Anfrage zum Ausstellen einer Verordnung (ServiceRequest)
Motivation
Als zentrales Element in einer Anfrage gelten in dieser Spezifikation ServiceRequests. Diese Bündeln die Informationen für eine konkrete Anfrage an einen anderen Leistungserbringer. Folgende Begriffe werden in diesem IG für diesen ServiceRequests genutzt:
- ServiceRequest meint den Request als Basisprofil von HL7
- ERPServiceRequestPrescriptionRequest meint konkret dieses Profil in diesem Projekt
- Verordnungsanfrage ist der fachliche Begriff für dieses Profil
Der ERPServiceRequestPrescriptionRequest ist eine Anfrage zum Ausstellen einer Verordnung an einen Arzt. Alle für den Arzt relevanten Informationen zum Ausstellen einer entsprechenden Verordnung sind hier aufgeführt, bzw. referenziert.
Die Identifikation als ERPServiceRequestPrescriptionRequest (Verordnungsanfrage) wird über .code.coding.code = #prescription-request angegeben.
Kompatibilität
Dieses Profil basiert auf dem Profil ServiceRequest der FHIR-Core Spezifikation (R4).
Profil
Die folgende FHIR Ressource stellt eine Anfrage an eine verordnende LEI dar. Enthalten sein muss eine strukturelle angabe der angefragten Medikation.
ERPServiceRequestPrescriptionRequest (ServiceRequest) | I | ServiceRequest | |
id | Σ | 0..1 | string |
meta | Σ | 0..1 | Meta |
implicitRules | Σ ?! | 0..1 | uri |
language | 0..1 | codeBinding | |
text | 0..1 | Narrative | |
contained | 0..* | Resource | |
extension | S I | 0..* | Extension |
EPrescriptionToken | S I | 0..1 | Extension(ERPServiceRequestEPrescriptionToken) |
modifierExtension | ?! I | 0..* | Extension |
identifier | S Σ | 1..* | Identifier |
requestId | Σ | 1..1 | ERPServiceRequestRequestIdentifier |
predisId | Σ | 0..1 | ERPServiceRequestPreDisIdentifier |
instantiatesCanonical | Σ | 0..* | canonical(ActivityDefinition | PlanDefinition) |
instantiatesUri | Σ | 0..* | uri |
basedOn | S Σ I | 1..1 | Reference(MedicationRequest) |
replaces | Σ I | 0..* | Reference(ServiceRequest) |
requisition | S Σ | 1..1 | ERPServiceRequestProcedureIdentifier |
status | S Σ ?! | 1..1 | codeBinding |
intent | Σ ?! | 1..1 | codeBindingFixed Value |
category | Σ | 0..* | CodeableConcept |
priority | Σ | 0..1 | codeBinding |
doNotPerform | Σ ?! | 0..1 | boolean |
code | S Σ | 0..1 | CodeableConcept |
id | 0..1 | string | |
extension | I | 0..* | Extension |
coding | S Σ | 1..1 | CodingBinding |
id | 0..1 | string | |
extension | I | 0..* | Extension |
system | Σ | 1..1 | uri |
version | Σ | 0..1 | string |
code | Σ | 1..1 | codeFixed Value |
display | Σ | 0..1 | string |
userSelected | Σ | 0..1 | boolean |
text | Σ | 0..1 | string |
orderDetail | S Σ I | 1..1 | CodeableConcept |
id | 0..1 | string | |
extension | I | 0..* | Extension |
coding | S Σ | 1..1 | CodingBinding |
text | Σ | 0..1 | string |
quantity[x] | Σ | 0..1 | |
quantityQuantity | Quantity | ||
quantityRatio | Ratio | ||
quantityRange | Range | ||
subject | S Σ I | 1..1 | Reference(Patient | Group | Location | Device) |
encounter | Σ I | 0..1 | Reference(Encounter) |
occurrence[x] | S Σ | 0..1 | |
occurrenceDateTime | dateTime | ||
asNeeded[x] | Σ | 0..1 | |
asNeededBoolean | boolean | ||
asNeededCodeableConcept | CodeableConcept | ||
authoredOn | S Σ | 1..1 | dateTime |
requester | S Σ I | 1..1 | Reference(Organization | Practitioner) |
performerType | Σ | 0..1 | CodeableConcept |
performer | S Σ I | 0..* | Reference(Practitioner) |
locationCode | Σ | 0..* | CodeableConcept |
locationReference | Σ I | 0..* | Reference(Location) |
reasonCode | S Σ | 0..* | CodeableConceptBinding |
reasonReference | Σ I | 0..* | Reference(ERPServiceRequestRemainingMedication) |
insurance | I | 0..* | Reference(Coverage | ClaimResponse) |
supportingInfo | S I | 0..* | Reference(Resource) |
AuslieferndeApotheke | S I | 0..1 | Reference(ERPServiceRequestOrganization) |
id | 0..1 | string | |
extension | I | 0..* | Extension |
reference | Σ I | 0..1 | string |
type | Σ | 1..1 | uriBindingPattern |
identifier | Σ | 0..1 | Identifier |
display | Σ | 0..1 | string |
specimen | Σ I | 0..* | Reference(Specimen) |
bodySite | Σ | 0..* | CodeableConcept |
note | S | 0..* | Annotation |
patientInstruction | Σ | 0..1 | string |
relevantHistory | I | 0..* | Reference(Provenance) |
Folgende Felder sind entsprechend zu befüllen, bzw. können befüllt werden:
id | short | comment |
---|---|---|
ServiceRequest | ||
ServiceRequest.extension | ||
ServiceRequest.extension:EPrescriptionToken | Here the e-prescription token can be made available for processing in a pharmacy. | The token is of the form '/Task/{PrescriptionID}/$accept?ac={AccessCode}. See gemSpec_DM_eRp'. |
ServiceRequest.identifier | Defines identifiers to be used in this profile. | |
ServiceRequest.identifier:requestId | Identifier that uniquely references a ServiceRequest. | For referencing and assignment of ServiceRequest, e.g. if one ServiceRequest is to replace another, it is important to be able to make this assignment with the identifier. Can be mapped via a UUID, for example. |
ServiceRequest.identifier:predisId | Identifier that connects a prescription and a dispensing request. | Can be mapped via a UUID, for example. |
ServiceRequest.basedOn | Requested or fulfilled MedicationRequest. | Exactly one MedicationRequest is assigned to a ServiceRequest, so that independent processing is possible. |
ServiceRequest.requisition | Identifier of the process. All ServiceRequests within a process receive the same ID. | Is to be understood as a case or process ID (see mapping) in order to be able to track which request the ServiceRequest belongs to. |
ServiceRequest.status | Indicates the processing status of a service request. | If the status changes, this value is overwritten. |
ServiceRequest.intent | ||
ServiceRequest.priority | ||
ServiceRequest.code | Indicates the type of service request. | |
ServiceRequest.code.coding | ||
ServiceRequest.code.coding.system | ||
ServiceRequest.code.coding.code | #prescription-request defines this ServiceRequest as a prescription request from a doctor. | |
ServiceRequest.orderDetail | ||
ServiceRequest.orderDetail.coding | Specifies how the recipe request should be fulfilled. | If the prescription goes to a pharmacy, a corresponding ServiceRequest must be included in the bundle. |
ServiceRequest.subject | Patient for whom a prescription is requested on behalf of the patient. | |
ServiceRequest.occurrence[x] | Specifies the date on which the prescription is to be issued. | Can be used by the requester to make the timely urgency clear. |
ServiceRequest.authoredOn | Creation date of the request. | Is initially created and then no longer changed. |
ServiceRequest.requester | Inquiring facility or practitioner. | The KIM address is already stored in the message header. Therefore, the preferred specification is to store a KBV_PR_FOR_Practitioner. |
ServiceRequest.performer | Doctor who is to write the prescription. | |
ServiceRequest.reasonCode | Code indicating why a prescription is requested. | Also used to indicate why the transaction was canceled in the event of a cancellation. |
ServiceRequest.reasonReference | Reference to an observation resource that indicates how long the current medication will last. | If a reference to the reason is provided, a human-readable entry in .note must also be added in case systems cannot process the referenced observation. |
ServiceRequest.supportingInfo | ||
ServiceRequest.supportingInfo:AuslieferndeApotheke | ||
ServiceRequest.supportingInfo:AuslieferndeApotheke.type | ||
ServiceRequest.note | Further information on the prescription request. | Any use cases that are not specified can be placed here in free text. |
Use-Case spezifische Anforderungen
- Für
based
MUSS das Profil ERPServiceRequestMedicationRequest oder KBV_PR_ERP_Prescription verwendet werden. - Für
subject
MUSS das Profil KBV_PR_FOR_Patient verwendet werden. - Für
requester
MUSS das Profil KBV_PR_FOR_Practitioner oder ERPServiceRequestOrganization verwendet werden. - Für
performer
MUSS das Profil KBV_PR_FOR_Practitioner verwendet werden.
Beispiel
Valides Beispiel einer Verordnungsanfrage:
{ "resourceType": "Bundle", "id": "UC1-1-Prescription-Request-To-Prescriber", "meta": { "profile": [ "https://gematik.de/fhir/erp-servicerequest/StructureDefinition/erp-service-request-message-container" ] }, "type": "message", "identifier": { "system": "urn:ietf:rfc:3986", "value": "urn:uuid:29888885-6639-481c-934e-4b7b51745084" }, "timestamp": "2015-02-07T13:28:17.239+02:00", "entry": [ { "fullUrl": "http://erp-servicerequest-test.de/MessageHeader/UC1-HealthCareService-to-Practitioner-MessageHeader", "resource": { "resourceType": "MessageHeader", "id": "UC1-HealthCareService-to-Practitioner-MessageHeader", "meta": { "profile": [ "https://gematik.de/fhir/erp-servicerequest/StructureDefinition/erp-service-request-request-header" ] }, "source": { "contact": { "system": "email", "value": "info@hcs.email" }, "name": "HealthCare-Source", "software": "HealthCare-Software", "version": "1.0.0", "endpoint": "mailto:healthcare-service@test.kim.de" }, "focus": [ { "reference": "ServiceRequest/UC1-Initial-Prescription-Request" } ], "sender": { "identifier": { "system": "https://gematik.de/fhir/sid/telematik-id", "value": "5-test-telematik-id" }, "display": "Pflegeheim Immergrün" }, "destination": [ { "receiver": { "identifier": { "system": "https://gematik.de/fhir/sid/telematik-id", "value": "1-test-telematik-id" }, "display": "Praxis Hans Topp-Glücklich" }, "endpoint": "mailto:practitioner@test.kim.de" } ], "eventCoding": { "code": "eRezept_Rezeptanforderung;Rezeptanfrage", "system": "https://gematik.de/fhir/atf/CodeSystem/service-identifier-cs" } } }, { "fullUrl": "http://erp-servicerequest-test.de/ServiceRequest/UC1-Initial-Prescription-Request", "resource": { "resourceType": "ServiceRequest", "id": "UC1-Initial-Prescription-Request", "meta": { "profile": [ "https://gematik.de/fhir/erp-servicerequest/StructureDefinition/erp-service-request-prescription-request" ] }, "intent": "order", "requisition": { "system": "https://gematik.de/fhir/erp-servicerequest/sid/NamingSystemProcedureIdentifier", "value": "GroupID-UC1" }, "code": { "coding": [ { "code": "prescription-request", "system": "https://gematik.de/fhir/erp-servicerequest/CodeSystem/service-request-type-cs" } ] }, "identifier": [ { "system": "https://gematik.de/fhir/erp-servicerequest/sid/NamingSystemRequestIdentifier", "value": "1" }, { "system": "https://gematik.de/fhir/erp-servicerequest/sid/NamingSystemPreDisIdentifier", "value": "PreDis-1" } ], "basedOn": [ { "reference": "MedicationRequest/Example-Initial-Medication-Request" } ], "status": "active", "subject": { "reference": "Patient/Example-Patient" }, "orderDetail": [ { "coding": [ { "code": "return-to-requester", "system": "https://gematik.de/fhir/erp-servicerequest/CodeSystem/prescription-fullfillment-type-cs" } ] } ], "occurrenceDateTime": "2023-02-01", "authoredOn": "2023-01-27", "requester": { "reference": "Organization/Example-HealthCareService-Organization" }, "performer": [ { "identifier": { "system": "https://gematik.de/fhir/sid/telematik-id", "value": "1-test-telematik-id" } } ], "reasonCode": [ { "coding": [ { "code": "medication-runs-out", "system": "https://gematik.de/fhir/erp-servicerequest/CodeSystem/medication-request-reason-cs" } ] } ], "reasonReference": [ { "reference": "Observation/Medication-Runs-Out-Example-dateTime" }, { "reference": "Observation/Medication-Runs-Out-Example-Quantity" } ], "note": [ { "text": "Medikament läuft am 31.01.2023 aus. Es sind noch 7 stk übrig. " } ] } }, { "fullUrl": "http://erp-servicerequest-test.de/MedicationRequest/Example-Initial-Medication-Request", "resource": { "resourceType": "MedicationRequest", "id": "Example-Initial-Medication-Request", "meta": { "profile": [ "https://gematik.de/fhir/erp-servicerequest/StructureDefinition/erp-service-request-medication-request" ] }, "extension": [ { "valueIdentifier": { "system": "https://gematik.de/fhir/erp/NamingSystem/GEM_ERP_NS_PrescriptionId", "value": "160.100.000.000.001.36" }, "url": "https://gematik.de/fhir/erp-servicerequest/StructureDefinition/prescription-id-ex" } ], "dispenseRequest": { "quantity": { "system": "http://unitsofmeasure.org", "code": "{Package}", "value": 1 } }, "status": "active", "intent": "order", "medicationReference": { "reference": "Medication/Example-Initial-Medication" }, "subject": { "reference": "Patient/Example-Patient" }, "authoredOn": "2022-05-20", "dosageInstruction": [ { "text": "2mal tägl. 5ml" } ], "substitution": { "allowedBoolean": true } } }, { "fullUrl": "http://erp-servicerequest-test.de/Medication/Example-Initial-Medication", "resource": { "resourceType": "Medication", "id": "Example-Initial-Medication", "meta": { "profile": [ "https://fhir.kbv.de/StructureDefinition/KBV_PR_ERP_Medication_PZN|1.1.0" ] }, "extension": [ { "url": "https://fhir.kbv.de/StructureDefinition/KBV_EX_Base_Medication_Type", "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "version": "http://snomed.info/sct/900000000000207008/version/20220331", "code": "763158003", "display": "Medicinal product (product)" } ] } }, { "url": "https://fhir.kbv.de/StructureDefinition/KBV_EX_ERP_Medication_Category", "valueCoding": { "code": "00", "system": "https://fhir.kbv.de/CodeSystem/KBV_CS_ERP_Medication_Category" } }, { "url": "https://fhir.kbv.de/StructureDefinition/KBV_EX_ERP_Medication_Vaccine", "valueBoolean": false }, { "url": "http://fhir.de/StructureDefinition/normgroesse", "valueCode": "N1" } ], "code": { "coding": [ { "system": "http://fhir.de/CodeSystem/ifa/pzn", "code": "08585997" } ], "text": "Prospan® Hustensaft 100ml" }, "form": { "coding": [ { "system": "https://fhir.kbv.de/CodeSystem/KBV_CS_SFHIR_KBV_DARREICHUNGSFORM", "code": "FLE" } ] } } }, { "fullUrl": "http://erp-servicerequest-test.de/Patient/Example-Patient", "resource": { "resourceType": "Patient", "id": "Example-Patient", "meta": { "profile": [ "https://fhir.kbv.de/StructureDefinition/KBV_PR_FOR_Patient|1.1.0" ] }, "identifier": [ { "type": { "coding": [ { "system": "http://fhir.de/CodeSystem/identifier-type-de-basis", "code": "GKV" } ] }, "system": "http://fhir.de/sid/gkv/kvid-10", "value": "X234567890" } ], "name": [ { "use": "official", "family": "Königsstein", "_family": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/humanname-own-name", "valueString": "Königsstein" } ] }, "given": [ "Ludger" ] } ], "address": [ { "type": "both", "line": [ "Musterstr. 1" ], "_line": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/iso21090-ADXP-houseNumber", "valueString": "1" }, { "url": "http://hl7.org/fhir/StructureDefinition/iso21090-ADXP-streetName", "valueString": "Musterstr." } ] } ], "city": "Berlin", "postalCode": "10623" } ], "birthDate": "1935-06-22" } }, { "fullUrl": "http://erp-servicerequest-test.de/Organization/Example-HealthCareService-Organization", "resource": { "resourceType": "Organization", "id": "Example-HealthCareService-Organization", "meta": { "profile": [ "https://gematik.de/fhir/erp-servicerequest/StructureDefinition/erp-service-request-organization" ] }, "identifier": [ { "type": { "coding": [ { "code": "kim-2.0", "system": "https://gematik.de/fhir/directory/CodeSystem/EndpointDirectoryConnectionType" } ] }, "system": "http://gematik.de/fhir/sid/KIM-Adresse", "value": "pflegeheim.immergrün.arzt@sana-pflegeheime.kim.telematik" }, { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "PRN" } ] }, "system": "https://gematik.de/fhir/sid/telematik-id", "value": "1-031234567" }, { "type": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0203", "code": "BSNR" } ] }, "system": "https://fhir.kbv.de/NamingSystem/KBV_NS_Base_BSNR", "value": "031234567" } ], "address": [ { "type": "both", "line": [ "Musterstr. 2" ], "_line": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/iso21090-ADXP-houseNumber", "valueString": "2" }, { "url": "http://hl7.org/fhir/StructureDefinition/iso21090-ADXP-streetName", "valueString": "Musterstr." } ] } ], "city": "Berlin", "postalCode": "10623" } ], "name": "Pflegeheim Immergrün", "telecom": [ { "system": "phone", "value": "0301234567" } ] } }, { "fullUrl": "http://erp-servicerequest-test.de/Observation/Medication-Runs-Out-Example-dateTime", "resource": { "resourceType": "Observation", "id": "Medication-Runs-Out-Example-dateTime", "meta": { "profile": [ "https://gematik.de/fhir/erp-servicerequest/StructureDefinition/erp-service-request-remaining-medication" ] }, "status": "final", "subject": { "reference": "Patient/Example-Patient" }, "code": { "coding": [ { "code": "range-of-medication", "system": "https://gematik.de/fhir/erp-servicerequest/CodeSystem/medication-observation-cs" } ] }, "valueDateTime": "2023-01-31" } }, { "fullUrl": "http://erp-servicerequest-test.de/Observation/Medication-Runs-Out-Example-Quantity", "resource": { "resourceType": "Observation", "id": "Medication-Runs-Out-Example-Quantity", "meta": { "profile": [ "https://gematik.de/fhir/erp-servicerequest/StructureDefinition/erp-service-request-remaining-medication" ] }, "status": "final", "subject": { "reference": "Patient/Example-Patient" }, "code": { "coding": [ { "code": "range-of-medication", "system": "https://gematik.de/fhir/erp-servicerequest/CodeSystem/medication-observation-cs" } ] }, "valueQuantity": { "value": 7, "unit": "stk" } } } ] }