FHIR Implementation Guide for ABDM CI Build v2.0.1
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This Implementation guide is published and maintained by NRCeS for NHA.
This version is based on the ABDM Health Data Interchange Specifications 1.0 and updated periodically.

StructureDefinition-PrescriptionRecord

This profile sets minimum expectations for the PrescriptionRecord to record, search, and fetch the details of medications prescribed to a patient in a particular encounter. It identifies the mandatory core elements, vocabularies and value sets which SHALL be present in the Composition resource when using this profile.

Examples

Formal Views of Profile Content

Description of Profiles, Differentials, and Snapshots.

The official URL for this profile is: https://nrces.in/ndhm/fhir/r4/StructureDefinition/PrescriptionRecord

This profile builds on Composition


NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation / A set of resources composed to define the prescription record.
... status S1..1codepreliminary | final | amended | entered-in-error
... type S1..1CodeableConceptKind of composition ("Prescription record ")
.... coding 1..1CodingCode defined by a terminology system/ Code defined by SNOMED CT for Prescription record
..... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code 1..1codeSymbol in syntax defined by the system
Fixed Value: 440545006
..... display 1..1stringRepresentation defined by the system
Fixed Value: Prescription record
.... text S0..1stringPlain text representation of the concept
... subject S1..1Reference(Patient)Who and/or what the composition/Prescription record is about
.... reference 1..1stringLiteral reference, Relative, internal or absolute URL
... encounter 0..1Reference(Encounter)Context of the Composition
... date S1..1dateTimeComposition editing time
... author S1..*Reference(Practitioner | Organization | PractitionerRole | Patient | Device | RelatedPerson)Who and/or what authored the composition/Presciption record
.... reference 1..1stringLiteral reference, Relative, internal or absolute URL
... title S1..1stringHuman Readable name/title
... attester S0..*BackboneElementAttests to accuracy of composition
.... party 0..1Reference(RelatedPerson | PractitionerRole | Practitioner | Patient | Organization)Who attested the composition
... custodian 0..1Reference(Organization)Organization which maintains the composition
... section S1..1BackboneElementComposition is broken into sections / Prescription record contains single section to define the relevant medication requests
.... code
..... coding S0..*CodingCode defined by a terminology system
...... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... code 1..1codeSymbol in syntax defined by the system
Fixed Value: 440545006
...... display 1..1stringRepresentation defined by the system
Fixed Value: Prescription record
..... text S0..1stringPlain text representation of the concept
.... Slices for entry S1..*Reference(MedicationRequest | Binary)A reference to data that supports this section
Slice: Unordered, Closed by value:type
..... entry:MedicationRequest S0..*Reference(MedicationRequest)A reference to data that supports this section
...... reference 1..1stringLiteral reference, Relative, internal or absolute URL
...... type 1..1uriType the reference refers to (e.g. "Patient")
Fixed Value: MedicationRequest
..... entry:Binary 0..1Reference(Binary)A reference to data that supports this section
...... reference 1..1stringLiteral reference, Relative, internal or absolute URL
...... type 1..1uriType the reference refers to (e.g. "Patient")
Fixed Value: Binary

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation / A set of resources composed to define the prescription record.
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..1IdentifierVersion-independent identifier for the Composition
... status ?!SΣ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.

... type SΣ1..1CodeableConceptKind of composition ("Prescription record ")
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.

.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ1..1CodingCode defined by a terminology system/ Code defined by SNOMED CT for Prescription record
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... version Σ0..1stringVersion of the system - if relevant
..... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 440545006
..... display Σ1..1stringRepresentation defined by the system
Fixed Value: Prescription record
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text SΣ0..1stringPlain text representation of the concept
... category Σ0..*CodeableConceptCategorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ1..1Reference(Patient)Who and/or what the composition/Prescription record is about
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... encounter Σ0..1Reference(Encounter)Context of the Composition
... date SΣ1..1dateTimeComposition editing time
... author SΣ1..*Reference(Practitioner | Organization | PractitionerRole | Patient | Device | RelatedPerson)Who and/or what authored the composition/Presciption record
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... title SΣ1..1stringHuman Readable name/title
... confidentiality Σ0..1codeAs defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.

... attester S0..*BackboneElementAttests to accuracy of composition
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode 1..1codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.

.... time 0..1dateTimeWhen the composition was attested
.... party 0..1Reference(RelatedPerson | PractitionerRole | Practitioner | Patient | Organization)Who attested the composition
... custodian Σ0..1Reference(Organization)Organization which maintains the composition
... relatesTo 0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target[x] 1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition)
... event Σ0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*Reference(Resource)The event(s) being documented
... section SI1..1BackboneElementComposition is broken into sections / Prescription record contains single section to define the relevant medication requests
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... title 0..1stringLabel for section (e.g. for ToC)
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣ0..*CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 440545006
...... display Σ1..1stringRepresentation defined by the system
Fixed Value: Prescription record
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... text SΣ0..1stringPlain text representation of the concept
.... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
.... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
.... text I0..1NarrativeText summary of the section, for human interpretation
.... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

.... Slices for entry SI1..*Reference(MedicationRequest | Binary)A reference to data that supports this section
Slice: Unordered, Closed by value:type
..... entry:MedicationRequest SI0..*Reference(MedicationRequest)A reference to data that supports this section
...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
...... type Σ1..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).


Fixed Value: MedicationRequest
...... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
...... display Σ0..1stringText alternative for the resource
..... entry:Binary I0..1Reference(Binary)A reference to data that supports this section
...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
...... type Σ1..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).


Fixed Value: Binary
...... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
...... display Σ0..1stringText alternative for the resource
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

.... section I0..*See section (Composition)Nested Section

doco Documentation for this format

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation / A set of resources composed to define the prescription record.
... status S1..1codepreliminary | final | amended | entered-in-error
... type S1..1CodeableConceptKind of composition ("Prescription record ")
.... coding 1..1CodingCode defined by a terminology system/ Code defined by SNOMED CT for Prescription record
..... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code 1..1codeSymbol in syntax defined by the system
Fixed Value: 440545006
..... display 1..1stringRepresentation defined by the system
Fixed Value: Prescription record
.... text S0..1stringPlain text representation of the concept
... subject S1..1Reference(Patient)Who and/or what the composition/Prescription record is about
.... reference 1..1stringLiteral reference, Relative, internal or absolute URL
... encounter 0..1Reference(Encounter)Context of the Composition
... date S1..1dateTimeComposition editing time
... author S1..*Reference(Practitioner | Organization | PractitionerRole | Patient | Device | RelatedPerson)Who and/or what authored the composition/Presciption record
.... reference 1..1stringLiteral reference, Relative, internal or absolute URL
... title S1..1stringHuman Readable name/title
... attester S0..*BackboneElementAttests to accuracy of composition
.... party 0..1Reference(RelatedPerson | PractitionerRole | Practitioner | Patient | Organization)Who attested the composition
... custodian 0..1Reference(Organization)Organization which maintains the composition
... section S1..1BackboneElementComposition is broken into sections / Prescription record contains single section to define the relevant medication requests
.... code
..... coding S0..*CodingCode defined by a terminology system
...... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... code 1..1codeSymbol in syntax defined by the system
Fixed Value: 440545006
...... display 1..1stringRepresentation defined by the system
Fixed Value: Prescription record
..... text S0..1stringPlain text representation of the concept
.... Slices for entry S1..*Reference(MedicationRequest | Binary)A reference to data that supports this section
Slice: Unordered, Closed by value:type
..... entry:MedicationRequest S0..*Reference(MedicationRequest)A reference to data that supports this section
...... reference 1..1stringLiteral reference, Relative, internal or absolute URL
...... type 1..1uriType the reference refers to (e.g. "Patient")
Fixed Value: MedicationRequest
..... entry:Binary 0..1Reference(Binary)A reference to data that supports this section
...... reference 1..1stringLiteral reference, Relative, internal or absolute URL
...... type 1..1uriType the reference refers to (e.g. "Patient")
Fixed Value: Binary

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation / A set of resources composed to define the prescription record.
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..1IdentifierVersion-independent identifier for the Composition
... status ?!SΣ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.

... type SΣ1..1CodeableConceptKind of composition ("Prescription record ")
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.

.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ1..1CodingCode defined by a terminology system/ Code defined by SNOMED CT for Prescription record
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... version Σ0..1stringVersion of the system - if relevant
..... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 440545006
..... display Σ1..1stringRepresentation defined by the system
Fixed Value: Prescription record
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text SΣ0..1stringPlain text representation of the concept
... category Σ0..*CodeableConceptCategorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ1..1Reference(Patient)Who and/or what the composition/Prescription record is about
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... encounter Σ0..1Reference(Encounter)Context of the Composition
... date SΣ1..1dateTimeComposition editing time
... author SΣ1..*Reference(Practitioner | Organization | PractitionerRole | Patient | Device | RelatedPerson)Who and/or what authored the composition/Presciption record
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... title SΣ1..1stringHuman Readable name/title
... confidentiality Σ0..1codeAs defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.

... attester S0..*BackboneElementAttests to accuracy of composition
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode 1..1codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.

.... time 0..1dateTimeWhen the composition was attested
.... party 0..1Reference(RelatedPerson | PractitionerRole | Practitioner | Patient | Organization)Who attested the composition
... custodian Σ0..1Reference(Organization)Organization which maintains the composition
... relatesTo 0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target[x] 1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition)
... event Σ0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*Reference(Resource)The event(s) being documented
... section SI1..1BackboneElementComposition is broken into sections / Prescription record contains single section to define the relevant medication requests
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... title 0..1stringLabel for section (e.g. for ToC)
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣ0..*CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 440545006
...... display Σ1..1stringRepresentation defined by the system
Fixed Value: Prescription record
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... text SΣ0..1stringPlain text representation of the concept
.... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
.... focus 0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
.... text I0..1NarrativeText summary of the section, for human interpretation
.... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

.... Slices for entry SI1..*Reference(MedicationRequest | Binary)A reference to data that supports this section
Slice: Unordered, Closed by value:type
..... entry:MedicationRequest SI0..*Reference(MedicationRequest)A reference to data that supports this section
...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
...... type Σ1..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).


Fixed Value: MedicationRequest
...... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
...... display Σ0..1stringText alternative for the resource
..... entry:Binary I0..1Reference(Binary)A reference to data that supports this section
...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
...... type Σ1..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).


Fixed Value: Binary
...... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
...... display Σ0..1stringText alternative for the resource
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

.... section I0..*See section (Composition)Nested Section

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron