Transaction: Physiotherapy prescription/referral

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.

Generalities


We recommend the use of a KMEHR message compliant with the KMEHR level 4 (see structure overview).


Transaction elements

application for example.

Element list
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 list
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 list

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