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Medication Management. Prescription Ordering Substance Administrations Supply (Dispenses) Prescription Status Changes Hold and Release (i.e. for hospital stays) Discontinue Non-Prescribed Orders Over-the-Counter medications Historical Orders Dispense Management
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Medication Management • Prescription Ordering • Substance Administrations • Supply (Dispenses) • Prescription Status Changes • Hold and Release (i.e. for hospital stays) • Discontinue • Non-Prescribed Orders • Over-the-Counter medications • Historical Orders • Dispense Management • Pickup is considered a distinct action
Prescription Orders • Core Paper Prescription Information • Prescribed From • Prescribed By • Prescribed For • Administration Instructions • Product Prescribed (Not limited to drugs) • Dispense Instructions (Instructions to Pharmacist) • Occasional or Implied Information • Prescribing Indications (Reasons for prescribing) • Protocols/Guidelines • Trial Program • Allowed Substitutions • New Information (or Rarely seen) • Based on Patient Measurements • Prescription Notes • Coverage Extensions • Treatment Type (Short-Term, Continuous, As-Directed)
Allergy Information • Modeled as a Concern that comprises a number of Allergy Observations • Each Allergy observation has a severity and a reaction (which itself has a severity) • Supporting Information: • Allergy Tests • Starts After Exposure Event
Lab Order Fulfillment • We capture three things: • What was ordered • What was actually done (which may be exactly what was ordered) • The results (known in HL7 as Observations) of what was done • The results can arrive piecemeal, especially for an ordered battery • There can be interim reports as well as a final report