Transaction: Physiotherapy prescription/referral
General information
STATUS:
Published
OWNER:
eHealth Platform
STANDARD:
KMEHR
VERSION:
1.0
DATE:
2016-09-01
DEFINITION:
This transaction aims to prescribe any physiotherapy. Using the correct values from the tables CD-TRANSACTION and CD-TRANSACTION-TYPE it can be used to describe a prescription for classic physiotherapy treatment, a single consultation with a pt or a day hospitalisation.
As explained infra, when this transaction is used for a single consultation with a pt or a day hospitalisation, it will actually be a ‘referral’ instead of a ‘prescription’ transaction. However, since the rules for creating these transactions in the physiotherapy context follow the same logic as the ‘prescription’, they are mentioned here.
Also, it is possible to use this format for the pt to send a proposal for a prescription to the prescribing party.
The prescription format is used by the project Recip-e.
STATUS:
Published
OWNER:
eHealth Platform
STANDARD:
KMEHR
VERSION:
1.0
DATE:
2016-09-01
DEFINITION:
This transaction aims to prescribe any physiotherapy. Using the correct values from the tables CD-TRANSACTION and CD-TRANSACTION-TYPE it can be used to describe a prescription for classic physiotherapy treatment, a single consultation with a pt or a day hospitalisation.
As explained infra, when this transaction is used for a single consultation with a pt or a day hospitalisation, it will actually be a ‘referral’ instead of a ‘prescription’ transaction. However, since the rules for creating these transactions in the physiotherapy context follow the same logic as the ‘prescription’, they are mentioned here.
Also, it is possible to use this format for the pt to send a proposal for a prescription to the prescribing party.
The prescription format is used by the project Recip-e.
Guidelines
Generalities
We recommend the use of a KMEHR message compliant with the KMEHR level 4 (see structure overview).
Transaction elements
application for example.
| Element | Purpose |
|---|---|
| id | id of the transaction according to the ID-KMEHR conventions. |
| cd |
You must use the value ‘prescription' or ‘referral’ from CD-TRANSACTION and ‘physiotherapy’ from CD-TRANSACTION-TYPE. A referral must be further clarified by using one of these local cd values. <cd S="LOCAL" SV="1.0" SL="PT-TYPE">consult</cd> <cd S="LOCAL" SV="1.0" SL="PT-TYPE">dayhospitalisation</cd> |
| date | This is the legal date of prescription by the physician. |
| time | This is the legal time of prescription by the physician. |
| author | This is the legal prescriber assuming the medical responsibility of the request. Only one physical healthcare party is allowed (possibly complemented by organisation and department). The ID-HCPARTY is mandatory. Additional information like name, address, phone are optional. |
| iscomplete | A prescription should always be complete. |
| isvalidated | A prescription should always be validated. |
Structure overview
The prescription must be build with:
• heading(s) and item(s): to further structure your prescription.
Headings
We recommend the use of the following headings from CD-HEADING.
| Heading | Purpose |
|---|---|
| assessment | To transfer clinical information about the patient. This heading must include at least 1 item ‘diagnosis’ and if it is not clear from the diagnosis: 1 site element |
| treatment | Optional heading to model any treatments the patient underwent that are relevant to be eligible for physiotherapy treatment. Strongly recommended if this information is available. |
| prescription | The actual physiotherapy prescribed. (Typically only number of sessions) This heading must include at least 1 item ‘acts.’ |
Each heading contains:
- text(s) : to further structure your paragraph.
Items
These item of CD-ITEM can be used:
|
Item type (cd) |
Item purpose |
Item structure |
|---|---|---|
|
diagnosis |
to be used to specify the indication(s) of the prescription. |
content(cd+) Preferably use coded systems to model the diagnosis. If it is not clear from the typical diagnosis, this item must also include a <site> element with a value from CD-SITE. [content] (text) to optionally (further) explain in text [site](cd) |
|
encounterdatetime |
to be used to specify the datetime of the treatment. |
content (date) |
|
treatment
|
to be used to specify a treatment the patient underwent
|
content(cd) Preferably refer to the treatment using a CD-NIHDI code. If needed, the following local codes can also be used here: <cd S="LOCAL" SL="PT-PRESCRIPTION" SV="1.0" DN="pt needed after surgery" L="en">postsurgery</cd>
<cd S="LOCAL" SL="PT-PRESCRIPTION" SV="1.0" DN="pt needed after neonatal care" L="en">postneonatal</cd>
<cd S="LOCAL" SL="PT-PRESCRIPTION" SV="1.0" DN="pt needed after intensive care" L="en">postic</cd> |
|
[content] (text) to optionally (further) explain in text |
||
|
acts
|
the actual physiotherapy. Typically only the number of sessions is included. |
[content] (text) Optional textual description of the nature of the prescribed act |
|
[beginmoment] (date) Specifies the begin date (and time) of the treatment. Optional, when the treatment is planned in the future. |
||
|
[lifecyle] (cd) Must refer to the fixed value of CD-LIFECYCLE. This is optional: Only use when the treatment is in the future ‘planned’.
The use of lifecycle is mandatory if the prescription is a proposal. In that case the value is ‘proposed’. |
||
|
quantity (decimal) Specifies the number of sessions as a decimal number. (mandatory) |
||
|
[frequency] There are two ways to describe the prescribed frequency of the sessions: using the frequency element or a sequence of regimen elements. This one to use for 'simple' administration schedules. It supports 3 options: a combination of nominator/denominator (e.g. '1day/1week'), a free text or value from CD-PERIODICITY. |
||
|
[regimen] This is one of the two ways to describe the frequency of sessions and is intended for more 'sophisticated' administration schedules: each administration is described by one element of the sequence that specifies: - the day within the schedule through either a daynumber, a specified date or a weekday. - the quantity number. |
||
|
feedback (reportrequested) Default the Boolean value of reportrequested will be ‘false’. Only if the prescriber explicitly asks a report from the pt should this be ‘true’. |
||
|
justification |
to describe the justification of a second session |
This element is optional but when a second session is prescribed this is mandatory and the message should also include a frequency or regimen specifying the second session. (in the acts item) content (text) Textual description of the justification. |
|
autonomy |
to describe the autonomy of the patient |
In the physiotherapy prescription, this is used to optionally define the patient is homebound. content (cd) Use the value ‘homebound’ from CD-AUTONOMY |
Generalities
We recommend the use of a KMEHR message compliant with the KMEHR level 4 (see structure overview).
Transaction elements
application for example.
| Element | Purpose |
|---|---|
| id | id of the transaction according to the ID-KMEHR conventions. |
| cd |
You must use the value ‘prescription' or ‘referral’ from CD-TRANSACTION and ‘physiotherapy’ from CD-TRANSACTION-TYPE. A referral must be further clarified by using one of these local cd values. <cd S="LOCAL" SV="1.0" SL="PT-TYPE">consult</cd> <cd S="LOCAL" SV="1.0" SL="PT-TYPE">dayhospitalisation</cd> |
| date | This is the legal date of prescription by the physician. |
| time | This is the legal time of prescription by the physician. |
| author | This is the legal prescriber assuming the medical responsibility of the request. Only one physical healthcare party is allowed (possibly complemented by organisation and department). The ID-HCPARTY is mandatory. Additional information like name, address, phone are optional. |
| iscomplete | A prescription should always be complete. |
| isvalidated | A prescription should always be validated. |
Structure overview
The prescription must be build with:
• heading(s) and item(s): to further structure your prescription.
Headings
We recommend the use of the following headings from CD-HEADING.
| Heading | Purpose |
|---|---|
| assessment | To transfer clinical information about the patient. This heading must include at least 1 item ‘diagnosis’ and if it is not clear from the diagnosis: 1 site element |
| treatment | Optional heading to model any treatments the patient underwent that are relevant to be eligible for physiotherapy treatment. Strongly recommended if this information is available. |
| prescription | The actual physiotherapy prescribed. (Typically only number of sessions) This heading must include at least 1 item ‘acts.’ |
Each heading contains:
- text(s) : to further structure your paragraph.
Items
These item of CD-ITEM can be used:
|
Item type (cd) |
Item purpose |
Item structure |
|---|---|---|
|
diagnosis |
to be used to specify the indication(s) of the prescription. |
content(cd+) Preferably use coded systems to model the diagnosis. If it is not clear from the typical diagnosis, this item must also include a <site> element with a value from CD-SITE. [content] (text) to optionally (further) explain in text [site](cd) |
|
encounterdatetime |
to be used to specify the datetime of the treatment. |
content (date) |
|
treatment
|
to be used to specify a treatment the patient underwent
|
content(cd) Preferably refer to the treatment using a CD-NIHDI code. If needed, the following local codes can also be used here: <cd S="LOCAL" SL="PT-PRESCRIPTION" SV="1.0" DN="pt needed after surgery" L="en">postsurgery</cd>
<cd S="LOCAL" SL="PT-PRESCRIPTION" SV="1.0" DN="pt needed after neonatal care" L="en">postneonatal</cd>
<cd S="LOCAL" SL="PT-PRESCRIPTION" SV="1.0" DN="pt needed after intensive care" L="en">postic</cd> |
|
[content] (text) to optionally (further) explain in text |
||
|
acts
|
the actual physiotherapy. Typically only the number of sessions is included. |
[content] (text) Optional textual description of the nature of the prescribed act |
|
[beginmoment] (date) Specifies the begin date (and time) of the treatment. Optional, when the treatment is planned in the future. |
||
|
[lifecyle] (cd) Must refer to the fixed value of CD-LIFECYCLE. This is optional: Only use when the treatment is in the future ‘planned’.
The use of lifecycle is mandatory if the prescription is a proposal. In that case the value is ‘proposed’. |
||
|
quantity (decimal) Specifies the number of sessions as a decimal number. (mandatory) |
||
|
[frequency] There are two ways to describe the prescribed frequency of the sessions: using the frequency element or a sequence of regimen elements. This one to use for 'simple' administration schedules. It supports 3 options: a combination of nominator/denominator (e.g. '1day/1week'), a free text or value from CD-PERIODICITY. |
||
|
[regimen] This is one of the two ways to describe the frequency of sessions and is intended for more 'sophisticated' administration schedules: each administration is described by one element of the sequence that specifies: - the day within the schedule through either a daynumber, a specified date or a weekday. - the quantity number. |
||
|
feedback (reportrequested) Default the Boolean value of reportrequested will be ‘false’. Only if the prescriber explicitly asks a report from the pt should this be ‘true’. |
||
|
justification |
to describe the justification of a second session |
This element is optional but when a second session is prescribed this is mandatory and the message should also include a frequency or regimen specifying the second session. (in the acts item) content (text) Textual description of the justification. |
|
autonomy |
to describe the autonomy of the patient |
In the physiotherapy prescription, this is used to optionally define the patient is homebound. content (cd) Use the value ‘homebound’ from CD-AUTONOMY |