRequest.dosageInstruction[0].sequence[0] | 1 |
MedicationRequest.dosageInstruction[0].text[0] | 2 tablets - take once - as required when migraine occurs - Max dose 2 tablets in 24 hours - Pink tablet |
MedicationRequest.dosageInstruction[0].additionalInstruction[0].text[0] | Pink tablets |
MedicationRequest.dosageInstruction[0].timing[0].repeat[0].count[0] | 1 |
MedicationRequest.dosageInstruction[0].asNeeded[0].coding[0].system[0] | http://snomed.info/sct |
MedicationRequest.dosageInstruction[0].asNeeded[0].coding[0].code[0] | 37796009 |
MedicationRequest.dosageInstruction[0].asNeeded[0].coding[0].display[0] | Migraine |
MedicationRequest.dosageInstruction[0].dose[0].value[0] | 2 |
MedicationRequest.dosageInstruction[0].dose[0].unit[0] | tablet |
MedicationRequest.dosageInstruction[0].dose[0].system[0] | http://snomed.info/sct |
MedicationRequest.dosageInstruction[0].dose[0].code[0] | 428673006 |
MedicationRequest.dosageInstruction[0].maxDosePerPeriod[0].numerator[0].value[0] | 2 |
MedicationRequest.dosageInstruction[0].maxDosePerPeriod[0].numerator[0].unit[0] | tablet |
MedicationRequest.dosageInstruction[0].maxDosePerPeriod[0].numerator[0].system[0] | http://snomed.info/sct |
MedicationRequest.dosageInstruction[0].maxDosePerPeriod[0].numerator[0].code[0] | 428673006 |
MedicationRequest.dosageInstruction[0].maxDosePerPeriod[0].denominator[0].value[0] | 24 |
MedicationRequest.dosageInstruction[0].maxDosePerPeriod[0].denominator[0].unit[0] | hour |
MedicationRequest.dosageInstruction[0].maxDosePerPeriod[0].denominator[0].system[0] | http://unitsofmeasure.org |
MedicationRequest.dosageInstruction[0].maxDosePerPeriod[0].denominator[0].code[0] | h |
MedicationRequest.dosageInstruction[1].sequence[0] | 2 |
MedicationRequest.dosageInstruction[1].text[0] | 2 tablets - every 4 hours - as required - max dose 6 tablets in 24 hours - Yellow tablets |
MedicationRequest.dosageInstruction[1].additionalInstruction[0].text[0] | Yellow tablets |
MedicationRequest.dosageInstruction[1].timing[0].repeat[0].frequency[0] | 1 |
MedicationRequest.dosageInstruction[1].timing[0].repeat[0].period[0] | 4 |
MedicationRequest.dosageInstruction[1].timing[0].repeat[0].periodUnit[0] | h |
MedicationRequest.dosageInstruction[1].asNeeded[0] | True |
MedicationRequest.dosageInstruction[1].dose[0].value[0] | 2 |
MedicationRequest.dosageInstruction[1].dose[0].unit[0] | tablet |
MedicationRequest.dosageInstruction[1].dose[0].system[0] | http://snomed.info/sct |
MedicationRequest.dosageInstruction[1].dose[0].code[0] | 428673006 |
MedicationRequest.dosageInstruction[1].maxDosePerPeriod[0].numerator[0].value[0] | 6 |
MedicationRequest.dosageInstruction[1].maxDosePerPeriod[0].numerator[0].unit[0] | tablet |
MedicationRequest.dosageInstruction[1].maxDosePerPeriod[0].numerator[0].system[0] | http://snomed.info/sct |
MedicationRequest.dosageInstruction[1].maxDosePerPeriod[0].numerator[0].code[0] | 428673006 |
MedicationRequest.dosageInstruction[1].maxDosePerPeriod[0].denominator[0].value[0] | 24 |
MedicationRequest.dosageInstruction[1].maxDosePerPeriod[0].denominator[0].unit[0] | hour |
MedicationRequest.dosageInstruction[1].maxDosePerPeriod[0].denominator[0].system[0] | http://unitsofmeasure.org |
MedicationRequest.dosageInstruction[1].maxDosePerPeriod[0].denominator[0].code[0] | h |
MedicationRequest |
id : 859e5d8a-391a-4b2a-8f29-15e8c75180bb |
contained |
id : internalMedicationIdentifer123abc |
code |
coding |
system : http://snomed.info/sct |
code : 3363411000001108 |
display : Migraleve tablets (McNeil Products Ltd) |
status : active |
intent : order |
medication |
reference : #internalMedicationIdentifer123abc |
display : Migraleve tablets (McNeil Products Ltd) |
subject |
identifier |
system : https://fhir.nhs.uk/Id/nhs-number |
value : 9999999999 |
dosageInstruction |
sequence : 1 |
text : 2 tablets - take once - as required when migraine occurs - Max dose 2 tablets in 24 hours - Pink tablet |
additionalInstruction |
text : Pink tablets |
timing |
repeat |
count : 1 |
asNeeded |
coding |
system : http://snomed.info/sct |
code : 37796009 |
display : Migraine |
dose |
value : 2 |
unit : tablet |
system : http://snomed.info/sct |
code : 428673006 |
maxDosePerPeriod |
numerator |
value : 2 |
unit : tablet |
system : http://snomed.info/sct |
code : 428673006 |
denominator |
value : 24 |
unit : hour |
system : http://unitsofmeasure.org |
code : h |
dosageInstruction |
sequence : 2 |
text : 2 tablets - every 4 hours - as required - max dose 6 tablets in 24 hours - Yellow tablets |
additionalInstruction |
text : Yellow tablets |
timing |
repeat |
frequency : 1 |
period : 4 |
periodUnit : h |
asNeeded : True |
dose |
value : 2 |
unit : tablet |
system : http://snomed.info/sct |
code : 428673006 |
maxDosePerPeriod |
numerator |
value : 6 |
unit : tablet |
system : http://snomed.info/sct |
code : 428673006 |
denominator |
value : 24 |
unit : hour |
system : http://unitsofmeasure.org |
code : h |