AU Base Implementation Guide
4.2.2-ballot - Ballot
This page is part of the Australian Base IG (v4.2.2-ballot: AU Base R4.2 Ballot 5) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 4.1.0. For a full list of available versions, see the Directory of published versions
Page standards status: Informative |
<List xmlns="http://hl7.org/fhir">
<id value="example2"/>
<meta>
<profile value="http://hl7.org.au/fhir/StructureDefinition/au-medlist"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<h1>MEDICINE LIST</h1>
<h2>PATIENT</h2>
<table>
<tbody>
<tr>
<th>Name</th>
<td>
<p>David Goodpatient</p>
</td>
</tr>
<tr>
<th>DoB</th>
<td>14 September 1953</td>
</tr>
<tr>
<th>Gender</th>
<td>Male</td>
</tr>
<tr>
<th>Address</th>
<td>2 Round Court, QLD 4113</td>
</tr>
</tbody>
</table>
<h2>SOURCE OF MEDICINE LIST</h2>
<table>
<tbody>
<tr>
<th>Name</th>
<td>
<p>Iam Practitioner</p>
</td>
</tr>
<tr>
<th>HPI-I</th>
<td>8003619900015717</td>
</tr>
<tr>
<th>Phone</th>
<td>0755501234</td>
</tr>
<tr>
<th>Email</th>
<td>iam.practitioner@example.com</td>
</tr>
</tbody>
</table>
<h2>CONSULTATION DETAILS</h2>
<table>
<tbody>
<tr>
<th>Consultation date</th>
<td>15 Mar 2019</td>
</tr>
<tr>
<th>Consultation summary</th>
<td>Patient presented with weakness over the last couple of days. No other
symptoms. Revised patient's medications. Advised patient to see the
usual GPs clinic for further consultation and review. </td>
</tr>
</tbody>
</table>
<h3>CURRENT MEDICINES</h3>
<table border="1">
<thead>
<tr>
<th>Medicine</th>
<th>Direction</th>
<th>Medicine Purpose</th>
<th>Medicine Status</th>
<th>Result of Action</th>
<th>Special Instructions</th>
</tr>
</thead>
<tbody>
<tr>
<td>Multi-vitamins</td>
<td>1 tablet daily</td>
<td/>
<td>New</td>
<td/>
<td/>
</tr>
<tr>
<td>Spiriva (tiotropium bromide 18mg per inhalation) inhalant</td>
<td>1 inhalation per day</td>
<td>Chronic Obstructive Pulmonary Disease</td>
<td>Amended</td>
<td>Reduced to one inhalation a day</td>
<td/>
</tr>
<tr>
<td>paracetamol 665 mg modified release tablet</td>
<td>Two tablets every 6-8 hours when required.</td>
<td>Osteoarthritis, pain relief</td>
<td>Unchanged</td>
<td/>
<td>No more than 6 tablets in 24hr</td>
</tr>
<tr>
<td>cilostazol 100 mg tablet</td>
<td>One a day at night time</td>
<td>Blood thinning</td>
<td>Amended</td>
<td>Form change</td>
<td/>
</tr>
</tbody>
</table>
<h3>CEASED MEDICINES</h3>
<table border="1">
<thead>
<tr>
<th>Medicine</th>
<th>Reason</th>
</tr>
</thead>
<tbody>
<tr>
<td>Ibuprofen</td>
<td>Allergic reaction</td>
</tr>
</tbody>
</table>
</div>
</text>
<contained>
<MedicationStatement>
<id value="medicationstatement-456"/>
<status value="active"/>
<medicationCodeableConcept>
<text value="Multi-vitamins"/>
</medicationCodeableConcept>
<subject>
<reference value="#patient-123"/>
</subject>
<dateAsserted value="2019-03-15"/>
<dosage>
<text value="1 tablet daily"/>
</dosage>
</MedicationStatement>
</contained>
<contained>
<MedicationStatement>
<id value="medicationstatement-678"/>
<status value="active"/>
<medicationCodeableConcept>
<text
value="Spiriva (tiotropium bromide 18mg per inhalation) inhalant"/>
</medicationCodeableConcept>
<subject>
<reference value="#patient-123"/>
</subject>
<dateAsserted value="2019-03-15"/>
<reasonCode>
<text value="COPD"/>
</reasonCode>
<dosage>
<text value="1 inhalation per day"/>
</dosage>
</MedicationStatement>
</contained>
<contained>
<MedicationStatement>
<id value="medicationstatement-234"/>
<status value="active"/>
<medicationCodeableConcept>
<coding>
<system value="http://snomed.info/sct"/>
<code value="22075011000036103"/>
</coding>
<text value="paracetamol 665 mg modified release tablet"/>
</medicationCodeableConcept>
<subject>
<reference value="#patient-123"/>
</subject>
<reasonCode>
<text value="Osteoarthritis, pain relief"/>
</reasonCode>
<dosage>
<text value="Two tablets every 6-8 hours when required."/>
<patientInstruction value="No more than 6 tablets in 24hr"/>
</dosage>
</MedicationStatement>
</contained>
<contained>
<MedicationStatement>
<id value="medicationstatement-890"/>
<status value="active"/>
<medicationCodeableConcept>
<coding>
<system value="http://snomed.info/sct"/>
<code value="82923011000036103"/>
</coding>
<text value="cilostazol 100 mg tablet"/>
</medicationCodeableConcept>
<subject>
<reference value="#patient-123"/>
</subject>
<reasonCode>
<text value="Blood thinning"/>
</reasonCode>
<dosage>
<text value="One a day at night time"/>
</dosage>
</MedicationStatement>
</contained>
<contained>
<MedicationStatement>
<id value="medicationstatement-246"/>
<status value="stopped"/>
<medicationCodeableConcept>
<coding>
<system value="http://snomed.info/sct"/>
<code value="38268001"/>
</coding>
<text value="Ibuprofen"/>
</medicationCodeableConcept>
<subject>
<reference value="#patient-123"/>
</subject>
<reasonCode>
<text value="Allergic reaction"/>
</reasonCode>
</MedicationStatement>
</contained>
<contained>
<Patient>
<id value="patient-123"/>
<extension
url="http://hl7.org.au/fhir/StructureDefinition/indigenous-status">
<valueCoding>
<system
value="https://healthterminologies.gov.au/fhir/CodeSystem/australian-indigenous-status-1"/>
<code value="9"/>
<display value="Not stated/inadequately described"/>
</valueCoding>
</extension>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="NI"/>
<display value="National unique individual identifier"/>
</coding>
</type>
<system value="http://ns.electronichealth.net.au/id/hi/ihi/1.0"/>
<value value="8003608666701594"/>
</identifier>
<name>
<text value="David Goodpatient"/>
<family value="Goodpatient"/>
<given value="David"/>
</name>
<gender value="male"/>
<birthDate value="1953-09-14"/>
<address>
<use value="home"/>
<line value="2 Round Court"/>
<state value="QLD"/>
<postalCode value="4113"/>
<country value="Australia"/>
</address>
<generalPractitioner>
<reference value="#gp-13579"/>
</generalPractitioner>
<managingOrganization>
<reference value="#org-24680"/>
</managingOrganization>
</Patient>
</contained>
<contained>
<Practitioner>
<id value="gp-13579"/>
<name>
<family value="Grey"/>
<prefix value="Dr"/>
</name>
</Practitioner>
</contained>
<contained>
<Practitioner>
<id value="dr-97531"/>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="NPI"/>
<display value="National provider identifier"/>
</coding>
<text value="HPI-I"/>
</type>
<system value="http://ns.electronichealth.net.au/id/hi/hpii/1.0"/>
<value value="8003619900015717"/>
</identifier>
<name>
<use value="official"/>
<family value="Practitioner"/>
<given value="Iam"/>
<suffix value="M.D."/>
</name>
<telecom>
<system value="phone"/>
<value value="0755501234"/>
<use value="work"/>
</telecom>
<telecom>
<system value="email"/>
<value value="iam.practitioner@example.com"/>
<use value="work"/>
</telecom>
<qualification>
<identifier>
<type>
<coding>
<system
value="http://terminology.hl7.org.au/CodeSystem/v2-0203"/>
<code value="AHPRA"/>
<display
value="Australian Health Practitioner Regulation Agency Registration Number"/>
</coding>
<text value="Ahpra registration number"/>
</type>
<system value="http://hl7.org.au/id/ahpra-registration-number"/>
<value value="MED0000932850"/>
</identifier>
<code>
<coding>
<system
value="http://www.abs.gov.au/ausstats/abs@.nsf/mf/1220.0"/>
<code value="253111"/>
<display value="General Medical Practitioner"/>
</coding>
<text value="Ahpra qualification for General Practitioner"/>
</code>
<issuer>
<display value="Ahpra"/>
</issuer>
</qualification>
</Practitioner>
</contained>
<contained>
<Organization>
<id value="org-24680"/>
<name value="Grey Medical Practice"/>
</Organization>
</contained>
<contained>
<Encounter>
<id value="enc-24680"/>
<extension
url="http://hl7.org.au/fhir/StructureDefinition/encounter-description">
<valueString
value="Patient presented with weakness over the last couple of days. No other symptoms. Revised patient's medications. Advised patient to see the usual GPs clinic for further consultation and review."/>
</extension>
<identifier>
<system value="https://tools.ietf.org/html/rfc4122"/>
<value value="5c48d068-4ffb-11e9-8647-d663bd873d93"/>
</identifier>
<status value="finished"/>
<class>
<system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
<code value="AMB"/>
<display value="ambulatory"/>
</class>
<type>
<coding>
<system value="http://loinc.org"/>
<code value="34764-1"/>
</coding>
</type>
<priority>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-ActPriority"/>
<code value="R"/>
</coding>
</priority>
<subject>
<reference value="#patient-123"/>
</subject>
<participant>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/v3-ParticipationType"/>
<code value="PPRF"/>
</coding>
</type>
<individual>
<reference value="#dr-97531"/>
</individual>
</participant>
<period>
<start value="2019-03-15"/>
<end value="2019-03-15"/>
</period>
</Encounter>
</contained>
<identifier>
<system value="https://tools.ietf.org/html/rfc4122"/>
<value value="7f8fb180-4ea8-11e9-8647-d663bd873d93"/>
</identifier>
<status value="current"/>
<mode value="snapshot"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10160-0"/>
</coding>
<text value="Medicine List"/>
</code>
<subject>
<reference value="#patient-123"/>
</subject>
<encounter>
<reference value="#enc-24680"/>
</encounter>
<date value="2019-03-15"/>
<source>
<reference value="#dr-97531"/>
</source>
<entry>
<flag>
<coding>
<system
value="http://terminology.hl7.org.au/CodeSystem/medicine-item-change"/>
<code value="new"/>
<display value="New"/>
</coding>
</flag>
<item>
<reference value="#medicationstatement-456"/>
</item>
</entry>
<entry>
<extension
url="http://hl7.org.au/fhir/StructureDefinition/change-description">
<valueString value="Reduced to one inhalation a day"/>
</extension>
<flag>
<coding>
<system
value="http://terminology.hl7.org.au/CodeSystem/medicine-item-change"/>
<code value="amended"/>
<display value="Amended"/>
</coding>
</flag>
<item>
<reference value="#medicationstatement-678"/>
</item>
</entry>
<entry>
<flag>
<coding>
<system
value="http://terminology.hl7.org.au/CodeSystem/medicine-item-change"/>
<code value="nochange"/>
<display value="Unchanged"/>
</coding>
</flag>
<item>
<reference value="#medicationstatement-234"/>
</item>
</entry>
<entry>
<extension
url="http://hl7.org.au/fhir/StructureDefinition/change-description">
<valueString value="Form change"/>
</extension>
<flag>
<coding>
<system
value="http://terminology.hl7.org.au/CodeSystem/medicine-item-change"/>
<code value="amended"/>
<display value="Amended"/>
</coding>
</flag>
<item>
<reference value="#medicationstatement-890"/>
</item>
</entry>
<entry>
<flag>
<coding>
<system
value="http://terminology.hl7.org.au/CodeSystem/medicine-item-change"/>
<code value="ceased"/>
<display value="Ceased"/>
</coding>
</flag>
<item>
<reference value="#medicationstatement-246"/>
</item>
</entry>
</List>