informatiestandaarden - Gebruikersbijdragen [nl]

mp:V2.0.0 Ontwerp medicatieproces 9 ENG

2022-04-04T14:53:58Z

Petra van Deursen: /* Temporarily halting for an intervention */

{{IssueBox|'''ATTENTION: This is a development version. For an overview of current documentation for Medication Process see here [[Landingspagina_Medicatieproces]].'''}}

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{{DISPLAYTITLE:DEVELOPMENT PAGE Functional Design Medication Process 9 version 2.0.0 English version}}
[[Bestand:ENG.jpg|50px]] [[mp:V2.0.0_Ontwerp_medicatieproces_9_ENG|This is the ENG version]] 
[[Bestand:NL.jpg|50px]] [[mp:V2.0.0_Ontwerp_medicatieproces_9|Klik hier voor de NL versie]] 
For an overview of relevant wiki pages for Medication Process see [[Landingspagina_Medicatieproces]]

=Introduction=

This document is the functional design for the Medication Process Information Standard (in Dutch: 'Informatiestandaard Medicatieproces'). It provides a general description as well as a description of specific practical situations. The recording and exchange of information is described for specific situations using actors (people, information systems) and transactions (which information is exchanged when).

Target groups for this document:
*Health professionals
*Information analysts and architects
*Software suppliers

==Scope and vision==

This document has been produced within the Medication process program. The Medication process program aims first to take away existing obstacles in the medication process, while taking into account current legislation and the possibility of obtaining tangible results in the foreseeable future.

One of the main obstacle entails the lack of insight in the actual medication use of patients. This is partly due to the fact that therapeutic and logistical information are often mixed, which results in the medication history becoming unclear. The following distinction between therapy and logistics exists:

* '''Therapy''' covers the medical side. This includes medication (and treatment) agreements, as well as the corresponding support and implementation. Therapeutic intention, (actual) medication use, self-medication and pharmacotherapy are also covered by the term ‘therapy’ as it is defined in this document.
* '''Logistics''' covers the physical flow of medicinal products, including requests, planning and dispense. This also includes medication supply and the medication use.

The program has taken into account current legislation and feasibility within the foreseeable future. The vision goes beyond the scope of the Medication process program and lays the foundations for a situation where a dispense request is no longer required. The ultimate objective is for prescribers to only have to concern themselves with the therapeutic side (which medicinal product, which strength, which dosage, when to start, etc.). It will no longer be necessary to create a dispense request. Instead, the prescriber will make medication agreements directly with the patient. Based on these medication agreements, the pharmacist will take care of the logistical process, eliminating the need for a dispense request altogether. Because of legislation this is not (yet) possible. The Medication process program does however take the first necessary step in the right direction.

==Reading guide==

The following paragraph introduces the main building blocks and the terminology used in this document. Detailed descriptions of the various processes (prescribe, dispense, administer, medication use) are given in [[#Medication process|Chapter 2]]. The purpose of the descriptions is to clarify how healthcare processes function in an ideal situation; which process steps are needed; which actors are participating; which information applies and which moments of exchange exist. The process descriptions follow a fixed format:

*Current situation  This paragraph describes the relevant differences between the current situation and the desired situation ('soll') in accordance with this information standard. Any obstacles will be described here.
*Process description with the paragraphs:
** ''Precondition'' The conditions that must be met before the process is started.
** ''Trigger Event'' The event that starts the process.
** ''One or more process steps'' Description of part of the process.
**''Post-condition'' The conditions that are met after the process steps have been carried out.
**''Use cases'' List of use cases associated with a specific subprocess. The use cases are detailed in [[#Description of use cases|Chapter 4]].
**''Information sytems and transaction groups'', This paragraph describes the information systems, system roles, transactions and transaction groups related to the process steps. All information concerning information systems and transaction groups is also included in [[#Information systems and transactions|Chapter 6]].

[[#Domain-specific handling of the medication process|Chapter 3]] describes a number of domain-specific interpretations of the medication process, for instance those of the thrombosis service and those related to service observation services in an ambulatory situation. [[#Description of use cases|Chapter 4]] describes several use cases in more detail. The practical situations are derived from general medical practice in a large number of cases but are illustrative of similar situations in a different setting. The use cases are classified according to subprocess, as indicated in [[#Medication process|Chapter 2]]. 
[[#Medication overview and inference rules|Chapter 5]] describes how a medication profile can be constructed from the different building blocks. [[#Information systems and transactions|Chapter 6]] includes an overview of all information systems, system roles, transactions and transaction groups. Guidelines for the functionality of the various information systems have been detailed in [[#Functionality|Chapter 7]].

In this document, Dutch terminology is used for the medication building blocks: 'medicatieafspraak' (MA), 'verstrekkingsverzoek' (VV), 'toedieningsafspraak' (TA), 'medicatieverstrekking' (MVE), 'medicatietoediening' (MTD), 'medicatiegebruik' (MGB), 'medicatieverbruik' (MVB) (see Table 1 for the English translations). Dutch terminology for the medication building blocks is consistently used even in translated documents, as a translation may not refer to exactly the same entity.

==Introduction of relevant terms==

===Therapeutic and logistical building blocks===

The use cases include a description of the process and the data elements associated with it. Related data elements are grouped together in a Clinical Information Model (CIM) or Clinical Building Block (CBB) (in Dutch: 'zorginformatiebouwsteen' - zib). The dataset details the data elements of which these zibs consist; data elements may have been added to the zibs in keeping with the clinical context and care process. The data set includes the complete set of definitions of the data elements of the building blocks. The building blocks together with their data elements can be used in various scenarios for arranging/modelling healthcare applications or for defining interfaces for data exchange.

The different building blocks are shown in the figure below. They have been ordered according to process and subprocesses, and according to therapy versus logistics.

{{anchor|figuur 1}}
[[Bestand:Figuur 1 Bouwstenen - overzicht.png|Figuur 1 Buildingblocks- overview]]

The table below provides a description of the building blocks. The four additional concepts ‘voorstel medicatieafspraak’ (therapeutic), 'antwoord voorstel medicatieafspraak' (therapeutic), ‘voorstel verstrekkingsverzoek’ (logistics) and ‘antwoord voorstel-verstrekkingsverzoek’ (logistics) are also described.

{{anchor|tabel 1}}
{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| Building blocks in Dutch
! style="text-align:left;"| Abbr. in Dutch
! style="text-align:left;"| Building blocks in English
! style="text-align:left;"| Description
|-
| style="background-color: white;vertical-align:top;"| Medicatieafspraak
| style="background-color: white;vertical-align:top;"| MA
| style="background-color: white;vertical-align:top;"| Medication agreement
| style="background-color: white;vertical-align:top;"| 'Medicatieafspraak' is the prescriber’s proposal for medication use with which the patient agrees. An agreement to discontinue medication is also a 'medicatieafspraak'<ref>This document only uses the term medicatieafspraak, which therefore also indicates the clinical equivalent provisional medication order</ref>.
|-
| style="background-color: white;vertical-align:top;"| Wisselend doseerschema
| style="background-color: white;vertical-align:top;"| WDS
| style="background-color: white;vertical-align:top;"| Variable dosing regimen
| style="background-color: white;vertical-align:top;"| 'Wisselend doseerschema' contains the dosing instruction as composed by an (external) prescriber. In the 'wisselend doseerschema' the element 'instructions for use' from the 'medicatieafspraak' is further specified. The 'wisselend doseerschema' can be adapted without changing the 'medicatieafspraak'.
|-
| style="background-color: white;vertical-align:top;"| Verstrekkingsverzoek
| style="background-color: white;vertical-align:top;"| VV
| style="background-color: white;vertical-align:top;"| Dispense request
| style="background-color: white;vertical-align:top;"| 'Verstrekkingsverzoek' is the request from a prescriber to a pharmacist to supply the patient with one or more medicinal products in support of the current 'medicatieafspraak'/'medicatieafspraken'<ref>The verstrekkingsverzoek building block is not applicable in the clinical setting. Dispensing medication is handled in different ways in the clinical setting. Replenishment of, for example, a department’s supply is not considered a medicatieverstrekking, but rather an extension of the pharmacist’s stock. Medicatieverstrekking only takes place when the link between the medication and patient has been made. In clinical situations, administration often takes place immediately afterwards.</ref>.
|-
| style="background-color: white;vertical-align:top;"| Toedieningsafspraak
| style="background-color: white;vertical-align:top;"| TA
| style="background-color: white;vertical-align:top;"| Administration agreement
| style="background-color: white;vertical-align:top;"| 'Toedieningsafspraak' contains the instructions for medication use (or administration) from the pharmacist to the patient (or his representative or administrator), adding to the 'medicatieafspraak'<ref name="MO">A provisional medication order, as it is used in hospitals, is both the request from the physician to the administrator to administer medication to the patient as a verstrekkingsverzoek to the pharmacist to ensure that the medication is available for the administrator. This last part corresponds to the medicatieafspraak and the verstrekkingsverzoek from the first line. In addition, the hospital pharmacist usually carries out a validation of the administration request (this creates the final medication order which is called a toedieningsafspraak here). The provisional medication order is therefore not the same as a proposal from, for example, from a nurse on the basis of a protocol that has not yet been approved by a physician. </ref>.
|-
| style="background-color: white;vertical-align:top;"| Medicatieverstrekking
| style="background-color: white;vertical-align:top;"| MVE
| style="background-color: white;vertical-align:top;"| Medication dispense
| style="background-color: white;vertical-align:top;"| 'Medicatieverstrekking' is the provision of a supply of medicinal product to the patient or his administrator or representative.
|-
| style="background-color: white;vertical-align:top;"| Medicatietoediening
| style="background-color: white;vertical-align:top;"| MTD
| style="background-color: white;vertical-align:top;"| Medication administration
| style="background-color: white;vertical-align:top;"| 'Medicatietoediening' is the registration of the individual administrations of the medicinal product to the patient by the person who administers them (such as a nurse or the patient himself) in relation to the agreements made.
|-
| style="background-color: white;vertical-align:top;"| Medicatiegebruik
| style="background-color: white;vertical-align:top;"| MGB
| style="background-color: white;vertical-align:top;"| Medication use
| style="background-color: white;vertical-align:top;"| 'Medicatiegebruik' is a statement about historical, current or intended use of a medicinal product<ref>Use may have been preceded by medicatietoediening. Registration of medicatiegebruik, for example after medicatietoediening of rabies vaccinations or infusion is not obvious.</ref>.
|-
| style="background-color: white;vertical-align:top;"| Medicatieverbruik
| style="background-color: white;vertical-align:top;"| MVB
| style="background-color: white;vertical-align:top;"| Medication consumption
| style="background-color: white;vertical-align:top;"| 'Medicatieverbruik' is the logistical perspective on medication use. It describes how long a (partial) supply of medicinal products has lasted or will last for a patient<ref>From one-time to a certain period. The building block ‘Medicatieverbruik’ has not been detailed any further in this information standard.</ref>.
|-
| style="background-color: white;vertical-align:top;"| Voorstel medicatieafspraak
| style="background-color: white;vertical-align:top;"| VMA
| style="background-color: white;vertical-align:top;"| Proposed medication agreement
| style="background-color: white;vertical-align:top;"| 'Voorstel medicatieafspraak' is a recommendation or request from the pharmacist, prescriber or the administer to the presciber of the MA about the agreed upon or to be agreed upon medication.The recommendation request may include discontinuing, starting or modifying medication. The patient is unable to send a VMA.
|-
| style="background-color: white;vertical-align:top;"| Antwoord voorstel medicatieafspraak
| style="background-color: white;vertical-align:top;"| AVMA
| style="background-color: white;vertical-align:top;"| Reply proposed medication agreement
| style="background-color: white;vertical-align:top;"| 'Antwoord voorstel medicatieafspraak' is a replay from the prescriber to the 'voorstel medicatieafspraak'.
|-
| style="background-color: white;vertical-align:top;"| Voorstel verstrekkingsverzoek
| style="background-color: white;vertical-align:top;"| VVV
| style="background-color: white;vertical-align:top;"| Proposed dispense request
| style="background-color: white;vertical-align:top;"| 'Voorstel verstrekkingsverzoek' is a proposal from the pharmacist to the prescriber to approve one or more 'medicatieverstrekking'/'medicatieverstrekkingen' in support of the current 'medicatieafspraak'/'medicatieafspraken'. This is comparable with the current situation of submitting the authorization form or combined prescription or submitting a repeat prescription for signing. The patient may also submit a 'voorstel verstrekkingsverzoek' to the prescriber.
|-
| style="background-color: white;vertical-align:top;"| Antwoord voorstel‐verstrekkingsverzoek
| style="background-color: white;vertical-align:top;"| AVVV
| style="background-color: white;vertical-align:top;"| Reply proposed dispense request
| style="background-color: white;vertical-align:top;"| 'Antwoord voorstel-verstrekkingsverzoek' is a reply from the prescriber to the 'voorstel verstrekkingsverzoek'.
|}Table 1 Building blocks – description

===Medication overview===
See [[#Medication overview and inference rules|Chapter 5]] for more information about these overviews, the applicable building blocks and how a medication profile/current overview can be compiled.

==='Medicamenteuze behandeling'===

The different medication building blocks represent steps in the medication process, from prescribing a medicinal product (MA and/or VV), followed by dispensing it (TA and/or MVE) up to and including administering and using the medicinal product. The model is designed in such a way that therapeutic building blocks and logistical building blocks are separated from each other. 
'''Scope''' 
In order to be able to give a name to the interdependence of the medication building blocks, the concept of ‘pharmaceutical treatment’ (in Dutch: 'medicamenteuze behandeling' - MBH) is introduced. 
:'''Medicamenteuze behandeling' is a '''technical concept''' in the information standard. Its purpose is'': 
:#''To unambiguously identify the set of interdependent medication building blocks, and'' 
:#''To apply rules to it to unambiguously determine the present situation''. 
The functional application of the concept of 'medicamenteuze behandeling' is as follows: 
*Medication (or 'medicamenteuze behandeling') is started by creating a first MA as part of a new 'medicamenteuze behandeling'.
*Medication (or 'medicamenteuze behandeling') is discontinued by creating a new MA within the same 'medicamenteuze behandeling' (stop-MA).
*Medication (or 'medicamenteuze behandeling') is modified by:
#Discontinuing the existing MA and
#Creating a new changed MA as part of the same 'medicamenteuze behandeling'. The starting date of this new MA may also be in the future.

Prescribing a new medicinal product always results in a new MA. An MA is always related to a single 'medicamenteuze behandeling'. For the time being, the PRK level (Prescription Code from the G-standard) of the medicinal product determines whether the MA belongs to a new or an existing 'medicamenteuze behandeling'. This may be extended to the SNK level (Substance Name Code from the G-standard) in the future, which would mean that changes in strength or between medicinal products from the same group no longer lead to a new 'medicamenteuze behandeling'. A detailed description can be found in [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5 Process step: Creating a medicatieafspraak]].

Exceptions:
*Products without PRK (a non-medicine such as crutches or bandages). In this case the HPK level (Trade Product Code from the G-standard) determines if the MA will lead to a new 'medicamenteuze behandeling'.
*Medication without PRK (magistrals often consist of several substances that are not covered by the same PRK, these substances are included separately as ingredients in the MA). Every magisterial or adaptation to it falls under a 'medicamenteuze behandeling'.
*Own articles without PRK (articles listed in the internal information system under 90 million numbers stored, such as half tablets, commonly used magistrals). Any item or adaptation to this falls under a 'medicamenteuze behandeling'.
*Intravenous (IV) therapy (still be selected).

'''Examples''' 
Five examples illustrate the scope of a 'medicamenteuze behandeling': 
*Diazepam, 5 mg, 1 tablet 4x daily is changed to diazepam, 5 mg, 1 tablet 3x daily. The PRK level of both products is the same, they are both part of the same 'medicamenteuze behandeling'.
*Paroxetin tablet, 10 mg, 1 tablet 1x daily, is changed to paroxetin tablet, 20 mg, 1 tablet 1x daily. This is a modification of an MA with two different medicinal products at the PRK level. This change requires that the first 'medicamenteuze behandeling' is discontinued and a new 'medicamenteuze behandeling' is started.
*A gastroprotective drugs has been agreed upon in a treatment with prednisone: prednisone and gastroprotective drugs are two different medicinal products, which are used parallel to each other and their use can be modified and discontinued independently of each other. This means they are not part of the same 'medicamenteuze behandeling'.
*Switching from a beta blocker to an ACE inhibitor means a new PRK and this is achieved by discontinuing the 'medicamenteuze behandeling' of the beta blocker and starting a new 'medicamenteuze behandeling' for the ACE inhibitor.
*When there is no PRK and the composition of the medicinal products in the MA changes (any change in the ingredients), the existing 'medicamenteuze behandeling' is discontinued and a new 'medicamenteuze behandeling' is started. This applies, for example, to extemporaneous preparations, drips and proprietary products. 

'''Creation of a 'medicamenteuze behandeling'''' 
A schematic overview of how a 'medicamenteuze behandeling' (MBH) is set up can be seen in the figure below. When a new building block (MA, TA, VV, MVE, MTD or MGB) is created, a check is first performed to determine whether this is a new medication or if there already is a current building block with the same product. This applies to all building blocks, both proprietary or third parties’. In most information systems, the user of the information system will indicate that he wants to change one of the existing medication building blocks or wants to introduce new medication. In that case, it is easy to find out whether there already is a 'medicamenteuze behandeling' that includes the building block.
*If there is no existing building block for this medication, a new building block with a new 'medicamenteuze behandeling' is created.
*If there is an existing building block with a 'medicamenteuze behandeling', the user of the information system is asked whether the new building block and the existing building block belong to the same treatment. When this is the case, the same 'medicamenteuze behandeling' will be used. When the building blocks do not belong to the same treatment, a new 'medicamenteuze behandeling' will be created.
{{anchor|figuur 2}}
[[Bestand:Ontstaan_MBH.png|500px|Figuur 2 Ontstaan medicamenteuze behandeling]]

 
'''Parallel occurrence of 'medicatieafspraken'''' 
Within a 'medicamenteuze behandeling', several MAs may be active simultaneously. These are all MAs that are valid ('current') at this time or that will become valid in the future. In principle, only one MA is valid at any time in a 'medicamenteuze behandeling'. However, there are a number of situations where parallel MAs are conceivable:
#The same medicinal product, but a different strength, where the total strength should essentially be prescribed in one agreement.
#Related (different) medicinal products that are given together, but that should be considered as a whole when evaluating treatment.
#Technical omissions in information systems. For example, in the case of complicated dosing schedules or combination drips. 

'''Situation 1''' can be resolved by prescribing at a higher level (SNK). G-standard/Z-Index is working on this, but it is not yet possible. Until that time, 1 or more products can be combined in the same MA by entering the products as ingredients. This is comparable to extemporaneous preparations. However, the instructions for use for all these products must be identical.<ref>In practice several MAs (with different PRKs) are often combined into a single product instead of a single MA with underlying the composition.</ref> 
'''Situation 2''' is solved in different ways in different information systems, each with their own grouping mechanisms. It concerns the correlation between different medicamenteuze behandelingmedicamenteuze behandelings. The information standard does not provide a universal grouping mechanism. 
'''Situation 3''' is the only situation in which parallel medicatieafspraken are permitted under one medicamenteuze behandelingmedicamenteuze behandeling. Complex phasing-in and phasing-out schedules and combination drips may be included in one medicatieafspraak, but not all information systems support this. For those information systems, it is permitted to create parallel medicatieafspraken within a single medicamenteuze behandelingmedicamenteuze behandeling. 

===Correlation between building blocks and 'medicamenteuze behandeling'===

The figure below shows the correlations between building blocks and the MBH. The relations between building blocks and the MBH as well as the relations between the building blocks themselves are described as follows:
*Building blocks belong to a single MBH. An MBH includes at least one MA and may include zero or more of the following building blocks VV, WDS, TA, MVE, MGB and MTD. Unless, for example, self-medication has been recorded with MGB or in case a paper prescription has been submitted, a drug treatment can exist without an MA, but with MGB or TA. A MBH will never cease to exist, but it may no longer be effective when there are no current building blocks linked to it. A VMA, AVMA, VVV and AVVV are not yet part of a MBH as these are still a draft/proposal that may or may not lead to a final MA or VV linked to an MBH. A VMA may lead to zero (if the recommendation is not followed), one or more MAs and a VVV may lead to zero (if the proposal is not honoured), one or more VVs.
*An MBH may also only have a stop-MA in addition to, for example, an MGB building block. For example, in the event that a health professional asks a patient to stop using free available medicine (self-care medication or over-the-counter (OTC) medication). The health professional records the use of the self-care medication in an MGB building block and discontinues the use by creating a stop-MA (stop-MA belonging to the same MBH).
*An MA may refer to the previous MA or a TA or MGB on which it is based. This may also be an MA, TA or MGB that belongs to another MBH. It is possible that no digital MA is available (e.g. paper prescription [[#Paper prescription|paragraph 4.1.17]]). This MA must then be created. This MA may refer to the TA or MGB. A pharmacist is never the source of an MA but he may have a copy.
*In principle, only one MA is valid at any one time in an MBH. Only when there are technical omissions in information systems, for example in case of complicated dosing schedules or combination drips, parallel MAs are allowed (see also the previous section).
*An MA is supported by zero (if there is still enough supply or if no medication dispense is needed), one or more (when there is, for example, continuous medication) VVs.
*A VV is based on the current MA and any existing corresponding TA in an MBH. There may be several.
*A VV refers to one or more MAs (for example, in the case of an interim dosage increase, a VV can be made that replenishes the supply for the existing MA and also starts the supply for the future MA).
*A VV may result in zero (for example when the patient does not pick up the medication) to several MVEs.
*A MA may result in zero, one or multiple WDS's.
*Multiple (possibly parallel) TAs may be based on the same MA (for example, when a pharmacist switches to a different commercial product or when the medicinal product is supplied as two or more medicinal products with different strengths, with the total strength remaining the same). When a paper prescription is submitted and the MA and the VV are not available in digital form, there is a TA without an MA.
*An MA does not always have to lead to a TA, for example when no VV is required with a short use MA, when the patient still has sufficient stock.
*A TA is supported by zero (when there is enough supply), one or more MVEs.
*An MVE is based on a MA (and TA) and, in an ambulatory situation, on a VV. The exception are over-the-counter (OTC/self-medication) sales for the purpose of self-care medication: these have no MAs and no VVs. Self-care medication provided by the pharmacist may be recorded by that pharmacist as a TA with MVE, or as MGB by a random health professional or by the patient himself.
*An MVE may support multiple TAs.
*An MA or a TA may be followed by a new MA or TA. This may be the case when existing medication is changed (modification of MA and/or TA) or when MGB is discontinued (stop-MA/TA).

{{anchor|figuur 2}}
[[Image: Datamodel_MP92.PNG|800px|Figuur 2 - Datamodel Medicatieproces]]

===Informing and (actively) making available===
[[#Medication process|Chapter 2]] describes the medication process. This includes process steps labelled ‘Inform’ or ‘(actively) make available’. The table below includes a detailed description of the reason for this. [[#Medication process|Chapter 2]] further elaborates on situations in which information is actively sent or made available. 

{{anchor|tabel 2}}
{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| Term
! style="text-align:left;"| Toelichting
|-
| style="background-color: white;vertical-align:top;"| Inform
| style="background-color: white;vertical-align:top;"| ‘Inform’ means sending an order or request addressed to another actor. This is a so-called ‘push’ of information: the actor sends the information specifically to recipient. This may be by means of
*An electronic message via a digital network,
*Paper (for example by giving a prescription intended for a pharmacist to the patient),
*A fax message,
*A combination of the above options.
|-
| style="background-color: white;vertical-align:top;"| (Actively) make available
| style="background-color: white;vertical-align:top;"| The health professional (actively) makes information available to another actor. This process step concerns:
*Actively sending or informing (‘push’) as described above or
*Automatically making information available to health professionals and/or the patient when they request it on the basis of prior permission or
*A combination of both previous bullets. 

Data are always made available. Additionally, the health professional has the option to specifically inform fellow health professionals and/or the patient at any time during the process. In consultation with the patient, data can be sent to a health professional of his choice (inform).
|} Table 2 Informing versus (actively) making available

The technical mechanism (‘pull’, ‘publish and subscribe’, ‘push’, etc.) used to (actively) make data available, is infrastructure-dependent and is therefore not detailed in this document. 

The Royal Dutch Medical Association (KNMG) describes in its publication 'Van wet naar praktijk: implementatie van de WGBO Deel 4. Toegang tot patiëntengegevens' [From law to practice: implementation of the Dutch Medical Treatment Contracts Act Part 4. Access to patient data] when there is implicit consent and explicit consent. The exchange described in this information standard is subject to current legal frameworks and guidelines concerning consent and opt-in and these are therefore not explicitly described.

==Legend/Explanation==
A manual for this Nictiz wiki documentation can be found at: 
http://informatiestandaarden.nictiz.nl/wiki/Handleiding_Wiki_documentatie 
It also includes a legend for the various figures that appear in this document.

=Medication process=
This chapter describes the medication process in relation to the building blocks for first-line, second-line and third-line health care. The process is fundamentally the same in each case. The main difference is which pharmacy supplies the medication: a community pharmacy (including an outpatient pharmacy) or a hospital pharmacy. Another difference is that in an ambulatory setting a VV is required for the supply of medicinal products. This is not required in a hospital setting: the (hospital) pharmacist ensures that the medicinal products are available as long as the MA continues.

The medication process is a cyclical process consisting of prescribing, dispensing, administering and using medication. The process starts when the patient/client visits a health professional/healthcare provider (general practitioner, hospital or other institution) for a treatment with a medicinal product and ends when the medication is no longer needed. The process is depicted in Figure 4. The yellow bar indicates the medication verification process, green prescription, purple dispensing, and orange administration and medication use. The blue bar indicates receipt or retrieval of data made available. This may occur in any of the subprocesses and is described in more detail in the continuation of this chapter for the relevant subprocesses.
The following paragraphs describe the medication verification, prescription, dispensing, administration and medication use processes.

{{anchor|figuur 3}}
[[Bestand:ActiviteitendiagramMP.png|1600px|Figuur 3 Activity diagram - medication process]]
 

==Process: medication verification==
Prior to the prescription process, the patient’s actual medication use is determined. This is done<ref>The patient may also verify his own medication. He then records medication use, see [[#Recording of medication use by the patient|paragraph 2.5.4.1]].</ref>:
*In the GP practice by the general practitioner during a consultation,
*At the GP service, A&E department or mental health crisis service by the triage specialist or the treating physician, as soon as possible, upon arrival or admission,
*In case of clinical or day admission at a hospital or other institutions by for example the nursing staff, pharmacy assistent or outpatient/hospital pharmacist,
*In case of outpatient consultation by for example nursing staff, doctors’ assistant or the treating physician.

===Current situation===
*In the current situation, patients or family/informal caregivers are asked which medication they are using. The patient is sometimes unable to answer this. Family/informal caregivers (if known) are also often unable to answer this. If this is the case, the physician will contact the general practitioner or the pharmacist to find out the medication. This is difficult outside office hours and during weekends.

===Precondition===
The patient comes in for a consultation/an outpatient consultation or is admitted (in the future).

===Trigger event===
*Outpatient setting: consultation of and/or prescription to outpatients and patients residing in another healthcare institution<ref>This is about patients from a nursing home or a mental health institution who are going to the outpatient clinic of a hospital.</ref>. In this case, medication verification often occurs during treatment assessment (see [[#Process step: Evaluating a (pharmaceutical) treatment|paragraph 2.2.4)]].
*Clinical setting: preparation of patient admission.

===Process===

The health professional collects the medication data from various sources, which may include:
*Patient’s own story,
*Dispense overviews from pharmacies,
*Digitally available medication data from healthcare providers or personal health records (PGO),
*Medication brought in by the patient,
*If necessary, information by telephone from the patient’s own pharmacist or general practitioner. 

The health professional verifies the medication together with the patient and records the verified medication as MGB, incl. self medication. This results in an updated medication profile; see also [[#Inference rules|paragraph 5.6]]. 

In practice, medication verification will lead to recording of MGB, only when it proves clinically relevant followed by updating the medication profile, particularly upon admission and discharge.
The medication overview and recorded data on MGB are made available to fellow health professionals and the patient, so that they can access the data. The medication overview may also be sent to a specific health professional.

===Post-condition===
The MGB is recorded and the resulting medication overview is made available if created. Medication data (MGB) are made available.

===Information systems and transaction groups===
[[#Information systems and transactions|Chapter 6]] includes an overview of all information systems, system roles, transactions, etc. Those most important for the medication verification process are included in the overview below.

{{anchor|figuur 4}}
[[Bestand:Medicatieverificatie.png|Figuur 4 Processtappen en transacties - medicatieverificatie]]

==Process: prescribe==
This paragraph describes the prescription process. This includes all prescribers, such as general practitioners, specialists, other physicians and specialist nurse prescribers. The prescription process consists of an evaluation of existing pharmaceutical treatment, if any. If necessary, an medication agreement is created and, only in an ambulatory situation, possibly a medication dispense request. Finally, the recorded data are (actively) made available. See [[#Appendix: General Diagram Medicatioprocess|chapter 12]] for a diagram depicting this process.

===Current situation===
The following deviations from the desired situation that are currently observed are:
*The logistical process often determines whether information is recorded (and certainly if it is communicated). Changes in medication or discontinuation are insufficiently recorded and/or communicated, resulting in, among other things, inaccurate monitoring, incorrect use and incorrect medication profiles.
The pharmacotherapeutic policy should be leading, not the logistical process as is currently the case.
*Since the therapeutic intention is not communicated to the pharmacist, it is not possible to deduce from the available data whether a request for a repeat prescription falls within that therapeutic intention. Because of this, use may be erroneously resumed or continued.
*If a change is not communicated, a request for a repeat prescription (through the pharmacist) may be based on outdated instructions for use. This can easily lead to errors.
*In an outpatient setting, medication agreements and/or medication dispense requests are usually not (electronically) sent to the pharmacist.

===Precondition===
There is a certain reason why a prescriber wants to start or evaluate/review a (pharamceutical) treatment.

===Trigger event===

The trigger event for the process is the start of a new MBH, the evaluation of an ongoing treatment, receipt of a VVV or VMA, receipt from a pharmacist of a prescription to be processed, or patient admission to or patient discharge from an institution.

===Process step: Evaluating a pharmaceutical treatment===

In order to evaluate treatment, an up-to-date overview of medication data is required. The medical file from the health professional is, where possible and if necessary, updated with data from external sources. In addition, the patient may be asked which medicinal products he is currently using. This medication use can be recorded by the health professional. If desired, a more extensive medication verification can be carried out (see [[#Process: medication verification|paragraph 2.1)]]. 

The treating physician<ref> This includes all health professionals who are authorised to prescribe: not only physicians, but also nurse practitioners and physician assistants, for example</ref> evaluates the (pharmaceutical) treatment and decides to:
*start a new MBH by creating an initial MA and/or
*continue, discontinue, temporarily halt or modify an existing MA (1 or more)<ref>In the case of substitution, the existing MA is discontinued and a new MA is created under a new MBH.</ref> and/or
*correct/cancel an existing MA and/or
*approve a VMA or a VVV (including a reply via the AVVV) 

These situations are further explained in the following paragraph. See also [[#Medicamenteuze behandeling|paragraph 1.3.3]] for more information on the concept of 'MBH'.
A new medication overview may be created to conclude the evaluation and the resulting new agreements and dispense requests (see [[#Inference rules|paragraph 5.6]]).

===Process step: Making a medication agreement===

When creating an MA, the following principle applies: each change is recorded in a new MA. Technically this means that the existing MA is terminated by entering an end date for the period of use and that a new MA is created with the desired changes<ref> Information systems keep an audit trail. In case of a change, the existing MA is discontinued (new record) and a new MA with the change is then created (new record). By using the records of the audit trail, no major adaptations are needed for discontinuing a MA in most information systems.</ref>.
 
An MA can also be created to begin at a point in the future. These MAs will receive a period of use with future starting date which is later than the date of the agreement itself. Any prior MA will end just before the starting date/time of the future one. In the period of use, only one effective date can be indicated (without duration or end date), this is the case with continuous medication. To avoid confusion between 'to/until/till' and 'up to and including', specifying the time is mandatory when entering an end date. In case of an 'up to and including' date (in case of an entire day), the time 23:59:59 applies.

Before the MA is made (actively) available, medication monitoring will occur in accordance with current guidelines. This is a part of this process step.

The next paragraphs describe the different situations in which an MA is created, i.e. initial medication agreement, continuing medication, discontinuing medication, temporarily halting medication or correcting/canceling a agreed medication. Information about 'MBH' is assumed to be known (see [[#Medicamenteuze behandeling|paragraph 1.3.3]]).

====New medication agreement====

A new MA is created at the start or modification of an MBH. When a new MBH is started, the prescriber should consider whether an existing MBH should be discontinued. The description in [[#Medicamenteuze behandeling|paragraph 1.3.3]] is based on the most common process from prescription to administering or using. In a transitional situation or in the absence of digital data, it is also technically possible that an MBH could start with a TA, for example. This might occur for instance when a pharmacist has not received the MA with the corresponding MBH in digital form. The pharmacist will consequently start a new MBH when the TA is created. This may also be the case for any other building block. A patient can, for example, start an MBH by recording MGB, without having the original MBH.

====Continuing medication====

In a number of cases the therapeutic intention of the prescriber remains the same and the MA does not have to be modified. For instance:
*In an ambulatory situation when, for a repeat prescription, only a new VV is needed, or
*At admission to an institution where the home medication continues to be used, whether or not in combination with self-medication. 

In both of these cases, the existing MA will not be adjusted. Should there be a change in PRK, e.g. at admission or discharge, the existing MBH will be discontinued by creating a stop-MA (see [[#Discontinuing medication|paragraph 2.2.5.3]]) and a new MBH is started (see [[#New medicatieafspraak|paragraph 2.2.5.1]]).

====Discontinuing medication====

Medication is discontinued by creating a new MA (stop-MA) within the same MBH. The reason for discontinuation is recorded in this MA. The medication may be discontinued immediately or in the future.
The new MA (stop-MA) is a copy of the existing MA with:
*The period of use as end date on which the MA ends (may also be in the future),
*An end date which has to be included in the text description of the instruction for use as well,
*Its own author,
*Its own agreement date,
*Stop type 'permanent',
*Reference to the specific MA that will be changed (future MAs will remain in place). It is not possible to create a stop-MA without referring to the MA that needs to be stopped except when the MA is not available. If there are only TA('s) or MGB('s) available in the MBH then a stop-MA has to be able to end these building blocks without referring to a MA,
*Its own reason for the MA to be discontinued (this does not apply to a stop-MA made as part of a modification. In that case, no reason is given). 

For an MA in which an end date is immediately agreed upon, e.g. in the case of a course of treatment, no additional stop-MA is needed. When an MA with an end date in the future is extended, it will be considered as a normal change (see [[#Changing medication|paragraph 2.2.5.5]]). A stop-MA always has the ‘permanent’ stop type, even if it is a stop-MA resulting from a change. In case of a change, the stop-MA is followed by a new MA. A stop-MA resulting from a change is not always relevant for end users. A stop-MA as a result of a change is also referred to as a technical stop-MA. The user interface must adequately support this. A prescriber will be less interested than a pharmacist who may need to adjust his logistical process because of the change.

====Temporarily halting and resuming medication====

Temporarily halting medication is the discontinuation of medication for a known or unknown period of time. Medication may be halted immediately or in the future. When medication use is temporarily halted, the medication still remains relevant for monitoring because the medication may be resumed in the future. Temporary substitution with another medicinal product is not considered an interruption but rather a discontinuation of the original medication and the start of a new pharmaceutical treatment with the substitute. Temporary halting medication is covered by two medication agreements<ref>This does not mean that end users actually have to create two agreements. A user friendly presentation by the information system is desired.</ref>: a MA (stop-MA) is created to stop medication use in accordance with guidelines for a stop-MA (see previous paragraph) and a new MA is created for resuming the medication (including the reason for this, if any). All MAs are part of the same MBH. The reason for the interruption is recorded in the stop-MA. The stop type for the stop-MA is 'temporary’.

====Changing medication====

Medication modifications may be related to:

:a) Dosage, 

:b) Strength of the medicinal product, 

:c) Method of administration, 

:d) Duration of treatment (such as an extension of the therapy). 

Switching to a completely different medicinal product is technically a switch to a different MBH (see also [[#Medicamenteuze behandeling|paragraph 1.3.3]]). In that case, the physician will discontinue the existing pharamceutical treatment (see [[#Discontinuing medication|paragraph 2.2.5.3]]) and start a new one (see [[#New medicatieafspraak|paragraph 2.2.5.1]]).
If the PRK stays the same, changes will be recorded under the same MBH. When a modification needs to be made, a technical stop-MA is created (see [[#Discontinuing medication|paragraph 2.2.5.3]]) and a new MA is made with the desired change. The appointment date of the technical stop-MA and the new MA must be always be the same. The reason for the modification is included in the new MA with a reference to the original MA, if possible. Modifications may take effect immediately or in the future. A technical stop-MA and the related new MA are made available simultaneously. In case of renewal of an MA of which the duration has already expired or the end date has already expired, then this is not seen as a change (a stop-MA on the already automatically stopped MA is unnecessary). In this case, a new MA under the same MBH can be made.

====Correcting/canceling a medication agreement<ref> Correcting/canceling administration agreements happens in the same way. XIS is a generic term for a random (health care) information system. PHR=personal health records.</ref>====

This paragraph describes correcting or canceling an MA when the prescriber has made an error. The error may have been discovered by the prescriber himself or by a fellow health professional.
For example, a physician who makes a typing error in the dosage of an MA: 10 inhalations, 2x daily, instead of 1 inhalation, 2x daily. If the MA has not yet been shared with other health professionals, the prescriber can personally correct that MA or delete (cancel) it from his own information system. If the MA has already been shared with other health professionals, the prescriber will mark the incorrect MA as ‘incorrect registration’ and he will then create a new MA under the same MBH with the correct information. The prescriber will actively inform the pharmacist and any fellow health professionals about both the cancelled and new MA and will make both available (see [[#Process step: (Actively) making available|paragraph 2.2.10]]).

====Stopping a prospective medication agreement====
This only concerns MA's that have their start date at some point in the future. For whatever reason a prescriber wants to end this prospective MA. The prescriber will not create a stop-MA in this scenario but cancels the MA instead. The prescriber cancels the MA by using the ‘canceled indicator’ field. The prescriber can only use the ‘canceled indicator’ when the start date of the MA is in the future. If the prescriber wants to end the prospective MA he/she changes the status of the MA to canceled with the indicator.

When the prescriber is not the initial creator of the original prospective MA the process works as follows. The prescriber creates a new MA with the canceled indicator activated. The ‘canceled MA’ will be sent to the original prescriber of the MA. The original prescriber will then cancel the original MA as well.

===Process step: Making a variable dosing regimen===
When a prescriber prescribes medication combined with a variable dosign regimen (WDS), the dosing of the medication can be adjusted by a (different) prescriber without having to adapt the medication agreement (MA). At the moment the variable dosing regimen is used for anticoagulants. When prescribing anticoagulants, the prescriber determines the therapeutic INR-range (International Normalized Ratio, a measure of blood clotting time), within which the treatment should take place.
The thrombosis service is responsible for drafting the viariable dosing regimen. The dosing regimen is composed by a prescriber (usually a thrombosis physician) in the building block variable dosing regimen (Wisselend doseerschema, WDS). The prescriber who made the medication agreement remains responsible for the dispense requests (VV). The thrombosis physician composes the WDS withing the agreed upon INR-range, the dosing regimen is usually based on a specific, measured INR-value. 
====Setting up a variable dosing regimen ====
The prescriber prescribes anticoagulants with a medication agreement (MA) and indicates:
* The medication (PRK) that is being prescribed to the patient. The medication in the variable dosing regimen is always the same as the medication in the MA.
* That for this medication a variable dosing regimen applies (this is added in the additional instructions). This also means there will be no dosage added in the medication agreement.
* The INR-range within which the treatment should take place. This information is included in a comment.

In order to bridge the period until the thrombosis service is involved and ready to take over the treatment, the original prescriber sets up a WDS for this first period (usually between 4 and 7 days). Usually a check-up date is agreed upon after the registration of the patient at the thrombosis service. During this check up the INR-value is measured. Based on the measured value and/ or the professional assessment of the thrombosis physician, a dosing regimen is composed that either changes of succeeds the previous WDS. From this moment on, the thrombosis service takes over the composition of the dosing regiment from the original prescriber.

''INR-value with the WDS'' 
The variable dosing regimen is often based on an INR-value. For other parties involved in the care for the patient, it’s important to be able to deduce the INR-value on which the WDS was based. That is the reason that the corresponding INR-value will be made available within the WDS. The INR-value is included in a comment within the WDS.

====Changing a variable dosing regimen ====
When the variable dosing regimen (WDS) is being used up until the stop date of the WDS, it can be replaced by a new WDS that succeeds it. The new WDS has a relation to the MA and the previous WDS.
Furthermore, it is possible to adjust the WDS before the stop date is reached. In that case, the information system stops the previous WDS, using a technical stop-WDS that is not visible to the user. The new WDS follows and has a reason for change and a relation to the MA and the previous WDS.
All changes related to the dosing regimen can be included in the WDS. Changes that concert the further treatment policy (e.g. the prescribed medication, the route of administration of the agreed upon INR-range) are to be made in the MA.

====Stopping a variable dosing regimen ====
There are various reasons that can cause the need to (temporarily) stop the use of anticoagulants. For example, in the event of a procedure of because there is temporary co-medication. Two kinds of situations can be distinguished. Depending on the situation and the assessment of the thrombosis physician one of twee methods is chosen:
#''(temporary) adjusting the policy'': The thrombosis physician can choose to temporarily adjust the dose for the anticoagulants to 0. For example, in the event of a planned procedure. In this case, the MA (and therefore the treatment with anticoagulants) and the TA will continue, but the dosage in the WDS is temporarily adjusted to 0. The MA will still be shown on the medication overview under ‘current medication’. In the event of such a temporary adjustment, only the WDS is changed. It is advised to include a reason for this change in the new WDS.
# ''(temporary) stopping the anticoagulants:'' The thrombosis physician (or another prescriber) can also choose to (temporarily) stop the treatment with anticoagulants. This means that the patient should not to take any anticoagulants anymore. In this case the thombosis physician (or another prescriber) creates a stop-MA (or sends a proposed MA to the original prescriber). Stopping the MA, also stops the underlying therapeutic building blocks (TA, WDS). The anticoagulant will be shown on the medication overview under ‘recently stopped medication’.
If, after a period of time, there is a need to restart the anticoagulant, the prescriber can do this by creating a new MA. The new MA can be created by the original prescriber, the thrombosis physician could also send a proposed MA. In many cases the thrombosis service would no longer be involved. And the MA is created by the original prescriber.

===Process step: Creating a medication dispense request===

A VV (besides an MA) only applies in an ambulatory situation. A VV may be made when the medication supply of the patient needs to be replenished. This does not have to coincide with an MA. At the start of a MBH for which the patient still has a sufficient supply at home from a previous agreement, a VV is not needed. When the dosage is reduced, the patient may also have a sufficient supply. In the case of a medicinal product that is used for a prolonged period of time (e.g. an antihypertensive drug), with a continuous MA (meaning a period of use with only a start date), several VVs may be made over time within the scope of this existing agreement.
Logistical and emergency instructions may be included in the VV, such as dispense location, request to not include in the GDS (medication distribution system, in Dutch: 'Geneesmiddel Distributie Systeem'), etc.

In the case of a VV, the quantity to be supplied can be stated or the consumption period. With a consumption period, the quantity must be clearly deducible from the dosing instruction of the MA. Note: a consumption period end date has a meaning other than the period of use end date from the MA and may be unequal.
*Period of medication use end date: date until which the pharmacist is allowed to to provide medication (and thereby provide sufficient supplies to the patient for use until that date).
*Period of use end date: date on which the patient must stop the medication (this can be equal to the consumption period end date or further in the future).

===Process step: Sending renal function value with prescription===

Renal function is important for certain medicines. The renal function value determines the choice of drug and/or drug dosage. It is legally stipulated that if a health professional has performed further research on a patient renal function, he should share abnormal renal function values with the appropriate pharmacist, appointed by the patient (article 6.10, 'regeling geneesmiddelenwet').

The renal function value is always sent with the prescription (using the building block laboratory test results) for medicines for which this is important (characteristic in the G-standard), so that the pharmacist can perform proper medication monitoring. The renal function value should not be older than 13 months, because with stable chronic renal impairment the renal function should be checked at least once a year. 1 month has been added to allow some backlog in practice.

If at the time of sending of an MA and/or VV no renal function is known, then the prescription policy remains unchanged. Sending the laboratory test result renal function value without an MA and/or VV is beyond the scope of this information standard.

===Process step: Sending height and weight values with prescription===

It is possible for the prescriber to send the body height and weight of the patient with the prescription. This is the height an weigh of the patient that the prescriber used for the medication agreement. Hence, it is possible for these values to diverge (be more accurate) from the height and weight values that are registered in the patient details. This could be necessary for prescribing for children or for medication where weight (e.g. coagulation medication) or height (e.g. oncolytic agents) are important factors to consider.

Body height and weight are separate building blocks. They can only be send together with the prescription and with the medication agreement. The information is not available on request.

===Process step: (Actively) making available===

This step involves information exchange. Information can be sent or made available with different intentions:

A. As an order for the pharmacist to dispense medication. The prescriber sends the MA to the pharmacist. In an ambulatory situation, the VV is also sent to the patient’s pharmacist. If the pharmacist is not known, this process step may also entail giving out a paper prescription and/or (reactively) making the data available (see C). When the pharmacist has filled the order, the prescriber will receive a notification (see [[#Information systems and transaction groups|paragraph 2.3.8]]). 

B. As an order for the pharmacist to implement a medication change (including stop-MA with stop type 'permanent' and 'temporary') that impacts or may impact current MVE by this pharmacist. A current MVE indicates an order (as in A) that has been accepted, but has not yet been completely filled. For example, when medication is still being dispensed or when a VV dictates that medication should be dispensed multiple times, but not all have taken place yet, e.g. with the GDS. 

C. Making medication data (MA, VV, MGB) and possibly the medication overview available to allow fellow health professionals and/or patients to access these later, possibly in combination with prescription without a specified recipient (see [[#Prescription without specified recipient (ambulatory)|paragraph 8.1]]). 

D. Actively sending (informing) medication data (one or more building blocks) to a specific health professional at the request of the patient when in the presence of this health professional or at discharge. 

In case of corrected data, the prescriber assesses who should be actively informed of this correction. This can be done, for example, by sending the new MA (option A or B above) or by means of a telephone consultation.
In an ambulatory setting (general practitioner/outpatient clinic) medication data are usually sent or made available directly; in a clinical setting, medication data is usually made available at discharge or interim leave from the institution.
This chapter deals with prescription with a specified recipient; [[#Prescription without specified recipient (ambulatory)|paragraph 7.5]] details prescription without a specified recipient.
See also [[#Informing and (actively) making available|paragraph 1.3.5]] for a further explanation on informing (situation A, B, D) and making available (situation C).

===Post-condition===
*A new MA may have been created (starting, changing or discontinuing medication)
*A VV may have been made (only outpatient)
*An order may have been sent to the pharmacist to carry out MVE
*An order may have been sent to the pharmacist to modify MVE
*Fellow health professionals and the patient have been informed or may inform themselves about the new medication data: MA, VV, MGB
*Fellow health professionals and the patient have been informed or may inform themselves about a medication overview.

===Information systems and transaction groups===

The prescriber and the pharmacist as well as other health professionals and users all make use of an information system, respectively, an electronic prescribing system (EVS), a pharmacist information system (AIS, incl. ZAIS), a XIS and a PGO<ref> XIS is a generic term for a random (health care) information system. PHR=personal health records.</ref>. These information systems each have different system roles which enable the exchange of data between these information systems as part of the prescription process.
[[#Information systems and transactions|Chapter 6]] includes an overview of all information systems, system roles, transactions, etc. The most important elements for the prescription process are included in the overview below.

{{anchor|figuur 5}}
[[Bestand:Uc Voorschrijven.png|Figuur 5 Processtappen en transacties - voorschrijven]]

===Use cases===
The following specific use cases have been elobarated:
*[[#Short-term medication|Short-term medication (paragraph 4.1.1)]]
*[[#Continuing medication|Continuing medication (paragraph 4.1.2)]]
*[[#Hard end date for period of medication use|Hard end date for period of medication use (paragraph 4.1.3)]]
*[[#Medication as needed|Medication as needed (paragraph 4.1.4)]]
*[[#Course of treatment as needed starting in future|Course of treatment as needed starting in future (paragraph 4.1.5)]]
*[[#Two dosages of the same medication at the same time|Two dosages of the same medication at the same time (paragraph 4.1.6)]]
*[[#The same medicinal product with different strengths at the same time|The same medicinal product with different strengths at the same time (paragraph 4.1.7)]]
*[[#Explanation in medicatieafspraak with deliberately chosen special characteristic|Explanation in medicatieafspraak with deliberately chosen special characteristic (paragraph 4.1.8)]]
*[[#New medicatieafspraak, no verstrekkingsverzoek|New medicatieafspraak, no verstrekkingsverzoek (paragraph 4.1.9)]]
*[[#New verstrekkingsverzoek under existing medicatieafspraak|New verstrekkingsverzoek under existing medicatieafspraak (paragraph 4.1.10)]]
*[[#Dosage change (sufficient supply)|Dosage change (sufficient supply) (paragraph 4.1.11)]]
*[[#Prescription no longer needed after first verstrekkingsverzoek|Prescription no longer needed after first verstrekkingsverzoek (paragraph 4.1.12)]]
*[[#Discontinuing medication|Discontinuing medication (paragraph 4.1.13)]]
*[[#Temporarily halting/resuming medication|Temporarily halting/resuming medication (paragraph 4.1.14)]]
*[[#Temporarily halting for an intervention|Temporarily halting for an intervention (paragraph 4.1.15)]]
*[[#Substitution|Substitution (paragraph 4.1.16)]]
*[[#Paper prescription|Paper prescription (paragraph 4.1.17)]]
*[[#Carrying out medication verification and evaluation of foreign or self-care medication|Carrying out medication verification and evaluation of foreign or self-care medication (paragraph 4.1.18)]]
*[[#Day treatment|Day treatment (paragraph 4.1.19)]]
*[[#Starting with medication before admission|Starting with medication before admission (paragraph 4.1.20)]]
*[[#Emergency admission|Emergency admission (paragraph 4.1.21)]]
*[[#Discharge|Discharge (paragraph 4.1.22)]]
*[[#Interim discharge|Interim discharge (paragraph 4.1.23)]]
*[[#Transfer to another institution|Transfer to another institution (paragraph 4.1.24)]]
*[[#Do not dispense before|Do not dispense before (paragraph 4.1.25)]]
*[[#Discontinuation of medication by third parties|Discontinuation of medication by third parties (paragraph 4.1.26)]]
*[[#Two PRKs in a single medicamenteuze behandeling|Two PRKs in a single medicamenteuze behandeling (paragraph 4.1.27)]]
*[[#Creating a medicatieafspraak after the fact|Creating a medicatieafspraak after the fact (paragraph 4.1.28)]]
*[[#Single medication use( medicatiegebruik)|Single medication use(medicatiegebruik)(paragraph 4.1.30)]]
*[[#Provisional and final medication order|Provisional and final medication order (paragraph 4.1.31)]]
*[[#Inadvertently ‘outstanding’ medication or 'orphans'|Inadvertently ‘outstanding’ medication or 'orphans' (paragraph 4.1.32)]]
*[[#Missing digital medicatieafspraak at admission|Missing digital medicatieafspraak at admission (paragraph 4.1.33)]]
*[[#Own articles (90 million numbers)|Own articles (90 million numbers) (paragraph 4.1.34)]]
*[[#Dosing with minimum interval|Dosing with minimum interval (paragraph 4.1.35)]]
*[[#Verstrekkingsverzoek with number of repetitions|Verstrekkingsverzoek with number of repetitions (paragraph 4.1.36)]]
*[[#Prescribing non-medicines|Prescribing non-medicines (paragraph 4.1.37)]]
*[[#Send renal function value in the prescription|Send renal function value in the prescription (paragraph 4.1.38)]]
*[[#Cancelling a prescription that was sent earlier|Cancelling a prescription that was sent earlier (paragraph 4.1.39)]]
*[[#Modification of someone else's medicatieafspraak|Modification of someone else's medicatieafspraak (paragraph 4.1.40)]]
*[[#Setting up a variable dosing regimen (WDS)|Setting up a variable dosing regimen (WDS) (paragraph 4.1.41)]]
*[[#Changing a variable dosing regimen (WDS) during period of use|Changing a variable dosing regimen (WDS) during period of use (paragraph 4.1.42)]]
*[[#Stopping medication with a variable dosing regimen (WDS)|Stopping medication with a variable dosing regimen (WDS) (paragraph 4.1.43)]]

==Process: dispense==

This paragraph describes the process of dispensing medication, including repeat prescriptions and GDS. This process encompasses all actions a pharmacist must take for the patient to not only receive a medicinal product, but to also receive the associated pharmaceutical care ensuring a safe and effective use of the medicinal product by the patient. The dispense process starts with providing pharmaceutical care. If necessary, a medication administration agreement will be made and if needed, medication is dispensed. Medication dispense (i.e. handing out a medicinal product) does not always take place. This may be the case when the medication agreement is changed (e.g., in case of dose reduction where the patient still has enough supply), when the medication is discontinued or, in an ambulatory situation, the medication is not picked up. When the MA and/or the VV do not comply (see [[#Process step: Informing the prescriber|paragraph 2.3.5]]), the prescriber will be informed. Finally, the recorded data are (actively) made available. See [[#Appendix: General Diagram Medicatioprocess|Chapter 12]] for a diagram of the dispense process.

Medication assessment is the process in which the physician and pharmacist consider all medication of the patient against the background of his condition, applicable treatment guidelines, the well-being of the patient, etc. Medication assessment is defined in this document as a combination of treatment evaluation (as described in the previous paragraphs) and pharmaceutical care. Depending on the findings, the previously described medication verification and prescription processes are followed, after which medication dispense takes place.

For the GDS, many pharmacists collaborate with another organisation that handles part of the pharmacists’ logistics. This then also requires data exchange with that party. Besides, not all medication can be included in the GDS packaging, which adds to the logistical complexity for the pharmacist. The internal logistics and communication between the pharmacist and his subcontractor(s) are outside the scope of this information standard. It has been established however that with the provision of the current building blocks and the underlying data elements, this logistical process can be adequately supported.

===Current situation===
The following deviations (from the desired situation that) are currently observed:
*In the current situation, in the case of GDS, the prescribing physician and other health professionals receive a large quantity of dispense messages. This becomes difficult to manage for these health professionals.
*In the current situation, in the case of GDS, pharmacists and general practitioners communicate via so-called authorisation lists. The pharmacist sends an overview of all the patient’s medication to the general practitioner for authorisation. This complicates matters for a general practitioner because he will need to verify all medication agreements. This should not be necessary, as most medication agreements/dispense requests have already been authorised. It would be much more efficient if the general practitioner only needs to authorise those medication agreements/disprense requests that have not been authorised yet, e.g. a new dispense request on the basis of an existing medication agreement.
*In the current situation, a locum pharmacy often does not inform the regular general practitioner and regular pharmacy when medication is dispensed.
*In the current situation, a proposal for a medication agreement may have been aligned with the prescriber over the phone and/or the pharmacist and prescriber have made an agreement about handling a warning from the medication monitoring system.
*The intention of the return message is not always clear: no distinction can be made in the return/delivery message between displaying a physical delivery and a transmission of information about a medication change.
*In the current situation, pharmacists sometimes register (and communicate) medication dispenses when they are preparing the medication for the patient instead of at the time when the medication is actually dispensed to the patient. This means that medication that has not been picked up, is sometimes erroneously registered as dispensed.

===Precondition===

An MA exists. In an ambulatory situation there may also be a corresponding VV.

===Trigger event===
The pharmacist starts the medication dispense process on the basis of one of the following events:
*Receipt of an order to make an MVE on the basis of a new MA. In an ambulatory situation, this order is always accompanied by a VV.
*Receipt of an order to process a new MA in an ongoing MVE.
*Receipt of a trigger (for example, via a patient or a repeat module of the pharmacist information system) for a repeat MVE under an existing MVE or a new VVV.

===Process step: Providing pharmaceutical care===
Pharmaceutical care is provided by a community, outpatient (i.e. at the hospital) or institutional pharmacy, depending on the health professional who has created the MA:
*MA, possibly with a VV from the general practitioner or specialist: care provided by a community or outpatient pharmacy.
*MA from specialists and other prescribers in hospitals/institutions: care provided by an institutional pharmacy or a community pharmacy that supplies the respective institution.
Medication monitoring is also part of pharmaceutical care.

Based on the received MA or a change in the situation of the patient, the pharmacist decides how to apply this by:
*Making one or more new TAs.
*Continuing, permanently discontinuing, temporarily halting or modifying an existing MA.
*Rejecting the MA.
*Proposing a new MA.
*Proposing a new medication dispense (VVV).

The last three situations are explained in the following paragraph. The first two situations are explained in [[#Process step: Creating a toedieningsafspraak|paragraph 2.3.6]].
In conclusion of provided pharmaceutical care, which may comprise new agreements and medication dispenses, a new up-to-date medication overview may be compiled and made available.

===Process step: Informing the prescriber===

There is a number of situations in which the pharmacist informs the prescriber, including:
*When a new or modified MA is needed
*When a new VV is needed
For more information about informing, see [[#Informing and (actively) making available|paragraph 1.3.5]].

A new or modified MA is needed:
*When a new TA cannot be created based on the received MA because the pharmacist suspects an error in the MA, or
*After a signal from the medication monitoring system as part of pharmaceutical care. The signal may indicate, for example, that the dosage should be lowered or increased, that it is advisable to select another medicinal product, that a product should be temporarily discontinued, that another additional product should be added, etc., or
*Based on medication use as reported by the patient during pharmaceutical care, or
*When the temporarily halted pharmaceutical treatment may be resumed.
*A TA is not yet created or modified in these situations.
Instead, the pharmacist starts by contacting the prescriber by phone, informing him of the suspected error and proposing an alternative. The pharmacist may also send a digital proposition called VMA to the prescriber. He recommends a specific MA in this proposal, together with the reason and arguments for that recommendation. The prescriber may approve the VMA and make it into a final MA (see also [[#Process step: Evaluating a (pharmaceutical) treatment|paragraph 2.2.4]]). 

A new VV is needed when the patient’s medication stock is depleted or nearly used and the treatment may need to be continued (request repeat prescription). The patient either requests a repeat MVE from the pharmacist or has signed up in the past for proactive repeat MVE and a notification signal is generated by the repeat module of the AIS when the patient requires new medication<ref> The patient may also request a repeat directly from the prescriber: see [[#2-5-6|paragraph 2.5.6]].</ref>.
When the existing VV is not adequate, the pharmacist may communicate this request over the phone or send a digital VVV to the prescriber. The VVV may contain indications for the prescriber, such as urgency. The prescriber may approve the received proposal and alter it into a final VV. The prescriber informs the requestor via a AVVV (see also [[#Process step: Evaluating a (pharmaceutical) treatment|paragraph 2.2.4]] and subsequent paragraphs).

===Process step: Creating an administration agreement===

If the MA and, if applicable, the corresponding VV can be processed, a TA will be created. By creating a TA, the pharmacist fulfills the MA. The TA is communicated to the patient or the person administrating the medication. The TA belongs to the same MBH as the MA it fulfills. As is the case with the corresponding MA, a TA may start in the future. The dosage in the TA may deviate from that in the MA, for example because a certain strength is not in stock. This means that another PRK can become part of the MBH when, for example, 1 tablet of 20 mg is changed into 2 tablets of 10 mg.
Before the TA is made (actively) available, medication monitoring will occur in accordance with applicable guidelines, as part of this process step.

On the basis of the TA, an administration list<ref> In this document, the administration list means both the digital and the paper version, unless otherwise indicated. Sublist and checklist are synonyms. </ref> can be compiled for home care or nursing staff, among others.

When creating a TA, the same principle applies as for the MA: each change is recorded in a new TA.

The following paragraphs describe the different situations in which a TA is created: new TA or continuing, permanently discontinuing, temporarily halting or modifying an existing TA.

====New administration agreement====

In case of a new MA, a new TA is always created. A new TA is also created in case of a new preference policy or a change in stock which results in the selection of a different medicinal product.
When creating a new TA, the pharmacist takes into account, among other things:
*Preference policy,
*Inclusion in GDS-packaging,
*Available stock of the institution (‘hospital formulary’) or the pharmacy itself. 

If, in an ambulatory situation, the first provision/dispense to the patient occurs later than agreed, the start date of the TA will be different from the start date of the MA.

====Continuing an administration agreement====

When the existing MA and TA are sufficient to carry out an MVE, the TA will not be adjusted.

====Discontinuing an administration agreement====

An MA in which it has been agreed to discontinue medication permanently, leads to a stop-TA under the same MBH (this also applies in case of a stop-MA as a result of a change) with stop type ‘permanent’. The stop-TA prevents a new MVE of the discontinued medication.
In an ambulatory situation, the prescriber can indicate in the MA that the medication will be discontinued with the next roll (with GDS). In this case, the start date of the stop-TA may be later than indicated in the original stop-TA.

====Temporarily interrupting an administration agreement====

Temporarily interrupting an MA results in a stop-TA (stop type: 'temporary'). Upon resuming, a new TA is created. Both TAs belong to the same MBH as the MA.

====Modifying an administration agreement====

A modified MA (leading to a new MA) leads to a new TA under the same MBH. As with the MA, a change to a TA means the termination of the existing TA (a technical stop-TA) and the creation of a new TA.

===Process step: Dispense===

After creating the TA, the pharmacist prepares the product and dispenses it to:
*The patient in a community setting,
*The patient admitted to a hospital, nursing home or other institution.
The pharmacist records MVE<ref>In a clinical situation, product may be taken from the department’s own supply, after which administration takes place immediately and the administration is recorded.</ref>.

Medication dispense to patients:
*In an ambulatory situation only occurs on the basis of a VV or a repeat VV,
*In a clinical situation occurs on the basis of the MA without the need for a VV.

===Process step: (Actively) making available===

This step involves information exchange. Information can be sent or made available with different intentions:

As a request to the prescriber to create a new medication agreement (VMA) or a new dispense request (VVV).

Informing the prescriber about the processing of the prescription (TA and/or MVE).

Making medication data available (VV and MVE) to allow fellow health professionals and/or patients to access these later.

Making a medication overview available to allow fellow health professionals and/or patients to access these later.

===Post-condition===
*A TA could have been created.
*An MVE could have taken place and, if necessary, the patient has received instructions on how to use the medicinal product.
*Fellow health professionals have been informed or may inform themselves. The prescriber has been informed.
*If necessary, the prescribing physician has been requested to provide a new/modified MA or VV.

===Information systems and transaction groups===

The prescriber and the pharmacist as well as other health professionals and users all make use of an information system, respectively, an electronic prescribing system (EVS), a pharmacist information system (AIS, incl. ZAIS), a XIS and a PGO<ref> XIS is a generic term for a random (health care) information system. PHR=personal health records. </ref>. These information systems each have different system roles which enable the exchange of data between these information systems as part of the prescription process.
[[#Information systems and transactions|Chapter 6]] includes an overview of all information systems, system roles, transactions, etc. The most important elements for the prescription process are included in the overview below.

{{anchor|figuur 6}}
[[Bestand:Uc Ter handstellen.png|Figuur 6 Processeps and transactions - dispense]]

===Use cases===
De volgende specifieke use cases van ter hand stellen zijn uitgewerkt:
*[[#New medicatieafspraak, medicatieverstrekking of the same product|New medicatieafspraak, medicatieverstrekking of the same product (paragraph 4.2.1)]]
*[[#New medicatieafspraak, medicatieverstrekking of the same product|New medicatieafspraak, medicatieverstrekking of the same product (paragraph 4.2.2)]]
*[[#Existing toedieningsafspraak is adequate|Existing toedieningsafspraak is adequate(paragraph 4.2.3)]]
*[[#Medicatieafspraak wanted (informing the prescriber)|Medicatieafspraak wanted (informing the prescriber) (paragraph 4.2.4)]]
*[[#Request and dispense|Request and dispense (paragraph 4.2.5)]]
*[[#Patient requests repeat prescription via physician (reactive repeat)|Patient requests repeat prescription via physician (reactive repeat) (paragraph 4.2.6)]]
*[[#Patient requests repeat prescription via pharmacist (informing prescriber)|Patient requests repeat prescription via pharmacist (informing prescriber) (paragraph 4.2.7)]]
*[[#Proactive repeat prescription by pharmacist (informing prescriber)|Proactive repeat prescription by pharmacist (informing prescriber) (paragraph 4.2.8)]]
*[[#Dispense based on an existing verstrekkingsverzoek|Dispense based on an existing verstrekkingsverzoek (paragraph 4.2.9)]]
*[[#Splitting a prescription|Splitting a prescription (paragraph 4.2.10)]]
*[[#Starting and continuing a GDS|Starting and continuing a GDS (paragraph 4.2.11)]]
*[[#The pharmacist changes commercial product|The pharmacist changes commercial product (paragraph 4.2.12)]]
*[[#Adding medication to a GDS|Adding medication to a GDS (paragraph 4.2.13)]]
*[[#Discontinuing medication in a GDS|Discontinuing medication in a GDS (paragraph 4.2.14)]]
*[[#GDS supplier supplies other commercial product|GDS supplier supplies other commercial product (paragraph 4.2.15)]]
*[[#Parallel administration agreements with GDS- and non-GDS-dispense|Parallel administration agreements with GDS- and non-GDS-dispense (paragraph 4.2.16)]]
*[[#Handling a stop medicatieafspraak|Handling a stop medicatieafspraak (paragraph 4.2.17)]]
*[[#Medication dispense with someone else’s administration agreement|Medication dispense with someone else’s administration agreement (paragraph 4.2.18)]]
*[[#Modification of someone else’s administration agreement|Modification of someone else’s administration agreement (paragraph 4.2.19)]]
*[[#Verstrekkingsverzoek with number of repetitions|Verstrekkingsverzoek with number of repetitions (paragraph 4.1.36)]]

==Process: administer==

 
This paragraph describes the administration process. This process comprises the compilation of the administration list for (professional) administrators and the administration which is carried out by a (professional) administrator, the patient himself or an informal caregiver. Professional administrators are physicians, nurses and caregivers (home care/institution).

In paragraph 2.4.1, the current situation is described, followed by a description of the new, altered situation.

===Current situation===
In the current situation, the (professional) administrator, together with the patient, verifies the medication which should be administered, using the available information (paper and/or digital administration list(s), the dosing schedule for, for example, anticoagulant medication, the information on the label), and, subsequently, administers the medication. In case of uncertain administration instructions, the administrator contacts the prescriber or pharmacist. Uncertainties are more likely to occur with an increasing number of prescribers, suppliers and administrators who are involved in the administration process.
In the current situation, for administrators, there are several challenges in the transfer of medication data:
*Transfer of medication data between inpatient health care or home care, and hospital health care is missing or is not available in time;
*Medication changes are not received (in time), and medication stops are missing;
*Up-to-date data on the administration list is not available in the case of supply by multiple pharmacies during after-hours care (evening, night or weekend);
*Separate dosing schedules, in addition to the administration list, of (highly) variable dosages, for example anticoagulant medication;
*Problems related to a separate dosing schedule of (highly) variable dosages; for example, loss of the dosing schedule, verbal information regarding changes of the dosing schedule;
*Medication as needed, injection schedules (for example, for insulin) are missing on the administration list (the injection schedules will be worked out in the information standard in the future);
*An overview is missing of all health professionals and healthcare providers which are involved.

In the current situation, the pharmacist compiles the administration list for the (professional) administrator or the patient. This administration list comprises the administration times, which are geared to the rounds of the home care organization, with account for the pharmaceutical ranges. A paper or digital administration list is used by the (professional) administrators for the registration of the medication administration. A paper administration list (including the administration registration) is in the patient’s home, and is therefore accessible for all professional administrators (irrespective of organization). The digitally recorded medication administrations are only exchanged with other health professionals in exceptional situations (for example, it may be exchanged in the case of admission or special circumstances). With the transition to an electronic administration registration, the administration list (with the recorded administration times) is no longer physically present; instead the administration is recorded in the E-TDR/E-TRS (electronic administration registration/electronic administration registration system) (see paragraph 2.4.8). The involved professional administrators of different organizations (with possibly different E-TRS applications) cannot consult or can only consult with difficulty the registered administration procedures of other organizations, because of registration in different applications and/or databases.

===Precondition===

The patient administers medication to himself or the patient must be administered medication by a(n) (professional) administrator and, therefore, requires an administration list.

===Trigger event===

The moment the medicinal products must be administered.

===Process step: Administration list===

The (professional) administrator or the patient receives or asks for the (actively) made available medication data that is required for automatic generation of the administration list. For the administration list, the building blocks ‘medicatieafspraak’ (MA), ‘wisselend doseerschema’ (WDS), ‘toedieningsafspraak’(TA), ‘medicatieverstrekking’ (MVE) and ‘medicatietoediening’ (MTD) are needed. In order to compile a complete administration list, the (guide) administration times and dosing instructions are required. The pharmacist and prescriber can enter these data in the TA, and MA or WDS, respectively. In general, pharmacists and prescribers in the ambulatory setting do not register the (guide) administration times and, therefore, they should receive a trigger which indicates that it concerns an ‘administration patient’; a patient who is aided in the medication administration or a patient who requires an administration list. For some medication, it is necessary to provide information on the previous ‘prick and patch locations’ (sites of administration); this is registered in the MTD. In the case of inpatient health care, administration lists are available for all patients, and (guide) administration times are registered by default.

Most (guide) administration times are chosen based on the administration times of other prescribed medication and the rounds of the administrator, especially for MAs and TAs with standard flexible (guide) administration times. Further agreements should be made regarding the (guide) administration times by those concerned in the healthcare field (for example, which deviations from the (guide) administration times are permitted). If the administration of a drug requires a specific time of administration, for example because of medication interactions, this is communicated by entering in the TA and/or MA that the (guide) administration time is not flexible.

The administration list differentiates between GDS medication (GDS: medication distribution system, in Dutch ‘Geneesmiddel Distributie Systeem’) and non-GDS medication based on the distribution type. This information is recorded in the building block MVE. Subsequently, the administrator (administration software) compiles the administration list, based on the MA, WDS, TA and MTD, with differentiation according to administration moment. Prescribers, pharmacists and administrators (PrickPatchLocation) are responsible for providing the medication data which is necessary for generating the administration list.

'''NB.''' It is currently explored in which way information regarding GDS can be best exchanged.

===Process step: Administering===

The (professional) administrator has received the medication data (MA, WDS, TA, MVE and MTD) that is required for the medication administration. These data is presented in the administration list as described above. The (professional) administrator, together with the patient, verifies the available medication and the administration data. If agreed and needed, the professional administrator prepares the medication for administration. The medication is administered and the administrator records the administration in the information system or on the administration list. Deviations in the medication administration (not administered, adjusted dosage, refusal by the patient, swallowing problems, adverse effects, etc.) are recorded as well.

===Process step: (Actively) making available===

In this step, information is exchanged. The administration data can be sent or be made available with the following aims:
*The recorded MTDs and deviations can be sent for information to a fellow health professional;
*The MTD can be made available so that the data can be accessed later by fellow health professionals and/or the patient. For example, the administration data can be retrieved upon transfer of the patient to another department or institution. Also, a health professional can check which medication is administered to a patient.

===Post-condition===

The patient has administered medication by himself or has been administered medication. The MTDs can be recorded in an information system and can be (actively) made available for fellow health professionals and/or the patient.

===Information systems and transaction groups===

The prescriber and the pharmacist as well as other administrators and patients (optional) all make use of an information system, respectively, an electronic prescribing system (‘elektronisch voorschrijfsysteem’ - EVS), an electronic client file (‘elektronisch cliëntendossier’ - ECD), a pharmacist information system (‘apothekersinformatiesysteem’ - AIS), a hospital pharmacist information system (‘ziekenhuisapotheekinformatiesysteem’ - ZAIS), an administration registration system (‘toedieningsregistratiesysteem’ - TRS), a thrombosis service information system (‘trombosedienstinformatiesysteem’ - TrIS) and a personal health environment (‘persoonlijke gezondheidsomgeving’ - PGO). These information systems each have different system roles which enable the exchange of data between these information systems as part of the administration process. The information systems may have a function in compiling an administration list, and in the registration, the exchange and the delivering of an MTD.
Chapter 6 provides an example of compiling an administration list. The most important elements for the administration process are included in the overview below.

{{anchor|figuur 7}}
[[Bestand:Toedienen.png|Figuur 7 Processtappen en transacties - toedienen|800px]]

===Use cases===

The following use cases for medication administration have been worked out:

*[[#Creating an administration list|4.3.1 Creating an administration list]]
*[[#Exact administration times required|4.3.2 Exact administration times required]]
*[[#Missing (guide) administration times|4.3.3 Missing (guide) administration times]]
*[[#Non GDS medication as needed|4.3.4 Non GDS medication as needed]]
*[[#Medication supply by multiple pharmacies|4.3.5 Medication supply by multiple pharmacies]]
*[[#Change in GDS from the next supply or immediately|4.3.6 Change in GDS from the next supply or immediately]]
*[[#Increasing dosage of GDS in new MBH|4.3.7 Increasing dosage of GDS in new MBH]]
*[[#Decreasing dosage of GDS in new MBH|4.3.8 Decreasing dosage of GDS in new MBH]]
*[[#Change processed by the pharmacist|4.3.9 Change processed by the pharmacist]]
*[[#Change not processed by the pharmacist|4.3.10 Change not processed by the pharmacist]]
*[[#Variable-dosing regimen|4.3.11 Variable-dosing regimen]]
*[[#Additional information|4.3.12 Additional information]]
*[[#Medication administration deviates from administration list|4.3.13 Medication administration deviates from administration list]]
*[[#Medication administration without medication agreement and administration agreement|4.3.14 Medication administration without medication agreement and administration agreement]]
*[[#Medication administration of self-care medication|4.3.15 Medication administration of self-care medication]]
*[[#Correction/cancellation of an administration|4.3.16 Correction/cancellation of an administration]]
*[[#Medication administration on hold|4.3.17 Medication administration on hold]]
*[[#Medication administration by a prescriber|4.3.18 Medication administration by a prescriber]]
*[[#Multiple administration organizations|4.3.19 Multiple administration organizations]]

==Process: medication use==
This paragraph describes the process of medication use including registration of medication use by the patient or a health professional. The information recorded by the patient or health professional may be used, among other things, for medication verification by the health professional. During medication verification, medication use is established by the health professional. See [[#Appendix: General Diagram Medicatioprocess|Chapter 12]] for a diagram of this process.

===Current situation===
*There is currently a limited number of information systems available in which the patient can record his own use of medication. Exchange to health professionals is also highly dependent on the information system used and is often limited to one specific health professional via, for example, one specific platform/app.
*The current medication profiles are often incomplete and not up to date.

===Precondition===
The patient has been prescribed medication.

===Trigger event===
The patient has used the medication or does not use it (anymore).

===Process step: Medication use===
The patient uses the prescribed medication, selfcare medication. Medication use may be recorded by
*The patient himself or his informal caregiver,
*A home care or institution nurse and/or
*Another health professional.
This third option often applies in the event of medication verification (see [[#Process: medication verification|paragraph 2.1]]). A variety of information systems is available to record medication use: PHR, XIS, EPF [electronic patient file] / ECF [electronic client file], app, etc.

The following can be recorded as medication use:
*Self-care and other proprietary medication,
*Discrepancies compared to agreements made,
*Confirmation of medication use (promoting compliance),
*Verified medication (see medication verification),
*Changes as a result of, for example, side effects (by the patient himself; a health professional will record this in a different way).

Patients who are being administered medication by a nurse sometimes take the medication by themselves at a later time, depending on the BEM-score (assessment of medication self-management, in Dutch: 'Beoordeling Eigen Beheer Medicatie'); in that case, MTD data may deviate from MGB. 
While medication is being used, pharmaceutical care is provided by the pharmacist (see [[#Process step: Providing pharmaceutical care|paragraph 2.3.4]], e.g. in case of new laboratory values). There may also be follow-up contact during which the pharmaceutical treatment is evaluated (see [[#Process step: Evaluating a (pharmaceutical) treatment|paragraph 2.2.4]]).

====''Recording of medication use by the patient''====
The patients makes use of a medication profile and indicates actual medication use for each medicinal product for which this is relevant. The patient can indicate whether or not he is using the product and/or whether this is ‘medication use according to agreement’ (whereby the MA and/or TA is displayed) or if there were deviations. In case of deviations, it is possible to enter specific deviations (i.e. with regard to the schedule actually followed by the patient), but deviations can also be entered in more general terms (for example, I take the medication: ‘from time to time’, [x] times per [days/week] on average’, ‘1x daily instead of 2x’, ‘not anymore since 22 January 2015’ or ‘not anymore since about a month’). In case of deviation from the agreements, the patient also indicates the reason for changing or discontinuing. 
The patient may also add his own medication to the overview and indicate any side effects as the reason for the changes.

Information about medication use will not always be present. There is also no certainty about the reliability of the information. Sometimes there are agreements between the health professional and the patient about keeping track of medication use, and sometimes the initiative is the patient’s entirely.

====''Recording of medication use by health professionals''====
During the process of medication verification ([[#Process: medication verification|paragraph 2.1]]) or evaluating a pharmaceutical treatment ([[#Process step: Evaluating a (pharmaceutical) treatment|2.2.4]]) the patient (or his informal caregiver) indicates, for example, that he does not use medication or uses it differently than was agreed. He may also indicate that he uses other medication as well (self-care products or foreign medication). The health professional can record these data as MGB. The data about medication use is recorded in addition to the primary medication data with the patient being recorded as the source of the information and the health professional as the author. 
Instead of or in addition to recording the MGB, a prescriber may also choose to make a new or modified MA with the patient (in accordance with the process described in [[#Process step: Creating a medication agreement|paragraph 2.2.5]]). This may occur when the prescriber sees reasons to adjust the agreement in response to the patient’s actual medication use. When the prescriber sees no reasons to adjust the agreement, he may choose to only record the medication use, perhaps with the remark that he has requested the patient to comply with the existing agreements.

In case of deviations in MGB, a pharmacist may create a VMA for the prescriber (see [[#Process step: Informing the prescriber|paragraph 2.3.5]]) and/or advise the patient to inform the prescriber about the deviations.

The assessment of medication use (effect and side effect) will be recorded by the physician in the medical history or used as a reason to modify or discontinue a medication agreement.

===Process step: (Actively) making available===
The recorded medication data (MGB) and possibly the medication overview may be sent for information to a fellow health professionals or be made available so that the data can be accessed later.

{{Anchor|2-5-6}}

===Process step: Informing the prescriber===
The patient may also directly inform the prescriber when a new or modified MA or new VV is needed. The process is similar to the process of the pharmacist informing the prescriber ([[#Process step: Informing the prescriber|paragraph 2.3.5]]).

===Post-condition===
The medication list has been updated by the patient and actual medication use has been added. If necessary, the patient has asked the prescriber for a new or modified MA or VV.

===Information systems and transaction groups===
The ''prescriber'' and the ''pharmacist'' as well as other ''health professionals'' and ''users'' all make use of an information system, respectively, an electronic prescribing system (EVS), a pharmacist information system (AIS, incl. ZAIS), a XIS and a PGO<ref>XIS is a generic term for a random (health care) information system. PHR=personal health records.</ref>. These information systems each have different system roles which enable the exchange of data between these information systems as part of the prescription process. 
[[#6 Information systems and transactions|Chapter 6]] includes an overview of all information systems, system roles, transactions, etc. The most important elements for the prescription process are included in the overview below.

{{anchor|figuur 8}}
[[Bestand:Gebruiken.png|Figuur 8 Processtappen en transacties - gebruiken]]

===Use cases===
The use cases for medication use are described on the basis of registration by the patient. The prescriber may record medication use in the same way but will rather record the assessment of medication use (effect and side effect) in the medical history or use it as a reason to modify or discontinue a medication agreement.

The following specific use cases for medication use have been worked out:
*[[#Self-care product|Self-care product (paragraph 4.4.1)]]
*[[#Medication from abroad|Medication from abroad (paragraph 4.4.2)]]
*[[#Modification on the patient’s initiative|Modification at the patient’s initiative (paragraph 4.4.3)]]
*[[#Discontinuation of medication on the patient’s initiative|Discontinuation of medication at the patient’s initiative (paragraph 4.4.4)]]
*[[#No more supply|No more supply (paragraph 4.4.5)]]
*[[#Feedback to patient through a medication adherence app|Feedback to patient through a medication adherence app (paragraph 4.4.6)]]
*[[#Registration of side effects by the patient|Registration of side effects by the patient (paragraph 4.4.7)]]
*[[#Register usage based on provision|Register usage based on provision (paragraph 4.4.8)]]

=Domain-specific handling of the medication process=

==After Hours General Practice clinics (HAP)==
The after hours general practitioner (AHGP) works on behalf of the regular general practitioner (GP). The AHGP may (among other things) start, modify and discontinue MAs in accordance with the process described in [[#Process: medication verification|paragraph 2.1]]. If necessary, the AHGP will also create the corresponding VVs. 
The AHGP will inform the regular GP about the observation. Currently, it has been agreed that the AHGP does not act as a source of information for other health professionals of this patient. This means that the AHGP will not carry out the process step ‘(actively) making available’. Instead, the regular GP will make the relevant information available to the fellow health professionals. An exception may be made for a prescription created by the AHGP without a specified recipient, see [[#Prescription without specified recipient (ambulatory)|paragraph 8.1]]. 
In principle, the AHGP will follow the generic prescription process, except that a AHGP will carry out certain steps on behalf of the regular GP (‘delegated’).

==Mental health care==
There are only few planned admissions in mental health care (almost only in departments for eating disorders, clinical rehabilitation, etc.). Most admissions are admissions as a result of acute crisis situations and are therefore comparable to admissions via the emergency departments in hospitals (see also [[#Starting with medication before admission|paragraph 4.1.20]]).

===Current situation===
In the current situation, patient or family/informal caregivers are asked which medication the patient is using. In most cases, the patient is unable to give an answer (often the reason for admission). Family/informal caregivers (if known) are also not always able to answer this. If this is the case, the admitting physician/psychiatrists will contact the general practitioner or the pharmacist to find out the medication. This is difficult outside office hours and during weekends. When data do come in, only part of them is retyped in the information system of the health professionals.

===Process===
In the new situation, it will be possible to retrieve the available medication data and medication overviews. On this basis, medication verification, assessment of the medicamenteuze behandeling (as soon as possible) and medication administration (in accordance with [[#Medication process|Chapter 2]]) can be started. Medication dispense is carried out by public pharmacists on an outpatient basis and, in clinical practice, often by a contracted hospital pharmacy. 
As is the case with hospital discharge, medicamenteuze behandeling will be assessed at discharge from a mental health institution ([[#Process step: Evaluating a (pharmaceutical) treatment|paragraph 2.2.4]] and subsequent). Clinical medication is discontinued and, if necessary, new medication is prescribed or temporarily halted outpatient medication is resumed or permanently discontinued. The physician/psychiatrist focuses mainly on psychiatric medication; somatic medication usually remains unaffected. 
Letting the psychiatric patient record his own medicatiegebruik may be experienced as undesirable control instead of it stimulating proper medication use. 
The medication data will be made available.

==Nursing, care and home care (VVT)==
The medication process in a VVT institution (nursing home, care home and home care) is similar to that of the clinical situation. However, in a VVT institution, a geriatrics specialist is responsible for prescribing medication to admitted clients and medication is being dispensed by one or more community pharmacists, possibly as part of GDS if needed. VVT institutions and home care make use of administration lists, which are drawn up based on the toedieningafspraken. The administration list is used to check medication before administering it and to sign off actual medicatiegebruik. Communication of the administration list between pharmacist, prescriber and nursing staff will be explained in more details further on in this information standard.

==Hospital admission and discharge==
A special situation in the transfer of medication data occurs when a patient is admitted to a hospital. At the moment of admission and of discharge, a lot of changes can take place in the medicatieafspraken and toedieningsafspraken. That is why this subject is separately illustrated in this chapter. This process is described in more detail in instruction manuals for caregivers and software suppliers.

===Prior to admission===
Before a patient is admitted to a hospital, changes in medication may be necessary. The medical specialist and patient can agree upon starting new medication or stopping continuous medication a few days before admission. The medical specialist subsequently registers a medicatieafspraak or stop-MA and mentions in the explanatory notes how many days before admission the patient has to start or stop the medication. When this medicatieafspraak is registered, the date of admission is often yet unknown. That is why the medical specialist records that this medicatieafspraak depends upon a hospital admission. This means that the start- or end date are uncertain. Technically, this is solved by registering the explanatory notes in the element ‘Condition’ of the period of use of the medicatieafspraak. If this condition is entered, it is clear to caregivers that the period of use is uncertain.

===During admission and at time of discharge===
When a patient is admitted, the following situations can occur, concerning the outpatient medication:
* Unchanged continuous use,
* Change in dosage,
* Generic substitution (active ingredient remains the same),
* Pharmacological substitution (active ingredient changes, but medication is registered for the same indication),
* (Temporary) stop.

Below, for each situation, an explanation is given for registration of the medication of the patient.

====Unchanged continuous use====
The patient continues using the outpatient medication during admission.

Both medicatieafspraak and toedieningsafspraak continue during admission and after discharge.

====Change in dosage====
The patient uses the outpatient medication during admission, but in a different dosage.

The medicatieafspraak for outpatient medication is stopped at admission. During admission, a new medicatieafspraak is registered with the changed dosage. At discharge, the prescriber decides which dosage will apply for the outpatient medication. Depending on this decision, the medicatieafspraak that applied before admission will be continued, or a new medicatieafspraak will be registered.
The toedieningsafspraak is also stopped at admission. During admission, a new toedieningsafspraak is registered, based on the new medicatieafspraak. At discharge, the toedieningsafspraak that applied before admission will be continued, or a new toedieningsafspraak will be registered.

====Generic substitution====
The patient uses a different medicinal product during admission, but with the same active ingredient and dosage as in the outpatient medication.

The medicatieafspraak for outpatient medication continues during admission and after discharge.
The toedieningsafspraak for outpatient medication is stopped at admission and continued at discharge. During admission, a new toedieningsafspraak is registered. This toedieningsafspraak will be stopped at discharge.

====Pharmacological substitution====
The patient uses a different medicinal product during admission, with a different active ingredient from the outpatient medication. This medicinal product, however, is registered for the same indication as the outpatient medication.

The medicatieafspraak for outpatient medication is stopped at admission and will be continued again at discharge. During admission, a new medicatieafspraak is registered. This medicatieafspraak will be stopped at discharge.
The toedieningsafspraak for outpatient medication is also stopped at admission and continued at discharge. During admission, a new toedieningsafspraak is registered. This toedieningsafspraak will be stopped at discharge.

====(Temporary) stop====
The patient (temporarily) stops using the outpatient medication during admission.

The medicatieafspraak for outpatient medication is (temporarily) stopped at admission. If the medication is stopped temporarily, this medicatieafspraak will be continued at discharge. If the medication is stopped definitively, the medicatieafspraak will not be continued.
The toedieningsafspraak for outpatient medication is also (temporarily) stopped at admission. If the medication is stopped temporarily, this toedieningsafspraak will be continued at discharge. If the medication is stopped definitively, the toedieningsafspraak will not be continued.

=Description of use cases=
This chapter contains a description of various use cases. Specific practical situations have been described for the various subprocesses. A large number of the practical situations are based on general medical practice, but are illustrative of similar situations in a different setting. This chapter assumes the knowledge as previously described in [[#Medication process|Chapter 2]].

==Use cases, Prescribe==

===Short-term medication===
A 35 year old female patient with a history of urinary tract infection brings her urine to the doctor’s assistant and tells her she has the same symptoms as the previous times. The assistant enquires about other symptoms such as fever and pain in the flank and checks the urine. There are no other symptoms and the urine reveals a urinary tract infection. She tells the patient that the general practitioner will prescribe a course of treatment and that she can pick it up from the pharmacist later. The General practitioner checks the previous courses of treatment and any cultures and records a medicatieafspraak. On ''27 January'' it was agreed:
:''Nitrofurantoin CR capsule, 100 mg, 2x daily, 1 capsule, from now on<ref>See also [[#Hard end date for period of use|paragraph 4.1.3]].</ref> for 5 days.''
He records this medicatieafspraak in his information system. The general practitioner then immediately also makes a verstrekkingsverzoek for the pharmacist chosen by the patient:
:''Nitrofurantoin CR capsule, 100 mg; 10 capsules.''
The general practitioner also records this verstrekkingsverzoek in his information system. 
The general practitioner consults with the patient to find out from which pharmacist she wants to pick up the medication. The general practitioner can then inform this pharmacist about the verstrekkingsverzoek and the medicatieafspraak. 
The information system of the general practitioner makes this information (verstrekkingsverzoek and medicatieafspraak) available to the other health professionals of this patient. 
 
[[Bestand:ENG_Voorschrijven_Kortdurende medicatie.png|800px]]

===Continuing medication===
The process for continuing medication is practically the same as for short-term medication (see [[#Short-term medication|paragraph 4.1.1]]), except that in the case of continuing medication the medicatieafspraak is made for an indefinite period of time.

For example: the prescriber agrees with a patient who has hypertension that he should use a diuretic on a continuous basis. On ''30 March 2013'' it was agreed:

:''Hydrochlorothiazide tablet, 12.5 mg; 1x daily, 1 tablet; from now on for an indefinite period.''
''For example, the prescriber chooses in the verstrekkingsverzoek for an initial dispensing quantity of 100 pieces.'' 
 
[[Bestand:ENG_Voorschrijven_Doorlopende medicatie.png|800px]]

===Hard end date for period of medication use===
A start date, end date and/or duration can be included in the period of medication use of a medicatieafspraak. If a hard end date is desired, this must also be explicitly stated in the explanation. Including an end date alone is not sufficient because this does not provide enough clarity about the intention of the prescriber. 
 
[[Bestand:ENG_Voorschrijven_Harde stopdatum gebruiksperiode.png|800px]]

===Medication as needed===
A 31-year-old female patient has had headaches a few times in a year, with migraine now being diagnosed. The general practitioner prescribes:
:''Rizatriptan tablets, 10 mg, as needed 1c1t under the tongue. First tablet at the next clear migraine attack.''
De huisarts legt de medicatieafspraak vast en doet een verstrekkingsverzoek:
:''6 sublingual rizatriptan tablets, 10 mg.''
 
[[Bestand:ENG_Voorschrijven_Zo nodig medicatie.png|800px]]

===Course of treatment as needed starting in future===
A 60-year-old patient with post-thrombotic syndrome experiences erysipelas (severe infection of the leg which can require admission if medication is not started quickly) sometimes every other year, sometimes three times a year. At the request of the patient, the general practitioner prescribes an antibiotic treatment the patient can start immediately in case of a recurrence of erysipelas. The following medicatieafspraak is created:
:''Flucloxacillin capsules, 500 mg, 1 capsule 4x daily, for 10 days. In the medicatieafspraak is indicated (if necessary): start in case of recurrence, as needed.''
The general practitioner immediately creates a verstrekkingsverzoek:
:''Flucloxacilline 500 mg capsules 40 stuks.'' 
 
[[Bestand:ENG_Voorschrijven_Kuur zo nodig startend in de toekomst.png|800px]]

===Two dosages of the same medication at the same time===
A 79-year-old man with metastatic prostate cancer is increasingly suffering from pain and his medication is being changed. The specialist prescribes oxycodone tablets, 10 mg, 1 tablet 4x daily and as needed for pain during the night, 1 tablet 1x daily, on October 9. The specialist records this in one single medicatieafspraak with two dosing instructions and creates a verstrekkingsverzoek for 60 tablets of oxycodone of 10 mg. 
 
[[Bestand:ENG_Voorschrijven_Twee doseringen van hetzelfde geneesmiddel tegelijkertijd.png|800px]]

===The same medicinal product with different strengths at the same time===
The same 79-year-old patient (see [[#Two dosages of the same medication at the same time|paragraph 4.1.6]]) is experiencing even more pain. The specialist discontinues the 10 mg tablets of oxycodone on October 16 and prescribes 20 mg retard tablets of oxycodone, 2 tablets 3x daily, and 20 mg normal release tablets of oxycodone as needed in case of nocturnal pain, 1 tablet 1x daily. The specialist records this in two medicatieafspraken (with, for the time being, two separate medicamenteuze behandelings) and creates a verstrekkingsverzoek for both medicatieafspraken, respectively 45 retard tablets of 20 mg oxycodone and 30 tablets of 20 mg oxycodone (normal release). 
 
[[Bestand:ENG_Voorschrijven_Hetzelfde geneesmiddel met verschillende sterkte tegelijkertijd.png|800px]]

===Explanation in medicatieafspraak with deliberately chosen special characteristic===
This use case is described in the zib medicatieafspraak/additional information. Here it is described for information purposes only. When selecting a medicinal product, it is possible to deviate from what is expected or standard. For example, when a hospital uses a different formulary than a community pharmacy. For reasons of efficiency the hospital has opted for a single gastric acid inhibitor: pantoprazole. 
At admission, a patient with omeprazole is switched to pantoprazole for the duration of the hospitalization. At discharge, the patient returns to omeprazole. 
It is clear that this may sometimes go wrong and that the patient might end up taking both omeprazole and pantoprazole if nothing is done. In the medicatieafspraak of the hospital for pantoprazole, a remark can be made about this deviation in order to make it clear that pantoprazole is the replacement of omeprazole or that it has to be used in addition to omeprazole.
 
 
Half-strengths are another example. The hospital sometimes as tablets available with half the strength of the normal commercial preparation (proprietary production). When a patient enters the hospital with a prescription of 25 mg of chlorthalidone, half a tablet 1x daily, he will receive 12.5 mg of chlorthalidone, 1 tablet 1x daily. In this specific case, this means that nursing staff does not have to break tablets in half. There is a risk that the patient will use the 25 mg again at home, but now a whole tablet at the time. An explanation in the medicatieafspraak (additional information) regarding the last 25 mg of chlorthalidone, makes it possible to indicate whether this was a deliberate increase. 
 
If a prescribed product has to be a very specific commercial product, this can be indicated with ‘medical necessity’.

===New medicatieafspraak, no verstrekkingsverzoek===
A 50-year-old man comes to the general practitioner with back problems. The symptoms have been present for three weeks and he is already using paracetamol. The general practitioner agrees with the patient that he can additionally use diclofenac:

On ''30 January'' it was agreed:
:''Diclofenac tablet, 50 mg, 1 tablet 3x daily, from now on for 3 weeks.''
He records this medicatieafspraak in his information system. The patient indicates there is sufficient supply at home: his wife still has an ample supply of diclofenac left because of a different problem a year ago.

A verstrekkingsverzoek is therefore not needed and the pharmacist also does not dispense any medication. 
The general practitioner makes the new medicatieafspraak available to any fellow health professionals of this patient. This allows the regular pharmacist to inform himself about this new medicatieafspraak. 
 
[[Bestand:ENG_Voorschrijven_Nieuwe medicatieafspraak geen verstrekkingsverzoek_a.png|800px]]

Another example: Mr Simons receives medication from the pharmacy weekly. In the past there were many requests for extra medication, which led to clear agreements about the dispense policy.

This is about:
:''Medicatieafspraak: Diazepam, 5 mg, 1 tablet 4x daily, from 1 January 2012 for an indefinite period''
:''Verstrekkingsverzoek: 28 tablets with 10 repeats; remark: weekly medicatieverstrekking''
The verstrekkingsverzoek is repeated approximately every 11 weeks.
The last verstrekkingsverzoek was on 3 March 2016:
:''one week (28 tablets) with 10 repeats''
This way, the pharmacy can go on for 11 weeks.
 
 
[[Bestand:ENG_Voorschrijven_Nieuwe medicatieafspraak geen verstrekkingsverzoek_b.png|800px]]

The last few years have been quiet. Mr. Simons is no longer asking for extra medication. At the last consultation he indicated that diazepam, 3x daily, is sufficient. This has been recorded in a medicatieafspraak:
:''1 April 2016 Diazepam, 5 mg, 1 tablet 3x daily, from 1 April 2016 for an indefinite period.''

The previous medicatieafspraak will be terminated as of 31 March 2016 (see discontinuation of medication in [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5]]).

In the current situation, the general practitioner would have called the pharmacy to make sure that 21 tablets of diazepam would be given with the following medicatieverstrekking, instead of 28. No new verstrekkingsverzoek would have been needed at the time.

In the new situation, the general practitioner sends the new medicatieafspraak to the pharmacy. Based on the new medicatieafspraak, the pharmacy provides 21 tablets per week, the previous verstrekkingsverzoek is still sufficient.

 
[[Bestand:ENG_Voorschrijven_Nieuwe medicatieafspraak geen verstrekkingsverzoek_c.png|800px]]

===New verstrekkingsverzoek under existing medicatieafspraak===
A prescriber may also create a new verstrekkingsverzoek as part of an existing medicatieafspraak. This medicatieafspraak may have been created by a different prescriber, for example a psychiatrist. This concerns repeat medication. This use case is described in [[#Patient requests repeat prescription via physician (reactive repeat)|paragraph 4.2.6]].

[[Bestand:ENG_Voorschrijven_Nieuw verstrekkingsverzoek onder bestaande medicatieafspraak.png|800px]]

===Dosage change (sufficient supply)===
Patient (37 years old, asthma) visited the pulmonologist on 13 August 2013 for a check-up of his asthma. The pulmonologist has established that patient’s asthma is not adequately controlled. 
The patient is currently using beclomethasone in accordance with a previously made and registered medicatieafspraak: on 10 June 2010 it was agreed:
:''Beclomethasone aerosol, 100 microgram/dose, inhaler; 1 inhalation 2x daily; from 10 June 2010 for an indefinite period.''
On 13 August 2013, the pulmonologist agrees with the patient on a dosage increase:
:''Beclomethasone aerosol, 100 microgram/dose, inhaler; 2 inhalations 2x daily; from 13 August 2013 for an indefinite period; reason for adjustment: insufficient effect.''
The previous medicatieafspraak of 10 June 2010 it is no longer valid: it is terminated (see Changing medication in [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5]]). The patient still has a sufficient supply, a verstrekkingsverzoek is therefore not needed.
 
 
[[Bestand:ENG_Voorschrijven_Wijziging in dosering voldoende voorraad.png|800px]] 
In case the patient has no more supply, a new verstrekkingsverzoek will be created. 
The information system of the pulmonologist makes the new medicatieafspraak available to the other health professionals of this patient. This modification is received by the pharmacist (fellow health professional). The pharmacist processes the modification. The pharmacist may also choose to accept the modifications automatically.

===Prescription no longer needed after first verstrekkingsverzoek===
A 16-year-old woman has a boyfriend and does not want to become pregnant. After explanation she opts for the pill. The general practitioner prescribes ethinylestradiol/levonorgestrel tablets of 20/100 µg, 1 tablet 1x daily for 21 days, then no tablet for 7 days, then another 21 days of taking a tablet once a day. Start on the first day of the next menstruation. The general practitioner records the medicatieafspraak and creates a verstrekkingsverzoek for 63 coated microgynon 20 tablets. He explains to her that if she does not experience any problems, she can continue to get the pill via the pharmacy. 
Three months later, the woman sends a request for repeat supply to the pharmacy. The pharmacy provides the product and communicates the medicatieverstrekking to the general practitioner.

 
[[Bestand:ENG_Voorschrijven_Recept niet meer nodig na eerste verstrekkingsverzoek.png|800px]] 

{{Anchor|4-1-13}}
===Discontinuing medication===
Patient (37 years old, asthma) visits the pulmonologist on 13 August 2013 for a check-up of his asthma. The patient is suffering from a side effect. The patient is currently using Beclomethasone in accordance with a previously made and registered medicatieafspraak. On ''10 June 2010'' it was agreed:
:''Beclometasone aerosol, 100 microgram/dose, inhaler; 1 inhalation 2x daily; from 10 June 2010 for an indefinite period.''
On 13 August 2013, the pulmonologist agrees with the patient to discontinue the medication (medicamenteuze behandeling is discontinued). Medication verification is also applicable here. In addition, medication monitoring may also be relevant here, for example if gastroprotrective drugs are being used because of the use of the medication to be discontinued (the information system will not always signal this automatically). 
The pulmonologist records:
:''Beclometasone aerosol, 100 microgram/dose, inhaler; stoptype ‘definite’; from 13 August 2013. Because of a side effect.''
This modification is received by the pharmacist (fellow health professional). The pharmacist processes the modification. The pharmacist may also choose to accept the modifications automatically. The pulmonologist decides to also actively inform a fellow health professional (such as a specialist) about this (part of the process step (actively) making available). 
The information system of the pulmonologist makes this information (agreement to discontinue) available to the other health professionals of this patient.
 
 
[[Bestand:ENG_Voorschrijven_Stoppen medicatie.png|800px]] 

===Temporarily halting/resuming medication===
A patient is being treated with simvastatin (cholesterol-lowering agent): 40 mg, 1 tablet 1x daily, for an indefinite period. Because of a throat infection in combination with an allergy for the first antibiotic of choice, Clarithromycin, 250 mg, 1 tablet 2x daily (antibiotic) is prescribed for 1 week. During that week, simvastatin is temporarily halted because of an interaction. 
The general practitioner records:
:''Simvastatin 40 mg; halt temporarily; for 1 week; reason: interaction''
:''Clarithromycin, 250 mg; 1 tablet 2x daily; for 1 week (and a corresponding verstrekkingsverzoek)''
The pharmacist is actively informed by the general practitioner about the temporary halt of simvastatin. A new medicatieafspraak is also created with which simvastatin is resumed after one week. The pharmacist will also receive the medicatieafspraak and the corresponding verstrekkingsverzoek for clarithromycin. See also Temporarily halting and resuming medication in [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5]].

 
[[Bestand:ENG_Voorschrijven_Onderbreken hervatten medicatie.png|800px]] 

===Temporarily halting for an intervention===
A 62-year-old man uses acetylsalicylic acid, 100 mg, 1 tablet 1x daily because of coronary disease. He has an intestinal polyp that must be removed. The general practitioner informs him that he should stop using acetylsalicylic acid three days before the intervention and resume the day after the intervention. The general practitioner records the temporary halt in a medicatieafspraak with an enddate 3 days before the intervention; stoptype ‘temporary’; reason for halting: ‘intervention’. In the (second) medicatieafspraak for presuming, 1 day after the intervention is used as the start date. The general practitioner actively informs the pharmacist and the gastroenterologist about the medicatieafspraken. 
When the date of the intervention is unknown or uncertain, the explanation will indicate that the medication should be halted three days before the intervention and resumed one day later. The duration of the temporary halt is then 4 days. See also Temporarily halting and resuming medication in [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5]] and Prior to admission in [[#Prior to admission|paragraaf 3.4.1]].

 
[[Bestand:ENG_Voorschrijven_Onderbreken voor een ingreep.png|800px]] 

===Paper prescription===
The physician gives the patient a paper prescription<ref>A similar situation occurs when the pharmacist receives a fax.</ref>. A paper prescription contains a medicatieafspraak and a verstrekkingsverzoek. The patient can use this prescription to pick up the medication from any pharmacist. The general practitioner does not inform the issuing pharmacist in this case. However, the process is actually the same: the activity ‘(actively) making available’ is now only ‘handled’ by the paper prescription in the hands of the patient. The supplying pharmacist will copy this paper medicatieafspraak and verstrekkingsverzoek in his own information system and complete it with a toedieningsafspraak. The pharmacist may also retrieve the medicatieafspraak and verstrekkingsverzoek that were made available digitally and process them in his own information system this way. 
The information system of the general practitioner makes the new medicatieafspraak and verstrekkingsverzoek available for fellow health professionals. When the information system of the general practitioner has not made these available this may be because it concerns a toedieningsafpsraak without digitally available medicatieafspraak and verstrekkingsverzoek. The pharmacist will not make the medicatieafspraak and verstrekkingsverzoek obtained ‘from paper’ available because he is not the owner. Next to that, this could lead to, possibly only in the future, wrongful duplication of medicatieafspraken and verstrekkingsverzoeken.
 
[[Bestand:ENG_Voorschrijven_Papieren recept.png|800px]]
 

===Carrying out medication verification and evaluation of foreign or self-care medication===
When medication cannot be found in the information system (such as foreign medication and self-care medication), this medication will be recorded as medicatiegebruik (see [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5]]).

===Day treatment===
An admission for day treatment is comparable with an outpatient consultation or an emergency admission during which the medication is supplied by the hospital pharmacist. In the case of admission for a day, extensive medication verification does not usually occur. In the case of admission for a day, the medication prescribed is recorded (often on the basis of protocols according to which verification is carried out afterwards) and administered. 
For treatments with cytostatics, for example, there is a medicatieafspraak, but it is not always clear in advance when the medicatieverstrekking/administration takes place. Reason: treatments are often postponed and then supplied and administered later.

===Starting with medication before admission===
Prior to cataract surgery, Nevanac is started three days before the surgery. The eye drops are used until three weeks after surgery (a total duration of medication use of 24 days). The specialist creates a medicatieafspraak for Nevanac, 1 drop in the morning, for 24 days. When the date of the surgery is unknown or uncertain, the explanation may indicate that Nevanac should be started 3 days before surgery takes place. See Prior to admission in [[#Prior to admission|paragraaf 3.4.1]]
 [[Bestand:ENG_Voorschrijven_Starten met medicatie voor opname.png|800px]]
 

===Emergency admission===
In the event of an emergency admission, extensive medication verification is not carried out beforehand as would normally be the case with clinical admissions. Agreeing on medication with the patient is also often not possible in the event of an emergency admission. Often, the patient is administered medication as soon as possible and verification only takes place afterward

===Interim discharge===
When a patient temporarily leaves the hospital/institution to go home, for example, for weekend leave, the clinical medication continues. In order to keep the patient’s own general practitioner informed, the medication overview is provided to the patient and the medication data are made available.

===Transfer to another institution===
In case of a transfer to another institution, the medicamenteuze behandeling is evaluated (see [[#Process step: Evaluating a (pharmaceutical) treatment|Chapter 2.2.4]] and [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5]]). Medication overview and medication data are (actively) made available. The new attending physician evaluates the medicamenteuze behandeling and determines the institutional medication.

===Do not dispense before===
The prescribing physician creates a verstrekkingsverzoek on 14 April 2017, but wants to indicate in that same verstrekkingsverzoek the medicatieverstrekking may only take place on or from a later date, for example, 23 April 2017. This cannot be recorded in a structured manner in the verstrekkingsverzoek, but is included in the explanation (as free text).
 
[[Bestand:ENG_Voorschrijven_Niet verstrekken voor.png|800px]]
 

===Discontinuation of medication by third parties===
Medication can be discontinued by the prescriber himself (see [[#Discontinuing medication|paragraph 4.1.13]]) but also by another prescriber. For example, the specialist can end medicatieafspraken made by a general practitioner that are up to date according to the information system, but that turn out not to be, for example after medication verification. When a health professional discontinues medication, he creates a new stop-MA. The health professional cannot modify someone else’s medicatieafspraak, only create a stop-MA. He therefore actively informs the health professional of the original medicatieafspraak about this change. The health professional of the original medicatieafspraak modifies the end date in the existing medicatieafspraak. If required, this may also be automated by the information system. This prevents the second health professional from not having to produce data after a period of time because the production period has expired (also no stop-MA), while the health professional of the original medicatieafspraak continues to produce it for no reason (without an end date).
 
 
[[Bestand:ENG_Voorschrijven_Stoppen van medicatie door derden.png|800px]]
 

===Two PRKs in a single medicamenteuze behandeling===
In certain circumstances, the pharmacy is allowed to select a different PRK for the toedieningsafspraak than is indicated in the medicatieafspraak made by a prescriber. If for instance a failure of the prescriber’s information system would result in only the communication of the toedieningsafspraak, a subsequent prescriber will only have this toedieningsafspraak with the new PRK. The next prescriber will then probably assume that this PRK is also the PRK of the medicatieafspraak. A modification of the medicatieafspraak will then also result in a stop-MA (without referring to the original MA) and a new medicatieafspraak on the basis of this PRK. This means that there are now two medicatieafspraken with different PRKs under the same medicamenteuze behandeling. These two medicatieafspraken continue to exist. After any information system failure, (the information system of) the prescriber must check whether there have been changes and implement them, if necessary (see also [[#Discontinuation of medication by third parties|paragraph 4.1.26]]).
 
[[Bestand:ENG_Voorschrijven_Twee PRKs onder een medicamenteuze behandeling.png|800px]]
 

===Creating a medicatieafspraak after the fact===
In emergency situations, for example, it may happen that the medicatieafspraak is only created after the medication has been dispensed or administered. This may lead to conflicting medicatieafspraken. This means that one or more medicatieafspraken must be discontinued in order to prevent the occurrence of parallel medicatieafspraken. The only exception for parallel medicatieafspraken is described in [[#Medicamenteuze behandeling|paragraph 1.3.3]].

===Single medication use( medicatiegebruik)===
For medication meant for single use, only an end date is included in the period of medication use. An example would be a vaccination (for example, a tetanus shot) or a situation in which a patient should take a medication just once, for example 3 weeks before he leaves on holiday.
 
[[Bestand:ENG_Voorschrijven_Eenmalig gebruik.png|800px]]
 

===Provisional and final medication order===
The prescriber at the clinic prescribes medication. This is recorded in a provisional medication order (the medicatieafspraak). The hospital pharmacist verifies this order and records it as a final medication order (the toedieningsafspraak). See also <ref name="MO"/>.

===Inadvertently ‘outstanding’ medication or 'orphans'===
In a transitional situation and in a situation where not every XIS is connected, medicatieafspraken for the same treatment may exist that have been created by different information systems under different medicamenteuze behandelings. These medicatieafspraken should ideally be combined in a single medicamenteuze behandeling. This particularly applies to medication with an open end date, as this medication may have been discontinued under a different medicamenteuze behandeling. The medicatieafspraak therefore remains open, resulting in continued medicatieverstrekking. This is a so-called ‘orphan’ (a building block that has been registered, but in which, at a certain point, the health professional no longer has an active role. However, his information system continues to provide the building block, even if it has already been discontinued elsewhere). For medication with an end date, this problem will solve itself. Therefore, it is not necessary to take any action. When medication verification or medication assessment reveals that the medication is inappropriately still ‘open’, a stop-MA is created under the same medicamenteuze behandeling. The original prescriber is actively informed about this stop-MA and enters an end date for the medicatieafspraak in his own information system. Depending on the supplier and the client’s wishes, setting this end date can be done automatically or through an intervention of the prescriber. See also [[#Discontinuation of medication by third parties|paragraph 4.1.26]] and [[#Modification of someone else's medicatieafspraak|paragraph 4.1.40]].
 
 
[[Bestand:ENG_Voorschrijven_Onterecht openstaande medicatie of weeskinderen.png|800px]]
 

===Missing digital medicatieafspraak at admission===
If no digital medicatieafspraak is available when medication verification is carried out, a new medicamenteuze behandeling is started by recording medicatiegebruik. When this medicatiegebruik has to be discontinued, a stop-medicatieafspraak is created under the same medicamenteuze behandeling that refers to the recorded medicatiegebruik. If possible, the original prescriber (for example, general practitioner) and the pharmacy are actively informed about the discontinuation of this medication.
 
[[Bestand:ENG_Voorschrijven_Ontbreken digitale medicatieafspraak bij opname.png|800px]]
 

===Own articles (90 million numbers)===
It is possible to exchange a 90 million number. The condition is that within an organization a 90 million number once created may never be modified. During the exchange, the root OID (unique technical identification of the organization) in combination with the 90 million number ensures that it is unique compared to all 90 million numbers form other organizations. The substances that make up this article are included as ingredients in the medicatieafspraak (at least one ingredient), as is the case with magistrals.

===Dosing with minimum interval ===
Medication can be prescribed at a fixed interval (for example: 2 tables every 6 hours). Prescribing medication with a minimum interval should be partly in free text. For example, if needed, a maximum of 3 times a day, a minimum of 6 hours between the intake moments: ''if needed, a maximum of 3 times a day'' is recorded in the standard way. The section “''at least 6 hours between intake times''” is recorded in free text as an Additional Instruction.
 
 [[Bestand:ENG_Voorschrijven_Dosering met minimum interval.png|800px]] 
 

===Verstrekkingsverzoek with number of repetitions ===
The prescriber makes a verstrekkingsverzoek with a medicatieafspraak in which she enters the number of repetitions. The prescriber hereby indicates to the provider that it may make additional provisions. The number of repetitions in combination with the quantity to be dispensed results in: (Number of repetitions + 1) X quantity to be dispensed. In case of “number of repetitions =3” and “quantity to be supplied = 30 pieces” the provider may provide 4 times 30 pieces (total 120 pieces). The number of repetitions in combination with the duration of medication usage period results in: (number of repetitions + 1) x duration of medication use. The amount to be dispensed depends on the dosage. In case of “dosage = 3 x per day 2 pieces”, and “Duration of medication usage period = 30 days” the provider may provide 180 pieces 4 times (6 pieces per day X 30 days = 180, 4 times = a total of 720 pieces).
 
 [[Bestand:ENG_Voorschrijven_Verstrekkingsverzoek met aantal herhalingen.png|800px]] 
 

===Prescribing non-medicines===
Non medicines can be prescribed from the G-standard at HPK level. For example, this could be an inhaler (Aerochamber, HPK 1915185) as an aid to prescribed aerosols. Non-medicinal products are not applicable for the medication overview or medication monitoring.

===Send renal function value in the prescription===

'''A) Renal function value with a new prescription:''' 
For the prevention of stroke, a patient (male, 65 years old) is prescribed Dabigatran for the first time. The patient has renal impairment and the prescriber has a recent renal function value available. Based on this renal function value, the prescriber deviates from the standard dose and makes a medicatieafspraak with a lower dosage of Dabigatran twice a day 1 capsule of 110 mg, starting from January 15, 2020. The prescriber also makes a verstrekkingsverzoek and sends the prescription (medicatieafspraak, verstrekkingsverzoek and the laboratory result of the renal function value) to the pharmacist.
 
[[Bestand:ENG_Voorschrijven_Nierfunctiewaarde sturen met het voorschrift_a.png|800px]] 

'''B) Renal function value reason for a change:''' 
A 70-year-old man was prescribed 1 tablet of metformin 500 mg 3 times a day a few days ago (medicatie afspraak and verstrekkingsverzoek). At the same time, the doctor initiated a blood test to determine the renal function value of the patient. The value was not yet known at the time of prescription.
 
[[Bestand:ENG_Voorschrijven_Nierfunctiewaarde sturen met het voorschrift_b1.png|800px]] 

The blood test shows that renal function is impaired and gives reason to adjust the medicatieafspraak. The prescriber adjusts the dose on January 17, 2020 to 2 tablets metformin 500 mg twice a day and discuss this with the patient. The new prescription (the 'technical' stop medicatieafspraak, new medicatieafsrpaak and the laboratory result of the renal function value) is sent to the pharmacy by the prescriber. Because the patient had already collected the medication and therefore has enough stock, no new verstrekkingsverzoek is sent along.
 
[[Bestand:ENG_Voorschrijven_Nierfunctiewaarde sturen met het voorschrift_b2.png|800px]] 

'''C) Renal function value due to drug:''' 
The patient is prescribed Nitrofurantoin 100 mg, 1 capsule twice daily as a 5-day course due to a bladder infection and must start immediately on January 6, 2020. With this drug, the renal function value (if known and not older than 13 months) needs to be sent along. The prescriber has a renal function value available for this patient, but this does not lead to an adjusted dosage. The prescriber sends the prescription (medicatieafspraak, verstrekkingsverzoek and the laboratory result of the renal function value) to the pharmacist.
 
[[Bestand:ENG_Voorschrijven_Nierfunctiewaarde sturen met het voorschrift_c.png|800px]] 
 

===Cancelling a prescription that was sent earlier ===
A patient visits the general practitioner (GP) one morning because of stomach complaints. The GP prescribes pantoprazole and sends the prescription (MA + VV1) to the preferred pharmacy as known to him. In the afternoon the patient calls the GP. He hasn’t picked up the prescription yet and he would like to pick it up at another pharmacy due to a recent move, but forgot to ask this morning. The GP resends the prescription to the old pharmacy, but the VV in the newly send prescription contains a canceled indicator (MA + VV1 “cancelled”), so the pharmacist knows he should not dispense on this prescription. The prescriber then sends a new prescription (MA + VV2) to the patient's new pharmacy. The patient can pick up the medication there. 
In medication building blocks it looks as follows: 
 [[Bestand:ENG_Voorschrijven_Annuleren eerder verstuurd voorschrift_a.png|800px]] 
 
The transactions look as follows: 
[[Bestand:ENG_Voorschrijven_Annuleren eerder verstuurd voorschrift_b.png]] 

===Modification of someone else's medicatieafspraak ===
A patient takes 40 mg Lisinopril once a day because of hypertension. This medicatieafspraak was previously made by the GP with the patient. The patient is admitted to the enters A&E department because of a fall due to dizziness. The specialist notices hypotension and decides to reduce the dose of Lisinopril to 20 mg once a day. The specialist then stops the current medicatieafspraak and starts the new medicatieafspraak with a lower dose. With this he changes the medicationafspraak with the patient. The specialist informs the original prescriber (the general practitioner) about this with a stop medicatieafspraak and the new medicatieafspraak.
The prescriber of the original medicatieafspraak adjusts the stop date in the original medicatieafspraak. If desired, this can also be automated by the information system. This prevents the second care provider no longer having to provide data over time because the delivery period has expired (including no stop MA) while the care provider of the original medication appointment continues to provide this incorrectly (without a stop date).
 
[[Bestand:ENG_Modification of someone else's medicatieafspraak.PNG|800px]]
 
===Setting up a variable dosing regimen (WDS) ===
The prescriber prescribes anticoagulants and states in the MA that the medication is used as recorded by the schedule of the thrombosis service (‘gebruik volgens schema trombosedienst). The prescriber sends a VV to the pharmacist and the patient is registered with the thrombosis service. In order to bridge the period until thrombosis care can take over, the prescriber creates a WDS for the first period. After registration, the thrombosis service creates a dosing regimen that overwrites or succeeds the previous regimen. From this moment on, the thrombosis service takes over creating the dosing regimen from the original prescriber.
[[Bestand:ENG_Uc_setting_up_WDS.png|800px]]

===Changing a variable dosing regimen (WDS) during period of use===
It could be necessary to revise the dosing regimen from a WDS before the scheduled stop date. For example, when the patient unexpectedly has to undergo minor surgery. In this case, the prescriber stops the current WDS with a technical stop (not visible to the user) and creates a new WDS with a few 0 doses the days before the procedure. In the meantime, the MA continues as usual.
[[Bestand:ENG_Uc_Changing_WDS.png|800px]]

===Stopping medication with a variable dosing regimen (WDS) ===
When the patient has to (temporarily) stop using anticoagulants completely, this is recorded at the level of the MA. The thrombosis physician creates a stop-MA. This also stops the underlying WDS and the associated TA. The original prescriber also processes the stop date in his MA.
If the anticoagulants needs to be restarted after several months, the original prescriber of the anticoagulant medication does this by following the process of starting a WDS. So by creating a new MA and a first WDS (see the use case [[#Setting up a variable dosing regimen (WDS)| Setting up a variable dosing regimen (WDS)]]). 
[[Bestand:ENG_Uc_stopping_WDS.png|800px]]

==Use case, Dispense==

===New medicatieafspraak, medicatieverstrekking of the same product===
The patient is at the pharmacist on 27 January 2013 to collect his medication. The pharmacist opens the file of the patient and verifies the medication file. It is a new medicatieafspraak for this patient. The relevant information of the prescribing physician is displayed on the screen of the pharmacist. 
Medicatieafspraak: ''Nitrofurantoin CR capsule, 100 mg, 1 capsule 2x daily, from now on for 5 days.'' 
Verstrekkingsverzoek: ''Nitrofurantoin CR capsule, 100 mg; 10 capsules.'' 
The pharmacist selects a product on the basis of the medicatieafspraak and other factors (such as the pharmacist’s stock and the preference policy of the healthcare insurer): 
''FURABID CR CAPSULE, 100 MG''. The pharmacist carries out medication monitoring using the information system, no (warning) signals are given. 
The pharmacist carries out pharmaceutical care (compliance, education, et cetera) and agrees with the patient on how she will use the medication. This toedieningsafspraak on 27 January 2013 reads: 
''FURABID CR CAPSULE, 100MG; 1 capsule 2x daily; from now on for 5 days''. The pharmacist provides the medication to the patient: 
''on 27 January 2013, FURABID CR CAPSULE, 100 MG; 10 capsules.'' The pharmacist actively informs the prescribing physician about the medicatieafspraak and the medicatieverstrekking. 
The information system of the pharmacist makes the new toedieningsafspraak and medicatieverstrekking available to the other health professionals of this patient.
 
 [[Bestand:ENG_Ter hand stellen_Nieuwe medicatieafspraak medicatieverstrekking zelfde product.png|800px]] 

===New medicatieafspraak, more precise product specification===
Here, the difference when specifying the product is that the toedieningsafpsraak and also the medicatieverstrekking deviates from the medicatieafspraak the patient has made with the prescribing physician. The process is otherwise the same as described in the previous paragraph.

'''Example''' 
''Medicatieafspraak: Nitrofurantoin capsule mga 100 mg, 1 capsule 2 times a day from today for 5 days.''

The pharmacist specifies a different product: 
''Nitrofurantoine MC Actavis capsule 50 mg.''
The pharmacist agrees with the patient on how she will use the medication. This toedieningsafspraak on 27 January 2013 reads: 
''Nitrofurantoin MC CR capsule 50 mg, 1 capsule 2x daily, from now on for 5 days.'' 
The pharmacist provides the medication to the patient: 
''on 27 January 2013, Nitrofurantoin MC Actavis capsule 50 mg; 20 pieces.''
 
 [[Bestand:ENG_Ter hand stellen_Nieuwe medicatieafspraak nadere specificering product.png|800px]] 

===Existing toedieningsafspraak is adequate===
The process of repeat medicatieverstrekking on the basis of an existing medicatieafspraak and possibly existing verstrekkingsverzoek and toedieningsafsrpaak occurs in case of repeat prescriptions and is described in [[#Splitting a prescription|paragraph 4.2.10]], situation 2.

===Medicatieafspraak wanted (informing the prescriber)===
'''Example 1 - adjusting dosage:''' 
For a 70-year-old patient with a creatinine clearance of 45 mL/min, the pharmacist enters a toedieningsafspraak for gabapentin tablets of 600 mg, 1 tablet 3x daily. Renal function has been recorded in the patient’s file at the pharmacy, and based on this a signal appears that the maximum dosage is 900 mg daily. The pharmacist sends the prescriber a proposed medicatieafspraak with an adjusted dosage of 300 mg, 3x daily, and the reason for this proposal (maximum dosage exceeded). The prescriber receives the proposed medicatieafspraak in his EVS. The prescriber sends an adjusted medicatieafspraak and possibly a reply proposed medication agreement (antwoord voorstel medicatieafspraak) back to the pharmacist.
 
 [[Bestand:ENG_Ter hand stellen_Medicatieafspraak gewenst - informeren voorschrijver_a.png|800px]] 
 
'''Example 2 – temporarily halting a medicinal product:''' 
For a 50-year-old patient with on oral fluconazole as part of his current medication, the pharmacist enters a toedieningsafspraak for simvastatin. A message appears with the advice to consider temporarily halting simvastatin. The pharmacist can make a proposed medicatieafspraak for halting the simvastatin (stoptype ‘temporary’). See example 1 for further steps.
 
 [[Bestand:ENG_Ter hand stellen_Medicatieafspraak gewenst - informeren voorschrijver_b.png|800px]] 
 
'''Example 3 – adding a medicinal product:''' 
For a 55-year-old woman, the pharmacist enters a toedieningsafspraak for prednisone, 10 mg daily for three months. The patient is not using osteoporosis prophylaxis. A message appears with the advice to add a biphosphonate drug and to check whether the patient is taking calcium and vitamin D. If the patient is not, the pharmacist can make a proposed medicatieafspraak for these products. See example 1 for further steps.
 
 [[Bestand:ENG_Ter hand stellen_Medicatieafspraak gewenst - informeren voorschrijver_c.png|800px]] 
 
PLEASE NOTE: it will depend on the situation whether it is useful to create an automated proposal for adjustment/addition of a MA. If the advice is complex, it may still be useful to phone and to consult instead of sending a digital proposal. 
The proposed medicatieafspraak may help the prescriber to enter this change in the system. The latter is important when medicatieafspraken are consulted, for example, by service observation general practitioners.

===Request and dispense ===
When a medicatieafspraak and verstrekkingsverzoek arrives at the pharmacy, it is processed by the pharmacy information system as an intended medicatieverstrekking. This is called the request date, which is captured as the request date of the medication dispensing The date of dispensing is only registered at the moment of pick up or hand over of the medication. The pharmacist informs the prescriber about the handling of the prescription (toedieningsafspraak and/or medicatieverstrekking).

It is possible to create multiple dispensings under the same toedieningsafpsraak:
*A verstrekkingsverzoek comes in with a medicatieafspraak with a one-year use period
*There will be a first provision with a new toedieningsafspraak and a medication supply that is sufficient for, for example, a period of 4 months.
 [[Bestand:ENG_Ter hand stellen_Aanschrijven en verstrekken_a.png|800px]] 

*The second dispensing is performed based on the existing medicatieafpsraak, verstrekkingsverzoek and toedieningsafspraak (no new prescription or new administration appointment is needed). The new second medication dispensing (with new write-up date and the pre-existing associated toedieningsafspraak) is sent to the prescriber when the dispensing date is registered.
 [[Bestand:ENG_Ter hand stellen_Aanschrijven en verstrekken_b.png|800px]] 

===Patient requests repeat prescription via physician (reactive repeat)===
A physician has previously diagnosed hypertension in a patient (57 years old) and has prescribed the patient medication for this. The patient uses this medication and the medication is running out. The patient makes a request to repeat the medication, for example through the repeat line, by phone, by email to the practice, counter/boxes, website, app or portal of the physician. The physician approves the repeat. This leads to a new verstrekkingsverzoek. 
For example:
The general practitioner makes, in the context of the medicatieafspraak of 30 March 2010:
:''Nifedipine CR 30 mg; 1 tablet 1x daily, from 30 March 2010 for an indefinite period''
on 13 April 2013 a verstrekkingsverzoek to a pharmacist chosen by the patient:
:''Nifedipine, CR tablet, 30 mg; ‘for three months’.''
In consultation with the patient, the prescriber can send the verstrekkingsverzoek with the corresponding medicatieafspraken and toedieningsafspraken as an order to a pharmacy of the patient’s choice. The prescriber also makes the new verstrekkingsverzoek available to fellow health professionals and the patient. The existing medicatieafspraken had already been made available. 
 [[Bestand:ENG_Ter hand stellen_Patiënt vraagt herhaalrecept via arts - reactief herhalen.png|800px]] 
The pharmacist receives the verstrekkingsverzoek together with the medicatieafspraak and processes it in accordance with the dispense process and starts with the pharmaceutical care process step.

When the patient, on the basis of a toedieningsafspraak or on the basis of his medicatiegebruik asks for a repeat prescription, and the medicatieafspraak is not digitally available, the physician creates a new medicatieafspraak based on this toedieningsafspraak or the patient’s medicatiegebruik of the medication. No reference is made to the existing medicatieafspraak in that case.

===Patient requests repeat prescription via pharmacist (informing prescriber)===
The patient requests a repeat medication from the pharmacist, for example through repeat line, by phone, email, counter/boxes, website, app or portal of the pharmacist. 
The pharmacist sends a proposed verstrekkingsverzoek for authorisation to the prescriber. The physician evaluates the proposed verstrekkingsverzoek and approves it. He informs the pharmacist via the reply proposed verstrekkingsverzoek and sends a new verstrekkingsverzoek together with the current agreements to the pharmacist. The pharmacist continues the dispense process and starts with the pharmaceutical care process step. 
Patiënt vraagt herhaalrecept via arts (reactief herhalen)
 [[Bestand:ENG_Ter hand stellen_Patiënt vraagt herhaalrecept via apotheker - informeren voorschrijver.png|800px]] 
 
If the prescriber does not provide a verstrekkingsverzoek, he informs the pharmacist via the answer proposed verstrekkingsverzoek.

===Proactive repeat prescription by pharmacist (informing prescriber)===
The patient has signed up in the past for proactive repeats and the pharmacist has registered this in his proprietary pharmacist information system (PIS). The repeat module of this information system will generate a signal when a patient needs new medication. When a new verstrekkingsverzoek is needed, this is similar to the process described in the previous paragraph, only the trigger is not the patient but the pharmacist (or his information system). Proactive repeats are also used for GDS, see [[#Starting and continuing a GDS|paragraph 4.2.11]].
 [[Bestand:ENG_Ter hand stellen_Proactief herhaalrecept door apotheker - informeren voorschrijver.png|800px]] 
 

===Dispense based on an existing verstrekkingsverzoek===
The patient submits a repeat prescription to the pharmacist. In this case, it is a request for medicatieverstrekking on the basis of an existing, still valid, verstrekkingsverzoek. See [[#Splitting a prescription|paragraph 4.2.10]] situation (3).

===Splitting a prescription===
The patient has been using the same medication for a number of years, which means that the medicatieafspraak can be created for an indefinite period. The toedieningsafspraak is also valid for an indefinite period. In such a case, the patient can be given a prescription for a year. This single year prescription will be split into several prescriptions by the pharmacist. These split prescriptions are commonly called ‘repeat prescriptions’, even though strictly speaking this is not true.

There are three possible situations: 
1) The patient returns to his attending physician still suffering from the same symptoms. The prescriber prescribes the same medication (in the case of an expired medicatieafspraak, a new medicatieafspraak is created with a new verstrekkingsverzoek and in the case of a medicatieafspraak that is still valid, only a new verstrekkingsverzoek is created). 
 [[Bestand:ENG_Ter hand stellen_Knippen van recept_a.png|800px]] 
 
2) Prescriber and patient initially agree on 90 tablets with 3 repeat prescriptions. The patient receives the first 90 tablets. The next time the patient visits the pharmacist, a medicatieverstrekking is made under the existing agreements. 
 [[Bestand:ENG_Ter hand stellen_Knippen van recept_b.png|800px]] 
 
3) Prescriber and patient initially agree on 360 tablets for one year. The pharmacist splits this into 4 separate occasions of medicatieverstrekking. The patient is initially dispensed 90 tablets and without a new verstrekkingsverzoek, can go to the pharmacist 3 more times to pick up another 90 tablets each time. 
Situation 3 best describes the way in which a pharmacist splits a year prescription. 
 [[Bestand:ENG_Ter hand stellen_Knippen van recept_c.png|800px]] 
 

===Starting and continuing a GDS===
The following example shows the process for one medicinal product used by the patient for an indefinite period of time. The information system of the prescriber and the pharmacist contains (among other things) the following data on a patient:
*The medicatieafspraak of 2 January 2013 reads: Metoprolol, CR tablet, 100 mg (succinate); 1x tablet daily; from 2 January 2013 for an indefinite period.
*The toedieningsafspraak of 2 January 2013 reads: Metoprolol PCH retard, 100 CR tablets of 95 mg; 1x tablet 1x daily; from 2 January 2013 for an indefinite period.
This elderly patient is taking so much medication that he has problems overseeing it all: a potentially dangerous situation. On 6 February, the pharmacist and the prescriber agree that the medicatieverstrekking of medicinal products to this patient will take place via GDS.

The GDS is started: the pharmacist sends a proposed verstrekkingsverzoek (a similar event to the current combined prescription or authorisation form).

The proposed verstrekkingsverzoek of 6 February reads:
*Verstrekkingsverzoek for the medicatieafspraak of 2 January 2013: Metoprolol, CR tablet, 100 mg (succinate), and a period of use to ensure enough stock up to and including 1 May 2013.
The pharmacist sends the proposal to the prescriber. The prescriber approves the proposal on February 6 and sends it unchanged to the pharmacist as a verstrekkingsverzoek. The GDS indicator is switched on in the information system of the prescriber as well as in the pharmacist’s information system.

The pharmacist and the patient select a partial duration for the product. This toedieningsafspraak reads as follows:
*On 7 February it was agreed: Metoprolol PCH retard, 100 CR tablets of 95 mg, 1 tablet in the morning, from 11 February (week 6), for an indefinite period.

Every second week, the pharmacist dispenses a Baxter medication roll containing (among other things) the metoprolol:
*Medicatieverstrekking 1: The pharmacist dispenses, on Friday, 8 February 2013: 14 tablets, scheduled for weeks 6 and 7 (a period of use of 2 weeks).
*Medicatieverstrekking 2: The pharmacist dispenses, on Friday, 22 February: 14 tablets, scheduled for weeks 8 and 9.
*Medicatieverstrekking 3, 4, 5, etc.
With each medicatieverstrekking, it is indicated that medicatieverstrekking was carried out via GDS.
After three months, there is a new proposed verstrekkingsverzoek from the pharmacy to the prescriber, etc.
 
 [[Bestand:ENG_Ter hand stellen_Het opstarten en continueren van GDS.png|800px]] 
'''Consideration ''' 
*The application of a proposed verstrekkingsverzoek instead of an authorisation form makes its meaning unambiguous.
*In the current situation, toedieningsafspraken and medicatieverstrekkingen are registered as a single dispense. This makes it difficult to find useful information in the large number of messages. By dividing the dispense order into two building blocks, the overview is easier to understand: there are no new medicatieafspraken and only one new toedieningsafpsraak is created. There are no hidden surprises in the remaining logistical data and the prescriber does not have to monitor the multiple medicatieverstrekkingen.
*This way of registering and exchanging prevents double registration, and errors caused by this.
*The toedieningsafspraken are the basis for the administration list and checklists of nursing homes and care homes. Signing them corresponds to the administration(s).

===The pharmacist changes commercial product===
This scenario builds on the previous scenario: after half a year a different commercial product is agreed with the patient (toedieningsafspraak), because the original product is not available. No new medicatieafspraak is made, as there is no change needed on that level. The toedieningsafspraak is changed:
*On 1 July it was agreed: Metoprolol Sandoz ret, 100 CR tablets, 95 mg, 1 tablet in the morning; from 3 July, for an indefinite period. Reason: not available.
The toedieningsafspraak is a modification of the toedieningsafspraak of 7 February, which stops on 2 July (11:59 p.m.) and is an actual handling of the medicatieafspraak of 2 January. The pharmacist informs the general practitioner about this. 
 [[Bestand:ENG_Ter hand stellen_De apotheker wijzigt van handelsproduct.png|800px]] 
'''Consideration ''' 
This change in the actual handling of the medicatieafspraak using a toedieningsafspraak, changes nothing to the validity of the medicatieafspraak itself, improving the overall view for all parties. In addition, since the pharmacist records and communicates the reason for the adjustment, the prescriber is better able to assess whether the information is relevant.
 

===Adding medication to a GDS===
When new medication is added to an existing GDS, the prescriber may opt for immediate addition to the current roll (Change in GDS immediately) or for addition starting from the next roll (Change in GDS per change of roll). The prescriber indicates this in the medicatieafspraak (Additional information).

If ‘Change in GDS immediately’ is chosen, the pharmacist will first dispense the medication separately, in addition to the existing GDS. This means that a toedieningsafspraak is created by the pharmacist for the bridging period. Starting with the new roll, the new medication is added to the roll. Starting with the start date of the new roll, a toedieningsafspraak can be made by the pharmacists with specific administration times. If the ‘bridging-toedieningsafspraak’ already includes the correct administration times, no new toedieningsafspraak is created at the date of inclusion in the roll. 
 [[Bestand:ENG_Ter hand stellen_Medicatie toevoegen aan GDS.png|800px]] 
 
If 'Change in GDS per change of roll' is chosen, the pharmacist will start to include the medication in the roll on the start date of the first new roll. In this case, a toedieningsafspraak for the bridging period is not required.

===Discontinuing medication in a GDS===
When medication is discontinued, the prescriber creates a discontinuation-medicatieafspraak. In accordance with the process, the pharmacist is informed about this stop-MA and can adjust the medicatieverstrekking accordingly. The pharmacist will create a staken toedieningsafspraak . See [[#Discontinuing medication|paragraphs 2.2.5.3]] and [[#Discontinuing a toedieningsafspraak|2.3.6.3]].

===GDS supplier supplies other commercial product===
It is possible that a GDS supplier delivers a different commercial product than that which is included in the toedieningsafspraak by the pharmacy. This is therefore a change in the HPK which results in a changed toedieningsafpsraak. This may only be afterwards, after feedback from the GDS supplier of the filling details.
 
 [[Bestand:ENG_Ter hand stellen_GDS leverancier levert ander handelsproduct.png|800px]] 

===Parallel administration agreements with GDS- and non-GDS-dispense===
A patient takes two to three times daily 20 mg pantoprazole because of gastric complaints. The first two tablets are fixed dosages, which are dispensed in GDS. The third tablet, which is prescribed as needed, is dispensed separately. At a certain moment, Sandoz is unable to supply the pantoprazole 20 mg for separate dispenses. Therefore, the pharmacist decides to dispense from Apotex. He stops the current TA and splits the TA in two TA’s, both with the same start date/time. The first TA concerns the fixed dosage in GDS, the second TA involves the as needed tablet. 
''NB. Currently, there is no relationship between medication dispense and TA. Therefore, it is only possible to retrieve which TA is associated with the medication dispense by assessment of the data content. It is evaluated whether the functional design should be adjusted for this use case in the future. 
''
 
[[Bestand:ENG-Uc4.2.16.png|800px]]
 

===Handling a stop medicatieafspraak===
When the prescriber agrees to discontinue medication, a stop medicatieafspraak is created. This stop-MA this processed by the pharmacist by discontinuing the corresponding toedieningsafspraak.

===Medication dispense with someone else’s administration agreement===
A patient takes two times daily 20 mg pantoprazole because of gastric complaints. During the holidays the patient notices that he has forgotten to bring his medication. He visits the after hours general practice clinic and asks for extra tablets for during his holidays. The after hours physician sends a VV to the after hours pharmacy, using an existing MA. 
The after hours pharmacist reads the medication prescription and creates an MVE, using the existing TA, for the ten tablets that the patient needs. The pharmacist notifies the after hours physician about the medication dispense, and sends a copy of the original TA. 
''NB. Although the original prescriber and supplier do not receive an automatic notification, the data will be made available to them.'' 
 
[[Bestand:ENG-Uc4.2.18.png|800px]]
 

===Modification of someone else’s administration agreement===
A patient takes two times daily 20 mg pantoprazole because of gastric complaints. During the holidays the patient notices that he has forgotten to bring his medication. He visits the after hours general practice clinic and asks for extra tablets for during his holidays. The after hours physician sends a VV to the after hours pharmacy, using an existing MA. 
The after hours pharmacist notices that they have no pantoprazole from Sandoz in stock, but they do have pantoprazole from Apotex. Therefore, she stops the current TA, starts a new TA for the Apotex, and creates an MVE for the ten tablets from Apotex. The after hours pharmacist notifies the original pharmacist and, subsequently, the original pharmacist processes the stop-TA. 
 
[[Bestand:ENG-Uc4.2.19.png|800px]]
 

==Use cases, Administer ==

===Creating an administration list===
When an administration list has to be created, for example when a patient starts to receive medication administered by a (professional) administrator, or when GDS medication or non-GDS medication is started, an intake is planned with the patient and the prescriber, pharmacist or administrator (the exact process may differ across institutions). Then, the prescriber, pharmacist, administrator and/or the patient consult on the administration list (which medication is recorded on the administration list, which (guide) administration times are suitable). The pharmacist enters the (guide) administration times in the TA and (actively) makes the relevant medication data available for the administrator and/or the patient.

===Exact administration times required===
When exact administration times are required, for example because of medication interactions, the prescriber or the pharmacist can indicate that an exact administration time is required (the administration time is not a guideline but denotes an exact time). The prescriber or pharmacist can register an exact administration time by indicating that the administration time is not flexible. By default, administration times are flexible. Exact administration times should be presented on the administration list, to ensure that the administrator is informed that it is not allowed to deviate from the entered administration time.

===Missing (guide) administration times===
When (guide) administration times are missing in the MA and TA, an administrator will contact the prescriber or pharmacist to retrieve the (guide) administration time. This is not supported digitally in this information standard.

===Non-GDS medication as needed===
Non-GDS medication as needed is included in the administration list, but is not listed according to the administration moment and/or administration time, because this information is not available beforehand. If relevant (for example because of drug interactions), (guide) administration times can be entered. See the following use cases for practical examples: [[#Medication as needed|4.1.4 Medication as needed]], [[#Course of treatment as needed starting in future|4.1.5 Course of treatment as needed starting in future]], [[#Two dosages of the same medication at the same time|4.1.6 Two dosages of the same medication at the same time]], [[#The same medicinal product with different strengths at the same time|4.1.7 The same medicinal product with different strengths at the same time]].

===Medication supply by multiple pharmacies===
Multiple pharmacies may be involved in the medication supply for one patient, for example in the following situations: medication supply by an outpatient pharmacy, in addition to supplies by a community pharmacy or supplies of add-on medication by a hospital pharmacy. In the case of medication supply by multiple pharmacies, each pharmacist is responsible for the medication data that is required for the administration list, including the (guide) administration times in the TA. It is the responsibility of the prescriber or pharmacist who has made the most recent medication adjustments to determine whether an addition/modification is appropriate with regard to the total of (known) medication data; this concerns both medication monitoring and (guide) administration times. The medication data is (actively) made available, in order to enable that all medication data from different pharmacies are compiled in one administration list.

===Change in GDS from the next supply or immediately===
If GDS medication is altered, it depends on the situation whether this change should occur immediately or from the next supply. The prescriber can indicate in the MA when the change in GDS medication should be implemented. An immediate modification should be immediately shown on the administration list, to ensure that the (professional) administrator administers the correct (amount of) medication. In contrast, a modification that should be implemented from the next supply, should not be processed immediately in the administration list, since previous agreements remain valid until the next supply. Thus, the administration list should not be modified until the change in GDS modification has become effective.

See also use case [[#Adding medication to a GDS|4.2.13 Adding medication to a GDS]].

===Increasing dosage of GDS in new MBH===
A patient is administered 1 tablet propranolol 40 mg 1 time a day. Due to insufficient effects, the prescriber decides to increase the dosage to 80 mg 1 time a day. A new MBH is created for this MA, as there is a change on prescription level. However, the patient still has the 40 mg tablets in the GDS medication roll for the coming days. Therefore, the pharmacists decides to supplement the GDS medication with the administration of 1 tablet propranolol 40 mg, separately from the GDS package, in addition to the tablet in the GDS package, until the next GDS medication roll change in 5 days. The pharmacists creates two TAs: one for the previous GDS medication and one for tiding over the period with medication dispense separately from GDS. In the new GDS supply (medication roll change), the 80 mg tablets are incorporated in this new GDS package. 
 [[Bestand:ENG_Toedienen_Verhogen dosering GDS-medicatie in nieuwe MBH_beta.png|800px]] 

===Decreasing dosage of GDS in new MBH===
A patient is administered 1 tablet propranolol 80 mg 1 time a day. Due to a too strong effect, the prescriber decides to reduce the dosage to 40 mg 1 time a day. A new MBH is created for this MA. The patient still has 80 mg tablets in the GDS medication roll for several days. Because the administrator is not allowed to divide the tablets into halves, the supplier decides that the remaining GDS packages should be collected the same day and be replaced by a new GDS medication roll with 40 mg tablets. 
 [[Bestand:ENG_Toedienen_Verlagen dosering GDS in nieuwe MBH_beta.png|800px]] 
 

===Change processed by the pharmacist===
A change by the prescriber, such as starting new medication, adjusting the dosage, (temporarily) halting medication, is recorded by the prescriber in the MA and/or the VV. Then, the pharmacists processes this change in the TA and/or the MVE. This may be done during the opening hours of the community pharmacist, or after hours when a medication dispense is needed. The after-hours pharmacist dispenses the medication; in this case, multiple pharmacists are supplying medication (see also paragraph 4.3.9). The medication data of the pharmacist(s) and the prescriber(s) are (actively) made available by the prescriber and the after-hours pharmacist to the administrator for the administration list.

===Change not processed by the pharmacist===
When medication is changed by a prescriber after the opening hours of the community pharmacist and medication dispense is not needed, no pharmacist is involved. In that case, the MA is decisive, and the prescriber (actively) makes the MA available. The administrator will be informed of the changed or stopped MA by the administration list; this MA overrules all medication building blocks within the same MBH. This situation also applies if the pharmacist has not processed the modification by the prescriber yet. The pharmacist is responsible for adjusting the TA as soon as possible.

===Variable-dosing regimen===
If a physician prescribes medication with a variable-dosing regimen, the dosing schedule of this medication may be specified by another physician. For example, this applies to thrombosis medication: the prescriber defines the therapeutic INR range (International Normalized Ratio, a measure for the coagulation time of blood), but refers the patient to the thrombosis service for defining the exact dosing schedule. The ‘trombosearts’ (physician affiliated to the thrombosis clinic, who is specialized in the management of anticoagulation therapy) enters the variable-dosing regimen in the medication building block WDS. The prescribing physician remains responsible for the supplies, the ‘trombosearts’ specifies the dosing regimen based on the therapeutic INR range. As the WDS is a separate medication building block, the medication overview remains unchanged (the MA is specified, not altered by the WDS). The WDS is used to compile the administration list, together with the medication data in the MA, TA, MVE and MTD.

===Changing a variable-dosing regimen===
If a dosing schedule is adjusted, the information system closes the current WDS, using a technical stop (not visible to the user). This new WDS is related to the MA and the previous WDS.

===Stop of medication with variable-dosing regimen===
Anticoagulation medication may be (temporality) halted for several reasons; for example, in the case of a medical procedure. Depending on the situation and based on professional judgment, the ‘trombosearts’ can choose one of the following two methods: 

'''A. (temporarily) adjusting the medication regimen''' 
In certain situations, the ‘trombosearts’ may choose to temporarily set the anticoagulation medication to zero, for example, in the period before the planned medical procedure. The MA (and, therefore, the treatment with anticoagulation medication) continues, but in the WDS, the dosage is temporarily adjusted to zero. In such situations, it is advisable to exchange the reason for the WDS change as well. 
 [[Bestand:ENG_Toedienen_Stoppen medicatie met wisselend doseerschema_a_beta.png|800px]] 
'''B. (temporarily) halting the anticoagulation medication''' 
Alternatively, the ‘trombosearts’ may choose to (temporarily) halt the anticoagulation medication. In this case, the ‘trombosearts’ creates a stop-MA. This implies that the underlying WDS and the related TA are stopped as well. If the MA should be restarted or adjusted after a certain period, this is done by the initial prescriber of the anticoagulation medication. In general, the thrombosis service may not be involved any more (temporarily); however, if the thrombosis service is still involved, the ‘trombosearts’ may send a VMA to the initial prescriber who can adopt this proposal in an MA. 
 [[Bestand:ENG_Toedienen_Stoppen medicatie met wisselend doseerschema_b_beta.png|800px]] 
 

===Additional information===
Additional information is an extra explanation about the medication use for the (professional) administrator and/or the patient. An example is the situation when fentanyl patch therapy is stopped; additional information is that the patch has to be removed. Another example is the dosing of half a tablet; the additional information contains the instruction what should be done with the other half. This information can be entered as free text, as a comment in the MA, TA and/or WDS.

See use case [[#Explanation in medicatieafspraak with deliberately chosen special characteristic|4.1.8 Explanation in medicatieafspraak with deliberately chosen special characteristic]] for more information.

===Medication administration deviates from administration list===
It may happen that the administration deviates from the instructions as entered by the prescriber and pharmacist in the MA or TA. This may be a deviation in administration time, administered amount, administration route, administration speed, administered product or no administration. A (professional) administrator can deviate from the rules, in consultation with the prescriber, for valid reasons, and under the condition of safe medical practice and safe working practice. The reason for deviation can be entered in the MTD.

===Medication administration without medication agreement and administration agreement===
In the case of an emergency, the MA and TA may be missing and, therefore, the (professional) administrator has to administer medication on the basis of an MA which is communicated verbally/by telephone. This medication is not incorporated in the administration list. In this situation, the (professional) administrator records the MTD in the information system of the administrator (including ECD, TDR). This is the first building block in a new pharmaceutical treatment; therefore, the administrator creates an MBH.

===Medication administration of self-care medication===
According to the safety principles in the medication chain, the administrator is not concerned with the administration of self-care medication, except for prescribed selfcare medication (a prescriber has created an MA). In that case, the self-care medication is listed on the administration list as GDS medication or non-GDS medication (as needed).

===Correction/cancellation of an administration===
This concerns correcting or cancelling an MTD, because an administrator has made a mistake in the registration and no medication has been administered. If the MTD has not been exchanged with other health professionals, the administrator can adjust the MTD by himself, or remove (cancel) the registration from his own information system. If the MTD has been exchanged with other health professionals, the administrator cancels this erroneous MTD and creates a new MTD under the same MBH with the correct information. The administrator (actively) makes the corrected MTD and the new MTD available.

===Medication administration on hold===
It may happen that the medication administration was unsuccessful, but that is still possible to administer the medication on a later moment, in consultation with a prescriber or pharmacist. If the medication administration is in keeping with the agreements on flexible administration times, the administrator is allowed to deviate from the (guide) administration time.

An example of suspending the medication administration:
* Medication administration is unsuccessful, but the medication can be administered on a later (or, in some cases, earlier) moment of the day. In this situation, the medication administration is suspended, and there is a deviation from the administration list.

===Medication administration by a prescriber===
A prescriber, similarly to a (professional) administrator, is able to administer medication to a patient, and record this procedure in an MTD.

===Multiple administration organizations===
Multiple administration organizations may be involved in a patient’s medication administration. For example, medication may be administered by another organization during the evening/night than during the day. If multiple administration organizations are involved in providing patient care, these health professionals can consult each other’s MTDs to track the process of medication administration. The acts of one organization can affect the process of another organization (for example, has medication been administered, have there been deviations from the administration list, etc.).

===Feedback to patient through a medication adherence app===
In this example the patient uses an app on his mobile phone to help manage his medication. The patient or the pharmacist has created an administration schedule with reminder times (where possible using the app to obtain the toedieningsafspraken from the medicatietoediening). When it is time to take his medication, the patient receives a reminder signal from the app. The patient registers the medication administration and thus indicates whether he has taken the medicine or not (for instance because he forgot to bring it along with him). If the app is linked, for example, to the patient’s PGO (personal health file), medication adherence is tracked automatically.
 
[[Bestand:ENG_Feedback_to_patient_through_a_medication_adherence_app.PNG|800px]] 
 


==Use cases, Medicatiegebruik==

===Self-care product===
A patient has acquired Ibuprofen from the drugstore and takes 1200 mg every day. The patient enters this product as gebruik, with such data as starting dates and dosage, and possibly the reason for medicatiegebruik.
 [[Bestand:ENG_Gebruik_Zelfzorgmiddel.png|800px]] 

===Medication from abroad===
A patient has been prescribed medication on holiday and is taking this. The patient enters the medication as gebruik, with data such as start date and dosage, and possibly the reason for medicatiegebruik. If known, the name of the prescriber is also recorded.
 [[Bestand:ENG_Gebruik_Medicatie uit buitenland.png|800px]] 

===Modification on the patient’s initiative===
The patient has been prescribed propranolol. The patient is having severe problems sleeping because of this and has reduced the medication herself. The patient records gebruik with the modified dosage and the start date for this lower dose. The patient also indicates that she initiated this change herself. In the case where a patient initiates a dose reduction, the patient can keep on using the medication for a longer period than initially agreed because she still has a supply. The patient can indicate this as additional gebruik. 
In the case where a patients initiates a dosage increase, the patient’s supply may run out sooner. The patient may then have to return to the physician earlier than expected.
 [[Bestand:ENG_Gebruik_Wijziging op initatief patiënt.png|800px]] 

===Discontinuation of medication on the patient’s initiative===
Since he started using propranolol, the patient suffers from insomnia. He decides to stop without immediately informing the prescribing physician. The patient himself records that he has discontinued medication, indicating the date and giving insomnia as the reason for discontinuing. 
[[Bestand:ENG_Gebruik_Stoppen medicatie op initatief patiënt.png|800px]] 

===No more supply===
A patient has received medication ‘as needed’ for his skin problems. The medication is still active in the medication profile, but is no longer available at the pharmacist. The patient indicates that the medication has been discontinued because it is no longer available, possibly with the addition that the symptoms have disappeared.
 
[[Bestand:ENG_Gebruik_Geen voorraad meer_a.png|800px]] 
 
The patient may also make a proposed verstrekkingsverzoek to replenish his supply In this case, the reply proposed verstrekkingsverzoek comes back to the patient (and if approved, a verstrekkingsverzoek is also sent from the prescriber to the pharmacist). 
[[Bestand:ENG_Gebruik_Geen voorraad meer_b.png|800px]] 

===Registrations of abnormal medicatiegebruik by patient due to adverse drug reactions===
Since he started taking propranolol, a patient has been suffering from insomnia. The patient records this side effect in the explanatory notes to the medicatiegebruik. When the patient changes the medicatiegebruik of this medication from what was previously agreed, for example when he takes less tablets, he can give the side effect as a reason for this change. When his symptoms diminish or cease, the patient records this in the explanation for medicatiegebruik. 
It is possible that the patient is suffering from side effects without exactly knowing which medicinal products cause them. There is no provision within medication process to record this (yet).

===Register medicatiegebruik based on provision===
This applies in the transition period from the old medication process standard 6.12 to this medication process information standard.

Only verstrekking (dispensing) is available digitally (according to medication process version 6.12). However, the user's information system offers the possibility to record all medicatiegebruik. In that case, the medicatiegebruik can be recorded with reference to the ID of the version 6.12 verstrekking.
 
[[Bestand:ENG_Gebruik_Gebruik registreren op basis van verstrekking.png|800px]] 

=Medication overview and inference rules=
This chapter shows a sample medication overview and also specifies inference rules for 'The most current relevant building block', Verification for each medicamenteuze behandeling, etc.

==Introduction==
The term 'current medication overview' has been replaced by the term 'basisset medicatiegegevens’ (basic set of medication data): the medication overview in combination with additional information that is required (at least) to be able to prescribe, change, stop or safely provide medication in a safe and responsible manner in the Transfer of Medication Data in the Chain (Leidraad Overdracht van Medicatiegegevens in de keten, final draft 2017).

This page contains an example of a medication overview. This example was developed in the Medication Process Information Standard program and serves as an example of how data can be displayed in an application. The data numbered in the pictures below are normative, they are mandatory to show. The other (unnumbered) data in the example is optional and may be added as normative in the future. The layout of the overview in a information system can differ per target group and per device. For pharmacists, for example, only toedieningsafspraken are initially visible, after which it is possible to click further to get to the corresponding medicatieafspraak and the medicatiegebruik. If only medicatiegebruik or a medicatieafspraak is known, this will of course be shown immediately. The basic principle is that the overview shows all medication of the patient, not just the medication that is registered in the patient's own information system.

The overview is described generically and therefore the same for all suppliers. The requirements of the end users are included on this page and no statements are made about the technical realization or implementation. The existing KNMP specification “User requirements specification Medication overview 2.0”, final concept “Guidance Transfer of Medication data in the chain (Leidraad OVerdracht van Medicatiegegevens in de keten)” and the new insights from the Medication process program have been incorporated in this.

Principles for the overview are:
*Health professionals want to see a distinction between the therapeutic building blocks on a medication overview:
**Medicatieafspraak
**Toedieningsafpsraak
**Medicatiegebruik
*Logistical building blocks (verstrekkingsverzoek, dispensing) and the medicatietoedieningbuilding block are not relevant for the medication overview.

[[Bestand:Medicatieoverzicht_1_v0.5.PNG|Medicatieoverzicht v0.5]]
[[Bestand:Medicatieoverzicht_2_v0.5.PNG|Medicatieoverzicht v0.5]]

==Functional specification==
In the figures below the parts with normative data are included. The other parts are not yet normative. The numbered elements in the table are normative, other elements are optional for the time being.

===Heading and General===
[[Bestand:Medicatieoverzicht_KopAlgemeen_v0.5.PNG]]

Filter: N/A

Sort: N/A

Medication Overview Date: This is the date that the last change to a medicatieafspraak, toedieningsafspraak or medicatiegebruik was recorded within the information system providing the medication overview.

NOTE: In the viewer, all dates are shown with the month in characters, so that there is no confusion between day-month and month-day (American format).

{| class="wikitable"
|-
! No !! Header !! Dataset !! Explanation
|-
| 1 || Name || Patient – Name data (Initials, Surname, PartnerSurname), Date of Birth, Gender ||
|-
| 2 || Telephone || Patient – Contact data – Telephone numbers || Primary telephone number of patient
|-
| 3 || BSN || Patient – Patient identification number || Always BSN
|-
| 4 || Adress || Patient – Address data ||
|-
| 5 || Healthcare Provider Name || Healthcare Provider – Organization name || Healthcare Provider who has compiled the medication overview
|-
| 6 || Healthcare Provider Adress || Healthcare Provider – Address – Address data || Healthcare Provider who has compiled the medication overview
|-
| 7 || Healthcare Provider Telephone || Healthcare Provider – TelephoneMail – Contact data – Telephone numbers || Healthcare Provider who has compiled the medication overview
|-
| 8 || Healthcare Provider Email || Healthcare Provider – TelephoneMail – Contact data – Email addresses || Healthcare Provider who has compiled the medication overview
|-
| 9 || Date of Medication Overview || Document data – Document date ||
|-
| || Height|| Body height – HeightValue, HeightDateTime ||
|-
| || Weight|| Bodyweight – WeightValue, WeightDateTime ||
|-
| || Checked by Health professional || Document data – Verification by health professional ||
|-
| || Verified with Patient/Informal Caregiver || Document data – Verification by patient ||
|}
Elements 5 through 8 are not shown if the patient is the creator of the medication summary.

===Contraindications and hypersensitivities (CiO)===
[[Bestand:Medicatieoverzicht_ICA_v0.5.PNG]]

Active contraindications and hypersensitivities (intolerances, allergies/adverse reactions) (in Dutch: 'contraindicaties en overgevoeligheden' - CiO).

Filter: end date is not filled, is in the future or was less than a year ago when compiling the overview.

Sort: most recent effective date at the top.

This part will be elaborated at a later time and is not yet normative.

===Current medication===
[[Bestand:Medicatieoverzicht_HuidigeMedicatie_v0.5.PNG]]

Filter: all current medication, i.e. all medicatieafspraken and toedieningsafspraken that apply at the time the overview is compiled and the associated medicatiegebruik per source. The temporarily interrupted medication is also shown in this category. When only medicatiegebruik is known, it is shown if it is not older than 13 months. When medicatiegebruik is recorded by both a health professional and a patient, the last registered medicatiegebruik is shown for both.

Sorting: by medicamenteuze behandeling (MBH): medicatieafspraak, toedieningsafspraak, medicatiegebruik (recorded by patient, care provider). Medicamenteuze behandelingen are sorted in descending order by startdate medicatieafspraak, toedieningsafspraak, medicatiegebruik.

{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| '''No'''
! style="text-align:left;"| '''Header'''
! style="text-align:left;" colspan="3"| '''Dataset'''
|-
|style="background-color: white;vertical-align:top;"|1
|style="background-color: white;vertical-align:top;"|Type
|style="background-color: white;vertical-align:top; text-align:center;"|Medicatieafspraak
|style="background-color: white;vertical-align:top; text-align:center;"|Toedieningsafspraak
|style="background-color: white;vertical-align:top; text-align:center;"|Medicatiegebruik
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|2
|style="background-color: white;vertical-align:top;" rowspan="2"|Medicinal product
|style="background-color: white;vertical-align:top; text-align:center;"|Agreed medicinal product-
|style="background-color: white;vertical-align:top; text-align:center;"|Medicinal product belonging to Toedieningsafspraak-
|style="background-color: white;vertical-align:top; text-align:center;"|Device-
|-
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Product – ProductCode (if absent: ProductSpecification, ProductName)
|-
|style="background-color: white;vertical-align:top;"|3
|style="background-color: white;vertical-align:top;"|Start date
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Start date
|-
|style="background-color: white;vertical-align:top;"|4
|style="background-color: white;vertical-align:top;"|End date/duration
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|End date (if not available: Duration)
|-
|style="background-color: white;vertical-align:top;"|5
|style="background-color: white;vertical-align:top;"|Dosage
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Instructions for medicatiegebruik – Description
|-
|style="background-color: white;vertical-align:top;"|6
|style="background-color: white;vertical-align:top;"|Route of toediening
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Instructions for medicatiegebruik – Route of toediening
|-
|style="background-color: white;vertical-align:top;"|7
|style="background-color: white;vertical-align:top;"|Reason
|style="background-color: white;vertical-align:top; text-align:center;"|Reason for prescribing &
if applicable reason for discontinuing/suspending medication
|style="background-color: white;vertical-align:top; text-align:center;"|Reason for discontinuing/suspending medication
|style="background-color: white;vertical-align:top; text-align:center;"|Reason for discontinuing/suspending medication
|-
|style="background-color: white;vertical-align:top;"|8
|style="background-color: white;vertical-align:top;"|Explanation
|style="background-color: white;vertical-align:top; text-align:center;" colspan="2"|Explanation & additional information
|style="background-color: white;vertical-align:top; text-align:center;"|Explanation
|-
|style="background-color: white;vertical-align:top;" rowspan="3"|9
|style="background-color: white;vertical-align:top;" rowspan="3"|Source
|style="background-color: white;vertical-align:top; text-align:center;"|Prescriber-
|style="background-color: white;vertical-align:top; text-align:center;"|Provider-
|style="background-color: white;vertical-align:top; text-align:center;"|Author-
|-
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Health professional – Name healthcare provider, specialty
|-
|style="background-color: white;vertical-align:top; text-align:center;"|n/a
|style="background-color: white;vertical-align:top; text-align:center;"|n/a
|style="background-color: white;vertical-align:top; text-align:center;"|or “Patient”
|}

===Future medication===
[[Bestand:Medicatieoverzicht_ToekomstigeMedicatie_v0.5.PNG]]

Filter: all medication that will become actual in the next 3 months. This includes intended medicatiegebruik.
For a description of the mapping, the same applies as with the current medication, see [[#Current medication|Current medication]].

===Recently discontinued medication===
[[Bestand:Medicatieoverzicht_RecentBeeindigde_v0.5.PNG]]

Filter: any medication that has ended or stopped in the past 2 months.

For a description of the mapping, the same applies as with the current medication, see [[#Current medication|Current medication]].

===Additional lab values ===
[[Bestand:Medicatieoverzicht_Labwaarden_v0.5.PNG]]

Most recent lab values and abnormal renal function values.

This part will be elaborated at a later time and is not yet normative.

===Remarks ===
[[Bestand:Medicatieoverzicht_Opmerkingen_v0.5.PNG]]

For example, relevant (limited) health skills (competences: literacy, calculation and digital skills) that can have an impact on medicatiegebruik / treatment.

This part will be elaborated at a later time and is not yet normative.

==Building block instantiations==
This section describes which instantiations of the building blocks belong to the medication overview. This concerns 'own' and 'other people's' building blocks ([[#GP observation service (HAP)|section 3.1]]) and then only the latest, relevant instantiations of this ([[#Thrombosis service|section 3.2]]).

===Own and other people===
Both the own and a copy of (known to the sender) building blocks from other sources are included in the medication overview. This so that the medication overview is as complete as possible for the recipient. This ensures that recipients can start using it immediately and that they are not dependent on other sources. The technical representation of someone else's building block may differ from that of the real source. It is important that the recipient is aware of this. The original OID of someone else's building block should simply be given. The recipient can then choose to also collect the building block from its source in its original form.

The medicatieafspraak, toedieningsafspraak and medicatiegebruik building blocks have been extended with a feature that indicates whether:
*there is an 'own' building block or
*that of "someone else" (an ''accent'' building block: MA’, TA’, MGB’)
This attribute only applies in the medication overview transaction, because that is the only transaction where other people's building blocks may be delivered.

The 'building block of someone else' attribute is on two levels:
*The template ID of an MA’, TA’, MGB’ differs from an MA, TA and MGB.
*In addition, the element copy indicator is always sent with value '''true''' in MA’, TA’, MGB’.
For the medication overview, it is permitted to offer the medicatieafspraken, toedieningsafspraken and medicatiegebruik via a information system-generated MGB or MGB '(Healthcare provider is author MGB). This must have a reference to an MA, TA or MGB.

====Medication overview and derivation rules====
An overview of medication that the patient is using (or should be using) can be put together in a information system in two ways: 
1) displaying a current medication overview (or overviews) obtained from another source (or sources) 
2) showing coherent medication building blocks obtained from one's own information system and from other sources. 
In both cases, this overview of medication consists of the information as included in the building blocks medicatieafspraak, toedieningsafspraak and medicatiegebruik.

Re 1) When this document refers to a current medication overview, this means a coherent overview in which current medicatieafspraken, toedieningsafspraken and medicatiegebruik are included. This current medication overview is built up by the source on the basis of the data known at that time at the source. This overview can be exchanged with the transaction group Medicatieoverzicht (Medication overview) (PULL or PUSH).

The data and building blocks that are known at the source, but originating from another source, are supplied in the transaction with the 'accent' indicator so that they are recognizable as building blocks from someone else (MA accent, TA accent, MGB accent).

Re 2) It is also possible for a information system to compile an overview by combining own and other people's separate individual medication building blocks. The transaction group Medicatiegegevens (medication data) (PULL) is used to request individual building blocks.

With the transaction group Medicatiegegevens (medication data) (PUSH), separate building blocks can also be sent directly to another health professional or the patient (so without requests). This happens, for example, at discharge or at the request of a co-practitioner who has the patient in front of him (e.g. patient appears to a GP or pharmacist outside the region, where this GP or pharmacist requests the data by telephone from the patient's own GP and receives it digitally).

Both Medicatiegegevens (medication data) PUSH and PULL should not provide data obtained from other sources.

===Last relevant===
Only the last relevant building blocks (per medicamenteuze behandeling) are part of the medication overview. This section describes what exactly those last relevant building blocks are for a medication overview. Firstly for prescription medication (section 3.2.1), then for "over the counter" medication (section 3.2.2). The following section 3.2.3 further discusses the special situation that, in addition to a current, a future medicatieafspraak within the same medicamenteuze behandeling is valid. Finally, the last paragraph summarizes the rules to be applied. 
Note: The (technical) stop-medicatieafspraken are not shown in the examples, but are implicitly assumed.

====Prescription medication====
=====Most simple "happy flow"=====
In a medicamenteuze behandeling, the simplest "happy flow" results in a sequence of:
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik''.
Usually, medicamenteuze behandeling (drug treatment) starts with a medicatieafspraak. A toedieningsafspraak concretely completes the medicatieafspraak. medicatiegebruik says something about the actual medication use of the patient in this medicamenteuze behandeling. All three building blocks are relevant in such a case and are part of the delivery of a medication overview, as indicated in green below.
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik.
A toedieningsafspraak refers to the medicatieafspraak he enters. If no referral is available in the toedieningsafspraak, the appointment date (administration appointment) must be later than that of the medicatieafspraak to be relevant to delivery. 
Medicatiegebruik can refer to a medicatieafspraak or toedieningsafspraak. If no referral is available in the medicatiegebruik, the registration date (medicatiegebruik) must be later than that of the medicatieafspraak to be relevant for delivery.

=====New medicatieafspraak in medicamenteuze behandeling=====
If you create a new medicatieafspraak in an existing medicamenteuze behandeling (drug treatment), the currently existing medicatieafspraken, toedieningsafspraken and records of medicatiegebruik are no longer relevant for the medication overview. The idea is that all older building blocks than the current medicatieafspraak are by definition "overruled" by this new medicatieafspraak and consequently no longer relevant for the medication overview.
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik'' - stop-Medicatieafspraak – Medicatieafspraak – stop-Toedieningsafspraak

If a toedieningsafspraak and possibly also medicatiegebruik are created and available following such a medicatieafspraak medication appointment, these will be included in the medication overview.
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik'' – stop-Medicatieafspraak – Medicatieafspraak – stop-Toedieningsafspraak - Toedieningsafspraak
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik'' – stop-Medicatieafspraak - Medicatieafspraak - stop-Toedieningsafspraak – Toedieningsafspraak – Medicatiegebruik 

The new MA can also be a stop-MA, if the patient has to stop medication permanently. This stop-MA remains relevant for the medication overview for 2 months. 
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – stop-Medicatieafspraak - stop-Toedieningsafspraak

=====Medicatiegebruik earlier than toedieningsafspraak =====
It is possible that you have registered medicatiegebruik before the toedieningsafspraak has been made. Here too, the idea is that the newer toedieningsafspraak "overrules" the older registration of toedieningsafspraak and medicatiegebruik. The older medicatiegebruik is therefore no longer relevant for the medication overview.
* Medicatieafspraak – Medicatiegebruik
* Medicatieafspraak – ''Medicatiegebruik'' – Toedieningsafspraak

Of course, a new record of medicatiegebruik can then be made, which is also relevant for the medication overview.
* Medicatieafspraak – ''Medicatiegebruik'' – Toedieningsafspraak - Medicatiegebruik

=====New toedieningsafspraak =====
Sometimes you make a new toedieningsafspraak under an existing medicatieafspraak. For example, because another product must be provided (as a result of preference policy or stock). In that case, too, such a new toedieningsafspraak may overrule older medicatieafspraken and medicatiegebruik.
* Medicatieafspraak – ''Toedieningsafspraak – Medicatiegebruik''- stop-Toedieningsafspraak - Toedieningsafspraak

Of course you can then record medicatiegebruik, which is also relevant for the medication overview.
* Medicatieafspraak – ''Toedieningsafspraak – Medicatiegebruik'' - stop-Toedieningsafspraak – Toedieningsafspraak - Medicatiegebruik

====Over the counter====
Sometimes a patient uses medication for which there is no prescription. This applies, for example, to painkillers such as paracetamol or ibuprofen, which are available without a prescription. We call this “over the counter” medication. Such use of "over the counter" medication can be recorded with the medicatiegebruik building block. This is also relevant for the medication overview.
* Medicatiegebruik

A new record of medicatiegebruik by the same type of author (type of author is patient or health professional) "overrules" any older records of medicatiegebruik. Elaborated below, in order of registration date:
* ''Medicatiegebruik'' - Medicatiegebruik

When a prescriber decides to formalize this medicamenteuze behandeling with a medicatieafspraak the rules as described above apply. Elaborated below, in order of appointment date (medicatieafspraak or toedieningsafspraak) / registration date (medicatiegebruik):
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak - Medicatiegebruik
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak – Toedieningsafspraak - Medicatiegebruik
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak – ''Medicatiegebruik'' - Toedieningsafspraak - Medicatiegebruik
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak - ''Medicatiegebruik'' - Medicatiegebruik

====Future medicatieafspraken and toedieningsafspraken====
A medicamenteuze behandeling may include more than one topical medicatieafspraak and toedieningsafspraak. Namely one for the current situation and one or more for the future situation. This section describes an example with one current and one future. For clarity, the future building blocks have a “T-” in the examples. Both current and future building blocks are relevant for the medication overview. The building blocks for toedieningsafspraak and medicatiegebruik must have adequate references to either the current or future appointments. Below are three examples, in order of appointment date / registration date (if these are equal, then sorted by period of use):
* Medicatieafspraak – T Medicatieafspraak
* Medicatieafspraak – Toedieningsafspraak – T Medicatieafspraak – T Toedieningsafspraak
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – T Medicatieafspraak – T Toedieningsafspraak – T Medicatiegebruik
Suppose that the toedieningsafspraak changes because the provider provides a different strength (2x 500mg tablets instead of 1x 1000mg tablets) and the patient still has enough stock for two weeks based on the first toedieningsafspraak:
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – T Toedieningsafspraak – T Medicatiegebruik

=====New medicatieafspraak =====
If you make a new medicatieafspraak in this situation, you always make a (technical) stop-medicatieafspraak. This stop-medicatieafspraak has two manifestations: 
1) with reference to a specific medicatieafspraak that you stop 
2) without a referral, and with that you stop the entire medicamenteuze behandeling (drug treatment)

Ad 1) Stop medicatieafspraak for one current medicatieafspraak. With this stop medicatieafspraak you stop one specific medicatieafspraak. You also make a new one for that medicatieafspraak. Suppose you only want to change the current medicatieafspraak, then this applies to the examples above, in order of appointment date:
* ''Medicatieafspraak'' – T Medicatieafspraak - stop-Medicatieafspraak – Medicatieafspraak 
* ''Medicatieafspraak – Toedieningsafspraak'' – T Medicatieafspraak – T Toedieningsafspraak - stop-Medicatieafspraak – Medicatieafspraak
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik'' – T Medicatieafspraak – T Toedieningsafspraak – T Medicatiegebruik - stop-Medicatieafspraak – Medicatieafspraak

Suppose you only want to change the future medicatieafspraak, then this applies to the examples above, in order of appointment date:
* Medicatieafspraak – ''T Medicatieafspraak'' - stop- T Medicatieafspraak – T Medicatieafspraak
* Medicatieafspraak – Toedieningsafspraak – ''T Medicatieafspraak – T Toedieningsafspraak'' - stop- T Medicatieafspraak – T Medicatieafspraak
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – ''T Medicatieafspraak – T Toedieningsafspraak – T Medicatiegebruik'' - stop- T Medicatieafspraak – T Medicatieafspraak 

 Ad 2) Stop medicatieafspraak for the entire medicamenteuze behandeling. With this stop medicatieafspraak you stop all existing (current and future) medicatieafspraken in the medicamenteuze behandeling. If you now want to make a medicatieafspraak for the future in addition to a current one, you must also make it again. Elaborated below for the same three examples as above, in order of appointment date.
* ''Medicatieafspraak – T-Medicatieafspraak'' – stop-Medicatieafspraak (zonder referentie) - Medicatieafspraak 
* ''Medicatieafspraak – Toedieningsafspraak – T-Medicatieafspraak – T-Toedieningsafspraak'' - stop-Medicatieafspraak (zonder referentie) – Medicatieafspraak – T Medicatieafspraak
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – T-Medicatieafspraak – T-Toedieningsafspraak – T Medicatiegebruik'' - stop-Medicatieafspraak (zonder referentie) – stop-Toedieningsafspraak -Medicatieafspraak – stop- T Toedieningsafspraak - T Medicatieafspraak 

=====New toedieningsafspraak=====
 However, you can also make a new toedieningsafspraak for the current medicatieafspraak only. This new toedieningsafspraak must then have a reference to that current medicatieafspraak. Elaborated below for three examples, in order of appointment date.
* Medicatieafspraak – T Medicatieafspraak – Toedieningsafspraak
* Medicatieafspraak – ''Toedieningsafspraak''– T-Medicatieafspraak – T Toedieningsafspraak - stop-Toedieningsafspraak – Toedieningsafspraak
* Medicatieafspraak – ''Toedieningsafspraak – Medicatiegebruik'' – T Medicatieafspraak – T-Toedieningsafspraak – T Medicatiegebruik – - stop-Toedieningsafspraak – Toedieningsafspraak

A new toedieningsafspraak with a reference to the future medicatieafspraak looks like this.
* Medicatieafspraak – T Medicatieafspraak – Toedieningsafspraak – T-Toedieningsafspraak
* Medicatieafspraak –Toedieningsafspraak – T-Medicatieafspraak – ''T Toedieningsafspraak'' – stop-T Toedieningsafspraak - T Toedieningsafspraak
* Medicatieafspraak –Toedieningsafspraak – Medicatiegebruik – T Medicatieafspraak – ''T Toedieningsafspraak – T Medicatiegebruik'' - stop- T Toedieningsafspraak – T-Toedieningsafspraak

====Rules of overruling listed====
Based on the above description / examples, the following general rules for overruling can be derived. This concerns the rules for determining whether a building block is relevant for delivery in the medication overview. Within a medicamenteuze behandeling:
*A new medicatieafspraak overrules all older building blocks (medicatieafspraak, toedieningsafspraak, medicatiegebruik) belonging to the medicatieafspraak /medicatieafspraken that this medicatieafspraak has stopped.
*A new toedieningsafspraak overrules all older building blocks of the type of toedieningsafspraak or medicatiegebruik that belong to the same medicatieafspraak as the new toedieningsafspraak.
*In principle, a new record of medicatiegebruik overrules (see exception below) older records of medicatiegebruik that belong to the same medicatieafspraak as the new medicatiegebruik.
**Exception to this rule: medicatiegebruik with the author as a patient DOES NOT overrule an older record of medicatiegebruik with the care provider as author and vice versa. Both are therefore relevant to the medication overview.
The latter exception applied to a number of situations:

Deze laatste uitzondering toegepast op een aantal situaties:
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik-ZVL – Medicatiegebruik-PAT
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik-PAT – Medicatiegebruik-ZVL
* Medicatieafspraak – Toedieningsafspraak – ''Medicatiegebruik-PAT'' – Medicatiegebruik-PAT
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik-ZVL – ''Medicatiegebruik-PAT'' – Medicatiegebruik-PAT
* Medicatieafspraak – Toedieningsafspraak – ''Medicatiegebruik-ZVL – Medicatiegebruik-PAT'' – Medicatiegebruik PAT – Medicatiegebruik-ZVL

==Verification by medicamenteuze behandeling ==
A health professional records verification per medicamenteuze behandeling with the medicatiegebruik building block:
*Author = Health professional
*Possible informant: the patient, a care provider or another person
*Possible characteristic "according to agreement": according to the author, is the medicatiegebruik in accordance with the medicatieafspraak or toedieningsafspraak?
*Possible link to medicatieafspraak or toedieningsafspraak:
**Medicatieafspraak or toedieningsafspraak that has been the reference for recording this medicatiegebruik.
**When it is indicated "by appointment", this is the medicatieafspraak or toedieningsafspraak according to which the patient uses.
Such a record of medicatiegebruik means: "I think the patient uses this drug as follows: ... ..".

Known: it is not currently provided in the information standard to indicate that a medicatieafspraak or toedieningsafspraak is correct, regardless of whether the patient uses it as such.

==Process of the medication overview exchange==
In addition to the content and verification, the process surrounding the medication overview is also important.

===Who, when, with what information===
The reliability and completeness of a medication overview depends on:
*who composed it,
*at what time and
*with what basic information.
We can make agreements about this, for example:
*only exchange/make available a medication overview once it has some form of reliability
**after an explicit action by a health professional or
**automatically if certain conditions are met.
*fully automatically exchange/make available medication overview without conditions
*make medication overview fully automatically available without the need for a new data type (so when registering one of the other medication data types you are automatically also the source of a medication overview).

====Decision====
The above questions have not yet been answered. It has been decided that during the Proof-Of-Concept all parties that can provide a medication overview will do the same.

===Responsibilities applicant and source===
The applicant receives medication overviews from multiple sources. Processing this is the responsibility of the recipient. The topicality of a medication overview is important here.

'''Action''': the transaction Medicatieoverzicht (medication record) must contain the most recent date of the collection of available appointment dates / registration dates of the delivered building block instantiations. The compiler (source) of the medication overview must therefore provide this date. This helps the recipient to better estimate the topicality of the medication overview.

===Agreements continued===
We continue the analysis with the results of the Proof-Of-Concept to arrive at a good process for the medication overview.

==Inference rules==
It is important that all parties, physician, pharmacist, nurse as well as patient can infer from the medication building blocks what is intended (i.e. what the current agreements are) and that this should be the same for all information systems. For that reason, information systems must be able to calculate the current situation using the same inference rules.

The current therapeutic situation is calculated on the basis of medicatieafspraken and toedieningsafspraken. Toedieningsafspraken have a relationship with the medicatieafspraak that they were added to. For this reason, toedieningsafspraken can be linked to the medicatieafspraak that they belong to. 
Of course it is also useful to have information about medicatiegebruik. However, this does not indicate the aim of the health professional, only what medication the patient has used. For that reason, the rules below do not take ‘medicatiegebruik’ in consideration. However, ‘gebruik’ is part of a medication profile but is shown separately under the medicamenteuze behandeling concerned.

===Effective period===
The effective period lies between an ''effective start date'' and an ''effective end date''. 
:''The effective period describes the period to which a medicatieafspraak or toedieningsafspraak (ultimately) applies.'' 
The effective period depends on adjustments (modifying/discontinuing/halting/resuming) of medication and by the ‘actual handling of a medicatieafspraak by a toedieningsafspraak. The effective period is not described in the dataset, because it is inferred which is only used to determine the current situation. The ''effective start date, effective end date'' and ''effective period'' are not data to be shown to the end user. Medication for an indefinite period has an effective end date that is in the future, but at a time that cannot be distracted (yet). It is only known that it is 'somewhere' in the future.

===Actual and current medication===
*''Actual (medicatieafspraken en toedieningsafspraken)'': the agreements of which the effective end date lies in the future.
*''Current (medicatieafspraken en toedieningsafspraken) agreements'': the agreements for which the present date lies between their effective start date and the effective end date.
*''Actual medication'': the collection of actual (current and future) medication and toedieningsafspraaks as well as current medicatiegebruik. It should be taken into account that it is never possible to say with certainty to what extent the patient complies with the agreements and/or reports actual gebruik.

===Details===
'''Approach''' 
Using a number of different situations the inference rules are described for arriving at the effective therapeutic period in a medication profile: 
:1) Starting medication
:2) Creating a toedieningsafspraak
:3) Changing medication
:4) Discontinuing medication
:5) Temporarily halting and resuming medication

The inference rules are described below. The number for each inference rule indicates the order in which the rules must be executed.

'''1) Starting medication''' 
Medication is started by creating a new medicatieafspraak. The medicatieafspraak has:
*An agreement date - the date on which the agreement was made with the patient.
*A period of use - this period is consists of:
**A start date - the start date of the medicatieafspraak may be in the future;
**The duration of medicatiegebruik;
**The end date – the date until which the medicatieafspraak is valid.

1a: The effective period of a new medicatieafspraak is equal to its period of medication use.

'''2) Creating a toedieningsafspraak ''' 
A toedieningsafspraak specifically fulfils a medicatieafspraak. From a patient perspective, the toedieningsafspraak, in a way, replaces a medicatieafspraak, as the toedieningsafspraak is a more specific indication of what the patient should be using.

Inference rule 1 is extended:

1b: The effective period of a new toedieningsafspraak is equal to its period of medication use

Inference rule 2 is applicable when a medicatieafspraak has underlying toedieningsafspraken (see inference rule 2b for further explanation):

2a: The effective period of a medicatieafspraak is equal to the effective period of the toedieningsafspraak.

'''3) Changing medication'''
:'''a) By means of a medicatieafspraak'''
The prescriber changes the medication (or the medicamenteuze behandeling) by creating a new medicatieafspraak (and discontinuing the existing one) within an existing medicamenteuze behandeling.
Because the start date of a medicatieafspraak may lie in the future, several medicatieafspraken may be actual at the same time. For example, when a medicatieafspraak applies ‘for an indefinite period’ (ma1) and it is agreed to change the dosage in two weeks (ma2), the first medicatieafspraak (ma1) remains valid for two weeks, after which the second medicatieafspraak (ma2) becomes effective. The previous inference rules do not change because of this.

:'''b) By means of a toedieningsafspraak '''
An toedieningsafspraak specifically fulfils a medicatieafspraak. This toedieningsafspraak may be modified. For example, when administration schedules are changed (when GDS is initiated), or when a commercial product is changed (for example, as a result of a preference policy). Several successive toedieningsafspraken can therefore be created under a single medicatieafspraak. Hence, rule 2 is expanded so that the effective period of the medicatieafspraak is determined by the entire series of underlying toedieningsafspraken.

2b: When several toedieningsafspraken are made under a single medicatieafspraak, the effective start date of the medicatieafspraak is then equal to the earliest start date of the underlying toedieningsafspraak and the end date of the last toedieningsafspraak.

Parallel toedieningsafspraken may exist under a single medicatieafspraak of which the agreement date and the start date are the same. Both are then valid at the same time and this does not change rule 2b.

The diagram below includes a simplified example of an actual profile composed of different building blocks. The patient, verification, CiO and lab data have been excluded from this overview. Only limited data has been included, mainly to demonstrate the way in which the effective period works. Lines starting with ‘-’ are detail lines which can be hidden in the medication profile, if required. The first line shows the effective period for the underlying MAs and TAs. The ‘medicatiegebruik” is also displayed, but this does not influence the calculation of the effective therapeutic period on the first line.

{{anchor|figuur 9}}
[[Bestand:Voorbeeldeffectieveperioden.png|Figuur 9 Voorbeeld effectieve periode]]

'''4) Discontinuing medication''' 
Discontinuing medication (i.e medicamenteuze behandeling) is done by creating a new medicatieafspraak in which stoptype ‘definite’ is indicated. The start date of this medicatieafspraak is the date on which the original medicatieafspraak started. The end date is the date on which the medication is discontinued. The effective period of the original medicatieafspraak is so replaced by the effective period of this new stop-MA.

1c: When a medicatieafspraak is discontinued, the effective period of the medicatieafspraak is then the effective period of the stop-MA.

An stop-toedieningsafspraak fulfils the stop-medicatieafspraak. In this way, for example, it is possible to indicate that the discontinuation starts when the next GDS roll is dispensed.

'''5) Temporarily halting and resuming medication''' 
Temporarily halting medication is carried out in the same way as discontinuing medication. A stop-MA is created (stoptype ‘temporary’) with the same start date as that of the original medicatieafspraak. The end date of the stop-MA is the timing of the temporary halt, the stop type is ‘temporary’. Resuming medication is done by creating a new medicatieafspraak with the old (or adjusted) dosage with the date of resuming as the start date. A meaningful reason (example: resume previous policy) may serve to clarify matters. If the medication is not resumed, ‘discontinue medication’ (stoptype ‘definite’) can be executed in order to permanently end the medicamenteuze behandeling, which means the medication is no longer valid. Medication that is halted remains valid, and so remains visible in the medication profile.

1d: When medication is temporarily halted, the effective period is not affected. The effective period is determined by the effective period of the original medicatieafspraak.

These inference rules are the basis for determining the current agreements. It is possible to conceive exceptional situations relating to a partial availability of medication data. These situations have not been elaborated. All inference rules are included and implemented in the open source medication viewer.

==Data that need not be shown==
Various data are important for the correct processing of information, but are not relevant to the end user:
*An application does not have to show the (technical) identification of a medicamenteuze behandeling (MBH) (nor that of the building blocks themselves), but the elaboration thereof: namely, building blocks shown in coherence.
*The copy indicator with the medicatieafspraak (MA), toedieningsafspraak (TA) and medicatiegebruik (MGB) when consulting the medication overview. Whether a building block is a copy is not that important to a user and can be deduced by other data from that building block (such as the author of the building block). So it is not so important that a user can see that this has been delivered 'as a copy' and is probably only confusing. However, this information is important for suppliers, for example because they sometimes want to perform calculations with the data and it is then safer to collect the data from the real source. It is therefore obvious to keep track of whether you have received data from the real source in your information system.
*An application does not have to show the stop type (temporary / definite) of a stop appointment, but the elaboration thereof: namely the processing of the meaning, so that an entire MBH is shown as stopped medication or as interrupted medication (remains clear under current medication) or as a change in the case of a 'technical stop appointment'.

=Administration list and inference rules=

This chapter shows a possible presentation/view of the administration list and, additionally, specifies the inference rules to identify the relevant medication building blocks within a pharmaceutical treatment, for the generation of an administration list.

==Introduction==
This paragraph contains an example of an administration list. The administration list shows the most recent medication data at any time of the day, to facilitate adequate medication administration. To ensure safe circumstances in which correct and up-to-date medication data is presented to the (professional) administrator, the administration software must be able to process the medication building blocks and to correlate the medication building blocks, as described in this information standard.

The term ‘administration list’ is defined as a digital list including all medicaments that are prescribed by a prescriber and that have to be administered to a patient/client. This list is generated based on the following medication building blocks: medication agreement (MA), administration agreement (TA), medication dispense (MVE), medication administration (MTD) and variable-dosing regimen (WDS).

The process of (actively) making medication data available to (professional) administrators enables the generation of a total overview of all medication which has to be administered. Importantly, this implies that information regarding discontinuation and change of medication with or without medication dispense is available at any time. Change in medication and variable-dosing regimens, for example as prescribed by the thrombosis service, are immediately available for administrators.

In the figures below, the numbered elements are normative; it is mandatory to show those components. The lay-out of the administration list in an information system may differ depending on the type of users or the type of device; this is dependent on the user requirements.

The administration list in this example is described generally. The chapter entails the general end user requirements for the administration list; this chapter does not comprise details on the technical requirements or implementation.

The project ‘Veilige principes in the medication’ comprises the sectors nursing care, nursing aid and home care. The specifications as described in ‘Veilige principes in de medicatieketen 2016’ and ‘Richtlijn overdracht van medicatiegegevens in de keten herziening 2018/2019’ as well as new insights from the program ‘Medicatieoverdracht’ are incorporated in this chapter.

The basis for the administration list entails:
*Medication building blocks
**Medication agreement (MA)
**Administration agreement (TA)
**Variable-dosing regimen (WDS)
**Medication administration (MTD)
**Medication dispense (MVE)
*All current medication; this comprises all MAs, TAs and WDSs which are available and applicable when the medication is administered. The PeriodOfUse defines whether medication should be considered current medication.
*The PrickPatchLocation is consulted based on the AdministrationDateTime.
*(Professional) administrators can distinguish the types of medication (in GDS package or separately) which should be administered to the patient by the data element DistributionForm (medication building block MVE) and the data element AsNeeded/Condition in the dosage (medication building blocks MA, TA or WDS). The different types of medication may be presented according to the following categories:
**GDS medication (including discontinued medication in order to show a notification/warning)
**Non-GDS medication
**Non-GDS medication as needed
*The remaining building blocks (dispense request (VV), medication use (MGB) and medication consumption (MVB)) are not relevant for the administration list.

{{anchor|figuur 1}}
[[Bestand:Toedienlijst_figuur_1a.PNG|Figuur 1: Voorbeeldweergave toedienlijst]]
[[Bestand:Toedienlijst_figuur_1b.PNG|Figuur 1: Voorbeeldweergave toedienlijst]]
[[Bestand:Toedienlijst_figuur_1c.PNG|Figuur 1: Voorbeeldweergave toedienlijst]]
 
''Figure 1: Example administration list.''
 
 
{| class="wikitable"
|-
! Nr
! style="text-align:left;"|Heading
! style="text-align:left;" colspan="3"|Dataset
|-
| 1 || Type || Medication Agreement || Administration Agreement || Variable-Dosing Regimen
|-
| 2 || Medicine || Agreed Medicine || Medicine To Be Dispensed ||
|-
| 3 || Prescriber
|style="text-align:left;" colspan="3"| Medication Agreement – Prescriber – Health Professional
|-
| 4 || Supplier
|style="text-align:left;" colspan="3"| Administration Agreement – Supplier – Healthcare Provider
|-
| || Author
|style="text-align:left;" colspan="3"| Variable-Dosing Regimen – Author – Health Professional (conditional)
|-
| 5 || Start Date || Medication Agreement – Period Of Use || Administration Agreement – Period Of Use || Variable-Dosing Regimen – Period Of Use
|-
| 6 || End Date/Duration || Medication Agreement – Period Of Use || Administration Agreement – Period Of Use || Variable-Dosing Regimen – Period Of Use
|-
| 7 || Description
|style="text-align:left;" colspan="3"| Instructions For Use – Description
|-
| || Route Of Administration
|style="text-align:left;" colspan="3"| Instructions For Use – Route Of Administration

|-
| || Additional Instructions
|style="text-align:left;" colspan="3"| Instructions For Use – Additional Instructions
|-
| || Dose
|style="text-align:left;" colspan="3"| Instructions For Use – Dosing Instructions – Dosage – Dose
|-
| || Administration Time
|style="text-align:left;" colspan="3"| Period Of Use – Dosing Instructions – Dosage – Administering Schedule – Administration Time
|-
| || Administration Speed
|style="text-align:left;" colspan="3"| Period Of Use – Dosing Instructions – Dosage – Administration Speed
|-
| || Duration Of Administration
|style="text-align:left;" colspan="3"| Period Of Use – Dosing Instructions – Dosage – Duration Of Administration
|-
| 8 || Prick-Patch Location
|style="text-align:left;" colspan="3"|Medication Administration – Prick-Patch Location
|-
| 9 || Comment
|style="text-align:left;" colspan="3"|Comment & Additional Information
|}
''Table 1: Normative medication data in the administration list.''


==Functional specification==
In the figures below the elements with normative data are presented. The other elements are not normative (not yet). The numbered elements in the table are normative; the other elements are optional (until further notice).

===Heading and general===

[[Bestand:Toedienlijst_Functionele_specificatie.png]]

===Remarks===

[[Bestand:Toedienlijst_Kop en algemeen.png]]

In the comment field, for example, (limiting) health literacy competences (competences: literacy, calculation and digital skills) can be recorded, which may affect the medication administration. This part is for internal use and is not exchanged (not yet).

'''NB.''' This part is not normative yet. This data is derived from the internal information system of the organization.

===GDS medication===

[[Bestand:Toedienlijst_Opmerkingen.png]]

GDS (medication distribution system, in Dutch: 'Geneesmiddel Distributie Systeem') is defined as a package in which medicaments are distributed in units per administration moment, labelled with the name of an individual patient/client ([https://www.knmp.nl/praktijkvoering/richtlijnen/knmp-richtlijnen-praktijkvoering/knmp-richtlijn-voor-geautomatiseerd-geneesmiddeldistributiesysteem-gds-september-2011 KNMP, 2011]). If medication is discontinued or changed, it is desired that a warning signal is shown, with the comment that, possibly, the medication is in the GDS package, and an additional act may be required. Further elaboration is needed.

===Non-GDS medication===

[[Bestand:Toedienlijst_Niet-GDS-medicatie.png]]

Non-GDS medication is medication which, for various reasons, cannot be included in an automated medication distribution system. The distribution type 'non-GDS' is specified in the data element DistributionForm in the corresponding MVE. Furthermore, for non-GDS medication, the condition AsNeeded remains empty.

===Non-GDS medication – as needed===

[[Bestand:Toedienlijst_Niet-GDS-medicatie_zo_nodig.png]]

Non-GDS medication as needed comprises separate medication which should be administered only in specific circumstances. The condition for administration of such medicament can be:
*a measured physiological value (plasma glucose level, body temperature, blood pressure);
*a symptom or other condition (headache, itching).
The distribution type 'non-GDS' is specified in the data element DistributionForm in the corresponding MVE. Furthermore, the condition AsNeeded is filled.

==Building block instantiations==
This paragraph describes which building block instantiations are related to the administration list. This includes only the ‘own’ building blocks (see [[#Own and other people|5.3.1]]) and only the latest, relevant instantiations (see [[#Last relevant|6.3.2]]).

===Therapeutic and logistical building blocks===
Compiling an administration list involves both therapeutic and logistical medication building blocks. Building blocks can be ‘overruled’ based on inference rules. All inference rules as described in [[#Medication overview and inference rules|Chapter 5]] are applicable. In addition, in this paragraph, the inference rules for WDS are described. The inference rules do not apply to MTD, as medication administration is a procedure at a certain time point; in contrast, the MA, TA and MBG comprise agreements valid for a certain period of time. The logistical medication building block MVE is part of compiling the administration list, as this building block is needed to derive the type of distribution of the medication.

====Administration list and inference rules====
An administration list can be compiled, for example in the administrator’s information system, based on separate medication building blocks.
The medication building blocks may be retrieved from the own information system or from other sources. The transaction Medication data (consulting/making available) is used for consulting and making available individual medication building blocks.
In the transaction group Medication data (sending/receiving), separate medication building blocks can be send to another health professional or patient directly (without prior consultation); for example, in the case of discharge or on request of a fellow health professional (for example, a patient sees a GP or pharmacist outside the region; the GP or pharmacist requests the data by telephone and receives the data digitally).
Both for Medication data sending/receiving and Medication data consulting/making available, data obtained from other sources is not allowed to be presented in the administration list.

===Last relevant===
Only the latest relevant medication building blocks (per pharmaceutical treatment) are part of the administration list. This paragraph provides a description of the latest relevant building blocks for an administration list comprising medication on prescription. [[#Medication with prescription with a variable-dosing regimen|Paragraph 6.3.2.1]] describes the situation in which a variable-dosing regimen (WDS) is applicable. For WDS, the same inference rules apply as for MA. For compiling an administration list, the presence of a WDS is decisive for the instructions for use. All other situations in which WDS is not applicable, as described in [[#Last relevant|paragraph 5.3.2]], are applicable as well.

Query to identify the correct, relevant and future medication building blocks:
{| class="wikitable"
|-
! Nr
! style="text-align:left;"|Medication building block
! style="text-align:left;"|Query Parameter
! style="text-align:left;"|What should be filled in specifically?
|-
| 1 || MA, TA, WDS || Period Of Use || All medication that should be administered today and, therefore, is applicable: Day = T, startDate = T: 00:00:00 h, endDate = T: 23:59:59 h
|-
| 2 || MTD || Administration Period || Depending on medical relevance (for example, historical information on prick and patch locations may be relevant back to one week ago). For example, is one week is sufficient (another period may be chosen): Day = T, startDate = T-7 day
|-
| 3 || MVE || Dispense Period || Broad request (+/- one month)
|}

If all medication building blocks are collected, the following medication data, depending on the situation, can be used:
{| class="wikitable"
|-
! style="text-align:left;"|Medication building block
! style="text-align:left;"|Situation: only MA*
! style="text-align:left;"|Situation: MA + TA
! style="text-align:left;"|Situation: MA + TA + WDS
|-
| MA || Decisive** for compiling the administration list (number: 2, 5, 6, 7, 9, 10) || Data from the prescriber || Data from the prescriber
|-
| TA || - || Decisive** for compiling the administration list (number 2, 5, 6, 7, 9, 10) || Data from the supplier and medicine
|-
| WDS || - || - || Decisive** for compiling the administration list (number 5, 6, 7, 10)
|}

* Situation in which the pharmacist has not processed the MA yet.
** ‘Decisive’ indicates the data elements which are included in the functional requirements (numbers of the elements are provided between brackets).

====Medication with prescription with a variable-dosing regimen====

=====Most simple ‘happy flow’=====
The most simple ‘happy flow’ in a pharmaceutical treatment is stated below.

*''MA – WDS – TA''

In general, a pharmaceutical treatment starts with an MA. A TA specifies the MA. In the WDS, it is defined whether a variable-dosing regimen applies. In both the MA and the TA, the instruction ‘according to schedule thrombosis service’ is recorded. Then, in the WDS, the dosing schedule is specified. The three medication building blocks MA, TA and WDS are relevant and are part of compiling an administration list, as indicated in green below.


*MA – WDS– TA


A TA refers to the MA, which is specified by the TA. Also, a WDS refers to the MA, which is specified by the WDS. A WDS is always related to an MA.

====New WSD====
*MA – WDS – TA – WDS

The period of use of the WDS has ended and a new dosing schedule is created.

=====Change of WDS=====

*MA – WDS– TA – stop-WDS – WDS

The variable-dosing regimen (WDS) is changed.

=====Discontinuation of medication=====
*MA – WDS – TA – stop-MA

Medication with a WDS is discontinued by a stop of the MA.

=====Change of trade product=====

*MA – WDS – TA – stop-TA – TA

The trade product is changed; this affects the WDS.

====Rules of overruling listed====
Based on the descriptions/examples above, the following general rules for overruling apply. Those rules indicate which medication building block is relevant to incorporate and present in the administration list. Within a pharmaceutical treatment:
*A new MA overrules all previous, older therapeutical medication building blocks (MA, TA, WDS) related to the MA(s) which is/are stopped by the new MA.
*A new TA overrules the previous, older TA related to the same MA as the new TA.
*A new WDS overrules all previous, older WDSs related to the same MA as the new WDS.



=Information systems and transactions=
This chapter contains a list of all system roles and transactions that are referred to in the various process chapters.

The figure below ([[#figuur 10|Figure 10]]) contains an overview of all information systems with their corresponding system roles. The system roles have been described in [[#tabel 3|Table 3]]. The system roles associated with consulting/making available medication data and the medication overview are important for all information systems depending on the process in which they are used. The electronic prescribing system (EPS) also includes the system roles for receiving a voorstel verstrekkingsverzoek, sending a reply voorstel verstrekkingsverzoek and receiving a voorstel medicatieafspraak and, in an outpatient situation, for sending a prescription and receiving data on the processing of a prescription. In addition to the basic system roles, a XIS and PGD also include the system roles for sending a voorstel medicatieafspraak and a voorstel verstrekkingsverzoek, for sending data on gebruik and for receiving a reply voorstel verstrekkingsverzoek. The pharmacist information system (PIS) also includes, in addition to the basic system roles, the roles for sending a voorstel medicatieafspraak, sending a voorstel verstrekkingsverzoek and data on processing of the prescription, and receiving a prescription and reply voorstel verstrekkingsverzoek. [[#Medication process|Chapter 2]] lists the main system roles per process.

{{anchor|figuur 10}}
[[Bestand:Systemen.png|Figuur 10 Overzicht systemen en systeemrollen]]

{{anchor|tabel 3}}
{| class="wikitable" "cellpadding="10"
!style="text-align:left;"|System role name
!style="text-align:left;"|Abbr.
!style="text-align:left;"|Description
|-
| style="background-color: white;"| MedicatieGegevensBeschikbaarstellend
| style="background-color: white;"| MP-MGB
| style="background-color: white;"| Making medication data available to fellow health professionals/patient
|-
| style="background-color: white;"| MedicatieGegevensRaadplegend
| style="background-color: white;"| MP-MGR
| style="background-color: white;"| Consulting medication data at fellow health professionals/patient
|-
| style="background-color: white;"| MedicatieGegevensSturend
| style="background-color: white;"| MP-MGS
| style="background-color: white;"| Sending data to fellow health professional/patient
|-
| style="background-color: white;"| MedicatieGegevensOntvangend
| style="background-color: white;"| MP-MGO
| style="background-color: white;"| Receiving medication data from fellow health professional/patient
|-
| style="background-color: white;"| MedicatieOverzichtBeschikbaarstellend
| style="background-color: white;"| MP-MOB
| style="background-color: white;"| Making medication overview available to fellow health professionals/patient
|-
| style="background-color: white;"| MedicatieOverzichtRaadplegend
| style="background-color: white;"| MP-MOR
| style="background-color: white;"| Consulting medication overview at fellow health professionals/patient
|-
| style="background-color: white;"| MedicatieOverzichtSturend
| style="background-color: white;"| MP-MOS
| style="background-color: white;"| Sturen medicatieoverzicht aan medebehandelaar/patiënt
|-
| style="background-color: white;"| MedicatieOverzichtOntvangend
| style="background-color: white;"| MP-MOO
| style="background-color: white;"| Receiving medication overview from fellow health professional/patient
|-
| style="background-color: white;"| VoorschriftSturend
| style="background-color: white;"| MP-VOS
| style="background-color: white;"| Sending a request to dispense medication (verstrekkingsverzoek) or process modifications to medicatieafspraak.
|-
| style="background-color: white;"| VoorschriftOntvangend
| style="background-color: white;"| MP-VOO
| style="background-color: white;"| Receiving verstrekkingsverzoek or request for processing of modifications to medicatieafspraak.
|-
| style="background-color: white;"| VoorschriftAfhandelingSturend
| style="background-color: white;"| MP-VAS
| style="background-color: white;"| Sending data on processing of medicatieafspraak and possibly verstrekkingsverzoek in toedieningsafspraak and/or medicatieverstrekking
|-
| style="background-color: white;"| VoorschriftAfhandelingOntvangend
| style="background-color: white;"| MP-VAO
| style="background-color: white;"| Receiving data on processing of medicatieafspraak and possibly verstrekkingsverzoek in toedieningsafspraak and/or medicatieverstrekking
|-
| style="background-color: white;"| VoorstelVerstrekkingsverzoekSturend
| style="background-color: white;"| MP-VVS
| style="background-color: white;"| Informing prescriber about voorstel new verstrekkingsverzoek, receiving reply to proposed verstrekkingsverzoek
|-
| style="background-color: white;"| VoorstelVerstrekkingsverzoekOntvangend
| style="background-color: white;"| MP-VVO
| style="background-color: white;"| Receiving new voorstel verstrekkingsverzoek, sending reply to voorstel verstrekkingsverzoek
|-
| style="background-color: white;"| VoorstelMedicatieafspraakSturend
| style="background-color: white;"| MP-VMS
| style="background-color: white;"| Informing prescriber about new voorstel or modified medicatieafspraak, receiving reply to proposed medicatieafspraak
|-
| style="background-color: white;"| VoorstelMedicatieafspraakOntvangend
| style="background-color: white;"| MP-VMO
| style="background-color: white;"|Receiving voorstel for new or modified medicatieafspraak, sending reply to voorstel medicatieafspraak
|}Table 3 Overview system roles

Table 4 gives an overview of all transaction groups, transactions, corresponding system roles and building blocks exchanged with this transaction group. The names of the transaction groups and transactions link to the ART-DECOR publication which details per scenario which data elements are used.

{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| '''Transaction group'''
! style="text-align:left;"| '''Transaction'''
! style="text-align:left;"| '''System role'''
! style="text-align:left;"| '''Building blocks'''
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.131-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.299_20220207000000 Medication data (PULL)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.301-2022-02-07T000000.html Making medication data available]
|style="background-color: white;vertical-align:top;"|MP-MGB
|style="background-color: white;vertical-align:top;" rowspan="2"|One or more: MA, VV, TA, MVE, MTD, MGB, WDS
|-
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.300-2022-02-07T000000.html Consulting medication data]
|style="background-color: white;vertical-align:top;"|MP-MGR
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.131-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.302_20220207000000 Medication data (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.303-2022-02-07T000000.html Sending medication data]
|style="background-color: white;vertical-align:top;"|MP-MGS
|style="background-color: white;vertical-align:top;" rowspan="2"|One or more: MA, VV, TA, MVE, MTD, MGB, WDS
|-
|style="background-color: white;vertical-align:top;"|Receiving medication data
|style="background-color: white;vertical-align:top;"|MP-MGO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.132-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.315_20220207000000 Medication overview (PULL)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.317-2022-02-07T000000.html Making medication overview available]
|style="background-color: white;vertical-align:top;"|MP-MOB
|style="background-color: white;vertical-align:top;" rowspan="4"|MA, TA, MGB
|-
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.316-2022-02-07T000000.html Consulting medication overview]
|style="background-color: white;vertical-align:top;"|MP-MOR
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.132-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.318_20220207000000 Medication overview (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.319-2022-02-07T000000.html Sending medication overview]
|style="background-color: white;vertical-align:top;"|MP-MOS
|-
|style="background-color: white;vertical-align:top;"|Receiving medication overview
|style="background-color: white;vertical-align:top;"|MP-MOO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.133-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.321_20220207000000 Medication prescription (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.322-2022-02-07T000000.html Sending medication prescription]
|style="background-color: white;vertical-align:top;"|MP-VOS
|style="background-color: white;vertical-align:top;" rowspan="2"|MA with or without VV, height, weight, renal function value
|-
|style="background-color: white;vertical-align:top;"|Receiving medication prescription
|style="background-color: white;vertical-align:top;"|MP-VOO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.135-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.333_20220207000000 Medication prescription processing (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.334-2022-02-07T000000.html Sending data on processing of medication prescription]
|style="background-color: white;vertical-align:top;"|MP-VAS
|style="background-color: white;vertical-align:top;" rowspan="2"|TA with or without MVE
|-
|style="background-color: white;vertical-align:top;"|Receiving data on processing of medication prescription
|style="background-color: white;vertical-align:top;"|MP-VAO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.134-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.327_20220207000000 Proposal dispense request (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.328-2022-02-07T000000.html Sending proposal dispense request]
|style="background-color: white;vertical-align:top;"|MP-VVS
|style="background-color: white;vertical-align:top;" rowspan="2"|VVV
|-
|style="background-color: white;vertical-align:top;"|Receiving proposal dispense request
|style="background-color: white;vertical-align:top;"|MP-VVO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.134-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.330_20220207000000 Reply proposal dispense request (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.331-2022-02-07T000000.html Sending reply proposal dispense request]
|style="background-color: white;vertical-align:top;"|MP-VVO
|style="background-color: white;vertical-align:top;" rowspan="2"|AVVV
|-
|style="background-color: white;vertical-align:top;"|Receiving reply proposal dispense request
|style="background-color: white;vertical-align:top;"|MP-VVS
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.134-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.324_20220207000000 Proposal medication agreement (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.325-2022-02-07T000000.html Sending proposal medication agreement]
|style="background-color: white;vertical-align:top;"|MP-VMS
|style="background-color: white;vertical-align:top;" rowspan="2"|VMA with or without height, weight
|-
|style="background-color: white;vertical-align:top;"|Receiving proposal medication agreement
|style="background-color: white;vertical-align:top;"|MP-VMO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.134-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.372_20220302000000 Reply proposal medicationagreement (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.373-2022-03-02T000000.html Sending reply proposal medicationagreement]
|style="background-color: white;vertical-align:top;"|MP-VMO
|style="background-color: white;vertical-align:top;" rowspan="2"|AVMA
|-
|style="background-color: white;vertical-align:top;"|Receiving reply proposal medicationagreement
|style="background-color: white;vertical-align:top;"|MP-VMS
|}Table 4 Overview transaction groups

[[#Medication process|Chapter 2]] lists for each process only the relevant transactions per process step. The transaction groups are not included in this. Table 4 includes all transaction groups and transactions.

=Functionality=
This chapter describes indications for the functionality of an information system.

==Filtering medication from 2nd/3rd line (all information systems)==
An institution makes all its medication data (all building blocks) available. Not all data may be relevant for the receiving health professionals. Receiving information systems may therefore include a filter depending on the requirements of the specific health professional/patient. The list below (Table 5) includes medication types of which it has been determined that medicatietoediening during admission is relevant for health professionals outside the institution.

{{anchor|tabel 5}}
{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| ATC-code
! style="text-align:left;"| Name
|-
| style="background-color: white;vertical-align:top;"|L01
| style="background-color: white;vertical-align:top;"|Cytostatics
|-
| style="background-color: white;vertical-align:top;"| L03AX03
| style="background-color: white;vertical-align:top;"|BCG vaccine, urology
|-
| style="background-color: white;vertical-align:top;"|L04AA23; L04AA25; L04AA26; L04AA33; L04AA34; L04AB; L04AC
| style="background-color: white;vertical-align:top;"|Immunosuppressive agents
|-
| style="background-color: white;vertical-align:top;"|B03AC; B03XA; B06AC
| style="background-color: white;vertical-align:top;"|Iron, erythropoietin, drugs used in angioedema
|-
| style="background-color: white;vertical-align:top;"|G03GA; G03GB02
| style="background-color: white;vertical-align:top;"|Gonadotropins (HCG, etc.), clomiphene
|-
| style="background-color: white;vertical-align:top;"|H01CA; H01CC; L02AE04
| style="background-color: white;vertical-align:top;"|Gonadorelin, hypothalamic hormones, triptorelin
|-
| style="background-color: white;vertical-align:top;"|J06; J07
| style="background-color: white;vertical-align:top;"|Immunoglobulins, vaccines
|-
| style="background-color: white;vertical-align:top;"|M03AX01
| style="background-color: white;vertical-align:top;"|Botulinum toxin
|-
| style="background-color: white;vertical-align:top;"|R03DX05
| style="background-color: white;vertical-align:top;"|Omalizumab
|-
| style="background-color: white;vertical-align:top;"|S01LA04; S01LA05; S01LA
| style="background-color: white;vertical-align:top;"|OOphthalmological antineovascularisation agents
|}Table 5 Types of clinical medication relevant for external health professionals

==Making medication data available (all information systems)==
All proprietary medication data may be made available when the patient has given his consent (in accordance with applicable laws and regulations). Data received from third parties copied (health care provider/patient) in one’s own information system and marked as ‘copy’, are not made available. The only exception is the transaction Medicatiegegevens (Medication data) PUSH and PULL and Medication overview PUSH and PULL, in which case third parties’ building blocks are made available on the condition that they include the original identification label (see also [[#Inference rules|paragraph 5.6]]).

==Notification date or dispense date (pharmacist information system)==
The notification date and the actual dispense date may be recorded in the medicatieverstrekking. When a verstrekkingsverzoek is processed immediately and the patient picks up the medication that same day, both dates will be the same. When the patient picks up the medication one or several days later, different dates must be entered. The dispense date is the date on which the medicatieverstrekking has actually taken place. The request date is the time at which a pharmacy records an intended medicatieverstrekking. When medication is dispensed on several occasions as part of the same verstrekkingsverzoek (for example, when prescriptions are split), each medicatieverstrekking has its own request date. When an automated dispense system is being used, the dispense date is the time at which the patient picks up the medication from the dispense system. Until this time is available in the PIS, the time at which the medication is deposited in the automated dispense system may be used. See also [[#Request and dispense|paragraph 4.2.5]].

==Updating after system malfunction==
After a system malfunction, the prescriber’s information system needs to determine whether changes have been made to medicatieafspraken. For use cases and rationale, see [[#Discontinuation of medication by third parties|paragraph 4.1.26]] and [[#Two PRKs in a single medicamenteuze behandeling|paragraph 4.1.27]].

==Construction for ‘once every 36 hours’ interval==
When the dosing instruction reads ‘1 tablet every 36 hours’, this may normally be recorded in one medicatieafspraak (dose: 1 tablet, interval: 36 hours). However, when a information system does not go beyond an interval of, for example, 24 hours, another solution needs to be found.

''Variation 1:''
Making use of an ‘as needed’ instruction with the criterion: ‘36 hours have passed since the last medicatietoediening’. This does however come with a certain amount of freedom that may not be desirable.

''Variation 2:''
A repeating dosing schedule can be created, with alternation between administration in the morning, administration in the evening and a day without medicatietoediening:
Repeat period: 3 days
Dosage instruction
Sequence number: 1
Dosage duration: 1 day
Dosage
Dose per administration: 1 tablet
Administration time: 9 am (per example, this could also be a part of the day)
Sequence number: 2
Dosage duration: 1 day
Dosage
Dose per administration: 1 tablet
Administration time: 9 pm (per example, this could also be a part of the day)

If it is not technically possible to choose a 36 hours interval, variation 2 applies.

==EVS / HIS processing Regulation processing==
The prescribing information system is informed by the pharmacist of all dispensings and changes in toedieningsafspraken through the transaction Afhandeling voorschrift (settlement prescription). This handling must be automatically processed in the prescribing information system. The prescriber only assesses the toedieningsafspraken and does not have to assess all the dispensings (verstrekkingen).

==Examples dosages==
See [[mp:V9.1 Voorbeelden doseringen|examples dosages 9.1.0]] (both functional and technical effect in HL7v3 CDA and in FHIR)

==Medicatiegebruik: use indicator, according to agreement indicator, stop type, period of use and dosing instructions==
{| class="wikitable"
|-
|style="text-align:center;" |Situation || 1. Medication is/will be used during period of use according to agreement|| 2. Medication is/will be used during period of use, but not according to agreement || 3. Contrary to agreement, medication is/will not be used during period of use || 4. Medication is/will not be used during period of use, which is according to agreement || 5.Medication is used during period of use but it is unknown if this is according to agreement (selfmedication)
|-
! Use indicator (is this product being used) !! Yes!! Yes !! No !! N/A (because this would lead to a double negative otherwise) !! Yes
|-
! According to agreement indicator !! No!! No !! No!! Yes!! -
|-
! Stoptype!! N/A!! N/A!! Discontinuation or Stop !! Definitve of Temporary !! N/A
|-
| || || || Stoptype depends if agreement is being stoped or dicontinued || Stoptype in acoordance with stop-agreement ||
|-
! Period of use!! In accordance with MA or TA !! Max. 2 out of 3 !! Max. 2 out of 3 !! Max. 2 out of 3 !! Max. 2 out of 3
|-
|style="text-align:right;" | start date || The time at which the medicatiegebruik was started. ||The time at which the deviating medicatiegebruik was/will be started. . || Contrary to agreement, medication is/will not be used during period of use || The time at which the medicatiegebruik was/will be discontinued. || The time at which the medicatiegebruik was started.
|-
|style="text-align:right;" | duration of medicatiegebruik|| The intended duration of medicatiegebruik. || The intended duration of deviating medicatiegebruik. || The (intended) duration of non-use||The (intended) duration of non-use. || The intended duration of medicatiegebruik.
|-
|style="text-align:right;" | end date || The time at which the period of use ends (or has ended or will end). || The time at which the period of deviating use ends (or has ended or will end). || The time at which the use was/will be resumed (or is intended to resume).|| The time at which the medicatiegebruik was/will be resumed (or is intended to resume). || The time at which the period of use ends (or has ended or will end).
|-
! Dosing instructions!! In accordance with MA or TA!! Required!! N/A !! N/A!! Required
|-
| || Medication was/will be used during the period of use according to the agreement, therefore dosage is known. || Medication was/will not be used according to the agreement, the actual dosage used must be communicated. || The medication was/will not be used, there is no dosage. || The medication was/will not be used, there is no dosage. || Dosage tha the patient has agreed upon himself
|}
'''Examples:''' 
'''Situation 1a: Medication is / is used during the period of use according to agreement''' 
Patient has been prescribed Ferrofumarate for anemia. Dosage is 1 tablet 3 times a day half a hour before eating, with a start date of June 4, 2018 and no end date. 
On 10 June, the patient registers the medicatiegebruik for the past period (from 4 to 10 June). 
{| class="wikitable"
|-
! Situation 1a !!
|-
| Medication || FERROFUMARATE 100MG TABLET
|-
| Use indicator || Yes
|-
| According to indicator agreement || Yes
|-
| Stoptype || Not applicable
|-
| Start date|| 4 June 2018
|-
| End date || 10 June 2018
|-
| Dosing instruction || ''According agreement''
|}

'''Situation 1b: Medication is / is used during the period of use according to agreement''' 
Patient has been prescribed Ferrofumarate for anemia. Dosage is 1 tablet 3 times a day half an hour before eating, with a start date of June 4, 2018 and no end date. 
On 10 June, the patient registers the medicatiegebruik for the past period (from 4 to 10 June).
 
{| class="wikitable"
|-
! Situation 1b !!
|-
| Medication || FERROFUMARATE 100MG TABLET
|-
| Use indicator || Yes
|-
| According to indicator agreement || Yes
|-
| Stoptype || Not applicable
|-
| Start date|| 4 June 2018
|-
| End date || -
|-
| Dosing instruction || ''According agreement''
|}

'''Situation 2: Medication is / is used during the period of use, but not by agreement''' 
Patient has been prescribed Ferrofumarate for anemia. Dosage is 1 tablet 3 times a day half an hour before eating, with a start date of June 4, 2018 and no end date. 
The patient is on the road a lot during the day and forgets for a week to take the medicines for lunch. However, the tablets are taken in the morning and evening before eating. 
{| class="wikitable"
|-
! Situation 2 !!
|-
| Medication || FERROFUMARATE 100MG TABLET
|-
| Use indicator || Yes
|-
| According to indicator agreement || No
|-
| Stoptype || Not applicable
|-
| Start date|| 11 June
|-
| End date || 15 June
|-
| Dosing instruction || 1 tablet 2 times a day
|}
'''Situation 3: Contrary to the agreement, the medication is / is not used during the period of use''' 
Patient has been prescribed Ferrofumarate for anemia. Dosage is 1 tablet 3 times a day half an hour before eating, with a start date of June 4, 2018 and no end date. 
The patient goes on vacation for a long weekend and finds out too late that the medication is not packed. The patient will not take the tablets for the next few days and wants to record it. 
{| class="wikitable"
|-
! Situation 3 !!
|-
| Medication || FERROFUMARATE 100MG TABLET
|-
| Use indicator || No
|-
| According to indicator agreement || No
|-
| Stoptype || Temporary
|-
| Start date|| 20 July
|-
| End date || 23 July
|-
| Dosing instruction || Not applicable
|}
'''Situation 4: Medication is / is not used during the period of use and that is also by agreement''' 
Patient has been prescribed Ferrofumarate for anemia. Dosage is 1 tablet 3 times a day half an hour before eating, with a start date of June 4, 2018. 
On August 12, it turns out after checking that there is no longer anemia and the doctor stops the medication. The patient wants to register that she has stopped taking the medication and registers this herself on August 15. 
{| class="wikitable"
|-
! Situation 4 !!
|-
| Medication || FERROFUMARATE 100MG TABLET
|-
| Use indicator || No
|-
| According to indicator agreement || Yes
|-
| Stoptype || Definite
|-
| Start date|| 12 August 2018
|-
| End date || -
|-
| Dosing instruction || Not applicable
|}
'''Situation 5: Medication is used during the period of use, but it is unknown whether this is by appointment or there is no appointment (self-care medication)''' 
Patient has the flu and he takes paracetamol 500 mg from the local drug store for fever and pain. He has been taking 4 to 6 tablets a day for four days and expects to do this for another three days. He registers this on August 12 as medicatiegebruik. 
{| class="wikitable"
|-
! Situation 5 !!
|-
| Medication || Paracetemol 500mg
|-
| Use indicator || Yes
|-
| According to indicator agreement || -
|-
| Stoptype || Not applicable
|-
| Start date|| 9 August 2018
|-
| End date || 7 days
|-
| Dosing instruction || 4 to 6 tablets a day
|}

==Implementation of medication distribution system (GDS) fields==

===Background===
More and more patients are receiving their medication through Individualized Distribution Forms (In dutch geindividualiseerde distributie vorm), with the pharmacist providing patients overview and organization of their drugs by preparing them in separate compartment units. This form of delivery took off when the Medicines Act in 2007 stipulated that in healthcare institutions without a pharmacy, the medication should be individually registered for the patients.

It is important for health professionals to know whether a patient is using GDS. In 2018, an analysis was conducted (under the direction of Z-Index, with health professionals) of the bottlenecks and wishes regarding the recording of a patient using GDS. Overall, it has emerged that it is desirable to be able to see whether a patient is using GDS at both the medication level and the patient level. For details see next paragraph.

The directions below provide guidance on how the Medication Process can support these needs.

===Wishes of care providers===
In 2018, an inventory was made with the user councils of Z-Index about the wishes regarding the recording and exchange of GDS. Below is an overview of these wishes. 

'''Who'''
*All healthcare parties (from prescriber to operator)
'''What'''
*Determines which pharmacy delivers
*Pharmacy must know whether the change applies to the current roll or not
*Important for stopping previous medication at the start of GDS
*Evaluation of GDS patients for health insurer
*Other logistics processes towards home care / informal care

'''Why'''
*Determines which pharmacy delivers
*Pharmacy must know whether the change applies to the current roll or not
*Important for stopping previous medication at the start of GDS
*Evaluation of GDS patients for health insurer
*Other logistics processes towards home care / informal care

'''When'''
*When starting medication, in a pharmacy already before notification of prescription
*When transferring 1st / 2nd line
*When changing (incl. Stopping) medication
*When changing CiO data

'''Where'''
*When working in the patient's file, it should be clear that this characteristic applies to the patient concerned. This can be different for each type of care provider (patient file, medication file). The wish of public pharmacists is that they always have this characteristic available for a specific patient.
*On medication overview

===Data elements Medication process===
The building blocks for the Medication Process have the following fields that play a role in recording GDS. 

{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| '''Buildingblock '''
! style="text-align:left;"| '''Data-element nr'''
! style="text-align:left;"| '''Description'''
! style="text-align:left;"| '''Type of content '''
|-
|style="background-color: white;vertical-align:top;"| Medicatieafspraak
|style="background-color: white;vertical-align:top;"|23283
|style="background-color: white;vertical-align:top;"|Additional information
|style="background-color: white;vertical-align:top;"|Additional information contains a list of details of the medicatieafsrpaak that are important for pharmacovigilance monitoring and completion by a pharmacist.

For example: "change in GDS immediately"..
|-
|style="background-color: white;vertical-align:top;"| Verstrekkingsverzoek
|style="background-color: white;vertical-align:top;"|22759
|style="background-color: white;vertical-align:top;"|Supplementary wishes
|style="background-color: white;vertical-align:top;"|Logistical instructions important for the completion of the dispensing request by the pharmacist.

For example: "do not include in GDS"
|-
|style="background-color: white;vertical-align:top;" rowspan="4"| Verstrekking
|style="background-color: white;vertical-align:top;"|20927
|style="background-color: white;vertical-align:top;"|Distribution form
|style="background-color: white;vertical-align:top;"|Distribution form.

For example: GDS
|-
|style="background-color: white;vertical-align:top;"|20924
|style="background-color: white;vertical-align:top;"|Consumption period
|style="background-color: white;vertical-align:top;"|Stock for this duration
|-
|style="background-color: white;vertical-align:top;"|22500
|style="background-color: white;vertical-align:top;"|Registration date
|style="background-color: white;vertical-align:top;"|The registration date is the time when a pharmacist records an intended dispensing
|-
|style="background-color: white;vertical-align:top;"|20272
|style="background-color: white;vertical-align:top;"|Date
|style="background-color: white;vertical-align:top;"|The time of the dispensing. The date when the medicine is made available to the patient
|}

===Application of data elements to support desired functionality for GDS patients===
====Recording that someone uses GDS====
When working in the patient's file it is important to see that someone is using GDS. This applies to the pharmacy that supplies the GDS, as well as other care providers of the patient. It is therefore important that this information can be communicated with and shown to other health professionals.

As long as there is no patient characteristic with which GDS can be registered, it can be decided to derive this information from the GDS data that have been recorded with the medication. A possible handle for this is the fact that medication is included in the distribution module together with the Distribution form field in the verstrekking (dispensing).
*Step 1: if medication is included in the distribution module: fill in the Distribution form field in the verstrekking with 'GDS'.
*Step 2: Based on the Distribution form field, deduce that a patient is using GDS. The fact that a patient has a dispensing (vertrekking) where the Distribution form field is filled with "GDS" indicates that the patient is using GDS. This dispensing can be a private dipsenisn, or it can be dispensed from another pharmacy (insofar as this data is collected and recorded in such a way that the contents of the Distribution form field are reusable). The fact that a patient uses GDS can then be shown when working in the medication file or the patient file. In consultation with end users, it should be further determined where and how this is shown.

====Recording why someone uses GDS====
Users have indicated that it is desirable to be able to record why someone uses GDS. There are currently no structural fields available for this.

====Record for medication that this must be in the GDS====
Prescribers want to be able to indicate whether or not a medicine should be provided via GDS. This can be done as follows:
*Verstrekkingsverzoek, Additional wishes (aanvullende wensen) field. The code list for this field contains the item "not in GDS". This code list is thesaurus 2051 from file 902 in the G-Standard.

====Establishing / exchanging the duration of a medication roll====
The duration of the medication roll can be determined on the basis of the "duration of use" of the provision: the "duration of use" indicates the duration of a medication roll.

====Establishing / exchanging whether a change in the medication should be effective immediately or not====
It is desirable that a prescriber can indicate whether changes in the medication should be implemented immediately or that they can wait until the next roll change. The handles for this are as follows:
*Medicatieafspraak, Additional information (aanvullende informatie) field. The code list for this field contains two items that relate to changes in the GDS, namely "Change in GDS immediately" and "Change in GDS per roll change". This code list is thesaurus 2050 from file 902 in the G-Standard.
*It is important that the prescriber has insight into the duration of the roll and how long it will take before the current medication roll is used up. This can be deduced from:
**The verstrekking, period of use (verbruiksduur), see above. For this, the prescribing system must have access to the verstrekking data of previous verstrekkingen (dispensings).
**Verstrekking (dispensing), Registration Date (aanschrijfdatum) or Date (datum) field (or if this field is not filled but the Registration date field is, then the registration date.; if both are filled, Date is preferred). Based on this date and the consumption period, it is possible to calculate the date on which the current medication roll is used.

=Reflections=
==Prescription without specified recipient (ambulatory)==
In this paragraph, the term ‘prescription’ is used to indicate the message through which a patient may pick up a medicinal product from a supplier. A prescription contains a medicatieafspraak and a verstrekkingsverzoek.

In the Netherlands it is customary to digitally send prescriptions to a receiving pharmacy instead of having to collect prescriptions. This requires that the pharmacy is already known. 

This paragraph considers whether more flexibility can be achieved in the logistical processing of prescriptions, without canceling out current advantages. This paragraph may be seen as a long-term vision that we aim towards.

===Basic principles===
When considering how to achieve flexibility in the processing of prescriptions, these basic principles have been formulated:
*The patient is free to choose where prescriptions are handled
*The current option for sending prescriptions remains possible.
*The information system must reuse the same functionality as much as possible.
*A prescription may only be dispensed once.
Since the methodology described below uses the existing method of sending prescriptions, the same legal rules and regulations apply to prescription validity. All discussions about electronic signatures are equally applicable to the current method of communicating prescriptions.

===Details===
A patient may choose from 3 options:
#A prescription is always sent to the same regular pharmacist.
#The patient indicates each time where the prescription has to be sent.
#The patient does not give any indication, and goes to a pharmacy which subsequently requests and processes the prescription.
Options 1 and 2 require a patient portal, in which the patient indicates his preference. For option 2, a patient may define a preferred pharmacy which would be at the top of the selection screen when the patient is asked where the prescription must be sent. If the patient does not give any indication, option 3 can be the only procedure.

The method partly uses a concept called “publish and subscribe”.

It is important that the pharmacist explains this principle to his customers.

===Work process===
A physician decides to create a prescription for a patient. This may be during a consultation or even when repeat prescriptions are requested. The physician registers the prescription in his prescribing system (EPS). The physician does not need to consider the pharmacy as the patient handles this through the portal.

After approval of the prescription, a central prescription index is updated. The EVS automatically sends a notification to this prescription registry to facilitate this. Here, the prescription index is seen as a separate registry with the data type “prescriptions”. It is always possible to consider whether or not this can be merged at a later time. Initially, atomic registration in the registry is being considered. However, at a later date, consideration could be given as to whether categorical registration would be sufficient.

It is important to realise that currently only a notification is given when a prescription is ready. After all, the prescription is still in the EVS database with the status “is available”. There is no prescription message yet.

The prescription registry knows from the patient’s preference settings what needs to be done with the notification:
#With the option ‘send to regular pharmacy’, a notification is sent to the subscription holder of the patient with the message that a prescription can be retrieved.
#With the option ‘patient indicates pharmacy’, the prescription registry sends a notification (e.g., SMS) to the patient. The prescription registry then waits until the patient uses a smartphone app or the patient portal to indicate to which pharmacy the notification should be sent.
#With the option ‘no indication’, the prescription registry does nothing. The patient does not have a regular subscription holder.

===Processing by pharmacy===
A receiving pharmacy can deduce from the transmitted notification signal (data type) that it refers to an open prescription. The signal also identifies who the patient is as well as the source of the prescription.

For patients who selected option 3 (no indication), the process starts now. The patient identifies himself and notifies the pharmacy that a prescription is ready at a certain institution. The pharmacist may look in the prescription registry to find out which EVS is involved.

The pharmacy information system asks the EVS source system to send the prescription of the respective patient. Since this is a request without medical content, it may even be submitted at lower trust levels.

===Sending via EVS===
If an EVS receives a request for “sending outstanding prescriptions”, the EVS will check whether prescriptions are indeed outstanding. This prevents a prescription from being retrieved several times. The address of the pharmacy is entered and the prepared prescription message is finally created. The prescription message is sent to the respective pharmacy.

If the prescription has been retrieved before, an error message is sent to the retrieving pharmacy announcing that the prescription is no longer available.

'''Sending prescriptions is the standard process and already customary for pushing prescriptions.''' The advantage of this is that the receiving pharmacy only needs to maintain one method for processing received prescriptions. It is noted again that the same legal rules and regulations continue to apply.

After sending a prescription, the EVS also sends a notification to the prescription registry to remove the entry of the outstanding prescription. This indicates that the respective prescription can no longer be retrieved.

{{anchor|figuur 11}}
[[Bestand:Interactiediagramvoorschrijven.png|Figuur 11 Interactiediagram Ongeadresseerd voorschrijven]]

=Appendix References=

==General references==
{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| Author(s)
! style="text-align:left;"| Title
! style="text-align:left;"| Version
! style="text-align:left;"| Date (consultation)
! style="text-align:left;"| Source
! style="text-align:left;"| Organisation
|-
| style="background-color: white;vertical-align:top;"| NHG, KNMP, Z-index
| style="background-color: white;vertical-align:top;"| Building blocks of the medication process
| style="background-color: white;vertical-align:top;"| 2014
| style="background-color: white;vertical-align:top;"| Augustus 2015
| style="background-color: white;vertical-align:top;"| https://www.nhg.org/bouwstenen
| style="background-color: white;vertical-align:top;"| NHG, KNMP, Z-index
|-
| style="background-color: white;vertical-align:top;"| ActiZ, KNMP, NVZA a.o
| style="background-color: white;vertical-align:top;"| Safe principles in the medication chain
| style="background-color: white;vertical-align:top;"| 2014
| style="background-color: white;vertical-align:top;"| August 2015
| style="background-color: white;vertical-align:top;"| http://www.knmp.nl/patiëntenzorg/samenwerking/brochure-veilige-principes-in-de-medicatieketen
| style="background-color: white;vertical-align:top;"| ActiZ, KNMP, NVZA a.o.
|-
| style="background-color: white;vertical-align:top;"| Miscellaneous
| style="background-color: white;vertical-align:top;"| Guideline on exchange of medication data in the medication chain
| style="background-color: white;vertical-align:top;"| 25 April 2008
| style="background-color: white;vertical-align:top;"| August 2015
| style="background-color: white;vertical-align:top;"| Website KNMP
| style="background-color: white;vertical-align:top;"| Miscellaneous
|-
| style="background-color: white;vertical-align:top;"| Paul Geels
| style="background-color: white;vertical-align:top;"| Assessment of medication self-management (BEM) in care homes, Institute for Responsible Medication Use
| style="background-color: white;vertical-align:top;"| February 2009
| style="background-color: white;vertical-align:top;"|
| style="background-color: white;vertical-align:top;"| http://www.instellingsapotheek.nl/downloads/rapporten/beoordeling_eigen_beheer_van_medicatie_in_verzorgingshuizen.pdf
| style="background-color: white;vertical-align:top;"| Institute for responsible medicatiegebruik
|-
| style="background-color: white;vertical-align:top;"| ActiZ
| style="background-color: white;vertical-align:top;"| Safety in the medication chain
| style="background-color: white;vertical-align:top;"| March 2012
| style="background-color: white;vertical-align:top;"|
| style="background-color: white;vertical-align:top;"| https://www.knmp.nl/downloads/brochure-veiligheid-in-de-medicatieketen.pdf
| style="background-color: white;vertical-align:top;"| ActiZ, Miscellaneous
|-
| style="background-color: white;vertical-align:top;"| KNMG
| style="background-color: white;vertical-align:top;"| Guideline on electronic prescription
| style="background-color: white;vertical-align:top;"| September 2013
| style="background-color: white;vertical-align:top;"|
| style="background-color: white;vertical-align:top;"| Website KNMG
| style="background-color: white;vertical-align:top;"| KNMG
|}

==Qualification scripts==
[[mp:Vdraft Kwalificatie|Qualification scripts]]

=Attachment: Document history=

{{anchor|tabel 6}}
{| class="wikitable" "cellpadding="10"
!style="text-align:left;"|Version
!style="text-align:left;"|Date
!style="text-align:left;"|Description
|-
| style="background-color: white;"| 0.95
| style="background-color: white;"| 15 July 2016
| style="background-color: white;"| Pilot version
|-
| style="background-color: white;"| 0.96
| style="background-color: white;"| 1 December 2016
| style="background-color: white;"| Paragraph 2.4 Process: Administer was adapted and C6: Sending/receiving administration data was added as a result.
|-
| style="background-color: white;vertical-align:top;"| 0.97
| style="background-color: white;vertical-align:top;"| 22 December 2016
| style="background-color: white;"| Paragraph 2.4, 4.3.1 review remarks incorporated. 
Paragraph 4.2.11 text made more precise.
|-
| style="background-color: white;vertical-align:top;"| 9.0.2
| style="background-color: white;vertical-align:top;"| 18 June 2017
| style="background-color: white;"| Conversion of the document to wiki.
|-
| style="background-color: white;vertical-align:top;"| 9.0.4
| style="background-color: white;vertical-align:top;"| September 2017
| style="background-color: white;vertical-align:top;"|
*Processed [[mp:V9.0_Ontwerpbeslissingen|Design decisions]] in functional design. This means the design decisions have become obsolete. The current Functional Design is now leading.
*Par. 1.3.1. Definitions of building blocks have been adapted and the abbreviation for medicatieverstrekking has changed to MVE.
*Par. 1.3.3. Medicamenteuze behandeling is now based on PRK, rewritten and introduced PT as well as added text on handling parallel MAs.
*Par. 1.3.4. New data model diagram, various relations added and adapted on the basis of design decisions.
*Par. 1.5 Glossary removed.
*C2 Medication process diagram changed: MO added to actively making available by the user; lines in swimlane of administrator/use adapted.
*C4.1 New use cases added: Do not dispense before, Two PRKs in a single medicamenteuze behandeling, Discontinuation of medication by third parties, Creating a medicatieafspraak after the fact, Parallel medicatieafspraken.
*C4.2 New use case: Discontinuing medication in a GDS; modified use case: Request, dispense and not picked up.
*C5: Differences between medication profile and medication overview were described; inference rules adapted on the basis of the new design decisions.
*Where necessary, references from ART-DECOR to FD C7 were added.
*Various grammatical and minor textual changes.
|-
| style="background-color: white;vertical-align:top;"| 9.0.5
| style="background-color: white;vertical-align:top;"| January 2018
| style="background-color: white;vertical-align:top;"|
*Terminology: Stop-MA was changed to stop-MA in accordance with earlier project agreements (in Dutch different terminology Stop changed to staken)
*Par. 1.3.4 Addition to indicate that MA may also refer to a building block under a different medicamenteuze behandeling.
*Par. 4.1.22 Discharge was adapted because outpatient medication that was discontinued earlier may be started again at discharge.
*Par. 4.1.26 Discontinuation of medication by third parties was adapted.
*Par. 4.1.27 Two PRKs under a single medicamenteuze behandeling.
*Par. 2.2.5.3 Medication discontinuation agreement was adapted to clarify the impact on previously entered future medicatieafspraken.
*Footnote 3 Provisional and final medication order clarified and use case Provisional and final medication order (par. 4.1.31) added.
*Par. 4.1.30 Use case Single use added.
*Paragraphs 2.2.4, 2.2.5.2, 2.2.5.4, 4.1.16, 4.1.22 were adapted for substitution. In case of substitution, a medicamenteuze behandeling is not temporarily halted but effectively discontinued. The substitution is started under a new medicamenteuze behandeling.
*Paragraph 4.1.33 Missing digital medicatieafspraak at admission was added.
*C5 Medication overview was adapted with a reference to a new content page with functional elaboration.
*Paragraph 7.10 Medicatiegebruik: use indicator, according to agreement indicator and stop type added as agreed.
*C6 Building blocks of medication overview were changed to MA, TA and MGB.
*Figure 2 Colours in data model in accordance with Figure 1.
*Various abbreviations explained.
|-
| style="background-color: white;vertical-align:top;"| 9.0.6
| style="background-color: white;vertical-align:top;"| May 2018
| style="background-color: white;vertical-align:top;"|
*Addition to proposed verstrekkingsverzoek and addition of reply proposed verstrekkingsverzoek
*Chapter 6 table 4 addition of links to ART-DECOR transactions
*Removed: chapter about LSP
*Par. 7.10 table was extended with period of use and dosing instructions
*Various paragraphs were made more precise
*Addition of the property ‘third parties’ building block’ for MA, TA and MGB in medication overview
|-
| style="background-color: white;vertical-align:top;"| 9.0.7
| style="background-color: white;vertical-align:top;"| December 2018
| style="background-color: white;vertical-align:top;"|
*Par 1.3.3. MBH at HPK level in case of 'non medicines' without a PRK level
*Par 1.3.3. MBH for medicines without PRK (magistrals, infusions, etc.)
*Par 2.2.5.5. Changing medication: Technical stop-ma: appointment date for stop-ma and new ma must be the same. Change on MA that has already been stopped explained (no extra Stop-ma needed)
*Par 2.2.6. Added: VV under MA of someone else
*Par 4.2.15. Explanation GDS supplier supplies different HPK
*Par 7.10: Medication use indicator, according to appointment indicator, stop type, period of use and dosing instruction: table adapted and examples added
*Par 4.1.34: Own articles explanation added
*Chapter 5: example medication overview inserted in this wiki page instead of a separate wiki page (to simplify searching within the FO).
*Various textual tightening / improvements
|-
| style="background-color: white;vertical-align:top;"| 9.0.7
| style="background-color: white;vertical-align:top;"| July 2019
| style="background-color: white;vertical-align:top;"|
*Removed examples of specific infrastructures
|-
| style="background-color: white;vertical-align:top;"| 9.1.0
| style="background-color: white;vertical-align:top;"| 29 January 2020
| style="background-color: white;vertical-align:top;"|
*Stop textual adjustments
*Par 7.11 added: Implementation of medication distribution system (GDS) fields
*[https://bits.nictiz.nl/browse/MP-85 BITS MP-85], [https://bits.nictiz.nl/browse/MP-93 BITS MP-93], [https://bits.nictiz.nl/browse/MP-122 BITS MP-122] Use cases added (Register usage based on verstrekkingn, Verstrekkingsverzoek with number of repetitions, Prescribe non-drug)
*Chapter 4: Added pictures of use cases
*Renal function value in the prescription
*[https://bits.nictiz.nl/browse/MP-48 BITS MP-48] Medication Overview: Par 5.7 added 'Fields not to be shown'
*Various textual specifications/ improvements, including [https://bits.nictiz.nl/browse/MP-131 o.a. BITS MP-131]
*Paragraph 'Unaddressed prescription' moved to chapter 'Considerations'
*[https://bits.nictiz.nl/browse/MP-151 BITS MP-151] Removed draft TA creation process
*[https://bits.nictiz.nl/browse/MP-128 BITS MP-128] Par 4.1.8: Explanation 'Medical necessity'
*[https://bits.nictiz.nl/browse/MP-129 BITS MP-129] Par 4.1.35: Use case added
|-
| style="background-color: white;vertical-align:top;"| 9.1.0
| style="background-color: white;vertical-align:top;"| September 2020
| style="background-color: white;vertical-align:top;"|
*[https://bits.nictiz.nl/browse/MP-167 BITS MP-167] FO Translated in English
|-
| style="background-color: white;vertical-align:top;"| 9 2.0.0 bèta
| style="background-color: white;vertical-align:top;"| 01 october 2021
| style="background-color: white;vertical-align:top;"| all changes see: *[https://informatiestandaarden.nictiz.nl/wiki/mp:V9_2.0.beta_releasenotes Releasenotes]
|}

=Appendix: Figures and tables=
[[#figuur 1|Figure 1 Building blocks - overview]] 
[[#figuur 2|Figure 2 Building blocks - coherence]] 
[[#figuur 3|Figure 3 Activity diagram - Medication process in general]] 
[[#figuur 4|Figure 4 Process steps and transactions - medication verification]] 
[[#figuur 5|Figure 5 Process steps and transactions - prescribing]] 
[[#figuur 6|Figure 6 Process steps and transactions - make available]] 
[[#figuur 7|Figure 7 Process steps and transactions - administer]] 
[[#figuur 8|Figure 8 Process steps and transactions - use]] 
[[#figuur 9|Figure 9 Example effective period]] 
[[#figuur 10|Figure 10 Overview of systems and system roles]] 
[[#figuur 11|Figure 11 Interaction diagram Prescribing without address]] 

[[#tabel 1|Table 1 Building blocks - description]] 
[[#tabel 2|Table 2 Informing versus (Active) making available]] 
[[#tabel 3|Table 3 Overview of system roles]] 
[[#tabel 4|Table 4 Overview of transaction groups]] 
[[#tabel 5|Table 5 Types of clinical medication relevant for outpatient care providers]]

mp:V2.0.0 Ontwerp medicatieproces 9 ENG

2022-04-04T14:52:47Z

Petra van Deursen: /* Starting with medication before admission */

{{IssueBox|'''ATTENTION: This is a development version. For an overview of current documentation for Medication Process see here [[Landingspagina_Medicatieproces]].'''}}

__NUMBEREDHEADINGS__
{{DISPLAYTITLE:DEVELOPMENT PAGE Functional Design Medication Process 9 version 2.0.0 English version}}
[[Bestand:ENG.jpg|50px]] [[mp:V2.0.0_Ontwerp_medicatieproces_9_ENG|This is the ENG version]] 
[[Bestand:NL.jpg|50px]] [[mp:V2.0.0_Ontwerp_medicatieproces_9|Klik hier voor de NL versie]] 
For an overview of relevant wiki pages for Medication Process see [[Landingspagina_Medicatieproces]]

=Introduction=

This document is the functional design for the Medication Process Information Standard (in Dutch: 'Informatiestandaard Medicatieproces'). It provides a general description as well as a description of specific practical situations. The recording and exchange of information is described for specific situations using actors (people, information systems) and transactions (which information is exchanged when).

Target groups for this document:
*Health professionals
*Information analysts and architects
*Software suppliers

==Scope and vision==

This document has been produced within the Medication process program. The Medication process program aims first to take away existing obstacles in the medication process, while taking into account current legislation and the possibility of obtaining tangible results in the foreseeable future.

One of the main obstacle entails the lack of insight in the actual medication use of patients. This is partly due to the fact that therapeutic and logistical information are often mixed, which results in the medication history becoming unclear. The following distinction between therapy and logistics exists:

* '''Therapy''' covers the medical side. This includes medication (and treatment) agreements, as well as the corresponding support and implementation. Therapeutic intention, (actual) medication use, self-medication and pharmacotherapy are also covered by the term ‘therapy’ as it is defined in this document.
* '''Logistics''' covers the physical flow of medicinal products, including requests, planning and dispense. This also includes medication supply and the medication use.

The program has taken into account current legislation and feasibility within the foreseeable future. The vision goes beyond the scope of the Medication process program and lays the foundations for a situation where a dispense request is no longer required. The ultimate objective is for prescribers to only have to concern themselves with the therapeutic side (which medicinal product, which strength, which dosage, when to start, etc.). It will no longer be necessary to create a dispense request. Instead, the prescriber will make medication agreements directly with the patient. Based on these medication agreements, the pharmacist will take care of the logistical process, eliminating the need for a dispense request altogether. Because of legislation this is not (yet) possible. The Medication process program does however take the first necessary step in the right direction.

==Reading guide==

The following paragraph introduces the main building blocks and the terminology used in this document. Detailed descriptions of the various processes (prescribe, dispense, administer, medication use) are given in [[#Medication process|Chapter 2]]. The purpose of the descriptions is to clarify how healthcare processes function in an ideal situation; which process steps are needed; which actors are participating; which information applies and which moments of exchange exist. The process descriptions follow a fixed format:

*Current situation  This paragraph describes the relevant differences between the current situation and the desired situation ('soll') in accordance with this information standard. Any obstacles will be described here.
*Process description with the paragraphs:
** ''Precondition'' The conditions that must be met before the process is started.
** ''Trigger Event'' The event that starts the process.
** ''One or more process steps'' Description of part of the process.
**''Post-condition'' The conditions that are met after the process steps have been carried out.
**''Use cases'' List of use cases associated with a specific subprocess. The use cases are detailed in [[#Description of use cases|Chapter 4]].
**''Information sytems and transaction groups'', This paragraph describes the information systems, system roles, transactions and transaction groups related to the process steps. All information concerning information systems and transaction groups is also included in [[#Information systems and transactions|Chapter 6]].

[[#Domain-specific handling of the medication process|Chapter 3]] describes a number of domain-specific interpretations of the medication process, for instance those of the thrombosis service and those related to service observation services in an ambulatory situation. [[#Description of use cases|Chapter 4]] describes several use cases in more detail. The practical situations are derived from general medical practice in a large number of cases but are illustrative of similar situations in a different setting. The use cases are classified according to subprocess, as indicated in [[#Medication process|Chapter 2]]. 
[[#Medication overview and inference rules|Chapter 5]] describes how a medication profile can be constructed from the different building blocks. [[#Information systems and transactions|Chapter 6]] includes an overview of all information systems, system roles, transactions and transaction groups. Guidelines for the functionality of the various information systems have been detailed in [[#Functionality|Chapter 7]].

In this document, Dutch terminology is used for the medication building blocks: 'medicatieafspraak' (MA), 'verstrekkingsverzoek' (VV), 'toedieningsafspraak' (TA), 'medicatieverstrekking' (MVE), 'medicatietoediening' (MTD), 'medicatiegebruik' (MGB), 'medicatieverbruik' (MVB) (see Table 1 for the English translations). Dutch terminology for the medication building blocks is consistently used even in translated documents, as a translation may not refer to exactly the same entity.

==Introduction of relevant terms==

===Therapeutic and logistical building blocks===

The use cases include a description of the process and the data elements associated with it. Related data elements are grouped together in a Clinical Information Model (CIM) or Clinical Building Block (CBB) (in Dutch: 'zorginformatiebouwsteen' - zib). The dataset details the data elements of which these zibs consist; data elements may have been added to the zibs in keeping with the clinical context and care process. The data set includes the complete set of definitions of the data elements of the building blocks. The building blocks together with their data elements can be used in various scenarios for arranging/modelling healthcare applications or for defining interfaces for data exchange.

The different building blocks are shown in the figure below. They have been ordered according to process and subprocesses, and according to therapy versus logistics.

{{anchor|figuur 1}}
[[Bestand:Figuur 1 Bouwstenen - overzicht.png|Figuur 1 Buildingblocks- overview]]

The table below provides a description of the building blocks. The four additional concepts ‘voorstel medicatieafspraak’ (therapeutic), 'antwoord voorstel medicatieafspraak' (therapeutic), ‘voorstel verstrekkingsverzoek’ (logistics) and ‘antwoord voorstel-verstrekkingsverzoek’ (logistics) are also described.

{{anchor|tabel 1}}
{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| Building blocks in Dutch
! style="text-align:left;"| Abbr. in Dutch
! style="text-align:left;"| Building blocks in English
! style="text-align:left;"| Description
|-
| style="background-color: white;vertical-align:top;"| Medicatieafspraak
| style="background-color: white;vertical-align:top;"| MA
| style="background-color: white;vertical-align:top;"| Medication agreement
| style="background-color: white;vertical-align:top;"| 'Medicatieafspraak' is the prescriber’s proposal for medication use with which the patient agrees. An agreement to discontinue medication is also a 'medicatieafspraak'<ref>This document only uses the term medicatieafspraak, which therefore also indicates the clinical equivalent provisional medication order</ref>.
|-
| style="background-color: white;vertical-align:top;"| Wisselend doseerschema
| style="background-color: white;vertical-align:top;"| WDS
| style="background-color: white;vertical-align:top;"| Variable dosing regimen
| style="background-color: white;vertical-align:top;"| 'Wisselend doseerschema' contains the dosing instruction as composed by an (external) prescriber. In the 'wisselend doseerschema' the element 'instructions for use' from the 'medicatieafspraak' is further specified. The 'wisselend doseerschema' can be adapted without changing the 'medicatieafspraak'.
|-
| style="background-color: white;vertical-align:top;"| Verstrekkingsverzoek
| style="background-color: white;vertical-align:top;"| VV
| style="background-color: white;vertical-align:top;"| Dispense request
| style="background-color: white;vertical-align:top;"| 'Verstrekkingsverzoek' is the request from a prescriber to a pharmacist to supply the patient with one or more medicinal products in support of the current 'medicatieafspraak'/'medicatieafspraken'<ref>The verstrekkingsverzoek building block is not applicable in the clinical setting. Dispensing medication is handled in different ways in the clinical setting. Replenishment of, for example, a department’s supply is not considered a medicatieverstrekking, but rather an extension of the pharmacist’s stock. Medicatieverstrekking only takes place when the link between the medication and patient has been made. In clinical situations, administration often takes place immediately afterwards.</ref>.
|-
| style="background-color: white;vertical-align:top;"| Toedieningsafspraak
| style="background-color: white;vertical-align:top;"| TA
| style="background-color: white;vertical-align:top;"| Administration agreement
| style="background-color: white;vertical-align:top;"| 'Toedieningsafspraak' contains the instructions for medication use (or administration) from the pharmacist to the patient (or his representative or administrator), adding to the 'medicatieafspraak'<ref name="MO">A provisional medication order, as it is used in hospitals, is both the request from the physician to the administrator to administer medication to the patient as a verstrekkingsverzoek to the pharmacist to ensure that the medication is available for the administrator. This last part corresponds to the medicatieafspraak and the verstrekkingsverzoek from the first line. In addition, the hospital pharmacist usually carries out a validation of the administration request (this creates the final medication order which is called a toedieningsafspraak here). The provisional medication order is therefore not the same as a proposal from, for example, from a nurse on the basis of a protocol that has not yet been approved by a physician. </ref>.
|-
| style="background-color: white;vertical-align:top;"| Medicatieverstrekking
| style="background-color: white;vertical-align:top;"| MVE
| style="background-color: white;vertical-align:top;"| Medication dispense
| style="background-color: white;vertical-align:top;"| 'Medicatieverstrekking' is the provision of a supply of medicinal product to the patient or his administrator or representative.
|-
| style="background-color: white;vertical-align:top;"| Medicatietoediening
| style="background-color: white;vertical-align:top;"| MTD
| style="background-color: white;vertical-align:top;"| Medication administration
| style="background-color: white;vertical-align:top;"| 'Medicatietoediening' is the registration of the individual administrations of the medicinal product to the patient by the person who administers them (such as a nurse or the patient himself) in relation to the agreements made.
|-
| style="background-color: white;vertical-align:top;"| Medicatiegebruik
| style="background-color: white;vertical-align:top;"| MGB
| style="background-color: white;vertical-align:top;"| Medication use
| style="background-color: white;vertical-align:top;"| 'Medicatiegebruik' is a statement about historical, current or intended use of a medicinal product<ref>Use may have been preceded by medicatietoediening. Registration of medicatiegebruik, for example after medicatietoediening of rabies vaccinations or infusion is not obvious.</ref>.
|-
| style="background-color: white;vertical-align:top;"| Medicatieverbruik
| style="background-color: white;vertical-align:top;"| MVB
| style="background-color: white;vertical-align:top;"| Medication consumption
| style="background-color: white;vertical-align:top;"| 'Medicatieverbruik' is the logistical perspective on medication use. It describes how long a (partial) supply of medicinal products has lasted or will last for a patient<ref>From one-time to a certain period. The building block ‘Medicatieverbruik’ has not been detailed any further in this information standard.</ref>.
|-
| style="background-color: white;vertical-align:top;"| Voorstel medicatieafspraak
| style="background-color: white;vertical-align:top;"| VMA
| style="background-color: white;vertical-align:top;"| Proposed medication agreement
| style="background-color: white;vertical-align:top;"| 'Voorstel medicatieafspraak' is a recommendation or request from the pharmacist, prescriber or the administer to the presciber of the MA about the agreed upon or to be agreed upon medication.The recommendation request may include discontinuing, starting or modifying medication. The patient is unable to send a VMA.
|-
| style="background-color: white;vertical-align:top;"| Antwoord voorstel medicatieafspraak
| style="background-color: white;vertical-align:top;"| AVMA
| style="background-color: white;vertical-align:top;"| Reply proposed medication agreement
| style="background-color: white;vertical-align:top;"| 'Antwoord voorstel medicatieafspraak' is a replay from the prescriber to the 'voorstel medicatieafspraak'.
|-
| style="background-color: white;vertical-align:top;"| Voorstel verstrekkingsverzoek
| style="background-color: white;vertical-align:top;"| VVV
| style="background-color: white;vertical-align:top;"| Proposed dispense request
| style="background-color: white;vertical-align:top;"| 'Voorstel verstrekkingsverzoek' is a proposal from the pharmacist to the prescriber to approve one or more 'medicatieverstrekking'/'medicatieverstrekkingen' in support of the current 'medicatieafspraak'/'medicatieafspraken'. This is comparable with the current situation of submitting the authorization form or combined prescription or submitting a repeat prescription for signing. The patient may also submit a 'voorstel verstrekkingsverzoek' to the prescriber.
|-
| style="background-color: white;vertical-align:top;"| Antwoord voorstel‐verstrekkingsverzoek
| style="background-color: white;vertical-align:top;"| AVVV
| style="background-color: white;vertical-align:top;"| Reply proposed dispense request
| style="background-color: white;vertical-align:top;"| 'Antwoord voorstel-verstrekkingsverzoek' is a reply from the prescriber to the 'voorstel verstrekkingsverzoek'.
|}Table 1 Building blocks – description

===Medication overview===
See [[#Medication overview and inference rules|Chapter 5]] for more information about these overviews, the applicable building blocks and how a medication profile/current overview can be compiled.

==='Medicamenteuze behandeling'===

The different medication building blocks represent steps in the medication process, from prescribing a medicinal product (MA and/or VV), followed by dispensing it (TA and/or MVE) up to and including administering and using the medicinal product. The model is designed in such a way that therapeutic building blocks and logistical building blocks are separated from each other. 
'''Scope''' 
In order to be able to give a name to the interdependence of the medication building blocks, the concept of ‘pharmaceutical treatment’ (in Dutch: 'medicamenteuze behandeling' - MBH) is introduced. 
:'''Medicamenteuze behandeling' is a '''technical concept''' in the information standard. Its purpose is'': 
:#''To unambiguously identify the set of interdependent medication building blocks, and'' 
:#''To apply rules to it to unambiguously determine the present situation''. 
The functional application of the concept of 'medicamenteuze behandeling' is as follows: 
*Medication (or 'medicamenteuze behandeling') is started by creating a first MA as part of a new 'medicamenteuze behandeling'.
*Medication (or 'medicamenteuze behandeling') is discontinued by creating a new MA within the same 'medicamenteuze behandeling' (stop-MA).
*Medication (or 'medicamenteuze behandeling') is modified by:
#Discontinuing the existing MA and
#Creating a new changed MA as part of the same 'medicamenteuze behandeling'. The starting date of this new MA may also be in the future.

Prescribing a new medicinal product always results in a new MA. An MA is always related to a single 'medicamenteuze behandeling'. For the time being, the PRK level (Prescription Code from the G-standard) of the medicinal product determines whether the MA belongs to a new or an existing 'medicamenteuze behandeling'. This may be extended to the SNK level (Substance Name Code from the G-standard) in the future, which would mean that changes in strength or between medicinal products from the same group no longer lead to a new 'medicamenteuze behandeling'. A detailed description can be found in [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5 Process step: Creating a medicatieafspraak]].

Exceptions:
*Products without PRK (a non-medicine such as crutches or bandages). In this case the HPK level (Trade Product Code from the G-standard) determines if the MA will lead to a new 'medicamenteuze behandeling'.
*Medication without PRK (magistrals often consist of several substances that are not covered by the same PRK, these substances are included separately as ingredients in the MA). Every magisterial or adaptation to it falls under a 'medicamenteuze behandeling'.
*Own articles without PRK (articles listed in the internal information system under 90 million numbers stored, such as half tablets, commonly used magistrals). Any item or adaptation to this falls under a 'medicamenteuze behandeling'.
*Intravenous (IV) therapy (still be selected).

'''Examples''' 
Five examples illustrate the scope of a 'medicamenteuze behandeling': 
*Diazepam, 5 mg, 1 tablet 4x daily is changed to diazepam, 5 mg, 1 tablet 3x daily. The PRK level of both products is the same, they are both part of the same 'medicamenteuze behandeling'.
*Paroxetin tablet, 10 mg, 1 tablet 1x daily, is changed to paroxetin tablet, 20 mg, 1 tablet 1x daily. This is a modification of an MA with two different medicinal products at the PRK level. This change requires that the first 'medicamenteuze behandeling' is discontinued and a new 'medicamenteuze behandeling' is started.
*A gastroprotective drugs has been agreed upon in a treatment with prednisone: prednisone and gastroprotective drugs are two different medicinal products, which are used parallel to each other and their use can be modified and discontinued independently of each other. This means they are not part of the same 'medicamenteuze behandeling'.
*Switching from a beta blocker to an ACE inhibitor means a new PRK and this is achieved by discontinuing the 'medicamenteuze behandeling' of the beta blocker and starting a new 'medicamenteuze behandeling' for the ACE inhibitor.
*When there is no PRK and the composition of the medicinal products in the MA changes (any change in the ingredients), the existing 'medicamenteuze behandeling' is discontinued and a new 'medicamenteuze behandeling' is started. This applies, for example, to extemporaneous preparations, drips and proprietary products. 

'''Creation of a 'medicamenteuze behandeling'''' 
A schematic overview of how a 'medicamenteuze behandeling' (MBH) is set up can be seen in the figure below. When a new building block (MA, TA, VV, MVE, MTD or MGB) is created, a check is first performed to determine whether this is a new medication or if there already is a current building block with the same product. This applies to all building blocks, both proprietary or third parties’. In most information systems, the user of the information system will indicate that he wants to change one of the existing medication building blocks or wants to introduce new medication. In that case, it is easy to find out whether there already is a 'medicamenteuze behandeling' that includes the building block.
*If there is no existing building block for this medication, a new building block with a new 'medicamenteuze behandeling' is created.
*If there is an existing building block with a 'medicamenteuze behandeling', the user of the information system is asked whether the new building block and the existing building block belong to the same treatment. When this is the case, the same 'medicamenteuze behandeling' will be used. When the building blocks do not belong to the same treatment, a new 'medicamenteuze behandeling' will be created.
{{anchor|figuur 2}}
[[Bestand:Ontstaan_MBH.png|500px|Figuur 2 Ontstaan medicamenteuze behandeling]]

 
'''Parallel occurrence of 'medicatieafspraken'''' 
Within a 'medicamenteuze behandeling', several MAs may be active simultaneously. These are all MAs that are valid ('current') at this time or that will become valid in the future. In principle, only one MA is valid at any time in a 'medicamenteuze behandeling'. However, there are a number of situations where parallel MAs are conceivable:
#The same medicinal product, but a different strength, where the total strength should essentially be prescribed in one agreement.
#Related (different) medicinal products that are given together, but that should be considered as a whole when evaluating treatment.
#Technical omissions in information systems. For example, in the case of complicated dosing schedules or combination drips. 

'''Situation 1''' can be resolved by prescribing at a higher level (SNK). G-standard/Z-Index is working on this, but it is not yet possible. Until that time, 1 or more products can be combined in the same MA by entering the products as ingredients. This is comparable to extemporaneous preparations. However, the instructions for use for all these products must be identical.<ref>In practice several MAs (with different PRKs) are often combined into a single product instead of a single MA with underlying the composition.</ref> 
'''Situation 2''' is solved in different ways in different information systems, each with their own grouping mechanisms. It concerns the correlation between different medicamenteuze behandelingmedicamenteuze behandelings. The information standard does not provide a universal grouping mechanism. 
'''Situation 3''' is the only situation in which parallel medicatieafspraken are permitted under one medicamenteuze behandelingmedicamenteuze behandeling. Complex phasing-in and phasing-out schedules and combination drips may be included in one medicatieafspraak, but not all information systems support this. For those information systems, it is permitted to create parallel medicatieafspraken within a single medicamenteuze behandelingmedicamenteuze behandeling. 

===Correlation between building blocks and 'medicamenteuze behandeling'===

The figure below shows the correlations between building blocks and the MBH. The relations between building blocks and the MBH as well as the relations between the building blocks themselves are described as follows:
*Building blocks belong to a single MBH. An MBH includes at least one MA and may include zero or more of the following building blocks VV, WDS, TA, MVE, MGB and MTD. Unless, for example, self-medication has been recorded with MGB or in case a paper prescription has been submitted, a drug treatment can exist without an MA, but with MGB or TA. A MBH will never cease to exist, but it may no longer be effective when there are no current building blocks linked to it. A VMA, AVMA, VVV and AVVV are not yet part of a MBH as these are still a draft/proposal that may or may not lead to a final MA or VV linked to an MBH. A VMA may lead to zero (if the recommendation is not followed), one or more MAs and a VVV may lead to zero (if the proposal is not honoured), one or more VVs.
*An MBH may also only have a stop-MA in addition to, for example, an MGB building block. For example, in the event that a health professional asks a patient to stop using free available medicine (self-care medication or over-the-counter (OTC) medication). The health professional records the use of the self-care medication in an MGB building block and discontinues the use by creating a stop-MA (stop-MA belonging to the same MBH).
*An MA may refer to the previous MA or a TA or MGB on which it is based. This may also be an MA, TA or MGB that belongs to another MBH. It is possible that no digital MA is available (e.g. paper prescription [[#Paper prescription|paragraph 4.1.17]]). This MA must then be created. This MA may refer to the TA or MGB. A pharmacist is never the source of an MA but he may have a copy.
*In principle, only one MA is valid at any one time in an MBH. Only when there are technical omissions in information systems, for example in case of complicated dosing schedules or combination drips, parallel MAs are allowed (see also the previous section).
*An MA is supported by zero (if there is still enough supply or if no medication dispense is needed), one or more (when there is, for example, continuous medication) VVs.
*A VV is based on the current MA and any existing corresponding TA in an MBH. There may be several.
*A VV refers to one or more MAs (for example, in the case of an interim dosage increase, a VV can be made that replenishes the supply for the existing MA and also starts the supply for the future MA).
*A VV may result in zero (for example when the patient does not pick up the medication) to several MVEs.
*A MA may result in zero, one or multiple WDS's.
*Multiple (possibly parallel) TAs may be based on the same MA (for example, when a pharmacist switches to a different commercial product or when the medicinal product is supplied as two or more medicinal products with different strengths, with the total strength remaining the same). When a paper prescription is submitted and the MA and the VV are not available in digital form, there is a TA without an MA.
*An MA does not always have to lead to a TA, for example when no VV is required with a short use MA, when the patient still has sufficient stock.
*A TA is supported by zero (when there is enough supply), one or more MVEs.
*An MVE is based on a MA (and TA) and, in an ambulatory situation, on a VV. The exception are over-the-counter (OTC/self-medication) sales for the purpose of self-care medication: these have no MAs and no VVs. Self-care medication provided by the pharmacist may be recorded by that pharmacist as a TA with MVE, or as MGB by a random health professional or by the patient himself.
*An MVE may support multiple TAs.
*An MA or a TA may be followed by a new MA or TA. This may be the case when existing medication is changed (modification of MA and/or TA) or when MGB is discontinued (stop-MA/TA).

{{anchor|figuur 2}}
[[Image: Datamodel_MP92.PNG|800px|Figuur 2 - Datamodel Medicatieproces]]

===Informing and (actively) making available===
[[#Medication process|Chapter 2]] describes the medication process. This includes process steps labelled ‘Inform’ or ‘(actively) make available’. The table below includes a detailed description of the reason for this. [[#Medication process|Chapter 2]] further elaborates on situations in which information is actively sent or made available. 

{{anchor|tabel 2}}
{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| Term
! style="text-align:left;"| Toelichting
|-
| style="background-color: white;vertical-align:top;"| Inform
| style="background-color: white;vertical-align:top;"| ‘Inform’ means sending an order or request addressed to another actor. This is a so-called ‘push’ of information: the actor sends the information specifically to recipient. This may be by means of
*An electronic message via a digital network,
*Paper (for example by giving a prescription intended for a pharmacist to the patient),
*A fax message,
*A combination of the above options.
|-
| style="background-color: white;vertical-align:top;"| (Actively) make available
| style="background-color: white;vertical-align:top;"| The health professional (actively) makes information available to another actor. This process step concerns:
*Actively sending or informing (‘push’) as described above or
*Automatically making information available to health professionals and/or the patient when they request it on the basis of prior permission or
*A combination of both previous bullets. 

Data are always made available. Additionally, the health professional has the option to specifically inform fellow health professionals and/or the patient at any time during the process. In consultation with the patient, data can be sent to a health professional of his choice (inform).
|} Table 2 Informing versus (actively) making available

The technical mechanism (‘pull’, ‘publish and subscribe’, ‘push’, etc.) used to (actively) make data available, is infrastructure-dependent and is therefore not detailed in this document. 

The Royal Dutch Medical Association (KNMG) describes in its publication 'Van wet naar praktijk: implementatie van de WGBO Deel 4. Toegang tot patiëntengegevens' [From law to practice: implementation of the Dutch Medical Treatment Contracts Act Part 4. Access to patient data] when there is implicit consent and explicit consent. The exchange described in this information standard is subject to current legal frameworks and guidelines concerning consent and opt-in and these are therefore not explicitly described.

==Legend/Explanation==
A manual for this Nictiz wiki documentation can be found at: 
http://informatiestandaarden.nictiz.nl/wiki/Handleiding_Wiki_documentatie 
It also includes a legend for the various figures that appear in this document.

=Medication process=
This chapter describes the medication process in relation to the building blocks for first-line, second-line and third-line health care. The process is fundamentally the same in each case. The main difference is which pharmacy supplies the medication: a community pharmacy (including an outpatient pharmacy) or a hospital pharmacy. Another difference is that in an ambulatory setting a VV is required for the supply of medicinal products. This is not required in a hospital setting: the (hospital) pharmacist ensures that the medicinal products are available as long as the MA continues.

The medication process is a cyclical process consisting of prescribing, dispensing, administering and using medication. The process starts when the patient/client visits a health professional/healthcare provider (general practitioner, hospital or other institution) for a treatment with a medicinal product and ends when the medication is no longer needed. The process is depicted in Figure 4. The yellow bar indicates the medication verification process, green prescription, purple dispensing, and orange administration and medication use. The blue bar indicates receipt or retrieval of data made available. This may occur in any of the subprocesses and is described in more detail in the continuation of this chapter for the relevant subprocesses.
The following paragraphs describe the medication verification, prescription, dispensing, administration and medication use processes.

{{anchor|figuur 3}}
[[Bestand:ActiviteitendiagramMP.png|1600px|Figuur 3 Activity diagram - medication process]]
 

==Process: medication verification==
Prior to the prescription process, the patient’s actual medication use is determined. This is done<ref>The patient may also verify his own medication. He then records medication use, see [[#Recording of medication use by the patient|paragraph 2.5.4.1]].</ref>:
*In the GP practice by the general practitioner during a consultation,
*At the GP service, A&E department or mental health crisis service by the triage specialist or the treating physician, as soon as possible, upon arrival or admission,
*In case of clinical or day admission at a hospital or other institutions by for example the nursing staff, pharmacy assistent or outpatient/hospital pharmacist,
*In case of outpatient consultation by for example nursing staff, doctors’ assistant or the treating physician.

===Current situation===
*In the current situation, patients or family/informal caregivers are asked which medication they are using. The patient is sometimes unable to answer this. Family/informal caregivers (if known) are also often unable to answer this. If this is the case, the physician will contact the general practitioner or the pharmacist to find out the medication. This is difficult outside office hours and during weekends.

===Precondition===
The patient comes in for a consultation/an outpatient consultation or is admitted (in the future).

===Trigger event===
*Outpatient setting: consultation of and/or prescription to outpatients and patients residing in another healthcare institution<ref>This is about patients from a nursing home or a mental health institution who are going to the outpatient clinic of a hospital.</ref>. In this case, medication verification often occurs during treatment assessment (see [[#Process step: Evaluating a (pharmaceutical) treatment|paragraph 2.2.4)]].
*Clinical setting: preparation of patient admission.

===Process===

The health professional collects the medication data from various sources, which may include:
*Patient’s own story,
*Dispense overviews from pharmacies,
*Digitally available medication data from healthcare providers or personal health records (PGO),
*Medication brought in by the patient,
*If necessary, information by telephone from the patient’s own pharmacist or general practitioner. 

The health professional verifies the medication together with the patient and records the verified medication as MGB, incl. self medication. This results in an updated medication profile; see also [[#Inference rules|paragraph 5.6]]. 

In practice, medication verification will lead to recording of MGB, only when it proves clinically relevant followed by updating the medication profile, particularly upon admission and discharge.
The medication overview and recorded data on MGB are made available to fellow health professionals and the patient, so that they can access the data. The medication overview may also be sent to a specific health professional.

===Post-condition===
The MGB is recorded and the resulting medication overview is made available if created. Medication data (MGB) are made available.

===Information systems and transaction groups===
[[#Information systems and transactions|Chapter 6]] includes an overview of all information systems, system roles, transactions, etc. Those most important for the medication verification process are included in the overview below.

{{anchor|figuur 4}}
[[Bestand:Medicatieverificatie.png|Figuur 4 Processtappen en transacties - medicatieverificatie]]

==Process: prescribe==
This paragraph describes the prescription process. This includes all prescribers, such as general practitioners, specialists, other physicians and specialist nurse prescribers. The prescription process consists of an evaluation of existing pharmaceutical treatment, if any. If necessary, an medication agreement is created and, only in an ambulatory situation, possibly a medication dispense request. Finally, the recorded data are (actively) made available. See [[#Appendix: General Diagram Medicatioprocess|chapter 12]] for a diagram depicting this process.

===Current situation===
The following deviations from the desired situation that are currently observed are:
*The logistical process often determines whether information is recorded (and certainly if it is communicated). Changes in medication or discontinuation are insufficiently recorded and/or communicated, resulting in, among other things, inaccurate monitoring, incorrect use and incorrect medication profiles.
The pharmacotherapeutic policy should be leading, not the logistical process as is currently the case.
*Since the therapeutic intention is not communicated to the pharmacist, it is not possible to deduce from the available data whether a request for a repeat prescription falls within that therapeutic intention. Because of this, use may be erroneously resumed or continued.
*If a change is not communicated, a request for a repeat prescription (through the pharmacist) may be based on outdated instructions for use. This can easily lead to errors.
*In an outpatient setting, medication agreements and/or medication dispense requests are usually not (electronically) sent to the pharmacist.

===Precondition===
There is a certain reason why a prescriber wants to start or evaluate/review a (pharamceutical) treatment.

===Trigger event===

The trigger event for the process is the start of a new MBH, the evaluation of an ongoing treatment, receipt of a VVV or VMA, receipt from a pharmacist of a prescription to be processed, or patient admission to or patient discharge from an institution.

===Process step: Evaluating a pharmaceutical treatment===

In order to evaluate treatment, an up-to-date overview of medication data is required. The medical file from the health professional is, where possible and if necessary, updated with data from external sources. In addition, the patient may be asked which medicinal products he is currently using. This medication use can be recorded by the health professional. If desired, a more extensive medication verification can be carried out (see [[#Process: medication verification|paragraph 2.1)]]. 

The treating physician<ref> This includes all health professionals who are authorised to prescribe: not only physicians, but also nurse practitioners and physician assistants, for example</ref> evaluates the (pharmaceutical) treatment and decides to:
*start a new MBH by creating an initial MA and/or
*continue, discontinue, temporarily halt or modify an existing MA (1 or more)<ref>In the case of substitution, the existing MA is discontinued and a new MA is created under a new MBH.</ref> and/or
*correct/cancel an existing MA and/or
*approve a VMA or a VVV (including a reply via the AVVV) 

These situations are further explained in the following paragraph. See also [[#Medicamenteuze behandeling|paragraph 1.3.3]] for more information on the concept of 'MBH'.
A new medication overview may be created to conclude the evaluation and the resulting new agreements and dispense requests (see [[#Inference rules|paragraph 5.6]]).

===Process step: Making a medication agreement===

When creating an MA, the following principle applies: each change is recorded in a new MA. Technically this means that the existing MA is terminated by entering an end date for the period of use and that a new MA is created with the desired changes<ref> Information systems keep an audit trail. In case of a change, the existing MA is discontinued (new record) and a new MA with the change is then created (new record). By using the records of the audit trail, no major adaptations are needed for discontinuing a MA in most information systems.</ref>.
 
An MA can also be created to begin at a point in the future. These MAs will receive a period of use with future starting date which is later than the date of the agreement itself. Any prior MA will end just before the starting date/time of the future one. In the period of use, only one effective date can be indicated (without duration or end date), this is the case with continuous medication. To avoid confusion between 'to/until/till' and 'up to and including', specifying the time is mandatory when entering an end date. In case of an 'up to and including' date (in case of an entire day), the time 23:59:59 applies.

Before the MA is made (actively) available, medication monitoring will occur in accordance with current guidelines. This is a part of this process step.

The next paragraphs describe the different situations in which an MA is created, i.e. initial medication agreement, continuing medication, discontinuing medication, temporarily halting medication or correcting/canceling a agreed medication. Information about 'MBH' is assumed to be known (see [[#Medicamenteuze behandeling|paragraph 1.3.3]]).

====New medication agreement====

A new MA is created at the start or modification of an MBH. When a new MBH is started, the prescriber should consider whether an existing MBH should be discontinued. The description in [[#Medicamenteuze behandeling|paragraph 1.3.3]] is based on the most common process from prescription to administering or using. In a transitional situation or in the absence of digital data, it is also technically possible that an MBH could start with a TA, for example. This might occur for instance when a pharmacist has not received the MA with the corresponding MBH in digital form. The pharmacist will consequently start a new MBH when the TA is created. This may also be the case for any other building block. A patient can, for example, start an MBH by recording MGB, without having the original MBH.

====Continuing medication====

In a number of cases the therapeutic intention of the prescriber remains the same and the MA does not have to be modified. For instance:
*In an ambulatory situation when, for a repeat prescription, only a new VV is needed, or
*At admission to an institution where the home medication continues to be used, whether or not in combination with self-medication. 

In both of these cases, the existing MA will not be adjusted. Should there be a change in PRK, e.g. at admission or discharge, the existing MBH will be discontinued by creating a stop-MA (see [[#Discontinuing medication|paragraph 2.2.5.3]]) and a new MBH is started (see [[#New medicatieafspraak|paragraph 2.2.5.1]]).

====Discontinuing medication====

Medication is discontinued by creating a new MA (stop-MA) within the same MBH. The reason for discontinuation is recorded in this MA. The medication may be discontinued immediately or in the future.
The new MA (stop-MA) is a copy of the existing MA with:
*The period of use as end date on which the MA ends (may also be in the future),
*An end date which has to be included in the text description of the instruction for use as well,
*Its own author,
*Its own agreement date,
*Stop type 'permanent',
*Reference to the specific MA that will be changed (future MAs will remain in place). It is not possible to create a stop-MA without referring to the MA that needs to be stopped except when the MA is not available. If there are only TA('s) or MGB('s) available in the MBH then a stop-MA has to be able to end these building blocks without referring to a MA,
*Its own reason for the MA to be discontinued (this does not apply to a stop-MA made as part of a modification. In that case, no reason is given). 

For an MA in which an end date is immediately agreed upon, e.g. in the case of a course of treatment, no additional stop-MA is needed. When an MA with an end date in the future is extended, it will be considered as a normal change (see [[#Changing medication|paragraph 2.2.5.5]]). A stop-MA always has the ‘permanent’ stop type, even if it is a stop-MA resulting from a change. In case of a change, the stop-MA is followed by a new MA. A stop-MA resulting from a change is not always relevant for end users. A stop-MA as a result of a change is also referred to as a technical stop-MA. The user interface must adequately support this. A prescriber will be less interested than a pharmacist who may need to adjust his logistical process because of the change.

====Temporarily halting and resuming medication====

Temporarily halting medication is the discontinuation of medication for a known or unknown period of time. Medication may be halted immediately or in the future. When medication use is temporarily halted, the medication still remains relevant for monitoring because the medication may be resumed in the future. Temporary substitution with another medicinal product is not considered an interruption but rather a discontinuation of the original medication and the start of a new pharmaceutical treatment with the substitute. Temporary halting medication is covered by two medication agreements<ref>This does not mean that end users actually have to create two agreements. A user friendly presentation by the information system is desired.</ref>: a MA (stop-MA) is created to stop medication use in accordance with guidelines for a stop-MA (see previous paragraph) and a new MA is created for resuming the medication (including the reason for this, if any). All MAs are part of the same MBH. The reason for the interruption is recorded in the stop-MA. The stop type for the stop-MA is 'temporary’.

====Changing medication====

Medication modifications may be related to:

:a) Dosage, 

:b) Strength of the medicinal product, 

:c) Method of administration, 

:d) Duration of treatment (such as an extension of the therapy). 

Switching to a completely different medicinal product is technically a switch to a different MBH (see also [[#Medicamenteuze behandeling|paragraph 1.3.3]]). In that case, the physician will discontinue the existing pharamceutical treatment (see [[#Discontinuing medication|paragraph 2.2.5.3]]) and start a new one (see [[#New medicatieafspraak|paragraph 2.2.5.1]]).
If the PRK stays the same, changes will be recorded under the same MBH. When a modification needs to be made, a technical stop-MA is created (see [[#Discontinuing medication|paragraph 2.2.5.3]]) and a new MA is made with the desired change. The appointment date of the technical stop-MA and the new MA must be always be the same. The reason for the modification is included in the new MA with a reference to the original MA, if possible. Modifications may take effect immediately or in the future. A technical stop-MA and the related new MA are made available simultaneously. In case of renewal of an MA of which the duration has already expired or the end date has already expired, then this is not seen as a change (a stop-MA on the already automatically stopped MA is unnecessary). In this case, a new MA under the same MBH can be made.

====Correcting/canceling a medication agreement<ref> Correcting/canceling administration agreements happens in the same way. XIS is a generic term for a random (health care) information system. PHR=personal health records.</ref>====

This paragraph describes correcting or canceling an MA when the prescriber has made an error. The error may have been discovered by the prescriber himself or by a fellow health professional.
For example, a physician who makes a typing error in the dosage of an MA: 10 inhalations, 2x daily, instead of 1 inhalation, 2x daily. If the MA has not yet been shared with other health professionals, the prescriber can personally correct that MA or delete (cancel) it from his own information system. If the MA has already been shared with other health professionals, the prescriber will mark the incorrect MA as ‘incorrect registration’ and he will then create a new MA under the same MBH with the correct information. The prescriber will actively inform the pharmacist and any fellow health professionals about both the cancelled and new MA and will make both available (see [[#Process step: (Actively) making available|paragraph 2.2.10]]).

====Stopping a prospective medication agreement====
This only concerns MA's that have their start date at some point in the future. For whatever reason a prescriber wants to end this prospective MA. The prescriber will not create a stop-MA in this scenario but cancels the MA instead. The prescriber cancels the MA by using the ‘canceled indicator’ field. The prescriber can only use the ‘canceled indicator’ when the start date of the MA is in the future. If the prescriber wants to end the prospective MA he/she changes the status of the MA to canceled with the indicator.

When the prescriber is not the initial creator of the original prospective MA the process works as follows. The prescriber creates a new MA with the canceled indicator activated. The ‘canceled MA’ will be sent to the original prescriber of the MA. The original prescriber will then cancel the original MA as well.

===Process step: Making a variable dosing regimen===
When a prescriber prescribes medication combined with a variable dosign regimen (WDS), the dosing of the medication can be adjusted by a (different) prescriber without having to adapt the medication agreement (MA). At the moment the variable dosing regimen is used for anticoagulants. When prescribing anticoagulants, the prescriber determines the therapeutic INR-range (International Normalized Ratio, a measure of blood clotting time), within which the treatment should take place.
The thrombosis service is responsible for drafting the viariable dosing regimen. The dosing regimen is composed by a prescriber (usually a thrombosis physician) in the building block variable dosing regimen (Wisselend doseerschema, WDS). The prescriber who made the medication agreement remains responsible for the dispense requests (VV). The thrombosis physician composes the WDS withing the agreed upon INR-range, the dosing regimen is usually based on a specific, measured INR-value. 
====Setting up a variable dosing regimen ====
The prescriber prescribes anticoagulants with a medication agreement (MA) and indicates:
* The medication (PRK) that is being prescribed to the patient. The medication in the variable dosing regimen is always the same as the medication in the MA.
* That for this medication a variable dosing regimen applies (this is added in the additional instructions). This also means there will be no dosage added in the medication agreement.
* The INR-range within which the treatment should take place. This information is included in a comment.

In order to bridge the period until the thrombosis service is involved and ready to take over the treatment, the original prescriber sets up a WDS for this first period (usually between 4 and 7 days). Usually a check-up date is agreed upon after the registration of the patient at the thrombosis service. During this check up the INR-value is measured. Based on the measured value and/ or the professional assessment of the thrombosis physician, a dosing regimen is composed that either changes of succeeds the previous WDS. From this moment on, the thrombosis service takes over the composition of the dosing regiment from the original prescriber.

''INR-value with the WDS'' 
The variable dosing regimen is often based on an INR-value. For other parties involved in the care for the patient, it’s important to be able to deduce the INR-value on which the WDS was based. That is the reason that the corresponding INR-value will be made available within the WDS. The INR-value is included in a comment within the WDS.

====Changing a variable dosing regimen ====
When the variable dosing regimen (WDS) is being used up until the stop date of the WDS, it can be replaced by a new WDS that succeeds it. The new WDS has a relation to the MA and the previous WDS.
Furthermore, it is possible to adjust the WDS before the stop date is reached. In that case, the information system stops the previous WDS, using a technical stop-WDS that is not visible to the user. The new WDS follows and has a reason for change and a relation to the MA and the previous WDS.
All changes related to the dosing regimen can be included in the WDS. Changes that concert the further treatment policy (e.g. the prescribed medication, the route of administration of the agreed upon INR-range) are to be made in the MA.

====Stopping a variable dosing regimen ====
There are various reasons that can cause the need to (temporarily) stop the use of anticoagulants. For example, in the event of a procedure of because there is temporary co-medication. Two kinds of situations can be distinguished. Depending on the situation and the assessment of the thrombosis physician one of twee methods is chosen:
#''(temporary) adjusting the policy'': The thrombosis physician can choose to temporarily adjust the dose for the anticoagulants to 0. For example, in the event of a planned procedure. In this case, the MA (and therefore the treatment with anticoagulants) and the TA will continue, but the dosage in the WDS is temporarily adjusted to 0. The MA will still be shown on the medication overview under ‘current medication’. In the event of such a temporary adjustment, only the WDS is changed. It is advised to include a reason for this change in the new WDS.
# ''(temporary) stopping the anticoagulants:'' The thrombosis physician (or another prescriber) can also choose to (temporarily) stop the treatment with anticoagulants. This means that the patient should not to take any anticoagulants anymore. In this case the thombosis physician (or another prescriber) creates a stop-MA (or sends a proposed MA to the original prescriber). Stopping the MA, also stops the underlying therapeutic building blocks (TA, WDS). The anticoagulant will be shown on the medication overview under ‘recently stopped medication’.
If, after a period of time, there is a need to restart the anticoagulant, the prescriber can do this by creating a new MA. The new MA can be created by the original prescriber, the thrombosis physician could also send a proposed MA. In many cases the thrombosis service would no longer be involved. And the MA is created by the original prescriber.

===Process step: Creating a medication dispense request===

A VV (besides an MA) only applies in an ambulatory situation. A VV may be made when the medication supply of the patient needs to be replenished. This does not have to coincide with an MA. At the start of a MBH for which the patient still has a sufficient supply at home from a previous agreement, a VV is not needed. When the dosage is reduced, the patient may also have a sufficient supply. In the case of a medicinal product that is used for a prolonged period of time (e.g. an antihypertensive drug), with a continuous MA (meaning a period of use with only a start date), several VVs may be made over time within the scope of this existing agreement.
Logistical and emergency instructions may be included in the VV, such as dispense location, request to not include in the GDS (medication distribution system, in Dutch: 'Geneesmiddel Distributie Systeem'), etc.

In the case of a VV, the quantity to be supplied can be stated or the consumption period. With a consumption period, the quantity must be clearly deducible from the dosing instruction of the MA. Note: a consumption period end date has a meaning other than the period of use end date from the MA and may be unequal.
*Period of medication use end date: date until which the pharmacist is allowed to to provide medication (and thereby provide sufficient supplies to the patient for use until that date).
*Period of use end date: date on which the patient must stop the medication (this can be equal to the consumption period end date or further in the future).

===Process step: Sending renal function value with prescription===

Renal function is important for certain medicines. The renal function value determines the choice of drug and/or drug dosage. It is legally stipulated that if a health professional has performed further research on a patient renal function, he should share abnormal renal function values with the appropriate pharmacist, appointed by the patient (article 6.10, 'regeling geneesmiddelenwet').

The renal function value is always sent with the prescription (using the building block laboratory test results) for medicines for which this is important (characteristic in the G-standard), so that the pharmacist can perform proper medication monitoring. The renal function value should not be older than 13 months, because with stable chronic renal impairment the renal function should be checked at least once a year. 1 month has been added to allow some backlog in practice.

If at the time of sending of an MA and/or VV no renal function is known, then the prescription policy remains unchanged. Sending the laboratory test result renal function value without an MA and/or VV is beyond the scope of this information standard.

===Process step: Sending height and weight values with prescription===

It is possible for the prescriber to send the body height and weight of the patient with the prescription. This is the height an weigh of the patient that the prescriber used for the medication agreement. Hence, it is possible for these values to diverge (be more accurate) from the height and weight values that are registered in the patient details. This could be necessary for prescribing for children or for medication where weight (e.g. coagulation medication) or height (e.g. oncolytic agents) are important factors to consider.

Body height and weight are separate building blocks. They can only be send together with the prescription and with the medication agreement. The information is not available on request.

===Process step: (Actively) making available===

This step involves information exchange. Information can be sent or made available with different intentions:

A. As an order for the pharmacist to dispense medication. The prescriber sends the MA to the pharmacist. In an ambulatory situation, the VV is also sent to the patient’s pharmacist. If the pharmacist is not known, this process step may also entail giving out a paper prescription and/or (reactively) making the data available (see C). When the pharmacist has filled the order, the prescriber will receive a notification (see [[#Information systems and transaction groups|paragraph 2.3.8]]). 

B. As an order for the pharmacist to implement a medication change (including stop-MA with stop type 'permanent' and 'temporary') that impacts or may impact current MVE by this pharmacist. A current MVE indicates an order (as in A) that has been accepted, but has not yet been completely filled. For example, when medication is still being dispensed or when a VV dictates that medication should be dispensed multiple times, but not all have taken place yet, e.g. with the GDS. 

C. Making medication data (MA, VV, MGB) and possibly the medication overview available to allow fellow health professionals and/or patients to access these later, possibly in combination with prescription without a specified recipient (see [[#Prescription without specified recipient (ambulatory)|paragraph 8.1]]). 

D. Actively sending (informing) medication data (one or more building blocks) to a specific health professional at the request of the patient when in the presence of this health professional or at discharge. 

In case of corrected data, the prescriber assesses who should be actively informed of this correction. This can be done, for example, by sending the new MA (option A or B above) or by means of a telephone consultation.
In an ambulatory setting (general practitioner/outpatient clinic) medication data are usually sent or made available directly; in a clinical setting, medication data is usually made available at discharge or interim leave from the institution.
This chapter deals with prescription with a specified recipient; [[#Prescription without specified recipient (ambulatory)|paragraph 7.5]] details prescription without a specified recipient.
See also [[#Informing and (actively) making available|paragraph 1.3.5]] for a further explanation on informing (situation A, B, D) and making available (situation C).

===Post-condition===
*A new MA may have been created (starting, changing or discontinuing medication)
*A VV may have been made (only outpatient)
*An order may have been sent to the pharmacist to carry out MVE
*An order may have been sent to the pharmacist to modify MVE
*Fellow health professionals and the patient have been informed or may inform themselves about the new medication data: MA, VV, MGB
*Fellow health professionals and the patient have been informed or may inform themselves about a medication overview.

===Information systems and transaction groups===

The prescriber and the pharmacist as well as other health professionals and users all make use of an information system, respectively, an electronic prescribing system (EVS), a pharmacist information system (AIS, incl. ZAIS), a XIS and a PGO<ref> XIS is a generic term for a random (health care) information system. PHR=personal health records.</ref>. These information systems each have different system roles which enable the exchange of data between these information systems as part of the prescription process.
[[#Information systems and transactions|Chapter 6]] includes an overview of all information systems, system roles, transactions, etc. The most important elements for the prescription process are included in the overview below.

{{anchor|figuur 5}}
[[Bestand:Uc Voorschrijven.png|Figuur 5 Processtappen en transacties - voorschrijven]]

===Use cases===
The following specific use cases have been elobarated:
*[[#Short-term medication|Short-term medication (paragraph 4.1.1)]]
*[[#Continuing medication|Continuing medication (paragraph 4.1.2)]]
*[[#Hard end date for period of medication use|Hard end date for period of medication use (paragraph 4.1.3)]]
*[[#Medication as needed|Medication as needed (paragraph 4.1.4)]]
*[[#Course of treatment as needed starting in future|Course of treatment as needed starting in future (paragraph 4.1.5)]]
*[[#Two dosages of the same medication at the same time|Two dosages of the same medication at the same time (paragraph 4.1.6)]]
*[[#The same medicinal product with different strengths at the same time|The same medicinal product with different strengths at the same time (paragraph 4.1.7)]]
*[[#Explanation in medicatieafspraak with deliberately chosen special characteristic|Explanation in medicatieafspraak with deliberately chosen special characteristic (paragraph 4.1.8)]]
*[[#New medicatieafspraak, no verstrekkingsverzoek|New medicatieafspraak, no verstrekkingsverzoek (paragraph 4.1.9)]]
*[[#New verstrekkingsverzoek under existing medicatieafspraak|New verstrekkingsverzoek under existing medicatieafspraak (paragraph 4.1.10)]]
*[[#Dosage change (sufficient supply)|Dosage change (sufficient supply) (paragraph 4.1.11)]]
*[[#Prescription no longer needed after first verstrekkingsverzoek|Prescription no longer needed after first verstrekkingsverzoek (paragraph 4.1.12)]]
*[[#Discontinuing medication|Discontinuing medication (paragraph 4.1.13)]]
*[[#Temporarily halting/resuming medication|Temporarily halting/resuming medication (paragraph 4.1.14)]]
*[[#Temporarily halting for an intervention|Temporarily halting for an intervention (paragraph 4.1.15)]]
*[[#Substitution|Substitution (paragraph 4.1.16)]]
*[[#Paper prescription|Paper prescription (paragraph 4.1.17)]]
*[[#Carrying out medication verification and evaluation of foreign or self-care medication|Carrying out medication verification and evaluation of foreign or self-care medication (paragraph 4.1.18)]]
*[[#Day treatment|Day treatment (paragraph 4.1.19)]]
*[[#Starting with medication before admission|Starting with medication before admission (paragraph 4.1.20)]]
*[[#Emergency admission|Emergency admission (paragraph 4.1.21)]]
*[[#Discharge|Discharge (paragraph 4.1.22)]]
*[[#Interim discharge|Interim discharge (paragraph 4.1.23)]]
*[[#Transfer to another institution|Transfer to another institution (paragraph 4.1.24)]]
*[[#Do not dispense before|Do not dispense before (paragraph 4.1.25)]]
*[[#Discontinuation of medication by third parties|Discontinuation of medication by third parties (paragraph 4.1.26)]]
*[[#Two PRKs in a single medicamenteuze behandeling|Two PRKs in a single medicamenteuze behandeling (paragraph 4.1.27)]]
*[[#Creating a medicatieafspraak after the fact|Creating a medicatieafspraak after the fact (paragraph 4.1.28)]]
*[[#Single medication use( medicatiegebruik)|Single medication use(medicatiegebruik)(paragraph 4.1.30)]]
*[[#Provisional and final medication order|Provisional and final medication order (paragraph 4.1.31)]]
*[[#Inadvertently ‘outstanding’ medication or 'orphans'|Inadvertently ‘outstanding’ medication or 'orphans' (paragraph 4.1.32)]]
*[[#Missing digital medicatieafspraak at admission|Missing digital medicatieafspraak at admission (paragraph 4.1.33)]]
*[[#Own articles (90 million numbers)|Own articles (90 million numbers) (paragraph 4.1.34)]]
*[[#Dosing with minimum interval|Dosing with minimum interval (paragraph 4.1.35)]]
*[[#Verstrekkingsverzoek with number of repetitions|Verstrekkingsverzoek with number of repetitions (paragraph 4.1.36)]]
*[[#Prescribing non-medicines|Prescribing non-medicines (paragraph 4.1.37)]]
*[[#Send renal function value in the prescription|Send renal function value in the prescription (paragraph 4.1.38)]]
*[[#Cancelling a prescription that was sent earlier|Cancelling a prescription that was sent earlier (paragraph 4.1.39)]]
*[[#Modification of someone else's medicatieafspraak|Modification of someone else's medicatieafspraak (paragraph 4.1.40)]]
*[[#Setting up a variable dosing regimen (WDS)|Setting up a variable dosing regimen (WDS) (paragraph 4.1.41)]]
*[[#Changing a variable dosing regimen (WDS) during period of use|Changing a variable dosing regimen (WDS) during period of use (paragraph 4.1.42)]]
*[[#Stopping medication with a variable dosing regimen (WDS)|Stopping medication with a variable dosing regimen (WDS) (paragraph 4.1.43)]]

==Process: dispense==

This paragraph describes the process of dispensing medication, including repeat prescriptions and GDS. This process encompasses all actions a pharmacist must take for the patient to not only receive a medicinal product, but to also receive the associated pharmaceutical care ensuring a safe and effective use of the medicinal product by the patient. The dispense process starts with providing pharmaceutical care. If necessary, a medication administration agreement will be made and if needed, medication is dispensed. Medication dispense (i.e. handing out a medicinal product) does not always take place. This may be the case when the medication agreement is changed (e.g., in case of dose reduction where the patient still has enough supply), when the medication is discontinued or, in an ambulatory situation, the medication is not picked up. When the MA and/or the VV do not comply (see [[#Process step: Informing the prescriber|paragraph 2.3.5]]), the prescriber will be informed. Finally, the recorded data are (actively) made available. See [[#Appendix: General Diagram Medicatioprocess|Chapter 12]] for a diagram of the dispense process.

Medication assessment is the process in which the physician and pharmacist consider all medication of the patient against the background of his condition, applicable treatment guidelines, the well-being of the patient, etc. Medication assessment is defined in this document as a combination of treatment evaluation (as described in the previous paragraphs) and pharmaceutical care. Depending on the findings, the previously described medication verification and prescription processes are followed, after which medication dispense takes place.

For the GDS, many pharmacists collaborate with another organisation that handles part of the pharmacists’ logistics. This then also requires data exchange with that party. Besides, not all medication can be included in the GDS packaging, which adds to the logistical complexity for the pharmacist. The internal logistics and communication between the pharmacist and his subcontractor(s) are outside the scope of this information standard. It has been established however that with the provision of the current building blocks and the underlying data elements, this logistical process can be adequately supported.

===Current situation===
The following deviations (from the desired situation that) are currently observed:
*In the current situation, in the case of GDS, the prescribing physician and other health professionals receive a large quantity of dispense messages. This becomes difficult to manage for these health professionals.
*In the current situation, in the case of GDS, pharmacists and general practitioners communicate via so-called authorisation lists. The pharmacist sends an overview of all the patient’s medication to the general practitioner for authorisation. This complicates matters for a general practitioner because he will need to verify all medication agreements. This should not be necessary, as most medication agreements/dispense requests have already been authorised. It would be much more efficient if the general practitioner only needs to authorise those medication agreements/disprense requests that have not been authorised yet, e.g. a new dispense request on the basis of an existing medication agreement.
*In the current situation, a locum pharmacy often does not inform the regular general practitioner and regular pharmacy when medication is dispensed.
*In the current situation, a proposal for a medication agreement may have been aligned with the prescriber over the phone and/or the pharmacist and prescriber have made an agreement about handling a warning from the medication monitoring system.
*The intention of the return message is not always clear: no distinction can be made in the return/delivery message between displaying a physical delivery and a transmission of information about a medication change.
*In the current situation, pharmacists sometimes register (and communicate) medication dispenses when they are preparing the medication for the patient instead of at the time when the medication is actually dispensed to the patient. This means that medication that has not been picked up, is sometimes erroneously registered as dispensed.

===Precondition===

An MA exists. In an ambulatory situation there may also be a corresponding VV.

===Trigger event===
The pharmacist starts the medication dispense process on the basis of one of the following events:
*Receipt of an order to make an MVE on the basis of a new MA. In an ambulatory situation, this order is always accompanied by a VV.
*Receipt of an order to process a new MA in an ongoing MVE.
*Receipt of a trigger (for example, via a patient or a repeat module of the pharmacist information system) for a repeat MVE under an existing MVE or a new VVV.

===Process step: Providing pharmaceutical care===
Pharmaceutical care is provided by a community, outpatient (i.e. at the hospital) or institutional pharmacy, depending on the health professional who has created the MA:
*MA, possibly with a VV from the general practitioner or specialist: care provided by a community or outpatient pharmacy.
*MA from specialists and other prescribers in hospitals/institutions: care provided by an institutional pharmacy or a community pharmacy that supplies the respective institution.
Medication monitoring is also part of pharmaceutical care.

Based on the received MA or a change in the situation of the patient, the pharmacist decides how to apply this by:
*Making one or more new TAs.
*Continuing, permanently discontinuing, temporarily halting or modifying an existing MA.
*Rejecting the MA.
*Proposing a new MA.
*Proposing a new medication dispense (VVV).

The last three situations are explained in the following paragraph. The first two situations are explained in [[#Process step: Creating a toedieningsafspraak|paragraph 2.3.6]].
In conclusion of provided pharmaceutical care, which may comprise new agreements and medication dispenses, a new up-to-date medication overview may be compiled and made available.

===Process step: Informing the prescriber===

There is a number of situations in which the pharmacist informs the prescriber, including:
*When a new or modified MA is needed
*When a new VV is needed
For more information about informing, see [[#Informing and (actively) making available|paragraph 1.3.5]].

A new or modified MA is needed:
*When a new TA cannot be created based on the received MA because the pharmacist suspects an error in the MA, or
*After a signal from the medication monitoring system as part of pharmaceutical care. The signal may indicate, for example, that the dosage should be lowered or increased, that it is advisable to select another medicinal product, that a product should be temporarily discontinued, that another additional product should be added, etc., or
*Based on medication use as reported by the patient during pharmaceutical care, or
*When the temporarily halted pharmaceutical treatment may be resumed.
*A TA is not yet created or modified in these situations.
Instead, the pharmacist starts by contacting the prescriber by phone, informing him of the suspected error and proposing an alternative. The pharmacist may also send a digital proposition called VMA to the prescriber. He recommends a specific MA in this proposal, together with the reason and arguments for that recommendation. The prescriber may approve the VMA and make it into a final MA (see also [[#Process step: Evaluating a (pharmaceutical) treatment|paragraph 2.2.4]]). 

A new VV is needed when the patient’s medication stock is depleted or nearly used and the treatment may need to be continued (request repeat prescription). The patient either requests a repeat MVE from the pharmacist or has signed up in the past for proactive repeat MVE and a notification signal is generated by the repeat module of the AIS when the patient requires new medication<ref> The patient may also request a repeat directly from the prescriber: see [[#2-5-6|paragraph 2.5.6]].</ref>.
When the existing VV is not adequate, the pharmacist may communicate this request over the phone or send a digital VVV to the prescriber. The VVV may contain indications for the prescriber, such as urgency. The prescriber may approve the received proposal and alter it into a final VV. The prescriber informs the requestor via a AVVV (see also [[#Process step: Evaluating a (pharmaceutical) treatment|paragraph 2.2.4]] and subsequent paragraphs).

===Process step: Creating an administration agreement===

If the MA and, if applicable, the corresponding VV can be processed, a TA will be created. By creating a TA, the pharmacist fulfills the MA. The TA is communicated to the patient or the person administrating the medication. The TA belongs to the same MBH as the MA it fulfills. As is the case with the corresponding MA, a TA may start in the future. The dosage in the TA may deviate from that in the MA, for example because a certain strength is not in stock. This means that another PRK can become part of the MBH when, for example, 1 tablet of 20 mg is changed into 2 tablets of 10 mg.
Before the TA is made (actively) available, medication monitoring will occur in accordance with applicable guidelines, as part of this process step.

On the basis of the TA, an administration list<ref> In this document, the administration list means both the digital and the paper version, unless otherwise indicated. Sublist and checklist are synonyms. </ref> can be compiled for home care or nursing staff, among others.

When creating a TA, the same principle applies as for the MA: each change is recorded in a new TA.

The following paragraphs describe the different situations in which a TA is created: new TA or continuing, permanently discontinuing, temporarily halting or modifying an existing TA.

====New administration agreement====

In case of a new MA, a new TA is always created. A new TA is also created in case of a new preference policy or a change in stock which results in the selection of a different medicinal product.
When creating a new TA, the pharmacist takes into account, among other things:
*Preference policy,
*Inclusion in GDS-packaging,
*Available stock of the institution (‘hospital formulary’) or the pharmacy itself. 

If, in an ambulatory situation, the first provision/dispense to the patient occurs later than agreed, the start date of the TA will be different from the start date of the MA.

====Continuing an administration agreement====

When the existing MA and TA are sufficient to carry out an MVE, the TA will not be adjusted.

====Discontinuing an administration agreement====

An MA in which it has been agreed to discontinue medication permanently, leads to a stop-TA under the same MBH (this also applies in case of a stop-MA as a result of a change) with stop type ‘permanent’. The stop-TA prevents a new MVE of the discontinued medication.
In an ambulatory situation, the prescriber can indicate in the MA that the medication will be discontinued with the next roll (with GDS). In this case, the start date of the stop-TA may be later than indicated in the original stop-TA.

====Temporarily interrupting an administration agreement====

Temporarily interrupting an MA results in a stop-TA (stop type: 'temporary'). Upon resuming, a new TA is created. Both TAs belong to the same MBH as the MA.

====Modifying an administration agreement====

A modified MA (leading to a new MA) leads to a new TA under the same MBH. As with the MA, a change to a TA means the termination of the existing TA (a technical stop-TA) and the creation of a new TA.

===Process step: Dispense===

After creating the TA, the pharmacist prepares the product and dispenses it to:
*The patient in a community setting,
*The patient admitted to a hospital, nursing home or other institution.
The pharmacist records MVE<ref>In a clinical situation, product may be taken from the department’s own supply, after which administration takes place immediately and the administration is recorded.</ref>.

Medication dispense to patients:
*In an ambulatory situation only occurs on the basis of a VV or a repeat VV,
*In a clinical situation occurs on the basis of the MA without the need for a VV.

===Process step: (Actively) making available===

This step involves information exchange. Information can be sent or made available with different intentions:

As a request to the prescriber to create a new medication agreement (VMA) or a new dispense request (VVV).

Informing the prescriber about the processing of the prescription (TA and/or MVE).

Making medication data available (VV and MVE) to allow fellow health professionals and/or patients to access these later.

Making a medication overview available to allow fellow health professionals and/or patients to access these later.

===Post-condition===
*A TA could have been created.
*An MVE could have taken place and, if necessary, the patient has received instructions on how to use the medicinal product.
*Fellow health professionals have been informed or may inform themselves. The prescriber has been informed.
*If necessary, the prescribing physician has been requested to provide a new/modified MA or VV.

===Information systems and transaction groups===

The prescriber and the pharmacist as well as other health professionals and users all make use of an information system, respectively, an electronic prescribing system (EVS), a pharmacist information system (AIS, incl. ZAIS), a XIS and a PGO<ref> XIS is a generic term for a random (health care) information system. PHR=personal health records. </ref>. These information systems each have different system roles which enable the exchange of data between these information systems as part of the prescription process.
[[#Information systems and transactions|Chapter 6]] includes an overview of all information systems, system roles, transactions, etc. The most important elements for the prescription process are included in the overview below.

{{anchor|figuur 6}}
[[Bestand:Uc Ter handstellen.png|Figuur 6 Processeps and transactions - dispense]]

===Use cases===
De volgende specifieke use cases van ter hand stellen zijn uitgewerkt:
*[[#New medicatieafspraak, medicatieverstrekking of the same product|New medicatieafspraak, medicatieverstrekking of the same product (paragraph 4.2.1)]]
*[[#New medicatieafspraak, medicatieverstrekking of the same product|New medicatieafspraak, medicatieverstrekking of the same product (paragraph 4.2.2)]]
*[[#Existing toedieningsafspraak is adequate|Existing toedieningsafspraak is adequate(paragraph 4.2.3)]]
*[[#Medicatieafspraak wanted (informing the prescriber)|Medicatieafspraak wanted (informing the prescriber) (paragraph 4.2.4)]]
*[[#Request and dispense|Request and dispense (paragraph 4.2.5)]]
*[[#Patient requests repeat prescription via physician (reactive repeat)|Patient requests repeat prescription via physician (reactive repeat) (paragraph 4.2.6)]]
*[[#Patient requests repeat prescription via pharmacist (informing prescriber)|Patient requests repeat prescription via pharmacist (informing prescriber) (paragraph 4.2.7)]]
*[[#Proactive repeat prescription by pharmacist (informing prescriber)|Proactive repeat prescription by pharmacist (informing prescriber) (paragraph 4.2.8)]]
*[[#Dispense based on an existing verstrekkingsverzoek|Dispense based on an existing verstrekkingsverzoek (paragraph 4.2.9)]]
*[[#Splitting a prescription|Splitting a prescription (paragraph 4.2.10)]]
*[[#Starting and continuing a GDS|Starting and continuing a GDS (paragraph 4.2.11)]]
*[[#The pharmacist changes commercial product|The pharmacist changes commercial product (paragraph 4.2.12)]]
*[[#Adding medication to a GDS|Adding medication to a GDS (paragraph 4.2.13)]]
*[[#Discontinuing medication in a GDS|Discontinuing medication in a GDS (paragraph 4.2.14)]]
*[[#GDS supplier supplies other commercial product|GDS supplier supplies other commercial product (paragraph 4.2.15)]]
*[[#Parallel administration agreements with GDS- and non-GDS-dispense|Parallel administration agreements with GDS- and non-GDS-dispense (paragraph 4.2.16)]]
*[[#Handling a stop medicatieafspraak|Handling a stop medicatieafspraak (paragraph 4.2.17)]]
*[[#Medication dispense with someone else’s administration agreement|Medication dispense with someone else’s administration agreement (paragraph 4.2.18)]]
*[[#Modification of someone else’s administration agreement|Modification of someone else’s administration agreement (paragraph 4.2.19)]]
*[[#Verstrekkingsverzoek with number of repetitions|Verstrekkingsverzoek with number of repetitions (paragraph 4.1.36)]]

==Process: administer==

 
This paragraph describes the administration process. This process comprises the compilation of the administration list for (professional) administrators and the administration which is carried out by a (professional) administrator, the patient himself or an informal caregiver. Professional administrators are physicians, nurses and caregivers (home care/institution).

In paragraph 2.4.1, the current situation is described, followed by a description of the new, altered situation.

===Current situation===
In the current situation, the (professional) administrator, together with the patient, verifies the medication which should be administered, using the available information (paper and/or digital administration list(s), the dosing schedule for, for example, anticoagulant medication, the information on the label), and, subsequently, administers the medication. In case of uncertain administration instructions, the administrator contacts the prescriber or pharmacist. Uncertainties are more likely to occur with an increasing number of prescribers, suppliers and administrators who are involved in the administration process.
In the current situation, for administrators, there are several challenges in the transfer of medication data:
*Transfer of medication data between inpatient health care or home care, and hospital health care is missing or is not available in time;
*Medication changes are not received (in time), and medication stops are missing;
*Up-to-date data on the administration list is not available in the case of supply by multiple pharmacies during after-hours care (evening, night or weekend);
*Separate dosing schedules, in addition to the administration list, of (highly) variable dosages, for example anticoagulant medication;
*Problems related to a separate dosing schedule of (highly) variable dosages; for example, loss of the dosing schedule, verbal information regarding changes of the dosing schedule;
*Medication as needed, injection schedules (for example, for insulin) are missing on the administration list (the injection schedules will be worked out in the information standard in the future);
*An overview is missing of all health professionals and healthcare providers which are involved.

In the current situation, the pharmacist compiles the administration list for the (professional) administrator or the patient. This administration list comprises the administration times, which are geared to the rounds of the home care organization, with account for the pharmaceutical ranges. A paper or digital administration list is used by the (professional) administrators for the registration of the medication administration. A paper administration list (including the administration registration) is in the patient’s home, and is therefore accessible for all professional administrators (irrespective of organization). The digitally recorded medication administrations are only exchanged with other health professionals in exceptional situations (for example, it may be exchanged in the case of admission or special circumstances). With the transition to an electronic administration registration, the administration list (with the recorded administration times) is no longer physically present; instead the administration is recorded in the E-TDR/E-TRS (electronic administration registration/electronic administration registration system) (see paragraph 2.4.8). The involved professional administrators of different organizations (with possibly different E-TRS applications) cannot consult or can only consult with difficulty the registered administration procedures of other organizations, because of registration in different applications and/or databases.

===Precondition===

The patient administers medication to himself or the patient must be administered medication by a(n) (professional) administrator and, therefore, requires an administration list.

===Trigger event===

The moment the medicinal products must be administered.

===Process step: Administration list===

The (professional) administrator or the patient receives or asks for the (actively) made available medication data that is required for automatic generation of the administration list. For the administration list, the building blocks ‘medicatieafspraak’ (MA), ‘wisselend doseerschema’ (WDS), ‘toedieningsafspraak’(TA), ‘medicatieverstrekking’ (MVE) and ‘medicatietoediening’ (MTD) are needed. In order to compile a complete administration list, the (guide) administration times and dosing instructions are required. The pharmacist and prescriber can enter these data in the TA, and MA or WDS, respectively. In general, pharmacists and prescribers in the ambulatory setting do not register the (guide) administration times and, therefore, they should receive a trigger which indicates that it concerns an ‘administration patient’; a patient who is aided in the medication administration or a patient who requires an administration list. For some medication, it is necessary to provide information on the previous ‘prick and patch locations’ (sites of administration); this is registered in the MTD. In the case of inpatient health care, administration lists are available for all patients, and (guide) administration times are registered by default.

Most (guide) administration times are chosen based on the administration times of other prescribed medication and the rounds of the administrator, especially for MAs and TAs with standard flexible (guide) administration times. Further agreements should be made regarding the (guide) administration times by those concerned in the healthcare field (for example, which deviations from the (guide) administration times are permitted). If the administration of a drug requires a specific time of administration, for example because of medication interactions, this is communicated by entering in the TA and/or MA that the (guide) administration time is not flexible.

The administration list differentiates between GDS medication (GDS: medication distribution system, in Dutch ‘Geneesmiddel Distributie Systeem’) and non-GDS medication based on the distribution type. This information is recorded in the building block MVE. Subsequently, the administrator (administration software) compiles the administration list, based on the MA, WDS, TA and MTD, with differentiation according to administration moment. Prescribers, pharmacists and administrators (PrickPatchLocation) are responsible for providing the medication data which is necessary for generating the administration list.

'''NB.''' It is currently explored in which way information regarding GDS can be best exchanged.

===Process step: Administering===

The (professional) administrator has received the medication data (MA, WDS, TA, MVE and MTD) that is required for the medication administration. These data is presented in the administration list as described above. The (professional) administrator, together with the patient, verifies the available medication and the administration data. If agreed and needed, the professional administrator prepares the medication for administration. The medication is administered and the administrator records the administration in the information system or on the administration list. Deviations in the medication administration (not administered, adjusted dosage, refusal by the patient, swallowing problems, adverse effects, etc.) are recorded as well.

===Process step: (Actively) making available===

In this step, information is exchanged. The administration data can be sent or be made available with the following aims:
*The recorded MTDs and deviations can be sent for information to a fellow health professional;
*The MTD can be made available so that the data can be accessed later by fellow health professionals and/or the patient. For example, the administration data can be retrieved upon transfer of the patient to another department or institution. Also, a health professional can check which medication is administered to a patient.

===Post-condition===

The patient has administered medication by himself or has been administered medication. The MTDs can be recorded in an information system and can be (actively) made available for fellow health professionals and/or the patient.

===Information systems and transaction groups===

The prescriber and the pharmacist as well as other administrators and patients (optional) all make use of an information system, respectively, an electronic prescribing system (‘elektronisch voorschrijfsysteem’ - EVS), an electronic client file (‘elektronisch cliëntendossier’ - ECD), a pharmacist information system (‘apothekersinformatiesysteem’ - AIS), a hospital pharmacist information system (‘ziekenhuisapotheekinformatiesysteem’ - ZAIS), an administration registration system (‘toedieningsregistratiesysteem’ - TRS), a thrombosis service information system (‘trombosedienstinformatiesysteem’ - TrIS) and a personal health environment (‘persoonlijke gezondheidsomgeving’ - PGO). These information systems each have different system roles which enable the exchange of data between these information systems as part of the administration process. The information systems may have a function in compiling an administration list, and in the registration, the exchange and the delivering of an MTD.
Chapter 6 provides an example of compiling an administration list. The most important elements for the administration process are included in the overview below.

{{anchor|figuur 7}}
[[Bestand:Toedienen.png|Figuur 7 Processtappen en transacties - toedienen|800px]]

===Use cases===

The following use cases for medication administration have been worked out:

*[[#Creating an administration list|4.3.1 Creating an administration list]]
*[[#Exact administration times required|4.3.2 Exact administration times required]]
*[[#Missing (guide) administration times|4.3.3 Missing (guide) administration times]]
*[[#Non GDS medication as needed|4.3.4 Non GDS medication as needed]]
*[[#Medication supply by multiple pharmacies|4.3.5 Medication supply by multiple pharmacies]]
*[[#Change in GDS from the next supply or immediately|4.3.6 Change in GDS from the next supply or immediately]]
*[[#Increasing dosage of GDS in new MBH|4.3.7 Increasing dosage of GDS in new MBH]]
*[[#Decreasing dosage of GDS in new MBH|4.3.8 Decreasing dosage of GDS in new MBH]]
*[[#Change processed by the pharmacist|4.3.9 Change processed by the pharmacist]]
*[[#Change not processed by the pharmacist|4.3.10 Change not processed by the pharmacist]]
*[[#Variable-dosing regimen|4.3.11 Variable-dosing regimen]]
*[[#Additional information|4.3.12 Additional information]]
*[[#Medication administration deviates from administration list|4.3.13 Medication administration deviates from administration list]]
*[[#Medication administration without medication agreement and administration agreement|4.3.14 Medication administration without medication agreement and administration agreement]]
*[[#Medication administration of self-care medication|4.3.15 Medication administration of self-care medication]]
*[[#Correction/cancellation of an administration|4.3.16 Correction/cancellation of an administration]]
*[[#Medication administration on hold|4.3.17 Medication administration on hold]]
*[[#Medication administration by a prescriber|4.3.18 Medication administration by a prescriber]]
*[[#Multiple administration organizations|4.3.19 Multiple administration organizations]]

==Process: medication use==
This paragraph describes the process of medication use including registration of medication use by the patient or a health professional. The information recorded by the patient or health professional may be used, among other things, for medication verification by the health professional. During medication verification, medication use is established by the health professional. See [[#Appendix: General Diagram Medicatioprocess|Chapter 12]] for a diagram of this process.

===Current situation===
*There is currently a limited number of information systems available in which the patient can record his own use of medication. Exchange to health professionals is also highly dependent on the information system used and is often limited to one specific health professional via, for example, one specific platform/app.
*The current medication profiles are often incomplete and not up to date.

===Precondition===
The patient has been prescribed medication.

===Trigger event===
The patient has used the medication or does not use it (anymore).

===Process step: Medication use===
The patient uses the prescribed medication, selfcare medication. Medication use may be recorded by
*The patient himself or his informal caregiver,
*A home care or institution nurse and/or
*Another health professional.
This third option often applies in the event of medication verification (see [[#Process: medication verification|paragraph 2.1]]). A variety of information systems is available to record medication use: PHR, XIS, EPF [electronic patient file] / ECF [electronic client file], app, etc.

The following can be recorded as medication use:
*Self-care and other proprietary medication,
*Discrepancies compared to agreements made,
*Confirmation of medication use (promoting compliance),
*Verified medication (see medication verification),
*Changes as a result of, for example, side effects (by the patient himself; a health professional will record this in a different way).

Patients who are being administered medication by a nurse sometimes take the medication by themselves at a later time, depending on the BEM-score (assessment of medication self-management, in Dutch: 'Beoordeling Eigen Beheer Medicatie'); in that case, MTD data may deviate from MGB. 
While medication is being used, pharmaceutical care is provided by the pharmacist (see [[#Process step: Providing pharmaceutical care|paragraph 2.3.4]], e.g. in case of new laboratory values). There may also be follow-up contact during which the pharmaceutical treatment is evaluated (see [[#Process step: Evaluating a (pharmaceutical) treatment|paragraph 2.2.4]]).

====''Recording of medication use by the patient''====
The patients makes use of a medication profile and indicates actual medication use for each medicinal product for which this is relevant. The patient can indicate whether or not he is using the product and/or whether this is ‘medication use according to agreement’ (whereby the MA and/or TA is displayed) or if there were deviations. In case of deviations, it is possible to enter specific deviations (i.e. with regard to the schedule actually followed by the patient), but deviations can also be entered in more general terms (for example, I take the medication: ‘from time to time’, [x] times per [days/week] on average’, ‘1x daily instead of 2x’, ‘not anymore since 22 January 2015’ or ‘not anymore since about a month’). In case of deviation from the agreements, the patient also indicates the reason for changing or discontinuing. 
The patient may also add his own medication to the overview and indicate any side effects as the reason for the changes.

Information about medication use will not always be present. There is also no certainty about the reliability of the information. Sometimes there are agreements between the health professional and the patient about keeping track of medication use, and sometimes the initiative is the patient’s entirely.

====''Recording of medication use by health professionals''====
During the process of medication verification ([[#Process: medication verification|paragraph 2.1]]) or evaluating a pharmaceutical treatment ([[#Process step: Evaluating a (pharmaceutical) treatment|2.2.4]]) the patient (or his informal caregiver) indicates, for example, that he does not use medication or uses it differently than was agreed. He may also indicate that he uses other medication as well (self-care products or foreign medication). The health professional can record these data as MGB. The data about medication use is recorded in addition to the primary medication data with the patient being recorded as the source of the information and the health professional as the author. 
Instead of or in addition to recording the MGB, a prescriber may also choose to make a new or modified MA with the patient (in accordance with the process described in [[#Process step: Creating a medication agreement|paragraph 2.2.5]]). This may occur when the prescriber sees reasons to adjust the agreement in response to the patient’s actual medication use. When the prescriber sees no reasons to adjust the agreement, he may choose to only record the medication use, perhaps with the remark that he has requested the patient to comply with the existing agreements.

In case of deviations in MGB, a pharmacist may create a VMA for the prescriber (see [[#Process step: Informing the prescriber|paragraph 2.3.5]]) and/or advise the patient to inform the prescriber about the deviations.

The assessment of medication use (effect and side effect) will be recorded by the physician in the medical history or used as a reason to modify or discontinue a medication agreement.

===Process step: (Actively) making available===
The recorded medication data (MGB) and possibly the medication overview may be sent for information to a fellow health professionals or be made available so that the data can be accessed later.

{{Anchor|2-5-6}}

===Process step: Informing the prescriber===
The patient may also directly inform the prescriber when a new or modified MA or new VV is needed. The process is similar to the process of the pharmacist informing the prescriber ([[#Process step: Informing the prescriber|paragraph 2.3.5]]).

===Post-condition===
The medication list has been updated by the patient and actual medication use has been added. If necessary, the patient has asked the prescriber for a new or modified MA or VV.

===Information systems and transaction groups===
The ''prescriber'' and the ''pharmacist'' as well as other ''health professionals'' and ''users'' all make use of an information system, respectively, an electronic prescribing system (EVS), a pharmacist information system (AIS, incl. ZAIS), a XIS and a PGO<ref>XIS is a generic term for a random (health care) information system. PHR=personal health records.</ref>. These information systems each have different system roles which enable the exchange of data between these information systems as part of the prescription process. 
[[#6 Information systems and transactions|Chapter 6]] includes an overview of all information systems, system roles, transactions, etc. The most important elements for the prescription process are included in the overview below.

{{anchor|figuur 8}}
[[Bestand:Gebruiken.png|Figuur 8 Processtappen en transacties - gebruiken]]

===Use cases===
The use cases for medication use are described on the basis of registration by the patient. The prescriber may record medication use in the same way but will rather record the assessment of medication use (effect and side effect) in the medical history or use it as a reason to modify or discontinue a medication agreement.

The following specific use cases for medication use have been worked out:
*[[#Self-care product|Self-care product (paragraph 4.4.1)]]
*[[#Medication from abroad|Medication from abroad (paragraph 4.4.2)]]
*[[#Modification on the patient’s initiative|Modification at the patient’s initiative (paragraph 4.4.3)]]
*[[#Discontinuation of medication on the patient’s initiative|Discontinuation of medication at the patient’s initiative (paragraph 4.4.4)]]
*[[#No more supply|No more supply (paragraph 4.4.5)]]
*[[#Feedback to patient through a medication adherence app|Feedback to patient through a medication adherence app (paragraph 4.4.6)]]
*[[#Registration of side effects by the patient|Registration of side effects by the patient (paragraph 4.4.7)]]
*[[#Register usage based on provision|Register usage based on provision (paragraph 4.4.8)]]

=Domain-specific handling of the medication process=

==After Hours General Practice clinics (HAP)==
The after hours general practitioner (AHGP) works on behalf of the regular general practitioner (GP). The AHGP may (among other things) start, modify and discontinue MAs in accordance with the process described in [[#Process: medication verification|paragraph 2.1]]. If necessary, the AHGP will also create the corresponding VVs. 
The AHGP will inform the regular GP about the observation. Currently, it has been agreed that the AHGP does not act as a source of information for other health professionals of this patient. This means that the AHGP will not carry out the process step ‘(actively) making available’. Instead, the regular GP will make the relevant information available to the fellow health professionals. An exception may be made for a prescription created by the AHGP without a specified recipient, see [[#Prescription without specified recipient (ambulatory)|paragraph 8.1]]. 
In principle, the AHGP will follow the generic prescription process, except that a AHGP will carry out certain steps on behalf of the regular GP (‘delegated’).

==Mental health care==
There are only few planned admissions in mental health care (almost only in departments for eating disorders, clinical rehabilitation, etc.). Most admissions are admissions as a result of acute crisis situations and are therefore comparable to admissions via the emergency departments in hospitals (see also [[#Starting with medication before admission|paragraph 4.1.20]]).

===Current situation===
In the current situation, patient or family/informal caregivers are asked which medication the patient is using. In most cases, the patient is unable to give an answer (often the reason for admission). Family/informal caregivers (if known) are also not always able to answer this. If this is the case, the admitting physician/psychiatrists will contact the general practitioner or the pharmacist to find out the medication. This is difficult outside office hours and during weekends. When data do come in, only part of them is retyped in the information system of the health professionals.

===Process===
In the new situation, it will be possible to retrieve the available medication data and medication overviews. On this basis, medication verification, assessment of the medicamenteuze behandeling (as soon as possible) and medication administration (in accordance with [[#Medication process|Chapter 2]]) can be started. Medication dispense is carried out by public pharmacists on an outpatient basis and, in clinical practice, often by a contracted hospital pharmacy. 
As is the case with hospital discharge, medicamenteuze behandeling will be assessed at discharge from a mental health institution ([[#Process step: Evaluating a (pharmaceutical) treatment|paragraph 2.2.4]] and subsequent). Clinical medication is discontinued and, if necessary, new medication is prescribed or temporarily halted outpatient medication is resumed or permanently discontinued. The physician/psychiatrist focuses mainly on psychiatric medication; somatic medication usually remains unaffected. 
Letting the psychiatric patient record his own medicatiegebruik may be experienced as undesirable control instead of it stimulating proper medication use. 
The medication data will be made available.

==Nursing, care and home care (VVT)==
The medication process in a VVT institution (nursing home, care home and home care) is similar to that of the clinical situation. However, in a VVT institution, a geriatrics specialist is responsible for prescribing medication to admitted clients and medication is being dispensed by one or more community pharmacists, possibly as part of GDS if needed. VVT institutions and home care make use of administration lists, which are drawn up based on the toedieningafspraken. The administration list is used to check medication before administering it and to sign off actual medicatiegebruik. Communication of the administration list between pharmacist, prescriber and nursing staff will be explained in more details further on in this information standard.

==Hospital admission and discharge==
A special situation in the transfer of medication data occurs when a patient is admitted to a hospital. At the moment of admission and of discharge, a lot of changes can take place in the medicatieafspraken and toedieningsafspraken. That is why this subject is separately illustrated in this chapter. This process is described in more detail in instruction manuals for caregivers and software suppliers.

===Prior to admission===
Before a patient is admitted to a hospital, changes in medication may be necessary. The medical specialist and patient can agree upon starting new medication or stopping continuous medication a few days before admission. The medical specialist subsequently registers a medicatieafspraak or stop-MA and mentions in the explanatory notes how many days before admission the patient has to start or stop the medication. When this medicatieafspraak is registered, the date of admission is often yet unknown. That is why the medical specialist records that this medicatieafspraak depends upon a hospital admission. This means that the start- or end date are uncertain. Technically, this is solved by registering the explanatory notes in the element ‘Condition’ of the period of use of the medicatieafspraak. If this condition is entered, it is clear to caregivers that the period of use is uncertain.

===During admission and at time of discharge===
When a patient is admitted, the following situations can occur, concerning the outpatient medication:
* Unchanged continuous use,
* Change in dosage,
* Generic substitution (active ingredient remains the same),
* Pharmacological substitution (active ingredient changes, but medication is registered for the same indication),
* (Temporary) stop.

Below, for each situation, an explanation is given for registration of the medication of the patient.

====Unchanged continuous use====
The patient continues using the outpatient medication during admission.

Both medicatieafspraak and toedieningsafspraak continue during admission and after discharge.

====Change in dosage====
The patient uses the outpatient medication during admission, but in a different dosage.

The medicatieafspraak for outpatient medication is stopped at admission. During admission, a new medicatieafspraak is registered with the changed dosage. At discharge, the prescriber decides which dosage will apply for the outpatient medication. Depending on this decision, the medicatieafspraak that applied before admission will be continued, or a new medicatieafspraak will be registered.
The toedieningsafspraak is also stopped at admission. During admission, a new toedieningsafspraak is registered, based on the new medicatieafspraak. At discharge, the toedieningsafspraak that applied before admission will be continued, or a new toedieningsafspraak will be registered.

====Generic substitution====
The patient uses a different medicinal product during admission, but with the same active ingredient and dosage as in the outpatient medication.

The medicatieafspraak for outpatient medication continues during admission and after discharge.
The toedieningsafspraak for outpatient medication is stopped at admission and continued at discharge. During admission, a new toedieningsafspraak is registered. This toedieningsafspraak will be stopped at discharge.

====Pharmacological substitution====
The patient uses a different medicinal product during admission, with a different active ingredient from the outpatient medication. This medicinal product, however, is registered for the same indication as the outpatient medication.

The medicatieafspraak for outpatient medication is stopped at admission and will be continued again at discharge. During admission, a new medicatieafspraak is registered. This medicatieafspraak will be stopped at discharge.
The toedieningsafspraak for outpatient medication is also stopped at admission and continued at discharge. During admission, a new toedieningsafspraak is registered. This toedieningsafspraak will be stopped at discharge.

====(Temporary) stop====
The patient (temporarily) stops using the outpatient medication during admission.

The medicatieafspraak for outpatient medication is (temporarily) stopped at admission. If the medication is stopped temporarily, this medicatieafspraak will be continued at discharge. If the medication is stopped definitively, the medicatieafspraak will not be continued.
The toedieningsafspraak for outpatient medication is also (temporarily) stopped at admission. If the medication is stopped temporarily, this toedieningsafspraak will be continued at discharge. If the medication is stopped definitively, the toedieningsafspraak will not be continued.

=Description of use cases=
This chapter contains a description of various use cases. Specific practical situations have been described for the various subprocesses. A large number of the practical situations are based on general medical practice, but are illustrative of similar situations in a different setting. This chapter assumes the knowledge as previously described in [[#Medication process|Chapter 2]].

==Use cases, Prescribe==

===Short-term medication===
A 35 year old female patient with a history of urinary tract infection brings her urine to the doctor’s assistant and tells her she has the same symptoms as the previous times. The assistant enquires about other symptoms such as fever and pain in the flank and checks the urine. There are no other symptoms and the urine reveals a urinary tract infection. She tells the patient that the general practitioner will prescribe a course of treatment and that she can pick it up from the pharmacist later. The General practitioner checks the previous courses of treatment and any cultures and records a medicatieafspraak. On ''27 January'' it was agreed:
:''Nitrofurantoin CR capsule, 100 mg, 2x daily, 1 capsule, from now on<ref>See also [[#Hard end date for period of use|paragraph 4.1.3]].</ref> for 5 days.''
He records this medicatieafspraak in his information system. The general practitioner then immediately also makes a verstrekkingsverzoek for the pharmacist chosen by the patient:
:''Nitrofurantoin CR capsule, 100 mg; 10 capsules.''
The general practitioner also records this verstrekkingsverzoek in his information system. 
The general practitioner consults with the patient to find out from which pharmacist she wants to pick up the medication. The general practitioner can then inform this pharmacist about the verstrekkingsverzoek and the medicatieafspraak. 
The information system of the general practitioner makes this information (verstrekkingsverzoek and medicatieafspraak) available to the other health professionals of this patient. 
 
[[Bestand:ENG_Voorschrijven_Kortdurende medicatie.png|800px]]

===Continuing medication===
The process for continuing medication is practically the same as for short-term medication (see [[#Short-term medication|paragraph 4.1.1]]), except that in the case of continuing medication the medicatieafspraak is made for an indefinite period of time.

For example: the prescriber agrees with a patient who has hypertension that he should use a diuretic on a continuous basis. On ''30 March 2013'' it was agreed:

:''Hydrochlorothiazide tablet, 12.5 mg; 1x daily, 1 tablet; from now on for an indefinite period.''
''For example, the prescriber chooses in the verstrekkingsverzoek for an initial dispensing quantity of 100 pieces.'' 
 
[[Bestand:ENG_Voorschrijven_Doorlopende medicatie.png|800px]]

===Hard end date for period of medication use===
A start date, end date and/or duration can be included in the period of medication use of a medicatieafspraak. If a hard end date is desired, this must also be explicitly stated in the explanation. Including an end date alone is not sufficient because this does not provide enough clarity about the intention of the prescriber. 
 
[[Bestand:ENG_Voorschrijven_Harde stopdatum gebruiksperiode.png|800px]]

===Medication as needed===
A 31-year-old female patient has had headaches a few times in a year, with migraine now being diagnosed. The general practitioner prescribes:
:''Rizatriptan tablets, 10 mg, as needed 1c1t under the tongue. First tablet at the next clear migraine attack.''
De huisarts legt de medicatieafspraak vast en doet een verstrekkingsverzoek:
:''6 sublingual rizatriptan tablets, 10 mg.''
 
[[Bestand:ENG_Voorschrijven_Zo nodig medicatie.png|800px]]

===Course of treatment as needed starting in future===
A 60-year-old patient with post-thrombotic syndrome experiences erysipelas (severe infection of the leg which can require admission if medication is not started quickly) sometimes every other year, sometimes three times a year. At the request of the patient, the general practitioner prescribes an antibiotic treatment the patient can start immediately in case of a recurrence of erysipelas. The following medicatieafspraak is created:
:''Flucloxacillin capsules, 500 mg, 1 capsule 4x daily, for 10 days. In the medicatieafspraak is indicated (if necessary): start in case of recurrence, as needed.''
The general practitioner immediately creates a verstrekkingsverzoek:
:''Flucloxacilline 500 mg capsules 40 stuks.'' 
 
[[Bestand:ENG_Voorschrijven_Kuur zo nodig startend in de toekomst.png|800px]]

===Two dosages of the same medication at the same time===
A 79-year-old man with metastatic prostate cancer is increasingly suffering from pain and his medication is being changed. The specialist prescribes oxycodone tablets, 10 mg, 1 tablet 4x daily and as needed for pain during the night, 1 tablet 1x daily, on October 9. The specialist records this in one single medicatieafspraak with two dosing instructions and creates a verstrekkingsverzoek for 60 tablets of oxycodone of 10 mg. 
 
[[Bestand:ENG_Voorschrijven_Twee doseringen van hetzelfde geneesmiddel tegelijkertijd.png|800px]]

===The same medicinal product with different strengths at the same time===
The same 79-year-old patient (see [[#Two dosages of the same medication at the same time|paragraph 4.1.6]]) is experiencing even more pain. The specialist discontinues the 10 mg tablets of oxycodone on October 16 and prescribes 20 mg retard tablets of oxycodone, 2 tablets 3x daily, and 20 mg normal release tablets of oxycodone as needed in case of nocturnal pain, 1 tablet 1x daily. The specialist records this in two medicatieafspraken (with, for the time being, two separate medicamenteuze behandelings) and creates a verstrekkingsverzoek for both medicatieafspraken, respectively 45 retard tablets of 20 mg oxycodone and 30 tablets of 20 mg oxycodone (normal release). 
 
[[Bestand:ENG_Voorschrijven_Hetzelfde geneesmiddel met verschillende sterkte tegelijkertijd.png|800px]]

===Explanation in medicatieafspraak with deliberately chosen special characteristic===
This use case is described in the zib medicatieafspraak/additional information. Here it is described for information purposes only. When selecting a medicinal product, it is possible to deviate from what is expected or standard. For example, when a hospital uses a different formulary than a community pharmacy. For reasons of efficiency the hospital has opted for a single gastric acid inhibitor: pantoprazole. 
At admission, a patient with omeprazole is switched to pantoprazole for the duration of the hospitalization. At discharge, the patient returns to omeprazole. 
It is clear that this may sometimes go wrong and that the patient might end up taking both omeprazole and pantoprazole if nothing is done. In the medicatieafspraak of the hospital for pantoprazole, a remark can be made about this deviation in order to make it clear that pantoprazole is the replacement of omeprazole or that it has to be used in addition to omeprazole.
 
 
Half-strengths are another example. The hospital sometimes as tablets available with half the strength of the normal commercial preparation (proprietary production). When a patient enters the hospital with a prescription of 25 mg of chlorthalidone, half a tablet 1x daily, he will receive 12.5 mg of chlorthalidone, 1 tablet 1x daily. In this specific case, this means that nursing staff does not have to break tablets in half. There is a risk that the patient will use the 25 mg again at home, but now a whole tablet at the time. An explanation in the medicatieafspraak (additional information) regarding the last 25 mg of chlorthalidone, makes it possible to indicate whether this was a deliberate increase. 
 
If a prescribed product has to be a very specific commercial product, this can be indicated with ‘medical necessity’.

===New medicatieafspraak, no verstrekkingsverzoek===
A 50-year-old man comes to the general practitioner with back problems. The symptoms have been present for three weeks and he is already using paracetamol. The general practitioner agrees with the patient that he can additionally use diclofenac:

On ''30 January'' it was agreed:
:''Diclofenac tablet, 50 mg, 1 tablet 3x daily, from now on for 3 weeks.''
He records this medicatieafspraak in his information system. The patient indicates there is sufficient supply at home: his wife still has an ample supply of diclofenac left because of a different problem a year ago.

A verstrekkingsverzoek is therefore not needed and the pharmacist also does not dispense any medication. 
The general practitioner makes the new medicatieafspraak available to any fellow health professionals of this patient. This allows the regular pharmacist to inform himself about this new medicatieafspraak. 
 
[[Bestand:ENG_Voorschrijven_Nieuwe medicatieafspraak geen verstrekkingsverzoek_a.png|800px]]

Another example: Mr Simons receives medication from the pharmacy weekly. In the past there were many requests for extra medication, which led to clear agreements about the dispense policy.

This is about:
:''Medicatieafspraak: Diazepam, 5 mg, 1 tablet 4x daily, from 1 January 2012 for an indefinite period''
:''Verstrekkingsverzoek: 28 tablets with 10 repeats; remark: weekly medicatieverstrekking''
The verstrekkingsverzoek is repeated approximately every 11 weeks.
The last verstrekkingsverzoek was on 3 March 2016:
:''one week (28 tablets) with 10 repeats''
This way, the pharmacy can go on for 11 weeks.
 
 
[[Bestand:ENG_Voorschrijven_Nieuwe medicatieafspraak geen verstrekkingsverzoek_b.png|800px]]

The last few years have been quiet. Mr. Simons is no longer asking for extra medication. At the last consultation he indicated that diazepam, 3x daily, is sufficient. This has been recorded in a medicatieafspraak:
:''1 April 2016 Diazepam, 5 mg, 1 tablet 3x daily, from 1 April 2016 for an indefinite period.''

The previous medicatieafspraak will be terminated as of 31 March 2016 (see discontinuation of medication in [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5]]).

In the current situation, the general practitioner would have called the pharmacy to make sure that 21 tablets of diazepam would be given with the following medicatieverstrekking, instead of 28. No new verstrekkingsverzoek would have been needed at the time.

In the new situation, the general practitioner sends the new medicatieafspraak to the pharmacy. Based on the new medicatieafspraak, the pharmacy provides 21 tablets per week, the previous verstrekkingsverzoek is still sufficient.

 
[[Bestand:ENG_Voorschrijven_Nieuwe medicatieafspraak geen verstrekkingsverzoek_c.png|800px]]

===New verstrekkingsverzoek under existing medicatieafspraak===
A prescriber may also create a new verstrekkingsverzoek as part of an existing medicatieafspraak. This medicatieafspraak may have been created by a different prescriber, for example a psychiatrist. This concerns repeat medication. This use case is described in [[#Patient requests repeat prescription via physician (reactive repeat)|paragraph 4.2.6]].

[[Bestand:ENG_Voorschrijven_Nieuw verstrekkingsverzoek onder bestaande medicatieafspraak.png|800px]]

===Dosage change (sufficient supply)===
Patient (37 years old, asthma) visited the pulmonologist on 13 August 2013 for a check-up of his asthma. The pulmonologist has established that patient’s asthma is not adequately controlled. 
The patient is currently using beclomethasone in accordance with a previously made and registered medicatieafspraak: on 10 June 2010 it was agreed:
:''Beclomethasone aerosol, 100 microgram/dose, inhaler; 1 inhalation 2x daily; from 10 June 2010 for an indefinite period.''
On 13 August 2013, the pulmonologist agrees with the patient on a dosage increase:
:''Beclomethasone aerosol, 100 microgram/dose, inhaler; 2 inhalations 2x daily; from 13 August 2013 for an indefinite period; reason for adjustment: insufficient effect.''
The previous medicatieafspraak of 10 June 2010 it is no longer valid: it is terminated (see Changing medication in [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5]]). The patient still has a sufficient supply, a verstrekkingsverzoek is therefore not needed.
 
 
[[Bestand:ENG_Voorschrijven_Wijziging in dosering voldoende voorraad.png|800px]] 
In case the patient has no more supply, a new verstrekkingsverzoek will be created. 
The information system of the pulmonologist makes the new medicatieafspraak available to the other health professionals of this patient. This modification is received by the pharmacist (fellow health professional). The pharmacist processes the modification. The pharmacist may also choose to accept the modifications automatically.

===Prescription no longer needed after first verstrekkingsverzoek===
A 16-year-old woman has a boyfriend and does not want to become pregnant. After explanation she opts for the pill. The general practitioner prescribes ethinylestradiol/levonorgestrel tablets of 20/100 µg, 1 tablet 1x daily for 21 days, then no tablet for 7 days, then another 21 days of taking a tablet once a day. Start on the first day of the next menstruation. The general practitioner records the medicatieafspraak and creates a verstrekkingsverzoek for 63 coated microgynon 20 tablets. He explains to her that if she does not experience any problems, she can continue to get the pill via the pharmacy. 
Three months later, the woman sends a request for repeat supply to the pharmacy. The pharmacy provides the product and communicates the medicatieverstrekking to the general practitioner.

 
[[Bestand:ENG_Voorschrijven_Recept niet meer nodig na eerste verstrekkingsverzoek.png|800px]] 

{{Anchor|4-1-13}}
===Discontinuing medication===
Patient (37 years old, asthma) visits the pulmonologist on 13 August 2013 for a check-up of his asthma. The patient is suffering from a side effect. The patient is currently using Beclomethasone in accordance with a previously made and registered medicatieafspraak. On ''10 June 2010'' it was agreed:
:''Beclometasone aerosol, 100 microgram/dose, inhaler; 1 inhalation 2x daily; from 10 June 2010 for an indefinite period.''
On 13 August 2013, the pulmonologist agrees with the patient to discontinue the medication (medicamenteuze behandeling is discontinued). Medication verification is also applicable here. In addition, medication monitoring may also be relevant here, for example if gastroprotrective drugs are being used because of the use of the medication to be discontinued (the information system will not always signal this automatically). 
The pulmonologist records:
:''Beclometasone aerosol, 100 microgram/dose, inhaler; stoptype ‘definite’; from 13 August 2013. Because of a side effect.''
This modification is received by the pharmacist (fellow health professional). The pharmacist processes the modification. The pharmacist may also choose to accept the modifications automatically. The pulmonologist decides to also actively inform a fellow health professional (such as a specialist) about this (part of the process step (actively) making available). 
The information system of the pulmonologist makes this information (agreement to discontinue) available to the other health professionals of this patient.
 
 
[[Bestand:ENG_Voorschrijven_Stoppen medicatie.png|800px]] 

===Temporarily halting/resuming medication===
A patient is being treated with simvastatin (cholesterol-lowering agent): 40 mg, 1 tablet 1x daily, for an indefinite period. Because of a throat infection in combination with an allergy for the first antibiotic of choice, Clarithromycin, 250 mg, 1 tablet 2x daily (antibiotic) is prescribed for 1 week. During that week, simvastatin is temporarily halted because of an interaction. 
The general practitioner records:
:''Simvastatin 40 mg; halt temporarily; for 1 week; reason: interaction''
:''Clarithromycin, 250 mg; 1 tablet 2x daily; for 1 week (and a corresponding verstrekkingsverzoek)''
The pharmacist is actively informed by the general practitioner about the temporary halt of simvastatin. A new medicatieafspraak is also created with which simvastatin is resumed after one week. The pharmacist will also receive the medicatieafspraak and the corresponding verstrekkingsverzoek for clarithromycin. See also Temporarily halting and resuming medication in [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5]].

 
[[Bestand:ENG_Voorschrijven_Onderbreken hervatten medicatie.png|800px]] 

===Temporarily halting for an intervention===
A 62-year-old man uses acetylsalicylic acid, 100 mg, 1 tablet 1x daily because of coronary disease. He has an intestinal polyp that must be removed. The general practitioner informs him that he should stop using acetylsalicylic acid three days before the intervention and resume the day after the intervention. The general practitioner records the temporary halt in a medicatieafspraak with an enddate 3 days before the intervention; stoptype ‘temporary’; reason for halting: ‘intervention’. In the (second) medicatieafspraak for presuming, 1 day after the intervention is used as the start date. The general practitioner actively informs the pharmacist and the gastroenterologist about the medicatieafspraken. 
When the date of the intervention is unknown or uncertain, the explanation will indicate that the medication should be halted three days before the intervention and resumed one day later. The duration of the temporary halt is then 4 days. See also Temporarily halting and resuming medication in [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5]].

 
[[Bestand:ENG_Voorschrijven_Onderbreken voor een ingreep.png|800px]] 

===Paper prescription===
The physician gives the patient a paper prescription<ref>A similar situation occurs when the pharmacist receives a fax.</ref>. A paper prescription contains a medicatieafspraak and a verstrekkingsverzoek. The patient can use this prescription to pick up the medication from any pharmacist. The general practitioner does not inform the issuing pharmacist in this case. However, the process is actually the same: the activity ‘(actively) making available’ is now only ‘handled’ by the paper prescription in the hands of the patient. The supplying pharmacist will copy this paper medicatieafspraak and verstrekkingsverzoek in his own information system and complete it with a toedieningsafspraak. The pharmacist may also retrieve the medicatieafspraak and verstrekkingsverzoek that were made available digitally and process them in his own information system this way. 
The information system of the general practitioner makes the new medicatieafspraak and verstrekkingsverzoek available for fellow health professionals. When the information system of the general practitioner has not made these available this may be because it concerns a toedieningsafpsraak without digitally available medicatieafspraak and verstrekkingsverzoek. The pharmacist will not make the medicatieafspraak and verstrekkingsverzoek obtained ‘from paper’ available because he is not the owner. Next to that, this could lead to, possibly only in the future, wrongful duplication of medicatieafspraken and verstrekkingsverzoeken.
 
[[Bestand:ENG_Voorschrijven_Papieren recept.png|800px]]
 

===Carrying out medication verification and evaluation of foreign or self-care medication===
When medication cannot be found in the information system (such as foreign medication and self-care medication), this medication will be recorded as medicatiegebruik (see [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5]]).

===Day treatment===
An admission for day treatment is comparable with an outpatient consultation or an emergency admission during which the medication is supplied by the hospital pharmacist. In the case of admission for a day, extensive medication verification does not usually occur. In the case of admission for a day, the medication prescribed is recorded (often on the basis of protocols according to which verification is carried out afterwards) and administered. 
For treatments with cytostatics, for example, there is a medicatieafspraak, but it is not always clear in advance when the medicatieverstrekking/administration takes place. Reason: treatments are often postponed and then supplied and administered later.

===Starting with medication before admission===
Prior to cataract surgery, Nevanac is started three days before the surgery. The eye drops are used until three weeks after surgery (a total duration of medication use of 24 days). The specialist creates a medicatieafspraak for Nevanac, 1 drop in the morning, for 24 days. When the date of the surgery is unknown or uncertain, the explanation may indicate that Nevanac should be started 3 days before surgery takes place. See Prior to admission in [[#Prior to admission|paragraaf 3.4.1]]
 [[Bestand:ENG_Voorschrijven_Starten met medicatie voor opname.png|800px]]
 

===Emergency admission===
In the event of an emergency admission, extensive medication verification is not carried out beforehand as would normally be the case with clinical admissions. Agreeing on medication with the patient is also often not possible in the event of an emergency admission. Often, the patient is administered medication as soon as possible and verification only takes place afterward

===Interim discharge===
When a patient temporarily leaves the hospital/institution to go home, for example, for weekend leave, the clinical medication continues. In order to keep the patient’s own general practitioner informed, the medication overview is provided to the patient and the medication data are made available.

===Transfer to another institution===
In case of a transfer to another institution, the medicamenteuze behandeling is evaluated (see [[#Process step: Evaluating a (pharmaceutical) treatment|Chapter 2.2.4]] and [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5]]). Medication overview and medication data are (actively) made available. The new attending physician evaluates the medicamenteuze behandeling and determines the institutional medication.

===Do not dispense before===
The prescribing physician creates a verstrekkingsverzoek on 14 April 2017, but wants to indicate in that same verstrekkingsverzoek the medicatieverstrekking may only take place on or from a later date, for example, 23 April 2017. This cannot be recorded in a structured manner in the verstrekkingsverzoek, but is included in the explanation (as free text).
 
[[Bestand:ENG_Voorschrijven_Niet verstrekken voor.png|800px]]
 

===Discontinuation of medication by third parties===
Medication can be discontinued by the prescriber himself (see [[#Discontinuing medication|paragraph 4.1.13]]) but also by another prescriber. For example, the specialist can end medicatieafspraken made by a general practitioner that are up to date according to the information system, but that turn out not to be, for example after medication verification. When a health professional discontinues medication, he creates a new stop-MA. The health professional cannot modify someone else’s medicatieafspraak, only create a stop-MA. He therefore actively informs the health professional of the original medicatieafspraak about this change. The health professional of the original medicatieafspraak modifies the end date in the existing medicatieafspraak. If required, this may also be automated by the information system. This prevents the second health professional from not having to produce data after a period of time because the production period has expired (also no stop-MA), while the health professional of the original medicatieafspraak continues to produce it for no reason (without an end date).
 
 
[[Bestand:ENG_Voorschrijven_Stoppen van medicatie door derden.png|800px]]
 

===Two PRKs in a single medicamenteuze behandeling===
In certain circumstances, the pharmacy is allowed to select a different PRK for the toedieningsafspraak than is indicated in the medicatieafspraak made by a prescriber. If for instance a failure of the prescriber’s information system would result in only the communication of the toedieningsafspraak, a subsequent prescriber will only have this toedieningsafspraak with the new PRK. The next prescriber will then probably assume that this PRK is also the PRK of the medicatieafspraak. A modification of the medicatieafspraak will then also result in a stop-MA (without referring to the original MA) and a new medicatieafspraak on the basis of this PRK. This means that there are now two medicatieafspraken with different PRKs under the same medicamenteuze behandeling. These two medicatieafspraken continue to exist. After any information system failure, (the information system of) the prescriber must check whether there have been changes and implement them, if necessary (see also [[#Discontinuation of medication by third parties|paragraph 4.1.26]]).
 
[[Bestand:ENG_Voorschrijven_Twee PRKs onder een medicamenteuze behandeling.png|800px]]
 

===Creating a medicatieafspraak after the fact===
In emergency situations, for example, it may happen that the medicatieafspraak is only created after the medication has been dispensed or administered. This may lead to conflicting medicatieafspraken. This means that one or more medicatieafspraken must be discontinued in order to prevent the occurrence of parallel medicatieafspraken. The only exception for parallel medicatieafspraken is described in [[#Medicamenteuze behandeling|paragraph 1.3.3]].

===Single medication use( medicatiegebruik)===
For medication meant for single use, only an end date is included in the period of medication use. An example would be a vaccination (for example, a tetanus shot) or a situation in which a patient should take a medication just once, for example 3 weeks before he leaves on holiday.
 
[[Bestand:ENG_Voorschrijven_Eenmalig gebruik.png|800px]]
 

===Provisional and final medication order===
The prescriber at the clinic prescribes medication. This is recorded in a provisional medication order (the medicatieafspraak). The hospital pharmacist verifies this order and records it as a final medication order (the toedieningsafspraak). See also <ref name="MO"/>.

===Inadvertently ‘outstanding’ medication or 'orphans'===
In a transitional situation and in a situation where not every XIS is connected, medicatieafspraken for the same treatment may exist that have been created by different information systems under different medicamenteuze behandelings. These medicatieafspraken should ideally be combined in a single medicamenteuze behandeling. This particularly applies to medication with an open end date, as this medication may have been discontinued under a different medicamenteuze behandeling. The medicatieafspraak therefore remains open, resulting in continued medicatieverstrekking. This is a so-called ‘orphan’ (a building block that has been registered, but in which, at a certain point, the health professional no longer has an active role. However, his information system continues to provide the building block, even if it has already been discontinued elsewhere). For medication with an end date, this problem will solve itself. Therefore, it is not necessary to take any action. When medication verification or medication assessment reveals that the medication is inappropriately still ‘open’, a stop-MA is created under the same medicamenteuze behandeling. The original prescriber is actively informed about this stop-MA and enters an end date for the medicatieafspraak in his own information system. Depending on the supplier and the client’s wishes, setting this end date can be done automatically or through an intervention of the prescriber. See also [[#Discontinuation of medication by third parties|paragraph 4.1.26]] and [[#Modification of someone else's medicatieafspraak|paragraph 4.1.40]].
 
 
[[Bestand:ENG_Voorschrijven_Onterecht openstaande medicatie of weeskinderen.png|800px]]
 

===Missing digital medicatieafspraak at admission===
If no digital medicatieafspraak is available when medication verification is carried out, a new medicamenteuze behandeling is started by recording medicatiegebruik. When this medicatiegebruik has to be discontinued, a stop-medicatieafspraak is created under the same medicamenteuze behandeling that refers to the recorded medicatiegebruik. If possible, the original prescriber (for example, general practitioner) and the pharmacy are actively informed about the discontinuation of this medication.
 
[[Bestand:ENG_Voorschrijven_Ontbreken digitale medicatieafspraak bij opname.png|800px]]
 

===Own articles (90 million numbers)===
It is possible to exchange a 90 million number. The condition is that within an organization a 90 million number once created may never be modified. During the exchange, the root OID (unique technical identification of the organization) in combination with the 90 million number ensures that it is unique compared to all 90 million numbers form other organizations. The substances that make up this article are included as ingredients in the medicatieafspraak (at least one ingredient), as is the case with magistrals.

===Dosing with minimum interval ===
Medication can be prescribed at a fixed interval (for example: 2 tables every 6 hours). Prescribing medication with a minimum interval should be partly in free text. For example, if needed, a maximum of 3 times a day, a minimum of 6 hours between the intake moments: ''if needed, a maximum of 3 times a day'' is recorded in the standard way. The section “''at least 6 hours between intake times''” is recorded in free text as an Additional Instruction.
 
 [[Bestand:ENG_Voorschrijven_Dosering met minimum interval.png|800px]] 
 

===Verstrekkingsverzoek with number of repetitions ===
The prescriber makes a verstrekkingsverzoek with a medicatieafspraak in which she enters the number of repetitions. The prescriber hereby indicates to the provider that it may make additional provisions. The number of repetitions in combination with the quantity to be dispensed results in: (Number of repetitions + 1) X quantity to be dispensed. In case of “number of repetitions =3” and “quantity to be supplied = 30 pieces” the provider may provide 4 times 30 pieces (total 120 pieces). The number of repetitions in combination with the duration of medication usage period results in: (number of repetitions + 1) x duration of medication use. The amount to be dispensed depends on the dosage. In case of “dosage = 3 x per day 2 pieces”, and “Duration of medication usage period = 30 days” the provider may provide 180 pieces 4 times (6 pieces per day X 30 days = 180, 4 times = a total of 720 pieces).
 
 [[Bestand:ENG_Voorschrijven_Verstrekkingsverzoek met aantal herhalingen.png|800px]] 
 

===Prescribing non-medicines===
Non medicines can be prescribed from the G-standard at HPK level. For example, this could be an inhaler (Aerochamber, HPK 1915185) as an aid to prescribed aerosols. Non-medicinal products are not applicable for the medication overview or medication monitoring.

===Send renal function value in the prescription===

'''A) Renal function value with a new prescription:''' 
For the prevention of stroke, a patient (male, 65 years old) is prescribed Dabigatran for the first time. The patient has renal impairment and the prescriber has a recent renal function value available. Based on this renal function value, the prescriber deviates from the standard dose and makes a medicatieafspraak with a lower dosage of Dabigatran twice a day 1 capsule of 110 mg, starting from January 15, 2020. The prescriber also makes a verstrekkingsverzoek and sends the prescription (medicatieafspraak, verstrekkingsverzoek and the laboratory result of the renal function value) to the pharmacist.
 
[[Bestand:ENG_Voorschrijven_Nierfunctiewaarde sturen met het voorschrift_a.png|800px]] 

'''B) Renal function value reason for a change:''' 
A 70-year-old man was prescribed 1 tablet of metformin 500 mg 3 times a day a few days ago (medicatie afspraak and verstrekkingsverzoek). At the same time, the doctor initiated a blood test to determine the renal function value of the patient. The value was not yet known at the time of prescription.
 
[[Bestand:ENG_Voorschrijven_Nierfunctiewaarde sturen met het voorschrift_b1.png|800px]] 

The blood test shows that renal function is impaired and gives reason to adjust the medicatieafspraak. The prescriber adjusts the dose on January 17, 2020 to 2 tablets metformin 500 mg twice a day and discuss this with the patient. The new prescription (the 'technical' stop medicatieafspraak, new medicatieafsrpaak and the laboratory result of the renal function value) is sent to the pharmacy by the prescriber. Because the patient had already collected the medication and therefore has enough stock, no new verstrekkingsverzoek is sent along.
 
[[Bestand:ENG_Voorschrijven_Nierfunctiewaarde sturen met het voorschrift_b2.png|800px]] 

'''C) Renal function value due to drug:''' 
The patient is prescribed Nitrofurantoin 100 mg, 1 capsule twice daily as a 5-day course due to a bladder infection and must start immediately on January 6, 2020. With this drug, the renal function value (if known and not older than 13 months) needs to be sent along. The prescriber has a renal function value available for this patient, but this does not lead to an adjusted dosage. The prescriber sends the prescription (medicatieafspraak, verstrekkingsverzoek and the laboratory result of the renal function value) to the pharmacist.
 
[[Bestand:ENG_Voorschrijven_Nierfunctiewaarde sturen met het voorschrift_c.png|800px]] 
 

===Cancelling a prescription that was sent earlier ===
A patient visits the general practitioner (GP) one morning because of stomach complaints. The GP prescribes pantoprazole and sends the prescription (MA + VV1) to the preferred pharmacy as known to him. In the afternoon the patient calls the GP. He hasn’t picked up the prescription yet and he would like to pick it up at another pharmacy due to a recent move, but forgot to ask this morning. The GP resends the prescription to the old pharmacy, but the VV in the newly send prescription contains a canceled indicator (MA + VV1 “cancelled”), so the pharmacist knows he should not dispense on this prescription. The prescriber then sends a new prescription (MA + VV2) to the patient's new pharmacy. The patient can pick up the medication there. 
In medication building blocks it looks as follows: 
 [[Bestand:ENG_Voorschrijven_Annuleren eerder verstuurd voorschrift_a.png|800px]] 
 
The transactions look as follows: 
[[Bestand:ENG_Voorschrijven_Annuleren eerder verstuurd voorschrift_b.png]] 

===Modification of someone else's medicatieafspraak ===
A patient takes 40 mg Lisinopril once a day because of hypertension. This medicatieafspraak was previously made by the GP with the patient. The patient is admitted to the enters A&E department because of a fall due to dizziness. The specialist notices hypotension and decides to reduce the dose of Lisinopril to 20 mg once a day. The specialist then stops the current medicatieafspraak and starts the new medicatieafspraak with a lower dose. With this he changes the medicationafspraak with the patient. The specialist informs the original prescriber (the general practitioner) about this with a stop medicatieafspraak and the new medicatieafspraak.
The prescriber of the original medicatieafspraak adjusts the stop date in the original medicatieafspraak. If desired, this can also be automated by the information system. This prevents the second care provider no longer having to provide data over time because the delivery period has expired (including no stop MA) while the care provider of the original medication appointment continues to provide this incorrectly (without a stop date).
 
[[Bestand:ENG_Modification of someone else's medicatieafspraak.PNG|800px]]
 
===Setting up a variable dosing regimen (WDS) ===
The prescriber prescribes anticoagulants and states in the MA that the medication is used as recorded by the schedule of the thrombosis service (‘gebruik volgens schema trombosedienst). The prescriber sends a VV to the pharmacist and the patient is registered with the thrombosis service. In order to bridge the period until thrombosis care can take over, the prescriber creates a WDS for the first period. After registration, the thrombosis service creates a dosing regimen that overwrites or succeeds the previous regimen. From this moment on, the thrombosis service takes over creating the dosing regimen from the original prescriber.
[[Bestand:ENG_Uc_setting_up_WDS.png|800px]]

===Changing a variable dosing regimen (WDS) during period of use===
It could be necessary to revise the dosing regimen from a WDS before the scheduled stop date. For example, when the patient unexpectedly has to undergo minor surgery. In this case, the prescriber stops the current WDS with a technical stop (not visible to the user) and creates a new WDS with a few 0 doses the days before the procedure. In the meantime, the MA continues as usual.
[[Bestand:ENG_Uc_Changing_WDS.png|800px]]

===Stopping medication with a variable dosing regimen (WDS) ===
When the patient has to (temporarily) stop using anticoagulants completely, this is recorded at the level of the MA. The thrombosis physician creates a stop-MA. This also stops the underlying WDS and the associated TA. The original prescriber also processes the stop date in his MA.
If the anticoagulants needs to be restarted after several months, the original prescriber of the anticoagulant medication does this by following the process of starting a WDS. So by creating a new MA and a first WDS (see the use case [[#Setting up a variable dosing regimen (WDS)| Setting up a variable dosing regimen (WDS)]]). 
[[Bestand:ENG_Uc_stopping_WDS.png|800px]]

==Use case, Dispense==

===New medicatieafspraak, medicatieverstrekking of the same product===
The patient is at the pharmacist on 27 January 2013 to collect his medication. The pharmacist opens the file of the patient and verifies the medication file. It is a new medicatieafspraak for this patient. The relevant information of the prescribing physician is displayed on the screen of the pharmacist. 
Medicatieafspraak: ''Nitrofurantoin CR capsule, 100 mg, 1 capsule 2x daily, from now on for 5 days.'' 
Verstrekkingsverzoek: ''Nitrofurantoin CR capsule, 100 mg; 10 capsules.'' 
The pharmacist selects a product on the basis of the medicatieafspraak and other factors (such as the pharmacist’s stock and the preference policy of the healthcare insurer): 
''FURABID CR CAPSULE, 100 MG''. The pharmacist carries out medication monitoring using the information system, no (warning) signals are given. 
The pharmacist carries out pharmaceutical care (compliance, education, et cetera) and agrees with the patient on how she will use the medication. This toedieningsafspraak on 27 January 2013 reads: 
''FURABID CR CAPSULE, 100MG; 1 capsule 2x daily; from now on for 5 days''. The pharmacist provides the medication to the patient: 
''on 27 January 2013, FURABID CR CAPSULE, 100 MG; 10 capsules.'' The pharmacist actively informs the prescribing physician about the medicatieafspraak and the medicatieverstrekking. 
The information system of the pharmacist makes the new toedieningsafspraak and medicatieverstrekking available to the other health professionals of this patient.
 
 [[Bestand:ENG_Ter hand stellen_Nieuwe medicatieafspraak medicatieverstrekking zelfde product.png|800px]] 

===New medicatieafspraak, more precise product specification===
Here, the difference when specifying the product is that the toedieningsafpsraak and also the medicatieverstrekking deviates from the medicatieafspraak the patient has made with the prescribing physician. The process is otherwise the same as described in the previous paragraph.

'''Example''' 
''Medicatieafspraak: Nitrofurantoin capsule mga 100 mg, 1 capsule 2 times a day from today for 5 days.''

The pharmacist specifies a different product: 
''Nitrofurantoine MC Actavis capsule 50 mg.''
The pharmacist agrees with the patient on how she will use the medication. This toedieningsafspraak on 27 January 2013 reads: 
''Nitrofurantoin MC CR capsule 50 mg, 1 capsule 2x daily, from now on for 5 days.'' 
The pharmacist provides the medication to the patient: 
''on 27 January 2013, Nitrofurantoin MC Actavis capsule 50 mg; 20 pieces.''
 
 [[Bestand:ENG_Ter hand stellen_Nieuwe medicatieafspraak nadere specificering product.png|800px]] 

===Existing toedieningsafspraak is adequate===
The process of repeat medicatieverstrekking on the basis of an existing medicatieafspraak and possibly existing verstrekkingsverzoek and toedieningsafsrpaak occurs in case of repeat prescriptions and is described in [[#Splitting a prescription|paragraph 4.2.10]], situation 2.

===Medicatieafspraak wanted (informing the prescriber)===
'''Example 1 - adjusting dosage:''' 
For a 70-year-old patient with a creatinine clearance of 45 mL/min, the pharmacist enters a toedieningsafspraak for gabapentin tablets of 600 mg, 1 tablet 3x daily. Renal function has been recorded in the patient’s file at the pharmacy, and based on this a signal appears that the maximum dosage is 900 mg daily. The pharmacist sends the prescriber a proposed medicatieafspraak with an adjusted dosage of 300 mg, 3x daily, and the reason for this proposal (maximum dosage exceeded). The prescriber receives the proposed medicatieafspraak in his EVS. The prescriber sends an adjusted medicatieafspraak and possibly a reply proposed medication agreement (antwoord voorstel medicatieafspraak) back to the pharmacist.
 
 [[Bestand:ENG_Ter hand stellen_Medicatieafspraak gewenst - informeren voorschrijver_a.png|800px]] 
 
'''Example 2 – temporarily halting a medicinal product:''' 
For a 50-year-old patient with on oral fluconazole as part of his current medication, the pharmacist enters a toedieningsafspraak for simvastatin. A message appears with the advice to consider temporarily halting simvastatin. The pharmacist can make a proposed medicatieafspraak for halting the simvastatin (stoptype ‘temporary’). See example 1 for further steps.
 
 [[Bestand:ENG_Ter hand stellen_Medicatieafspraak gewenst - informeren voorschrijver_b.png|800px]] 
 
'''Example 3 – adding a medicinal product:''' 
For a 55-year-old woman, the pharmacist enters a toedieningsafspraak for prednisone, 10 mg daily for three months. The patient is not using osteoporosis prophylaxis. A message appears with the advice to add a biphosphonate drug and to check whether the patient is taking calcium and vitamin D. If the patient is not, the pharmacist can make a proposed medicatieafspraak for these products. See example 1 for further steps.
 
 [[Bestand:ENG_Ter hand stellen_Medicatieafspraak gewenst - informeren voorschrijver_c.png|800px]] 
 
PLEASE NOTE: it will depend on the situation whether it is useful to create an automated proposal for adjustment/addition of a MA. If the advice is complex, it may still be useful to phone and to consult instead of sending a digital proposal. 
The proposed medicatieafspraak may help the prescriber to enter this change in the system. The latter is important when medicatieafspraken are consulted, for example, by service observation general practitioners.

===Request and dispense ===
When a medicatieafspraak and verstrekkingsverzoek arrives at the pharmacy, it is processed by the pharmacy information system as an intended medicatieverstrekking. This is called the request date, which is captured as the request date of the medication dispensing The date of dispensing is only registered at the moment of pick up or hand over of the medication. The pharmacist informs the prescriber about the handling of the prescription (toedieningsafspraak and/or medicatieverstrekking).

It is possible to create multiple dispensings under the same toedieningsafpsraak:
*A verstrekkingsverzoek comes in with a medicatieafspraak with a one-year use period
*There will be a first provision with a new toedieningsafspraak and a medication supply that is sufficient for, for example, a period of 4 months.
 [[Bestand:ENG_Ter hand stellen_Aanschrijven en verstrekken_a.png|800px]] 

*The second dispensing is performed based on the existing medicatieafpsraak, verstrekkingsverzoek and toedieningsafspraak (no new prescription or new administration appointment is needed). The new second medication dispensing (with new write-up date and the pre-existing associated toedieningsafspraak) is sent to the prescriber when the dispensing date is registered.
 [[Bestand:ENG_Ter hand stellen_Aanschrijven en verstrekken_b.png|800px]] 

===Patient requests repeat prescription via physician (reactive repeat)===
A physician has previously diagnosed hypertension in a patient (57 years old) and has prescribed the patient medication for this. The patient uses this medication and the medication is running out. The patient makes a request to repeat the medication, for example through the repeat line, by phone, by email to the practice, counter/boxes, website, app or portal of the physician. The physician approves the repeat. This leads to a new verstrekkingsverzoek. 
For example:
The general practitioner makes, in the context of the medicatieafspraak of 30 March 2010:
:''Nifedipine CR 30 mg; 1 tablet 1x daily, from 30 March 2010 for an indefinite period''
on 13 April 2013 a verstrekkingsverzoek to a pharmacist chosen by the patient:
:''Nifedipine, CR tablet, 30 mg; ‘for three months’.''
In consultation with the patient, the prescriber can send the verstrekkingsverzoek with the corresponding medicatieafspraken and toedieningsafspraken as an order to a pharmacy of the patient’s choice. The prescriber also makes the new verstrekkingsverzoek available to fellow health professionals and the patient. The existing medicatieafspraken had already been made available. 
 [[Bestand:ENG_Ter hand stellen_Patiënt vraagt herhaalrecept via arts - reactief herhalen.png|800px]] 
The pharmacist receives the verstrekkingsverzoek together with the medicatieafspraak and processes it in accordance with the dispense process and starts with the pharmaceutical care process step.

When the patient, on the basis of a toedieningsafspraak or on the basis of his medicatiegebruik asks for a repeat prescription, and the medicatieafspraak is not digitally available, the physician creates a new medicatieafspraak based on this toedieningsafspraak or the patient’s medicatiegebruik of the medication. No reference is made to the existing medicatieafspraak in that case.

===Patient requests repeat prescription via pharmacist (informing prescriber)===
The patient requests a repeat medication from the pharmacist, for example through repeat line, by phone, email, counter/boxes, website, app or portal of the pharmacist. 
The pharmacist sends a proposed verstrekkingsverzoek for authorisation to the prescriber. The physician evaluates the proposed verstrekkingsverzoek and approves it. He informs the pharmacist via the reply proposed verstrekkingsverzoek and sends a new verstrekkingsverzoek together with the current agreements to the pharmacist. The pharmacist continues the dispense process and starts with the pharmaceutical care process step. 
Patiënt vraagt herhaalrecept via arts (reactief herhalen)
 [[Bestand:ENG_Ter hand stellen_Patiënt vraagt herhaalrecept via apotheker - informeren voorschrijver.png|800px]] 
 
If the prescriber does not provide a verstrekkingsverzoek, he informs the pharmacist via the answer proposed verstrekkingsverzoek.

===Proactive repeat prescription by pharmacist (informing prescriber)===
The patient has signed up in the past for proactive repeats and the pharmacist has registered this in his proprietary pharmacist information system (PIS). The repeat module of this information system will generate a signal when a patient needs new medication. When a new verstrekkingsverzoek is needed, this is similar to the process described in the previous paragraph, only the trigger is not the patient but the pharmacist (or his information system). Proactive repeats are also used for GDS, see [[#Starting and continuing a GDS|paragraph 4.2.11]].
 [[Bestand:ENG_Ter hand stellen_Proactief herhaalrecept door apotheker - informeren voorschrijver.png|800px]] 
 

===Dispense based on an existing verstrekkingsverzoek===
The patient submits a repeat prescription to the pharmacist. In this case, it is a request for medicatieverstrekking on the basis of an existing, still valid, verstrekkingsverzoek. See [[#Splitting a prescription|paragraph 4.2.10]] situation (3).

===Splitting a prescription===
The patient has been using the same medication for a number of years, which means that the medicatieafspraak can be created for an indefinite period. The toedieningsafspraak is also valid for an indefinite period. In such a case, the patient can be given a prescription for a year. This single year prescription will be split into several prescriptions by the pharmacist. These split prescriptions are commonly called ‘repeat prescriptions’, even though strictly speaking this is not true.

There are three possible situations: 
1) The patient returns to his attending physician still suffering from the same symptoms. The prescriber prescribes the same medication (in the case of an expired medicatieafspraak, a new medicatieafspraak is created with a new verstrekkingsverzoek and in the case of a medicatieafspraak that is still valid, only a new verstrekkingsverzoek is created). 
 [[Bestand:ENG_Ter hand stellen_Knippen van recept_a.png|800px]] 
 
2) Prescriber and patient initially agree on 90 tablets with 3 repeat prescriptions. The patient receives the first 90 tablets. The next time the patient visits the pharmacist, a medicatieverstrekking is made under the existing agreements. 
 [[Bestand:ENG_Ter hand stellen_Knippen van recept_b.png|800px]] 
 
3) Prescriber and patient initially agree on 360 tablets for one year. The pharmacist splits this into 4 separate occasions of medicatieverstrekking. The patient is initially dispensed 90 tablets and without a new verstrekkingsverzoek, can go to the pharmacist 3 more times to pick up another 90 tablets each time. 
Situation 3 best describes the way in which a pharmacist splits a year prescription. 
 [[Bestand:ENG_Ter hand stellen_Knippen van recept_c.png|800px]] 
 

===Starting and continuing a GDS===
The following example shows the process for one medicinal product used by the patient for an indefinite period of time. The information system of the prescriber and the pharmacist contains (among other things) the following data on a patient:
*The medicatieafspraak of 2 January 2013 reads: Metoprolol, CR tablet, 100 mg (succinate); 1x tablet daily; from 2 January 2013 for an indefinite period.
*The toedieningsafspraak of 2 January 2013 reads: Metoprolol PCH retard, 100 CR tablets of 95 mg; 1x tablet 1x daily; from 2 January 2013 for an indefinite period.
This elderly patient is taking so much medication that he has problems overseeing it all: a potentially dangerous situation. On 6 February, the pharmacist and the prescriber agree that the medicatieverstrekking of medicinal products to this patient will take place via GDS.

The GDS is started: the pharmacist sends a proposed verstrekkingsverzoek (a similar event to the current combined prescription or authorisation form).

The proposed verstrekkingsverzoek of 6 February reads:
*Verstrekkingsverzoek for the medicatieafspraak of 2 January 2013: Metoprolol, CR tablet, 100 mg (succinate), and a period of use to ensure enough stock up to and including 1 May 2013.
The pharmacist sends the proposal to the prescriber. The prescriber approves the proposal on February 6 and sends it unchanged to the pharmacist as a verstrekkingsverzoek. The GDS indicator is switched on in the information system of the prescriber as well as in the pharmacist’s information system.

The pharmacist and the patient select a partial duration for the product. This toedieningsafspraak reads as follows:
*On 7 February it was agreed: Metoprolol PCH retard, 100 CR tablets of 95 mg, 1 tablet in the morning, from 11 February (week 6), for an indefinite period.

Every second week, the pharmacist dispenses a Baxter medication roll containing (among other things) the metoprolol:
*Medicatieverstrekking 1: The pharmacist dispenses, on Friday, 8 February 2013: 14 tablets, scheduled for weeks 6 and 7 (a period of use of 2 weeks).
*Medicatieverstrekking 2: The pharmacist dispenses, on Friday, 22 February: 14 tablets, scheduled for weeks 8 and 9.
*Medicatieverstrekking 3, 4, 5, etc.
With each medicatieverstrekking, it is indicated that medicatieverstrekking was carried out via GDS.
After three months, there is a new proposed verstrekkingsverzoek from the pharmacy to the prescriber, etc.
 
 [[Bestand:ENG_Ter hand stellen_Het opstarten en continueren van GDS.png|800px]] 
'''Consideration ''' 
*The application of a proposed verstrekkingsverzoek instead of an authorisation form makes its meaning unambiguous.
*In the current situation, toedieningsafspraken and medicatieverstrekkingen are registered as a single dispense. This makes it difficult to find useful information in the large number of messages. By dividing the dispense order into two building blocks, the overview is easier to understand: there are no new medicatieafspraken and only one new toedieningsafpsraak is created. There are no hidden surprises in the remaining logistical data and the prescriber does not have to monitor the multiple medicatieverstrekkingen.
*This way of registering and exchanging prevents double registration, and errors caused by this.
*The toedieningsafspraken are the basis for the administration list and checklists of nursing homes and care homes. Signing them corresponds to the administration(s).

===The pharmacist changes commercial product===
This scenario builds on the previous scenario: after half a year a different commercial product is agreed with the patient (toedieningsafspraak), because the original product is not available. No new medicatieafspraak is made, as there is no change needed on that level. The toedieningsafspraak is changed:
*On 1 July it was agreed: Metoprolol Sandoz ret, 100 CR tablets, 95 mg, 1 tablet in the morning; from 3 July, for an indefinite period. Reason: not available.
The toedieningsafspraak is a modification of the toedieningsafspraak of 7 February, which stops on 2 July (11:59 p.m.) and is an actual handling of the medicatieafspraak of 2 January. The pharmacist informs the general practitioner about this. 
 [[Bestand:ENG_Ter hand stellen_De apotheker wijzigt van handelsproduct.png|800px]] 
'''Consideration ''' 
This change in the actual handling of the medicatieafspraak using a toedieningsafspraak, changes nothing to the validity of the medicatieafspraak itself, improving the overall view for all parties. In addition, since the pharmacist records and communicates the reason for the adjustment, the prescriber is better able to assess whether the information is relevant.
 

===Adding medication to a GDS===
When new medication is added to an existing GDS, the prescriber may opt for immediate addition to the current roll (Change in GDS immediately) or for addition starting from the next roll (Change in GDS per change of roll). The prescriber indicates this in the medicatieafspraak (Additional information).

If ‘Change in GDS immediately’ is chosen, the pharmacist will first dispense the medication separately, in addition to the existing GDS. This means that a toedieningsafspraak is created by the pharmacist for the bridging period. Starting with the new roll, the new medication is added to the roll. Starting with the start date of the new roll, a toedieningsafspraak can be made by the pharmacists with specific administration times. If the ‘bridging-toedieningsafspraak’ already includes the correct administration times, no new toedieningsafspraak is created at the date of inclusion in the roll. 
 [[Bestand:ENG_Ter hand stellen_Medicatie toevoegen aan GDS.png|800px]] 
 
If 'Change in GDS per change of roll' is chosen, the pharmacist will start to include the medication in the roll on the start date of the first new roll. In this case, a toedieningsafspraak for the bridging period is not required.

===Discontinuing medication in a GDS===
When medication is discontinued, the prescriber creates a discontinuation-medicatieafspraak. In accordance with the process, the pharmacist is informed about this stop-MA and can adjust the medicatieverstrekking accordingly. The pharmacist will create a staken toedieningsafspraak . See [[#Discontinuing medication|paragraphs 2.2.5.3]] and [[#Discontinuing a toedieningsafspraak|2.3.6.3]].

===GDS supplier supplies other commercial product===
It is possible that a GDS supplier delivers a different commercial product than that which is included in the toedieningsafspraak by the pharmacy. This is therefore a change in the HPK which results in a changed toedieningsafpsraak. This may only be afterwards, after feedback from the GDS supplier of the filling details.
 
 [[Bestand:ENG_Ter hand stellen_GDS leverancier levert ander handelsproduct.png|800px]] 

===Parallel administration agreements with GDS- and non-GDS-dispense===
A patient takes two to three times daily 20 mg pantoprazole because of gastric complaints. The first two tablets are fixed dosages, which are dispensed in GDS. The third tablet, which is prescribed as needed, is dispensed separately. At a certain moment, Sandoz is unable to supply the pantoprazole 20 mg for separate dispenses. Therefore, the pharmacist decides to dispense from Apotex. He stops the current TA and splits the TA in two TA’s, both with the same start date/time. The first TA concerns the fixed dosage in GDS, the second TA involves the as needed tablet. 
''NB. Currently, there is no relationship between medication dispense and TA. Therefore, it is only possible to retrieve which TA is associated with the medication dispense by assessment of the data content. It is evaluated whether the functional design should be adjusted for this use case in the future. 
''
 
[[Bestand:ENG-Uc4.2.16.png|800px]]
 

===Handling a stop medicatieafspraak===
When the prescriber agrees to discontinue medication, a stop medicatieafspraak is created. This stop-MA this processed by the pharmacist by discontinuing the corresponding toedieningsafspraak.

===Medication dispense with someone else’s administration agreement===
A patient takes two times daily 20 mg pantoprazole because of gastric complaints. During the holidays the patient notices that he has forgotten to bring his medication. He visits the after hours general practice clinic and asks for extra tablets for during his holidays. The after hours physician sends a VV to the after hours pharmacy, using an existing MA. 
The after hours pharmacist reads the medication prescription and creates an MVE, using the existing TA, for the ten tablets that the patient needs. The pharmacist notifies the after hours physician about the medication dispense, and sends a copy of the original TA. 
''NB. Although the original prescriber and supplier do not receive an automatic notification, the data will be made available to them.'' 
 
[[Bestand:ENG-Uc4.2.18.png|800px]]
 

===Modification of someone else’s administration agreement===
A patient takes two times daily 20 mg pantoprazole because of gastric complaints. During the holidays the patient notices that he has forgotten to bring his medication. He visits the after hours general practice clinic and asks for extra tablets for during his holidays. The after hours physician sends a VV to the after hours pharmacy, using an existing MA. 
The after hours pharmacist notices that they have no pantoprazole from Sandoz in stock, but they do have pantoprazole from Apotex. Therefore, she stops the current TA, starts a new TA for the Apotex, and creates an MVE for the ten tablets from Apotex. The after hours pharmacist notifies the original pharmacist and, subsequently, the original pharmacist processes the stop-TA. 
 
[[Bestand:ENG-Uc4.2.19.png|800px]]
 

==Use cases, Administer ==

===Creating an administration list===
When an administration list has to be created, for example when a patient starts to receive medication administered by a (professional) administrator, or when GDS medication or non-GDS medication is started, an intake is planned with the patient and the prescriber, pharmacist or administrator (the exact process may differ across institutions). Then, the prescriber, pharmacist, administrator and/or the patient consult on the administration list (which medication is recorded on the administration list, which (guide) administration times are suitable). The pharmacist enters the (guide) administration times in the TA and (actively) makes the relevant medication data available for the administrator and/or the patient.

===Exact administration times required===
When exact administration times are required, for example because of medication interactions, the prescriber or the pharmacist can indicate that an exact administration time is required (the administration time is not a guideline but denotes an exact time). The prescriber or pharmacist can register an exact administration time by indicating that the administration time is not flexible. By default, administration times are flexible. Exact administration times should be presented on the administration list, to ensure that the administrator is informed that it is not allowed to deviate from the entered administration time.

===Missing (guide) administration times===
When (guide) administration times are missing in the MA and TA, an administrator will contact the prescriber or pharmacist to retrieve the (guide) administration time. This is not supported digitally in this information standard.

===Non-GDS medication as needed===
Non-GDS medication as needed is included in the administration list, but is not listed according to the administration moment and/or administration time, because this information is not available beforehand. If relevant (for example because of drug interactions), (guide) administration times can be entered. See the following use cases for practical examples: [[#Medication as needed|4.1.4 Medication as needed]], [[#Course of treatment as needed starting in future|4.1.5 Course of treatment as needed starting in future]], [[#Two dosages of the same medication at the same time|4.1.6 Two dosages of the same medication at the same time]], [[#The same medicinal product with different strengths at the same time|4.1.7 The same medicinal product with different strengths at the same time]].

===Medication supply by multiple pharmacies===
Multiple pharmacies may be involved in the medication supply for one patient, for example in the following situations: medication supply by an outpatient pharmacy, in addition to supplies by a community pharmacy or supplies of add-on medication by a hospital pharmacy. In the case of medication supply by multiple pharmacies, each pharmacist is responsible for the medication data that is required for the administration list, including the (guide) administration times in the TA. It is the responsibility of the prescriber or pharmacist who has made the most recent medication adjustments to determine whether an addition/modification is appropriate with regard to the total of (known) medication data; this concerns both medication monitoring and (guide) administration times. The medication data is (actively) made available, in order to enable that all medication data from different pharmacies are compiled in one administration list.

===Change in GDS from the next supply or immediately===
If GDS medication is altered, it depends on the situation whether this change should occur immediately or from the next supply. The prescriber can indicate in the MA when the change in GDS medication should be implemented. An immediate modification should be immediately shown on the administration list, to ensure that the (professional) administrator administers the correct (amount of) medication. In contrast, a modification that should be implemented from the next supply, should not be processed immediately in the administration list, since previous agreements remain valid until the next supply. Thus, the administration list should not be modified until the change in GDS modification has become effective.

See also use case [[#Adding medication to a GDS|4.2.13 Adding medication to a GDS]].

===Increasing dosage of GDS in new MBH===
A patient is administered 1 tablet propranolol 40 mg 1 time a day. Due to insufficient effects, the prescriber decides to increase the dosage to 80 mg 1 time a day. A new MBH is created for this MA, as there is a change on prescription level. However, the patient still has the 40 mg tablets in the GDS medication roll for the coming days. Therefore, the pharmacists decides to supplement the GDS medication with the administration of 1 tablet propranolol 40 mg, separately from the GDS package, in addition to the tablet in the GDS package, until the next GDS medication roll change in 5 days. The pharmacists creates two TAs: one for the previous GDS medication and one for tiding over the period with medication dispense separately from GDS. In the new GDS supply (medication roll change), the 80 mg tablets are incorporated in this new GDS package. 
 [[Bestand:ENG_Toedienen_Verhogen dosering GDS-medicatie in nieuwe MBH_beta.png|800px]] 

===Decreasing dosage of GDS in new MBH===
A patient is administered 1 tablet propranolol 80 mg 1 time a day. Due to a too strong effect, the prescriber decides to reduce the dosage to 40 mg 1 time a day. A new MBH is created for this MA. The patient still has 80 mg tablets in the GDS medication roll for several days. Because the administrator is not allowed to divide the tablets into halves, the supplier decides that the remaining GDS packages should be collected the same day and be replaced by a new GDS medication roll with 40 mg tablets. 
 [[Bestand:ENG_Toedienen_Verlagen dosering GDS in nieuwe MBH_beta.png|800px]] 
 

===Change processed by the pharmacist===
A change by the prescriber, such as starting new medication, adjusting the dosage, (temporarily) halting medication, is recorded by the prescriber in the MA and/or the VV. Then, the pharmacists processes this change in the TA and/or the MVE. This may be done during the opening hours of the community pharmacist, or after hours when a medication dispense is needed. The after-hours pharmacist dispenses the medication; in this case, multiple pharmacists are supplying medication (see also paragraph 4.3.9). The medication data of the pharmacist(s) and the prescriber(s) are (actively) made available by the prescriber and the after-hours pharmacist to the administrator for the administration list.

===Change not processed by the pharmacist===
When medication is changed by a prescriber after the opening hours of the community pharmacist and medication dispense is not needed, no pharmacist is involved. In that case, the MA is decisive, and the prescriber (actively) makes the MA available. The administrator will be informed of the changed or stopped MA by the administration list; this MA overrules all medication building blocks within the same MBH. This situation also applies if the pharmacist has not processed the modification by the prescriber yet. The pharmacist is responsible for adjusting the TA as soon as possible.

===Variable-dosing regimen===
If a physician prescribes medication with a variable-dosing regimen, the dosing schedule of this medication may be specified by another physician. For example, this applies to thrombosis medication: the prescriber defines the therapeutic INR range (International Normalized Ratio, a measure for the coagulation time of blood), but refers the patient to the thrombosis service for defining the exact dosing schedule. The ‘trombosearts’ (physician affiliated to the thrombosis clinic, who is specialized in the management of anticoagulation therapy) enters the variable-dosing regimen in the medication building block WDS. The prescribing physician remains responsible for the supplies, the ‘trombosearts’ specifies the dosing regimen based on the therapeutic INR range. As the WDS is a separate medication building block, the medication overview remains unchanged (the MA is specified, not altered by the WDS). The WDS is used to compile the administration list, together with the medication data in the MA, TA, MVE and MTD.

===Changing a variable-dosing regimen===
If a dosing schedule is adjusted, the information system closes the current WDS, using a technical stop (not visible to the user). This new WDS is related to the MA and the previous WDS.

===Stop of medication with variable-dosing regimen===
Anticoagulation medication may be (temporality) halted for several reasons; for example, in the case of a medical procedure. Depending on the situation and based on professional judgment, the ‘trombosearts’ can choose one of the following two methods: 

'''A. (temporarily) adjusting the medication regimen''' 
In certain situations, the ‘trombosearts’ may choose to temporarily set the anticoagulation medication to zero, for example, in the period before the planned medical procedure. The MA (and, therefore, the treatment with anticoagulation medication) continues, but in the WDS, the dosage is temporarily adjusted to zero. In such situations, it is advisable to exchange the reason for the WDS change as well. 
 [[Bestand:ENG_Toedienen_Stoppen medicatie met wisselend doseerschema_a_beta.png|800px]] 
'''B. (temporarily) halting the anticoagulation medication''' 
Alternatively, the ‘trombosearts’ may choose to (temporarily) halt the anticoagulation medication. In this case, the ‘trombosearts’ creates a stop-MA. This implies that the underlying WDS and the related TA are stopped as well. If the MA should be restarted or adjusted after a certain period, this is done by the initial prescriber of the anticoagulation medication. In general, the thrombosis service may not be involved any more (temporarily); however, if the thrombosis service is still involved, the ‘trombosearts’ may send a VMA to the initial prescriber who can adopt this proposal in an MA. 
 [[Bestand:ENG_Toedienen_Stoppen medicatie met wisselend doseerschema_b_beta.png|800px]] 
 

===Additional information===
Additional information is an extra explanation about the medication use for the (professional) administrator and/or the patient. An example is the situation when fentanyl patch therapy is stopped; additional information is that the patch has to be removed. Another example is the dosing of half a tablet; the additional information contains the instruction what should be done with the other half. This information can be entered as free text, as a comment in the MA, TA and/or WDS.

See use case [[#Explanation in medicatieafspraak with deliberately chosen special characteristic|4.1.8 Explanation in medicatieafspraak with deliberately chosen special characteristic]] for more information.

===Medication administration deviates from administration list===
It may happen that the administration deviates from the instructions as entered by the prescriber and pharmacist in the MA or TA. This may be a deviation in administration time, administered amount, administration route, administration speed, administered product or no administration. A (professional) administrator can deviate from the rules, in consultation with the prescriber, for valid reasons, and under the condition of safe medical practice and safe working practice. The reason for deviation can be entered in the MTD.

===Medication administration without medication agreement and administration agreement===
In the case of an emergency, the MA and TA may be missing and, therefore, the (professional) administrator has to administer medication on the basis of an MA which is communicated verbally/by telephone. This medication is not incorporated in the administration list. In this situation, the (professional) administrator records the MTD in the information system of the administrator (including ECD, TDR). This is the first building block in a new pharmaceutical treatment; therefore, the administrator creates an MBH.

===Medication administration of self-care medication===
According to the safety principles in the medication chain, the administrator is not concerned with the administration of self-care medication, except for prescribed selfcare medication (a prescriber has created an MA). In that case, the self-care medication is listed on the administration list as GDS medication or non-GDS medication (as needed).

===Correction/cancellation of an administration===
This concerns correcting or cancelling an MTD, because an administrator has made a mistake in the registration and no medication has been administered. If the MTD has not been exchanged with other health professionals, the administrator can adjust the MTD by himself, or remove (cancel) the registration from his own information system. If the MTD has been exchanged with other health professionals, the administrator cancels this erroneous MTD and creates a new MTD under the same MBH with the correct information. The administrator (actively) makes the corrected MTD and the new MTD available.

===Medication administration on hold===
It may happen that the medication administration was unsuccessful, but that is still possible to administer the medication on a later moment, in consultation with a prescriber or pharmacist. If the medication administration is in keeping with the agreements on flexible administration times, the administrator is allowed to deviate from the (guide) administration time.

An example of suspending the medication administration:
* Medication administration is unsuccessful, but the medication can be administered on a later (or, in some cases, earlier) moment of the day. In this situation, the medication administration is suspended, and there is a deviation from the administration list.

===Medication administration by a prescriber===
A prescriber, similarly to a (professional) administrator, is able to administer medication to a patient, and record this procedure in an MTD.

===Multiple administration organizations===
Multiple administration organizations may be involved in a patient’s medication administration. For example, medication may be administered by another organization during the evening/night than during the day. If multiple administration organizations are involved in providing patient care, these health professionals can consult each other’s MTDs to track the process of medication administration. The acts of one organization can affect the process of another organization (for example, has medication been administered, have there been deviations from the administration list, etc.).

===Feedback to patient through a medication adherence app===
In this example the patient uses an app on his mobile phone to help manage his medication. The patient or the pharmacist has created an administration schedule with reminder times (where possible using the app to obtain the toedieningsafspraken from the medicatietoediening). When it is time to take his medication, the patient receives a reminder signal from the app. The patient registers the medication administration and thus indicates whether he has taken the medicine or not (for instance because he forgot to bring it along with him). If the app is linked, for example, to the patient’s PGO (personal health file), medication adherence is tracked automatically.
 
[[Bestand:ENG_Feedback_to_patient_through_a_medication_adherence_app.PNG|800px]] 
 


==Use cases, Medicatiegebruik==

===Self-care product===
A patient has acquired Ibuprofen from the drugstore and takes 1200 mg every day. The patient enters this product as gebruik, with such data as starting dates and dosage, and possibly the reason for medicatiegebruik.
 [[Bestand:ENG_Gebruik_Zelfzorgmiddel.png|800px]] 

===Medication from abroad===
A patient has been prescribed medication on holiday and is taking this. The patient enters the medication as gebruik, with data such as start date and dosage, and possibly the reason for medicatiegebruik. If known, the name of the prescriber is also recorded.
 [[Bestand:ENG_Gebruik_Medicatie uit buitenland.png|800px]] 

===Modification on the patient’s initiative===
The patient has been prescribed propranolol. The patient is having severe problems sleeping because of this and has reduced the medication herself. The patient records gebruik with the modified dosage and the start date for this lower dose. The patient also indicates that she initiated this change herself. In the case where a patient initiates a dose reduction, the patient can keep on using the medication for a longer period than initially agreed because she still has a supply. The patient can indicate this as additional gebruik. 
In the case where a patients initiates a dosage increase, the patient’s supply may run out sooner. The patient may then have to return to the physician earlier than expected.
 [[Bestand:ENG_Gebruik_Wijziging op initatief patiënt.png|800px]] 

===Discontinuation of medication on the patient’s initiative===
Since he started using propranolol, the patient suffers from insomnia. He decides to stop without immediately informing the prescribing physician. The patient himself records that he has discontinued medication, indicating the date and giving insomnia as the reason for discontinuing. 
[[Bestand:ENG_Gebruik_Stoppen medicatie op initatief patiënt.png|800px]] 

===No more supply===
A patient has received medication ‘as needed’ for his skin problems. The medication is still active in the medication profile, but is no longer available at the pharmacist. The patient indicates that the medication has been discontinued because it is no longer available, possibly with the addition that the symptoms have disappeared.
 
[[Bestand:ENG_Gebruik_Geen voorraad meer_a.png|800px]] 
 
The patient may also make a proposed verstrekkingsverzoek to replenish his supply In this case, the reply proposed verstrekkingsverzoek comes back to the patient (and if approved, a verstrekkingsverzoek is also sent from the prescriber to the pharmacist). 
[[Bestand:ENG_Gebruik_Geen voorraad meer_b.png|800px]] 

===Registrations of abnormal medicatiegebruik by patient due to adverse drug reactions===
Since he started taking propranolol, a patient has been suffering from insomnia. The patient records this side effect in the explanatory notes to the medicatiegebruik. When the patient changes the medicatiegebruik of this medication from what was previously agreed, for example when he takes less tablets, he can give the side effect as a reason for this change. When his symptoms diminish or cease, the patient records this in the explanation for medicatiegebruik. 
It is possible that the patient is suffering from side effects without exactly knowing which medicinal products cause them. There is no provision within medication process to record this (yet).

===Register medicatiegebruik based on provision===
This applies in the transition period from the old medication process standard 6.12 to this medication process information standard.

Only verstrekking (dispensing) is available digitally (according to medication process version 6.12). However, the user's information system offers the possibility to record all medicatiegebruik. In that case, the medicatiegebruik can be recorded with reference to the ID of the version 6.12 verstrekking.
 
[[Bestand:ENG_Gebruik_Gebruik registreren op basis van verstrekking.png|800px]] 

=Medication overview and inference rules=
This chapter shows a sample medication overview and also specifies inference rules for 'The most current relevant building block', Verification for each medicamenteuze behandeling, etc.

==Introduction==
The term 'current medication overview' has been replaced by the term 'basisset medicatiegegevens’ (basic set of medication data): the medication overview in combination with additional information that is required (at least) to be able to prescribe, change, stop or safely provide medication in a safe and responsible manner in the Transfer of Medication Data in the Chain (Leidraad Overdracht van Medicatiegegevens in de keten, final draft 2017).

This page contains an example of a medication overview. This example was developed in the Medication Process Information Standard program and serves as an example of how data can be displayed in an application. The data numbered in the pictures below are normative, they are mandatory to show. The other (unnumbered) data in the example is optional and may be added as normative in the future. The layout of the overview in a information system can differ per target group and per device. For pharmacists, for example, only toedieningsafspraken are initially visible, after which it is possible to click further to get to the corresponding medicatieafspraak and the medicatiegebruik. If only medicatiegebruik or a medicatieafspraak is known, this will of course be shown immediately. The basic principle is that the overview shows all medication of the patient, not just the medication that is registered in the patient's own information system.

The overview is described generically and therefore the same for all suppliers. The requirements of the end users are included on this page and no statements are made about the technical realization or implementation. The existing KNMP specification “User requirements specification Medication overview 2.0”, final concept “Guidance Transfer of Medication data in the chain (Leidraad OVerdracht van Medicatiegegevens in de keten)” and the new insights from the Medication process program have been incorporated in this.

Principles for the overview are:
*Health professionals want to see a distinction between the therapeutic building blocks on a medication overview:
**Medicatieafspraak
**Toedieningsafpsraak
**Medicatiegebruik
*Logistical building blocks (verstrekkingsverzoek, dispensing) and the medicatietoedieningbuilding block are not relevant for the medication overview.

[[Bestand:Medicatieoverzicht_1_v0.5.PNG|Medicatieoverzicht v0.5]]
[[Bestand:Medicatieoverzicht_2_v0.5.PNG|Medicatieoverzicht v0.5]]

==Functional specification==
In the figures below the parts with normative data are included. The other parts are not yet normative. The numbered elements in the table are normative, other elements are optional for the time being.

===Heading and General===
[[Bestand:Medicatieoverzicht_KopAlgemeen_v0.5.PNG]]

Filter: N/A

Sort: N/A

Medication Overview Date: This is the date that the last change to a medicatieafspraak, toedieningsafspraak or medicatiegebruik was recorded within the information system providing the medication overview.

NOTE: In the viewer, all dates are shown with the month in characters, so that there is no confusion between day-month and month-day (American format).

{| class="wikitable"
|-
! No !! Header !! Dataset !! Explanation
|-
| 1 || Name || Patient – Name data (Initials, Surname, PartnerSurname), Date of Birth, Gender ||
|-
| 2 || Telephone || Patient – Contact data – Telephone numbers || Primary telephone number of patient
|-
| 3 || BSN || Patient – Patient identification number || Always BSN
|-
| 4 || Adress || Patient – Address data ||
|-
| 5 || Healthcare Provider Name || Healthcare Provider – Organization name || Healthcare Provider who has compiled the medication overview
|-
| 6 || Healthcare Provider Adress || Healthcare Provider – Address – Address data || Healthcare Provider who has compiled the medication overview
|-
| 7 || Healthcare Provider Telephone || Healthcare Provider – TelephoneMail – Contact data – Telephone numbers || Healthcare Provider who has compiled the medication overview
|-
| 8 || Healthcare Provider Email || Healthcare Provider – TelephoneMail – Contact data – Email addresses || Healthcare Provider who has compiled the medication overview
|-
| 9 || Date of Medication Overview || Document data – Document date ||
|-
| || Height|| Body height – HeightValue, HeightDateTime ||
|-
| || Weight|| Bodyweight – WeightValue, WeightDateTime ||
|-
| || Checked by Health professional || Document data – Verification by health professional ||
|-
| || Verified with Patient/Informal Caregiver || Document data – Verification by patient ||
|}
Elements 5 through 8 are not shown if the patient is the creator of the medication summary.

===Contraindications and hypersensitivities (CiO)===
[[Bestand:Medicatieoverzicht_ICA_v0.5.PNG]]

Active contraindications and hypersensitivities (intolerances, allergies/adverse reactions) (in Dutch: 'contraindicaties en overgevoeligheden' - CiO).

Filter: end date is not filled, is in the future or was less than a year ago when compiling the overview.

Sort: most recent effective date at the top.

This part will be elaborated at a later time and is not yet normative.

===Current medication===
[[Bestand:Medicatieoverzicht_HuidigeMedicatie_v0.5.PNG]]

Filter: all current medication, i.e. all medicatieafspraken and toedieningsafspraken that apply at the time the overview is compiled and the associated medicatiegebruik per source. The temporarily interrupted medication is also shown in this category. When only medicatiegebruik is known, it is shown if it is not older than 13 months. When medicatiegebruik is recorded by both a health professional and a patient, the last registered medicatiegebruik is shown for both.

Sorting: by medicamenteuze behandeling (MBH): medicatieafspraak, toedieningsafspraak, medicatiegebruik (recorded by patient, care provider). Medicamenteuze behandelingen are sorted in descending order by startdate medicatieafspraak, toedieningsafspraak, medicatiegebruik.

{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| '''No'''
! style="text-align:left;"| '''Header'''
! style="text-align:left;" colspan="3"| '''Dataset'''
|-
|style="background-color: white;vertical-align:top;"|1
|style="background-color: white;vertical-align:top;"|Type
|style="background-color: white;vertical-align:top; text-align:center;"|Medicatieafspraak
|style="background-color: white;vertical-align:top; text-align:center;"|Toedieningsafspraak
|style="background-color: white;vertical-align:top; text-align:center;"|Medicatiegebruik
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|2
|style="background-color: white;vertical-align:top;" rowspan="2"|Medicinal product
|style="background-color: white;vertical-align:top; text-align:center;"|Agreed medicinal product-
|style="background-color: white;vertical-align:top; text-align:center;"|Medicinal product belonging to Toedieningsafspraak-
|style="background-color: white;vertical-align:top; text-align:center;"|Device-
|-
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Product – ProductCode (if absent: ProductSpecification, ProductName)
|-
|style="background-color: white;vertical-align:top;"|3
|style="background-color: white;vertical-align:top;"|Start date
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Start date
|-
|style="background-color: white;vertical-align:top;"|4
|style="background-color: white;vertical-align:top;"|End date/duration
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|End date (if not available: Duration)
|-
|style="background-color: white;vertical-align:top;"|5
|style="background-color: white;vertical-align:top;"|Dosage
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Instructions for medicatiegebruik – Description
|-
|style="background-color: white;vertical-align:top;"|6
|style="background-color: white;vertical-align:top;"|Route of toediening
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Instructions for medicatiegebruik – Route of toediening
|-
|style="background-color: white;vertical-align:top;"|7
|style="background-color: white;vertical-align:top;"|Reason
|style="background-color: white;vertical-align:top; text-align:center;"|Reason for prescribing &
if applicable reason for discontinuing/suspending medication
|style="background-color: white;vertical-align:top; text-align:center;"|Reason for discontinuing/suspending medication
|style="background-color: white;vertical-align:top; text-align:center;"|Reason for discontinuing/suspending medication
|-
|style="background-color: white;vertical-align:top;"|8
|style="background-color: white;vertical-align:top;"|Explanation
|style="background-color: white;vertical-align:top; text-align:center;" colspan="2"|Explanation & additional information
|style="background-color: white;vertical-align:top; text-align:center;"|Explanation
|-
|style="background-color: white;vertical-align:top;" rowspan="3"|9
|style="background-color: white;vertical-align:top;" rowspan="3"|Source
|style="background-color: white;vertical-align:top; text-align:center;"|Prescriber-
|style="background-color: white;vertical-align:top; text-align:center;"|Provider-
|style="background-color: white;vertical-align:top; text-align:center;"|Author-
|-
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Health professional – Name healthcare provider, specialty
|-
|style="background-color: white;vertical-align:top; text-align:center;"|n/a
|style="background-color: white;vertical-align:top; text-align:center;"|n/a
|style="background-color: white;vertical-align:top; text-align:center;"|or “Patient”
|}

===Future medication===
[[Bestand:Medicatieoverzicht_ToekomstigeMedicatie_v0.5.PNG]]

Filter: all medication that will become actual in the next 3 months. This includes intended medicatiegebruik.
For a description of the mapping, the same applies as with the current medication, see [[#Current medication|Current medication]].

===Recently discontinued medication===
[[Bestand:Medicatieoverzicht_RecentBeeindigde_v0.5.PNG]]

Filter: any medication that has ended or stopped in the past 2 months.

For a description of the mapping, the same applies as with the current medication, see [[#Current medication|Current medication]].

===Additional lab values ===
[[Bestand:Medicatieoverzicht_Labwaarden_v0.5.PNG]]

Most recent lab values and abnormal renal function values.

This part will be elaborated at a later time and is not yet normative.

===Remarks ===
[[Bestand:Medicatieoverzicht_Opmerkingen_v0.5.PNG]]

For example, relevant (limited) health skills (competences: literacy, calculation and digital skills) that can have an impact on medicatiegebruik / treatment.

This part will be elaborated at a later time and is not yet normative.

==Building block instantiations==
This section describes which instantiations of the building blocks belong to the medication overview. This concerns 'own' and 'other people's' building blocks ([[#GP observation service (HAP)|section 3.1]]) and then only the latest, relevant instantiations of this ([[#Thrombosis service|section 3.2]]).

===Own and other people===
Both the own and a copy of (known to the sender) building blocks from other sources are included in the medication overview. This so that the medication overview is as complete as possible for the recipient. This ensures that recipients can start using it immediately and that they are not dependent on other sources. The technical representation of someone else's building block may differ from that of the real source. It is important that the recipient is aware of this. The original OID of someone else's building block should simply be given. The recipient can then choose to also collect the building block from its source in its original form.

The medicatieafspraak, toedieningsafspraak and medicatiegebruik building blocks have been extended with a feature that indicates whether:
*there is an 'own' building block or
*that of "someone else" (an ''accent'' building block: MA’, TA’, MGB’)
This attribute only applies in the medication overview transaction, because that is the only transaction where other people's building blocks may be delivered.

The 'building block of someone else' attribute is on two levels:
*The template ID of an MA’, TA’, MGB’ differs from an MA, TA and MGB.
*In addition, the element copy indicator is always sent with value '''true''' in MA’, TA’, MGB’.
For the medication overview, it is permitted to offer the medicatieafspraken, toedieningsafspraken and medicatiegebruik via a information system-generated MGB or MGB '(Healthcare provider is author MGB). This must have a reference to an MA, TA or MGB.

====Medication overview and derivation rules====
An overview of medication that the patient is using (or should be using) can be put together in a information system in two ways: 
1) displaying a current medication overview (or overviews) obtained from another source (or sources) 
2) showing coherent medication building blocks obtained from one's own information system and from other sources. 
In both cases, this overview of medication consists of the information as included in the building blocks medicatieafspraak, toedieningsafspraak and medicatiegebruik.

Re 1) When this document refers to a current medication overview, this means a coherent overview in which current medicatieafspraken, toedieningsafspraken and medicatiegebruik are included. This current medication overview is built up by the source on the basis of the data known at that time at the source. This overview can be exchanged with the transaction group Medicatieoverzicht (Medication overview) (PULL or PUSH).

The data and building blocks that are known at the source, but originating from another source, are supplied in the transaction with the 'accent' indicator so that they are recognizable as building blocks from someone else (MA accent, TA accent, MGB accent).

Re 2) It is also possible for a information system to compile an overview by combining own and other people's separate individual medication building blocks. The transaction group Medicatiegegevens (medication data) (PULL) is used to request individual building blocks.

With the transaction group Medicatiegegevens (medication data) (PUSH), separate building blocks can also be sent directly to another health professional or the patient (so without requests). This happens, for example, at discharge or at the request of a co-practitioner who has the patient in front of him (e.g. patient appears to a GP or pharmacist outside the region, where this GP or pharmacist requests the data by telephone from the patient's own GP and receives it digitally).

Both Medicatiegegevens (medication data) PUSH and PULL should not provide data obtained from other sources.

===Last relevant===
Only the last relevant building blocks (per medicamenteuze behandeling) are part of the medication overview. This section describes what exactly those last relevant building blocks are for a medication overview. Firstly for prescription medication (section 3.2.1), then for "over the counter" medication (section 3.2.2). The following section 3.2.3 further discusses the special situation that, in addition to a current, a future medicatieafspraak within the same medicamenteuze behandeling is valid. Finally, the last paragraph summarizes the rules to be applied. 
Note: The (technical) stop-medicatieafspraken are not shown in the examples, but are implicitly assumed.

====Prescription medication====
=====Most simple "happy flow"=====
In a medicamenteuze behandeling, the simplest "happy flow" results in a sequence of:
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik''.
Usually, medicamenteuze behandeling (drug treatment) starts with a medicatieafspraak. A toedieningsafspraak concretely completes the medicatieafspraak. medicatiegebruik says something about the actual medication use of the patient in this medicamenteuze behandeling. All three building blocks are relevant in such a case and are part of the delivery of a medication overview, as indicated in green below.
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik.
A toedieningsafspraak refers to the medicatieafspraak he enters. If no referral is available in the toedieningsafspraak, the appointment date (administration appointment) must be later than that of the medicatieafspraak to be relevant to delivery. 
Medicatiegebruik can refer to a medicatieafspraak or toedieningsafspraak. If no referral is available in the medicatiegebruik, the registration date (medicatiegebruik) must be later than that of the medicatieafspraak to be relevant for delivery.

=====New medicatieafspraak in medicamenteuze behandeling=====
If you create a new medicatieafspraak in an existing medicamenteuze behandeling (drug treatment), the currently existing medicatieafspraken, toedieningsafspraken and records of medicatiegebruik are no longer relevant for the medication overview. The idea is that all older building blocks than the current medicatieafspraak are by definition "overruled" by this new medicatieafspraak and consequently no longer relevant for the medication overview.
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik'' - stop-Medicatieafspraak – Medicatieafspraak – stop-Toedieningsafspraak

If a toedieningsafspraak and possibly also medicatiegebruik are created and available following such a medicatieafspraak medication appointment, these will be included in the medication overview.
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik'' – stop-Medicatieafspraak – Medicatieafspraak – stop-Toedieningsafspraak - Toedieningsafspraak
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik'' – stop-Medicatieafspraak - Medicatieafspraak - stop-Toedieningsafspraak – Toedieningsafspraak – Medicatiegebruik 

The new MA can also be a stop-MA, if the patient has to stop medication permanently. This stop-MA remains relevant for the medication overview for 2 months. 
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – stop-Medicatieafspraak - stop-Toedieningsafspraak

=====Medicatiegebruik earlier than toedieningsafspraak =====
It is possible that you have registered medicatiegebruik before the toedieningsafspraak has been made. Here too, the idea is that the newer toedieningsafspraak "overrules" the older registration of toedieningsafspraak and medicatiegebruik. The older medicatiegebruik is therefore no longer relevant for the medication overview.
* Medicatieafspraak – Medicatiegebruik
* Medicatieafspraak – ''Medicatiegebruik'' – Toedieningsafspraak

Of course, a new record of medicatiegebruik can then be made, which is also relevant for the medication overview.
* Medicatieafspraak – ''Medicatiegebruik'' – Toedieningsafspraak - Medicatiegebruik

=====New toedieningsafspraak =====
Sometimes you make a new toedieningsafspraak under an existing medicatieafspraak. For example, because another product must be provided (as a result of preference policy or stock). In that case, too, such a new toedieningsafspraak may overrule older medicatieafspraken and medicatiegebruik.
* Medicatieafspraak – ''Toedieningsafspraak – Medicatiegebruik''- stop-Toedieningsafspraak - Toedieningsafspraak

Of course you can then record medicatiegebruik, which is also relevant for the medication overview.
* Medicatieafspraak – ''Toedieningsafspraak – Medicatiegebruik'' - stop-Toedieningsafspraak – Toedieningsafspraak - Medicatiegebruik

====Over the counter====
Sometimes a patient uses medication for which there is no prescription. This applies, for example, to painkillers such as paracetamol or ibuprofen, which are available without a prescription. We call this “over the counter” medication. Such use of "over the counter" medication can be recorded with the medicatiegebruik building block. This is also relevant for the medication overview.
* Medicatiegebruik

A new record of medicatiegebruik by the same type of author (type of author is patient or health professional) "overrules" any older records of medicatiegebruik. Elaborated below, in order of registration date:
* ''Medicatiegebruik'' - Medicatiegebruik

When a prescriber decides to formalize this medicamenteuze behandeling with a medicatieafspraak the rules as described above apply. Elaborated below, in order of appointment date (medicatieafspraak or toedieningsafspraak) / registration date (medicatiegebruik):
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak - Medicatiegebruik
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak – Toedieningsafspraak - Medicatiegebruik
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak – ''Medicatiegebruik'' - Toedieningsafspraak - Medicatiegebruik
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak - ''Medicatiegebruik'' - Medicatiegebruik

====Future medicatieafspraken and toedieningsafspraken====
A medicamenteuze behandeling may include more than one topical medicatieafspraak and toedieningsafspraak. Namely one for the current situation and one or more for the future situation. This section describes an example with one current and one future. For clarity, the future building blocks have a “T-” in the examples. Both current and future building blocks are relevant for the medication overview. The building blocks for toedieningsafspraak and medicatiegebruik must have adequate references to either the current or future appointments. Below are three examples, in order of appointment date / registration date (if these are equal, then sorted by period of use):
* Medicatieafspraak – T Medicatieafspraak
* Medicatieafspraak – Toedieningsafspraak – T Medicatieafspraak – T Toedieningsafspraak
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – T Medicatieafspraak – T Toedieningsafspraak – T Medicatiegebruik
Suppose that the toedieningsafspraak changes because the provider provides a different strength (2x 500mg tablets instead of 1x 1000mg tablets) and the patient still has enough stock for two weeks based on the first toedieningsafspraak:
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – T Toedieningsafspraak – T Medicatiegebruik

=====New medicatieafspraak =====
If you make a new medicatieafspraak in this situation, you always make a (technical) stop-medicatieafspraak. This stop-medicatieafspraak has two manifestations: 
1) with reference to a specific medicatieafspraak that you stop 
2) without a referral, and with that you stop the entire medicamenteuze behandeling (drug treatment)

Ad 1) Stop medicatieafspraak for one current medicatieafspraak. With this stop medicatieafspraak you stop one specific medicatieafspraak. You also make a new one for that medicatieafspraak. Suppose you only want to change the current medicatieafspraak, then this applies to the examples above, in order of appointment date:
* ''Medicatieafspraak'' – T Medicatieafspraak - stop-Medicatieafspraak – Medicatieafspraak 
* ''Medicatieafspraak – Toedieningsafspraak'' – T Medicatieafspraak – T Toedieningsafspraak - stop-Medicatieafspraak – Medicatieafspraak
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik'' – T Medicatieafspraak – T Toedieningsafspraak – T Medicatiegebruik - stop-Medicatieafspraak – Medicatieafspraak

Suppose you only want to change the future medicatieafspraak, then this applies to the examples above, in order of appointment date:
* Medicatieafspraak – ''T Medicatieafspraak'' - stop- T Medicatieafspraak – T Medicatieafspraak
* Medicatieafspraak – Toedieningsafspraak – ''T Medicatieafspraak – T Toedieningsafspraak'' - stop- T Medicatieafspraak – T Medicatieafspraak
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – ''T Medicatieafspraak – T Toedieningsafspraak – T Medicatiegebruik'' - stop- T Medicatieafspraak – T Medicatieafspraak 

 Ad 2) Stop medicatieafspraak for the entire medicamenteuze behandeling. With this stop medicatieafspraak you stop all existing (current and future) medicatieafspraken in the medicamenteuze behandeling. If you now want to make a medicatieafspraak for the future in addition to a current one, you must also make it again. Elaborated below for the same three examples as above, in order of appointment date.
* ''Medicatieafspraak – T-Medicatieafspraak'' – stop-Medicatieafspraak (zonder referentie) - Medicatieafspraak 
* ''Medicatieafspraak – Toedieningsafspraak – T-Medicatieafspraak – T-Toedieningsafspraak'' - stop-Medicatieafspraak (zonder referentie) – Medicatieafspraak – T Medicatieafspraak
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – T-Medicatieafspraak – T-Toedieningsafspraak – T Medicatiegebruik'' - stop-Medicatieafspraak (zonder referentie) – stop-Toedieningsafspraak -Medicatieafspraak – stop- T Toedieningsafspraak - T Medicatieafspraak 

=====New toedieningsafspraak=====
 However, you can also make a new toedieningsafspraak for the current medicatieafspraak only. This new toedieningsafspraak must then have a reference to that current medicatieafspraak. Elaborated below for three examples, in order of appointment date.
* Medicatieafspraak – T Medicatieafspraak – Toedieningsafspraak
* Medicatieafspraak – ''Toedieningsafspraak''– T-Medicatieafspraak – T Toedieningsafspraak - stop-Toedieningsafspraak – Toedieningsafspraak
* Medicatieafspraak – ''Toedieningsafspraak – Medicatiegebruik'' – T Medicatieafspraak – T-Toedieningsafspraak – T Medicatiegebruik – - stop-Toedieningsafspraak – Toedieningsafspraak

A new toedieningsafspraak with a reference to the future medicatieafspraak looks like this.
* Medicatieafspraak – T Medicatieafspraak – Toedieningsafspraak – T-Toedieningsafspraak
* Medicatieafspraak –Toedieningsafspraak – T-Medicatieafspraak – ''T Toedieningsafspraak'' – stop-T Toedieningsafspraak - T Toedieningsafspraak
* Medicatieafspraak –Toedieningsafspraak – Medicatiegebruik – T Medicatieafspraak – ''T Toedieningsafspraak – T Medicatiegebruik'' - stop- T Toedieningsafspraak – T-Toedieningsafspraak

====Rules of overruling listed====
Based on the above description / examples, the following general rules for overruling can be derived. This concerns the rules for determining whether a building block is relevant for delivery in the medication overview. Within a medicamenteuze behandeling:
*A new medicatieafspraak overrules all older building blocks (medicatieafspraak, toedieningsafspraak, medicatiegebruik) belonging to the medicatieafspraak /medicatieafspraken that this medicatieafspraak has stopped.
*A new toedieningsafspraak overrules all older building blocks of the type of toedieningsafspraak or medicatiegebruik that belong to the same medicatieafspraak as the new toedieningsafspraak.
*In principle, a new record of medicatiegebruik overrules (see exception below) older records of medicatiegebruik that belong to the same medicatieafspraak as the new medicatiegebruik.
**Exception to this rule: medicatiegebruik with the author as a patient DOES NOT overrule an older record of medicatiegebruik with the care provider as author and vice versa. Both are therefore relevant to the medication overview.
The latter exception applied to a number of situations:

Deze laatste uitzondering toegepast op een aantal situaties:
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik-ZVL – Medicatiegebruik-PAT
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik-PAT – Medicatiegebruik-ZVL
* Medicatieafspraak – Toedieningsafspraak – ''Medicatiegebruik-PAT'' – Medicatiegebruik-PAT
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik-ZVL – ''Medicatiegebruik-PAT'' – Medicatiegebruik-PAT
* Medicatieafspraak – Toedieningsafspraak – ''Medicatiegebruik-ZVL – Medicatiegebruik-PAT'' – Medicatiegebruik PAT – Medicatiegebruik-ZVL

==Verification by medicamenteuze behandeling ==
A health professional records verification per medicamenteuze behandeling with the medicatiegebruik building block:
*Author = Health professional
*Possible informant: the patient, a care provider or another person
*Possible characteristic "according to agreement": according to the author, is the medicatiegebruik in accordance with the medicatieafspraak or toedieningsafspraak?
*Possible link to medicatieafspraak or toedieningsafspraak:
**Medicatieafspraak or toedieningsafspraak that has been the reference for recording this medicatiegebruik.
**When it is indicated "by appointment", this is the medicatieafspraak or toedieningsafspraak according to which the patient uses.
Such a record of medicatiegebruik means: "I think the patient uses this drug as follows: ... ..".

Known: it is not currently provided in the information standard to indicate that a medicatieafspraak or toedieningsafspraak is correct, regardless of whether the patient uses it as such.

==Process of the medication overview exchange==
In addition to the content and verification, the process surrounding the medication overview is also important.

===Who, when, with what information===
The reliability and completeness of a medication overview depends on:
*who composed it,
*at what time and
*with what basic information.
We can make agreements about this, for example:
*only exchange/make available a medication overview once it has some form of reliability
**after an explicit action by a health professional or
**automatically if certain conditions are met.
*fully automatically exchange/make available medication overview without conditions
*make medication overview fully automatically available without the need for a new data type (so when registering one of the other medication data types you are automatically also the source of a medication overview).

====Decision====
The above questions have not yet been answered. It has been decided that during the Proof-Of-Concept all parties that can provide a medication overview will do the same.

===Responsibilities applicant and source===
The applicant receives medication overviews from multiple sources. Processing this is the responsibility of the recipient. The topicality of a medication overview is important here.

'''Action''': the transaction Medicatieoverzicht (medication record) must contain the most recent date of the collection of available appointment dates / registration dates of the delivered building block instantiations. The compiler (source) of the medication overview must therefore provide this date. This helps the recipient to better estimate the topicality of the medication overview.

===Agreements continued===
We continue the analysis with the results of the Proof-Of-Concept to arrive at a good process for the medication overview.

==Inference rules==
It is important that all parties, physician, pharmacist, nurse as well as patient can infer from the medication building blocks what is intended (i.e. what the current agreements are) and that this should be the same for all information systems. For that reason, information systems must be able to calculate the current situation using the same inference rules.

The current therapeutic situation is calculated on the basis of medicatieafspraken and toedieningsafspraken. Toedieningsafspraken have a relationship with the medicatieafspraak that they were added to. For this reason, toedieningsafspraken can be linked to the medicatieafspraak that they belong to. 
Of course it is also useful to have information about medicatiegebruik. However, this does not indicate the aim of the health professional, only what medication the patient has used. For that reason, the rules below do not take ‘medicatiegebruik’ in consideration. However, ‘gebruik’ is part of a medication profile but is shown separately under the medicamenteuze behandeling concerned.

===Effective period===
The effective period lies between an ''effective start date'' and an ''effective end date''. 
:''The effective period describes the period to which a medicatieafspraak or toedieningsafspraak (ultimately) applies.'' 
The effective period depends on adjustments (modifying/discontinuing/halting/resuming) of medication and by the ‘actual handling of a medicatieafspraak by a toedieningsafspraak. The effective period is not described in the dataset, because it is inferred which is only used to determine the current situation. The ''effective start date, effective end date'' and ''effective period'' are not data to be shown to the end user. Medication for an indefinite period has an effective end date that is in the future, but at a time that cannot be distracted (yet). It is only known that it is 'somewhere' in the future.

===Actual and current medication===
*''Actual (medicatieafspraken en toedieningsafspraken)'': the agreements of which the effective end date lies in the future.
*''Current (medicatieafspraken en toedieningsafspraken) agreements'': the agreements for which the present date lies between their effective start date and the effective end date.
*''Actual medication'': the collection of actual (current and future) medication and toedieningsafspraaks as well as current medicatiegebruik. It should be taken into account that it is never possible to say with certainty to what extent the patient complies with the agreements and/or reports actual gebruik.

===Details===
'''Approach''' 
Using a number of different situations the inference rules are described for arriving at the effective therapeutic period in a medication profile: 
:1) Starting medication
:2) Creating a toedieningsafspraak
:3) Changing medication
:4) Discontinuing medication
:5) Temporarily halting and resuming medication

The inference rules are described below. The number for each inference rule indicates the order in which the rules must be executed.

'''1) Starting medication''' 
Medication is started by creating a new medicatieafspraak. The medicatieafspraak has:
*An agreement date - the date on which the agreement was made with the patient.
*A period of use - this period is consists of:
**A start date - the start date of the medicatieafspraak may be in the future;
**The duration of medicatiegebruik;
**The end date – the date until which the medicatieafspraak is valid.

1a: The effective period of a new medicatieafspraak is equal to its period of medication use.

'''2) Creating a toedieningsafspraak ''' 
A toedieningsafspraak specifically fulfils a medicatieafspraak. From a patient perspective, the toedieningsafspraak, in a way, replaces a medicatieafspraak, as the toedieningsafspraak is a more specific indication of what the patient should be using.

Inference rule 1 is extended:

1b: The effective period of a new toedieningsafspraak is equal to its period of medication use

Inference rule 2 is applicable when a medicatieafspraak has underlying toedieningsafspraken (see inference rule 2b for further explanation):

2a: The effective period of a medicatieafspraak is equal to the effective period of the toedieningsafspraak.

'''3) Changing medication'''
:'''a) By means of a medicatieafspraak'''
The prescriber changes the medication (or the medicamenteuze behandeling) by creating a new medicatieafspraak (and discontinuing the existing one) within an existing medicamenteuze behandeling.
Because the start date of a medicatieafspraak may lie in the future, several medicatieafspraken may be actual at the same time. For example, when a medicatieafspraak applies ‘for an indefinite period’ (ma1) and it is agreed to change the dosage in two weeks (ma2), the first medicatieafspraak (ma1) remains valid for two weeks, after which the second medicatieafspraak (ma2) becomes effective. The previous inference rules do not change because of this.

:'''b) By means of a toedieningsafspraak '''
An toedieningsafspraak specifically fulfils a medicatieafspraak. This toedieningsafspraak may be modified. For example, when administration schedules are changed (when GDS is initiated), or when a commercial product is changed (for example, as a result of a preference policy). Several successive toedieningsafspraken can therefore be created under a single medicatieafspraak. Hence, rule 2 is expanded so that the effective period of the medicatieafspraak is determined by the entire series of underlying toedieningsafspraken.

2b: When several toedieningsafspraken are made under a single medicatieafspraak, the effective start date of the medicatieafspraak is then equal to the earliest start date of the underlying toedieningsafspraak and the end date of the last toedieningsafspraak.

Parallel toedieningsafspraken may exist under a single medicatieafspraak of which the agreement date and the start date are the same. Both are then valid at the same time and this does not change rule 2b.

The diagram below includes a simplified example of an actual profile composed of different building blocks. The patient, verification, CiO and lab data have been excluded from this overview. Only limited data has been included, mainly to demonstrate the way in which the effective period works. Lines starting with ‘-’ are detail lines which can be hidden in the medication profile, if required. The first line shows the effective period for the underlying MAs and TAs. The ‘medicatiegebruik” is also displayed, but this does not influence the calculation of the effective therapeutic period on the first line.

{{anchor|figuur 9}}
[[Bestand:Voorbeeldeffectieveperioden.png|Figuur 9 Voorbeeld effectieve periode]]

'''4) Discontinuing medication''' 
Discontinuing medication (i.e medicamenteuze behandeling) is done by creating a new medicatieafspraak in which stoptype ‘definite’ is indicated. The start date of this medicatieafspraak is the date on which the original medicatieafspraak started. The end date is the date on which the medication is discontinued. The effective period of the original medicatieafspraak is so replaced by the effective period of this new stop-MA.

1c: When a medicatieafspraak is discontinued, the effective period of the medicatieafspraak is then the effective period of the stop-MA.

An stop-toedieningsafspraak fulfils the stop-medicatieafspraak. In this way, for example, it is possible to indicate that the discontinuation starts when the next GDS roll is dispensed.

'''5) Temporarily halting and resuming medication''' 
Temporarily halting medication is carried out in the same way as discontinuing medication. A stop-MA is created (stoptype ‘temporary’) with the same start date as that of the original medicatieafspraak. The end date of the stop-MA is the timing of the temporary halt, the stop type is ‘temporary’. Resuming medication is done by creating a new medicatieafspraak with the old (or adjusted) dosage with the date of resuming as the start date. A meaningful reason (example: resume previous policy) may serve to clarify matters. If the medication is not resumed, ‘discontinue medication’ (stoptype ‘definite’) can be executed in order to permanently end the medicamenteuze behandeling, which means the medication is no longer valid. Medication that is halted remains valid, and so remains visible in the medication profile.

1d: When medication is temporarily halted, the effective period is not affected. The effective period is determined by the effective period of the original medicatieafspraak.

These inference rules are the basis for determining the current agreements. It is possible to conceive exceptional situations relating to a partial availability of medication data. These situations have not been elaborated. All inference rules are included and implemented in the open source medication viewer.

==Data that need not be shown==
Various data are important for the correct processing of information, but are not relevant to the end user:
*An application does not have to show the (technical) identification of a medicamenteuze behandeling (MBH) (nor that of the building blocks themselves), but the elaboration thereof: namely, building blocks shown in coherence.
*The copy indicator with the medicatieafspraak (MA), toedieningsafspraak (TA) and medicatiegebruik (MGB) when consulting the medication overview. Whether a building block is a copy is not that important to a user and can be deduced by other data from that building block (such as the author of the building block). So it is not so important that a user can see that this has been delivered 'as a copy' and is probably only confusing. However, this information is important for suppliers, for example because they sometimes want to perform calculations with the data and it is then safer to collect the data from the real source. It is therefore obvious to keep track of whether you have received data from the real source in your information system.
*An application does not have to show the stop type (temporary / definite) of a stop appointment, but the elaboration thereof: namely the processing of the meaning, so that an entire MBH is shown as stopped medication or as interrupted medication (remains clear under current medication) or as a change in the case of a 'technical stop appointment'.

=Administration list and inference rules=

This chapter shows a possible presentation/view of the administration list and, additionally, specifies the inference rules to identify the relevant medication building blocks within a pharmaceutical treatment, for the generation of an administration list.

==Introduction==
This paragraph contains an example of an administration list. The administration list shows the most recent medication data at any time of the day, to facilitate adequate medication administration. To ensure safe circumstances in which correct and up-to-date medication data is presented to the (professional) administrator, the administration software must be able to process the medication building blocks and to correlate the medication building blocks, as described in this information standard.

The term ‘administration list’ is defined as a digital list including all medicaments that are prescribed by a prescriber and that have to be administered to a patient/client. This list is generated based on the following medication building blocks: medication agreement (MA), administration agreement (TA), medication dispense (MVE), medication administration (MTD) and variable-dosing regimen (WDS).

The process of (actively) making medication data available to (professional) administrators enables the generation of a total overview of all medication which has to be administered. Importantly, this implies that information regarding discontinuation and change of medication with or without medication dispense is available at any time. Change in medication and variable-dosing regimens, for example as prescribed by the thrombosis service, are immediately available for administrators.

In the figures below, the numbered elements are normative; it is mandatory to show those components. The lay-out of the administration list in an information system may differ depending on the type of users or the type of device; this is dependent on the user requirements.

The administration list in this example is described generally. The chapter entails the general end user requirements for the administration list; this chapter does not comprise details on the technical requirements or implementation.

The project ‘Veilige principes in the medication’ comprises the sectors nursing care, nursing aid and home care. The specifications as described in ‘Veilige principes in de medicatieketen 2016’ and ‘Richtlijn overdracht van medicatiegegevens in de keten herziening 2018/2019’ as well as new insights from the program ‘Medicatieoverdracht’ are incorporated in this chapter.

The basis for the administration list entails:
*Medication building blocks
**Medication agreement (MA)
**Administration agreement (TA)
**Variable-dosing regimen (WDS)
**Medication administration (MTD)
**Medication dispense (MVE)
*All current medication; this comprises all MAs, TAs and WDSs which are available and applicable when the medication is administered. The PeriodOfUse defines whether medication should be considered current medication.
*The PrickPatchLocation is consulted based on the AdministrationDateTime.
*(Professional) administrators can distinguish the types of medication (in GDS package or separately) which should be administered to the patient by the data element DistributionForm (medication building block MVE) and the data element AsNeeded/Condition in the dosage (medication building blocks MA, TA or WDS). The different types of medication may be presented according to the following categories:
**GDS medication (including discontinued medication in order to show a notification/warning)
**Non-GDS medication
**Non-GDS medication as needed
*The remaining building blocks (dispense request (VV), medication use (MGB) and medication consumption (MVB)) are not relevant for the administration list.

{{anchor|figuur 1}}
[[Bestand:Toedienlijst_figuur_1a.PNG|Figuur 1: Voorbeeldweergave toedienlijst]]
[[Bestand:Toedienlijst_figuur_1b.PNG|Figuur 1: Voorbeeldweergave toedienlijst]]
[[Bestand:Toedienlijst_figuur_1c.PNG|Figuur 1: Voorbeeldweergave toedienlijst]]
 
''Figure 1: Example administration list.''
 
 
{| class="wikitable"
|-
! Nr
! style="text-align:left;"|Heading
! style="text-align:left;" colspan="3"|Dataset
|-
| 1 || Type || Medication Agreement || Administration Agreement || Variable-Dosing Regimen
|-
| 2 || Medicine || Agreed Medicine || Medicine To Be Dispensed ||
|-
| 3 || Prescriber
|style="text-align:left;" colspan="3"| Medication Agreement – Prescriber – Health Professional
|-
| 4 || Supplier
|style="text-align:left;" colspan="3"| Administration Agreement – Supplier – Healthcare Provider
|-
| || Author
|style="text-align:left;" colspan="3"| Variable-Dosing Regimen – Author – Health Professional (conditional)
|-
| 5 || Start Date || Medication Agreement – Period Of Use || Administration Agreement – Period Of Use || Variable-Dosing Regimen – Period Of Use
|-
| 6 || End Date/Duration || Medication Agreement – Period Of Use || Administration Agreement – Period Of Use || Variable-Dosing Regimen – Period Of Use
|-
| 7 || Description
|style="text-align:left;" colspan="3"| Instructions For Use – Description
|-
| || Route Of Administration
|style="text-align:left;" colspan="3"| Instructions For Use – Route Of Administration

|-
| || Additional Instructions
|style="text-align:left;" colspan="3"| Instructions For Use – Additional Instructions
|-
| || Dose
|style="text-align:left;" colspan="3"| Instructions For Use – Dosing Instructions – Dosage – Dose
|-
| || Administration Time
|style="text-align:left;" colspan="3"| Period Of Use – Dosing Instructions – Dosage – Administering Schedule – Administration Time
|-
| || Administration Speed
|style="text-align:left;" colspan="3"| Period Of Use – Dosing Instructions – Dosage – Administration Speed
|-
| || Duration Of Administration
|style="text-align:left;" colspan="3"| Period Of Use – Dosing Instructions – Dosage – Duration Of Administration
|-
| 8 || Prick-Patch Location
|style="text-align:left;" colspan="3"|Medication Administration – Prick-Patch Location
|-
| 9 || Comment
|style="text-align:left;" colspan="3"|Comment & Additional Information
|}
''Table 1: Normative medication data in the administration list.''


==Functional specification==
In the figures below the elements with normative data are presented. The other elements are not normative (not yet). The numbered elements in the table are normative; the other elements are optional (until further notice).

===Heading and general===

[[Bestand:Toedienlijst_Functionele_specificatie.png]]

===Remarks===

[[Bestand:Toedienlijst_Kop en algemeen.png]]

In the comment field, for example, (limiting) health literacy competences (competences: literacy, calculation and digital skills) can be recorded, which may affect the medication administration. This part is for internal use and is not exchanged (not yet).

'''NB.''' This part is not normative yet. This data is derived from the internal information system of the organization.

===GDS medication===

[[Bestand:Toedienlijst_Opmerkingen.png]]

GDS (medication distribution system, in Dutch: 'Geneesmiddel Distributie Systeem') is defined as a package in which medicaments are distributed in units per administration moment, labelled with the name of an individual patient/client ([https://www.knmp.nl/praktijkvoering/richtlijnen/knmp-richtlijnen-praktijkvoering/knmp-richtlijn-voor-geautomatiseerd-geneesmiddeldistributiesysteem-gds-september-2011 KNMP, 2011]). If medication is discontinued or changed, it is desired that a warning signal is shown, with the comment that, possibly, the medication is in the GDS package, and an additional act may be required. Further elaboration is needed.

===Non-GDS medication===

[[Bestand:Toedienlijst_Niet-GDS-medicatie.png]]

Non-GDS medication is medication which, for various reasons, cannot be included in an automated medication distribution system. The distribution type 'non-GDS' is specified in the data element DistributionForm in the corresponding MVE. Furthermore, for non-GDS medication, the condition AsNeeded remains empty.

===Non-GDS medication – as needed===

[[Bestand:Toedienlijst_Niet-GDS-medicatie_zo_nodig.png]]

Non-GDS medication as needed comprises separate medication which should be administered only in specific circumstances. The condition for administration of such medicament can be:
*a measured physiological value (plasma glucose level, body temperature, blood pressure);
*a symptom or other condition (headache, itching).
The distribution type 'non-GDS' is specified in the data element DistributionForm in the corresponding MVE. Furthermore, the condition AsNeeded is filled.

==Building block instantiations==
This paragraph describes which building block instantiations are related to the administration list. This includes only the ‘own’ building blocks (see [[#Own and other people|5.3.1]]) and only the latest, relevant instantiations (see [[#Last relevant|6.3.2]]).

===Therapeutic and logistical building blocks===
Compiling an administration list involves both therapeutic and logistical medication building blocks. Building blocks can be ‘overruled’ based on inference rules. All inference rules as described in [[#Medication overview and inference rules|Chapter 5]] are applicable. In addition, in this paragraph, the inference rules for WDS are described. The inference rules do not apply to MTD, as medication administration is a procedure at a certain time point; in contrast, the MA, TA and MBG comprise agreements valid for a certain period of time. The logistical medication building block MVE is part of compiling the administration list, as this building block is needed to derive the type of distribution of the medication.

====Administration list and inference rules====
An administration list can be compiled, for example in the administrator’s information system, based on separate medication building blocks.
The medication building blocks may be retrieved from the own information system or from other sources. The transaction Medication data (consulting/making available) is used for consulting and making available individual medication building blocks.
In the transaction group Medication data (sending/receiving), separate medication building blocks can be send to another health professional or patient directly (without prior consultation); for example, in the case of discharge or on request of a fellow health professional (for example, a patient sees a GP or pharmacist outside the region; the GP or pharmacist requests the data by telephone and receives the data digitally).
Both for Medication data sending/receiving and Medication data consulting/making available, data obtained from other sources is not allowed to be presented in the administration list.

===Last relevant===
Only the latest relevant medication building blocks (per pharmaceutical treatment) are part of the administration list. This paragraph provides a description of the latest relevant building blocks for an administration list comprising medication on prescription. [[#Medication with prescription with a variable-dosing regimen|Paragraph 6.3.2.1]] describes the situation in which a variable-dosing regimen (WDS) is applicable. For WDS, the same inference rules apply as for MA. For compiling an administration list, the presence of a WDS is decisive for the instructions for use. All other situations in which WDS is not applicable, as described in [[#Last relevant|paragraph 5.3.2]], are applicable as well.

Query to identify the correct, relevant and future medication building blocks:
{| class="wikitable"
|-
! Nr
! style="text-align:left;"|Medication building block
! style="text-align:left;"|Query Parameter
! style="text-align:left;"|What should be filled in specifically?
|-
| 1 || MA, TA, WDS || Period Of Use || All medication that should be administered today and, therefore, is applicable: Day = T, startDate = T: 00:00:00 h, endDate = T: 23:59:59 h
|-
| 2 || MTD || Administration Period || Depending on medical relevance (for example, historical information on prick and patch locations may be relevant back to one week ago). For example, is one week is sufficient (another period may be chosen): Day = T, startDate = T-7 day
|-
| 3 || MVE || Dispense Period || Broad request (+/- one month)
|}

If all medication building blocks are collected, the following medication data, depending on the situation, can be used:
{| class="wikitable"
|-
! style="text-align:left;"|Medication building block
! style="text-align:left;"|Situation: only MA*
! style="text-align:left;"|Situation: MA + TA
! style="text-align:left;"|Situation: MA + TA + WDS
|-
| MA || Decisive** for compiling the administration list (number: 2, 5, 6, 7, 9, 10) || Data from the prescriber || Data from the prescriber
|-
| TA || - || Decisive** for compiling the administration list (number 2, 5, 6, 7, 9, 10) || Data from the supplier and medicine
|-
| WDS || - || - || Decisive** for compiling the administration list (number 5, 6, 7, 10)
|}

* Situation in which the pharmacist has not processed the MA yet.
** ‘Decisive’ indicates the data elements which are included in the functional requirements (numbers of the elements are provided between brackets).

====Medication with prescription with a variable-dosing regimen====

=====Most simple ‘happy flow’=====
The most simple ‘happy flow’ in a pharmaceutical treatment is stated below.

*''MA – WDS – TA''

In general, a pharmaceutical treatment starts with an MA. A TA specifies the MA. In the WDS, it is defined whether a variable-dosing regimen applies. In both the MA and the TA, the instruction ‘according to schedule thrombosis service’ is recorded. Then, in the WDS, the dosing schedule is specified. The three medication building blocks MA, TA and WDS are relevant and are part of compiling an administration list, as indicated in green below.


*MA – WDS– TA


A TA refers to the MA, which is specified by the TA. Also, a WDS refers to the MA, which is specified by the WDS. A WDS is always related to an MA.

====New WSD====
*MA – WDS – TA – WDS

The period of use of the WDS has ended and a new dosing schedule is created.

=====Change of WDS=====

*MA – WDS– TA – stop-WDS – WDS

The variable-dosing regimen (WDS) is changed.

=====Discontinuation of medication=====
*MA – WDS – TA – stop-MA

Medication with a WDS is discontinued by a stop of the MA.

=====Change of trade product=====

*MA – WDS – TA – stop-TA – TA

The trade product is changed; this affects the WDS.

====Rules of overruling listed====
Based on the descriptions/examples above, the following general rules for overruling apply. Those rules indicate which medication building block is relevant to incorporate and present in the administration list. Within a pharmaceutical treatment:
*A new MA overrules all previous, older therapeutical medication building blocks (MA, TA, WDS) related to the MA(s) which is/are stopped by the new MA.
*A new TA overrules the previous, older TA related to the same MA as the new TA.
*A new WDS overrules all previous, older WDSs related to the same MA as the new WDS.



=Information systems and transactions=
This chapter contains a list of all system roles and transactions that are referred to in the various process chapters.

The figure below ([[#figuur 10|Figure 10]]) contains an overview of all information systems with their corresponding system roles. The system roles have been described in [[#tabel 3|Table 3]]. The system roles associated with consulting/making available medication data and the medication overview are important for all information systems depending on the process in which they are used. The electronic prescribing system (EPS) also includes the system roles for receiving a voorstel verstrekkingsverzoek, sending a reply voorstel verstrekkingsverzoek and receiving a voorstel medicatieafspraak and, in an outpatient situation, for sending a prescription and receiving data on the processing of a prescription. In addition to the basic system roles, a XIS and PGD also include the system roles for sending a voorstel medicatieafspraak and a voorstel verstrekkingsverzoek, for sending data on gebruik and for receiving a reply voorstel verstrekkingsverzoek. The pharmacist information system (PIS) also includes, in addition to the basic system roles, the roles for sending a voorstel medicatieafspraak, sending a voorstel verstrekkingsverzoek and data on processing of the prescription, and receiving a prescription and reply voorstel verstrekkingsverzoek. [[#Medication process|Chapter 2]] lists the main system roles per process.

{{anchor|figuur 10}}
[[Bestand:Systemen.png|Figuur 10 Overzicht systemen en systeemrollen]]

{{anchor|tabel 3}}
{| class="wikitable" "cellpadding="10"
!style="text-align:left;"|System role name
!style="text-align:left;"|Abbr.
!style="text-align:left;"|Description
|-
| style="background-color: white;"| MedicatieGegevensBeschikbaarstellend
| style="background-color: white;"| MP-MGB
| style="background-color: white;"| Making medication data available to fellow health professionals/patient
|-
| style="background-color: white;"| MedicatieGegevensRaadplegend
| style="background-color: white;"| MP-MGR
| style="background-color: white;"| Consulting medication data at fellow health professionals/patient
|-
| style="background-color: white;"| MedicatieGegevensSturend
| style="background-color: white;"| MP-MGS
| style="background-color: white;"| Sending data to fellow health professional/patient
|-
| style="background-color: white;"| MedicatieGegevensOntvangend
| style="background-color: white;"| MP-MGO
| style="background-color: white;"| Receiving medication data from fellow health professional/patient
|-
| style="background-color: white;"| MedicatieOverzichtBeschikbaarstellend
| style="background-color: white;"| MP-MOB
| style="background-color: white;"| Making medication overview available to fellow health professionals/patient
|-
| style="background-color: white;"| MedicatieOverzichtRaadplegend
| style="background-color: white;"| MP-MOR
| style="background-color: white;"| Consulting medication overview at fellow health professionals/patient
|-
| style="background-color: white;"| MedicatieOverzichtSturend
| style="background-color: white;"| MP-MOS
| style="background-color: white;"| Sturen medicatieoverzicht aan medebehandelaar/patiënt
|-
| style="background-color: white;"| MedicatieOverzichtOntvangend
| style="background-color: white;"| MP-MOO
| style="background-color: white;"| Receiving medication overview from fellow health professional/patient
|-
| style="background-color: white;"| VoorschriftSturend
| style="background-color: white;"| MP-VOS
| style="background-color: white;"| Sending a request to dispense medication (verstrekkingsverzoek) or process modifications to medicatieafspraak.
|-
| style="background-color: white;"| VoorschriftOntvangend
| style="background-color: white;"| MP-VOO
| style="background-color: white;"| Receiving verstrekkingsverzoek or request for processing of modifications to medicatieafspraak.
|-
| style="background-color: white;"| VoorschriftAfhandelingSturend
| style="background-color: white;"| MP-VAS
| style="background-color: white;"| Sending data on processing of medicatieafspraak and possibly verstrekkingsverzoek in toedieningsafspraak and/or medicatieverstrekking
|-
| style="background-color: white;"| VoorschriftAfhandelingOntvangend
| style="background-color: white;"| MP-VAO
| style="background-color: white;"| Receiving data on processing of medicatieafspraak and possibly verstrekkingsverzoek in toedieningsafspraak and/or medicatieverstrekking
|-
| style="background-color: white;"| VoorstelVerstrekkingsverzoekSturend
| style="background-color: white;"| MP-VVS
| style="background-color: white;"| Informing prescriber about voorstel new verstrekkingsverzoek, receiving reply to proposed verstrekkingsverzoek
|-
| style="background-color: white;"| VoorstelVerstrekkingsverzoekOntvangend
| style="background-color: white;"| MP-VVO
| style="background-color: white;"| Receiving new voorstel verstrekkingsverzoek, sending reply to voorstel verstrekkingsverzoek
|-
| style="background-color: white;"| VoorstelMedicatieafspraakSturend
| style="background-color: white;"| MP-VMS
| style="background-color: white;"| Informing prescriber about new voorstel or modified medicatieafspraak, receiving reply to proposed medicatieafspraak
|-
| style="background-color: white;"| VoorstelMedicatieafspraakOntvangend
| style="background-color: white;"| MP-VMO
| style="background-color: white;"|Receiving voorstel for new or modified medicatieafspraak, sending reply to voorstel medicatieafspraak
|}Table 3 Overview system roles

Table 4 gives an overview of all transaction groups, transactions, corresponding system roles and building blocks exchanged with this transaction group. The names of the transaction groups and transactions link to the ART-DECOR publication which details per scenario which data elements are used.

{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| '''Transaction group'''
! style="text-align:left;"| '''Transaction'''
! style="text-align:left;"| '''System role'''
! style="text-align:left;"| '''Building blocks'''
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.131-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.299_20220207000000 Medication data (PULL)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.301-2022-02-07T000000.html Making medication data available]
|style="background-color: white;vertical-align:top;"|MP-MGB
|style="background-color: white;vertical-align:top;" rowspan="2"|One or more: MA, VV, TA, MVE, MTD, MGB, WDS
|-
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.300-2022-02-07T000000.html Consulting medication data]
|style="background-color: white;vertical-align:top;"|MP-MGR
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.131-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.302_20220207000000 Medication data (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.303-2022-02-07T000000.html Sending medication data]
|style="background-color: white;vertical-align:top;"|MP-MGS
|style="background-color: white;vertical-align:top;" rowspan="2"|One or more: MA, VV, TA, MVE, MTD, MGB, WDS
|-
|style="background-color: white;vertical-align:top;"|Receiving medication data
|style="background-color: white;vertical-align:top;"|MP-MGO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.132-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.315_20220207000000 Medication overview (PULL)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.317-2022-02-07T000000.html Making medication overview available]
|style="background-color: white;vertical-align:top;"|MP-MOB
|style="background-color: white;vertical-align:top;" rowspan="4"|MA, TA, MGB
|-
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.316-2022-02-07T000000.html Consulting medication overview]
|style="background-color: white;vertical-align:top;"|MP-MOR
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.132-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.318_20220207000000 Medication overview (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.319-2022-02-07T000000.html Sending medication overview]
|style="background-color: white;vertical-align:top;"|MP-MOS
|-
|style="background-color: white;vertical-align:top;"|Receiving medication overview
|style="background-color: white;vertical-align:top;"|MP-MOO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.133-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.321_20220207000000 Medication prescription (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.322-2022-02-07T000000.html Sending medication prescription]
|style="background-color: white;vertical-align:top;"|MP-VOS
|style="background-color: white;vertical-align:top;" rowspan="2"|MA with or without VV, height, weight, renal function value
|-
|style="background-color: white;vertical-align:top;"|Receiving medication prescription
|style="background-color: white;vertical-align:top;"|MP-VOO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.135-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.333_20220207000000 Medication prescription processing (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.334-2022-02-07T000000.html Sending data on processing of medication prescription]
|style="background-color: white;vertical-align:top;"|MP-VAS
|style="background-color: white;vertical-align:top;" rowspan="2"|TA with or without MVE
|-
|style="background-color: white;vertical-align:top;"|Receiving data on processing of medication prescription
|style="background-color: white;vertical-align:top;"|MP-VAO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.134-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.327_20220207000000 Proposal dispense request (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.328-2022-02-07T000000.html Sending proposal dispense request]
|style="background-color: white;vertical-align:top;"|MP-VVS
|style="background-color: white;vertical-align:top;" rowspan="2"|VVV
|-
|style="background-color: white;vertical-align:top;"|Receiving proposal dispense request
|style="background-color: white;vertical-align:top;"|MP-VVO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.134-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.330_20220207000000 Reply proposal dispense request (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.331-2022-02-07T000000.html Sending reply proposal dispense request]
|style="background-color: white;vertical-align:top;"|MP-VVO
|style="background-color: white;vertical-align:top;" rowspan="2"|AVVV
|-
|style="background-color: white;vertical-align:top;"|Receiving reply proposal dispense request
|style="background-color: white;vertical-align:top;"|MP-VVS
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.134-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.324_20220207000000 Proposal medication agreement (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.325-2022-02-07T000000.html Sending proposal medication agreement]
|style="background-color: white;vertical-align:top;"|MP-VMS
|style="background-color: white;vertical-align:top;" rowspan="2"|VMA with or without height, weight
|-
|style="background-color: white;vertical-align:top;"|Receiving proposal medication agreement
|style="background-color: white;vertical-align:top;"|MP-VMO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.134-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.372_20220302000000 Reply proposal medicationagreement (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.373-2022-03-02T000000.html Sending reply proposal medicationagreement]
|style="background-color: white;vertical-align:top;"|MP-VMO
|style="background-color: white;vertical-align:top;" rowspan="2"|AVMA
|-
|style="background-color: white;vertical-align:top;"|Receiving reply proposal medicationagreement
|style="background-color: white;vertical-align:top;"|MP-VMS
|}Table 4 Overview transaction groups

[[#Medication process|Chapter 2]] lists for each process only the relevant transactions per process step. The transaction groups are not included in this. Table 4 includes all transaction groups and transactions.

=Functionality=
This chapter describes indications for the functionality of an information system.

==Filtering medication from 2nd/3rd line (all information systems)==
An institution makes all its medication data (all building blocks) available. Not all data may be relevant for the receiving health professionals. Receiving information systems may therefore include a filter depending on the requirements of the specific health professional/patient. The list below (Table 5) includes medication types of which it has been determined that medicatietoediening during admission is relevant for health professionals outside the institution.

{{anchor|tabel 5}}
{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| ATC-code
! style="text-align:left;"| Name
|-
| style="background-color: white;vertical-align:top;"|L01
| style="background-color: white;vertical-align:top;"|Cytostatics
|-
| style="background-color: white;vertical-align:top;"| L03AX03
| style="background-color: white;vertical-align:top;"|BCG vaccine, urology
|-
| style="background-color: white;vertical-align:top;"|L04AA23; L04AA25; L04AA26; L04AA33; L04AA34; L04AB; L04AC
| style="background-color: white;vertical-align:top;"|Immunosuppressive agents
|-
| style="background-color: white;vertical-align:top;"|B03AC; B03XA; B06AC
| style="background-color: white;vertical-align:top;"|Iron, erythropoietin, drugs used in angioedema
|-
| style="background-color: white;vertical-align:top;"|G03GA; G03GB02
| style="background-color: white;vertical-align:top;"|Gonadotropins (HCG, etc.), clomiphene
|-
| style="background-color: white;vertical-align:top;"|H01CA; H01CC; L02AE04
| style="background-color: white;vertical-align:top;"|Gonadorelin, hypothalamic hormones, triptorelin
|-
| style="background-color: white;vertical-align:top;"|J06; J07
| style="background-color: white;vertical-align:top;"|Immunoglobulins, vaccines
|-
| style="background-color: white;vertical-align:top;"|M03AX01
| style="background-color: white;vertical-align:top;"|Botulinum toxin
|-
| style="background-color: white;vertical-align:top;"|R03DX05
| style="background-color: white;vertical-align:top;"|Omalizumab
|-
| style="background-color: white;vertical-align:top;"|S01LA04; S01LA05; S01LA
| style="background-color: white;vertical-align:top;"|OOphthalmological antineovascularisation agents
|}Table 5 Types of clinical medication relevant for external health professionals

==Making medication data available (all information systems)==
All proprietary medication data may be made available when the patient has given his consent (in accordance with applicable laws and regulations). Data received from third parties copied (health care provider/patient) in one’s own information system and marked as ‘copy’, are not made available. The only exception is the transaction Medicatiegegevens (Medication data) PUSH and PULL and Medication overview PUSH and PULL, in which case third parties’ building blocks are made available on the condition that they include the original identification label (see also [[#Inference rules|paragraph 5.6]]).

==Notification date or dispense date (pharmacist information system)==
The notification date and the actual dispense date may be recorded in the medicatieverstrekking. When a verstrekkingsverzoek is processed immediately and the patient picks up the medication that same day, both dates will be the same. When the patient picks up the medication one or several days later, different dates must be entered. The dispense date is the date on which the medicatieverstrekking has actually taken place. The request date is the time at which a pharmacy records an intended medicatieverstrekking. When medication is dispensed on several occasions as part of the same verstrekkingsverzoek (for example, when prescriptions are split), each medicatieverstrekking has its own request date. When an automated dispense system is being used, the dispense date is the time at which the patient picks up the medication from the dispense system. Until this time is available in the PIS, the time at which the medication is deposited in the automated dispense system may be used. See also [[#Request and dispense|paragraph 4.2.5]].

==Updating after system malfunction==
After a system malfunction, the prescriber’s information system needs to determine whether changes have been made to medicatieafspraken. For use cases and rationale, see [[#Discontinuation of medication by third parties|paragraph 4.1.26]] and [[#Two PRKs in a single medicamenteuze behandeling|paragraph 4.1.27]].

==Construction for ‘once every 36 hours’ interval==
When the dosing instruction reads ‘1 tablet every 36 hours’, this may normally be recorded in one medicatieafspraak (dose: 1 tablet, interval: 36 hours). However, when a information system does not go beyond an interval of, for example, 24 hours, another solution needs to be found.

''Variation 1:''
Making use of an ‘as needed’ instruction with the criterion: ‘36 hours have passed since the last medicatietoediening’. This does however come with a certain amount of freedom that may not be desirable.

''Variation 2:''
A repeating dosing schedule can be created, with alternation between administration in the morning, administration in the evening and a day without medicatietoediening:
Repeat period: 3 days
Dosage instruction
Sequence number: 1
Dosage duration: 1 day
Dosage
Dose per administration: 1 tablet
Administration time: 9 am (per example, this could also be a part of the day)
Sequence number: 2
Dosage duration: 1 day
Dosage
Dose per administration: 1 tablet
Administration time: 9 pm (per example, this could also be a part of the day)

If it is not technically possible to choose a 36 hours interval, variation 2 applies.

==EVS / HIS processing Regulation processing==
The prescribing information system is informed by the pharmacist of all dispensings and changes in toedieningsafspraken through the transaction Afhandeling voorschrift (settlement prescription). This handling must be automatically processed in the prescribing information system. The prescriber only assesses the toedieningsafspraken and does not have to assess all the dispensings (verstrekkingen).

==Examples dosages==
See [[mp:V9.1 Voorbeelden doseringen|examples dosages 9.1.0]] (both functional and technical effect in HL7v3 CDA and in FHIR)

==Medicatiegebruik: use indicator, according to agreement indicator, stop type, period of use and dosing instructions==
{| class="wikitable"
|-
|style="text-align:center;" |Situation || 1. Medication is/will be used during period of use according to agreement|| 2. Medication is/will be used during period of use, but not according to agreement || 3. Contrary to agreement, medication is/will not be used during period of use || 4. Medication is/will not be used during period of use, which is according to agreement || 5.Medication is used during period of use but it is unknown if this is according to agreement (selfmedication)
|-
! Use indicator (is this product being used) !! Yes!! Yes !! No !! N/A (because this would lead to a double negative otherwise) !! Yes
|-
! According to agreement indicator !! No!! No !! No!! Yes!! -
|-
! Stoptype!! N/A!! N/A!! Discontinuation or Stop !! Definitve of Temporary !! N/A
|-
| || || || Stoptype depends if agreement is being stoped or dicontinued || Stoptype in acoordance with stop-agreement ||
|-
! Period of use!! In accordance with MA or TA !! Max. 2 out of 3 !! Max. 2 out of 3 !! Max. 2 out of 3 !! Max. 2 out of 3
|-
|style="text-align:right;" | start date || The time at which the medicatiegebruik was started. ||The time at which the deviating medicatiegebruik was/will be started. . || Contrary to agreement, medication is/will not be used during period of use || The time at which the medicatiegebruik was/will be discontinued. || The time at which the medicatiegebruik was started.
|-
|style="text-align:right;" | duration of medicatiegebruik|| The intended duration of medicatiegebruik. || The intended duration of deviating medicatiegebruik. || The (intended) duration of non-use||The (intended) duration of non-use. || The intended duration of medicatiegebruik.
|-
|style="text-align:right;" | end date || The time at which the period of use ends (or has ended or will end). || The time at which the period of deviating use ends (or has ended or will end). || The time at which the use was/will be resumed (or is intended to resume).|| The time at which the medicatiegebruik was/will be resumed (or is intended to resume). || The time at which the period of use ends (or has ended or will end).
|-
! Dosing instructions!! In accordance with MA or TA!! Required!! N/A !! N/A!! Required
|-
| || Medication was/will be used during the period of use according to the agreement, therefore dosage is known. || Medication was/will not be used according to the agreement, the actual dosage used must be communicated. || The medication was/will not be used, there is no dosage. || The medication was/will not be used, there is no dosage. || Dosage tha the patient has agreed upon himself
|}
'''Examples:''' 
'''Situation 1a: Medication is / is used during the period of use according to agreement''' 
Patient has been prescribed Ferrofumarate for anemia. Dosage is 1 tablet 3 times a day half a hour before eating, with a start date of June 4, 2018 and no end date. 
On 10 June, the patient registers the medicatiegebruik for the past period (from 4 to 10 June). 
{| class="wikitable"
|-
! Situation 1a !!
|-
| Medication || FERROFUMARATE 100MG TABLET
|-
| Use indicator || Yes
|-
| According to indicator agreement || Yes
|-
| Stoptype || Not applicable
|-
| Start date|| 4 June 2018
|-
| End date || 10 June 2018
|-
| Dosing instruction || ''According agreement''
|}

'''Situation 1b: Medication is / is used during the period of use according to agreement''' 
Patient has been prescribed Ferrofumarate for anemia. Dosage is 1 tablet 3 times a day half an hour before eating, with a start date of June 4, 2018 and no end date. 
On 10 June, the patient registers the medicatiegebruik for the past period (from 4 to 10 June).
 
{| class="wikitable"
|-
! Situation 1b !!
|-
| Medication || FERROFUMARATE 100MG TABLET
|-
| Use indicator || Yes
|-
| According to indicator agreement || Yes
|-
| Stoptype || Not applicable
|-
| Start date|| 4 June 2018
|-
| End date || -
|-
| Dosing instruction || ''According agreement''
|}

'''Situation 2: Medication is / is used during the period of use, but not by agreement''' 
Patient has been prescribed Ferrofumarate for anemia. Dosage is 1 tablet 3 times a day half an hour before eating, with a start date of June 4, 2018 and no end date. 
The patient is on the road a lot during the day and forgets for a week to take the medicines for lunch. However, the tablets are taken in the morning and evening before eating. 
{| class="wikitable"
|-
! Situation 2 !!
|-
| Medication || FERROFUMARATE 100MG TABLET
|-
| Use indicator || Yes
|-
| According to indicator agreement || No
|-
| Stoptype || Not applicable
|-
| Start date|| 11 June
|-
| End date || 15 June
|-
| Dosing instruction || 1 tablet 2 times a day
|}
'''Situation 3: Contrary to the agreement, the medication is / is not used during the period of use''' 
Patient has been prescribed Ferrofumarate for anemia. Dosage is 1 tablet 3 times a day half an hour before eating, with a start date of June 4, 2018 and no end date. 
The patient goes on vacation for a long weekend and finds out too late that the medication is not packed. The patient will not take the tablets for the next few days and wants to record it. 
{| class="wikitable"
|-
! Situation 3 !!
|-
| Medication || FERROFUMARATE 100MG TABLET
|-
| Use indicator || No
|-
| According to indicator agreement || No
|-
| Stoptype || Temporary
|-
| Start date|| 20 July
|-
| End date || 23 July
|-
| Dosing instruction || Not applicable
|}
'''Situation 4: Medication is / is not used during the period of use and that is also by agreement''' 
Patient has been prescribed Ferrofumarate for anemia. Dosage is 1 tablet 3 times a day half an hour before eating, with a start date of June 4, 2018. 
On August 12, it turns out after checking that there is no longer anemia and the doctor stops the medication. The patient wants to register that she has stopped taking the medication and registers this herself on August 15. 
{| class="wikitable"
|-
! Situation 4 !!
|-
| Medication || FERROFUMARATE 100MG TABLET
|-
| Use indicator || No
|-
| According to indicator agreement || Yes
|-
| Stoptype || Definite
|-
| Start date|| 12 August 2018
|-
| End date || -
|-
| Dosing instruction || Not applicable
|}
'''Situation 5: Medication is used during the period of use, but it is unknown whether this is by appointment or there is no appointment (self-care medication)''' 
Patient has the flu and he takes paracetamol 500 mg from the local drug store for fever and pain. He has been taking 4 to 6 tablets a day for four days and expects to do this for another three days. He registers this on August 12 as medicatiegebruik. 
{| class="wikitable"
|-
! Situation 5 !!
|-
| Medication || Paracetemol 500mg
|-
| Use indicator || Yes
|-
| According to indicator agreement || -
|-
| Stoptype || Not applicable
|-
| Start date|| 9 August 2018
|-
| End date || 7 days
|-
| Dosing instruction || 4 to 6 tablets a day
|}

==Implementation of medication distribution system (GDS) fields==

===Background===
More and more patients are receiving their medication through Individualized Distribution Forms (In dutch geindividualiseerde distributie vorm), with the pharmacist providing patients overview and organization of their drugs by preparing them in separate compartment units. This form of delivery took off when the Medicines Act in 2007 stipulated that in healthcare institutions without a pharmacy, the medication should be individually registered for the patients.

It is important for health professionals to know whether a patient is using GDS. In 2018, an analysis was conducted (under the direction of Z-Index, with health professionals) of the bottlenecks and wishes regarding the recording of a patient using GDS. Overall, it has emerged that it is desirable to be able to see whether a patient is using GDS at both the medication level and the patient level. For details see next paragraph.

The directions below provide guidance on how the Medication Process can support these needs.

===Wishes of care providers===
In 2018, an inventory was made with the user councils of Z-Index about the wishes regarding the recording and exchange of GDS. Below is an overview of these wishes. 

'''Who'''
*All healthcare parties (from prescriber to operator)
'''What'''
*Determines which pharmacy delivers
*Pharmacy must know whether the change applies to the current roll or not
*Important for stopping previous medication at the start of GDS
*Evaluation of GDS patients for health insurer
*Other logistics processes towards home care / informal care

'''Why'''
*Determines which pharmacy delivers
*Pharmacy must know whether the change applies to the current roll or not
*Important for stopping previous medication at the start of GDS
*Evaluation of GDS patients for health insurer
*Other logistics processes towards home care / informal care

'''When'''
*When starting medication, in a pharmacy already before notification of prescription
*When transferring 1st / 2nd line
*When changing (incl. Stopping) medication
*When changing CiO data

'''Where'''
*When working in the patient's file, it should be clear that this characteristic applies to the patient concerned. This can be different for each type of care provider (patient file, medication file). The wish of public pharmacists is that they always have this characteristic available for a specific patient.
*On medication overview

===Data elements Medication process===
The building blocks for the Medication Process have the following fields that play a role in recording GDS. 

{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| '''Buildingblock '''
! style="text-align:left;"| '''Data-element nr'''
! style="text-align:left;"| '''Description'''
! style="text-align:left;"| '''Type of content '''
|-
|style="background-color: white;vertical-align:top;"| Medicatieafspraak
|style="background-color: white;vertical-align:top;"|23283
|style="background-color: white;vertical-align:top;"|Additional information
|style="background-color: white;vertical-align:top;"|Additional information contains a list of details of the medicatieafsrpaak that are important for pharmacovigilance monitoring and completion by a pharmacist.

For example: "change in GDS immediately"..
|-
|style="background-color: white;vertical-align:top;"| Verstrekkingsverzoek
|style="background-color: white;vertical-align:top;"|22759
|style="background-color: white;vertical-align:top;"|Supplementary wishes
|style="background-color: white;vertical-align:top;"|Logistical instructions important for the completion of the dispensing request by the pharmacist.

For example: "do not include in GDS"
|-
|style="background-color: white;vertical-align:top;" rowspan="4"| Verstrekking
|style="background-color: white;vertical-align:top;"|20927
|style="background-color: white;vertical-align:top;"|Distribution form
|style="background-color: white;vertical-align:top;"|Distribution form.

For example: GDS
|-
|style="background-color: white;vertical-align:top;"|20924
|style="background-color: white;vertical-align:top;"|Consumption period
|style="background-color: white;vertical-align:top;"|Stock for this duration
|-
|style="background-color: white;vertical-align:top;"|22500
|style="background-color: white;vertical-align:top;"|Registration date
|style="background-color: white;vertical-align:top;"|The registration date is the time when a pharmacist records an intended dispensing
|-
|style="background-color: white;vertical-align:top;"|20272
|style="background-color: white;vertical-align:top;"|Date
|style="background-color: white;vertical-align:top;"|The time of the dispensing. The date when the medicine is made available to the patient
|}

===Application of data elements to support desired functionality for GDS patients===
====Recording that someone uses GDS====
When working in the patient's file it is important to see that someone is using GDS. This applies to the pharmacy that supplies the GDS, as well as other care providers of the patient. It is therefore important that this information can be communicated with and shown to other health professionals.

As long as there is no patient characteristic with which GDS can be registered, it can be decided to derive this information from the GDS data that have been recorded with the medication. A possible handle for this is the fact that medication is included in the distribution module together with the Distribution form field in the verstrekking (dispensing).
*Step 1: if medication is included in the distribution module: fill in the Distribution form field in the verstrekking with 'GDS'.
*Step 2: Based on the Distribution form field, deduce that a patient is using GDS. The fact that a patient has a dispensing (vertrekking) where the Distribution form field is filled with "GDS" indicates that the patient is using GDS. This dispensing can be a private dipsenisn, or it can be dispensed from another pharmacy (insofar as this data is collected and recorded in such a way that the contents of the Distribution form field are reusable). The fact that a patient uses GDS can then be shown when working in the medication file or the patient file. In consultation with end users, it should be further determined where and how this is shown.

====Recording why someone uses GDS====
Users have indicated that it is desirable to be able to record why someone uses GDS. There are currently no structural fields available for this.

====Record for medication that this must be in the GDS====
Prescribers want to be able to indicate whether or not a medicine should be provided via GDS. This can be done as follows:
*Verstrekkingsverzoek, Additional wishes (aanvullende wensen) field. The code list for this field contains the item "not in GDS". This code list is thesaurus 2051 from file 902 in the G-Standard.

====Establishing / exchanging the duration of a medication roll====
The duration of the medication roll can be determined on the basis of the "duration of use" of the provision: the "duration of use" indicates the duration of a medication roll.

====Establishing / exchanging whether a change in the medication should be effective immediately or not====
It is desirable that a prescriber can indicate whether changes in the medication should be implemented immediately or that they can wait until the next roll change. The handles for this are as follows:
*Medicatieafspraak, Additional information (aanvullende informatie) field. The code list for this field contains two items that relate to changes in the GDS, namely "Change in GDS immediately" and "Change in GDS per roll change". This code list is thesaurus 2050 from file 902 in the G-Standard.
*It is important that the prescriber has insight into the duration of the roll and how long it will take before the current medication roll is used up. This can be deduced from:
**The verstrekking, period of use (verbruiksduur), see above. For this, the prescribing system must have access to the verstrekking data of previous verstrekkingen (dispensings).
**Verstrekking (dispensing), Registration Date (aanschrijfdatum) or Date (datum) field (or if this field is not filled but the Registration date field is, then the registration date.; if both are filled, Date is preferred). Based on this date and the consumption period, it is possible to calculate the date on which the current medication roll is used.

=Reflections=
==Prescription without specified recipient (ambulatory)==
In this paragraph, the term ‘prescription’ is used to indicate the message through which a patient may pick up a medicinal product from a supplier. A prescription contains a medicatieafspraak and a verstrekkingsverzoek.

In the Netherlands it is customary to digitally send prescriptions to a receiving pharmacy instead of having to collect prescriptions. This requires that the pharmacy is already known. 

This paragraph considers whether more flexibility can be achieved in the logistical processing of prescriptions, without canceling out current advantages. This paragraph may be seen as a long-term vision that we aim towards.

===Basic principles===
When considering how to achieve flexibility in the processing of prescriptions, these basic principles have been formulated:
*The patient is free to choose where prescriptions are handled
*The current option for sending prescriptions remains possible.
*The information system must reuse the same functionality as much as possible.
*A prescription may only be dispensed once.
Since the methodology described below uses the existing method of sending prescriptions, the same legal rules and regulations apply to prescription validity. All discussions about electronic signatures are equally applicable to the current method of communicating prescriptions.

===Details===
A patient may choose from 3 options:
#A prescription is always sent to the same regular pharmacist.
#The patient indicates each time where the prescription has to be sent.
#The patient does not give any indication, and goes to a pharmacy which subsequently requests and processes the prescription.
Options 1 and 2 require a patient portal, in which the patient indicates his preference. For option 2, a patient may define a preferred pharmacy which would be at the top of the selection screen when the patient is asked where the prescription must be sent. If the patient does not give any indication, option 3 can be the only procedure.

The method partly uses a concept called “publish and subscribe”.

It is important that the pharmacist explains this principle to his customers.

===Work process===
A physician decides to create a prescription for a patient. This may be during a consultation or even when repeat prescriptions are requested. The physician registers the prescription in his prescribing system (EPS). The physician does not need to consider the pharmacy as the patient handles this through the portal.

After approval of the prescription, a central prescription index is updated. The EVS automatically sends a notification to this prescription registry to facilitate this. Here, the prescription index is seen as a separate registry with the data type “prescriptions”. It is always possible to consider whether or not this can be merged at a later time. Initially, atomic registration in the registry is being considered. However, at a later date, consideration could be given as to whether categorical registration would be sufficient.

It is important to realise that currently only a notification is given when a prescription is ready. After all, the prescription is still in the EVS database with the status “is available”. There is no prescription message yet.

The prescription registry knows from the patient’s preference settings what needs to be done with the notification:
#With the option ‘send to regular pharmacy’, a notification is sent to the subscription holder of the patient with the message that a prescription can be retrieved.
#With the option ‘patient indicates pharmacy’, the prescription registry sends a notification (e.g., SMS) to the patient. The prescription registry then waits until the patient uses a smartphone app or the patient portal to indicate to which pharmacy the notification should be sent.
#With the option ‘no indication’, the prescription registry does nothing. The patient does not have a regular subscription holder.

===Processing by pharmacy===
A receiving pharmacy can deduce from the transmitted notification signal (data type) that it refers to an open prescription. The signal also identifies who the patient is as well as the source of the prescription.

For patients who selected option 3 (no indication), the process starts now. The patient identifies himself and notifies the pharmacy that a prescription is ready at a certain institution. The pharmacist may look in the prescription registry to find out which EVS is involved.

The pharmacy information system asks the EVS source system to send the prescription of the respective patient. Since this is a request without medical content, it may even be submitted at lower trust levels.

===Sending via EVS===
If an EVS receives a request for “sending outstanding prescriptions”, the EVS will check whether prescriptions are indeed outstanding. This prevents a prescription from being retrieved several times. The address of the pharmacy is entered and the prepared prescription message is finally created. The prescription message is sent to the respective pharmacy.

If the prescription has been retrieved before, an error message is sent to the retrieving pharmacy announcing that the prescription is no longer available.

'''Sending prescriptions is the standard process and already customary for pushing prescriptions.''' The advantage of this is that the receiving pharmacy only needs to maintain one method for processing received prescriptions. It is noted again that the same legal rules and regulations continue to apply.

After sending a prescription, the EVS also sends a notification to the prescription registry to remove the entry of the outstanding prescription. This indicates that the respective prescription can no longer be retrieved.

{{anchor|figuur 11}}
[[Bestand:Interactiediagramvoorschrijven.png|Figuur 11 Interactiediagram Ongeadresseerd voorschrijven]]

=Appendix References=

==General references==
{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| Author(s)
! style="text-align:left;"| Title
! style="text-align:left;"| Version
! style="text-align:left;"| Date (consultation)
! style="text-align:left;"| Source
! style="text-align:left;"| Organisation
|-
| style="background-color: white;vertical-align:top;"| NHG, KNMP, Z-index
| style="background-color: white;vertical-align:top;"| Building blocks of the medication process
| style="background-color: white;vertical-align:top;"| 2014
| style="background-color: white;vertical-align:top;"| Augustus 2015
| style="background-color: white;vertical-align:top;"| https://www.nhg.org/bouwstenen
| style="background-color: white;vertical-align:top;"| NHG, KNMP, Z-index
|-
| style="background-color: white;vertical-align:top;"| ActiZ, KNMP, NVZA a.o
| style="background-color: white;vertical-align:top;"| Safe principles in the medication chain
| style="background-color: white;vertical-align:top;"| 2014
| style="background-color: white;vertical-align:top;"| August 2015
| style="background-color: white;vertical-align:top;"| http://www.knmp.nl/patiëntenzorg/samenwerking/brochure-veilige-principes-in-de-medicatieketen
| style="background-color: white;vertical-align:top;"| ActiZ, KNMP, NVZA a.o.
|-
| style="background-color: white;vertical-align:top;"| Miscellaneous
| style="background-color: white;vertical-align:top;"| Guideline on exchange of medication data in the medication chain
| style="background-color: white;vertical-align:top;"| 25 April 2008
| style="background-color: white;vertical-align:top;"| August 2015
| style="background-color: white;vertical-align:top;"| Website KNMP
| style="background-color: white;vertical-align:top;"| Miscellaneous
|-
| style="background-color: white;vertical-align:top;"| Paul Geels
| style="background-color: white;vertical-align:top;"| Assessment of medication self-management (BEM) in care homes, Institute for Responsible Medication Use
| style="background-color: white;vertical-align:top;"| February 2009
| style="background-color: white;vertical-align:top;"|
| style="background-color: white;vertical-align:top;"| http://www.instellingsapotheek.nl/downloads/rapporten/beoordeling_eigen_beheer_van_medicatie_in_verzorgingshuizen.pdf
| style="background-color: white;vertical-align:top;"| Institute for responsible medicatiegebruik
|-
| style="background-color: white;vertical-align:top;"| ActiZ
| style="background-color: white;vertical-align:top;"| Safety in the medication chain
| style="background-color: white;vertical-align:top;"| March 2012
| style="background-color: white;vertical-align:top;"|
| style="background-color: white;vertical-align:top;"| https://www.knmp.nl/downloads/brochure-veiligheid-in-de-medicatieketen.pdf
| style="background-color: white;vertical-align:top;"| ActiZ, Miscellaneous
|-
| style="background-color: white;vertical-align:top;"| KNMG
| style="background-color: white;vertical-align:top;"| Guideline on electronic prescription
| style="background-color: white;vertical-align:top;"| September 2013
| style="background-color: white;vertical-align:top;"|
| style="background-color: white;vertical-align:top;"| Website KNMG
| style="background-color: white;vertical-align:top;"| KNMG
|}

==Qualification scripts==
[[mp:Vdraft Kwalificatie|Qualification scripts]]

=Attachment: Document history=

{{anchor|tabel 6}}
{| class="wikitable" "cellpadding="10"
!style="text-align:left;"|Version
!style="text-align:left;"|Date
!style="text-align:left;"|Description
|-
| style="background-color: white;"| 0.95
| style="background-color: white;"| 15 July 2016
| style="background-color: white;"| Pilot version
|-
| style="background-color: white;"| 0.96
| style="background-color: white;"| 1 December 2016
| style="background-color: white;"| Paragraph 2.4 Process: Administer was adapted and C6: Sending/receiving administration data was added as a result.
|-
| style="background-color: white;vertical-align:top;"| 0.97
| style="background-color: white;vertical-align:top;"| 22 December 2016
| style="background-color: white;"| Paragraph 2.4, 4.3.1 review remarks incorporated. 
Paragraph 4.2.11 text made more precise.
|-
| style="background-color: white;vertical-align:top;"| 9.0.2
| style="background-color: white;vertical-align:top;"| 18 June 2017
| style="background-color: white;"| Conversion of the document to wiki.
|-
| style="background-color: white;vertical-align:top;"| 9.0.4
| style="background-color: white;vertical-align:top;"| September 2017
| style="background-color: white;vertical-align:top;"|
*Processed [[mp:V9.0_Ontwerpbeslissingen|Design decisions]] in functional design. This means the design decisions have become obsolete. The current Functional Design is now leading.
*Par. 1.3.1. Definitions of building blocks have been adapted and the abbreviation for medicatieverstrekking has changed to MVE.
*Par. 1.3.3. Medicamenteuze behandeling is now based on PRK, rewritten and introduced PT as well as added text on handling parallel MAs.
*Par. 1.3.4. New data model diagram, various relations added and adapted on the basis of design decisions.
*Par. 1.5 Glossary removed.
*C2 Medication process diagram changed: MO added to actively making available by the user; lines in swimlane of administrator/use adapted.
*C4.1 New use cases added: Do not dispense before, Two PRKs in a single medicamenteuze behandeling, Discontinuation of medication by third parties, Creating a medicatieafspraak after the fact, Parallel medicatieafspraken.
*C4.2 New use case: Discontinuing medication in a GDS; modified use case: Request, dispense and not picked up.
*C5: Differences between medication profile and medication overview were described; inference rules adapted on the basis of the new design decisions.
*Where necessary, references from ART-DECOR to FD C7 were added.
*Various grammatical and minor textual changes.
|-
| style="background-color: white;vertical-align:top;"| 9.0.5
| style="background-color: white;vertical-align:top;"| January 2018
| style="background-color: white;vertical-align:top;"|
*Terminology: Stop-MA was changed to stop-MA in accordance with earlier project agreements (in Dutch different terminology Stop changed to staken)
*Par. 1.3.4 Addition to indicate that MA may also refer to a building block under a different medicamenteuze behandeling.
*Par. 4.1.22 Discharge was adapted because outpatient medication that was discontinued earlier may be started again at discharge.
*Par. 4.1.26 Discontinuation of medication by third parties was adapted.
*Par. 4.1.27 Two PRKs under a single medicamenteuze behandeling.
*Par. 2.2.5.3 Medication discontinuation agreement was adapted to clarify the impact on previously entered future medicatieafspraken.
*Footnote 3 Provisional and final medication order clarified and use case Provisional and final medication order (par. 4.1.31) added.
*Par. 4.1.30 Use case Single use added.
*Paragraphs 2.2.4, 2.2.5.2, 2.2.5.4, 4.1.16, 4.1.22 were adapted for substitution. In case of substitution, a medicamenteuze behandeling is not temporarily halted but effectively discontinued. The substitution is started under a new medicamenteuze behandeling.
*Paragraph 4.1.33 Missing digital medicatieafspraak at admission was added.
*C5 Medication overview was adapted with a reference to a new content page with functional elaboration.
*Paragraph 7.10 Medicatiegebruik: use indicator, according to agreement indicator and stop type added as agreed.
*C6 Building blocks of medication overview were changed to MA, TA and MGB.
*Figure 2 Colours in data model in accordance with Figure 1.
*Various abbreviations explained.
|-
| style="background-color: white;vertical-align:top;"| 9.0.6
| style="background-color: white;vertical-align:top;"| May 2018
| style="background-color: white;vertical-align:top;"|
*Addition to proposed verstrekkingsverzoek and addition of reply proposed verstrekkingsverzoek
*Chapter 6 table 4 addition of links to ART-DECOR transactions
*Removed: chapter about LSP
*Par. 7.10 table was extended with period of use and dosing instructions
*Various paragraphs were made more precise
*Addition of the property ‘third parties’ building block’ for MA, TA and MGB in medication overview
|-
| style="background-color: white;vertical-align:top;"| 9.0.7
| style="background-color: white;vertical-align:top;"| December 2018
| style="background-color: white;vertical-align:top;"|
*Par 1.3.3. MBH at HPK level in case of 'non medicines' without a PRK level
*Par 1.3.3. MBH for medicines without PRK (magistrals, infusions, etc.)
*Par 2.2.5.5. Changing medication: Technical stop-ma: appointment date for stop-ma and new ma must be the same. Change on MA that has already been stopped explained (no extra Stop-ma needed)
*Par 2.2.6. Added: VV under MA of someone else
*Par 4.2.15. Explanation GDS supplier supplies different HPK
*Par 7.10: Medication use indicator, according to appointment indicator, stop type, period of use and dosing instruction: table adapted and examples added
*Par 4.1.34: Own articles explanation added
*Chapter 5: example medication overview inserted in this wiki page instead of a separate wiki page (to simplify searching within the FO).
*Various textual tightening / improvements
|-
| style="background-color: white;vertical-align:top;"| 9.0.7
| style="background-color: white;vertical-align:top;"| July 2019
| style="background-color: white;vertical-align:top;"|
*Removed examples of specific infrastructures
|-
| style="background-color: white;vertical-align:top;"| 9.1.0
| style="background-color: white;vertical-align:top;"| 29 January 2020
| style="background-color: white;vertical-align:top;"|
*Stop textual adjustments
*Par 7.11 added: Implementation of medication distribution system (GDS) fields
*[https://bits.nictiz.nl/browse/MP-85 BITS MP-85], [https://bits.nictiz.nl/browse/MP-93 BITS MP-93], [https://bits.nictiz.nl/browse/MP-122 BITS MP-122] Use cases added (Register usage based on verstrekkingn, Verstrekkingsverzoek with number of repetitions, Prescribe non-drug)
*Chapter 4: Added pictures of use cases
*Renal function value in the prescription
*[https://bits.nictiz.nl/browse/MP-48 BITS MP-48] Medication Overview: Par 5.7 added 'Fields not to be shown'
*Various textual specifications/ improvements, including [https://bits.nictiz.nl/browse/MP-131 o.a. BITS MP-131]
*Paragraph 'Unaddressed prescription' moved to chapter 'Considerations'
*[https://bits.nictiz.nl/browse/MP-151 BITS MP-151] Removed draft TA creation process
*[https://bits.nictiz.nl/browse/MP-128 BITS MP-128] Par 4.1.8: Explanation 'Medical necessity'
*[https://bits.nictiz.nl/browse/MP-129 BITS MP-129] Par 4.1.35: Use case added
|-
| style="background-color: white;vertical-align:top;"| 9.1.0
| style="background-color: white;vertical-align:top;"| September 2020
| style="background-color: white;vertical-align:top;"|
*[https://bits.nictiz.nl/browse/MP-167 BITS MP-167] FO Translated in English
|-
| style="background-color: white;vertical-align:top;"| 9 2.0.0 bèta
| style="background-color: white;vertical-align:top;"| 01 october 2021
| style="background-color: white;vertical-align:top;"| all changes see: *[https://informatiestandaarden.nictiz.nl/wiki/mp:V9_2.0.beta_releasenotes Releasenotes]
|}

=Appendix: Figures and tables=
[[#figuur 1|Figure 1 Building blocks - overview]] 
[[#figuur 2|Figure 2 Building blocks - coherence]] 
[[#figuur 3|Figure 3 Activity diagram - Medication process in general]] 
[[#figuur 4|Figure 4 Process steps and transactions - medication verification]] 
[[#figuur 5|Figure 5 Process steps and transactions - prescribing]] 
[[#figuur 6|Figure 6 Process steps and transactions - make available]] 
[[#figuur 7|Figure 7 Process steps and transactions - administer]] 
[[#figuur 8|Figure 8 Process steps and transactions - use]] 
[[#figuur 9|Figure 9 Example effective period]] 
[[#figuur 10|Figure 10 Overview of systems and system roles]] 
[[#figuur 11|Figure 11 Interaction diagram Prescribing without address]] 

[[#tabel 1|Table 1 Building blocks - description]] 
[[#tabel 2|Table 2 Informing versus (Active) making available]] 
[[#tabel 3|Table 3 Overview of system roles]] 
[[#tabel 4|Table 4 Overview of transaction groups]] 
[[#tabel 5|Table 5 Types of clinical medication relevant for outpatient care providers]]

mp:V2.0.0 Ontwerp medicatieproces 9 ENG

2022-04-04T14:50:56Z

Petra van Deursen: /* Discharge */

{{IssueBox|'''ATTENTION: This is a development version. For an overview of current documentation for Medication Process see here [[Landingspagina_Medicatieproces]].'''}}

__NUMBEREDHEADINGS__
{{DISPLAYTITLE:DEVELOPMENT PAGE Functional Design Medication Process 9 version 2.0.0 English version}}
[[Bestand:ENG.jpg|50px]] [[mp:V2.0.0_Ontwerp_medicatieproces_9_ENG|This is the ENG version]] 
[[Bestand:NL.jpg|50px]] [[mp:V2.0.0_Ontwerp_medicatieproces_9|Klik hier voor de NL versie]] 
For an overview of relevant wiki pages for Medication Process see [[Landingspagina_Medicatieproces]]

=Introduction=

This document is the functional design for the Medication Process Information Standard (in Dutch: 'Informatiestandaard Medicatieproces'). It provides a general description as well as a description of specific practical situations. The recording and exchange of information is described for specific situations using actors (people, information systems) and transactions (which information is exchanged when).

Target groups for this document:
*Health professionals
*Information analysts and architects
*Software suppliers

==Scope and vision==

This document has been produced within the Medication process program. The Medication process program aims first to take away existing obstacles in the medication process, while taking into account current legislation and the possibility of obtaining tangible results in the foreseeable future.

One of the main obstacle entails the lack of insight in the actual medication use of patients. This is partly due to the fact that therapeutic and logistical information are often mixed, which results in the medication history becoming unclear. The following distinction between therapy and logistics exists:

* '''Therapy''' covers the medical side. This includes medication (and treatment) agreements, as well as the corresponding support and implementation. Therapeutic intention, (actual) medication use, self-medication and pharmacotherapy are also covered by the term ‘therapy’ as it is defined in this document.
* '''Logistics''' covers the physical flow of medicinal products, including requests, planning and dispense. This also includes medication supply and the medication use.

The program has taken into account current legislation and feasibility within the foreseeable future. The vision goes beyond the scope of the Medication process program and lays the foundations for a situation where a dispense request is no longer required. The ultimate objective is for prescribers to only have to concern themselves with the therapeutic side (which medicinal product, which strength, which dosage, when to start, etc.). It will no longer be necessary to create a dispense request. Instead, the prescriber will make medication agreements directly with the patient. Based on these medication agreements, the pharmacist will take care of the logistical process, eliminating the need for a dispense request altogether. Because of legislation this is not (yet) possible. The Medication process program does however take the first necessary step in the right direction.

==Reading guide==

The following paragraph introduces the main building blocks and the terminology used in this document. Detailed descriptions of the various processes (prescribe, dispense, administer, medication use) are given in [[#Medication process|Chapter 2]]. The purpose of the descriptions is to clarify how healthcare processes function in an ideal situation; which process steps are needed; which actors are participating; which information applies and which moments of exchange exist. The process descriptions follow a fixed format:

*Current situation  This paragraph describes the relevant differences between the current situation and the desired situation ('soll') in accordance with this information standard. Any obstacles will be described here.
*Process description with the paragraphs:
** ''Precondition'' The conditions that must be met before the process is started.
** ''Trigger Event'' The event that starts the process.
** ''One or more process steps'' Description of part of the process.
**''Post-condition'' The conditions that are met after the process steps have been carried out.
**''Use cases'' List of use cases associated with a specific subprocess. The use cases are detailed in [[#Description of use cases|Chapter 4]].
**''Information sytems and transaction groups'', This paragraph describes the information systems, system roles, transactions and transaction groups related to the process steps. All information concerning information systems and transaction groups is also included in [[#Information systems and transactions|Chapter 6]].

[[#Domain-specific handling of the medication process|Chapter 3]] describes a number of domain-specific interpretations of the medication process, for instance those of the thrombosis service and those related to service observation services in an ambulatory situation. [[#Description of use cases|Chapter 4]] describes several use cases in more detail. The practical situations are derived from general medical practice in a large number of cases but are illustrative of similar situations in a different setting. The use cases are classified according to subprocess, as indicated in [[#Medication process|Chapter 2]]. 
[[#Medication overview and inference rules|Chapter 5]] describes how a medication profile can be constructed from the different building blocks. [[#Information systems and transactions|Chapter 6]] includes an overview of all information systems, system roles, transactions and transaction groups. Guidelines for the functionality of the various information systems have been detailed in [[#Functionality|Chapter 7]].

In this document, Dutch terminology is used for the medication building blocks: 'medicatieafspraak' (MA), 'verstrekkingsverzoek' (VV), 'toedieningsafspraak' (TA), 'medicatieverstrekking' (MVE), 'medicatietoediening' (MTD), 'medicatiegebruik' (MGB), 'medicatieverbruik' (MVB) (see Table 1 for the English translations). Dutch terminology for the medication building blocks is consistently used even in translated documents, as a translation may not refer to exactly the same entity.

==Introduction of relevant terms==

===Therapeutic and logistical building blocks===

The use cases include a description of the process and the data elements associated with it. Related data elements are grouped together in a Clinical Information Model (CIM) or Clinical Building Block (CBB) (in Dutch: 'zorginformatiebouwsteen' - zib). The dataset details the data elements of which these zibs consist; data elements may have been added to the zibs in keeping with the clinical context and care process. The data set includes the complete set of definitions of the data elements of the building blocks. The building blocks together with their data elements can be used in various scenarios for arranging/modelling healthcare applications or for defining interfaces for data exchange.

The different building blocks are shown in the figure below. They have been ordered according to process and subprocesses, and according to therapy versus logistics.

{{anchor|figuur 1}}
[[Bestand:Figuur 1 Bouwstenen - overzicht.png|Figuur 1 Buildingblocks- overview]]

The table below provides a description of the building blocks. The four additional concepts ‘voorstel medicatieafspraak’ (therapeutic), 'antwoord voorstel medicatieafspraak' (therapeutic), ‘voorstel verstrekkingsverzoek’ (logistics) and ‘antwoord voorstel-verstrekkingsverzoek’ (logistics) are also described.

{{anchor|tabel 1}}
{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| Building blocks in Dutch
! style="text-align:left;"| Abbr. in Dutch
! style="text-align:left;"| Building blocks in English
! style="text-align:left;"| Description
|-
| style="background-color: white;vertical-align:top;"| Medicatieafspraak
| style="background-color: white;vertical-align:top;"| MA
| style="background-color: white;vertical-align:top;"| Medication agreement
| style="background-color: white;vertical-align:top;"| 'Medicatieafspraak' is the prescriber’s proposal for medication use with which the patient agrees. An agreement to discontinue medication is also a 'medicatieafspraak'<ref>This document only uses the term medicatieafspraak, which therefore also indicates the clinical equivalent provisional medication order</ref>.
|-
| style="background-color: white;vertical-align:top;"| Wisselend doseerschema
| style="background-color: white;vertical-align:top;"| WDS
| style="background-color: white;vertical-align:top;"| Variable dosing regimen
| style="background-color: white;vertical-align:top;"| 'Wisselend doseerschema' contains the dosing instruction as composed by an (external) prescriber. In the 'wisselend doseerschema' the element 'instructions for use' from the 'medicatieafspraak' is further specified. The 'wisselend doseerschema' can be adapted without changing the 'medicatieafspraak'.
|-
| style="background-color: white;vertical-align:top;"| Verstrekkingsverzoek
| style="background-color: white;vertical-align:top;"| VV
| style="background-color: white;vertical-align:top;"| Dispense request
| style="background-color: white;vertical-align:top;"| 'Verstrekkingsverzoek' is the request from a prescriber to a pharmacist to supply the patient with one or more medicinal products in support of the current 'medicatieafspraak'/'medicatieafspraken'<ref>The verstrekkingsverzoek building block is not applicable in the clinical setting. Dispensing medication is handled in different ways in the clinical setting. Replenishment of, for example, a department’s supply is not considered a medicatieverstrekking, but rather an extension of the pharmacist’s stock. Medicatieverstrekking only takes place when the link between the medication and patient has been made. In clinical situations, administration often takes place immediately afterwards.</ref>.
|-
| style="background-color: white;vertical-align:top;"| Toedieningsafspraak
| style="background-color: white;vertical-align:top;"| TA
| style="background-color: white;vertical-align:top;"| Administration agreement
| style="background-color: white;vertical-align:top;"| 'Toedieningsafspraak' contains the instructions for medication use (or administration) from the pharmacist to the patient (or his representative or administrator), adding to the 'medicatieafspraak'<ref name="MO">A provisional medication order, as it is used in hospitals, is both the request from the physician to the administrator to administer medication to the patient as a verstrekkingsverzoek to the pharmacist to ensure that the medication is available for the administrator. This last part corresponds to the medicatieafspraak and the verstrekkingsverzoek from the first line. In addition, the hospital pharmacist usually carries out a validation of the administration request (this creates the final medication order which is called a toedieningsafspraak here). The provisional medication order is therefore not the same as a proposal from, for example, from a nurse on the basis of a protocol that has not yet been approved by a physician. </ref>.
|-
| style="background-color: white;vertical-align:top;"| Medicatieverstrekking
| style="background-color: white;vertical-align:top;"| MVE
| style="background-color: white;vertical-align:top;"| Medication dispense
| style="background-color: white;vertical-align:top;"| 'Medicatieverstrekking' is the provision of a supply of medicinal product to the patient or his administrator or representative.
|-
| style="background-color: white;vertical-align:top;"| Medicatietoediening
| style="background-color: white;vertical-align:top;"| MTD
| style="background-color: white;vertical-align:top;"| Medication administration
| style="background-color: white;vertical-align:top;"| 'Medicatietoediening' is the registration of the individual administrations of the medicinal product to the patient by the person who administers them (such as a nurse or the patient himself) in relation to the agreements made.
|-
| style="background-color: white;vertical-align:top;"| Medicatiegebruik
| style="background-color: white;vertical-align:top;"| MGB
| style="background-color: white;vertical-align:top;"| Medication use
| style="background-color: white;vertical-align:top;"| 'Medicatiegebruik' is a statement about historical, current or intended use of a medicinal product<ref>Use may have been preceded by medicatietoediening. Registration of medicatiegebruik, for example after medicatietoediening of rabies vaccinations or infusion is not obvious.</ref>.
|-
| style="background-color: white;vertical-align:top;"| Medicatieverbruik
| style="background-color: white;vertical-align:top;"| MVB
| style="background-color: white;vertical-align:top;"| Medication consumption
| style="background-color: white;vertical-align:top;"| 'Medicatieverbruik' is the logistical perspective on medication use. It describes how long a (partial) supply of medicinal products has lasted or will last for a patient<ref>From one-time to a certain period. The building block ‘Medicatieverbruik’ has not been detailed any further in this information standard.</ref>.
|-
| style="background-color: white;vertical-align:top;"| Voorstel medicatieafspraak
| style="background-color: white;vertical-align:top;"| VMA
| style="background-color: white;vertical-align:top;"| Proposed medication agreement
| style="background-color: white;vertical-align:top;"| 'Voorstel medicatieafspraak' is a recommendation or request from the pharmacist, prescriber or the administer to the presciber of the MA about the agreed upon or to be agreed upon medication.The recommendation request may include discontinuing, starting or modifying medication. The patient is unable to send a VMA.
|-
| style="background-color: white;vertical-align:top;"| Antwoord voorstel medicatieafspraak
| style="background-color: white;vertical-align:top;"| AVMA
| style="background-color: white;vertical-align:top;"| Reply proposed medication agreement
| style="background-color: white;vertical-align:top;"| 'Antwoord voorstel medicatieafspraak' is a replay from the prescriber to the 'voorstel medicatieafspraak'.
|-
| style="background-color: white;vertical-align:top;"| Voorstel verstrekkingsverzoek
| style="background-color: white;vertical-align:top;"| VVV
| style="background-color: white;vertical-align:top;"| Proposed dispense request
| style="background-color: white;vertical-align:top;"| 'Voorstel verstrekkingsverzoek' is a proposal from the pharmacist to the prescriber to approve one or more 'medicatieverstrekking'/'medicatieverstrekkingen' in support of the current 'medicatieafspraak'/'medicatieafspraken'. This is comparable with the current situation of submitting the authorization form or combined prescription or submitting a repeat prescription for signing. The patient may also submit a 'voorstel verstrekkingsverzoek' to the prescriber.
|-
| style="background-color: white;vertical-align:top;"| Antwoord voorstel‐verstrekkingsverzoek
| style="background-color: white;vertical-align:top;"| AVVV
| style="background-color: white;vertical-align:top;"| Reply proposed dispense request
| style="background-color: white;vertical-align:top;"| 'Antwoord voorstel-verstrekkingsverzoek' is a reply from the prescriber to the 'voorstel verstrekkingsverzoek'.
|}Table 1 Building blocks – description

===Medication overview===
See [[#Medication overview and inference rules|Chapter 5]] for more information about these overviews, the applicable building blocks and how a medication profile/current overview can be compiled.

==='Medicamenteuze behandeling'===

The different medication building blocks represent steps in the medication process, from prescribing a medicinal product (MA and/or VV), followed by dispensing it (TA and/or MVE) up to and including administering and using the medicinal product. The model is designed in such a way that therapeutic building blocks and logistical building blocks are separated from each other. 
'''Scope''' 
In order to be able to give a name to the interdependence of the medication building blocks, the concept of ‘pharmaceutical treatment’ (in Dutch: 'medicamenteuze behandeling' - MBH) is introduced. 
:'''Medicamenteuze behandeling' is a '''technical concept''' in the information standard. Its purpose is'': 
:#''To unambiguously identify the set of interdependent medication building blocks, and'' 
:#''To apply rules to it to unambiguously determine the present situation''. 
The functional application of the concept of 'medicamenteuze behandeling' is as follows: 
*Medication (or 'medicamenteuze behandeling') is started by creating a first MA as part of a new 'medicamenteuze behandeling'.
*Medication (or 'medicamenteuze behandeling') is discontinued by creating a new MA within the same 'medicamenteuze behandeling' (stop-MA).
*Medication (or 'medicamenteuze behandeling') is modified by:
#Discontinuing the existing MA and
#Creating a new changed MA as part of the same 'medicamenteuze behandeling'. The starting date of this new MA may also be in the future.

Prescribing a new medicinal product always results in a new MA. An MA is always related to a single 'medicamenteuze behandeling'. For the time being, the PRK level (Prescription Code from the G-standard) of the medicinal product determines whether the MA belongs to a new or an existing 'medicamenteuze behandeling'. This may be extended to the SNK level (Substance Name Code from the G-standard) in the future, which would mean that changes in strength or between medicinal products from the same group no longer lead to a new 'medicamenteuze behandeling'. A detailed description can be found in [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5 Process step: Creating a medicatieafspraak]].

Exceptions:
*Products without PRK (a non-medicine such as crutches or bandages). In this case the HPK level (Trade Product Code from the G-standard) determines if the MA will lead to a new 'medicamenteuze behandeling'.
*Medication without PRK (magistrals often consist of several substances that are not covered by the same PRK, these substances are included separately as ingredients in the MA). Every magisterial or adaptation to it falls under a 'medicamenteuze behandeling'.
*Own articles without PRK (articles listed in the internal information system under 90 million numbers stored, such as half tablets, commonly used magistrals). Any item or adaptation to this falls under a 'medicamenteuze behandeling'.
*Intravenous (IV) therapy (still be selected).

'''Examples''' 
Five examples illustrate the scope of a 'medicamenteuze behandeling': 
*Diazepam, 5 mg, 1 tablet 4x daily is changed to diazepam, 5 mg, 1 tablet 3x daily. The PRK level of both products is the same, they are both part of the same 'medicamenteuze behandeling'.
*Paroxetin tablet, 10 mg, 1 tablet 1x daily, is changed to paroxetin tablet, 20 mg, 1 tablet 1x daily. This is a modification of an MA with two different medicinal products at the PRK level. This change requires that the first 'medicamenteuze behandeling' is discontinued and a new 'medicamenteuze behandeling' is started.
*A gastroprotective drugs has been agreed upon in a treatment with prednisone: prednisone and gastroprotective drugs are two different medicinal products, which are used parallel to each other and their use can be modified and discontinued independently of each other. This means they are not part of the same 'medicamenteuze behandeling'.
*Switching from a beta blocker to an ACE inhibitor means a new PRK and this is achieved by discontinuing the 'medicamenteuze behandeling' of the beta blocker and starting a new 'medicamenteuze behandeling' for the ACE inhibitor.
*When there is no PRK and the composition of the medicinal products in the MA changes (any change in the ingredients), the existing 'medicamenteuze behandeling' is discontinued and a new 'medicamenteuze behandeling' is started. This applies, for example, to extemporaneous preparations, drips and proprietary products. 

'''Creation of a 'medicamenteuze behandeling'''' 
A schematic overview of how a 'medicamenteuze behandeling' (MBH) is set up can be seen in the figure below. When a new building block (MA, TA, VV, MVE, MTD or MGB) is created, a check is first performed to determine whether this is a new medication or if there already is a current building block with the same product. This applies to all building blocks, both proprietary or third parties’. In most information systems, the user of the information system will indicate that he wants to change one of the existing medication building blocks or wants to introduce new medication. In that case, it is easy to find out whether there already is a 'medicamenteuze behandeling' that includes the building block.
*If there is no existing building block for this medication, a new building block with a new 'medicamenteuze behandeling' is created.
*If there is an existing building block with a 'medicamenteuze behandeling', the user of the information system is asked whether the new building block and the existing building block belong to the same treatment. When this is the case, the same 'medicamenteuze behandeling' will be used. When the building blocks do not belong to the same treatment, a new 'medicamenteuze behandeling' will be created.
{{anchor|figuur 2}}
[[Bestand:Ontstaan_MBH.png|500px|Figuur 2 Ontstaan medicamenteuze behandeling]]

 
'''Parallel occurrence of 'medicatieafspraken'''' 
Within a 'medicamenteuze behandeling', several MAs may be active simultaneously. These are all MAs that are valid ('current') at this time or that will become valid in the future. In principle, only one MA is valid at any time in a 'medicamenteuze behandeling'. However, there are a number of situations where parallel MAs are conceivable:
#The same medicinal product, but a different strength, where the total strength should essentially be prescribed in one agreement.
#Related (different) medicinal products that are given together, but that should be considered as a whole when evaluating treatment.
#Technical omissions in information systems. For example, in the case of complicated dosing schedules or combination drips. 

'''Situation 1''' can be resolved by prescribing at a higher level (SNK). G-standard/Z-Index is working on this, but it is not yet possible. Until that time, 1 or more products can be combined in the same MA by entering the products as ingredients. This is comparable to extemporaneous preparations. However, the instructions for use for all these products must be identical.<ref>In practice several MAs (with different PRKs) are often combined into a single product instead of a single MA with underlying the composition.</ref> 
'''Situation 2''' is solved in different ways in different information systems, each with their own grouping mechanisms. It concerns the correlation between different medicamenteuze behandelingmedicamenteuze behandelings. The information standard does not provide a universal grouping mechanism. 
'''Situation 3''' is the only situation in which parallel medicatieafspraken are permitted under one medicamenteuze behandelingmedicamenteuze behandeling. Complex phasing-in and phasing-out schedules and combination drips may be included in one medicatieafspraak, but not all information systems support this. For those information systems, it is permitted to create parallel medicatieafspraken within a single medicamenteuze behandelingmedicamenteuze behandeling. 

===Correlation between building blocks and 'medicamenteuze behandeling'===

The figure below shows the correlations between building blocks and the MBH. The relations between building blocks and the MBH as well as the relations between the building blocks themselves are described as follows:
*Building blocks belong to a single MBH. An MBH includes at least one MA and may include zero or more of the following building blocks VV, WDS, TA, MVE, MGB and MTD. Unless, for example, self-medication has been recorded with MGB or in case a paper prescription has been submitted, a drug treatment can exist without an MA, but with MGB or TA. A MBH will never cease to exist, but it may no longer be effective when there are no current building blocks linked to it. A VMA, AVMA, VVV and AVVV are not yet part of a MBH as these are still a draft/proposal that may or may not lead to a final MA or VV linked to an MBH. A VMA may lead to zero (if the recommendation is not followed), one or more MAs and a VVV may lead to zero (if the proposal is not honoured), one or more VVs.
*An MBH may also only have a stop-MA in addition to, for example, an MGB building block. For example, in the event that a health professional asks a patient to stop using free available medicine (self-care medication or over-the-counter (OTC) medication). The health professional records the use of the self-care medication in an MGB building block and discontinues the use by creating a stop-MA (stop-MA belonging to the same MBH).
*An MA may refer to the previous MA or a TA or MGB on which it is based. This may also be an MA, TA or MGB that belongs to another MBH. It is possible that no digital MA is available (e.g. paper prescription [[#Paper prescription|paragraph 4.1.17]]). This MA must then be created. This MA may refer to the TA or MGB. A pharmacist is never the source of an MA but he may have a copy.
*In principle, only one MA is valid at any one time in an MBH. Only when there are technical omissions in information systems, for example in case of complicated dosing schedules or combination drips, parallel MAs are allowed (see also the previous section).
*An MA is supported by zero (if there is still enough supply or if no medication dispense is needed), one or more (when there is, for example, continuous medication) VVs.
*A VV is based on the current MA and any existing corresponding TA in an MBH. There may be several.
*A VV refers to one or more MAs (for example, in the case of an interim dosage increase, a VV can be made that replenishes the supply for the existing MA and also starts the supply for the future MA).
*A VV may result in zero (for example when the patient does not pick up the medication) to several MVEs.
*A MA may result in zero, one or multiple WDS's.
*Multiple (possibly parallel) TAs may be based on the same MA (for example, when a pharmacist switches to a different commercial product or when the medicinal product is supplied as two or more medicinal products with different strengths, with the total strength remaining the same). When a paper prescription is submitted and the MA and the VV are not available in digital form, there is a TA without an MA.
*An MA does not always have to lead to a TA, for example when no VV is required with a short use MA, when the patient still has sufficient stock.
*A TA is supported by zero (when there is enough supply), one or more MVEs.
*An MVE is based on a MA (and TA) and, in an ambulatory situation, on a VV. The exception are over-the-counter (OTC/self-medication) sales for the purpose of self-care medication: these have no MAs and no VVs. Self-care medication provided by the pharmacist may be recorded by that pharmacist as a TA with MVE, or as MGB by a random health professional or by the patient himself.
*An MVE may support multiple TAs.
*An MA or a TA may be followed by a new MA or TA. This may be the case when existing medication is changed (modification of MA and/or TA) or when MGB is discontinued (stop-MA/TA).

{{anchor|figuur 2}}
[[Image: Datamodel_MP92.PNG|800px|Figuur 2 - Datamodel Medicatieproces]]

===Informing and (actively) making available===
[[#Medication process|Chapter 2]] describes the medication process. This includes process steps labelled ‘Inform’ or ‘(actively) make available’. The table below includes a detailed description of the reason for this. [[#Medication process|Chapter 2]] further elaborates on situations in which information is actively sent or made available. 

{{anchor|tabel 2}}
{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| Term
! style="text-align:left;"| Toelichting
|-
| style="background-color: white;vertical-align:top;"| Inform
| style="background-color: white;vertical-align:top;"| ‘Inform’ means sending an order or request addressed to another actor. This is a so-called ‘push’ of information: the actor sends the information specifically to recipient. This may be by means of
*An electronic message via a digital network,
*Paper (for example by giving a prescription intended for a pharmacist to the patient),
*A fax message,
*A combination of the above options.
|-
| style="background-color: white;vertical-align:top;"| (Actively) make available
| style="background-color: white;vertical-align:top;"| The health professional (actively) makes information available to another actor. This process step concerns:
*Actively sending or informing (‘push’) as described above or
*Automatically making information available to health professionals and/or the patient when they request it on the basis of prior permission or
*A combination of both previous bullets. 

Data are always made available. Additionally, the health professional has the option to specifically inform fellow health professionals and/or the patient at any time during the process. In consultation with the patient, data can be sent to a health professional of his choice (inform).
|} Table 2 Informing versus (actively) making available

The technical mechanism (‘pull’, ‘publish and subscribe’, ‘push’, etc.) used to (actively) make data available, is infrastructure-dependent and is therefore not detailed in this document. 

The Royal Dutch Medical Association (KNMG) describes in its publication 'Van wet naar praktijk: implementatie van de WGBO Deel 4. Toegang tot patiëntengegevens' [From law to practice: implementation of the Dutch Medical Treatment Contracts Act Part 4. Access to patient data] when there is implicit consent and explicit consent. The exchange described in this information standard is subject to current legal frameworks and guidelines concerning consent and opt-in and these are therefore not explicitly described.

==Legend/Explanation==
A manual for this Nictiz wiki documentation can be found at: 
http://informatiestandaarden.nictiz.nl/wiki/Handleiding_Wiki_documentatie 
It also includes a legend for the various figures that appear in this document.

=Medication process=
This chapter describes the medication process in relation to the building blocks for first-line, second-line and third-line health care. The process is fundamentally the same in each case. The main difference is which pharmacy supplies the medication: a community pharmacy (including an outpatient pharmacy) or a hospital pharmacy. Another difference is that in an ambulatory setting a VV is required for the supply of medicinal products. This is not required in a hospital setting: the (hospital) pharmacist ensures that the medicinal products are available as long as the MA continues.

The medication process is a cyclical process consisting of prescribing, dispensing, administering and using medication. The process starts when the patient/client visits a health professional/healthcare provider (general practitioner, hospital or other institution) for a treatment with a medicinal product and ends when the medication is no longer needed. The process is depicted in Figure 4. The yellow bar indicates the medication verification process, green prescription, purple dispensing, and orange administration and medication use. The blue bar indicates receipt or retrieval of data made available. This may occur in any of the subprocesses and is described in more detail in the continuation of this chapter for the relevant subprocesses.
The following paragraphs describe the medication verification, prescription, dispensing, administration and medication use processes.

{{anchor|figuur 3}}
[[Bestand:ActiviteitendiagramMP.png|1600px|Figuur 3 Activity diagram - medication process]]
 

==Process: medication verification==
Prior to the prescription process, the patient’s actual medication use is determined. This is done<ref>The patient may also verify his own medication. He then records medication use, see [[#Recording of medication use by the patient|paragraph 2.5.4.1]].</ref>:
*In the GP practice by the general practitioner during a consultation,
*At the GP service, A&E department or mental health crisis service by the triage specialist or the treating physician, as soon as possible, upon arrival or admission,
*In case of clinical or day admission at a hospital or other institutions by for example the nursing staff, pharmacy assistent or outpatient/hospital pharmacist,
*In case of outpatient consultation by for example nursing staff, doctors’ assistant or the treating physician.

===Current situation===
*In the current situation, patients or family/informal caregivers are asked which medication they are using. The patient is sometimes unable to answer this. Family/informal caregivers (if known) are also often unable to answer this. If this is the case, the physician will contact the general practitioner or the pharmacist to find out the medication. This is difficult outside office hours and during weekends.

===Precondition===
The patient comes in for a consultation/an outpatient consultation or is admitted (in the future).

===Trigger event===
*Outpatient setting: consultation of and/or prescription to outpatients and patients residing in another healthcare institution<ref>This is about patients from a nursing home or a mental health institution who are going to the outpatient clinic of a hospital.</ref>. In this case, medication verification often occurs during treatment assessment (see [[#Process step: Evaluating a (pharmaceutical) treatment|paragraph 2.2.4)]].
*Clinical setting: preparation of patient admission.

===Process===

The health professional collects the medication data from various sources, which may include:
*Patient’s own story,
*Dispense overviews from pharmacies,
*Digitally available medication data from healthcare providers or personal health records (PGO),
*Medication brought in by the patient,
*If necessary, information by telephone from the patient’s own pharmacist or general practitioner. 

The health professional verifies the medication together with the patient and records the verified medication as MGB, incl. self medication. This results in an updated medication profile; see also [[#Inference rules|paragraph 5.6]]. 

In practice, medication verification will lead to recording of MGB, only when it proves clinically relevant followed by updating the medication profile, particularly upon admission and discharge.
The medication overview and recorded data on MGB are made available to fellow health professionals and the patient, so that they can access the data. The medication overview may also be sent to a specific health professional.

===Post-condition===
The MGB is recorded and the resulting medication overview is made available if created. Medication data (MGB) are made available.

===Information systems and transaction groups===
[[#Information systems and transactions|Chapter 6]] includes an overview of all information systems, system roles, transactions, etc. Those most important for the medication verification process are included in the overview below.

{{anchor|figuur 4}}
[[Bestand:Medicatieverificatie.png|Figuur 4 Processtappen en transacties - medicatieverificatie]]

==Process: prescribe==
This paragraph describes the prescription process. This includes all prescribers, such as general practitioners, specialists, other physicians and specialist nurse prescribers. The prescription process consists of an evaluation of existing pharmaceutical treatment, if any. If necessary, an medication agreement is created and, only in an ambulatory situation, possibly a medication dispense request. Finally, the recorded data are (actively) made available. See [[#Appendix: General Diagram Medicatioprocess|chapter 12]] for a diagram depicting this process.

===Current situation===
The following deviations from the desired situation that are currently observed are:
*The logistical process often determines whether information is recorded (and certainly if it is communicated). Changes in medication or discontinuation are insufficiently recorded and/or communicated, resulting in, among other things, inaccurate monitoring, incorrect use and incorrect medication profiles.
The pharmacotherapeutic policy should be leading, not the logistical process as is currently the case.
*Since the therapeutic intention is not communicated to the pharmacist, it is not possible to deduce from the available data whether a request for a repeat prescription falls within that therapeutic intention. Because of this, use may be erroneously resumed or continued.
*If a change is not communicated, a request for a repeat prescription (through the pharmacist) may be based on outdated instructions for use. This can easily lead to errors.
*In an outpatient setting, medication agreements and/or medication dispense requests are usually not (electronically) sent to the pharmacist.

===Precondition===
There is a certain reason why a prescriber wants to start or evaluate/review a (pharamceutical) treatment.

===Trigger event===

The trigger event for the process is the start of a new MBH, the evaluation of an ongoing treatment, receipt of a VVV or VMA, receipt from a pharmacist of a prescription to be processed, or patient admission to or patient discharge from an institution.

===Process step: Evaluating a pharmaceutical treatment===

In order to evaluate treatment, an up-to-date overview of medication data is required. The medical file from the health professional is, where possible and if necessary, updated with data from external sources. In addition, the patient may be asked which medicinal products he is currently using. This medication use can be recorded by the health professional. If desired, a more extensive medication verification can be carried out (see [[#Process: medication verification|paragraph 2.1)]]. 

The treating physician<ref> This includes all health professionals who are authorised to prescribe: not only physicians, but also nurse practitioners and physician assistants, for example</ref> evaluates the (pharmaceutical) treatment and decides to:
*start a new MBH by creating an initial MA and/or
*continue, discontinue, temporarily halt or modify an existing MA (1 or more)<ref>In the case of substitution, the existing MA is discontinued and a new MA is created under a new MBH.</ref> and/or
*correct/cancel an existing MA and/or
*approve a VMA or a VVV (including a reply via the AVVV) 

These situations are further explained in the following paragraph. See also [[#Medicamenteuze behandeling|paragraph 1.3.3]] for more information on the concept of 'MBH'.
A new medication overview may be created to conclude the evaluation and the resulting new agreements and dispense requests (see [[#Inference rules|paragraph 5.6]]).

===Process step: Making a medication agreement===

When creating an MA, the following principle applies: each change is recorded in a new MA. Technically this means that the existing MA is terminated by entering an end date for the period of use and that a new MA is created with the desired changes<ref> Information systems keep an audit trail. In case of a change, the existing MA is discontinued (new record) and a new MA with the change is then created (new record). By using the records of the audit trail, no major adaptations are needed for discontinuing a MA in most information systems.</ref>.
 
An MA can also be created to begin at a point in the future. These MAs will receive a period of use with future starting date which is later than the date of the agreement itself. Any prior MA will end just before the starting date/time of the future one. In the period of use, only one effective date can be indicated (without duration or end date), this is the case with continuous medication. To avoid confusion between 'to/until/till' and 'up to and including', specifying the time is mandatory when entering an end date. In case of an 'up to and including' date (in case of an entire day), the time 23:59:59 applies.

Before the MA is made (actively) available, medication monitoring will occur in accordance with current guidelines. This is a part of this process step.

The next paragraphs describe the different situations in which an MA is created, i.e. initial medication agreement, continuing medication, discontinuing medication, temporarily halting medication or correcting/canceling a agreed medication. Information about 'MBH' is assumed to be known (see [[#Medicamenteuze behandeling|paragraph 1.3.3]]).

====New medication agreement====

A new MA is created at the start or modification of an MBH. When a new MBH is started, the prescriber should consider whether an existing MBH should be discontinued. The description in [[#Medicamenteuze behandeling|paragraph 1.3.3]] is based on the most common process from prescription to administering or using. In a transitional situation or in the absence of digital data, it is also technically possible that an MBH could start with a TA, for example. This might occur for instance when a pharmacist has not received the MA with the corresponding MBH in digital form. The pharmacist will consequently start a new MBH when the TA is created. This may also be the case for any other building block. A patient can, for example, start an MBH by recording MGB, without having the original MBH.

====Continuing medication====

In a number of cases the therapeutic intention of the prescriber remains the same and the MA does not have to be modified. For instance:
*In an ambulatory situation when, for a repeat prescription, only a new VV is needed, or
*At admission to an institution where the home medication continues to be used, whether or not in combination with self-medication. 

In both of these cases, the existing MA will not be adjusted. Should there be a change in PRK, e.g. at admission or discharge, the existing MBH will be discontinued by creating a stop-MA (see [[#Discontinuing medication|paragraph 2.2.5.3]]) and a new MBH is started (see [[#New medicatieafspraak|paragraph 2.2.5.1]]).

====Discontinuing medication====

Medication is discontinued by creating a new MA (stop-MA) within the same MBH. The reason for discontinuation is recorded in this MA. The medication may be discontinued immediately or in the future.
The new MA (stop-MA) is a copy of the existing MA with:
*The period of use as end date on which the MA ends (may also be in the future),
*An end date which has to be included in the text description of the instruction for use as well,
*Its own author,
*Its own agreement date,
*Stop type 'permanent',
*Reference to the specific MA that will be changed (future MAs will remain in place). It is not possible to create a stop-MA without referring to the MA that needs to be stopped except when the MA is not available. If there are only TA('s) or MGB('s) available in the MBH then a stop-MA has to be able to end these building blocks without referring to a MA,
*Its own reason for the MA to be discontinued (this does not apply to a stop-MA made as part of a modification. In that case, no reason is given). 

For an MA in which an end date is immediately agreed upon, e.g. in the case of a course of treatment, no additional stop-MA is needed. When an MA with an end date in the future is extended, it will be considered as a normal change (see [[#Changing medication|paragraph 2.2.5.5]]). A stop-MA always has the ‘permanent’ stop type, even if it is a stop-MA resulting from a change. In case of a change, the stop-MA is followed by a new MA. A stop-MA resulting from a change is not always relevant for end users. A stop-MA as a result of a change is also referred to as a technical stop-MA. The user interface must adequately support this. A prescriber will be less interested than a pharmacist who may need to adjust his logistical process because of the change.

====Temporarily halting and resuming medication====

Temporarily halting medication is the discontinuation of medication for a known or unknown period of time. Medication may be halted immediately or in the future. When medication use is temporarily halted, the medication still remains relevant for monitoring because the medication may be resumed in the future. Temporary substitution with another medicinal product is not considered an interruption but rather a discontinuation of the original medication and the start of a new pharmaceutical treatment with the substitute. Temporary halting medication is covered by two medication agreements<ref>This does not mean that end users actually have to create two agreements. A user friendly presentation by the information system is desired.</ref>: a MA (stop-MA) is created to stop medication use in accordance with guidelines for a stop-MA (see previous paragraph) and a new MA is created for resuming the medication (including the reason for this, if any). All MAs are part of the same MBH. The reason for the interruption is recorded in the stop-MA. The stop type for the stop-MA is 'temporary’.

====Changing medication====

Medication modifications may be related to:

:a) Dosage, 

:b) Strength of the medicinal product, 

:c) Method of administration, 

:d) Duration of treatment (such as an extension of the therapy). 

Switching to a completely different medicinal product is technically a switch to a different MBH (see also [[#Medicamenteuze behandeling|paragraph 1.3.3]]). In that case, the physician will discontinue the existing pharamceutical treatment (see [[#Discontinuing medication|paragraph 2.2.5.3]]) and start a new one (see [[#New medicatieafspraak|paragraph 2.2.5.1]]).
If the PRK stays the same, changes will be recorded under the same MBH. When a modification needs to be made, a technical stop-MA is created (see [[#Discontinuing medication|paragraph 2.2.5.3]]) and a new MA is made with the desired change. The appointment date of the technical stop-MA and the new MA must be always be the same. The reason for the modification is included in the new MA with a reference to the original MA, if possible. Modifications may take effect immediately or in the future. A technical stop-MA and the related new MA are made available simultaneously. In case of renewal of an MA of which the duration has already expired or the end date has already expired, then this is not seen as a change (a stop-MA on the already automatically stopped MA is unnecessary). In this case, a new MA under the same MBH can be made.

====Correcting/canceling a medication agreement<ref> Correcting/canceling administration agreements happens in the same way. XIS is a generic term for a random (health care) information system. PHR=personal health records.</ref>====

This paragraph describes correcting or canceling an MA when the prescriber has made an error. The error may have been discovered by the prescriber himself or by a fellow health professional.
For example, a physician who makes a typing error in the dosage of an MA: 10 inhalations, 2x daily, instead of 1 inhalation, 2x daily. If the MA has not yet been shared with other health professionals, the prescriber can personally correct that MA or delete (cancel) it from his own information system. If the MA has already been shared with other health professionals, the prescriber will mark the incorrect MA as ‘incorrect registration’ and he will then create a new MA under the same MBH with the correct information. The prescriber will actively inform the pharmacist and any fellow health professionals about both the cancelled and new MA and will make both available (see [[#Process step: (Actively) making available|paragraph 2.2.10]]).

====Stopping a prospective medication agreement====
This only concerns MA's that have their start date at some point in the future. For whatever reason a prescriber wants to end this prospective MA. The prescriber will not create a stop-MA in this scenario but cancels the MA instead. The prescriber cancels the MA by using the ‘canceled indicator’ field. The prescriber can only use the ‘canceled indicator’ when the start date of the MA is in the future. If the prescriber wants to end the prospective MA he/she changes the status of the MA to canceled with the indicator.

When the prescriber is not the initial creator of the original prospective MA the process works as follows. The prescriber creates a new MA with the canceled indicator activated. The ‘canceled MA’ will be sent to the original prescriber of the MA. The original prescriber will then cancel the original MA as well.

===Process step: Making a variable dosing regimen===
When a prescriber prescribes medication combined with a variable dosign regimen (WDS), the dosing of the medication can be adjusted by a (different) prescriber without having to adapt the medication agreement (MA). At the moment the variable dosing regimen is used for anticoagulants. When prescribing anticoagulants, the prescriber determines the therapeutic INR-range (International Normalized Ratio, a measure of blood clotting time), within which the treatment should take place.
The thrombosis service is responsible for drafting the viariable dosing regimen. The dosing regimen is composed by a prescriber (usually a thrombosis physician) in the building block variable dosing regimen (Wisselend doseerschema, WDS). The prescriber who made the medication agreement remains responsible for the dispense requests (VV). The thrombosis physician composes the WDS withing the agreed upon INR-range, the dosing regimen is usually based on a specific, measured INR-value. 
====Setting up a variable dosing regimen ====
The prescriber prescribes anticoagulants with a medication agreement (MA) and indicates:
* The medication (PRK) that is being prescribed to the patient. The medication in the variable dosing regimen is always the same as the medication in the MA.
* That for this medication a variable dosing regimen applies (this is added in the additional instructions). This also means there will be no dosage added in the medication agreement.
* The INR-range within which the treatment should take place. This information is included in a comment.

In order to bridge the period until the thrombosis service is involved and ready to take over the treatment, the original prescriber sets up a WDS for this first period (usually between 4 and 7 days). Usually a check-up date is agreed upon after the registration of the patient at the thrombosis service. During this check up the INR-value is measured. Based on the measured value and/ or the professional assessment of the thrombosis physician, a dosing regimen is composed that either changes of succeeds the previous WDS. From this moment on, the thrombosis service takes over the composition of the dosing regiment from the original prescriber.

''INR-value with the WDS'' 
The variable dosing regimen is often based on an INR-value. For other parties involved in the care for the patient, it’s important to be able to deduce the INR-value on which the WDS was based. That is the reason that the corresponding INR-value will be made available within the WDS. The INR-value is included in a comment within the WDS.

====Changing a variable dosing regimen ====
When the variable dosing regimen (WDS) is being used up until the stop date of the WDS, it can be replaced by a new WDS that succeeds it. The new WDS has a relation to the MA and the previous WDS.
Furthermore, it is possible to adjust the WDS before the stop date is reached. In that case, the information system stops the previous WDS, using a technical stop-WDS that is not visible to the user. The new WDS follows and has a reason for change and a relation to the MA and the previous WDS.
All changes related to the dosing regimen can be included in the WDS. Changes that concert the further treatment policy (e.g. the prescribed medication, the route of administration of the agreed upon INR-range) are to be made in the MA.

====Stopping a variable dosing regimen ====
There are various reasons that can cause the need to (temporarily) stop the use of anticoagulants. For example, in the event of a procedure of because there is temporary co-medication. Two kinds of situations can be distinguished. Depending on the situation and the assessment of the thrombosis physician one of twee methods is chosen:
#''(temporary) adjusting the policy'': The thrombosis physician can choose to temporarily adjust the dose for the anticoagulants to 0. For example, in the event of a planned procedure. In this case, the MA (and therefore the treatment with anticoagulants) and the TA will continue, but the dosage in the WDS is temporarily adjusted to 0. The MA will still be shown on the medication overview under ‘current medication’. In the event of such a temporary adjustment, only the WDS is changed. It is advised to include a reason for this change in the new WDS.
# ''(temporary) stopping the anticoagulants:'' The thrombosis physician (or another prescriber) can also choose to (temporarily) stop the treatment with anticoagulants. This means that the patient should not to take any anticoagulants anymore. In this case the thombosis physician (or another prescriber) creates a stop-MA (or sends a proposed MA to the original prescriber). Stopping the MA, also stops the underlying therapeutic building blocks (TA, WDS). The anticoagulant will be shown on the medication overview under ‘recently stopped medication’.
If, after a period of time, there is a need to restart the anticoagulant, the prescriber can do this by creating a new MA. The new MA can be created by the original prescriber, the thrombosis physician could also send a proposed MA. In many cases the thrombosis service would no longer be involved. And the MA is created by the original prescriber.

===Process step: Creating a medication dispense request===

A VV (besides an MA) only applies in an ambulatory situation. A VV may be made when the medication supply of the patient needs to be replenished. This does not have to coincide with an MA. At the start of a MBH for which the patient still has a sufficient supply at home from a previous agreement, a VV is not needed. When the dosage is reduced, the patient may also have a sufficient supply. In the case of a medicinal product that is used for a prolonged period of time (e.g. an antihypertensive drug), with a continuous MA (meaning a period of use with only a start date), several VVs may be made over time within the scope of this existing agreement.
Logistical and emergency instructions may be included in the VV, such as dispense location, request to not include in the GDS (medication distribution system, in Dutch: 'Geneesmiddel Distributie Systeem'), etc.

In the case of a VV, the quantity to be supplied can be stated or the consumption period. With a consumption period, the quantity must be clearly deducible from the dosing instruction of the MA. Note: a consumption period end date has a meaning other than the period of use end date from the MA and may be unequal.
*Period of medication use end date: date until which the pharmacist is allowed to to provide medication (and thereby provide sufficient supplies to the patient for use until that date).
*Period of use end date: date on which the patient must stop the medication (this can be equal to the consumption period end date or further in the future).

===Process step: Sending renal function value with prescription===

Renal function is important for certain medicines. The renal function value determines the choice of drug and/or drug dosage. It is legally stipulated that if a health professional has performed further research on a patient renal function, he should share abnormal renal function values with the appropriate pharmacist, appointed by the patient (article 6.10, 'regeling geneesmiddelenwet').

The renal function value is always sent with the prescription (using the building block laboratory test results) for medicines for which this is important (characteristic in the G-standard), so that the pharmacist can perform proper medication monitoring. The renal function value should not be older than 13 months, because with stable chronic renal impairment the renal function should be checked at least once a year. 1 month has been added to allow some backlog in practice.

If at the time of sending of an MA and/or VV no renal function is known, then the prescription policy remains unchanged. Sending the laboratory test result renal function value without an MA and/or VV is beyond the scope of this information standard.

===Process step: Sending height and weight values with prescription===

It is possible for the prescriber to send the body height and weight of the patient with the prescription. This is the height an weigh of the patient that the prescriber used for the medication agreement. Hence, it is possible for these values to diverge (be more accurate) from the height and weight values that are registered in the patient details. This could be necessary for prescribing for children or for medication where weight (e.g. coagulation medication) or height (e.g. oncolytic agents) are important factors to consider.

Body height and weight are separate building blocks. They can only be send together with the prescription and with the medication agreement. The information is not available on request.

===Process step: (Actively) making available===

This step involves information exchange. Information can be sent or made available with different intentions:

A. As an order for the pharmacist to dispense medication. The prescriber sends the MA to the pharmacist. In an ambulatory situation, the VV is also sent to the patient’s pharmacist. If the pharmacist is not known, this process step may also entail giving out a paper prescription and/or (reactively) making the data available (see C). When the pharmacist has filled the order, the prescriber will receive a notification (see [[#Information systems and transaction groups|paragraph 2.3.8]]). 

B. As an order for the pharmacist to implement a medication change (including stop-MA with stop type 'permanent' and 'temporary') that impacts or may impact current MVE by this pharmacist. A current MVE indicates an order (as in A) that has been accepted, but has not yet been completely filled. For example, when medication is still being dispensed or when a VV dictates that medication should be dispensed multiple times, but not all have taken place yet, e.g. with the GDS. 

C. Making medication data (MA, VV, MGB) and possibly the medication overview available to allow fellow health professionals and/or patients to access these later, possibly in combination with prescription without a specified recipient (see [[#Prescription without specified recipient (ambulatory)|paragraph 8.1]]). 

D. Actively sending (informing) medication data (one or more building blocks) to a specific health professional at the request of the patient when in the presence of this health professional or at discharge. 

In case of corrected data, the prescriber assesses who should be actively informed of this correction. This can be done, for example, by sending the new MA (option A or B above) or by means of a telephone consultation.
In an ambulatory setting (general practitioner/outpatient clinic) medication data are usually sent or made available directly; in a clinical setting, medication data is usually made available at discharge or interim leave from the institution.
This chapter deals with prescription with a specified recipient; [[#Prescription without specified recipient (ambulatory)|paragraph 7.5]] details prescription without a specified recipient.
See also [[#Informing and (actively) making available|paragraph 1.3.5]] for a further explanation on informing (situation A, B, D) and making available (situation C).

===Post-condition===
*A new MA may have been created (starting, changing or discontinuing medication)
*A VV may have been made (only outpatient)
*An order may have been sent to the pharmacist to carry out MVE
*An order may have been sent to the pharmacist to modify MVE
*Fellow health professionals and the patient have been informed or may inform themselves about the new medication data: MA, VV, MGB
*Fellow health professionals and the patient have been informed or may inform themselves about a medication overview.

===Information systems and transaction groups===

The prescriber and the pharmacist as well as other health professionals and users all make use of an information system, respectively, an electronic prescribing system (EVS), a pharmacist information system (AIS, incl. ZAIS), a XIS and a PGO<ref> XIS is a generic term for a random (health care) information system. PHR=personal health records.</ref>. These information systems each have different system roles which enable the exchange of data between these information systems as part of the prescription process.
[[#Information systems and transactions|Chapter 6]] includes an overview of all information systems, system roles, transactions, etc. The most important elements for the prescription process are included in the overview below.

{{anchor|figuur 5}}
[[Bestand:Uc Voorschrijven.png|Figuur 5 Processtappen en transacties - voorschrijven]]

===Use cases===
The following specific use cases have been elobarated:
*[[#Short-term medication|Short-term medication (paragraph 4.1.1)]]
*[[#Continuing medication|Continuing medication (paragraph 4.1.2)]]
*[[#Hard end date for period of medication use|Hard end date for period of medication use (paragraph 4.1.3)]]
*[[#Medication as needed|Medication as needed (paragraph 4.1.4)]]
*[[#Course of treatment as needed starting in future|Course of treatment as needed starting in future (paragraph 4.1.5)]]
*[[#Two dosages of the same medication at the same time|Two dosages of the same medication at the same time (paragraph 4.1.6)]]
*[[#The same medicinal product with different strengths at the same time|The same medicinal product with different strengths at the same time (paragraph 4.1.7)]]
*[[#Explanation in medicatieafspraak with deliberately chosen special characteristic|Explanation in medicatieafspraak with deliberately chosen special characteristic (paragraph 4.1.8)]]
*[[#New medicatieafspraak, no verstrekkingsverzoek|New medicatieafspraak, no verstrekkingsverzoek (paragraph 4.1.9)]]
*[[#New verstrekkingsverzoek under existing medicatieafspraak|New verstrekkingsverzoek under existing medicatieafspraak (paragraph 4.1.10)]]
*[[#Dosage change (sufficient supply)|Dosage change (sufficient supply) (paragraph 4.1.11)]]
*[[#Prescription no longer needed after first verstrekkingsverzoek|Prescription no longer needed after first verstrekkingsverzoek (paragraph 4.1.12)]]
*[[#Discontinuing medication|Discontinuing medication (paragraph 4.1.13)]]
*[[#Temporarily halting/resuming medication|Temporarily halting/resuming medication (paragraph 4.1.14)]]
*[[#Temporarily halting for an intervention|Temporarily halting for an intervention (paragraph 4.1.15)]]
*[[#Substitution|Substitution (paragraph 4.1.16)]]
*[[#Paper prescription|Paper prescription (paragraph 4.1.17)]]
*[[#Carrying out medication verification and evaluation of foreign or self-care medication|Carrying out medication verification and evaluation of foreign or self-care medication (paragraph 4.1.18)]]
*[[#Day treatment|Day treatment (paragraph 4.1.19)]]
*[[#Starting with medication before admission|Starting with medication before admission (paragraph 4.1.20)]]
*[[#Emergency admission|Emergency admission (paragraph 4.1.21)]]
*[[#Discharge|Discharge (paragraph 4.1.22)]]
*[[#Interim discharge|Interim discharge (paragraph 4.1.23)]]
*[[#Transfer to another institution|Transfer to another institution (paragraph 4.1.24)]]
*[[#Do not dispense before|Do not dispense before (paragraph 4.1.25)]]
*[[#Discontinuation of medication by third parties|Discontinuation of medication by third parties (paragraph 4.1.26)]]
*[[#Two PRKs in a single medicamenteuze behandeling|Two PRKs in a single medicamenteuze behandeling (paragraph 4.1.27)]]
*[[#Creating a medicatieafspraak after the fact|Creating a medicatieafspraak after the fact (paragraph 4.1.28)]]
*[[#Single medication use( medicatiegebruik)|Single medication use(medicatiegebruik)(paragraph 4.1.30)]]
*[[#Provisional and final medication order|Provisional and final medication order (paragraph 4.1.31)]]
*[[#Inadvertently ‘outstanding’ medication or 'orphans'|Inadvertently ‘outstanding’ medication or 'orphans' (paragraph 4.1.32)]]
*[[#Missing digital medicatieafspraak at admission|Missing digital medicatieafspraak at admission (paragraph 4.1.33)]]
*[[#Own articles (90 million numbers)|Own articles (90 million numbers) (paragraph 4.1.34)]]
*[[#Dosing with minimum interval|Dosing with minimum interval (paragraph 4.1.35)]]
*[[#Verstrekkingsverzoek with number of repetitions|Verstrekkingsverzoek with number of repetitions (paragraph 4.1.36)]]
*[[#Prescribing non-medicines|Prescribing non-medicines (paragraph 4.1.37)]]
*[[#Send renal function value in the prescription|Send renal function value in the prescription (paragraph 4.1.38)]]
*[[#Cancelling a prescription that was sent earlier|Cancelling a prescription that was sent earlier (paragraph 4.1.39)]]
*[[#Modification of someone else's medicatieafspraak|Modification of someone else's medicatieafspraak (paragraph 4.1.40)]]
*[[#Setting up a variable dosing regimen (WDS)|Setting up a variable dosing regimen (WDS) (paragraph 4.1.41)]]
*[[#Changing a variable dosing regimen (WDS) during period of use|Changing a variable dosing regimen (WDS) during period of use (paragraph 4.1.42)]]
*[[#Stopping medication with a variable dosing regimen (WDS)|Stopping medication with a variable dosing regimen (WDS) (paragraph 4.1.43)]]

==Process: dispense==

This paragraph describes the process of dispensing medication, including repeat prescriptions and GDS. This process encompasses all actions a pharmacist must take for the patient to not only receive a medicinal product, but to also receive the associated pharmaceutical care ensuring a safe and effective use of the medicinal product by the patient. The dispense process starts with providing pharmaceutical care. If necessary, a medication administration agreement will be made and if needed, medication is dispensed. Medication dispense (i.e. handing out a medicinal product) does not always take place. This may be the case when the medication agreement is changed (e.g., in case of dose reduction where the patient still has enough supply), when the medication is discontinued or, in an ambulatory situation, the medication is not picked up. When the MA and/or the VV do not comply (see [[#Process step: Informing the prescriber|paragraph 2.3.5]]), the prescriber will be informed. Finally, the recorded data are (actively) made available. See [[#Appendix: General Diagram Medicatioprocess|Chapter 12]] for a diagram of the dispense process.

Medication assessment is the process in which the physician and pharmacist consider all medication of the patient against the background of his condition, applicable treatment guidelines, the well-being of the patient, etc. Medication assessment is defined in this document as a combination of treatment evaluation (as described in the previous paragraphs) and pharmaceutical care. Depending on the findings, the previously described medication verification and prescription processes are followed, after which medication dispense takes place.

For the GDS, many pharmacists collaborate with another organisation that handles part of the pharmacists’ logistics. This then also requires data exchange with that party. Besides, not all medication can be included in the GDS packaging, which adds to the logistical complexity for the pharmacist. The internal logistics and communication between the pharmacist and his subcontractor(s) are outside the scope of this information standard. It has been established however that with the provision of the current building blocks and the underlying data elements, this logistical process can be adequately supported.

===Current situation===
The following deviations (from the desired situation that) are currently observed:
*In the current situation, in the case of GDS, the prescribing physician and other health professionals receive a large quantity of dispense messages. This becomes difficult to manage for these health professionals.
*In the current situation, in the case of GDS, pharmacists and general practitioners communicate via so-called authorisation lists. The pharmacist sends an overview of all the patient’s medication to the general practitioner for authorisation. This complicates matters for a general practitioner because he will need to verify all medication agreements. This should not be necessary, as most medication agreements/dispense requests have already been authorised. It would be much more efficient if the general practitioner only needs to authorise those medication agreements/disprense requests that have not been authorised yet, e.g. a new dispense request on the basis of an existing medication agreement.
*In the current situation, a locum pharmacy often does not inform the regular general practitioner and regular pharmacy when medication is dispensed.
*In the current situation, a proposal for a medication agreement may have been aligned with the prescriber over the phone and/or the pharmacist and prescriber have made an agreement about handling a warning from the medication monitoring system.
*The intention of the return message is not always clear: no distinction can be made in the return/delivery message between displaying a physical delivery and a transmission of information about a medication change.
*In the current situation, pharmacists sometimes register (and communicate) medication dispenses when they are preparing the medication for the patient instead of at the time when the medication is actually dispensed to the patient. This means that medication that has not been picked up, is sometimes erroneously registered as dispensed.

===Precondition===

An MA exists. In an ambulatory situation there may also be a corresponding VV.

===Trigger event===
The pharmacist starts the medication dispense process on the basis of one of the following events:
*Receipt of an order to make an MVE on the basis of a new MA. In an ambulatory situation, this order is always accompanied by a VV.
*Receipt of an order to process a new MA in an ongoing MVE.
*Receipt of a trigger (for example, via a patient or a repeat module of the pharmacist information system) for a repeat MVE under an existing MVE or a new VVV.

===Process step: Providing pharmaceutical care===
Pharmaceutical care is provided by a community, outpatient (i.e. at the hospital) or institutional pharmacy, depending on the health professional who has created the MA:
*MA, possibly with a VV from the general practitioner or specialist: care provided by a community or outpatient pharmacy.
*MA from specialists and other prescribers in hospitals/institutions: care provided by an institutional pharmacy or a community pharmacy that supplies the respective institution.
Medication monitoring is also part of pharmaceutical care.

Based on the received MA or a change in the situation of the patient, the pharmacist decides how to apply this by:
*Making one or more new TAs.
*Continuing, permanently discontinuing, temporarily halting or modifying an existing MA.
*Rejecting the MA.
*Proposing a new MA.
*Proposing a new medication dispense (VVV).

The last three situations are explained in the following paragraph. The first two situations are explained in [[#Process step: Creating a toedieningsafspraak|paragraph 2.3.6]].
In conclusion of provided pharmaceutical care, which may comprise new agreements and medication dispenses, a new up-to-date medication overview may be compiled and made available.

===Process step: Informing the prescriber===

There is a number of situations in which the pharmacist informs the prescriber, including:
*When a new or modified MA is needed
*When a new VV is needed
For more information about informing, see [[#Informing and (actively) making available|paragraph 1.3.5]].

A new or modified MA is needed:
*When a new TA cannot be created based on the received MA because the pharmacist suspects an error in the MA, or
*After a signal from the medication monitoring system as part of pharmaceutical care. The signal may indicate, for example, that the dosage should be lowered or increased, that it is advisable to select another medicinal product, that a product should be temporarily discontinued, that another additional product should be added, etc., or
*Based on medication use as reported by the patient during pharmaceutical care, or
*When the temporarily halted pharmaceutical treatment may be resumed.
*A TA is not yet created or modified in these situations.
Instead, the pharmacist starts by contacting the prescriber by phone, informing him of the suspected error and proposing an alternative. The pharmacist may also send a digital proposition called VMA to the prescriber. He recommends a specific MA in this proposal, together with the reason and arguments for that recommendation. The prescriber may approve the VMA and make it into a final MA (see also [[#Process step: Evaluating a (pharmaceutical) treatment|paragraph 2.2.4]]). 

A new VV is needed when the patient’s medication stock is depleted or nearly used and the treatment may need to be continued (request repeat prescription). The patient either requests a repeat MVE from the pharmacist or has signed up in the past for proactive repeat MVE and a notification signal is generated by the repeat module of the AIS when the patient requires new medication<ref> The patient may also request a repeat directly from the prescriber: see [[#2-5-6|paragraph 2.5.6]].</ref>.
When the existing VV is not adequate, the pharmacist may communicate this request over the phone or send a digital VVV to the prescriber. The VVV may contain indications for the prescriber, such as urgency. The prescriber may approve the received proposal and alter it into a final VV. The prescriber informs the requestor via a AVVV (see also [[#Process step: Evaluating a (pharmaceutical) treatment|paragraph 2.2.4]] and subsequent paragraphs).

===Process step: Creating an administration agreement===

If the MA and, if applicable, the corresponding VV can be processed, a TA will be created. By creating a TA, the pharmacist fulfills the MA. The TA is communicated to the patient or the person administrating the medication. The TA belongs to the same MBH as the MA it fulfills. As is the case with the corresponding MA, a TA may start in the future. The dosage in the TA may deviate from that in the MA, for example because a certain strength is not in stock. This means that another PRK can become part of the MBH when, for example, 1 tablet of 20 mg is changed into 2 tablets of 10 mg.
Before the TA is made (actively) available, medication monitoring will occur in accordance with applicable guidelines, as part of this process step.

On the basis of the TA, an administration list<ref> In this document, the administration list means both the digital and the paper version, unless otherwise indicated. Sublist and checklist are synonyms. </ref> can be compiled for home care or nursing staff, among others.

When creating a TA, the same principle applies as for the MA: each change is recorded in a new TA.

The following paragraphs describe the different situations in which a TA is created: new TA or continuing, permanently discontinuing, temporarily halting or modifying an existing TA.

====New administration agreement====

In case of a new MA, a new TA is always created. A new TA is also created in case of a new preference policy or a change in stock which results in the selection of a different medicinal product.
When creating a new TA, the pharmacist takes into account, among other things:
*Preference policy,
*Inclusion in GDS-packaging,
*Available stock of the institution (‘hospital formulary’) or the pharmacy itself. 

If, in an ambulatory situation, the first provision/dispense to the patient occurs later than agreed, the start date of the TA will be different from the start date of the MA.

====Continuing an administration agreement====

When the existing MA and TA are sufficient to carry out an MVE, the TA will not be adjusted.

====Discontinuing an administration agreement====

An MA in which it has been agreed to discontinue medication permanently, leads to a stop-TA under the same MBH (this also applies in case of a stop-MA as a result of a change) with stop type ‘permanent’. The stop-TA prevents a new MVE of the discontinued medication.
In an ambulatory situation, the prescriber can indicate in the MA that the medication will be discontinued with the next roll (with GDS). In this case, the start date of the stop-TA may be later than indicated in the original stop-TA.

====Temporarily interrupting an administration agreement====

Temporarily interrupting an MA results in a stop-TA (stop type: 'temporary'). Upon resuming, a new TA is created. Both TAs belong to the same MBH as the MA.

====Modifying an administration agreement====

A modified MA (leading to a new MA) leads to a new TA under the same MBH. As with the MA, a change to a TA means the termination of the existing TA (a technical stop-TA) and the creation of a new TA.

===Process step: Dispense===

After creating the TA, the pharmacist prepares the product and dispenses it to:
*The patient in a community setting,
*The patient admitted to a hospital, nursing home or other institution.
The pharmacist records MVE<ref>In a clinical situation, product may be taken from the department’s own supply, after which administration takes place immediately and the administration is recorded.</ref>.

Medication dispense to patients:
*In an ambulatory situation only occurs on the basis of a VV or a repeat VV,
*In a clinical situation occurs on the basis of the MA without the need for a VV.

===Process step: (Actively) making available===

This step involves information exchange. Information can be sent or made available with different intentions:

As a request to the prescriber to create a new medication agreement (VMA) or a new dispense request (VVV).

Informing the prescriber about the processing of the prescription (TA and/or MVE).

Making medication data available (VV and MVE) to allow fellow health professionals and/or patients to access these later.

Making a medication overview available to allow fellow health professionals and/or patients to access these later.

===Post-condition===
*A TA could have been created.
*An MVE could have taken place and, if necessary, the patient has received instructions on how to use the medicinal product.
*Fellow health professionals have been informed or may inform themselves. The prescriber has been informed.
*If necessary, the prescribing physician has been requested to provide a new/modified MA or VV.

===Information systems and transaction groups===

The prescriber and the pharmacist as well as other health professionals and users all make use of an information system, respectively, an electronic prescribing system (EVS), a pharmacist information system (AIS, incl. ZAIS), a XIS and a PGO<ref> XIS is a generic term for a random (health care) information system. PHR=personal health records. </ref>. These information systems each have different system roles which enable the exchange of data between these information systems as part of the prescription process.
[[#Information systems and transactions|Chapter 6]] includes an overview of all information systems, system roles, transactions, etc. The most important elements for the prescription process are included in the overview below.

{{anchor|figuur 6}}
[[Bestand:Uc Ter handstellen.png|Figuur 6 Processeps and transactions - dispense]]

===Use cases===
De volgende specifieke use cases van ter hand stellen zijn uitgewerkt:
*[[#New medicatieafspraak, medicatieverstrekking of the same product|New medicatieafspraak, medicatieverstrekking of the same product (paragraph 4.2.1)]]
*[[#New medicatieafspraak, medicatieverstrekking of the same product|New medicatieafspraak, medicatieverstrekking of the same product (paragraph 4.2.2)]]
*[[#Existing toedieningsafspraak is adequate|Existing toedieningsafspraak is adequate(paragraph 4.2.3)]]
*[[#Medicatieafspraak wanted (informing the prescriber)|Medicatieafspraak wanted (informing the prescriber) (paragraph 4.2.4)]]
*[[#Request and dispense|Request and dispense (paragraph 4.2.5)]]
*[[#Patient requests repeat prescription via physician (reactive repeat)|Patient requests repeat prescription via physician (reactive repeat) (paragraph 4.2.6)]]
*[[#Patient requests repeat prescription via pharmacist (informing prescriber)|Patient requests repeat prescription via pharmacist (informing prescriber) (paragraph 4.2.7)]]
*[[#Proactive repeat prescription by pharmacist (informing prescriber)|Proactive repeat prescription by pharmacist (informing prescriber) (paragraph 4.2.8)]]
*[[#Dispense based on an existing verstrekkingsverzoek|Dispense based on an existing verstrekkingsverzoek (paragraph 4.2.9)]]
*[[#Splitting a prescription|Splitting a prescription (paragraph 4.2.10)]]
*[[#Starting and continuing a GDS|Starting and continuing a GDS (paragraph 4.2.11)]]
*[[#The pharmacist changes commercial product|The pharmacist changes commercial product (paragraph 4.2.12)]]
*[[#Adding medication to a GDS|Adding medication to a GDS (paragraph 4.2.13)]]
*[[#Discontinuing medication in a GDS|Discontinuing medication in a GDS (paragraph 4.2.14)]]
*[[#GDS supplier supplies other commercial product|GDS supplier supplies other commercial product (paragraph 4.2.15)]]
*[[#Parallel administration agreements with GDS- and non-GDS-dispense|Parallel administration agreements with GDS- and non-GDS-dispense (paragraph 4.2.16)]]
*[[#Handling a stop medicatieafspraak|Handling a stop medicatieafspraak (paragraph 4.2.17)]]
*[[#Medication dispense with someone else’s administration agreement|Medication dispense with someone else’s administration agreement (paragraph 4.2.18)]]
*[[#Modification of someone else’s administration agreement|Modification of someone else’s administration agreement (paragraph 4.2.19)]]
*[[#Verstrekkingsverzoek with number of repetitions|Verstrekkingsverzoek with number of repetitions (paragraph 4.1.36)]]

==Process: administer==

 
This paragraph describes the administration process. This process comprises the compilation of the administration list for (professional) administrators and the administration which is carried out by a (professional) administrator, the patient himself or an informal caregiver. Professional administrators are physicians, nurses and caregivers (home care/institution).

In paragraph 2.4.1, the current situation is described, followed by a description of the new, altered situation.

===Current situation===
In the current situation, the (professional) administrator, together with the patient, verifies the medication which should be administered, using the available information (paper and/or digital administration list(s), the dosing schedule for, for example, anticoagulant medication, the information on the label), and, subsequently, administers the medication. In case of uncertain administration instructions, the administrator contacts the prescriber or pharmacist. Uncertainties are more likely to occur with an increasing number of prescribers, suppliers and administrators who are involved in the administration process.
In the current situation, for administrators, there are several challenges in the transfer of medication data:
*Transfer of medication data between inpatient health care or home care, and hospital health care is missing or is not available in time;
*Medication changes are not received (in time), and medication stops are missing;
*Up-to-date data on the administration list is not available in the case of supply by multiple pharmacies during after-hours care (evening, night or weekend);
*Separate dosing schedules, in addition to the administration list, of (highly) variable dosages, for example anticoagulant medication;
*Problems related to a separate dosing schedule of (highly) variable dosages; for example, loss of the dosing schedule, verbal information regarding changes of the dosing schedule;
*Medication as needed, injection schedules (for example, for insulin) are missing on the administration list (the injection schedules will be worked out in the information standard in the future);
*An overview is missing of all health professionals and healthcare providers which are involved.

In the current situation, the pharmacist compiles the administration list for the (professional) administrator or the patient. This administration list comprises the administration times, which are geared to the rounds of the home care organization, with account for the pharmaceutical ranges. A paper or digital administration list is used by the (professional) administrators for the registration of the medication administration. A paper administration list (including the administration registration) is in the patient’s home, and is therefore accessible for all professional administrators (irrespective of organization). The digitally recorded medication administrations are only exchanged with other health professionals in exceptional situations (for example, it may be exchanged in the case of admission or special circumstances). With the transition to an electronic administration registration, the administration list (with the recorded administration times) is no longer physically present; instead the administration is recorded in the E-TDR/E-TRS (electronic administration registration/electronic administration registration system) (see paragraph 2.4.8). The involved professional administrators of different organizations (with possibly different E-TRS applications) cannot consult or can only consult with difficulty the registered administration procedures of other organizations, because of registration in different applications and/or databases.

===Precondition===

The patient administers medication to himself or the patient must be administered medication by a(n) (professional) administrator and, therefore, requires an administration list.

===Trigger event===

The moment the medicinal products must be administered.

===Process step: Administration list===

The (professional) administrator or the patient receives or asks for the (actively) made available medication data that is required for automatic generation of the administration list. For the administration list, the building blocks ‘medicatieafspraak’ (MA), ‘wisselend doseerschema’ (WDS), ‘toedieningsafspraak’(TA), ‘medicatieverstrekking’ (MVE) and ‘medicatietoediening’ (MTD) are needed. In order to compile a complete administration list, the (guide) administration times and dosing instructions are required. The pharmacist and prescriber can enter these data in the TA, and MA or WDS, respectively. In general, pharmacists and prescribers in the ambulatory setting do not register the (guide) administration times and, therefore, they should receive a trigger which indicates that it concerns an ‘administration patient’; a patient who is aided in the medication administration or a patient who requires an administration list. For some medication, it is necessary to provide information on the previous ‘prick and patch locations’ (sites of administration); this is registered in the MTD. In the case of inpatient health care, administration lists are available for all patients, and (guide) administration times are registered by default.

Most (guide) administration times are chosen based on the administration times of other prescribed medication and the rounds of the administrator, especially for MAs and TAs with standard flexible (guide) administration times. Further agreements should be made regarding the (guide) administration times by those concerned in the healthcare field (for example, which deviations from the (guide) administration times are permitted). If the administration of a drug requires a specific time of administration, for example because of medication interactions, this is communicated by entering in the TA and/or MA that the (guide) administration time is not flexible.

The administration list differentiates between GDS medication (GDS: medication distribution system, in Dutch ‘Geneesmiddel Distributie Systeem’) and non-GDS medication based on the distribution type. This information is recorded in the building block MVE. Subsequently, the administrator (administration software) compiles the administration list, based on the MA, WDS, TA and MTD, with differentiation according to administration moment. Prescribers, pharmacists and administrators (PrickPatchLocation) are responsible for providing the medication data which is necessary for generating the administration list.

'''NB.''' It is currently explored in which way information regarding GDS can be best exchanged.

===Process step: Administering===

The (professional) administrator has received the medication data (MA, WDS, TA, MVE and MTD) that is required for the medication administration. These data is presented in the administration list as described above. The (professional) administrator, together with the patient, verifies the available medication and the administration data. If agreed and needed, the professional administrator prepares the medication for administration. The medication is administered and the administrator records the administration in the information system or on the administration list. Deviations in the medication administration (not administered, adjusted dosage, refusal by the patient, swallowing problems, adverse effects, etc.) are recorded as well.

===Process step: (Actively) making available===

In this step, information is exchanged. The administration data can be sent or be made available with the following aims:
*The recorded MTDs and deviations can be sent for information to a fellow health professional;
*The MTD can be made available so that the data can be accessed later by fellow health professionals and/or the patient. For example, the administration data can be retrieved upon transfer of the patient to another department or institution. Also, a health professional can check which medication is administered to a patient.

===Post-condition===

The patient has administered medication by himself or has been administered medication. The MTDs can be recorded in an information system and can be (actively) made available for fellow health professionals and/or the patient.

===Information systems and transaction groups===

The prescriber and the pharmacist as well as other administrators and patients (optional) all make use of an information system, respectively, an electronic prescribing system (‘elektronisch voorschrijfsysteem’ - EVS), an electronic client file (‘elektronisch cliëntendossier’ - ECD), a pharmacist information system (‘apothekersinformatiesysteem’ - AIS), a hospital pharmacist information system (‘ziekenhuisapotheekinformatiesysteem’ - ZAIS), an administration registration system (‘toedieningsregistratiesysteem’ - TRS), a thrombosis service information system (‘trombosedienstinformatiesysteem’ - TrIS) and a personal health environment (‘persoonlijke gezondheidsomgeving’ - PGO). These information systems each have different system roles which enable the exchange of data between these information systems as part of the administration process. The information systems may have a function in compiling an administration list, and in the registration, the exchange and the delivering of an MTD.
Chapter 6 provides an example of compiling an administration list. The most important elements for the administration process are included in the overview below.

{{anchor|figuur 7}}
[[Bestand:Toedienen.png|Figuur 7 Processtappen en transacties - toedienen|800px]]

===Use cases===

The following use cases for medication administration have been worked out:

*[[#Creating an administration list|4.3.1 Creating an administration list]]
*[[#Exact administration times required|4.3.2 Exact administration times required]]
*[[#Missing (guide) administration times|4.3.3 Missing (guide) administration times]]
*[[#Non GDS medication as needed|4.3.4 Non GDS medication as needed]]
*[[#Medication supply by multiple pharmacies|4.3.5 Medication supply by multiple pharmacies]]
*[[#Change in GDS from the next supply or immediately|4.3.6 Change in GDS from the next supply or immediately]]
*[[#Increasing dosage of GDS in new MBH|4.3.7 Increasing dosage of GDS in new MBH]]
*[[#Decreasing dosage of GDS in new MBH|4.3.8 Decreasing dosage of GDS in new MBH]]
*[[#Change processed by the pharmacist|4.3.9 Change processed by the pharmacist]]
*[[#Change not processed by the pharmacist|4.3.10 Change not processed by the pharmacist]]
*[[#Variable-dosing regimen|4.3.11 Variable-dosing regimen]]
*[[#Additional information|4.3.12 Additional information]]
*[[#Medication administration deviates from administration list|4.3.13 Medication administration deviates from administration list]]
*[[#Medication administration without medication agreement and administration agreement|4.3.14 Medication administration without medication agreement and administration agreement]]
*[[#Medication administration of self-care medication|4.3.15 Medication administration of self-care medication]]
*[[#Correction/cancellation of an administration|4.3.16 Correction/cancellation of an administration]]
*[[#Medication administration on hold|4.3.17 Medication administration on hold]]
*[[#Medication administration by a prescriber|4.3.18 Medication administration by a prescriber]]
*[[#Multiple administration organizations|4.3.19 Multiple administration organizations]]

==Process: medication use==
This paragraph describes the process of medication use including registration of medication use by the patient or a health professional. The information recorded by the patient or health professional may be used, among other things, for medication verification by the health professional. During medication verification, medication use is established by the health professional. See [[#Appendix: General Diagram Medicatioprocess|Chapter 12]] for a diagram of this process.

===Current situation===
*There is currently a limited number of information systems available in which the patient can record his own use of medication. Exchange to health professionals is also highly dependent on the information system used and is often limited to one specific health professional via, for example, one specific platform/app.
*The current medication profiles are often incomplete and not up to date.

===Precondition===
The patient has been prescribed medication.

===Trigger event===
The patient has used the medication or does not use it (anymore).

===Process step: Medication use===
The patient uses the prescribed medication, selfcare medication. Medication use may be recorded by
*The patient himself or his informal caregiver,
*A home care or institution nurse and/or
*Another health professional.
This third option often applies in the event of medication verification (see [[#Process: medication verification|paragraph 2.1]]). A variety of information systems is available to record medication use: PHR, XIS, EPF [electronic patient file] / ECF [electronic client file], app, etc.

The following can be recorded as medication use:
*Self-care and other proprietary medication,
*Discrepancies compared to agreements made,
*Confirmation of medication use (promoting compliance),
*Verified medication (see medication verification),
*Changes as a result of, for example, side effects (by the patient himself; a health professional will record this in a different way).

Patients who are being administered medication by a nurse sometimes take the medication by themselves at a later time, depending on the BEM-score (assessment of medication self-management, in Dutch: 'Beoordeling Eigen Beheer Medicatie'); in that case, MTD data may deviate from MGB. 
While medication is being used, pharmaceutical care is provided by the pharmacist (see [[#Process step: Providing pharmaceutical care|paragraph 2.3.4]], e.g. in case of new laboratory values). There may also be follow-up contact during which the pharmaceutical treatment is evaluated (see [[#Process step: Evaluating a (pharmaceutical) treatment|paragraph 2.2.4]]).

====''Recording of medication use by the patient''====
The patients makes use of a medication profile and indicates actual medication use for each medicinal product for which this is relevant. The patient can indicate whether or not he is using the product and/or whether this is ‘medication use according to agreement’ (whereby the MA and/or TA is displayed) or if there were deviations. In case of deviations, it is possible to enter specific deviations (i.e. with regard to the schedule actually followed by the patient), but deviations can also be entered in more general terms (for example, I take the medication: ‘from time to time’, [x] times per [days/week] on average’, ‘1x daily instead of 2x’, ‘not anymore since 22 January 2015’ or ‘not anymore since about a month’). In case of deviation from the agreements, the patient also indicates the reason for changing or discontinuing. 
The patient may also add his own medication to the overview and indicate any side effects as the reason for the changes.

Information about medication use will not always be present. There is also no certainty about the reliability of the information. Sometimes there are agreements between the health professional and the patient about keeping track of medication use, and sometimes the initiative is the patient’s entirely.

====''Recording of medication use by health professionals''====
During the process of medication verification ([[#Process: medication verification|paragraph 2.1]]) or evaluating a pharmaceutical treatment ([[#Process step: Evaluating a (pharmaceutical) treatment|2.2.4]]) the patient (or his informal caregiver) indicates, for example, that he does not use medication or uses it differently than was agreed. He may also indicate that he uses other medication as well (self-care products or foreign medication). The health professional can record these data as MGB. The data about medication use is recorded in addition to the primary medication data with the patient being recorded as the source of the information and the health professional as the author. 
Instead of or in addition to recording the MGB, a prescriber may also choose to make a new or modified MA with the patient (in accordance with the process described in [[#Process step: Creating a medication agreement|paragraph 2.2.5]]). This may occur when the prescriber sees reasons to adjust the agreement in response to the patient’s actual medication use. When the prescriber sees no reasons to adjust the agreement, he may choose to only record the medication use, perhaps with the remark that he has requested the patient to comply with the existing agreements.

In case of deviations in MGB, a pharmacist may create a VMA for the prescriber (see [[#Process step: Informing the prescriber|paragraph 2.3.5]]) and/or advise the patient to inform the prescriber about the deviations.

The assessment of medication use (effect and side effect) will be recorded by the physician in the medical history or used as a reason to modify or discontinue a medication agreement.

===Process step: (Actively) making available===
The recorded medication data (MGB) and possibly the medication overview may be sent for information to a fellow health professionals or be made available so that the data can be accessed later.

{{Anchor|2-5-6}}

===Process step: Informing the prescriber===
The patient may also directly inform the prescriber when a new or modified MA or new VV is needed. The process is similar to the process of the pharmacist informing the prescriber ([[#Process step: Informing the prescriber|paragraph 2.3.5]]).

===Post-condition===
The medication list has been updated by the patient and actual medication use has been added. If necessary, the patient has asked the prescriber for a new or modified MA or VV.

===Information systems and transaction groups===
The ''prescriber'' and the ''pharmacist'' as well as other ''health professionals'' and ''users'' all make use of an information system, respectively, an electronic prescribing system (EVS), a pharmacist information system (AIS, incl. ZAIS), a XIS and a PGO<ref>XIS is a generic term for a random (health care) information system. PHR=personal health records.</ref>. These information systems each have different system roles which enable the exchange of data between these information systems as part of the prescription process. 
[[#6 Information systems and transactions|Chapter 6]] includes an overview of all information systems, system roles, transactions, etc. The most important elements for the prescription process are included in the overview below.

{{anchor|figuur 8}}
[[Bestand:Gebruiken.png|Figuur 8 Processtappen en transacties - gebruiken]]

===Use cases===
The use cases for medication use are described on the basis of registration by the patient. The prescriber may record medication use in the same way but will rather record the assessment of medication use (effect and side effect) in the medical history or use it as a reason to modify or discontinue a medication agreement.

The following specific use cases for medication use have been worked out:
*[[#Self-care product|Self-care product (paragraph 4.4.1)]]
*[[#Medication from abroad|Medication from abroad (paragraph 4.4.2)]]
*[[#Modification on the patient’s initiative|Modification at the patient’s initiative (paragraph 4.4.3)]]
*[[#Discontinuation of medication on the patient’s initiative|Discontinuation of medication at the patient’s initiative (paragraph 4.4.4)]]
*[[#No more supply|No more supply (paragraph 4.4.5)]]
*[[#Feedback to patient through a medication adherence app|Feedback to patient through a medication adherence app (paragraph 4.4.6)]]
*[[#Registration of side effects by the patient|Registration of side effects by the patient (paragraph 4.4.7)]]
*[[#Register usage based on provision|Register usage based on provision (paragraph 4.4.8)]]

=Domain-specific handling of the medication process=

==After Hours General Practice clinics (HAP)==
The after hours general practitioner (AHGP) works on behalf of the regular general practitioner (GP). The AHGP may (among other things) start, modify and discontinue MAs in accordance with the process described in [[#Process: medication verification|paragraph 2.1]]. If necessary, the AHGP will also create the corresponding VVs. 
The AHGP will inform the regular GP about the observation. Currently, it has been agreed that the AHGP does not act as a source of information for other health professionals of this patient. This means that the AHGP will not carry out the process step ‘(actively) making available’. Instead, the regular GP will make the relevant information available to the fellow health professionals. An exception may be made for a prescription created by the AHGP without a specified recipient, see [[#Prescription without specified recipient (ambulatory)|paragraph 8.1]]. 
In principle, the AHGP will follow the generic prescription process, except that a AHGP will carry out certain steps on behalf of the regular GP (‘delegated’).

==Mental health care==
There are only few planned admissions in mental health care (almost only in departments for eating disorders, clinical rehabilitation, etc.). Most admissions are admissions as a result of acute crisis situations and are therefore comparable to admissions via the emergency departments in hospitals (see also [[#Starting with medication before admission|paragraph 4.1.20]]).

===Current situation===
In the current situation, patient or family/informal caregivers are asked which medication the patient is using. In most cases, the patient is unable to give an answer (often the reason for admission). Family/informal caregivers (if known) are also not always able to answer this. If this is the case, the admitting physician/psychiatrists will contact the general practitioner or the pharmacist to find out the medication. This is difficult outside office hours and during weekends. When data do come in, only part of them is retyped in the information system of the health professionals.

===Process===
In the new situation, it will be possible to retrieve the available medication data and medication overviews. On this basis, medication verification, assessment of the medicamenteuze behandeling (as soon as possible) and medication administration (in accordance with [[#Medication process|Chapter 2]]) can be started. Medication dispense is carried out by public pharmacists on an outpatient basis and, in clinical practice, often by a contracted hospital pharmacy. 
As is the case with hospital discharge, medicamenteuze behandeling will be assessed at discharge from a mental health institution ([[#Process step: Evaluating a (pharmaceutical) treatment|paragraph 2.2.4]] and subsequent). Clinical medication is discontinued and, if necessary, new medication is prescribed or temporarily halted outpatient medication is resumed or permanently discontinued. The physician/psychiatrist focuses mainly on psychiatric medication; somatic medication usually remains unaffected. 
Letting the psychiatric patient record his own medicatiegebruik may be experienced as undesirable control instead of it stimulating proper medication use. 
The medication data will be made available.

==Nursing, care and home care (VVT)==
The medication process in a VVT institution (nursing home, care home and home care) is similar to that of the clinical situation. However, in a VVT institution, a geriatrics specialist is responsible for prescribing medication to admitted clients and medication is being dispensed by one or more community pharmacists, possibly as part of GDS if needed. VVT institutions and home care make use of administration lists, which are drawn up based on the toedieningafspraken. The administration list is used to check medication before administering it and to sign off actual medicatiegebruik. Communication of the administration list between pharmacist, prescriber and nursing staff will be explained in more details further on in this information standard.

==Hospital admission and discharge==
A special situation in the transfer of medication data occurs when a patient is admitted to a hospital. At the moment of admission and of discharge, a lot of changes can take place in the medicatieafspraken and toedieningsafspraken. That is why this subject is separately illustrated in this chapter. This process is described in more detail in instruction manuals for caregivers and software suppliers.

===Prior to admission===
Before a patient is admitted to a hospital, changes in medication may be necessary. The medical specialist and patient can agree upon starting new medication or stopping continuous medication a few days before admission. The medical specialist subsequently registers a medicatieafspraak or stop-MA and mentions in the explanatory notes how many days before admission the patient has to start or stop the medication. When this medicatieafspraak is registered, the date of admission is often yet unknown. That is why the medical specialist records that this medicatieafspraak depends upon a hospital admission. This means that the start- or end date are uncertain. Technically, this is solved by registering the explanatory notes in the element ‘Condition’ of the period of use of the medicatieafspraak. If this condition is entered, it is clear to caregivers that the period of use is uncertain.

===During admission and at time of discharge===
When a patient is admitted, the following situations can occur, concerning the outpatient medication:
* Unchanged continuous use,
* Change in dosage,
* Generic substitution (active ingredient remains the same),
* Pharmacological substitution (active ingredient changes, but medication is registered for the same indication),
* (Temporary) stop.

Below, for each situation, an explanation is given for registration of the medication of the patient.

====Unchanged continuous use====
The patient continues using the outpatient medication during admission.

Both medicatieafspraak and toedieningsafspraak continue during admission and after discharge.

====Change in dosage====
The patient uses the outpatient medication during admission, but in a different dosage.

The medicatieafspraak for outpatient medication is stopped at admission. During admission, a new medicatieafspraak is registered with the changed dosage. At discharge, the prescriber decides which dosage will apply for the outpatient medication. Depending on this decision, the medicatieafspraak that applied before admission will be continued, or a new medicatieafspraak will be registered.
The toedieningsafspraak is also stopped at admission. During admission, a new toedieningsafspraak is registered, based on the new medicatieafspraak. At discharge, the toedieningsafspraak that applied before admission will be continued, or a new toedieningsafspraak will be registered.

====Generic substitution====
The patient uses a different medicinal product during admission, but with the same active ingredient and dosage as in the outpatient medication.

The medicatieafspraak for outpatient medication continues during admission and after discharge.
The toedieningsafspraak for outpatient medication is stopped at admission and continued at discharge. During admission, a new toedieningsafspraak is registered. This toedieningsafspraak will be stopped at discharge.

====Pharmacological substitution====
The patient uses a different medicinal product during admission, with a different active ingredient from the outpatient medication. This medicinal product, however, is registered for the same indication as the outpatient medication.

The medicatieafspraak for outpatient medication is stopped at admission and will be continued again at discharge. During admission, a new medicatieafspraak is registered. This medicatieafspraak will be stopped at discharge.
The toedieningsafspraak for outpatient medication is also stopped at admission and continued at discharge. During admission, a new toedieningsafspraak is registered. This toedieningsafspraak will be stopped at discharge.

====(Temporary) stop====
The patient (temporarily) stops using the outpatient medication during admission.

The medicatieafspraak for outpatient medication is (temporarily) stopped at admission. If the medication is stopped temporarily, this medicatieafspraak will be continued at discharge. If the medication is stopped definitively, the medicatieafspraak will not be continued.
The toedieningsafspraak for outpatient medication is also (temporarily) stopped at admission. If the medication is stopped temporarily, this toedieningsafspraak will be continued at discharge. If the medication is stopped definitively, the toedieningsafspraak will not be continued.

=Description of use cases=
This chapter contains a description of various use cases. Specific practical situations have been described for the various subprocesses. A large number of the practical situations are based on general medical practice, but are illustrative of similar situations in a different setting. This chapter assumes the knowledge as previously described in [[#Medication process|Chapter 2]].

==Use cases, Prescribe==

===Short-term medication===
A 35 year old female patient with a history of urinary tract infection brings her urine to the doctor’s assistant and tells her she has the same symptoms as the previous times. The assistant enquires about other symptoms such as fever and pain in the flank and checks the urine. There are no other symptoms and the urine reveals a urinary tract infection. She tells the patient that the general practitioner will prescribe a course of treatment and that she can pick it up from the pharmacist later. The General practitioner checks the previous courses of treatment and any cultures and records a medicatieafspraak. On ''27 January'' it was agreed:
:''Nitrofurantoin CR capsule, 100 mg, 2x daily, 1 capsule, from now on<ref>See also [[#Hard end date for period of use|paragraph 4.1.3]].</ref> for 5 days.''
He records this medicatieafspraak in his information system. The general practitioner then immediately also makes a verstrekkingsverzoek for the pharmacist chosen by the patient:
:''Nitrofurantoin CR capsule, 100 mg; 10 capsules.''
The general practitioner also records this verstrekkingsverzoek in his information system. 
The general practitioner consults with the patient to find out from which pharmacist she wants to pick up the medication. The general practitioner can then inform this pharmacist about the verstrekkingsverzoek and the medicatieafspraak. 
The information system of the general practitioner makes this information (verstrekkingsverzoek and medicatieafspraak) available to the other health professionals of this patient. 
 
[[Bestand:ENG_Voorschrijven_Kortdurende medicatie.png|800px]]

===Continuing medication===
The process for continuing medication is practically the same as for short-term medication (see [[#Short-term medication|paragraph 4.1.1]]), except that in the case of continuing medication the medicatieafspraak is made for an indefinite period of time.

For example: the prescriber agrees with a patient who has hypertension that he should use a diuretic on a continuous basis. On ''30 March 2013'' it was agreed:

:''Hydrochlorothiazide tablet, 12.5 mg; 1x daily, 1 tablet; from now on for an indefinite period.''
''For example, the prescriber chooses in the verstrekkingsverzoek for an initial dispensing quantity of 100 pieces.'' 
 
[[Bestand:ENG_Voorschrijven_Doorlopende medicatie.png|800px]]

===Hard end date for period of medication use===
A start date, end date and/or duration can be included in the period of medication use of a medicatieafspraak. If a hard end date is desired, this must also be explicitly stated in the explanation. Including an end date alone is not sufficient because this does not provide enough clarity about the intention of the prescriber. 
 
[[Bestand:ENG_Voorschrijven_Harde stopdatum gebruiksperiode.png|800px]]

===Medication as needed===
A 31-year-old female patient has had headaches a few times in a year, with migraine now being diagnosed. The general practitioner prescribes:
:''Rizatriptan tablets, 10 mg, as needed 1c1t under the tongue. First tablet at the next clear migraine attack.''
De huisarts legt de medicatieafspraak vast en doet een verstrekkingsverzoek:
:''6 sublingual rizatriptan tablets, 10 mg.''
 
[[Bestand:ENG_Voorschrijven_Zo nodig medicatie.png|800px]]

===Course of treatment as needed starting in future===
A 60-year-old patient with post-thrombotic syndrome experiences erysipelas (severe infection of the leg which can require admission if medication is not started quickly) sometimes every other year, sometimes three times a year. At the request of the patient, the general practitioner prescribes an antibiotic treatment the patient can start immediately in case of a recurrence of erysipelas. The following medicatieafspraak is created:
:''Flucloxacillin capsules, 500 mg, 1 capsule 4x daily, for 10 days. In the medicatieafspraak is indicated (if necessary): start in case of recurrence, as needed.''
The general practitioner immediately creates a verstrekkingsverzoek:
:''Flucloxacilline 500 mg capsules 40 stuks.'' 
 
[[Bestand:ENG_Voorschrijven_Kuur zo nodig startend in de toekomst.png|800px]]

===Two dosages of the same medication at the same time===
A 79-year-old man with metastatic prostate cancer is increasingly suffering from pain and his medication is being changed. The specialist prescribes oxycodone tablets, 10 mg, 1 tablet 4x daily and as needed for pain during the night, 1 tablet 1x daily, on October 9. The specialist records this in one single medicatieafspraak with two dosing instructions and creates a verstrekkingsverzoek for 60 tablets of oxycodone of 10 mg. 
 
[[Bestand:ENG_Voorschrijven_Twee doseringen van hetzelfde geneesmiddel tegelijkertijd.png|800px]]

===The same medicinal product with different strengths at the same time===
The same 79-year-old patient (see [[#Two dosages of the same medication at the same time|paragraph 4.1.6]]) is experiencing even more pain. The specialist discontinues the 10 mg tablets of oxycodone on October 16 and prescribes 20 mg retard tablets of oxycodone, 2 tablets 3x daily, and 20 mg normal release tablets of oxycodone as needed in case of nocturnal pain, 1 tablet 1x daily. The specialist records this in two medicatieafspraken (with, for the time being, two separate medicamenteuze behandelings) and creates a verstrekkingsverzoek for both medicatieafspraken, respectively 45 retard tablets of 20 mg oxycodone and 30 tablets of 20 mg oxycodone (normal release). 
 
[[Bestand:ENG_Voorschrijven_Hetzelfde geneesmiddel met verschillende sterkte tegelijkertijd.png|800px]]

===Explanation in medicatieafspraak with deliberately chosen special characteristic===
This use case is described in the zib medicatieafspraak/additional information. Here it is described for information purposes only. When selecting a medicinal product, it is possible to deviate from what is expected or standard. For example, when a hospital uses a different formulary than a community pharmacy. For reasons of efficiency the hospital has opted for a single gastric acid inhibitor: pantoprazole. 
At admission, a patient with omeprazole is switched to pantoprazole for the duration of the hospitalization. At discharge, the patient returns to omeprazole. 
It is clear that this may sometimes go wrong and that the patient might end up taking both omeprazole and pantoprazole if nothing is done. In the medicatieafspraak of the hospital for pantoprazole, a remark can be made about this deviation in order to make it clear that pantoprazole is the replacement of omeprazole or that it has to be used in addition to omeprazole.
 
 
Half-strengths are another example. The hospital sometimes as tablets available with half the strength of the normal commercial preparation (proprietary production). When a patient enters the hospital with a prescription of 25 mg of chlorthalidone, half a tablet 1x daily, he will receive 12.5 mg of chlorthalidone, 1 tablet 1x daily. In this specific case, this means that nursing staff does not have to break tablets in half. There is a risk that the patient will use the 25 mg again at home, but now a whole tablet at the time. An explanation in the medicatieafspraak (additional information) regarding the last 25 mg of chlorthalidone, makes it possible to indicate whether this was a deliberate increase. 
 
If a prescribed product has to be a very specific commercial product, this can be indicated with ‘medical necessity’.

===New medicatieafspraak, no verstrekkingsverzoek===
A 50-year-old man comes to the general practitioner with back problems. The symptoms have been present for three weeks and he is already using paracetamol. The general practitioner agrees with the patient that he can additionally use diclofenac:

On ''30 January'' it was agreed:
:''Diclofenac tablet, 50 mg, 1 tablet 3x daily, from now on for 3 weeks.''
He records this medicatieafspraak in his information system. The patient indicates there is sufficient supply at home: his wife still has an ample supply of diclofenac left because of a different problem a year ago.

A verstrekkingsverzoek is therefore not needed and the pharmacist also does not dispense any medication. 
The general practitioner makes the new medicatieafspraak available to any fellow health professionals of this patient. This allows the regular pharmacist to inform himself about this new medicatieafspraak. 
 
[[Bestand:ENG_Voorschrijven_Nieuwe medicatieafspraak geen verstrekkingsverzoek_a.png|800px]]

Another example: Mr Simons receives medication from the pharmacy weekly. In the past there were many requests for extra medication, which led to clear agreements about the dispense policy.

This is about:
:''Medicatieafspraak: Diazepam, 5 mg, 1 tablet 4x daily, from 1 January 2012 for an indefinite period''
:''Verstrekkingsverzoek: 28 tablets with 10 repeats; remark: weekly medicatieverstrekking''
The verstrekkingsverzoek is repeated approximately every 11 weeks.
The last verstrekkingsverzoek was on 3 March 2016:
:''one week (28 tablets) with 10 repeats''
This way, the pharmacy can go on for 11 weeks.
 
 
[[Bestand:ENG_Voorschrijven_Nieuwe medicatieafspraak geen verstrekkingsverzoek_b.png|800px]]

The last few years have been quiet. Mr. Simons is no longer asking for extra medication. At the last consultation he indicated that diazepam, 3x daily, is sufficient. This has been recorded in a medicatieafspraak:
:''1 April 2016 Diazepam, 5 mg, 1 tablet 3x daily, from 1 April 2016 for an indefinite period.''

The previous medicatieafspraak will be terminated as of 31 March 2016 (see discontinuation of medication in [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5]]).

In the current situation, the general practitioner would have called the pharmacy to make sure that 21 tablets of diazepam would be given with the following medicatieverstrekking, instead of 28. No new verstrekkingsverzoek would have been needed at the time.

In the new situation, the general practitioner sends the new medicatieafspraak to the pharmacy. Based on the new medicatieafspraak, the pharmacy provides 21 tablets per week, the previous verstrekkingsverzoek is still sufficient.

 
[[Bestand:ENG_Voorschrijven_Nieuwe medicatieafspraak geen verstrekkingsverzoek_c.png|800px]]

===New verstrekkingsverzoek under existing medicatieafspraak===
A prescriber may also create a new verstrekkingsverzoek as part of an existing medicatieafspraak. This medicatieafspraak may have been created by a different prescriber, for example a psychiatrist. This concerns repeat medication. This use case is described in [[#Patient requests repeat prescription via physician (reactive repeat)|paragraph 4.2.6]].

[[Bestand:ENG_Voorschrijven_Nieuw verstrekkingsverzoek onder bestaande medicatieafspraak.png|800px]]

===Dosage change (sufficient supply)===
Patient (37 years old, asthma) visited the pulmonologist on 13 August 2013 for a check-up of his asthma. The pulmonologist has established that patient’s asthma is not adequately controlled. 
The patient is currently using beclomethasone in accordance with a previously made and registered medicatieafspraak: on 10 June 2010 it was agreed:
:''Beclomethasone aerosol, 100 microgram/dose, inhaler; 1 inhalation 2x daily; from 10 June 2010 for an indefinite period.''
On 13 August 2013, the pulmonologist agrees with the patient on a dosage increase:
:''Beclomethasone aerosol, 100 microgram/dose, inhaler; 2 inhalations 2x daily; from 13 August 2013 for an indefinite period; reason for adjustment: insufficient effect.''
The previous medicatieafspraak of 10 June 2010 it is no longer valid: it is terminated (see Changing medication in [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5]]). The patient still has a sufficient supply, a verstrekkingsverzoek is therefore not needed.
 
 
[[Bestand:ENG_Voorschrijven_Wijziging in dosering voldoende voorraad.png|800px]] 
In case the patient has no more supply, a new verstrekkingsverzoek will be created. 
The information system of the pulmonologist makes the new medicatieafspraak available to the other health professionals of this patient. This modification is received by the pharmacist (fellow health professional). The pharmacist processes the modification. The pharmacist may also choose to accept the modifications automatically.

===Prescription no longer needed after first verstrekkingsverzoek===
A 16-year-old woman has a boyfriend and does not want to become pregnant. After explanation she opts for the pill. The general practitioner prescribes ethinylestradiol/levonorgestrel tablets of 20/100 µg, 1 tablet 1x daily for 21 days, then no tablet for 7 days, then another 21 days of taking a tablet once a day. Start on the first day of the next menstruation. The general practitioner records the medicatieafspraak and creates a verstrekkingsverzoek for 63 coated microgynon 20 tablets. He explains to her that if she does not experience any problems, she can continue to get the pill via the pharmacy. 
Three months later, the woman sends a request for repeat supply to the pharmacy. The pharmacy provides the product and communicates the medicatieverstrekking to the general practitioner.

 
[[Bestand:ENG_Voorschrijven_Recept niet meer nodig na eerste verstrekkingsverzoek.png|800px]] 

{{Anchor|4-1-13}}
===Discontinuing medication===
Patient (37 years old, asthma) visits the pulmonologist on 13 August 2013 for a check-up of his asthma. The patient is suffering from a side effect. The patient is currently using Beclomethasone in accordance with a previously made and registered medicatieafspraak. On ''10 June 2010'' it was agreed:
:''Beclometasone aerosol, 100 microgram/dose, inhaler; 1 inhalation 2x daily; from 10 June 2010 for an indefinite period.''
On 13 August 2013, the pulmonologist agrees with the patient to discontinue the medication (medicamenteuze behandeling is discontinued). Medication verification is also applicable here. In addition, medication monitoring may also be relevant here, for example if gastroprotrective drugs are being used because of the use of the medication to be discontinued (the information system will not always signal this automatically). 
The pulmonologist records:
:''Beclometasone aerosol, 100 microgram/dose, inhaler; stoptype ‘definite’; from 13 August 2013. Because of a side effect.''
This modification is received by the pharmacist (fellow health professional). The pharmacist processes the modification. The pharmacist may also choose to accept the modifications automatically. The pulmonologist decides to also actively inform a fellow health professional (such as a specialist) about this (part of the process step (actively) making available). 
The information system of the pulmonologist makes this information (agreement to discontinue) available to the other health professionals of this patient.
 
 
[[Bestand:ENG_Voorschrijven_Stoppen medicatie.png|800px]] 

===Temporarily halting/resuming medication===
A patient is being treated with simvastatin (cholesterol-lowering agent): 40 mg, 1 tablet 1x daily, for an indefinite period. Because of a throat infection in combination with an allergy for the first antibiotic of choice, Clarithromycin, 250 mg, 1 tablet 2x daily (antibiotic) is prescribed for 1 week. During that week, simvastatin is temporarily halted because of an interaction. 
The general practitioner records:
:''Simvastatin 40 mg; halt temporarily; for 1 week; reason: interaction''
:''Clarithromycin, 250 mg; 1 tablet 2x daily; for 1 week (and a corresponding verstrekkingsverzoek)''
The pharmacist is actively informed by the general practitioner about the temporary halt of simvastatin. A new medicatieafspraak is also created with which simvastatin is resumed after one week. The pharmacist will also receive the medicatieafspraak and the corresponding verstrekkingsverzoek for clarithromycin. See also Temporarily halting and resuming medication in [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5]].

 
[[Bestand:ENG_Voorschrijven_Onderbreken hervatten medicatie.png|800px]] 

===Temporarily halting for an intervention===
A 62-year-old man uses acetylsalicylic acid, 100 mg, 1 tablet 1x daily because of coronary disease. He has an intestinal polyp that must be removed. The general practitioner informs him that he should stop using acetylsalicylic acid three days before the intervention and resume the day after the intervention. The general practitioner records the temporary halt in a medicatieafspraak with an enddate 3 days before the intervention; stoptype ‘temporary’; reason for halting: ‘intervention’. In the (second) medicatieafspraak for presuming, 1 day after the intervention is used as the start date. The general practitioner actively informs the pharmacist and the gastroenterologist about the medicatieafspraken. 
When the date of the intervention is unknown or uncertain, the explanation will indicate that the medication should be halted three days before the intervention and resumed one day later. The duration of the temporary halt is then 4 days. See also Temporarily halting and resuming medication in [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5]].

 
[[Bestand:ENG_Voorschrijven_Onderbreken voor een ingreep.png|800px]] 

===Paper prescription===
The physician gives the patient a paper prescription<ref>A similar situation occurs when the pharmacist receives a fax.</ref>. A paper prescription contains a medicatieafspraak and a verstrekkingsverzoek. The patient can use this prescription to pick up the medication from any pharmacist. The general practitioner does not inform the issuing pharmacist in this case. However, the process is actually the same: the activity ‘(actively) making available’ is now only ‘handled’ by the paper prescription in the hands of the patient. The supplying pharmacist will copy this paper medicatieafspraak and verstrekkingsverzoek in his own information system and complete it with a toedieningsafspraak. The pharmacist may also retrieve the medicatieafspraak and verstrekkingsverzoek that were made available digitally and process them in his own information system this way. 
The information system of the general practitioner makes the new medicatieafspraak and verstrekkingsverzoek available for fellow health professionals. When the information system of the general practitioner has not made these available this may be because it concerns a toedieningsafpsraak without digitally available medicatieafspraak and verstrekkingsverzoek. The pharmacist will not make the medicatieafspraak and verstrekkingsverzoek obtained ‘from paper’ available because he is not the owner. Next to that, this could lead to, possibly only in the future, wrongful duplication of medicatieafspraken and verstrekkingsverzoeken.
 
[[Bestand:ENG_Voorschrijven_Papieren recept.png|800px]]
 

===Carrying out medication verification and evaluation of foreign or self-care medication===
When medication cannot be found in the information system (such as foreign medication and self-care medication), this medication will be recorded as medicatiegebruik (see [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5]]).

===Day treatment===
An admission for day treatment is comparable with an outpatient consultation or an emergency admission during which the medication is supplied by the hospital pharmacist. In the case of admission for a day, extensive medication verification does not usually occur. In the case of admission for a day, the medication prescribed is recorded (often on the basis of protocols according to which verification is carried out afterwards) and administered. 
For treatments with cytostatics, for example, there is a medicatieafspraak, but it is not always clear in advance when the medicatieverstrekking/administration takes place. Reason: treatments are often postponed and then supplied and administered later.

===Starting with medication before admission===
Prior to cataract surgery, Nevanac is started three days before the surgery. The eye drops are used until three weeks after surgery (a total duration of medication use of 24 days). The specialist creates a medicatieafspraak for Nevanac, 1 drop in the morning, for 24 days. When the date of the surgery is unknown or uncertain, the explanation may indicate that Nevanac should be started 3 days before surgery takes place.
 [[Bestand:ENG_Voorschrijven_Starten met medicatie voor opname.png|800px]]
 

===Emergency admission===
In the event of an emergency admission, extensive medication verification is not carried out beforehand as would normally be the case with clinical admissions. Agreeing on medication with the patient is also often not possible in the event of an emergency admission. Often, the patient is administered medication as soon as possible and verification only takes place afterward

===Interim discharge===
When a patient temporarily leaves the hospital/institution to go home, for example, for weekend leave, the clinical medication continues. In order to keep the patient’s own general practitioner informed, the medication overview is provided to the patient and the medication data are made available.

===Transfer to another institution===
In case of a transfer to another institution, the medicamenteuze behandeling is evaluated (see [[#Process step: Evaluating a (pharmaceutical) treatment|Chapter 2.2.4]] and [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5]]). Medication overview and medication data are (actively) made available. The new attending physician evaluates the medicamenteuze behandeling and determines the institutional medication.

===Do not dispense before===
The prescribing physician creates a verstrekkingsverzoek on 14 April 2017, but wants to indicate in that same verstrekkingsverzoek the medicatieverstrekking may only take place on or from a later date, for example, 23 April 2017. This cannot be recorded in a structured manner in the verstrekkingsverzoek, but is included in the explanation (as free text).
 
[[Bestand:ENG_Voorschrijven_Niet verstrekken voor.png|800px]]
 

===Discontinuation of medication by third parties===
Medication can be discontinued by the prescriber himself (see [[#Discontinuing medication|paragraph 4.1.13]]) but also by another prescriber. For example, the specialist can end medicatieafspraken made by a general practitioner that are up to date according to the information system, but that turn out not to be, for example after medication verification. When a health professional discontinues medication, he creates a new stop-MA. The health professional cannot modify someone else’s medicatieafspraak, only create a stop-MA. He therefore actively informs the health professional of the original medicatieafspraak about this change. The health professional of the original medicatieafspraak modifies the end date in the existing medicatieafspraak. If required, this may also be automated by the information system. This prevents the second health professional from not having to produce data after a period of time because the production period has expired (also no stop-MA), while the health professional of the original medicatieafspraak continues to produce it for no reason (without an end date).
 
 
[[Bestand:ENG_Voorschrijven_Stoppen van medicatie door derden.png|800px]]
 

===Two PRKs in a single medicamenteuze behandeling===
In certain circumstances, the pharmacy is allowed to select a different PRK for the toedieningsafspraak than is indicated in the medicatieafspraak made by a prescriber. If for instance a failure of the prescriber’s information system would result in only the communication of the toedieningsafspraak, a subsequent prescriber will only have this toedieningsafspraak with the new PRK. The next prescriber will then probably assume that this PRK is also the PRK of the medicatieafspraak. A modification of the medicatieafspraak will then also result in a stop-MA (without referring to the original MA) and a new medicatieafspraak on the basis of this PRK. This means that there are now two medicatieafspraken with different PRKs under the same medicamenteuze behandeling. These two medicatieafspraken continue to exist. After any information system failure, (the information system of) the prescriber must check whether there have been changes and implement them, if necessary (see also [[#Discontinuation of medication by third parties|paragraph 4.1.26]]).
 
[[Bestand:ENG_Voorschrijven_Twee PRKs onder een medicamenteuze behandeling.png|800px]]
 

===Creating a medicatieafspraak after the fact===
In emergency situations, for example, it may happen that the medicatieafspraak is only created after the medication has been dispensed or administered. This may lead to conflicting medicatieafspraken. This means that one or more medicatieafspraken must be discontinued in order to prevent the occurrence of parallel medicatieafspraken. The only exception for parallel medicatieafspraken is described in [[#Medicamenteuze behandeling|paragraph 1.3.3]].

===Single medication use( medicatiegebruik)===
For medication meant for single use, only an end date is included in the period of medication use. An example would be a vaccination (for example, a tetanus shot) or a situation in which a patient should take a medication just once, for example 3 weeks before he leaves on holiday.
 
[[Bestand:ENG_Voorschrijven_Eenmalig gebruik.png|800px]]
 

===Provisional and final medication order===
The prescriber at the clinic prescribes medication. This is recorded in a provisional medication order (the medicatieafspraak). The hospital pharmacist verifies this order and records it as a final medication order (the toedieningsafspraak). See also <ref name="MO"/>.

===Inadvertently ‘outstanding’ medication or 'orphans'===
In a transitional situation and in a situation where not every XIS is connected, medicatieafspraken for the same treatment may exist that have been created by different information systems under different medicamenteuze behandelings. These medicatieafspraken should ideally be combined in a single medicamenteuze behandeling. This particularly applies to medication with an open end date, as this medication may have been discontinued under a different medicamenteuze behandeling. The medicatieafspraak therefore remains open, resulting in continued medicatieverstrekking. This is a so-called ‘orphan’ (a building block that has been registered, but in which, at a certain point, the health professional no longer has an active role. However, his information system continues to provide the building block, even if it has already been discontinued elsewhere). For medication with an end date, this problem will solve itself. Therefore, it is not necessary to take any action. When medication verification or medication assessment reveals that the medication is inappropriately still ‘open’, a stop-MA is created under the same medicamenteuze behandeling. The original prescriber is actively informed about this stop-MA and enters an end date for the medicatieafspraak in his own information system. Depending on the supplier and the client’s wishes, setting this end date can be done automatically or through an intervention of the prescriber. See also [[#Discontinuation of medication by third parties|paragraph 4.1.26]] and [[#Modification of someone else's medicatieafspraak|paragraph 4.1.40]].
 
 
[[Bestand:ENG_Voorschrijven_Onterecht openstaande medicatie of weeskinderen.png|800px]]
 

===Missing digital medicatieafspraak at admission===
If no digital medicatieafspraak is available when medication verification is carried out, a new medicamenteuze behandeling is started by recording medicatiegebruik. When this medicatiegebruik has to be discontinued, a stop-medicatieafspraak is created under the same medicamenteuze behandeling that refers to the recorded medicatiegebruik. If possible, the original prescriber (for example, general practitioner) and the pharmacy are actively informed about the discontinuation of this medication.
 
[[Bestand:ENG_Voorschrijven_Ontbreken digitale medicatieafspraak bij opname.png|800px]]
 

===Own articles (90 million numbers)===
It is possible to exchange a 90 million number. The condition is that within an organization a 90 million number once created may never be modified. During the exchange, the root OID (unique technical identification of the organization) in combination with the 90 million number ensures that it is unique compared to all 90 million numbers form other organizations. The substances that make up this article are included as ingredients in the medicatieafspraak (at least one ingredient), as is the case with magistrals.

===Dosing with minimum interval ===
Medication can be prescribed at a fixed interval (for example: 2 tables every 6 hours). Prescribing medication with a minimum interval should be partly in free text. For example, if needed, a maximum of 3 times a day, a minimum of 6 hours between the intake moments: ''if needed, a maximum of 3 times a day'' is recorded in the standard way. The section “''at least 6 hours between intake times''” is recorded in free text as an Additional Instruction.
 
 [[Bestand:ENG_Voorschrijven_Dosering met minimum interval.png|800px]] 
 

===Verstrekkingsverzoek with number of repetitions ===
The prescriber makes a verstrekkingsverzoek with a medicatieafspraak in which she enters the number of repetitions. The prescriber hereby indicates to the provider that it may make additional provisions. The number of repetitions in combination with the quantity to be dispensed results in: (Number of repetitions + 1) X quantity to be dispensed. In case of “number of repetitions =3” and “quantity to be supplied = 30 pieces” the provider may provide 4 times 30 pieces (total 120 pieces). The number of repetitions in combination with the duration of medication usage period results in: (number of repetitions + 1) x duration of medication use. The amount to be dispensed depends on the dosage. In case of “dosage = 3 x per day 2 pieces”, and “Duration of medication usage period = 30 days” the provider may provide 180 pieces 4 times (6 pieces per day X 30 days = 180, 4 times = a total of 720 pieces).
 
 [[Bestand:ENG_Voorschrijven_Verstrekkingsverzoek met aantal herhalingen.png|800px]] 
 

===Prescribing non-medicines===
Non medicines can be prescribed from the G-standard at HPK level. For example, this could be an inhaler (Aerochamber, HPK 1915185) as an aid to prescribed aerosols. Non-medicinal products are not applicable for the medication overview or medication monitoring.

===Send renal function value in the prescription===

'''A) Renal function value with a new prescription:''' 
For the prevention of stroke, a patient (male, 65 years old) is prescribed Dabigatran for the first time. The patient has renal impairment and the prescriber has a recent renal function value available. Based on this renal function value, the prescriber deviates from the standard dose and makes a medicatieafspraak with a lower dosage of Dabigatran twice a day 1 capsule of 110 mg, starting from January 15, 2020. The prescriber also makes a verstrekkingsverzoek and sends the prescription (medicatieafspraak, verstrekkingsverzoek and the laboratory result of the renal function value) to the pharmacist.
 
[[Bestand:ENG_Voorschrijven_Nierfunctiewaarde sturen met het voorschrift_a.png|800px]] 

'''B) Renal function value reason for a change:''' 
A 70-year-old man was prescribed 1 tablet of metformin 500 mg 3 times a day a few days ago (medicatie afspraak and verstrekkingsverzoek). At the same time, the doctor initiated a blood test to determine the renal function value of the patient. The value was not yet known at the time of prescription.
 
[[Bestand:ENG_Voorschrijven_Nierfunctiewaarde sturen met het voorschrift_b1.png|800px]] 

The blood test shows that renal function is impaired and gives reason to adjust the medicatieafspraak. The prescriber adjusts the dose on January 17, 2020 to 2 tablets metformin 500 mg twice a day and discuss this with the patient. The new prescription (the 'technical' stop medicatieafspraak, new medicatieafsrpaak and the laboratory result of the renal function value) is sent to the pharmacy by the prescriber. Because the patient had already collected the medication and therefore has enough stock, no new verstrekkingsverzoek is sent along.
 
[[Bestand:ENG_Voorschrijven_Nierfunctiewaarde sturen met het voorschrift_b2.png|800px]] 

'''C) Renal function value due to drug:''' 
The patient is prescribed Nitrofurantoin 100 mg, 1 capsule twice daily as a 5-day course due to a bladder infection and must start immediately on January 6, 2020. With this drug, the renal function value (if known and not older than 13 months) needs to be sent along. The prescriber has a renal function value available for this patient, but this does not lead to an adjusted dosage. The prescriber sends the prescription (medicatieafspraak, verstrekkingsverzoek and the laboratory result of the renal function value) to the pharmacist.
 
[[Bestand:ENG_Voorschrijven_Nierfunctiewaarde sturen met het voorschrift_c.png|800px]] 
 

===Cancelling a prescription that was sent earlier ===
A patient visits the general practitioner (GP) one morning because of stomach complaints. The GP prescribes pantoprazole and sends the prescription (MA + VV1) to the preferred pharmacy as known to him. In the afternoon the patient calls the GP. He hasn’t picked up the prescription yet and he would like to pick it up at another pharmacy due to a recent move, but forgot to ask this morning. The GP resends the prescription to the old pharmacy, but the VV in the newly send prescription contains a canceled indicator (MA + VV1 “cancelled”), so the pharmacist knows he should not dispense on this prescription. The prescriber then sends a new prescription (MA + VV2) to the patient's new pharmacy. The patient can pick up the medication there. 
In medication building blocks it looks as follows: 
 [[Bestand:ENG_Voorschrijven_Annuleren eerder verstuurd voorschrift_a.png|800px]] 
 
The transactions look as follows: 
[[Bestand:ENG_Voorschrijven_Annuleren eerder verstuurd voorschrift_b.png]] 

===Modification of someone else's medicatieafspraak ===
A patient takes 40 mg Lisinopril once a day because of hypertension. This medicatieafspraak was previously made by the GP with the patient. The patient is admitted to the enters A&E department because of a fall due to dizziness. The specialist notices hypotension and decides to reduce the dose of Lisinopril to 20 mg once a day. The specialist then stops the current medicatieafspraak and starts the new medicatieafspraak with a lower dose. With this he changes the medicationafspraak with the patient. The specialist informs the original prescriber (the general practitioner) about this with a stop medicatieafspraak and the new medicatieafspraak.
The prescriber of the original medicatieafspraak adjusts the stop date in the original medicatieafspraak. If desired, this can also be automated by the information system. This prevents the second care provider no longer having to provide data over time because the delivery period has expired (including no stop MA) while the care provider of the original medication appointment continues to provide this incorrectly (without a stop date).
 
[[Bestand:ENG_Modification of someone else's medicatieafspraak.PNG|800px]]
 
===Setting up a variable dosing regimen (WDS) ===
The prescriber prescribes anticoagulants and states in the MA that the medication is used as recorded by the schedule of the thrombosis service (‘gebruik volgens schema trombosedienst). The prescriber sends a VV to the pharmacist and the patient is registered with the thrombosis service. In order to bridge the period until thrombosis care can take over, the prescriber creates a WDS for the first period. After registration, the thrombosis service creates a dosing regimen that overwrites or succeeds the previous regimen. From this moment on, the thrombosis service takes over creating the dosing regimen from the original prescriber.
[[Bestand:ENG_Uc_setting_up_WDS.png|800px]]

===Changing a variable dosing regimen (WDS) during period of use===
It could be necessary to revise the dosing regimen from a WDS before the scheduled stop date. For example, when the patient unexpectedly has to undergo minor surgery. In this case, the prescriber stops the current WDS with a technical stop (not visible to the user) and creates a new WDS with a few 0 doses the days before the procedure. In the meantime, the MA continues as usual.
[[Bestand:ENG_Uc_Changing_WDS.png|800px]]

===Stopping medication with a variable dosing regimen (WDS) ===
When the patient has to (temporarily) stop using anticoagulants completely, this is recorded at the level of the MA. The thrombosis physician creates a stop-MA. This also stops the underlying WDS and the associated TA. The original prescriber also processes the stop date in his MA.
If the anticoagulants needs to be restarted after several months, the original prescriber of the anticoagulant medication does this by following the process of starting a WDS. So by creating a new MA and a first WDS (see the use case [[#Setting up a variable dosing regimen (WDS)| Setting up a variable dosing regimen (WDS)]]). 
[[Bestand:ENG_Uc_stopping_WDS.png|800px]]

==Use case, Dispense==

===New medicatieafspraak, medicatieverstrekking of the same product===
The patient is at the pharmacist on 27 January 2013 to collect his medication. The pharmacist opens the file of the patient and verifies the medication file. It is a new medicatieafspraak for this patient. The relevant information of the prescribing physician is displayed on the screen of the pharmacist. 
Medicatieafspraak: ''Nitrofurantoin CR capsule, 100 mg, 1 capsule 2x daily, from now on for 5 days.'' 
Verstrekkingsverzoek: ''Nitrofurantoin CR capsule, 100 mg; 10 capsules.'' 
The pharmacist selects a product on the basis of the medicatieafspraak and other factors (such as the pharmacist’s stock and the preference policy of the healthcare insurer): 
''FURABID CR CAPSULE, 100 MG''. The pharmacist carries out medication monitoring using the information system, no (warning) signals are given. 
The pharmacist carries out pharmaceutical care (compliance, education, et cetera) and agrees with the patient on how she will use the medication. This toedieningsafspraak on 27 January 2013 reads: 
''FURABID CR CAPSULE, 100MG; 1 capsule 2x daily; from now on for 5 days''. The pharmacist provides the medication to the patient: 
''on 27 January 2013, FURABID CR CAPSULE, 100 MG; 10 capsules.'' The pharmacist actively informs the prescribing physician about the medicatieafspraak and the medicatieverstrekking. 
The information system of the pharmacist makes the new toedieningsafspraak and medicatieverstrekking available to the other health professionals of this patient.
 
 [[Bestand:ENG_Ter hand stellen_Nieuwe medicatieafspraak medicatieverstrekking zelfde product.png|800px]] 

===New medicatieafspraak, more precise product specification===
Here, the difference when specifying the product is that the toedieningsafpsraak and also the medicatieverstrekking deviates from the medicatieafspraak the patient has made with the prescribing physician. The process is otherwise the same as described in the previous paragraph.

'''Example''' 
''Medicatieafspraak: Nitrofurantoin capsule mga 100 mg, 1 capsule 2 times a day from today for 5 days.''

The pharmacist specifies a different product: 
''Nitrofurantoine MC Actavis capsule 50 mg.''
The pharmacist agrees with the patient on how she will use the medication. This toedieningsafspraak on 27 January 2013 reads: 
''Nitrofurantoin MC CR capsule 50 mg, 1 capsule 2x daily, from now on for 5 days.'' 
The pharmacist provides the medication to the patient: 
''on 27 January 2013, Nitrofurantoin MC Actavis capsule 50 mg; 20 pieces.''
 
 [[Bestand:ENG_Ter hand stellen_Nieuwe medicatieafspraak nadere specificering product.png|800px]] 

===Existing toedieningsafspraak is adequate===
The process of repeat medicatieverstrekking on the basis of an existing medicatieafspraak and possibly existing verstrekkingsverzoek and toedieningsafsrpaak occurs in case of repeat prescriptions and is described in [[#Splitting a prescription|paragraph 4.2.10]], situation 2.

===Medicatieafspraak wanted (informing the prescriber)===
'''Example 1 - adjusting dosage:''' 
For a 70-year-old patient with a creatinine clearance of 45 mL/min, the pharmacist enters a toedieningsafspraak for gabapentin tablets of 600 mg, 1 tablet 3x daily. Renal function has been recorded in the patient’s file at the pharmacy, and based on this a signal appears that the maximum dosage is 900 mg daily. The pharmacist sends the prescriber a proposed medicatieafspraak with an adjusted dosage of 300 mg, 3x daily, and the reason for this proposal (maximum dosage exceeded). The prescriber receives the proposed medicatieafspraak in his EVS. The prescriber sends an adjusted medicatieafspraak and possibly a reply proposed medication agreement (antwoord voorstel medicatieafspraak) back to the pharmacist.
 
 [[Bestand:ENG_Ter hand stellen_Medicatieafspraak gewenst - informeren voorschrijver_a.png|800px]] 
 
'''Example 2 – temporarily halting a medicinal product:''' 
For a 50-year-old patient with on oral fluconazole as part of his current medication, the pharmacist enters a toedieningsafspraak for simvastatin. A message appears with the advice to consider temporarily halting simvastatin. The pharmacist can make a proposed medicatieafspraak for halting the simvastatin (stoptype ‘temporary’). See example 1 for further steps.
 
 [[Bestand:ENG_Ter hand stellen_Medicatieafspraak gewenst - informeren voorschrijver_b.png|800px]] 
 
'''Example 3 – adding a medicinal product:''' 
For a 55-year-old woman, the pharmacist enters a toedieningsafspraak for prednisone, 10 mg daily for three months. The patient is not using osteoporosis prophylaxis. A message appears with the advice to add a biphosphonate drug and to check whether the patient is taking calcium and vitamin D. If the patient is not, the pharmacist can make a proposed medicatieafspraak for these products. See example 1 for further steps.
 
 [[Bestand:ENG_Ter hand stellen_Medicatieafspraak gewenst - informeren voorschrijver_c.png|800px]] 
 
PLEASE NOTE: it will depend on the situation whether it is useful to create an automated proposal for adjustment/addition of a MA. If the advice is complex, it may still be useful to phone and to consult instead of sending a digital proposal. 
The proposed medicatieafspraak may help the prescriber to enter this change in the system. The latter is important when medicatieafspraken are consulted, for example, by service observation general practitioners.

===Request and dispense ===
When a medicatieafspraak and verstrekkingsverzoek arrives at the pharmacy, it is processed by the pharmacy information system as an intended medicatieverstrekking. This is called the request date, which is captured as the request date of the medication dispensing The date of dispensing is only registered at the moment of pick up or hand over of the medication. The pharmacist informs the prescriber about the handling of the prescription (toedieningsafspraak and/or medicatieverstrekking).

It is possible to create multiple dispensings under the same toedieningsafpsraak:
*A verstrekkingsverzoek comes in with a medicatieafspraak with a one-year use period
*There will be a first provision with a new toedieningsafspraak and a medication supply that is sufficient for, for example, a period of 4 months.
 [[Bestand:ENG_Ter hand stellen_Aanschrijven en verstrekken_a.png|800px]] 

*The second dispensing is performed based on the existing medicatieafpsraak, verstrekkingsverzoek and toedieningsafspraak (no new prescription or new administration appointment is needed). The new second medication dispensing (with new write-up date and the pre-existing associated toedieningsafspraak) is sent to the prescriber when the dispensing date is registered.
 [[Bestand:ENG_Ter hand stellen_Aanschrijven en verstrekken_b.png|800px]] 

===Patient requests repeat prescription via physician (reactive repeat)===
A physician has previously diagnosed hypertension in a patient (57 years old) and has prescribed the patient medication for this. The patient uses this medication and the medication is running out. The patient makes a request to repeat the medication, for example through the repeat line, by phone, by email to the practice, counter/boxes, website, app or portal of the physician. The physician approves the repeat. This leads to a new verstrekkingsverzoek. 
For example:
The general practitioner makes, in the context of the medicatieafspraak of 30 March 2010:
:''Nifedipine CR 30 mg; 1 tablet 1x daily, from 30 March 2010 for an indefinite period''
on 13 April 2013 a verstrekkingsverzoek to a pharmacist chosen by the patient:
:''Nifedipine, CR tablet, 30 mg; ‘for three months’.''
In consultation with the patient, the prescriber can send the verstrekkingsverzoek with the corresponding medicatieafspraken and toedieningsafspraken as an order to a pharmacy of the patient’s choice. The prescriber also makes the new verstrekkingsverzoek available to fellow health professionals and the patient. The existing medicatieafspraken had already been made available. 
 [[Bestand:ENG_Ter hand stellen_Patiënt vraagt herhaalrecept via arts - reactief herhalen.png|800px]] 
The pharmacist receives the verstrekkingsverzoek together with the medicatieafspraak and processes it in accordance with the dispense process and starts with the pharmaceutical care process step.

When the patient, on the basis of a toedieningsafspraak or on the basis of his medicatiegebruik asks for a repeat prescription, and the medicatieafspraak is not digitally available, the physician creates a new medicatieafspraak based on this toedieningsafspraak or the patient’s medicatiegebruik of the medication. No reference is made to the existing medicatieafspraak in that case.

===Patient requests repeat prescription via pharmacist (informing prescriber)===
The patient requests a repeat medication from the pharmacist, for example through repeat line, by phone, email, counter/boxes, website, app or portal of the pharmacist. 
The pharmacist sends a proposed verstrekkingsverzoek for authorisation to the prescriber. The physician evaluates the proposed verstrekkingsverzoek and approves it. He informs the pharmacist via the reply proposed verstrekkingsverzoek and sends a new verstrekkingsverzoek together with the current agreements to the pharmacist. The pharmacist continues the dispense process and starts with the pharmaceutical care process step. 
Patiënt vraagt herhaalrecept via arts (reactief herhalen)
 [[Bestand:ENG_Ter hand stellen_Patiënt vraagt herhaalrecept via apotheker - informeren voorschrijver.png|800px]] 
 
If the prescriber does not provide a verstrekkingsverzoek, he informs the pharmacist via the answer proposed verstrekkingsverzoek.

===Proactive repeat prescription by pharmacist (informing prescriber)===
The patient has signed up in the past for proactive repeats and the pharmacist has registered this in his proprietary pharmacist information system (PIS). The repeat module of this information system will generate a signal when a patient needs new medication. When a new verstrekkingsverzoek is needed, this is similar to the process described in the previous paragraph, only the trigger is not the patient but the pharmacist (or his information system). Proactive repeats are also used for GDS, see [[#Starting and continuing a GDS|paragraph 4.2.11]].
 [[Bestand:ENG_Ter hand stellen_Proactief herhaalrecept door apotheker - informeren voorschrijver.png|800px]] 
 

===Dispense based on an existing verstrekkingsverzoek===
The patient submits a repeat prescription to the pharmacist. In this case, it is a request for medicatieverstrekking on the basis of an existing, still valid, verstrekkingsverzoek. See [[#Splitting a prescription|paragraph 4.2.10]] situation (3).

===Splitting a prescription===
The patient has been using the same medication for a number of years, which means that the medicatieafspraak can be created for an indefinite period. The toedieningsafspraak is also valid for an indefinite period. In such a case, the patient can be given a prescription for a year. This single year prescription will be split into several prescriptions by the pharmacist. These split prescriptions are commonly called ‘repeat prescriptions’, even though strictly speaking this is not true.

There are three possible situations: 
1) The patient returns to his attending physician still suffering from the same symptoms. The prescriber prescribes the same medication (in the case of an expired medicatieafspraak, a new medicatieafspraak is created with a new verstrekkingsverzoek and in the case of a medicatieafspraak that is still valid, only a new verstrekkingsverzoek is created). 
 [[Bestand:ENG_Ter hand stellen_Knippen van recept_a.png|800px]] 
 
2) Prescriber and patient initially agree on 90 tablets with 3 repeat prescriptions. The patient receives the first 90 tablets. The next time the patient visits the pharmacist, a medicatieverstrekking is made under the existing agreements. 
 [[Bestand:ENG_Ter hand stellen_Knippen van recept_b.png|800px]] 
 
3) Prescriber and patient initially agree on 360 tablets for one year. The pharmacist splits this into 4 separate occasions of medicatieverstrekking. The patient is initially dispensed 90 tablets and without a new verstrekkingsverzoek, can go to the pharmacist 3 more times to pick up another 90 tablets each time. 
Situation 3 best describes the way in which a pharmacist splits a year prescription. 
 [[Bestand:ENG_Ter hand stellen_Knippen van recept_c.png|800px]] 
 

===Starting and continuing a GDS===
The following example shows the process for one medicinal product used by the patient for an indefinite period of time. The information system of the prescriber and the pharmacist contains (among other things) the following data on a patient:
*The medicatieafspraak of 2 January 2013 reads: Metoprolol, CR tablet, 100 mg (succinate); 1x tablet daily; from 2 January 2013 for an indefinite period.
*The toedieningsafspraak of 2 January 2013 reads: Metoprolol PCH retard, 100 CR tablets of 95 mg; 1x tablet 1x daily; from 2 January 2013 for an indefinite period.
This elderly patient is taking so much medication that he has problems overseeing it all: a potentially dangerous situation. On 6 February, the pharmacist and the prescriber agree that the medicatieverstrekking of medicinal products to this patient will take place via GDS.

The GDS is started: the pharmacist sends a proposed verstrekkingsverzoek (a similar event to the current combined prescription or authorisation form).

The proposed verstrekkingsverzoek of 6 February reads:
*Verstrekkingsverzoek for the medicatieafspraak of 2 January 2013: Metoprolol, CR tablet, 100 mg (succinate), and a period of use to ensure enough stock up to and including 1 May 2013.
The pharmacist sends the proposal to the prescriber. The prescriber approves the proposal on February 6 and sends it unchanged to the pharmacist as a verstrekkingsverzoek. The GDS indicator is switched on in the information system of the prescriber as well as in the pharmacist’s information system.

The pharmacist and the patient select a partial duration for the product. This toedieningsafspraak reads as follows:
*On 7 February it was agreed: Metoprolol PCH retard, 100 CR tablets of 95 mg, 1 tablet in the morning, from 11 February (week 6), for an indefinite period.

Every second week, the pharmacist dispenses a Baxter medication roll containing (among other things) the metoprolol:
*Medicatieverstrekking 1: The pharmacist dispenses, on Friday, 8 February 2013: 14 tablets, scheduled for weeks 6 and 7 (a period of use of 2 weeks).
*Medicatieverstrekking 2: The pharmacist dispenses, on Friday, 22 February: 14 tablets, scheduled for weeks 8 and 9.
*Medicatieverstrekking 3, 4, 5, etc.
With each medicatieverstrekking, it is indicated that medicatieverstrekking was carried out via GDS.
After three months, there is a new proposed verstrekkingsverzoek from the pharmacy to the prescriber, etc.
 
 [[Bestand:ENG_Ter hand stellen_Het opstarten en continueren van GDS.png|800px]] 
'''Consideration ''' 
*The application of a proposed verstrekkingsverzoek instead of an authorisation form makes its meaning unambiguous.
*In the current situation, toedieningsafspraken and medicatieverstrekkingen are registered as a single dispense. This makes it difficult to find useful information in the large number of messages. By dividing the dispense order into two building blocks, the overview is easier to understand: there are no new medicatieafspraken and only one new toedieningsafpsraak is created. There are no hidden surprises in the remaining logistical data and the prescriber does not have to monitor the multiple medicatieverstrekkingen.
*This way of registering and exchanging prevents double registration, and errors caused by this.
*The toedieningsafspraken are the basis for the administration list and checklists of nursing homes and care homes. Signing them corresponds to the administration(s).

===The pharmacist changes commercial product===
This scenario builds on the previous scenario: after half a year a different commercial product is agreed with the patient (toedieningsafspraak), because the original product is not available. No new medicatieafspraak is made, as there is no change needed on that level. The toedieningsafspraak is changed:
*On 1 July it was agreed: Metoprolol Sandoz ret, 100 CR tablets, 95 mg, 1 tablet in the morning; from 3 July, for an indefinite period. Reason: not available.
The toedieningsafspraak is a modification of the toedieningsafspraak of 7 February, which stops on 2 July (11:59 p.m.) and is an actual handling of the medicatieafspraak of 2 January. The pharmacist informs the general practitioner about this. 
 [[Bestand:ENG_Ter hand stellen_De apotheker wijzigt van handelsproduct.png|800px]] 
'''Consideration ''' 
This change in the actual handling of the medicatieafspraak using a toedieningsafspraak, changes nothing to the validity of the medicatieafspraak itself, improving the overall view for all parties. In addition, since the pharmacist records and communicates the reason for the adjustment, the prescriber is better able to assess whether the information is relevant.
 

===Adding medication to a GDS===
When new medication is added to an existing GDS, the prescriber may opt for immediate addition to the current roll (Change in GDS immediately) or for addition starting from the next roll (Change in GDS per change of roll). The prescriber indicates this in the medicatieafspraak (Additional information).

If ‘Change in GDS immediately’ is chosen, the pharmacist will first dispense the medication separately, in addition to the existing GDS. This means that a toedieningsafspraak is created by the pharmacist for the bridging period. Starting with the new roll, the new medication is added to the roll. Starting with the start date of the new roll, a toedieningsafspraak can be made by the pharmacists with specific administration times. If the ‘bridging-toedieningsafspraak’ already includes the correct administration times, no new toedieningsafspraak is created at the date of inclusion in the roll. 
 [[Bestand:ENG_Ter hand stellen_Medicatie toevoegen aan GDS.png|800px]] 
 
If 'Change in GDS per change of roll' is chosen, the pharmacist will start to include the medication in the roll on the start date of the first new roll. In this case, a toedieningsafspraak for the bridging period is not required.

===Discontinuing medication in a GDS===
When medication is discontinued, the prescriber creates a discontinuation-medicatieafspraak. In accordance with the process, the pharmacist is informed about this stop-MA and can adjust the medicatieverstrekking accordingly. The pharmacist will create a staken toedieningsafspraak . See [[#Discontinuing medication|paragraphs 2.2.5.3]] and [[#Discontinuing a toedieningsafspraak|2.3.6.3]].

===GDS supplier supplies other commercial product===
It is possible that a GDS supplier delivers a different commercial product than that which is included in the toedieningsafspraak by the pharmacy. This is therefore a change in the HPK which results in a changed toedieningsafpsraak. This may only be afterwards, after feedback from the GDS supplier of the filling details.
 
 [[Bestand:ENG_Ter hand stellen_GDS leverancier levert ander handelsproduct.png|800px]] 

===Parallel administration agreements with GDS- and non-GDS-dispense===
A patient takes two to three times daily 20 mg pantoprazole because of gastric complaints. The first two tablets are fixed dosages, which are dispensed in GDS. The third tablet, which is prescribed as needed, is dispensed separately. At a certain moment, Sandoz is unable to supply the pantoprazole 20 mg for separate dispenses. Therefore, the pharmacist decides to dispense from Apotex. He stops the current TA and splits the TA in two TA’s, both with the same start date/time. The first TA concerns the fixed dosage in GDS, the second TA involves the as needed tablet. 
''NB. Currently, there is no relationship between medication dispense and TA. Therefore, it is only possible to retrieve which TA is associated with the medication dispense by assessment of the data content. It is evaluated whether the functional design should be adjusted for this use case in the future. 
''
 
[[Bestand:ENG-Uc4.2.16.png|800px]]
 

===Handling a stop medicatieafspraak===
When the prescriber agrees to discontinue medication, a stop medicatieafspraak is created. This stop-MA this processed by the pharmacist by discontinuing the corresponding toedieningsafspraak.

===Medication dispense with someone else’s administration agreement===
A patient takes two times daily 20 mg pantoprazole because of gastric complaints. During the holidays the patient notices that he has forgotten to bring his medication. He visits the after hours general practice clinic and asks for extra tablets for during his holidays. The after hours physician sends a VV to the after hours pharmacy, using an existing MA. 
The after hours pharmacist reads the medication prescription and creates an MVE, using the existing TA, for the ten tablets that the patient needs. The pharmacist notifies the after hours physician about the medication dispense, and sends a copy of the original TA. 
''NB. Although the original prescriber and supplier do not receive an automatic notification, the data will be made available to them.'' 
 
[[Bestand:ENG-Uc4.2.18.png|800px]]
 

===Modification of someone else’s administration agreement===
A patient takes two times daily 20 mg pantoprazole because of gastric complaints. During the holidays the patient notices that he has forgotten to bring his medication. He visits the after hours general practice clinic and asks for extra tablets for during his holidays. The after hours physician sends a VV to the after hours pharmacy, using an existing MA. 
The after hours pharmacist notices that they have no pantoprazole from Sandoz in stock, but they do have pantoprazole from Apotex. Therefore, she stops the current TA, starts a new TA for the Apotex, and creates an MVE for the ten tablets from Apotex. The after hours pharmacist notifies the original pharmacist and, subsequently, the original pharmacist processes the stop-TA. 
 
[[Bestand:ENG-Uc4.2.19.png|800px]]
 

==Use cases, Administer ==

===Creating an administration list===
When an administration list has to be created, for example when a patient starts to receive medication administered by a (professional) administrator, or when GDS medication or non-GDS medication is started, an intake is planned with the patient and the prescriber, pharmacist or administrator (the exact process may differ across institutions). Then, the prescriber, pharmacist, administrator and/or the patient consult on the administration list (which medication is recorded on the administration list, which (guide) administration times are suitable). The pharmacist enters the (guide) administration times in the TA and (actively) makes the relevant medication data available for the administrator and/or the patient.

===Exact administration times required===
When exact administration times are required, for example because of medication interactions, the prescriber or the pharmacist can indicate that an exact administration time is required (the administration time is not a guideline but denotes an exact time). The prescriber or pharmacist can register an exact administration time by indicating that the administration time is not flexible. By default, administration times are flexible. Exact administration times should be presented on the administration list, to ensure that the administrator is informed that it is not allowed to deviate from the entered administration time.

===Missing (guide) administration times===
When (guide) administration times are missing in the MA and TA, an administrator will contact the prescriber or pharmacist to retrieve the (guide) administration time. This is not supported digitally in this information standard.

===Non-GDS medication as needed===
Non-GDS medication as needed is included in the administration list, but is not listed according to the administration moment and/or administration time, because this information is not available beforehand. If relevant (for example because of drug interactions), (guide) administration times can be entered. See the following use cases for practical examples: [[#Medication as needed|4.1.4 Medication as needed]], [[#Course of treatment as needed starting in future|4.1.5 Course of treatment as needed starting in future]], [[#Two dosages of the same medication at the same time|4.1.6 Two dosages of the same medication at the same time]], [[#The same medicinal product with different strengths at the same time|4.1.7 The same medicinal product with different strengths at the same time]].

===Medication supply by multiple pharmacies===
Multiple pharmacies may be involved in the medication supply for one patient, for example in the following situations: medication supply by an outpatient pharmacy, in addition to supplies by a community pharmacy or supplies of add-on medication by a hospital pharmacy. In the case of medication supply by multiple pharmacies, each pharmacist is responsible for the medication data that is required for the administration list, including the (guide) administration times in the TA. It is the responsibility of the prescriber or pharmacist who has made the most recent medication adjustments to determine whether an addition/modification is appropriate with regard to the total of (known) medication data; this concerns both medication monitoring and (guide) administration times. The medication data is (actively) made available, in order to enable that all medication data from different pharmacies are compiled in one administration list.

===Change in GDS from the next supply or immediately===
If GDS medication is altered, it depends on the situation whether this change should occur immediately or from the next supply. The prescriber can indicate in the MA when the change in GDS medication should be implemented. An immediate modification should be immediately shown on the administration list, to ensure that the (professional) administrator administers the correct (amount of) medication. In contrast, a modification that should be implemented from the next supply, should not be processed immediately in the administration list, since previous agreements remain valid until the next supply. Thus, the administration list should not be modified until the change in GDS modification has become effective.

See also use case [[#Adding medication to a GDS|4.2.13 Adding medication to a GDS]].

===Increasing dosage of GDS in new MBH===
A patient is administered 1 tablet propranolol 40 mg 1 time a day. Due to insufficient effects, the prescriber decides to increase the dosage to 80 mg 1 time a day. A new MBH is created for this MA, as there is a change on prescription level. However, the patient still has the 40 mg tablets in the GDS medication roll for the coming days. Therefore, the pharmacists decides to supplement the GDS medication with the administration of 1 tablet propranolol 40 mg, separately from the GDS package, in addition to the tablet in the GDS package, until the next GDS medication roll change in 5 days. The pharmacists creates two TAs: one for the previous GDS medication and one for tiding over the period with medication dispense separately from GDS. In the new GDS supply (medication roll change), the 80 mg tablets are incorporated in this new GDS package. 
 [[Bestand:ENG_Toedienen_Verhogen dosering GDS-medicatie in nieuwe MBH_beta.png|800px]] 

===Decreasing dosage of GDS in new MBH===
A patient is administered 1 tablet propranolol 80 mg 1 time a day. Due to a too strong effect, the prescriber decides to reduce the dosage to 40 mg 1 time a day. A new MBH is created for this MA. The patient still has 80 mg tablets in the GDS medication roll for several days. Because the administrator is not allowed to divide the tablets into halves, the supplier decides that the remaining GDS packages should be collected the same day and be replaced by a new GDS medication roll with 40 mg tablets. 
 [[Bestand:ENG_Toedienen_Verlagen dosering GDS in nieuwe MBH_beta.png|800px]] 
 

===Change processed by the pharmacist===
A change by the prescriber, such as starting new medication, adjusting the dosage, (temporarily) halting medication, is recorded by the prescriber in the MA and/or the VV. Then, the pharmacists processes this change in the TA and/or the MVE. This may be done during the opening hours of the community pharmacist, or after hours when a medication dispense is needed. The after-hours pharmacist dispenses the medication; in this case, multiple pharmacists are supplying medication (see also paragraph 4.3.9). The medication data of the pharmacist(s) and the prescriber(s) are (actively) made available by the prescriber and the after-hours pharmacist to the administrator for the administration list.

===Change not processed by the pharmacist===
When medication is changed by a prescriber after the opening hours of the community pharmacist and medication dispense is not needed, no pharmacist is involved. In that case, the MA is decisive, and the prescriber (actively) makes the MA available. The administrator will be informed of the changed or stopped MA by the administration list; this MA overrules all medication building blocks within the same MBH. This situation also applies if the pharmacist has not processed the modification by the prescriber yet. The pharmacist is responsible for adjusting the TA as soon as possible.

===Variable-dosing regimen===
If a physician prescribes medication with a variable-dosing regimen, the dosing schedule of this medication may be specified by another physician. For example, this applies to thrombosis medication: the prescriber defines the therapeutic INR range (International Normalized Ratio, a measure for the coagulation time of blood), but refers the patient to the thrombosis service for defining the exact dosing schedule. The ‘trombosearts’ (physician affiliated to the thrombosis clinic, who is specialized in the management of anticoagulation therapy) enters the variable-dosing regimen in the medication building block WDS. The prescribing physician remains responsible for the supplies, the ‘trombosearts’ specifies the dosing regimen based on the therapeutic INR range. As the WDS is a separate medication building block, the medication overview remains unchanged (the MA is specified, not altered by the WDS). The WDS is used to compile the administration list, together with the medication data in the MA, TA, MVE and MTD.

===Changing a variable-dosing regimen===
If a dosing schedule is adjusted, the information system closes the current WDS, using a technical stop (not visible to the user). This new WDS is related to the MA and the previous WDS.

===Stop of medication with variable-dosing regimen===
Anticoagulation medication may be (temporality) halted for several reasons; for example, in the case of a medical procedure. Depending on the situation and based on professional judgment, the ‘trombosearts’ can choose one of the following two methods: 

'''A. (temporarily) adjusting the medication regimen''' 
In certain situations, the ‘trombosearts’ may choose to temporarily set the anticoagulation medication to zero, for example, in the period before the planned medical procedure. The MA (and, therefore, the treatment with anticoagulation medication) continues, but in the WDS, the dosage is temporarily adjusted to zero. In such situations, it is advisable to exchange the reason for the WDS change as well. 
 [[Bestand:ENG_Toedienen_Stoppen medicatie met wisselend doseerschema_a_beta.png|800px]] 
'''B. (temporarily) halting the anticoagulation medication''' 
Alternatively, the ‘trombosearts’ may choose to (temporarily) halt the anticoagulation medication. In this case, the ‘trombosearts’ creates a stop-MA. This implies that the underlying WDS and the related TA are stopped as well. If the MA should be restarted or adjusted after a certain period, this is done by the initial prescriber of the anticoagulation medication. In general, the thrombosis service may not be involved any more (temporarily); however, if the thrombosis service is still involved, the ‘trombosearts’ may send a VMA to the initial prescriber who can adopt this proposal in an MA. 
 [[Bestand:ENG_Toedienen_Stoppen medicatie met wisselend doseerschema_b_beta.png|800px]] 
 

===Additional information===
Additional information is an extra explanation about the medication use for the (professional) administrator and/or the patient. An example is the situation when fentanyl patch therapy is stopped; additional information is that the patch has to be removed. Another example is the dosing of half a tablet; the additional information contains the instruction what should be done with the other half. This information can be entered as free text, as a comment in the MA, TA and/or WDS.

See use case [[#Explanation in medicatieafspraak with deliberately chosen special characteristic|4.1.8 Explanation in medicatieafspraak with deliberately chosen special characteristic]] for more information.

===Medication administration deviates from administration list===
It may happen that the administration deviates from the instructions as entered by the prescriber and pharmacist in the MA or TA. This may be a deviation in administration time, administered amount, administration route, administration speed, administered product or no administration. A (professional) administrator can deviate from the rules, in consultation with the prescriber, for valid reasons, and under the condition of safe medical practice and safe working practice. The reason for deviation can be entered in the MTD.

===Medication administration without medication agreement and administration agreement===
In the case of an emergency, the MA and TA may be missing and, therefore, the (professional) administrator has to administer medication on the basis of an MA which is communicated verbally/by telephone. This medication is not incorporated in the administration list. In this situation, the (professional) administrator records the MTD in the information system of the administrator (including ECD, TDR). This is the first building block in a new pharmaceutical treatment; therefore, the administrator creates an MBH.

===Medication administration of self-care medication===
According to the safety principles in the medication chain, the administrator is not concerned with the administration of self-care medication, except for prescribed selfcare medication (a prescriber has created an MA). In that case, the self-care medication is listed on the administration list as GDS medication or non-GDS medication (as needed).

===Correction/cancellation of an administration===
This concerns correcting or cancelling an MTD, because an administrator has made a mistake in the registration and no medication has been administered. If the MTD has not been exchanged with other health professionals, the administrator can adjust the MTD by himself, or remove (cancel) the registration from his own information system. If the MTD has been exchanged with other health professionals, the administrator cancels this erroneous MTD and creates a new MTD under the same MBH with the correct information. The administrator (actively) makes the corrected MTD and the new MTD available.

===Medication administration on hold===
It may happen that the medication administration was unsuccessful, but that is still possible to administer the medication on a later moment, in consultation with a prescriber or pharmacist. If the medication administration is in keeping with the agreements on flexible administration times, the administrator is allowed to deviate from the (guide) administration time.

An example of suspending the medication administration:
* Medication administration is unsuccessful, but the medication can be administered on a later (or, in some cases, earlier) moment of the day. In this situation, the medication administration is suspended, and there is a deviation from the administration list.

===Medication administration by a prescriber===
A prescriber, similarly to a (professional) administrator, is able to administer medication to a patient, and record this procedure in an MTD.

===Multiple administration organizations===
Multiple administration organizations may be involved in a patient’s medication administration. For example, medication may be administered by another organization during the evening/night than during the day. If multiple administration organizations are involved in providing patient care, these health professionals can consult each other’s MTDs to track the process of medication administration. The acts of one organization can affect the process of another organization (for example, has medication been administered, have there been deviations from the administration list, etc.).

===Feedback to patient through a medication adherence app===
In this example the patient uses an app on his mobile phone to help manage his medication. The patient or the pharmacist has created an administration schedule with reminder times (where possible using the app to obtain the toedieningsafspraken from the medicatietoediening). When it is time to take his medication, the patient receives a reminder signal from the app. The patient registers the medication administration and thus indicates whether he has taken the medicine or not (for instance because he forgot to bring it along with him). If the app is linked, for example, to the patient’s PGO (personal health file), medication adherence is tracked automatically.
 
[[Bestand:ENG_Feedback_to_patient_through_a_medication_adherence_app.PNG|800px]] 
 


==Use cases, Medicatiegebruik==

===Self-care product===
A patient has acquired Ibuprofen from the drugstore and takes 1200 mg every day. The patient enters this product as gebruik, with such data as starting dates and dosage, and possibly the reason for medicatiegebruik.
 [[Bestand:ENG_Gebruik_Zelfzorgmiddel.png|800px]] 

===Medication from abroad===
A patient has been prescribed medication on holiday and is taking this. The patient enters the medication as gebruik, with data such as start date and dosage, and possibly the reason for medicatiegebruik. If known, the name of the prescriber is also recorded.
 [[Bestand:ENG_Gebruik_Medicatie uit buitenland.png|800px]] 

===Modification on the patient’s initiative===
The patient has been prescribed propranolol. The patient is having severe problems sleeping because of this and has reduced the medication herself. The patient records gebruik with the modified dosage and the start date for this lower dose. The patient also indicates that she initiated this change herself. In the case where a patient initiates a dose reduction, the patient can keep on using the medication for a longer period than initially agreed because she still has a supply. The patient can indicate this as additional gebruik. 
In the case where a patients initiates a dosage increase, the patient’s supply may run out sooner. The patient may then have to return to the physician earlier than expected.
 [[Bestand:ENG_Gebruik_Wijziging op initatief patiënt.png|800px]] 

===Discontinuation of medication on the patient’s initiative===
Since he started using propranolol, the patient suffers from insomnia. He decides to stop without immediately informing the prescribing physician. The patient himself records that he has discontinued medication, indicating the date and giving insomnia as the reason for discontinuing. 
[[Bestand:ENG_Gebruik_Stoppen medicatie op initatief patiënt.png|800px]] 

===No more supply===
A patient has received medication ‘as needed’ for his skin problems. The medication is still active in the medication profile, but is no longer available at the pharmacist. The patient indicates that the medication has been discontinued because it is no longer available, possibly with the addition that the symptoms have disappeared.
 
[[Bestand:ENG_Gebruik_Geen voorraad meer_a.png|800px]] 
 
The patient may also make a proposed verstrekkingsverzoek to replenish his supply In this case, the reply proposed verstrekkingsverzoek comes back to the patient (and if approved, a verstrekkingsverzoek is also sent from the prescriber to the pharmacist). 
[[Bestand:ENG_Gebruik_Geen voorraad meer_b.png|800px]] 

===Registrations of abnormal medicatiegebruik by patient due to adverse drug reactions===
Since he started taking propranolol, a patient has been suffering from insomnia. The patient records this side effect in the explanatory notes to the medicatiegebruik. When the patient changes the medicatiegebruik of this medication from what was previously agreed, for example when he takes less tablets, he can give the side effect as a reason for this change. When his symptoms diminish or cease, the patient records this in the explanation for medicatiegebruik. 
It is possible that the patient is suffering from side effects without exactly knowing which medicinal products cause them. There is no provision within medication process to record this (yet).

===Register medicatiegebruik based on provision===
This applies in the transition period from the old medication process standard 6.12 to this medication process information standard.

Only verstrekking (dispensing) is available digitally (according to medication process version 6.12). However, the user's information system offers the possibility to record all medicatiegebruik. In that case, the medicatiegebruik can be recorded with reference to the ID of the version 6.12 verstrekking.
 
[[Bestand:ENG_Gebruik_Gebruik registreren op basis van verstrekking.png|800px]] 

=Medication overview and inference rules=
This chapter shows a sample medication overview and also specifies inference rules for 'The most current relevant building block', Verification for each medicamenteuze behandeling, etc.

==Introduction==
The term 'current medication overview' has been replaced by the term 'basisset medicatiegegevens’ (basic set of medication data): the medication overview in combination with additional information that is required (at least) to be able to prescribe, change, stop or safely provide medication in a safe and responsible manner in the Transfer of Medication Data in the Chain (Leidraad Overdracht van Medicatiegegevens in de keten, final draft 2017).

This page contains an example of a medication overview. This example was developed in the Medication Process Information Standard program and serves as an example of how data can be displayed in an application. The data numbered in the pictures below are normative, they are mandatory to show. The other (unnumbered) data in the example is optional and may be added as normative in the future. The layout of the overview in a information system can differ per target group and per device. For pharmacists, for example, only toedieningsafspraken are initially visible, after which it is possible to click further to get to the corresponding medicatieafspraak and the medicatiegebruik. If only medicatiegebruik or a medicatieafspraak is known, this will of course be shown immediately. The basic principle is that the overview shows all medication of the patient, not just the medication that is registered in the patient's own information system.

The overview is described generically and therefore the same for all suppliers. The requirements of the end users are included on this page and no statements are made about the technical realization or implementation. The existing KNMP specification “User requirements specification Medication overview 2.0”, final concept “Guidance Transfer of Medication data in the chain (Leidraad OVerdracht van Medicatiegegevens in de keten)” and the new insights from the Medication process program have been incorporated in this.

Principles for the overview are:
*Health professionals want to see a distinction between the therapeutic building blocks on a medication overview:
**Medicatieafspraak
**Toedieningsafpsraak
**Medicatiegebruik
*Logistical building blocks (verstrekkingsverzoek, dispensing) and the medicatietoedieningbuilding block are not relevant for the medication overview.

[[Bestand:Medicatieoverzicht_1_v0.5.PNG|Medicatieoverzicht v0.5]]
[[Bestand:Medicatieoverzicht_2_v0.5.PNG|Medicatieoverzicht v0.5]]

==Functional specification==
In the figures below the parts with normative data are included. The other parts are not yet normative. The numbered elements in the table are normative, other elements are optional for the time being.

===Heading and General===
[[Bestand:Medicatieoverzicht_KopAlgemeen_v0.5.PNG]]

Filter: N/A

Sort: N/A

Medication Overview Date: This is the date that the last change to a medicatieafspraak, toedieningsafspraak or medicatiegebruik was recorded within the information system providing the medication overview.

NOTE: In the viewer, all dates are shown with the month in characters, so that there is no confusion between day-month and month-day (American format).

{| class="wikitable"
|-
! No !! Header !! Dataset !! Explanation
|-
| 1 || Name || Patient – Name data (Initials, Surname, PartnerSurname), Date of Birth, Gender ||
|-
| 2 || Telephone || Patient – Contact data – Telephone numbers || Primary telephone number of patient
|-
| 3 || BSN || Patient – Patient identification number || Always BSN
|-
| 4 || Adress || Patient – Address data ||
|-
| 5 || Healthcare Provider Name || Healthcare Provider – Organization name || Healthcare Provider who has compiled the medication overview
|-
| 6 || Healthcare Provider Adress || Healthcare Provider – Address – Address data || Healthcare Provider who has compiled the medication overview
|-
| 7 || Healthcare Provider Telephone || Healthcare Provider – TelephoneMail – Contact data – Telephone numbers || Healthcare Provider who has compiled the medication overview
|-
| 8 || Healthcare Provider Email || Healthcare Provider – TelephoneMail – Contact data – Email addresses || Healthcare Provider who has compiled the medication overview
|-
| 9 || Date of Medication Overview || Document data – Document date ||
|-
| || Height|| Body height – HeightValue, HeightDateTime ||
|-
| || Weight|| Bodyweight – WeightValue, WeightDateTime ||
|-
| || Checked by Health professional || Document data – Verification by health professional ||
|-
| || Verified with Patient/Informal Caregiver || Document data – Verification by patient ||
|}
Elements 5 through 8 are not shown if the patient is the creator of the medication summary.

===Contraindications and hypersensitivities (CiO)===
[[Bestand:Medicatieoverzicht_ICA_v0.5.PNG]]

Active contraindications and hypersensitivities (intolerances, allergies/adverse reactions) (in Dutch: 'contraindicaties en overgevoeligheden' - CiO).

Filter: end date is not filled, is in the future or was less than a year ago when compiling the overview.

Sort: most recent effective date at the top.

This part will be elaborated at a later time and is not yet normative.

===Current medication===
[[Bestand:Medicatieoverzicht_HuidigeMedicatie_v0.5.PNG]]

Filter: all current medication, i.e. all medicatieafspraken and toedieningsafspraken that apply at the time the overview is compiled and the associated medicatiegebruik per source. The temporarily interrupted medication is also shown in this category. When only medicatiegebruik is known, it is shown if it is not older than 13 months. When medicatiegebruik is recorded by both a health professional and a patient, the last registered medicatiegebruik is shown for both.

Sorting: by medicamenteuze behandeling (MBH): medicatieafspraak, toedieningsafspraak, medicatiegebruik (recorded by patient, care provider). Medicamenteuze behandelingen are sorted in descending order by startdate medicatieafspraak, toedieningsafspraak, medicatiegebruik.

{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| '''No'''
! style="text-align:left;"| '''Header'''
! style="text-align:left;" colspan="3"| '''Dataset'''
|-
|style="background-color: white;vertical-align:top;"|1
|style="background-color: white;vertical-align:top;"|Type
|style="background-color: white;vertical-align:top; text-align:center;"|Medicatieafspraak
|style="background-color: white;vertical-align:top; text-align:center;"|Toedieningsafspraak
|style="background-color: white;vertical-align:top; text-align:center;"|Medicatiegebruik
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|2
|style="background-color: white;vertical-align:top;" rowspan="2"|Medicinal product
|style="background-color: white;vertical-align:top; text-align:center;"|Agreed medicinal product-
|style="background-color: white;vertical-align:top; text-align:center;"|Medicinal product belonging to Toedieningsafspraak-
|style="background-color: white;vertical-align:top; text-align:center;"|Device-
|-
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Product – ProductCode (if absent: ProductSpecification, ProductName)
|-
|style="background-color: white;vertical-align:top;"|3
|style="background-color: white;vertical-align:top;"|Start date
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Start date
|-
|style="background-color: white;vertical-align:top;"|4
|style="background-color: white;vertical-align:top;"|End date/duration
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|End date (if not available: Duration)
|-
|style="background-color: white;vertical-align:top;"|5
|style="background-color: white;vertical-align:top;"|Dosage
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Instructions for medicatiegebruik – Description
|-
|style="background-color: white;vertical-align:top;"|6
|style="background-color: white;vertical-align:top;"|Route of toediening
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Instructions for medicatiegebruik – Route of toediening
|-
|style="background-color: white;vertical-align:top;"|7
|style="background-color: white;vertical-align:top;"|Reason
|style="background-color: white;vertical-align:top; text-align:center;"|Reason for prescribing &
if applicable reason for discontinuing/suspending medication
|style="background-color: white;vertical-align:top; text-align:center;"|Reason for discontinuing/suspending medication
|style="background-color: white;vertical-align:top; text-align:center;"|Reason for discontinuing/suspending medication
|-
|style="background-color: white;vertical-align:top;"|8
|style="background-color: white;vertical-align:top;"|Explanation
|style="background-color: white;vertical-align:top; text-align:center;" colspan="2"|Explanation & additional information
|style="background-color: white;vertical-align:top; text-align:center;"|Explanation
|-
|style="background-color: white;vertical-align:top;" rowspan="3"|9
|style="background-color: white;vertical-align:top;" rowspan="3"|Source
|style="background-color: white;vertical-align:top; text-align:center;"|Prescriber-
|style="background-color: white;vertical-align:top; text-align:center;"|Provider-
|style="background-color: white;vertical-align:top; text-align:center;"|Author-
|-
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Health professional – Name healthcare provider, specialty
|-
|style="background-color: white;vertical-align:top; text-align:center;"|n/a
|style="background-color: white;vertical-align:top; text-align:center;"|n/a
|style="background-color: white;vertical-align:top; text-align:center;"|or “Patient”
|}

===Future medication===
[[Bestand:Medicatieoverzicht_ToekomstigeMedicatie_v0.5.PNG]]

Filter: all medication that will become actual in the next 3 months. This includes intended medicatiegebruik.
For a description of the mapping, the same applies as with the current medication, see [[#Current medication|Current medication]].

===Recently discontinued medication===
[[Bestand:Medicatieoverzicht_RecentBeeindigde_v0.5.PNG]]

Filter: any medication that has ended or stopped in the past 2 months.

For a description of the mapping, the same applies as with the current medication, see [[#Current medication|Current medication]].

===Additional lab values ===
[[Bestand:Medicatieoverzicht_Labwaarden_v0.5.PNG]]

Most recent lab values and abnormal renal function values.

This part will be elaborated at a later time and is not yet normative.

===Remarks ===
[[Bestand:Medicatieoverzicht_Opmerkingen_v0.5.PNG]]

For example, relevant (limited) health skills (competences: literacy, calculation and digital skills) that can have an impact on medicatiegebruik / treatment.

This part will be elaborated at a later time and is not yet normative.

==Building block instantiations==
This section describes which instantiations of the building blocks belong to the medication overview. This concerns 'own' and 'other people's' building blocks ([[#GP observation service (HAP)|section 3.1]]) and then only the latest, relevant instantiations of this ([[#Thrombosis service|section 3.2]]).

===Own and other people===
Both the own and a copy of (known to the sender) building blocks from other sources are included in the medication overview. This so that the medication overview is as complete as possible for the recipient. This ensures that recipients can start using it immediately and that they are not dependent on other sources. The technical representation of someone else's building block may differ from that of the real source. It is important that the recipient is aware of this. The original OID of someone else's building block should simply be given. The recipient can then choose to also collect the building block from its source in its original form.

The medicatieafspraak, toedieningsafspraak and medicatiegebruik building blocks have been extended with a feature that indicates whether:
*there is an 'own' building block or
*that of "someone else" (an ''accent'' building block: MA’, TA’, MGB’)
This attribute only applies in the medication overview transaction, because that is the only transaction where other people's building blocks may be delivered.

The 'building block of someone else' attribute is on two levels:
*The template ID of an MA’, TA’, MGB’ differs from an MA, TA and MGB.
*In addition, the element copy indicator is always sent with value '''true''' in MA’, TA’, MGB’.
For the medication overview, it is permitted to offer the medicatieafspraken, toedieningsafspraken and medicatiegebruik via a information system-generated MGB or MGB '(Healthcare provider is author MGB). This must have a reference to an MA, TA or MGB.

====Medication overview and derivation rules====
An overview of medication that the patient is using (or should be using) can be put together in a information system in two ways: 
1) displaying a current medication overview (or overviews) obtained from another source (or sources) 
2) showing coherent medication building blocks obtained from one's own information system and from other sources. 
In both cases, this overview of medication consists of the information as included in the building blocks medicatieafspraak, toedieningsafspraak and medicatiegebruik.

Re 1) When this document refers to a current medication overview, this means a coherent overview in which current medicatieafspraken, toedieningsafspraken and medicatiegebruik are included. This current medication overview is built up by the source on the basis of the data known at that time at the source. This overview can be exchanged with the transaction group Medicatieoverzicht (Medication overview) (PULL or PUSH).

The data and building blocks that are known at the source, but originating from another source, are supplied in the transaction with the 'accent' indicator so that they are recognizable as building blocks from someone else (MA accent, TA accent, MGB accent).

Re 2) It is also possible for a information system to compile an overview by combining own and other people's separate individual medication building blocks. The transaction group Medicatiegegevens (medication data) (PULL) is used to request individual building blocks.

With the transaction group Medicatiegegevens (medication data) (PUSH), separate building blocks can also be sent directly to another health professional or the patient (so without requests). This happens, for example, at discharge or at the request of a co-practitioner who has the patient in front of him (e.g. patient appears to a GP or pharmacist outside the region, where this GP or pharmacist requests the data by telephone from the patient's own GP and receives it digitally).

Both Medicatiegegevens (medication data) PUSH and PULL should not provide data obtained from other sources.

===Last relevant===
Only the last relevant building blocks (per medicamenteuze behandeling) are part of the medication overview. This section describes what exactly those last relevant building blocks are for a medication overview. Firstly for prescription medication (section 3.2.1), then for "over the counter" medication (section 3.2.2). The following section 3.2.3 further discusses the special situation that, in addition to a current, a future medicatieafspraak within the same medicamenteuze behandeling is valid. Finally, the last paragraph summarizes the rules to be applied. 
Note: The (technical) stop-medicatieafspraken are not shown in the examples, but are implicitly assumed.

====Prescription medication====
=====Most simple "happy flow"=====
In a medicamenteuze behandeling, the simplest "happy flow" results in a sequence of:
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik''.
Usually, medicamenteuze behandeling (drug treatment) starts with a medicatieafspraak. A toedieningsafspraak concretely completes the medicatieafspraak. medicatiegebruik says something about the actual medication use of the patient in this medicamenteuze behandeling. All three building blocks are relevant in such a case and are part of the delivery of a medication overview, as indicated in green below.
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik.
A toedieningsafspraak refers to the medicatieafspraak he enters. If no referral is available in the toedieningsafspraak, the appointment date (administration appointment) must be later than that of the medicatieafspraak to be relevant to delivery. 
Medicatiegebruik can refer to a medicatieafspraak or toedieningsafspraak. If no referral is available in the medicatiegebruik, the registration date (medicatiegebruik) must be later than that of the medicatieafspraak to be relevant for delivery.

=====New medicatieafspraak in medicamenteuze behandeling=====
If you create a new medicatieafspraak in an existing medicamenteuze behandeling (drug treatment), the currently existing medicatieafspraken, toedieningsafspraken and records of medicatiegebruik are no longer relevant for the medication overview. The idea is that all older building blocks than the current medicatieafspraak are by definition "overruled" by this new medicatieafspraak and consequently no longer relevant for the medication overview.
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik'' - stop-Medicatieafspraak – Medicatieafspraak – stop-Toedieningsafspraak

If a toedieningsafspraak and possibly also medicatiegebruik are created and available following such a medicatieafspraak medication appointment, these will be included in the medication overview.
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik'' – stop-Medicatieafspraak – Medicatieafspraak – stop-Toedieningsafspraak - Toedieningsafspraak
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik'' – stop-Medicatieafspraak - Medicatieafspraak - stop-Toedieningsafspraak – Toedieningsafspraak – Medicatiegebruik 

The new MA can also be a stop-MA, if the patient has to stop medication permanently. This stop-MA remains relevant for the medication overview for 2 months. 
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – stop-Medicatieafspraak - stop-Toedieningsafspraak

=====Medicatiegebruik earlier than toedieningsafspraak =====
It is possible that you have registered medicatiegebruik before the toedieningsafspraak has been made. Here too, the idea is that the newer toedieningsafspraak "overrules" the older registration of toedieningsafspraak and medicatiegebruik. The older medicatiegebruik is therefore no longer relevant for the medication overview.
* Medicatieafspraak – Medicatiegebruik
* Medicatieafspraak – ''Medicatiegebruik'' – Toedieningsafspraak

Of course, a new record of medicatiegebruik can then be made, which is also relevant for the medication overview.
* Medicatieafspraak – ''Medicatiegebruik'' – Toedieningsafspraak - Medicatiegebruik

=====New toedieningsafspraak =====
Sometimes you make a new toedieningsafspraak under an existing medicatieafspraak. For example, because another product must be provided (as a result of preference policy or stock). In that case, too, such a new toedieningsafspraak may overrule older medicatieafspraken and medicatiegebruik.
* Medicatieafspraak – ''Toedieningsafspraak – Medicatiegebruik''- stop-Toedieningsafspraak - Toedieningsafspraak

Of course you can then record medicatiegebruik, which is also relevant for the medication overview.
* Medicatieafspraak – ''Toedieningsafspraak – Medicatiegebruik'' - stop-Toedieningsafspraak – Toedieningsafspraak - Medicatiegebruik

====Over the counter====
Sometimes a patient uses medication for which there is no prescription. This applies, for example, to painkillers such as paracetamol or ibuprofen, which are available without a prescription. We call this “over the counter” medication. Such use of "over the counter" medication can be recorded with the medicatiegebruik building block. This is also relevant for the medication overview.
* Medicatiegebruik

A new record of medicatiegebruik by the same type of author (type of author is patient or health professional) "overrules" any older records of medicatiegebruik. Elaborated below, in order of registration date:
* ''Medicatiegebruik'' - Medicatiegebruik

When a prescriber decides to formalize this medicamenteuze behandeling with a medicatieafspraak the rules as described above apply. Elaborated below, in order of appointment date (medicatieafspraak or toedieningsafspraak) / registration date (medicatiegebruik):
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak - Medicatiegebruik
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak – Toedieningsafspraak - Medicatiegebruik
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak – ''Medicatiegebruik'' - Toedieningsafspraak - Medicatiegebruik
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak - ''Medicatiegebruik'' - Medicatiegebruik

====Future medicatieafspraken and toedieningsafspraken====
A medicamenteuze behandeling may include more than one topical medicatieafspraak and toedieningsafspraak. Namely one for the current situation and one or more for the future situation. This section describes an example with one current and one future. For clarity, the future building blocks have a “T-” in the examples. Both current and future building blocks are relevant for the medication overview. The building blocks for toedieningsafspraak and medicatiegebruik must have adequate references to either the current or future appointments. Below are three examples, in order of appointment date / registration date (if these are equal, then sorted by period of use):
* Medicatieafspraak – T Medicatieafspraak
* Medicatieafspraak – Toedieningsafspraak – T Medicatieafspraak – T Toedieningsafspraak
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – T Medicatieafspraak – T Toedieningsafspraak – T Medicatiegebruik
Suppose that the toedieningsafspraak changes because the provider provides a different strength (2x 500mg tablets instead of 1x 1000mg tablets) and the patient still has enough stock for two weeks based on the first toedieningsafspraak:
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – T Toedieningsafspraak – T Medicatiegebruik

=====New medicatieafspraak =====
If you make a new medicatieafspraak in this situation, you always make a (technical) stop-medicatieafspraak. This stop-medicatieafspraak has two manifestations: 
1) with reference to a specific medicatieafspraak that you stop 
2) without a referral, and with that you stop the entire medicamenteuze behandeling (drug treatment)

Ad 1) Stop medicatieafspraak for one current medicatieafspraak. With this stop medicatieafspraak you stop one specific medicatieafspraak. You also make a new one for that medicatieafspraak. Suppose you only want to change the current medicatieafspraak, then this applies to the examples above, in order of appointment date:
* ''Medicatieafspraak'' – T Medicatieafspraak - stop-Medicatieafspraak – Medicatieafspraak 
* ''Medicatieafspraak – Toedieningsafspraak'' – T Medicatieafspraak – T Toedieningsafspraak - stop-Medicatieafspraak – Medicatieafspraak
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik'' – T Medicatieafspraak – T Toedieningsafspraak – T Medicatiegebruik - stop-Medicatieafspraak – Medicatieafspraak

Suppose you only want to change the future medicatieafspraak, then this applies to the examples above, in order of appointment date:
* Medicatieafspraak – ''T Medicatieafspraak'' - stop- T Medicatieafspraak – T Medicatieafspraak
* Medicatieafspraak – Toedieningsafspraak – ''T Medicatieafspraak – T Toedieningsafspraak'' - stop- T Medicatieafspraak – T Medicatieafspraak
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – ''T Medicatieafspraak – T Toedieningsafspraak – T Medicatiegebruik'' - stop- T Medicatieafspraak – T Medicatieafspraak 

 Ad 2) Stop medicatieafspraak for the entire medicamenteuze behandeling. With this stop medicatieafspraak you stop all existing (current and future) medicatieafspraken in the medicamenteuze behandeling. If you now want to make a medicatieafspraak for the future in addition to a current one, you must also make it again. Elaborated below for the same three examples as above, in order of appointment date.
* ''Medicatieafspraak – T-Medicatieafspraak'' – stop-Medicatieafspraak (zonder referentie) - Medicatieafspraak 
* ''Medicatieafspraak – Toedieningsafspraak – T-Medicatieafspraak – T-Toedieningsafspraak'' - stop-Medicatieafspraak (zonder referentie) – Medicatieafspraak – T Medicatieafspraak
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – T-Medicatieafspraak – T-Toedieningsafspraak – T Medicatiegebruik'' - stop-Medicatieafspraak (zonder referentie) – stop-Toedieningsafspraak -Medicatieafspraak – stop- T Toedieningsafspraak - T Medicatieafspraak 

=====New toedieningsafspraak=====
 However, you can also make a new toedieningsafspraak for the current medicatieafspraak only. This new toedieningsafspraak must then have a reference to that current medicatieafspraak. Elaborated below for three examples, in order of appointment date.
* Medicatieafspraak – T Medicatieafspraak – Toedieningsafspraak
* Medicatieafspraak – ''Toedieningsafspraak''– T-Medicatieafspraak – T Toedieningsafspraak - stop-Toedieningsafspraak – Toedieningsafspraak
* Medicatieafspraak – ''Toedieningsafspraak – Medicatiegebruik'' – T Medicatieafspraak – T-Toedieningsafspraak – T Medicatiegebruik – - stop-Toedieningsafspraak – Toedieningsafspraak

A new toedieningsafspraak with a reference to the future medicatieafspraak looks like this.
* Medicatieafspraak – T Medicatieafspraak – Toedieningsafspraak – T-Toedieningsafspraak
* Medicatieafspraak –Toedieningsafspraak – T-Medicatieafspraak – ''T Toedieningsafspraak'' – stop-T Toedieningsafspraak - T Toedieningsafspraak
* Medicatieafspraak –Toedieningsafspraak – Medicatiegebruik – T Medicatieafspraak – ''T Toedieningsafspraak – T Medicatiegebruik'' - stop- T Toedieningsafspraak – T-Toedieningsafspraak

====Rules of overruling listed====
Based on the above description / examples, the following general rules for overruling can be derived. This concerns the rules for determining whether a building block is relevant for delivery in the medication overview. Within a medicamenteuze behandeling:
*A new medicatieafspraak overrules all older building blocks (medicatieafspraak, toedieningsafspraak, medicatiegebruik) belonging to the medicatieafspraak /medicatieafspraken that this medicatieafspraak has stopped.
*A new toedieningsafspraak overrules all older building blocks of the type of toedieningsafspraak or medicatiegebruik that belong to the same medicatieafspraak as the new toedieningsafspraak.
*In principle, a new record of medicatiegebruik overrules (see exception below) older records of medicatiegebruik that belong to the same medicatieafspraak as the new medicatiegebruik.
**Exception to this rule: medicatiegebruik with the author as a patient DOES NOT overrule an older record of medicatiegebruik with the care provider as author and vice versa. Both are therefore relevant to the medication overview.
The latter exception applied to a number of situations:

Deze laatste uitzondering toegepast op een aantal situaties:
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik-ZVL – Medicatiegebruik-PAT
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik-PAT – Medicatiegebruik-ZVL
* Medicatieafspraak – Toedieningsafspraak – ''Medicatiegebruik-PAT'' – Medicatiegebruik-PAT
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik-ZVL – ''Medicatiegebruik-PAT'' – Medicatiegebruik-PAT
* Medicatieafspraak – Toedieningsafspraak – ''Medicatiegebruik-ZVL – Medicatiegebruik-PAT'' – Medicatiegebruik PAT – Medicatiegebruik-ZVL

==Verification by medicamenteuze behandeling ==
A health professional records verification per medicamenteuze behandeling with the medicatiegebruik building block:
*Author = Health professional
*Possible informant: the patient, a care provider or another person
*Possible characteristic "according to agreement": according to the author, is the medicatiegebruik in accordance with the medicatieafspraak or toedieningsafspraak?
*Possible link to medicatieafspraak or toedieningsafspraak:
**Medicatieafspraak or toedieningsafspraak that has been the reference for recording this medicatiegebruik.
**When it is indicated "by appointment", this is the medicatieafspraak or toedieningsafspraak according to which the patient uses.
Such a record of medicatiegebruik means: "I think the patient uses this drug as follows: ... ..".

Known: it is not currently provided in the information standard to indicate that a medicatieafspraak or toedieningsafspraak is correct, regardless of whether the patient uses it as such.

==Process of the medication overview exchange==
In addition to the content and verification, the process surrounding the medication overview is also important.

===Who, when, with what information===
The reliability and completeness of a medication overview depends on:
*who composed it,
*at what time and
*with what basic information.
We can make agreements about this, for example:
*only exchange/make available a medication overview once it has some form of reliability
**after an explicit action by a health professional or
**automatically if certain conditions are met.
*fully automatically exchange/make available medication overview without conditions
*make medication overview fully automatically available without the need for a new data type (so when registering one of the other medication data types you are automatically also the source of a medication overview).

====Decision====
The above questions have not yet been answered. It has been decided that during the Proof-Of-Concept all parties that can provide a medication overview will do the same.

===Responsibilities applicant and source===
The applicant receives medication overviews from multiple sources. Processing this is the responsibility of the recipient. The topicality of a medication overview is important here.

'''Action''': the transaction Medicatieoverzicht (medication record) must contain the most recent date of the collection of available appointment dates / registration dates of the delivered building block instantiations. The compiler (source) of the medication overview must therefore provide this date. This helps the recipient to better estimate the topicality of the medication overview.

===Agreements continued===
We continue the analysis with the results of the Proof-Of-Concept to arrive at a good process for the medication overview.

==Inference rules==
It is important that all parties, physician, pharmacist, nurse as well as patient can infer from the medication building blocks what is intended (i.e. what the current agreements are) and that this should be the same for all information systems. For that reason, information systems must be able to calculate the current situation using the same inference rules.

The current therapeutic situation is calculated on the basis of medicatieafspraken and toedieningsafspraken. Toedieningsafspraken have a relationship with the medicatieafspraak that they were added to. For this reason, toedieningsafspraken can be linked to the medicatieafspraak that they belong to. 
Of course it is also useful to have information about medicatiegebruik. However, this does not indicate the aim of the health professional, only what medication the patient has used. For that reason, the rules below do not take ‘medicatiegebruik’ in consideration. However, ‘gebruik’ is part of a medication profile but is shown separately under the medicamenteuze behandeling concerned.

===Effective period===
The effective period lies between an ''effective start date'' and an ''effective end date''. 
:''The effective period describes the period to which a medicatieafspraak or toedieningsafspraak (ultimately) applies.'' 
The effective period depends on adjustments (modifying/discontinuing/halting/resuming) of medication and by the ‘actual handling of a medicatieafspraak by a toedieningsafspraak. The effective period is not described in the dataset, because it is inferred which is only used to determine the current situation. The ''effective start date, effective end date'' and ''effective period'' are not data to be shown to the end user. Medication for an indefinite period has an effective end date that is in the future, but at a time that cannot be distracted (yet). It is only known that it is 'somewhere' in the future.

===Actual and current medication===
*''Actual (medicatieafspraken en toedieningsafspraken)'': the agreements of which the effective end date lies in the future.
*''Current (medicatieafspraken en toedieningsafspraken) agreements'': the agreements for which the present date lies between their effective start date and the effective end date.
*''Actual medication'': the collection of actual (current and future) medication and toedieningsafspraaks as well as current medicatiegebruik. It should be taken into account that it is never possible to say with certainty to what extent the patient complies with the agreements and/or reports actual gebruik.

===Details===
'''Approach''' 
Using a number of different situations the inference rules are described for arriving at the effective therapeutic period in a medication profile: 
:1) Starting medication
:2) Creating a toedieningsafspraak
:3) Changing medication
:4) Discontinuing medication
:5) Temporarily halting and resuming medication

The inference rules are described below. The number for each inference rule indicates the order in which the rules must be executed.

'''1) Starting medication''' 
Medication is started by creating a new medicatieafspraak. The medicatieafspraak has:
*An agreement date - the date on which the agreement was made with the patient.
*A period of use - this period is consists of:
**A start date - the start date of the medicatieafspraak may be in the future;
**The duration of medicatiegebruik;
**The end date – the date until which the medicatieafspraak is valid.

1a: The effective period of a new medicatieafspraak is equal to its period of medication use.

'''2) Creating a toedieningsafspraak ''' 
A toedieningsafspraak specifically fulfils a medicatieafspraak. From a patient perspective, the toedieningsafspraak, in a way, replaces a medicatieafspraak, as the toedieningsafspraak is a more specific indication of what the patient should be using.

Inference rule 1 is extended:

1b: The effective period of a new toedieningsafspraak is equal to its period of medication use

Inference rule 2 is applicable when a medicatieafspraak has underlying toedieningsafspraken (see inference rule 2b for further explanation):

2a: The effective period of a medicatieafspraak is equal to the effective period of the toedieningsafspraak.

'''3) Changing medication'''
:'''a) By means of a medicatieafspraak'''
The prescriber changes the medication (or the medicamenteuze behandeling) by creating a new medicatieafspraak (and discontinuing the existing one) within an existing medicamenteuze behandeling.
Because the start date of a medicatieafspraak may lie in the future, several medicatieafspraken may be actual at the same time. For example, when a medicatieafspraak applies ‘for an indefinite period’ (ma1) and it is agreed to change the dosage in two weeks (ma2), the first medicatieafspraak (ma1) remains valid for two weeks, after which the second medicatieafspraak (ma2) becomes effective. The previous inference rules do not change because of this.

:'''b) By means of a toedieningsafspraak '''
An toedieningsafspraak specifically fulfils a medicatieafspraak. This toedieningsafspraak may be modified. For example, when administration schedules are changed (when GDS is initiated), or when a commercial product is changed (for example, as a result of a preference policy). Several successive toedieningsafspraken can therefore be created under a single medicatieafspraak. Hence, rule 2 is expanded so that the effective period of the medicatieafspraak is determined by the entire series of underlying toedieningsafspraken.

2b: When several toedieningsafspraken are made under a single medicatieafspraak, the effective start date of the medicatieafspraak is then equal to the earliest start date of the underlying toedieningsafspraak and the end date of the last toedieningsafspraak.

Parallel toedieningsafspraken may exist under a single medicatieafspraak of which the agreement date and the start date are the same. Both are then valid at the same time and this does not change rule 2b.

The diagram below includes a simplified example of an actual profile composed of different building blocks. The patient, verification, CiO and lab data have been excluded from this overview. Only limited data has been included, mainly to demonstrate the way in which the effective period works. Lines starting with ‘-’ are detail lines which can be hidden in the medication profile, if required. The first line shows the effective period for the underlying MAs and TAs. The ‘medicatiegebruik” is also displayed, but this does not influence the calculation of the effective therapeutic period on the first line.

{{anchor|figuur 9}}
[[Bestand:Voorbeeldeffectieveperioden.png|Figuur 9 Voorbeeld effectieve periode]]

'''4) Discontinuing medication''' 
Discontinuing medication (i.e medicamenteuze behandeling) is done by creating a new medicatieafspraak in which stoptype ‘definite’ is indicated. The start date of this medicatieafspraak is the date on which the original medicatieafspraak started. The end date is the date on which the medication is discontinued. The effective period of the original medicatieafspraak is so replaced by the effective period of this new stop-MA.

1c: When a medicatieafspraak is discontinued, the effective period of the medicatieafspraak is then the effective period of the stop-MA.

An stop-toedieningsafspraak fulfils the stop-medicatieafspraak. In this way, for example, it is possible to indicate that the discontinuation starts when the next GDS roll is dispensed.

'''5) Temporarily halting and resuming medication''' 
Temporarily halting medication is carried out in the same way as discontinuing medication. A stop-MA is created (stoptype ‘temporary’) with the same start date as that of the original medicatieafspraak. The end date of the stop-MA is the timing of the temporary halt, the stop type is ‘temporary’. Resuming medication is done by creating a new medicatieafspraak with the old (or adjusted) dosage with the date of resuming as the start date. A meaningful reason (example: resume previous policy) may serve to clarify matters. If the medication is not resumed, ‘discontinue medication’ (stoptype ‘definite’) can be executed in order to permanently end the medicamenteuze behandeling, which means the medication is no longer valid. Medication that is halted remains valid, and so remains visible in the medication profile.

1d: When medication is temporarily halted, the effective period is not affected. The effective period is determined by the effective period of the original medicatieafspraak.

These inference rules are the basis for determining the current agreements. It is possible to conceive exceptional situations relating to a partial availability of medication data. These situations have not been elaborated. All inference rules are included and implemented in the open source medication viewer.

==Data that need not be shown==
Various data are important for the correct processing of information, but are not relevant to the end user:
*An application does not have to show the (technical) identification of a medicamenteuze behandeling (MBH) (nor that of the building blocks themselves), but the elaboration thereof: namely, building blocks shown in coherence.
*The copy indicator with the medicatieafspraak (MA), toedieningsafspraak (TA) and medicatiegebruik (MGB) when consulting the medication overview. Whether a building block is a copy is not that important to a user and can be deduced by other data from that building block (such as the author of the building block). So it is not so important that a user can see that this has been delivered 'as a copy' and is probably only confusing. However, this information is important for suppliers, for example because they sometimes want to perform calculations with the data and it is then safer to collect the data from the real source. It is therefore obvious to keep track of whether you have received data from the real source in your information system.
*An application does not have to show the stop type (temporary / definite) of a stop appointment, but the elaboration thereof: namely the processing of the meaning, so that an entire MBH is shown as stopped medication or as interrupted medication (remains clear under current medication) or as a change in the case of a 'technical stop appointment'.

=Administration list and inference rules=

This chapter shows a possible presentation/view of the administration list and, additionally, specifies the inference rules to identify the relevant medication building blocks within a pharmaceutical treatment, for the generation of an administration list.

==Introduction==
This paragraph contains an example of an administration list. The administration list shows the most recent medication data at any time of the day, to facilitate adequate medication administration. To ensure safe circumstances in which correct and up-to-date medication data is presented to the (professional) administrator, the administration software must be able to process the medication building blocks and to correlate the medication building blocks, as described in this information standard.

The term ‘administration list’ is defined as a digital list including all medicaments that are prescribed by a prescriber and that have to be administered to a patient/client. This list is generated based on the following medication building blocks: medication agreement (MA), administration agreement (TA), medication dispense (MVE), medication administration (MTD) and variable-dosing regimen (WDS).

The process of (actively) making medication data available to (professional) administrators enables the generation of a total overview of all medication which has to be administered. Importantly, this implies that information regarding discontinuation and change of medication with or without medication dispense is available at any time. Change in medication and variable-dosing regimens, for example as prescribed by the thrombosis service, are immediately available for administrators.

In the figures below, the numbered elements are normative; it is mandatory to show those components. The lay-out of the administration list in an information system may differ depending on the type of users or the type of device; this is dependent on the user requirements.

The administration list in this example is described generally. The chapter entails the general end user requirements for the administration list; this chapter does not comprise details on the technical requirements or implementation.

The project ‘Veilige principes in the medication’ comprises the sectors nursing care, nursing aid and home care. The specifications as described in ‘Veilige principes in de medicatieketen 2016’ and ‘Richtlijn overdracht van medicatiegegevens in de keten herziening 2018/2019’ as well as new insights from the program ‘Medicatieoverdracht’ are incorporated in this chapter.

The basis for the administration list entails:
*Medication building blocks
**Medication agreement (MA)
**Administration agreement (TA)
**Variable-dosing regimen (WDS)
**Medication administration (MTD)
**Medication dispense (MVE)
*All current medication; this comprises all MAs, TAs and WDSs which are available and applicable when the medication is administered. The PeriodOfUse defines whether medication should be considered current medication.
*The PrickPatchLocation is consulted based on the AdministrationDateTime.
*(Professional) administrators can distinguish the types of medication (in GDS package or separately) which should be administered to the patient by the data element DistributionForm (medication building block MVE) and the data element AsNeeded/Condition in the dosage (medication building blocks MA, TA or WDS). The different types of medication may be presented according to the following categories:
**GDS medication (including discontinued medication in order to show a notification/warning)
**Non-GDS medication
**Non-GDS medication as needed
*The remaining building blocks (dispense request (VV), medication use (MGB) and medication consumption (MVB)) are not relevant for the administration list.

{{anchor|figuur 1}}
[[Bestand:Toedienlijst_figuur_1a.PNG|Figuur 1: Voorbeeldweergave toedienlijst]]
[[Bestand:Toedienlijst_figuur_1b.PNG|Figuur 1: Voorbeeldweergave toedienlijst]]
[[Bestand:Toedienlijst_figuur_1c.PNG|Figuur 1: Voorbeeldweergave toedienlijst]]
 
''Figure 1: Example administration list.''
 
 
{| class="wikitable"
|-
! Nr
! style="text-align:left;"|Heading
! style="text-align:left;" colspan="3"|Dataset
|-
| 1 || Type || Medication Agreement || Administration Agreement || Variable-Dosing Regimen
|-
| 2 || Medicine || Agreed Medicine || Medicine To Be Dispensed ||
|-
| 3 || Prescriber
|style="text-align:left;" colspan="3"| Medication Agreement – Prescriber – Health Professional
|-
| 4 || Supplier
|style="text-align:left;" colspan="3"| Administration Agreement – Supplier – Healthcare Provider
|-
| || Author
|style="text-align:left;" colspan="3"| Variable-Dosing Regimen – Author – Health Professional (conditional)
|-
| 5 || Start Date || Medication Agreement – Period Of Use || Administration Agreement – Period Of Use || Variable-Dosing Regimen – Period Of Use
|-
| 6 || End Date/Duration || Medication Agreement – Period Of Use || Administration Agreement – Period Of Use || Variable-Dosing Regimen – Period Of Use
|-
| 7 || Description
|style="text-align:left;" colspan="3"| Instructions For Use – Description
|-
| || Route Of Administration
|style="text-align:left;" colspan="3"| Instructions For Use – Route Of Administration

|-
| || Additional Instructions
|style="text-align:left;" colspan="3"| Instructions For Use – Additional Instructions
|-
| || Dose
|style="text-align:left;" colspan="3"| Instructions For Use – Dosing Instructions – Dosage – Dose
|-
| || Administration Time
|style="text-align:left;" colspan="3"| Period Of Use – Dosing Instructions – Dosage – Administering Schedule – Administration Time
|-
| || Administration Speed
|style="text-align:left;" colspan="3"| Period Of Use – Dosing Instructions – Dosage – Administration Speed
|-
| || Duration Of Administration
|style="text-align:left;" colspan="3"| Period Of Use – Dosing Instructions – Dosage – Duration Of Administration
|-
| 8 || Prick-Patch Location
|style="text-align:left;" colspan="3"|Medication Administration – Prick-Patch Location
|-
| 9 || Comment
|style="text-align:left;" colspan="3"|Comment & Additional Information
|}
''Table 1: Normative medication data in the administration list.''


==Functional specification==
In the figures below the elements with normative data are presented. The other elements are not normative (not yet). The numbered elements in the table are normative; the other elements are optional (until further notice).

===Heading and general===

[[Bestand:Toedienlijst_Functionele_specificatie.png]]

===Remarks===

[[Bestand:Toedienlijst_Kop en algemeen.png]]

In the comment field, for example, (limiting) health literacy competences (competences: literacy, calculation and digital skills) can be recorded, which may affect the medication administration. This part is for internal use and is not exchanged (not yet).

'''NB.''' This part is not normative yet. This data is derived from the internal information system of the organization.

===GDS medication===

[[Bestand:Toedienlijst_Opmerkingen.png]]

GDS (medication distribution system, in Dutch: 'Geneesmiddel Distributie Systeem') is defined as a package in which medicaments are distributed in units per administration moment, labelled with the name of an individual patient/client ([https://www.knmp.nl/praktijkvoering/richtlijnen/knmp-richtlijnen-praktijkvoering/knmp-richtlijn-voor-geautomatiseerd-geneesmiddeldistributiesysteem-gds-september-2011 KNMP, 2011]). If medication is discontinued or changed, it is desired that a warning signal is shown, with the comment that, possibly, the medication is in the GDS package, and an additional act may be required. Further elaboration is needed.

===Non-GDS medication===

[[Bestand:Toedienlijst_Niet-GDS-medicatie.png]]

Non-GDS medication is medication which, for various reasons, cannot be included in an automated medication distribution system. The distribution type 'non-GDS' is specified in the data element DistributionForm in the corresponding MVE. Furthermore, for non-GDS medication, the condition AsNeeded remains empty.

===Non-GDS medication – as needed===

[[Bestand:Toedienlijst_Niet-GDS-medicatie_zo_nodig.png]]

Non-GDS medication as needed comprises separate medication which should be administered only in specific circumstances. The condition for administration of such medicament can be:
*a measured physiological value (plasma glucose level, body temperature, blood pressure);
*a symptom or other condition (headache, itching).
The distribution type 'non-GDS' is specified in the data element DistributionForm in the corresponding MVE. Furthermore, the condition AsNeeded is filled.

==Building block instantiations==
This paragraph describes which building block instantiations are related to the administration list. This includes only the ‘own’ building blocks (see [[#Own and other people|5.3.1]]) and only the latest, relevant instantiations (see [[#Last relevant|6.3.2]]).

===Therapeutic and logistical building blocks===
Compiling an administration list involves both therapeutic and logistical medication building blocks. Building blocks can be ‘overruled’ based on inference rules. All inference rules as described in [[#Medication overview and inference rules|Chapter 5]] are applicable. In addition, in this paragraph, the inference rules for WDS are described. The inference rules do not apply to MTD, as medication administration is a procedure at a certain time point; in contrast, the MA, TA and MBG comprise agreements valid for a certain period of time. The logistical medication building block MVE is part of compiling the administration list, as this building block is needed to derive the type of distribution of the medication.

====Administration list and inference rules====
An administration list can be compiled, for example in the administrator’s information system, based on separate medication building blocks.
The medication building blocks may be retrieved from the own information system or from other sources. The transaction Medication data (consulting/making available) is used for consulting and making available individual medication building blocks.
In the transaction group Medication data (sending/receiving), separate medication building blocks can be send to another health professional or patient directly (without prior consultation); for example, in the case of discharge or on request of a fellow health professional (for example, a patient sees a GP or pharmacist outside the region; the GP or pharmacist requests the data by telephone and receives the data digitally).
Both for Medication data sending/receiving and Medication data consulting/making available, data obtained from other sources is not allowed to be presented in the administration list.

===Last relevant===
Only the latest relevant medication building blocks (per pharmaceutical treatment) are part of the administration list. This paragraph provides a description of the latest relevant building blocks for an administration list comprising medication on prescription. [[#Medication with prescription with a variable-dosing regimen|Paragraph 6.3.2.1]] describes the situation in which a variable-dosing regimen (WDS) is applicable. For WDS, the same inference rules apply as for MA. For compiling an administration list, the presence of a WDS is decisive for the instructions for use. All other situations in which WDS is not applicable, as described in [[#Last relevant|paragraph 5.3.2]], are applicable as well.

Query to identify the correct, relevant and future medication building blocks:
{| class="wikitable"
|-
! Nr
! style="text-align:left;"|Medication building block
! style="text-align:left;"|Query Parameter
! style="text-align:left;"|What should be filled in specifically?
|-
| 1 || MA, TA, WDS || Period Of Use || All medication that should be administered today and, therefore, is applicable: Day = T, startDate = T: 00:00:00 h, endDate = T: 23:59:59 h
|-
| 2 || MTD || Administration Period || Depending on medical relevance (for example, historical information on prick and patch locations may be relevant back to one week ago). For example, is one week is sufficient (another period may be chosen): Day = T, startDate = T-7 day
|-
| 3 || MVE || Dispense Period || Broad request (+/- one month)
|}

If all medication building blocks are collected, the following medication data, depending on the situation, can be used:
{| class="wikitable"
|-
! style="text-align:left;"|Medication building block
! style="text-align:left;"|Situation: only MA*
! style="text-align:left;"|Situation: MA + TA
! style="text-align:left;"|Situation: MA + TA + WDS
|-
| MA || Decisive** for compiling the administration list (number: 2, 5, 6, 7, 9, 10) || Data from the prescriber || Data from the prescriber
|-
| TA || - || Decisive** for compiling the administration list (number 2, 5, 6, 7, 9, 10) || Data from the supplier and medicine
|-
| WDS || - || - || Decisive** for compiling the administration list (number 5, 6, 7, 10)
|}

* Situation in which the pharmacist has not processed the MA yet.
** ‘Decisive’ indicates the data elements which are included in the functional requirements (numbers of the elements are provided between brackets).

====Medication with prescription with a variable-dosing regimen====

=====Most simple ‘happy flow’=====
The most simple ‘happy flow’ in a pharmaceutical treatment is stated below.

*''MA – WDS – TA''

In general, a pharmaceutical treatment starts with an MA. A TA specifies the MA. In the WDS, it is defined whether a variable-dosing regimen applies. In both the MA and the TA, the instruction ‘according to schedule thrombosis service’ is recorded. Then, in the WDS, the dosing schedule is specified. The three medication building blocks MA, TA and WDS are relevant and are part of compiling an administration list, as indicated in green below.


*MA – WDS– TA


A TA refers to the MA, which is specified by the TA. Also, a WDS refers to the MA, which is specified by the WDS. A WDS is always related to an MA.

====New WSD====
*MA – WDS – TA – WDS

The period of use of the WDS has ended and a new dosing schedule is created.

=====Change of WDS=====

*MA – WDS– TA – stop-WDS – WDS

The variable-dosing regimen (WDS) is changed.

=====Discontinuation of medication=====
*MA – WDS – TA – stop-MA

Medication with a WDS is discontinued by a stop of the MA.

=====Change of trade product=====

*MA – WDS – TA – stop-TA – TA

The trade product is changed; this affects the WDS.

====Rules of overruling listed====
Based on the descriptions/examples above, the following general rules for overruling apply. Those rules indicate which medication building block is relevant to incorporate and present in the administration list. Within a pharmaceutical treatment:
*A new MA overrules all previous, older therapeutical medication building blocks (MA, TA, WDS) related to the MA(s) which is/are stopped by the new MA.
*A new TA overrules the previous, older TA related to the same MA as the new TA.
*A new WDS overrules all previous, older WDSs related to the same MA as the new WDS.



=Information systems and transactions=
This chapter contains a list of all system roles and transactions that are referred to in the various process chapters.

The figure below ([[#figuur 10|Figure 10]]) contains an overview of all information systems with their corresponding system roles. The system roles have been described in [[#tabel 3|Table 3]]. The system roles associated with consulting/making available medication data and the medication overview are important for all information systems depending on the process in which they are used. The electronic prescribing system (EPS) also includes the system roles for receiving a voorstel verstrekkingsverzoek, sending a reply voorstel verstrekkingsverzoek and receiving a voorstel medicatieafspraak and, in an outpatient situation, for sending a prescription and receiving data on the processing of a prescription. In addition to the basic system roles, a XIS and PGD also include the system roles for sending a voorstel medicatieafspraak and a voorstel verstrekkingsverzoek, for sending data on gebruik and for receiving a reply voorstel verstrekkingsverzoek. The pharmacist information system (PIS) also includes, in addition to the basic system roles, the roles for sending a voorstel medicatieafspraak, sending a voorstel verstrekkingsverzoek and data on processing of the prescription, and receiving a prescription and reply voorstel verstrekkingsverzoek. [[#Medication process|Chapter 2]] lists the main system roles per process.

{{anchor|figuur 10}}
[[Bestand:Systemen.png|Figuur 10 Overzicht systemen en systeemrollen]]

{{anchor|tabel 3}}
{| class="wikitable" "cellpadding="10"
!style="text-align:left;"|System role name
!style="text-align:left;"|Abbr.
!style="text-align:left;"|Description
|-
| style="background-color: white;"| MedicatieGegevensBeschikbaarstellend
| style="background-color: white;"| MP-MGB
| style="background-color: white;"| Making medication data available to fellow health professionals/patient
|-
| style="background-color: white;"| MedicatieGegevensRaadplegend
| style="background-color: white;"| MP-MGR
| style="background-color: white;"| Consulting medication data at fellow health professionals/patient
|-
| style="background-color: white;"| MedicatieGegevensSturend
| style="background-color: white;"| MP-MGS
| style="background-color: white;"| Sending data to fellow health professional/patient
|-
| style="background-color: white;"| MedicatieGegevensOntvangend
| style="background-color: white;"| MP-MGO
| style="background-color: white;"| Receiving medication data from fellow health professional/patient
|-
| style="background-color: white;"| MedicatieOverzichtBeschikbaarstellend
| style="background-color: white;"| MP-MOB
| style="background-color: white;"| Making medication overview available to fellow health professionals/patient
|-
| style="background-color: white;"| MedicatieOverzichtRaadplegend
| style="background-color: white;"| MP-MOR
| style="background-color: white;"| Consulting medication overview at fellow health professionals/patient
|-
| style="background-color: white;"| MedicatieOverzichtSturend
| style="background-color: white;"| MP-MOS
| style="background-color: white;"| Sturen medicatieoverzicht aan medebehandelaar/patiënt
|-
| style="background-color: white;"| MedicatieOverzichtOntvangend
| style="background-color: white;"| MP-MOO
| style="background-color: white;"| Receiving medication overview from fellow health professional/patient
|-
| style="background-color: white;"| VoorschriftSturend
| style="background-color: white;"| MP-VOS
| style="background-color: white;"| Sending a request to dispense medication (verstrekkingsverzoek) or process modifications to medicatieafspraak.
|-
| style="background-color: white;"| VoorschriftOntvangend
| style="background-color: white;"| MP-VOO
| style="background-color: white;"| Receiving verstrekkingsverzoek or request for processing of modifications to medicatieafspraak.
|-
| style="background-color: white;"| VoorschriftAfhandelingSturend
| style="background-color: white;"| MP-VAS
| style="background-color: white;"| Sending data on processing of medicatieafspraak and possibly verstrekkingsverzoek in toedieningsafspraak and/or medicatieverstrekking
|-
| style="background-color: white;"| VoorschriftAfhandelingOntvangend
| style="background-color: white;"| MP-VAO
| style="background-color: white;"| Receiving data on processing of medicatieafspraak and possibly verstrekkingsverzoek in toedieningsafspraak and/or medicatieverstrekking
|-
| style="background-color: white;"| VoorstelVerstrekkingsverzoekSturend
| style="background-color: white;"| MP-VVS
| style="background-color: white;"| Informing prescriber about voorstel new verstrekkingsverzoek, receiving reply to proposed verstrekkingsverzoek
|-
| style="background-color: white;"| VoorstelVerstrekkingsverzoekOntvangend
| style="background-color: white;"| MP-VVO
| style="background-color: white;"| Receiving new voorstel verstrekkingsverzoek, sending reply to voorstel verstrekkingsverzoek
|-
| style="background-color: white;"| VoorstelMedicatieafspraakSturend
| style="background-color: white;"| MP-VMS
| style="background-color: white;"| Informing prescriber about new voorstel or modified medicatieafspraak, receiving reply to proposed medicatieafspraak
|-
| style="background-color: white;"| VoorstelMedicatieafspraakOntvangend
| style="background-color: white;"| MP-VMO
| style="background-color: white;"|Receiving voorstel for new or modified medicatieafspraak, sending reply to voorstel medicatieafspraak
|}Table 3 Overview system roles

Table 4 gives an overview of all transaction groups, transactions, corresponding system roles and building blocks exchanged with this transaction group. The names of the transaction groups and transactions link to the ART-DECOR publication which details per scenario which data elements are used.

{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| '''Transaction group'''
! style="text-align:left;"| '''Transaction'''
! style="text-align:left;"| '''System role'''
! style="text-align:left;"| '''Building blocks'''
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.131-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.299_20220207000000 Medication data (PULL)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.301-2022-02-07T000000.html Making medication data available]
|style="background-color: white;vertical-align:top;"|MP-MGB
|style="background-color: white;vertical-align:top;" rowspan="2"|One or more: MA, VV, TA, MVE, MTD, MGB, WDS
|-
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.300-2022-02-07T000000.html Consulting medication data]
|style="background-color: white;vertical-align:top;"|MP-MGR
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.131-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.302_20220207000000 Medication data (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.303-2022-02-07T000000.html Sending medication data]
|style="background-color: white;vertical-align:top;"|MP-MGS
|style="background-color: white;vertical-align:top;" rowspan="2"|One or more: MA, VV, TA, MVE, MTD, MGB, WDS
|-
|style="background-color: white;vertical-align:top;"|Receiving medication data
|style="background-color: white;vertical-align:top;"|MP-MGO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.132-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.315_20220207000000 Medication overview (PULL)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.317-2022-02-07T000000.html Making medication overview available]
|style="background-color: white;vertical-align:top;"|MP-MOB
|style="background-color: white;vertical-align:top;" rowspan="4"|MA, TA, MGB
|-
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.316-2022-02-07T000000.html Consulting medication overview]
|style="background-color: white;vertical-align:top;"|MP-MOR
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.132-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.318_20220207000000 Medication overview (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.319-2022-02-07T000000.html Sending medication overview]
|style="background-color: white;vertical-align:top;"|MP-MOS
|-
|style="background-color: white;vertical-align:top;"|Receiving medication overview
|style="background-color: white;vertical-align:top;"|MP-MOO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.133-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.321_20220207000000 Medication prescription (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.322-2022-02-07T000000.html Sending medication prescription]
|style="background-color: white;vertical-align:top;"|MP-VOS
|style="background-color: white;vertical-align:top;" rowspan="2"|MA with or without VV, height, weight, renal function value
|-
|style="background-color: white;vertical-align:top;"|Receiving medication prescription
|style="background-color: white;vertical-align:top;"|MP-VOO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.135-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.333_20220207000000 Medication prescription processing (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.334-2022-02-07T000000.html Sending data on processing of medication prescription]
|style="background-color: white;vertical-align:top;"|MP-VAS
|style="background-color: white;vertical-align:top;" rowspan="2"|TA with or without MVE
|-
|style="background-color: white;vertical-align:top;"|Receiving data on processing of medication prescription
|style="background-color: white;vertical-align:top;"|MP-VAO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.134-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.327_20220207000000 Proposal dispense request (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.328-2022-02-07T000000.html Sending proposal dispense request]
|style="background-color: white;vertical-align:top;"|MP-VVS
|style="background-color: white;vertical-align:top;" rowspan="2"|VVV
|-
|style="background-color: white;vertical-align:top;"|Receiving proposal dispense request
|style="background-color: white;vertical-align:top;"|MP-VVO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.134-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.330_20220207000000 Reply proposal dispense request (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.331-2022-02-07T000000.html Sending reply proposal dispense request]
|style="background-color: white;vertical-align:top;"|MP-VVO
|style="background-color: white;vertical-align:top;" rowspan="2"|AVVV
|-
|style="background-color: white;vertical-align:top;"|Receiving reply proposal dispense request
|style="background-color: white;vertical-align:top;"|MP-VVS
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.134-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.324_20220207000000 Proposal medication agreement (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.325-2022-02-07T000000.html Sending proposal medication agreement]
|style="background-color: white;vertical-align:top;"|MP-VMS
|style="background-color: white;vertical-align:top;" rowspan="2"|VMA with or without height, weight
|-
|style="background-color: white;vertical-align:top;"|Receiving proposal medication agreement
|style="background-color: white;vertical-align:top;"|MP-VMO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.134-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.372_20220302000000 Reply proposal medicationagreement (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.373-2022-03-02T000000.html Sending reply proposal medicationagreement]
|style="background-color: white;vertical-align:top;"|MP-VMO
|style="background-color: white;vertical-align:top;" rowspan="2"|AVMA
|-
|style="background-color: white;vertical-align:top;"|Receiving reply proposal medicationagreement
|style="background-color: white;vertical-align:top;"|MP-VMS
|}Table 4 Overview transaction groups

[[#Medication process|Chapter 2]] lists for each process only the relevant transactions per process step. The transaction groups are not included in this. Table 4 includes all transaction groups and transactions.

=Functionality=
This chapter describes indications for the functionality of an information system.

==Filtering medication from 2nd/3rd line (all information systems)==
An institution makes all its medication data (all building blocks) available. Not all data may be relevant for the receiving health professionals. Receiving information systems may therefore include a filter depending on the requirements of the specific health professional/patient. The list below (Table 5) includes medication types of which it has been determined that medicatietoediening during admission is relevant for health professionals outside the institution.

{{anchor|tabel 5}}
{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| ATC-code
! style="text-align:left;"| Name
|-
| style="background-color: white;vertical-align:top;"|L01
| style="background-color: white;vertical-align:top;"|Cytostatics
|-
| style="background-color: white;vertical-align:top;"| L03AX03
| style="background-color: white;vertical-align:top;"|BCG vaccine, urology
|-
| style="background-color: white;vertical-align:top;"|L04AA23; L04AA25; L04AA26; L04AA33; L04AA34; L04AB; L04AC
| style="background-color: white;vertical-align:top;"|Immunosuppressive agents
|-
| style="background-color: white;vertical-align:top;"|B03AC; B03XA; B06AC
| style="background-color: white;vertical-align:top;"|Iron, erythropoietin, drugs used in angioedema
|-
| style="background-color: white;vertical-align:top;"|G03GA; G03GB02
| style="background-color: white;vertical-align:top;"|Gonadotropins (HCG, etc.), clomiphene
|-
| style="background-color: white;vertical-align:top;"|H01CA; H01CC; L02AE04
| style="background-color: white;vertical-align:top;"|Gonadorelin, hypothalamic hormones, triptorelin
|-
| style="background-color: white;vertical-align:top;"|J06; J07
| style="background-color: white;vertical-align:top;"|Immunoglobulins, vaccines
|-
| style="background-color: white;vertical-align:top;"|M03AX01
| style="background-color: white;vertical-align:top;"|Botulinum toxin
|-
| style="background-color: white;vertical-align:top;"|R03DX05
| style="background-color: white;vertical-align:top;"|Omalizumab
|-
| style="background-color: white;vertical-align:top;"|S01LA04; S01LA05; S01LA
| style="background-color: white;vertical-align:top;"|OOphthalmological antineovascularisation agents
|}Table 5 Types of clinical medication relevant for external health professionals

==Making medication data available (all information systems)==
All proprietary medication data may be made available when the patient has given his consent (in accordance with applicable laws and regulations). Data received from third parties copied (health care provider/patient) in one’s own information system and marked as ‘copy’, are not made available. The only exception is the transaction Medicatiegegevens (Medication data) PUSH and PULL and Medication overview PUSH and PULL, in which case third parties’ building blocks are made available on the condition that they include the original identification label (see also [[#Inference rules|paragraph 5.6]]).

==Notification date or dispense date (pharmacist information system)==
The notification date and the actual dispense date may be recorded in the medicatieverstrekking. When a verstrekkingsverzoek is processed immediately and the patient picks up the medication that same day, both dates will be the same. When the patient picks up the medication one or several days later, different dates must be entered. The dispense date is the date on which the medicatieverstrekking has actually taken place. The request date is the time at which a pharmacy records an intended medicatieverstrekking. When medication is dispensed on several occasions as part of the same verstrekkingsverzoek (for example, when prescriptions are split), each medicatieverstrekking has its own request date. When an automated dispense system is being used, the dispense date is the time at which the patient picks up the medication from the dispense system. Until this time is available in the PIS, the time at which the medication is deposited in the automated dispense system may be used. See also [[#Request and dispense|paragraph 4.2.5]].

==Updating after system malfunction==
After a system malfunction, the prescriber’s information system needs to determine whether changes have been made to medicatieafspraken. For use cases and rationale, see [[#Discontinuation of medication by third parties|paragraph 4.1.26]] and [[#Two PRKs in a single medicamenteuze behandeling|paragraph 4.1.27]].

==Construction for ‘once every 36 hours’ interval==
When the dosing instruction reads ‘1 tablet every 36 hours’, this may normally be recorded in one medicatieafspraak (dose: 1 tablet, interval: 36 hours). However, when a information system does not go beyond an interval of, for example, 24 hours, another solution needs to be found.

''Variation 1:''
Making use of an ‘as needed’ instruction with the criterion: ‘36 hours have passed since the last medicatietoediening’. This does however come with a certain amount of freedom that may not be desirable.

''Variation 2:''
A repeating dosing schedule can be created, with alternation between administration in the morning, administration in the evening and a day without medicatietoediening:
Repeat period: 3 days
Dosage instruction
Sequence number: 1
Dosage duration: 1 day
Dosage
Dose per administration: 1 tablet
Administration time: 9 am (per example, this could also be a part of the day)
Sequence number: 2
Dosage duration: 1 day
Dosage
Dose per administration: 1 tablet
Administration time: 9 pm (per example, this could also be a part of the day)

If it is not technically possible to choose a 36 hours interval, variation 2 applies.

==EVS / HIS processing Regulation processing==
The prescribing information system is informed by the pharmacist of all dispensings and changes in toedieningsafspraken through the transaction Afhandeling voorschrift (settlement prescription). This handling must be automatically processed in the prescribing information system. The prescriber only assesses the toedieningsafspraken and does not have to assess all the dispensings (verstrekkingen).

==Examples dosages==
See [[mp:V9.1 Voorbeelden doseringen|examples dosages 9.1.0]] (both functional and technical effect in HL7v3 CDA and in FHIR)

==Medicatiegebruik: use indicator, according to agreement indicator, stop type, period of use and dosing instructions==
{| class="wikitable"
|-
|style="text-align:center;" |Situation || 1. Medication is/will be used during period of use according to agreement|| 2. Medication is/will be used during period of use, but not according to agreement || 3. Contrary to agreement, medication is/will not be used during period of use || 4. Medication is/will not be used during period of use, which is according to agreement || 5.Medication is used during period of use but it is unknown if this is according to agreement (selfmedication)
|-
! Use indicator (is this product being used) !! Yes!! Yes !! No !! N/A (because this would lead to a double negative otherwise) !! Yes
|-
! According to agreement indicator !! No!! No !! No!! Yes!! -
|-
! Stoptype!! N/A!! N/A!! Discontinuation or Stop !! Definitve of Temporary !! N/A
|-
| || || || Stoptype depends if agreement is being stoped or dicontinued || Stoptype in acoordance with stop-agreement ||
|-
! Period of use!! In accordance with MA or TA !! Max. 2 out of 3 !! Max. 2 out of 3 !! Max. 2 out of 3 !! Max. 2 out of 3
|-
|style="text-align:right;" | start date || The time at which the medicatiegebruik was started. ||The time at which the deviating medicatiegebruik was/will be started. . || Contrary to agreement, medication is/will not be used during period of use || The time at which the medicatiegebruik was/will be discontinued. || The time at which the medicatiegebruik was started.
|-
|style="text-align:right;" | duration of medicatiegebruik|| The intended duration of medicatiegebruik. || The intended duration of deviating medicatiegebruik. || The (intended) duration of non-use||The (intended) duration of non-use. || The intended duration of medicatiegebruik.
|-
|style="text-align:right;" | end date || The time at which the period of use ends (or has ended or will end). || The time at which the period of deviating use ends (or has ended or will end). || The time at which the use was/will be resumed (or is intended to resume).|| The time at which the medicatiegebruik was/will be resumed (or is intended to resume). || The time at which the period of use ends (or has ended or will end).
|-
! Dosing instructions!! In accordance with MA or TA!! Required!! N/A !! N/A!! Required
|-
| || Medication was/will be used during the period of use according to the agreement, therefore dosage is known. || Medication was/will not be used according to the agreement, the actual dosage used must be communicated. || The medication was/will not be used, there is no dosage. || The medication was/will not be used, there is no dosage. || Dosage tha the patient has agreed upon himself
|}
'''Examples:''' 
'''Situation 1a: Medication is / is used during the period of use according to agreement''' 
Patient has been prescribed Ferrofumarate for anemia. Dosage is 1 tablet 3 times a day half a hour before eating, with a start date of June 4, 2018 and no end date. 
On 10 June, the patient registers the medicatiegebruik for the past period (from 4 to 10 June). 
{| class="wikitable"
|-
! Situation 1a !!
|-
| Medication || FERROFUMARATE 100MG TABLET
|-
| Use indicator || Yes
|-
| According to indicator agreement || Yes
|-
| Stoptype || Not applicable
|-
| Start date|| 4 June 2018
|-
| End date || 10 June 2018
|-
| Dosing instruction || ''According agreement''
|}

'''Situation 1b: Medication is / is used during the period of use according to agreement''' 
Patient has been prescribed Ferrofumarate for anemia. Dosage is 1 tablet 3 times a day half an hour before eating, with a start date of June 4, 2018 and no end date. 
On 10 June, the patient registers the medicatiegebruik for the past period (from 4 to 10 June).
 
{| class="wikitable"
|-
! Situation 1b !!
|-
| Medication || FERROFUMARATE 100MG TABLET
|-
| Use indicator || Yes
|-
| According to indicator agreement || Yes
|-
| Stoptype || Not applicable
|-
| Start date|| 4 June 2018
|-
| End date || -
|-
| Dosing instruction || ''According agreement''
|}

'''Situation 2: Medication is / is used during the period of use, but not by agreement''' 
Patient has been prescribed Ferrofumarate for anemia. Dosage is 1 tablet 3 times a day half an hour before eating, with a start date of June 4, 2018 and no end date. 
The patient is on the road a lot during the day and forgets for a week to take the medicines for lunch. However, the tablets are taken in the morning and evening before eating. 
{| class="wikitable"
|-
! Situation 2 !!
|-
| Medication || FERROFUMARATE 100MG TABLET
|-
| Use indicator || Yes
|-
| According to indicator agreement || No
|-
| Stoptype || Not applicable
|-
| Start date|| 11 June
|-
| End date || 15 June
|-
| Dosing instruction || 1 tablet 2 times a day
|}
'''Situation 3: Contrary to the agreement, the medication is / is not used during the period of use''' 
Patient has been prescribed Ferrofumarate for anemia. Dosage is 1 tablet 3 times a day half an hour before eating, with a start date of June 4, 2018 and no end date. 
The patient goes on vacation for a long weekend and finds out too late that the medication is not packed. The patient will not take the tablets for the next few days and wants to record it. 
{| class="wikitable"
|-
! Situation 3 !!
|-
| Medication || FERROFUMARATE 100MG TABLET
|-
| Use indicator || No
|-
| According to indicator agreement || No
|-
| Stoptype || Temporary
|-
| Start date|| 20 July
|-
| End date || 23 July
|-
| Dosing instruction || Not applicable
|}
'''Situation 4: Medication is / is not used during the period of use and that is also by agreement''' 
Patient has been prescribed Ferrofumarate for anemia. Dosage is 1 tablet 3 times a day half an hour before eating, with a start date of June 4, 2018. 
On August 12, it turns out after checking that there is no longer anemia and the doctor stops the medication. The patient wants to register that she has stopped taking the medication and registers this herself on August 15. 
{| class="wikitable"
|-
! Situation 4 !!
|-
| Medication || FERROFUMARATE 100MG TABLET
|-
| Use indicator || No
|-
| According to indicator agreement || Yes
|-
| Stoptype || Definite
|-
| Start date|| 12 August 2018
|-
| End date || -
|-
| Dosing instruction || Not applicable
|}
'''Situation 5: Medication is used during the period of use, but it is unknown whether this is by appointment or there is no appointment (self-care medication)''' 
Patient has the flu and he takes paracetamol 500 mg from the local drug store for fever and pain. He has been taking 4 to 6 tablets a day for four days and expects to do this for another three days. He registers this on August 12 as medicatiegebruik. 
{| class="wikitable"
|-
! Situation 5 !!
|-
| Medication || Paracetemol 500mg
|-
| Use indicator || Yes
|-
| According to indicator agreement || -
|-
| Stoptype || Not applicable
|-
| Start date|| 9 August 2018
|-
| End date || 7 days
|-
| Dosing instruction || 4 to 6 tablets a day
|}

==Implementation of medication distribution system (GDS) fields==

===Background===
More and more patients are receiving their medication through Individualized Distribution Forms (In dutch geindividualiseerde distributie vorm), with the pharmacist providing patients overview and organization of their drugs by preparing them in separate compartment units. This form of delivery took off when the Medicines Act in 2007 stipulated that in healthcare institutions without a pharmacy, the medication should be individually registered for the patients.

It is important for health professionals to know whether a patient is using GDS. In 2018, an analysis was conducted (under the direction of Z-Index, with health professionals) of the bottlenecks and wishes regarding the recording of a patient using GDS. Overall, it has emerged that it is desirable to be able to see whether a patient is using GDS at both the medication level and the patient level. For details see next paragraph.

The directions below provide guidance on how the Medication Process can support these needs.

===Wishes of care providers===
In 2018, an inventory was made with the user councils of Z-Index about the wishes regarding the recording and exchange of GDS. Below is an overview of these wishes. 

'''Who'''
*All healthcare parties (from prescriber to operator)
'''What'''
*Determines which pharmacy delivers
*Pharmacy must know whether the change applies to the current roll or not
*Important for stopping previous medication at the start of GDS
*Evaluation of GDS patients for health insurer
*Other logistics processes towards home care / informal care

'''Why'''
*Determines which pharmacy delivers
*Pharmacy must know whether the change applies to the current roll or not
*Important for stopping previous medication at the start of GDS
*Evaluation of GDS patients for health insurer
*Other logistics processes towards home care / informal care

'''When'''
*When starting medication, in a pharmacy already before notification of prescription
*When transferring 1st / 2nd line
*When changing (incl. Stopping) medication
*When changing CiO data

'''Where'''
*When working in the patient's file, it should be clear that this characteristic applies to the patient concerned. This can be different for each type of care provider (patient file, medication file). The wish of public pharmacists is that they always have this characteristic available for a specific patient.
*On medication overview

===Data elements Medication process===
The building blocks for the Medication Process have the following fields that play a role in recording GDS. 

{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| '''Buildingblock '''
! style="text-align:left;"| '''Data-element nr'''
! style="text-align:left;"| '''Description'''
! style="text-align:left;"| '''Type of content '''
|-
|style="background-color: white;vertical-align:top;"| Medicatieafspraak
|style="background-color: white;vertical-align:top;"|23283
|style="background-color: white;vertical-align:top;"|Additional information
|style="background-color: white;vertical-align:top;"|Additional information contains a list of details of the medicatieafsrpaak that are important for pharmacovigilance monitoring and completion by a pharmacist.

For example: "change in GDS immediately"..
|-
|style="background-color: white;vertical-align:top;"| Verstrekkingsverzoek
|style="background-color: white;vertical-align:top;"|22759
|style="background-color: white;vertical-align:top;"|Supplementary wishes
|style="background-color: white;vertical-align:top;"|Logistical instructions important for the completion of the dispensing request by the pharmacist.

For example: "do not include in GDS"
|-
|style="background-color: white;vertical-align:top;" rowspan="4"| Verstrekking
|style="background-color: white;vertical-align:top;"|20927
|style="background-color: white;vertical-align:top;"|Distribution form
|style="background-color: white;vertical-align:top;"|Distribution form.

For example: GDS
|-
|style="background-color: white;vertical-align:top;"|20924
|style="background-color: white;vertical-align:top;"|Consumption period
|style="background-color: white;vertical-align:top;"|Stock for this duration
|-
|style="background-color: white;vertical-align:top;"|22500
|style="background-color: white;vertical-align:top;"|Registration date
|style="background-color: white;vertical-align:top;"|The registration date is the time when a pharmacist records an intended dispensing
|-
|style="background-color: white;vertical-align:top;"|20272
|style="background-color: white;vertical-align:top;"|Date
|style="background-color: white;vertical-align:top;"|The time of the dispensing. The date when the medicine is made available to the patient
|}

===Application of data elements to support desired functionality for GDS patients===
====Recording that someone uses GDS====
When working in the patient's file it is important to see that someone is using GDS. This applies to the pharmacy that supplies the GDS, as well as other care providers of the patient. It is therefore important that this information can be communicated with and shown to other health professionals.

As long as there is no patient characteristic with which GDS can be registered, it can be decided to derive this information from the GDS data that have been recorded with the medication. A possible handle for this is the fact that medication is included in the distribution module together with the Distribution form field in the verstrekking (dispensing).
*Step 1: if medication is included in the distribution module: fill in the Distribution form field in the verstrekking with 'GDS'.
*Step 2: Based on the Distribution form field, deduce that a patient is using GDS. The fact that a patient has a dispensing (vertrekking) where the Distribution form field is filled with "GDS" indicates that the patient is using GDS. This dispensing can be a private dipsenisn, or it can be dispensed from another pharmacy (insofar as this data is collected and recorded in such a way that the contents of the Distribution form field are reusable). The fact that a patient uses GDS can then be shown when working in the medication file or the patient file. In consultation with end users, it should be further determined where and how this is shown.

====Recording why someone uses GDS====
Users have indicated that it is desirable to be able to record why someone uses GDS. There are currently no structural fields available for this.

====Record for medication that this must be in the GDS====
Prescribers want to be able to indicate whether or not a medicine should be provided via GDS. This can be done as follows:
*Verstrekkingsverzoek, Additional wishes (aanvullende wensen) field. The code list for this field contains the item "not in GDS". This code list is thesaurus 2051 from file 902 in the G-Standard.

====Establishing / exchanging the duration of a medication roll====
The duration of the medication roll can be determined on the basis of the "duration of use" of the provision: the "duration of use" indicates the duration of a medication roll.

====Establishing / exchanging whether a change in the medication should be effective immediately or not====
It is desirable that a prescriber can indicate whether changes in the medication should be implemented immediately or that they can wait until the next roll change. The handles for this are as follows:
*Medicatieafspraak, Additional information (aanvullende informatie) field. The code list for this field contains two items that relate to changes in the GDS, namely "Change in GDS immediately" and "Change in GDS per roll change". This code list is thesaurus 2050 from file 902 in the G-Standard.
*It is important that the prescriber has insight into the duration of the roll and how long it will take before the current medication roll is used up. This can be deduced from:
**The verstrekking, period of use (verbruiksduur), see above. For this, the prescribing system must have access to the verstrekking data of previous verstrekkingen (dispensings).
**Verstrekking (dispensing), Registration Date (aanschrijfdatum) or Date (datum) field (or if this field is not filled but the Registration date field is, then the registration date.; if both are filled, Date is preferred). Based on this date and the consumption period, it is possible to calculate the date on which the current medication roll is used.

=Reflections=
==Prescription without specified recipient (ambulatory)==
In this paragraph, the term ‘prescription’ is used to indicate the message through which a patient may pick up a medicinal product from a supplier. A prescription contains a medicatieafspraak and a verstrekkingsverzoek.

In the Netherlands it is customary to digitally send prescriptions to a receiving pharmacy instead of having to collect prescriptions. This requires that the pharmacy is already known. 

This paragraph considers whether more flexibility can be achieved in the logistical processing of prescriptions, without canceling out current advantages. This paragraph may be seen as a long-term vision that we aim towards.

===Basic principles===
When considering how to achieve flexibility in the processing of prescriptions, these basic principles have been formulated:
*The patient is free to choose where prescriptions are handled
*The current option for sending prescriptions remains possible.
*The information system must reuse the same functionality as much as possible.
*A prescription may only be dispensed once.
Since the methodology described below uses the existing method of sending prescriptions, the same legal rules and regulations apply to prescription validity. All discussions about electronic signatures are equally applicable to the current method of communicating prescriptions.

===Details===
A patient may choose from 3 options:
#A prescription is always sent to the same regular pharmacist.
#The patient indicates each time where the prescription has to be sent.
#The patient does not give any indication, and goes to a pharmacy which subsequently requests and processes the prescription.
Options 1 and 2 require a patient portal, in which the patient indicates his preference. For option 2, a patient may define a preferred pharmacy which would be at the top of the selection screen when the patient is asked where the prescription must be sent. If the patient does not give any indication, option 3 can be the only procedure.

The method partly uses a concept called “publish and subscribe”.

It is important that the pharmacist explains this principle to his customers.

===Work process===
A physician decides to create a prescription for a patient. This may be during a consultation or even when repeat prescriptions are requested. The physician registers the prescription in his prescribing system (EPS). The physician does not need to consider the pharmacy as the patient handles this through the portal.

After approval of the prescription, a central prescription index is updated. The EVS automatically sends a notification to this prescription registry to facilitate this. Here, the prescription index is seen as a separate registry with the data type “prescriptions”. It is always possible to consider whether or not this can be merged at a later time. Initially, atomic registration in the registry is being considered. However, at a later date, consideration could be given as to whether categorical registration would be sufficient.

It is important to realise that currently only a notification is given when a prescription is ready. After all, the prescription is still in the EVS database with the status “is available”. There is no prescription message yet.

The prescription registry knows from the patient’s preference settings what needs to be done with the notification:
#With the option ‘send to regular pharmacy’, a notification is sent to the subscription holder of the patient with the message that a prescription can be retrieved.
#With the option ‘patient indicates pharmacy’, the prescription registry sends a notification (e.g., SMS) to the patient. The prescription registry then waits until the patient uses a smartphone app or the patient portal to indicate to which pharmacy the notification should be sent.
#With the option ‘no indication’, the prescription registry does nothing. The patient does not have a regular subscription holder.

===Processing by pharmacy===
A receiving pharmacy can deduce from the transmitted notification signal (data type) that it refers to an open prescription. The signal also identifies who the patient is as well as the source of the prescription.

For patients who selected option 3 (no indication), the process starts now. The patient identifies himself and notifies the pharmacy that a prescription is ready at a certain institution. The pharmacist may look in the prescription registry to find out which EVS is involved.

The pharmacy information system asks the EVS source system to send the prescription of the respective patient. Since this is a request without medical content, it may even be submitted at lower trust levels.

===Sending via EVS===
If an EVS receives a request for “sending outstanding prescriptions”, the EVS will check whether prescriptions are indeed outstanding. This prevents a prescription from being retrieved several times. The address of the pharmacy is entered and the prepared prescription message is finally created. The prescription message is sent to the respective pharmacy.

If the prescription has been retrieved before, an error message is sent to the retrieving pharmacy announcing that the prescription is no longer available.

'''Sending prescriptions is the standard process and already customary for pushing prescriptions.''' The advantage of this is that the receiving pharmacy only needs to maintain one method for processing received prescriptions. It is noted again that the same legal rules and regulations continue to apply.

After sending a prescription, the EVS also sends a notification to the prescription registry to remove the entry of the outstanding prescription. This indicates that the respective prescription can no longer be retrieved.

{{anchor|figuur 11}}
[[Bestand:Interactiediagramvoorschrijven.png|Figuur 11 Interactiediagram Ongeadresseerd voorschrijven]]

=Appendix References=

==General references==
{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| Author(s)
! style="text-align:left;"| Title
! style="text-align:left;"| Version
! style="text-align:left;"| Date (consultation)
! style="text-align:left;"| Source
! style="text-align:left;"| Organisation
|-
| style="background-color: white;vertical-align:top;"| NHG, KNMP, Z-index
| style="background-color: white;vertical-align:top;"| Building blocks of the medication process
| style="background-color: white;vertical-align:top;"| 2014
| style="background-color: white;vertical-align:top;"| Augustus 2015
| style="background-color: white;vertical-align:top;"| https://www.nhg.org/bouwstenen
| style="background-color: white;vertical-align:top;"| NHG, KNMP, Z-index
|-
| style="background-color: white;vertical-align:top;"| ActiZ, KNMP, NVZA a.o
| style="background-color: white;vertical-align:top;"| Safe principles in the medication chain
| style="background-color: white;vertical-align:top;"| 2014
| style="background-color: white;vertical-align:top;"| August 2015
| style="background-color: white;vertical-align:top;"| http://www.knmp.nl/patiëntenzorg/samenwerking/brochure-veilige-principes-in-de-medicatieketen
| style="background-color: white;vertical-align:top;"| ActiZ, KNMP, NVZA a.o.
|-
| style="background-color: white;vertical-align:top;"| Miscellaneous
| style="background-color: white;vertical-align:top;"| Guideline on exchange of medication data in the medication chain
| style="background-color: white;vertical-align:top;"| 25 April 2008
| style="background-color: white;vertical-align:top;"| August 2015
| style="background-color: white;vertical-align:top;"| Website KNMP
| style="background-color: white;vertical-align:top;"| Miscellaneous
|-
| style="background-color: white;vertical-align:top;"| Paul Geels
| style="background-color: white;vertical-align:top;"| Assessment of medication self-management (BEM) in care homes, Institute for Responsible Medication Use
| style="background-color: white;vertical-align:top;"| February 2009
| style="background-color: white;vertical-align:top;"|
| style="background-color: white;vertical-align:top;"| http://www.instellingsapotheek.nl/downloads/rapporten/beoordeling_eigen_beheer_van_medicatie_in_verzorgingshuizen.pdf
| style="background-color: white;vertical-align:top;"| Institute for responsible medicatiegebruik
|-
| style="background-color: white;vertical-align:top;"| ActiZ
| style="background-color: white;vertical-align:top;"| Safety in the medication chain
| style="background-color: white;vertical-align:top;"| March 2012
| style="background-color: white;vertical-align:top;"|
| style="background-color: white;vertical-align:top;"| https://www.knmp.nl/downloads/brochure-veiligheid-in-de-medicatieketen.pdf
| style="background-color: white;vertical-align:top;"| ActiZ, Miscellaneous
|-
| style="background-color: white;vertical-align:top;"| KNMG
| style="background-color: white;vertical-align:top;"| Guideline on electronic prescription
| style="background-color: white;vertical-align:top;"| September 2013
| style="background-color: white;vertical-align:top;"|
| style="background-color: white;vertical-align:top;"| Website KNMG
| style="background-color: white;vertical-align:top;"| KNMG
|}

==Qualification scripts==
[[mp:Vdraft Kwalificatie|Qualification scripts]]

=Attachment: Document history=

{{anchor|tabel 6}}
{| class="wikitable" "cellpadding="10"
!style="text-align:left;"|Version
!style="text-align:left;"|Date
!style="text-align:left;"|Description
|-
| style="background-color: white;"| 0.95
| style="background-color: white;"| 15 July 2016
| style="background-color: white;"| Pilot version
|-
| style="background-color: white;"| 0.96
| style="background-color: white;"| 1 December 2016
| style="background-color: white;"| Paragraph 2.4 Process: Administer was adapted and C6: Sending/receiving administration data was added as a result.
|-
| style="background-color: white;vertical-align:top;"| 0.97
| style="background-color: white;vertical-align:top;"| 22 December 2016
| style="background-color: white;"| Paragraph 2.4, 4.3.1 review remarks incorporated. 
Paragraph 4.2.11 text made more precise.
|-
| style="background-color: white;vertical-align:top;"| 9.0.2
| style="background-color: white;vertical-align:top;"| 18 June 2017
| style="background-color: white;"| Conversion of the document to wiki.
|-
| style="background-color: white;vertical-align:top;"| 9.0.4
| style="background-color: white;vertical-align:top;"| September 2017
| style="background-color: white;vertical-align:top;"|
*Processed [[mp:V9.0_Ontwerpbeslissingen|Design decisions]] in functional design. This means the design decisions have become obsolete. The current Functional Design is now leading.
*Par. 1.3.1. Definitions of building blocks have been adapted and the abbreviation for medicatieverstrekking has changed to MVE.
*Par. 1.3.3. Medicamenteuze behandeling is now based on PRK, rewritten and introduced PT as well as added text on handling parallel MAs.
*Par. 1.3.4. New data model diagram, various relations added and adapted on the basis of design decisions.
*Par. 1.5 Glossary removed.
*C2 Medication process diagram changed: MO added to actively making available by the user; lines in swimlane of administrator/use adapted.
*C4.1 New use cases added: Do not dispense before, Two PRKs in a single medicamenteuze behandeling, Discontinuation of medication by third parties, Creating a medicatieafspraak after the fact, Parallel medicatieafspraken.
*C4.2 New use case: Discontinuing medication in a GDS; modified use case: Request, dispense and not picked up.
*C5: Differences between medication profile and medication overview were described; inference rules adapted on the basis of the new design decisions.
*Where necessary, references from ART-DECOR to FD C7 were added.
*Various grammatical and minor textual changes.
|-
| style="background-color: white;vertical-align:top;"| 9.0.5
| style="background-color: white;vertical-align:top;"| January 2018
| style="background-color: white;vertical-align:top;"|
*Terminology: Stop-MA was changed to stop-MA in accordance with earlier project agreements (in Dutch different terminology Stop changed to staken)
*Par. 1.3.4 Addition to indicate that MA may also refer to a building block under a different medicamenteuze behandeling.
*Par. 4.1.22 Discharge was adapted because outpatient medication that was discontinued earlier may be started again at discharge.
*Par. 4.1.26 Discontinuation of medication by third parties was adapted.
*Par. 4.1.27 Two PRKs under a single medicamenteuze behandeling.
*Par. 2.2.5.3 Medication discontinuation agreement was adapted to clarify the impact on previously entered future medicatieafspraken.
*Footnote 3 Provisional and final medication order clarified and use case Provisional and final medication order (par. 4.1.31) added.
*Par. 4.1.30 Use case Single use added.
*Paragraphs 2.2.4, 2.2.5.2, 2.2.5.4, 4.1.16, 4.1.22 were adapted for substitution. In case of substitution, a medicamenteuze behandeling is not temporarily halted but effectively discontinued. The substitution is started under a new medicamenteuze behandeling.
*Paragraph 4.1.33 Missing digital medicatieafspraak at admission was added.
*C5 Medication overview was adapted with a reference to a new content page with functional elaboration.
*Paragraph 7.10 Medicatiegebruik: use indicator, according to agreement indicator and stop type added as agreed.
*C6 Building blocks of medication overview were changed to MA, TA and MGB.
*Figure 2 Colours in data model in accordance with Figure 1.
*Various abbreviations explained.
|-
| style="background-color: white;vertical-align:top;"| 9.0.6
| style="background-color: white;vertical-align:top;"| May 2018
| style="background-color: white;vertical-align:top;"|
*Addition to proposed verstrekkingsverzoek and addition of reply proposed verstrekkingsverzoek
*Chapter 6 table 4 addition of links to ART-DECOR transactions
*Removed: chapter about LSP
*Par. 7.10 table was extended with period of use and dosing instructions
*Various paragraphs were made more precise
*Addition of the property ‘third parties’ building block’ for MA, TA and MGB in medication overview
|-
| style="background-color: white;vertical-align:top;"| 9.0.7
| style="background-color: white;vertical-align:top;"| December 2018
| style="background-color: white;vertical-align:top;"|
*Par 1.3.3. MBH at HPK level in case of 'non medicines' without a PRK level
*Par 1.3.3. MBH for medicines without PRK (magistrals, infusions, etc.)
*Par 2.2.5.5. Changing medication: Technical stop-ma: appointment date for stop-ma and new ma must be the same. Change on MA that has already been stopped explained (no extra Stop-ma needed)
*Par 2.2.6. Added: VV under MA of someone else
*Par 4.2.15. Explanation GDS supplier supplies different HPK
*Par 7.10: Medication use indicator, according to appointment indicator, stop type, period of use and dosing instruction: table adapted and examples added
*Par 4.1.34: Own articles explanation added
*Chapter 5: example medication overview inserted in this wiki page instead of a separate wiki page (to simplify searching within the FO).
*Various textual tightening / improvements
|-
| style="background-color: white;vertical-align:top;"| 9.0.7
| style="background-color: white;vertical-align:top;"| July 2019
| style="background-color: white;vertical-align:top;"|
*Removed examples of specific infrastructures
|-
| style="background-color: white;vertical-align:top;"| 9.1.0
| style="background-color: white;vertical-align:top;"| 29 January 2020
| style="background-color: white;vertical-align:top;"|
*Stop textual adjustments
*Par 7.11 added: Implementation of medication distribution system (GDS) fields
*[https://bits.nictiz.nl/browse/MP-85 BITS MP-85], [https://bits.nictiz.nl/browse/MP-93 BITS MP-93], [https://bits.nictiz.nl/browse/MP-122 BITS MP-122] Use cases added (Register usage based on verstrekkingn, Verstrekkingsverzoek with number of repetitions, Prescribe non-drug)
*Chapter 4: Added pictures of use cases
*Renal function value in the prescription
*[https://bits.nictiz.nl/browse/MP-48 BITS MP-48] Medication Overview: Par 5.7 added 'Fields not to be shown'
*Various textual specifications/ improvements, including [https://bits.nictiz.nl/browse/MP-131 o.a. BITS MP-131]
*Paragraph 'Unaddressed prescription' moved to chapter 'Considerations'
*[https://bits.nictiz.nl/browse/MP-151 BITS MP-151] Removed draft TA creation process
*[https://bits.nictiz.nl/browse/MP-128 BITS MP-128] Par 4.1.8: Explanation 'Medical necessity'
*[https://bits.nictiz.nl/browse/MP-129 BITS MP-129] Par 4.1.35: Use case added
|-
| style="background-color: white;vertical-align:top;"| 9.1.0
| style="background-color: white;vertical-align:top;"| September 2020
| style="background-color: white;vertical-align:top;"|
*[https://bits.nictiz.nl/browse/MP-167 BITS MP-167] FO Translated in English
|-
| style="background-color: white;vertical-align:top;"| 9 2.0.0 bèta
| style="background-color: white;vertical-align:top;"| 01 october 2021
| style="background-color: white;vertical-align:top;"| all changes see: *[https://informatiestandaarden.nictiz.nl/wiki/mp:V9_2.0.beta_releasenotes Releasenotes]
|}

=Appendix: Figures and tables=
[[#figuur 1|Figure 1 Building blocks - overview]] 
[[#figuur 2|Figure 2 Building blocks - coherence]] 
[[#figuur 3|Figure 3 Activity diagram - Medication process in general]] 
[[#figuur 4|Figure 4 Process steps and transactions - medication verification]] 
[[#figuur 5|Figure 5 Process steps and transactions - prescribing]] 
[[#figuur 6|Figure 6 Process steps and transactions - make available]] 
[[#figuur 7|Figure 7 Process steps and transactions - administer]] 
[[#figuur 8|Figure 8 Process steps and transactions - use]] 
[[#figuur 9|Figure 9 Example effective period]] 
[[#figuur 10|Figure 10 Overview of systems and system roles]] 
[[#figuur 11|Figure 11 Interaction diagram Prescribing without address]] 

[[#tabel 1|Table 1 Building blocks - description]] 
[[#tabel 2|Table 2 Informing versus (Active) making available]] 
[[#tabel 3|Table 3 Overview of system roles]] 
[[#tabel 4|Table 4 Overview of transaction groups]] 
[[#tabel 5|Table 5 Types of clinical medication relevant for outpatient care providers]]

mp:V2.0.0 Ontwerp medicatieproces 9 ENG

2022-04-04T14:49:55Z

Petra van Deursen: /* Substitution */

{{IssueBox|'''ATTENTION: This is a development version. For an overview of current documentation for Medication Process see here [[Landingspagina_Medicatieproces]].'''}}

__NUMBEREDHEADINGS__
{{DISPLAYTITLE:DEVELOPMENT PAGE Functional Design Medication Process 9 version 2.0.0 English version}}
[[Bestand:ENG.jpg|50px]] [[mp:V2.0.0_Ontwerp_medicatieproces_9_ENG|This is the ENG version]] 
[[Bestand:NL.jpg|50px]] [[mp:V2.0.0_Ontwerp_medicatieproces_9|Klik hier voor de NL versie]] 
For an overview of relevant wiki pages for Medication Process see [[Landingspagina_Medicatieproces]]

=Introduction=

This document is the functional design for the Medication Process Information Standard (in Dutch: 'Informatiestandaard Medicatieproces'). It provides a general description as well as a description of specific practical situations. The recording and exchange of information is described for specific situations using actors (people, information systems) and transactions (which information is exchanged when).

Target groups for this document:
*Health professionals
*Information analysts and architects
*Software suppliers

==Scope and vision==

This document has been produced within the Medication process program. The Medication process program aims first to take away existing obstacles in the medication process, while taking into account current legislation and the possibility of obtaining tangible results in the foreseeable future.

One of the main obstacle entails the lack of insight in the actual medication use of patients. This is partly due to the fact that therapeutic and logistical information are often mixed, which results in the medication history becoming unclear. The following distinction between therapy and logistics exists:

* '''Therapy''' covers the medical side. This includes medication (and treatment) agreements, as well as the corresponding support and implementation. Therapeutic intention, (actual) medication use, self-medication and pharmacotherapy are also covered by the term ‘therapy’ as it is defined in this document.
* '''Logistics''' covers the physical flow of medicinal products, including requests, planning and dispense. This also includes medication supply and the medication use.

The program has taken into account current legislation and feasibility within the foreseeable future. The vision goes beyond the scope of the Medication process program and lays the foundations for a situation where a dispense request is no longer required. The ultimate objective is for prescribers to only have to concern themselves with the therapeutic side (which medicinal product, which strength, which dosage, when to start, etc.). It will no longer be necessary to create a dispense request. Instead, the prescriber will make medication agreements directly with the patient. Based on these medication agreements, the pharmacist will take care of the logistical process, eliminating the need for a dispense request altogether. Because of legislation this is not (yet) possible. The Medication process program does however take the first necessary step in the right direction.

==Reading guide==

The following paragraph introduces the main building blocks and the terminology used in this document. Detailed descriptions of the various processes (prescribe, dispense, administer, medication use) are given in [[#Medication process|Chapter 2]]. The purpose of the descriptions is to clarify how healthcare processes function in an ideal situation; which process steps are needed; which actors are participating; which information applies and which moments of exchange exist. The process descriptions follow a fixed format:

*Current situation  This paragraph describes the relevant differences between the current situation and the desired situation ('soll') in accordance with this information standard. Any obstacles will be described here.
*Process description with the paragraphs:
** ''Precondition'' The conditions that must be met before the process is started.
** ''Trigger Event'' The event that starts the process.
** ''One or more process steps'' Description of part of the process.
**''Post-condition'' The conditions that are met after the process steps have been carried out.
**''Use cases'' List of use cases associated with a specific subprocess. The use cases are detailed in [[#Description of use cases|Chapter 4]].
**''Information sytems and transaction groups'', This paragraph describes the information systems, system roles, transactions and transaction groups related to the process steps. All information concerning information systems and transaction groups is also included in [[#Information systems and transactions|Chapter 6]].

[[#Domain-specific handling of the medication process|Chapter 3]] describes a number of domain-specific interpretations of the medication process, for instance those of the thrombosis service and those related to service observation services in an ambulatory situation. [[#Description of use cases|Chapter 4]] describes several use cases in more detail. The practical situations are derived from general medical practice in a large number of cases but are illustrative of similar situations in a different setting. The use cases are classified according to subprocess, as indicated in [[#Medication process|Chapter 2]]. 
[[#Medication overview and inference rules|Chapter 5]] describes how a medication profile can be constructed from the different building blocks. [[#Information systems and transactions|Chapter 6]] includes an overview of all information systems, system roles, transactions and transaction groups. Guidelines for the functionality of the various information systems have been detailed in [[#Functionality|Chapter 7]].

In this document, Dutch terminology is used for the medication building blocks: 'medicatieafspraak' (MA), 'verstrekkingsverzoek' (VV), 'toedieningsafspraak' (TA), 'medicatieverstrekking' (MVE), 'medicatietoediening' (MTD), 'medicatiegebruik' (MGB), 'medicatieverbruik' (MVB) (see Table 1 for the English translations). Dutch terminology for the medication building blocks is consistently used even in translated documents, as a translation may not refer to exactly the same entity.

==Introduction of relevant terms==

===Therapeutic and logistical building blocks===

The use cases include a description of the process and the data elements associated with it. Related data elements are grouped together in a Clinical Information Model (CIM) or Clinical Building Block (CBB) (in Dutch: 'zorginformatiebouwsteen' - zib). The dataset details the data elements of which these zibs consist; data elements may have been added to the zibs in keeping with the clinical context and care process. The data set includes the complete set of definitions of the data elements of the building blocks. The building blocks together with their data elements can be used in various scenarios for arranging/modelling healthcare applications or for defining interfaces for data exchange.

The different building blocks are shown in the figure below. They have been ordered according to process and subprocesses, and according to therapy versus logistics.

{{anchor|figuur 1}}
[[Bestand:Figuur 1 Bouwstenen - overzicht.png|Figuur 1 Buildingblocks- overview]]

The table below provides a description of the building blocks. The four additional concepts ‘voorstel medicatieafspraak’ (therapeutic), 'antwoord voorstel medicatieafspraak' (therapeutic), ‘voorstel verstrekkingsverzoek’ (logistics) and ‘antwoord voorstel-verstrekkingsverzoek’ (logistics) are also described.

{{anchor|tabel 1}}
{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| Building blocks in Dutch
! style="text-align:left;"| Abbr. in Dutch
! style="text-align:left;"| Building blocks in English
! style="text-align:left;"| Description
|-
| style="background-color: white;vertical-align:top;"| Medicatieafspraak
| style="background-color: white;vertical-align:top;"| MA
| style="background-color: white;vertical-align:top;"| Medication agreement
| style="background-color: white;vertical-align:top;"| 'Medicatieafspraak' is the prescriber’s proposal for medication use with which the patient agrees. An agreement to discontinue medication is also a 'medicatieafspraak'<ref>This document only uses the term medicatieafspraak, which therefore also indicates the clinical equivalent provisional medication order</ref>.
|-
| style="background-color: white;vertical-align:top;"| Wisselend doseerschema
| style="background-color: white;vertical-align:top;"| WDS
| style="background-color: white;vertical-align:top;"| Variable dosing regimen
| style="background-color: white;vertical-align:top;"| 'Wisselend doseerschema' contains the dosing instruction as composed by an (external) prescriber. In the 'wisselend doseerschema' the element 'instructions for use' from the 'medicatieafspraak' is further specified. The 'wisselend doseerschema' can be adapted without changing the 'medicatieafspraak'.
|-
| style="background-color: white;vertical-align:top;"| Verstrekkingsverzoek
| style="background-color: white;vertical-align:top;"| VV
| style="background-color: white;vertical-align:top;"| Dispense request
| style="background-color: white;vertical-align:top;"| 'Verstrekkingsverzoek' is the request from a prescriber to a pharmacist to supply the patient with one or more medicinal products in support of the current 'medicatieafspraak'/'medicatieafspraken'<ref>The verstrekkingsverzoek building block is not applicable in the clinical setting. Dispensing medication is handled in different ways in the clinical setting. Replenishment of, for example, a department’s supply is not considered a medicatieverstrekking, but rather an extension of the pharmacist’s stock. Medicatieverstrekking only takes place when the link between the medication and patient has been made. In clinical situations, administration often takes place immediately afterwards.</ref>.
|-
| style="background-color: white;vertical-align:top;"| Toedieningsafspraak
| style="background-color: white;vertical-align:top;"| TA
| style="background-color: white;vertical-align:top;"| Administration agreement
| style="background-color: white;vertical-align:top;"| 'Toedieningsafspraak' contains the instructions for medication use (or administration) from the pharmacist to the patient (or his representative or administrator), adding to the 'medicatieafspraak'<ref name="MO">A provisional medication order, as it is used in hospitals, is both the request from the physician to the administrator to administer medication to the patient as a verstrekkingsverzoek to the pharmacist to ensure that the medication is available for the administrator. This last part corresponds to the medicatieafspraak and the verstrekkingsverzoek from the first line. In addition, the hospital pharmacist usually carries out a validation of the administration request (this creates the final medication order which is called a toedieningsafspraak here). The provisional medication order is therefore not the same as a proposal from, for example, from a nurse on the basis of a protocol that has not yet been approved by a physician. </ref>.
|-
| style="background-color: white;vertical-align:top;"| Medicatieverstrekking
| style="background-color: white;vertical-align:top;"| MVE
| style="background-color: white;vertical-align:top;"| Medication dispense
| style="background-color: white;vertical-align:top;"| 'Medicatieverstrekking' is the provision of a supply of medicinal product to the patient or his administrator or representative.
|-
| style="background-color: white;vertical-align:top;"| Medicatietoediening
| style="background-color: white;vertical-align:top;"| MTD
| style="background-color: white;vertical-align:top;"| Medication administration
| style="background-color: white;vertical-align:top;"| 'Medicatietoediening' is the registration of the individual administrations of the medicinal product to the patient by the person who administers them (such as a nurse or the patient himself) in relation to the agreements made.
|-
| style="background-color: white;vertical-align:top;"| Medicatiegebruik
| style="background-color: white;vertical-align:top;"| MGB
| style="background-color: white;vertical-align:top;"| Medication use
| style="background-color: white;vertical-align:top;"| 'Medicatiegebruik' is a statement about historical, current or intended use of a medicinal product<ref>Use may have been preceded by medicatietoediening. Registration of medicatiegebruik, for example after medicatietoediening of rabies vaccinations or infusion is not obvious.</ref>.
|-
| style="background-color: white;vertical-align:top;"| Medicatieverbruik
| style="background-color: white;vertical-align:top;"| MVB
| style="background-color: white;vertical-align:top;"| Medication consumption
| style="background-color: white;vertical-align:top;"| 'Medicatieverbruik' is the logistical perspective on medication use. It describes how long a (partial) supply of medicinal products has lasted or will last for a patient<ref>From one-time to a certain period. The building block ‘Medicatieverbruik’ has not been detailed any further in this information standard.</ref>.
|-
| style="background-color: white;vertical-align:top;"| Voorstel medicatieafspraak
| style="background-color: white;vertical-align:top;"| VMA
| style="background-color: white;vertical-align:top;"| Proposed medication agreement
| style="background-color: white;vertical-align:top;"| 'Voorstel medicatieafspraak' is a recommendation or request from the pharmacist, prescriber or the administer to the presciber of the MA about the agreed upon or to be agreed upon medication.The recommendation request may include discontinuing, starting or modifying medication. The patient is unable to send a VMA.
|-
| style="background-color: white;vertical-align:top;"| Antwoord voorstel medicatieafspraak
| style="background-color: white;vertical-align:top;"| AVMA
| style="background-color: white;vertical-align:top;"| Reply proposed medication agreement
| style="background-color: white;vertical-align:top;"| 'Antwoord voorstel medicatieafspraak' is a replay from the prescriber to the 'voorstel medicatieafspraak'.
|-
| style="background-color: white;vertical-align:top;"| Voorstel verstrekkingsverzoek
| style="background-color: white;vertical-align:top;"| VVV
| style="background-color: white;vertical-align:top;"| Proposed dispense request
| style="background-color: white;vertical-align:top;"| 'Voorstel verstrekkingsverzoek' is a proposal from the pharmacist to the prescriber to approve one or more 'medicatieverstrekking'/'medicatieverstrekkingen' in support of the current 'medicatieafspraak'/'medicatieafspraken'. This is comparable with the current situation of submitting the authorization form or combined prescription or submitting a repeat prescription for signing. The patient may also submit a 'voorstel verstrekkingsverzoek' to the prescriber.
|-
| style="background-color: white;vertical-align:top;"| Antwoord voorstel‐verstrekkingsverzoek
| style="background-color: white;vertical-align:top;"| AVVV
| style="background-color: white;vertical-align:top;"| Reply proposed dispense request
| style="background-color: white;vertical-align:top;"| 'Antwoord voorstel-verstrekkingsverzoek' is a reply from the prescriber to the 'voorstel verstrekkingsverzoek'.
|}Table 1 Building blocks – description

===Medication overview===
See [[#Medication overview and inference rules|Chapter 5]] for more information about these overviews, the applicable building blocks and how a medication profile/current overview can be compiled.

==='Medicamenteuze behandeling'===

The different medication building blocks represent steps in the medication process, from prescribing a medicinal product (MA and/or VV), followed by dispensing it (TA and/or MVE) up to and including administering and using the medicinal product. The model is designed in such a way that therapeutic building blocks and logistical building blocks are separated from each other. 
'''Scope''' 
In order to be able to give a name to the interdependence of the medication building blocks, the concept of ‘pharmaceutical treatment’ (in Dutch: 'medicamenteuze behandeling' - MBH) is introduced. 
:'''Medicamenteuze behandeling' is a '''technical concept''' in the information standard. Its purpose is'': 
:#''To unambiguously identify the set of interdependent medication building blocks, and'' 
:#''To apply rules to it to unambiguously determine the present situation''. 
The functional application of the concept of 'medicamenteuze behandeling' is as follows: 
*Medication (or 'medicamenteuze behandeling') is started by creating a first MA as part of a new 'medicamenteuze behandeling'.
*Medication (or 'medicamenteuze behandeling') is discontinued by creating a new MA within the same 'medicamenteuze behandeling' (stop-MA).
*Medication (or 'medicamenteuze behandeling') is modified by:
#Discontinuing the existing MA and
#Creating a new changed MA as part of the same 'medicamenteuze behandeling'. The starting date of this new MA may also be in the future.

Prescribing a new medicinal product always results in a new MA. An MA is always related to a single 'medicamenteuze behandeling'. For the time being, the PRK level (Prescription Code from the G-standard) of the medicinal product determines whether the MA belongs to a new or an existing 'medicamenteuze behandeling'. This may be extended to the SNK level (Substance Name Code from the G-standard) in the future, which would mean that changes in strength or between medicinal products from the same group no longer lead to a new 'medicamenteuze behandeling'. A detailed description can be found in [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5 Process step: Creating a medicatieafspraak]].

Exceptions:
*Products without PRK (a non-medicine such as crutches or bandages). In this case the HPK level (Trade Product Code from the G-standard) determines if the MA will lead to a new 'medicamenteuze behandeling'.
*Medication without PRK (magistrals often consist of several substances that are not covered by the same PRK, these substances are included separately as ingredients in the MA). Every magisterial or adaptation to it falls under a 'medicamenteuze behandeling'.
*Own articles without PRK (articles listed in the internal information system under 90 million numbers stored, such as half tablets, commonly used magistrals). Any item or adaptation to this falls under a 'medicamenteuze behandeling'.
*Intravenous (IV) therapy (still be selected).

'''Examples''' 
Five examples illustrate the scope of a 'medicamenteuze behandeling': 
*Diazepam, 5 mg, 1 tablet 4x daily is changed to diazepam, 5 mg, 1 tablet 3x daily. The PRK level of both products is the same, they are both part of the same 'medicamenteuze behandeling'.
*Paroxetin tablet, 10 mg, 1 tablet 1x daily, is changed to paroxetin tablet, 20 mg, 1 tablet 1x daily. This is a modification of an MA with two different medicinal products at the PRK level. This change requires that the first 'medicamenteuze behandeling' is discontinued and a new 'medicamenteuze behandeling' is started.
*A gastroprotective drugs has been agreed upon in a treatment with prednisone: prednisone and gastroprotective drugs are two different medicinal products, which are used parallel to each other and their use can be modified and discontinued independently of each other. This means they are not part of the same 'medicamenteuze behandeling'.
*Switching from a beta blocker to an ACE inhibitor means a new PRK and this is achieved by discontinuing the 'medicamenteuze behandeling' of the beta blocker and starting a new 'medicamenteuze behandeling' for the ACE inhibitor.
*When there is no PRK and the composition of the medicinal products in the MA changes (any change in the ingredients), the existing 'medicamenteuze behandeling' is discontinued and a new 'medicamenteuze behandeling' is started. This applies, for example, to extemporaneous preparations, drips and proprietary products. 

'''Creation of a 'medicamenteuze behandeling'''' 
A schematic overview of how a 'medicamenteuze behandeling' (MBH) is set up can be seen in the figure below. When a new building block (MA, TA, VV, MVE, MTD or MGB) is created, a check is first performed to determine whether this is a new medication or if there already is a current building block with the same product. This applies to all building blocks, both proprietary or third parties’. In most information systems, the user of the information system will indicate that he wants to change one of the existing medication building blocks or wants to introduce new medication. In that case, it is easy to find out whether there already is a 'medicamenteuze behandeling' that includes the building block.
*If there is no existing building block for this medication, a new building block with a new 'medicamenteuze behandeling' is created.
*If there is an existing building block with a 'medicamenteuze behandeling', the user of the information system is asked whether the new building block and the existing building block belong to the same treatment. When this is the case, the same 'medicamenteuze behandeling' will be used. When the building blocks do not belong to the same treatment, a new 'medicamenteuze behandeling' will be created.
{{anchor|figuur 2}}
[[Bestand:Ontstaan_MBH.png|500px|Figuur 2 Ontstaan medicamenteuze behandeling]]

 
'''Parallel occurrence of 'medicatieafspraken'''' 
Within a 'medicamenteuze behandeling', several MAs may be active simultaneously. These are all MAs that are valid ('current') at this time or that will become valid in the future. In principle, only one MA is valid at any time in a 'medicamenteuze behandeling'. However, there are a number of situations where parallel MAs are conceivable:
#The same medicinal product, but a different strength, where the total strength should essentially be prescribed in one agreement.
#Related (different) medicinal products that are given together, but that should be considered as a whole when evaluating treatment.
#Technical omissions in information systems. For example, in the case of complicated dosing schedules or combination drips. 

'''Situation 1''' can be resolved by prescribing at a higher level (SNK). G-standard/Z-Index is working on this, but it is not yet possible. Until that time, 1 or more products can be combined in the same MA by entering the products as ingredients. This is comparable to extemporaneous preparations. However, the instructions for use for all these products must be identical.<ref>In practice several MAs (with different PRKs) are often combined into a single product instead of a single MA with underlying the composition.</ref> 
'''Situation 2''' is solved in different ways in different information systems, each with their own grouping mechanisms. It concerns the correlation between different medicamenteuze behandelingmedicamenteuze behandelings. The information standard does not provide a universal grouping mechanism. 
'''Situation 3''' is the only situation in which parallel medicatieafspraken are permitted under one medicamenteuze behandelingmedicamenteuze behandeling. Complex phasing-in and phasing-out schedules and combination drips may be included in one medicatieafspraak, but not all information systems support this. For those information systems, it is permitted to create parallel medicatieafspraken within a single medicamenteuze behandelingmedicamenteuze behandeling. 

===Correlation between building blocks and 'medicamenteuze behandeling'===

The figure below shows the correlations between building blocks and the MBH. The relations between building blocks and the MBH as well as the relations between the building blocks themselves are described as follows:
*Building blocks belong to a single MBH. An MBH includes at least one MA and may include zero or more of the following building blocks VV, WDS, TA, MVE, MGB and MTD. Unless, for example, self-medication has been recorded with MGB or in case a paper prescription has been submitted, a drug treatment can exist without an MA, but with MGB or TA. A MBH will never cease to exist, but it may no longer be effective when there are no current building blocks linked to it. A VMA, AVMA, VVV and AVVV are not yet part of a MBH as these are still a draft/proposal that may or may not lead to a final MA or VV linked to an MBH. A VMA may lead to zero (if the recommendation is not followed), one or more MAs and a VVV may lead to zero (if the proposal is not honoured), one or more VVs.
*An MBH may also only have a stop-MA in addition to, for example, an MGB building block. For example, in the event that a health professional asks a patient to stop using free available medicine (self-care medication or over-the-counter (OTC) medication). The health professional records the use of the self-care medication in an MGB building block and discontinues the use by creating a stop-MA (stop-MA belonging to the same MBH).
*An MA may refer to the previous MA or a TA or MGB on which it is based. This may also be an MA, TA or MGB that belongs to another MBH. It is possible that no digital MA is available (e.g. paper prescription [[#Paper prescription|paragraph 4.1.17]]). This MA must then be created. This MA may refer to the TA or MGB. A pharmacist is never the source of an MA but he may have a copy.
*In principle, only one MA is valid at any one time in an MBH. Only when there are technical omissions in information systems, for example in case of complicated dosing schedules or combination drips, parallel MAs are allowed (see also the previous section).
*An MA is supported by zero (if there is still enough supply or if no medication dispense is needed), one or more (when there is, for example, continuous medication) VVs.
*A VV is based on the current MA and any existing corresponding TA in an MBH. There may be several.
*A VV refers to one or more MAs (for example, in the case of an interim dosage increase, a VV can be made that replenishes the supply for the existing MA and also starts the supply for the future MA).
*A VV may result in zero (for example when the patient does not pick up the medication) to several MVEs.
*A MA may result in zero, one or multiple WDS's.
*Multiple (possibly parallel) TAs may be based on the same MA (for example, when a pharmacist switches to a different commercial product or when the medicinal product is supplied as two or more medicinal products with different strengths, with the total strength remaining the same). When a paper prescription is submitted and the MA and the VV are not available in digital form, there is a TA without an MA.
*An MA does not always have to lead to a TA, for example when no VV is required with a short use MA, when the patient still has sufficient stock.
*A TA is supported by zero (when there is enough supply), one or more MVEs.
*An MVE is based on a MA (and TA) and, in an ambulatory situation, on a VV. The exception are over-the-counter (OTC/self-medication) sales for the purpose of self-care medication: these have no MAs and no VVs. Self-care medication provided by the pharmacist may be recorded by that pharmacist as a TA with MVE, or as MGB by a random health professional or by the patient himself.
*An MVE may support multiple TAs.
*An MA or a TA may be followed by a new MA or TA. This may be the case when existing medication is changed (modification of MA and/or TA) or when MGB is discontinued (stop-MA/TA).

{{anchor|figuur 2}}
[[Image: Datamodel_MP92.PNG|800px|Figuur 2 - Datamodel Medicatieproces]]

===Informing and (actively) making available===
[[#Medication process|Chapter 2]] describes the medication process. This includes process steps labelled ‘Inform’ or ‘(actively) make available’. The table below includes a detailed description of the reason for this. [[#Medication process|Chapter 2]] further elaborates on situations in which information is actively sent or made available. 

{{anchor|tabel 2}}
{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| Term
! style="text-align:left;"| Toelichting
|-
| style="background-color: white;vertical-align:top;"| Inform
| style="background-color: white;vertical-align:top;"| ‘Inform’ means sending an order or request addressed to another actor. This is a so-called ‘push’ of information: the actor sends the information specifically to recipient. This may be by means of
*An electronic message via a digital network,
*Paper (for example by giving a prescription intended for a pharmacist to the patient),
*A fax message,
*A combination of the above options.
|-
| style="background-color: white;vertical-align:top;"| (Actively) make available
| style="background-color: white;vertical-align:top;"| The health professional (actively) makes information available to another actor. This process step concerns:
*Actively sending or informing (‘push’) as described above or
*Automatically making information available to health professionals and/or the patient when they request it on the basis of prior permission or
*A combination of both previous bullets. 

Data are always made available. Additionally, the health professional has the option to specifically inform fellow health professionals and/or the patient at any time during the process. In consultation with the patient, data can be sent to a health professional of his choice (inform).
|} Table 2 Informing versus (actively) making available

The technical mechanism (‘pull’, ‘publish and subscribe’, ‘push’, etc.) used to (actively) make data available, is infrastructure-dependent and is therefore not detailed in this document. 

The Royal Dutch Medical Association (KNMG) describes in its publication 'Van wet naar praktijk: implementatie van de WGBO Deel 4. Toegang tot patiëntengegevens' [From law to practice: implementation of the Dutch Medical Treatment Contracts Act Part 4. Access to patient data] when there is implicit consent and explicit consent. The exchange described in this information standard is subject to current legal frameworks and guidelines concerning consent and opt-in and these are therefore not explicitly described.

==Legend/Explanation==
A manual for this Nictiz wiki documentation can be found at: 
http://informatiestandaarden.nictiz.nl/wiki/Handleiding_Wiki_documentatie 
It also includes a legend for the various figures that appear in this document.

=Medication process=
This chapter describes the medication process in relation to the building blocks for first-line, second-line and third-line health care. The process is fundamentally the same in each case. The main difference is which pharmacy supplies the medication: a community pharmacy (including an outpatient pharmacy) or a hospital pharmacy. Another difference is that in an ambulatory setting a VV is required for the supply of medicinal products. This is not required in a hospital setting: the (hospital) pharmacist ensures that the medicinal products are available as long as the MA continues.

The medication process is a cyclical process consisting of prescribing, dispensing, administering and using medication. The process starts when the patient/client visits a health professional/healthcare provider (general practitioner, hospital or other institution) for a treatment with a medicinal product and ends when the medication is no longer needed. The process is depicted in Figure 4. The yellow bar indicates the medication verification process, green prescription, purple dispensing, and orange administration and medication use. The blue bar indicates receipt or retrieval of data made available. This may occur in any of the subprocesses and is described in more detail in the continuation of this chapter for the relevant subprocesses.
The following paragraphs describe the medication verification, prescription, dispensing, administration and medication use processes.

{{anchor|figuur 3}}
[[Bestand:ActiviteitendiagramMP.png|1600px|Figuur 3 Activity diagram - medication process]]
 

==Process: medication verification==
Prior to the prescription process, the patient’s actual medication use is determined. This is done<ref>The patient may also verify his own medication. He then records medication use, see [[#Recording of medication use by the patient|paragraph 2.5.4.1]].</ref>:
*In the GP practice by the general practitioner during a consultation,
*At the GP service, A&E department or mental health crisis service by the triage specialist or the treating physician, as soon as possible, upon arrival or admission,
*In case of clinical or day admission at a hospital or other institutions by for example the nursing staff, pharmacy assistent or outpatient/hospital pharmacist,
*In case of outpatient consultation by for example nursing staff, doctors’ assistant or the treating physician.

===Current situation===
*In the current situation, patients or family/informal caregivers are asked which medication they are using. The patient is sometimes unable to answer this. Family/informal caregivers (if known) are also often unable to answer this. If this is the case, the physician will contact the general practitioner or the pharmacist to find out the medication. This is difficult outside office hours and during weekends.

===Precondition===
The patient comes in for a consultation/an outpatient consultation or is admitted (in the future).

===Trigger event===
*Outpatient setting: consultation of and/or prescription to outpatients and patients residing in another healthcare institution<ref>This is about patients from a nursing home or a mental health institution who are going to the outpatient clinic of a hospital.</ref>. In this case, medication verification often occurs during treatment assessment (see [[#Process step: Evaluating a (pharmaceutical) treatment|paragraph 2.2.4)]].
*Clinical setting: preparation of patient admission.

===Process===

The health professional collects the medication data from various sources, which may include:
*Patient’s own story,
*Dispense overviews from pharmacies,
*Digitally available medication data from healthcare providers or personal health records (PGO),
*Medication brought in by the patient,
*If necessary, information by telephone from the patient’s own pharmacist or general practitioner. 

The health professional verifies the medication together with the patient and records the verified medication as MGB, incl. self medication. This results in an updated medication profile; see also [[#Inference rules|paragraph 5.6]]. 

In practice, medication verification will lead to recording of MGB, only when it proves clinically relevant followed by updating the medication profile, particularly upon admission and discharge.
The medication overview and recorded data on MGB are made available to fellow health professionals and the patient, so that they can access the data. The medication overview may also be sent to a specific health professional.

===Post-condition===
The MGB is recorded and the resulting medication overview is made available if created. Medication data (MGB) are made available.

===Information systems and transaction groups===
[[#Information systems and transactions|Chapter 6]] includes an overview of all information systems, system roles, transactions, etc. Those most important for the medication verification process are included in the overview below.

{{anchor|figuur 4}}
[[Bestand:Medicatieverificatie.png|Figuur 4 Processtappen en transacties - medicatieverificatie]]

==Process: prescribe==
This paragraph describes the prescription process. This includes all prescribers, such as general practitioners, specialists, other physicians and specialist nurse prescribers. The prescription process consists of an evaluation of existing pharmaceutical treatment, if any. If necessary, an medication agreement is created and, only in an ambulatory situation, possibly a medication dispense request. Finally, the recorded data are (actively) made available. See [[#Appendix: General Diagram Medicatioprocess|chapter 12]] for a diagram depicting this process.

===Current situation===
The following deviations from the desired situation that are currently observed are:
*The logistical process often determines whether information is recorded (and certainly if it is communicated). Changes in medication or discontinuation are insufficiently recorded and/or communicated, resulting in, among other things, inaccurate monitoring, incorrect use and incorrect medication profiles.
The pharmacotherapeutic policy should be leading, not the logistical process as is currently the case.
*Since the therapeutic intention is not communicated to the pharmacist, it is not possible to deduce from the available data whether a request for a repeat prescription falls within that therapeutic intention. Because of this, use may be erroneously resumed or continued.
*If a change is not communicated, a request for a repeat prescription (through the pharmacist) may be based on outdated instructions for use. This can easily lead to errors.
*In an outpatient setting, medication agreements and/or medication dispense requests are usually not (electronically) sent to the pharmacist.

===Precondition===
There is a certain reason why a prescriber wants to start or evaluate/review a (pharamceutical) treatment.

===Trigger event===

The trigger event for the process is the start of a new MBH, the evaluation of an ongoing treatment, receipt of a VVV or VMA, receipt from a pharmacist of a prescription to be processed, or patient admission to or patient discharge from an institution.

===Process step: Evaluating a pharmaceutical treatment===

In order to evaluate treatment, an up-to-date overview of medication data is required. The medical file from the health professional is, where possible and if necessary, updated with data from external sources. In addition, the patient may be asked which medicinal products he is currently using. This medication use can be recorded by the health professional. If desired, a more extensive medication verification can be carried out (see [[#Process: medication verification|paragraph 2.1)]]. 

The treating physician<ref> This includes all health professionals who are authorised to prescribe: not only physicians, but also nurse practitioners and physician assistants, for example</ref> evaluates the (pharmaceutical) treatment and decides to:
*start a new MBH by creating an initial MA and/or
*continue, discontinue, temporarily halt or modify an existing MA (1 or more)<ref>In the case of substitution, the existing MA is discontinued and a new MA is created under a new MBH.</ref> and/or
*correct/cancel an existing MA and/or
*approve a VMA or a VVV (including a reply via the AVVV) 

These situations are further explained in the following paragraph. See also [[#Medicamenteuze behandeling|paragraph 1.3.3]] for more information on the concept of 'MBH'.
A new medication overview may be created to conclude the evaluation and the resulting new agreements and dispense requests (see [[#Inference rules|paragraph 5.6]]).

===Process step: Making a medication agreement===

When creating an MA, the following principle applies: each change is recorded in a new MA. Technically this means that the existing MA is terminated by entering an end date for the period of use and that a new MA is created with the desired changes<ref> Information systems keep an audit trail. In case of a change, the existing MA is discontinued (new record) and a new MA with the change is then created (new record). By using the records of the audit trail, no major adaptations are needed for discontinuing a MA in most information systems.</ref>.
 
An MA can also be created to begin at a point in the future. These MAs will receive a period of use with future starting date which is later than the date of the agreement itself. Any prior MA will end just before the starting date/time of the future one. In the period of use, only one effective date can be indicated (without duration or end date), this is the case with continuous medication. To avoid confusion between 'to/until/till' and 'up to and including', specifying the time is mandatory when entering an end date. In case of an 'up to and including' date (in case of an entire day), the time 23:59:59 applies.

Before the MA is made (actively) available, medication monitoring will occur in accordance with current guidelines. This is a part of this process step.

The next paragraphs describe the different situations in which an MA is created, i.e. initial medication agreement, continuing medication, discontinuing medication, temporarily halting medication or correcting/canceling a agreed medication. Information about 'MBH' is assumed to be known (see [[#Medicamenteuze behandeling|paragraph 1.3.3]]).

====New medication agreement====

A new MA is created at the start or modification of an MBH. When a new MBH is started, the prescriber should consider whether an existing MBH should be discontinued. The description in [[#Medicamenteuze behandeling|paragraph 1.3.3]] is based on the most common process from prescription to administering or using. In a transitional situation or in the absence of digital data, it is also technically possible that an MBH could start with a TA, for example. This might occur for instance when a pharmacist has not received the MA with the corresponding MBH in digital form. The pharmacist will consequently start a new MBH when the TA is created. This may also be the case for any other building block. A patient can, for example, start an MBH by recording MGB, without having the original MBH.

====Continuing medication====

In a number of cases the therapeutic intention of the prescriber remains the same and the MA does not have to be modified. For instance:
*In an ambulatory situation when, for a repeat prescription, only a new VV is needed, or
*At admission to an institution where the home medication continues to be used, whether or not in combination with self-medication. 

In both of these cases, the existing MA will not be adjusted. Should there be a change in PRK, e.g. at admission or discharge, the existing MBH will be discontinued by creating a stop-MA (see [[#Discontinuing medication|paragraph 2.2.5.3]]) and a new MBH is started (see [[#New medicatieafspraak|paragraph 2.2.5.1]]).

====Discontinuing medication====

Medication is discontinued by creating a new MA (stop-MA) within the same MBH. The reason for discontinuation is recorded in this MA. The medication may be discontinued immediately or in the future.
The new MA (stop-MA) is a copy of the existing MA with:
*The period of use as end date on which the MA ends (may also be in the future),
*An end date which has to be included in the text description of the instruction for use as well,
*Its own author,
*Its own agreement date,
*Stop type 'permanent',
*Reference to the specific MA that will be changed (future MAs will remain in place). It is not possible to create a stop-MA without referring to the MA that needs to be stopped except when the MA is not available. If there are only TA('s) or MGB('s) available in the MBH then a stop-MA has to be able to end these building blocks without referring to a MA,
*Its own reason for the MA to be discontinued (this does not apply to a stop-MA made as part of a modification. In that case, no reason is given). 

For an MA in which an end date is immediately agreed upon, e.g. in the case of a course of treatment, no additional stop-MA is needed. When an MA with an end date in the future is extended, it will be considered as a normal change (see [[#Changing medication|paragraph 2.2.5.5]]). A stop-MA always has the ‘permanent’ stop type, even if it is a stop-MA resulting from a change. In case of a change, the stop-MA is followed by a new MA. A stop-MA resulting from a change is not always relevant for end users. A stop-MA as a result of a change is also referred to as a technical stop-MA. The user interface must adequately support this. A prescriber will be less interested than a pharmacist who may need to adjust his logistical process because of the change.

====Temporarily halting and resuming medication====

Temporarily halting medication is the discontinuation of medication for a known or unknown period of time. Medication may be halted immediately or in the future. When medication use is temporarily halted, the medication still remains relevant for monitoring because the medication may be resumed in the future. Temporary substitution with another medicinal product is not considered an interruption but rather a discontinuation of the original medication and the start of a new pharmaceutical treatment with the substitute. Temporary halting medication is covered by two medication agreements<ref>This does not mean that end users actually have to create two agreements. A user friendly presentation by the information system is desired.</ref>: a MA (stop-MA) is created to stop medication use in accordance with guidelines for a stop-MA (see previous paragraph) and a new MA is created for resuming the medication (including the reason for this, if any). All MAs are part of the same MBH. The reason for the interruption is recorded in the stop-MA. The stop type for the stop-MA is 'temporary’.

====Changing medication====

Medication modifications may be related to:

:a) Dosage, 

:b) Strength of the medicinal product, 

:c) Method of administration, 

:d) Duration of treatment (such as an extension of the therapy). 

Switching to a completely different medicinal product is technically a switch to a different MBH (see also [[#Medicamenteuze behandeling|paragraph 1.3.3]]). In that case, the physician will discontinue the existing pharamceutical treatment (see [[#Discontinuing medication|paragraph 2.2.5.3]]) and start a new one (see [[#New medicatieafspraak|paragraph 2.2.5.1]]).
If the PRK stays the same, changes will be recorded under the same MBH. When a modification needs to be made, a technical stop-MA is created (see [[#Discontinuing medication|paragraph 2.2.5.3]]) and a new MA is made with the desired change. The appointment date of the technical stop-MA and the new MA must be always be the same. The reason for the modification is included in the new MA with a reference to the original MA, if possible. Modifications may take effect immediately or in the future. A technical stop-MA and the related new MA are made available simultaneously. In case of renewal of an MA of which the duration has already expired or the end date has already expired, then this is not seen as a change (a stop-MA on the already automatically stopped MA is unnecessary). In this case, a new MA under the same MBH can be made.

====Correcting/canceling a medication agreement<ref> Correcting/canceling administration agreements happens in the same way. XIS is a generic term for a random (health care) information system. PHR=personal health records.</ref>====

This paragraph describes correcting or canceling an MA when the prescriber has made an error. The error may have been discovered by the prescriber himself or by a fellow health professional.
For example, a physician who makes a typing error in the dosage of an MA: 10 inhalations, 2x daily, instead of 1 inhalation, 2x daily. If the MA has not yet been shared with other health professionals, the prescriber can personally correct that MA or delete (cancel) it from his own information system. If the MA has already been shared with other health professionals, the prescriber will mark the incorrect MA as ‘incorrect registration’ and he will then create a new MA under the same MBH with the correct information. The prescriber will actively inform the pharmacist and any fellow health professionals about both the cancelled and new MA and will make both available (see [[#Process step: (Actively) making available|paragraph 2.2.10]]).

====Stopping a prospective medication agreement====
This only concerns MA's that have their start date at some point in the future. For whatever reason a prescriber wants to end this prospective MA. The prescriber will not create a stop-MA in this scenario but cancels the MA instead. The prescriber cancels the MA by using the ‘canceled indicator’ field. The prescriber can only use the ‘canceled indicator’ when the start date of the MA is in the future. If the prescriber wants to end the prospective MA he/she changes the status of the MA to canceled with the indicator.

When the prescriber is not the initial creator of the original prospective MA the process works as follows. The prescriber creates a new MA with the canceled indicator activated. The ‘canceled MA’ will be sent to the original prescriber of the MA. The original prescriber will then cancel the original MA as well.

===Process step: Making a variable dosing regimen===
When a prescriber prescribes medication combined with a variable dosign regimen (WDS), the dosing of the medication can be adjusted by a (different) prescriber without having to adapt the medication agreement (MA). At the moment the variable dosing regimen is used for anticoagulants. When prescribing anticoagulants, the prescriber determines the therapeutic INR-range (International Normalized Ratio, a measure of blood clotting time), within which the treatment should take place.
The thrombosis service is responsible for drafting the viariable dosing regimen. The dosing regimen is composed by a prescriber (usually a thrombosis physician) in the building block variable dosing regimen (Wisselend doseerschema, WDS). The prescriber who made the medication agreement remains responsible for the dispense requests (VV). The thrombosis physician composes the WDS withing the agreed upon INR-range, the dosing regimen is usually based on a specific, measured INR-value. 
====Setting up a variable dosing regimen ====
The prescriber prescribes anticoagulants with a medication agreement (MA) and indicates:
* The medication (PRK) that is being prescribed to the patient. The medication in the variable dosing regimen is always the same as the medication in the MA.
* That for this medication a variable dosing regimen applies (this is added in the additional instructions). This also means there will be no dosage added in the medication agreement.
* The INR-range within which the treatment should take place. This information is included in a comment.

In order to bridge the period until the thrombosis service is involved and ready to take over the treatment, the original prescriber sets up a WDS for this first period (usually between 4 and 7 days). Usually a check-up date is agreed upon after the registration of the patient at the thrombosis service. During this check up the INR-value is measured. Based on the measured value and/ or the professional assessment of the thrombosis physician, a dosing regimen is composed that either changes of succeeds the previous WDS. From this moment on, the thrombosis service takes over the composition of the dosing regiment from the original prescriber.

''INR-value with the WDS'' 
The variable dosing regimen is often based on an INR-value. For other parties involved in the care for the patient, it’s important to be able to deduce the INR-value on which the WDS was based. That is the reason that the corresponding INR-value will be made available within the WDS. The INR-value is included in a comment within the WDS.

====Changing a variable dosing regimen ====
When the variable dosing regimen (WDS) is being used up until the stop date of the WDS, it can be replaced by a new WDS that succeeds it. The new WDS has a relation to the MA and the previous WDS.
Furthermore, it is possible to adjust the WDS before the stop date is reached. In that case, the information system stops the previous WDS, using a technical stop-WDS that is not visible to the user. The new WDS follows and has a reason for change and a relation to the MA and the previous WDS.
All changes related to the dosing regimen can be included in the WDS. Changes that concert the further treatment policy (e.g. the prescribed medication, the route of administration of the agreed upon INR-range) are to be made in the MA.

====Stopping a variable dosing regimen ====
There are various reasons that can cause the need to (temporarily) stop the use of anticoagulants. For example, in the event of a procedure of because there is temporary co-medication. Two kinds of situations can be distinguished. Depending on the situation and the assessment of the thrombosis physician one of twee methods is chosen:
#''(temporary) adjusting the policy'': The thrombosis physician can choose to temporarily adjust the dose for the anticoagulants to 0. For example, in the event of a planned procedure. In this case, the MA (and therefore the treatment with anticoagulants) and the TA will continue, but the dosage in the WDS is temporarily adjusted to 0. The MA will still be shown on the medication overview under ‘current medication’. In the event of such a temporary adjustment, only the WDS is changed. It is advised to include a reason for this change in the new WDS.
# ''(temporary) stopping the anticoagulants:'' The thrombosis physician (or another prescriber) can also choose to (temporarily) stop the treatment with anticoagulants. This means that the patient should not to take any anticoagulants anymore. In this case the thombosis physician (or another prescriber) creates a stop-MA (or sends a proposed MA to the original prescriber). Stopping the MA, also stops the underlying therapeutic building blocks (TA, WDS). The anticoagulant will be shown on the medication overview under ‘recently stopped medication’.
If, after a period of time, there is a need to restart the anticoagulant, the prescriber can do this by creating a new MA. The new MA can be created by the original prescriber, the thrombosis physician could also send a proposed MA. In many cases the thrombosis service would no longer be involved. And the MA is created by the original prescriber.

===Process step: Creating a medication dispense request===

A VV (besides an MA) only applies in an ambulatory situation. A VV may be made when the medication supply of the patient needs to be replenished. This does not have to coincide with an MA. At the start of a MBH for which the patient still has a sufficient supply at home from a previous agreement, a VV is not needed. When the dosage is reduced, the patient may also have a sufficient supply. In the case of a medicinal product that is used for a prolonged period of time (e.g. an antihypertensive drug), with a continuous MA (meaning a period of use with only a start date), several VVs may be made over time within the scope of this existing agreement.
Logistical and emergency instructions may be included in the VV, such as dispense location, request to not include in the GDS (medication distribution system, in Dutch: 'Geneesmiddel Distributie Systeem'), etc.

In the case of a VV, the quantity to be supplied can be stated or the consumption period. With a consumption period, the quantity must be clearly deducible from the dosing instruction of the MA. Note: a consumption period end date has a meaning other than the period of use end date from the MA and may be unequal.
*Period of medication use end date: date until which the pharmacist is allowed to to provide medication (and thereby provide sufficient supplies to the patient for use until that date).
*Period of use end date: date on which the patient must stop the medication (this can be equal to the consumption period end date or further in the future).

===Process step: Sending renal function value with prescription===

Renal function is important for certain medicines. The renal function value determines the choice of drug and/or drug dosage. It is legally stipulated that if a health professional has performed further research on a patient renal function, he should share abnormal renal function values with the appropriate pharmacist, appointed by the patient (article 6.10, 'regeling geneesmiddelenwet').

The renal function value is always sent with the prescription (using the building block laboratory test results) for medicines for which this is important (characteristic in the G-standard), so that the pharmacist can perform proper medication monitoring. The renal function value should not be older than 13 months, because with stable chronic renal impairment the renal function should be checked at least once a year. 1 month has been added to allow some backlog in practice.

If at the time of sending of an MA and/or VV no renal function is known, then the prescription policy remains unchanged. Sending the laboratory test result renal function value without an MA and/or VV is beyond the scope of this information standard.

===Process step: Sending height and weight values with prescription===

It is possible for the prescriber to send the body height and weight of the patient with the prescription. This is the height an weigh of the patient that the prescriber used for the medication agreement. Hence, it is possible for these values to diverge (be more accurate) from the height and weight values that are registered in the patient details. This could be necessary for prescribing for children or for medication where weight (e.g. coagulation medication) or height (e.g. oncolytic agents) are important factors to consider.

Body height and weight are separate building blocks. They can only be send together with the prescription and with the medication agreement. The information is not available on request.

===Process step: (Actively) making available===

This step involves information exchange. Information can be sent or made available with different intentions:

A. As an order for the pharmacist to dispense medication. The prescriber sends the MA to the pharmacist. In an ambulatory situation, the VV is also sent to the patient’s pharmacist. If the pharmacist is not known, this process step may also entail giving out a paper prescription and/or (reactively) making the data available (see C). When the pharmacist has filled the order, the prescriber will receive a notification (see [[#Information systems and transaction groups|paragraph 2.3.8]]). 

B. As an order for the pharmacist to implement a medication change (including stop-MA with stop type 'permanent' and 'temporary') that impacts or may impact current MVE by this pharmacist. A current MVE indicates an order (as in A) that has been accepted, but has not yet been completely filled. For example, when medication is still being dispensed or when a VV dictates that medication should be dispensed multiple times, but not all have taken place yet, e.g. with the GDS. 

C. Making medication data (MA, VV, MGB) and possibly the medication overview available to allow fellow health professionals and/or patients to access these later, possibly in combination with prescription without a specified recipient (see [[#Prescription without specified recipient (ambulatory)|paragraph 8.1]]). 

D. Actively sending (informing) medication data (one or more building blocks) to a specific health professional at the request of the patient when in the presence of this health professional or at discharge. 

In case of corrected data, the prescriber assesses who should be actively informed of this correction. This can be done, for example, by sending the new MA (option A or B above) or by means of a telephone consultation.
In an ambulatory setting (general practitioner/outpatient clinic) medication data are usually sent or made available directly; in a clinical setting, medication data is usually made available at discharge or interim leave from the institution.
This chapter deals with prescription with a specified recipient; [[#Prescription without specified recipient (ambulatory)|paragraph 7.5]] details prescription without a specified recipient.
See also [[#Informing and (actively) making available|paragraph 1.3.5]] for a further explanation on informing (situation A, B, D) and making available (situation C).

===Post-condition===
*A new MA may have been created (starting, changing or discontinuing medication)
*A VV may have been made (only outpatient)
*An order may have been sent to the pharmacist to carry out MVE
*An order may have been sent to the pharmacist to modify MVE
*Fellow health professionals and the patient have been informed or may inform themselves about the new medication data: MA, VV, MGB
*Fellow health professionals and the patient have been informed or may inform themselves about a medication overview.

===Information systems and transaction groups===

The prescriber and the pharmacist as well as other health professionals and users all make use of an information system, respectively, an electronic prescribing system (EVS), a pharmacist information system (AIS, incl. ZAIS), a XIS and a PGO<ref> XIS is a generic term for a random (health care) information system. PHR=personal health records.</ref>. These information systems each have different system roles which enable the exchange of data between these information systems as part of the prescription process.
[[#Information systems and transactions|Chapter 6]] includes an overview of all information systems, system roles, transactions, etc. The most important elements for the prescription process are included in the overview below.

{{anchor|figuur 5}}
[[Bestand:Uc Voorschrijven.png|Figuur 5 Processtappen en transacties - voorschrijven]]

===Use cases===
The following specific use cases have been elobarated:
*[[#Short-term medication|Short-term medication (paragraph 4.1.1)]]
*[[#Continuing medication|Continuing medication (paragraph 4.1.2)]]
*[[#Hard end date for period of medication use|Hard end date for period of medication use (paragraph 4.1.3)]]
*[[#Medication as needed|Medication as needed (paragraph 4.1.4)]]
*[[#Course of treatment as needed starting in future|Course of treatment as needed starting in future (paragraph 4.1.5)]]
*[[#Two dosages of the same medication at the same time|Two dosages of the same medication at the same time (paragraph 4.1.6)]]
*[[#The same medicinal product with different strengths at the same time|The same medicinal product with different strengths at the same time (paragraph 4.1.7)]]
*[[#Explanation in medicatieafspraak with deliberately chosen special characteristic|Explanation in medicatieafspraak with deliberately chosen special characteristic (paragraph 4.1.8)]]
*[[#New medicatieafspraak, no verstrekkingsverzoek|New medicatieafspraak, no verstrekkingsverzoek (paragraph 4.1.9)]]
*[[#New verstrekkingsverzoek under existing medicatieafspraak|New verstrekkingsverzoek under existing medicatieafspraak (paragraph 4.1.10)]]
*[[#Dosage change (sufficient supply)|Dosage change (sufficient supply) (paragraph 4.1.11)]]
*[[#Prescription no longer needed after first verstrekkingsverzoek|Prescription no longer needed after first verstrekkingsverzoek (paragraph 4.1.12)]]
*[[#Discontinuing medication|Discontinuing medication (paragraph 4.1.13)]]
*[[#Temporarily halting/resuming medication|Temporarily halting/resuming medication (paragraph 4.1.14)]]
*[[#Temporarily halting for an intervention|Temporarily halting for an intervention (paragraph 4.1.15)]]
*[[#Substitution|Substitution (paragraph 4.1.16)]]
*[[#Paper prescription|Paper prescription (paragraph 4.1.17)]]
*[[#Carrying out medication verification and evaluation of foreign or self-care medication|Carrying out medication verification and evaluation of foreign or self-care medication (paragraph 4.1.18)]]
*[[#Day treatment|Day treatment (paragraph 4.1.19)]]
*[[#Starting with medication before admission|Starting with medication before admission (paragraph 4.1.20)]]
*[[#Emergency admission|Emergency admission (paragraph 4.1.21)]]
*[[#Discharge|Discharge (paragraph 4.1.22)]]
*[[#Interim discharge|Interim discharge (paragraph 4.1.23)]]
*[[#Transfer to another institution|Transfer to another institution (paragraph 4.1.24)]]
*[[#Do not dispense before|Do not dispense before (paragraph 4.1.25)]]
*[[#Discontinuation of medication by third parties|Discontinuation of medication by third parties (paragraph 4.1.26)]]
*[[#Two PRKs in a single medicamenteuze behandeling|Two PRKs in a single medicamenteuze behandeling (paragraph 4.1.27)]]
*[[#Creating a medicatieafspraak after the fact|Creating a medicatieafspraak after the fact (paragraph 4.1.28)]]
*[[#Single medication use( medicatiegebruik)|Single medication use(medicatiegebruik)(paragraph 4.1.30)]]
*[[#Provisional and final medication order|Provisional and final medication order (paragraph 4.1.31)]]
*[[#Inadvertently ‘outstanding’ medication or 'orphans'|Inadvertently ‘outstanding’ medication or 'orphans' (paragraph 4.1.32)]]
*[[#Missing digital medicatieafspraak at admission|Missing digital medicatieafspraak at admission (paragraph 4.1.33)]]
*[[#Own articles (90 million numbers)|Own articles (90 million numbers) (paragraph 4.1.34)]]
*[[#Dosing with minimum interval|Dosing with minimum interval (paragraph 4.1.35)]]
*[[#Verstrekkingsverzoek with number of repetitions|Verstrekkingsverzoek with number of repetitions (paragraph 4.1.36)]]
*[[#Prescribing non-medicines|Prescribing non-medicines (paragraph 4.1.37)]]
*[[#Send renal function value in the prescription|Send renal function value in the prescription (paragraph 4.1.38)]]
*[[#Cancelling a prescription that was sent earlier|Cancelling a prescription that was sent earlier (paragraph 4.1.39)]]
*[[#Modification of someone else's medicatieafspraak|Modification of someone else's medicatieafspraak (paragraph 4.1.40)]]
*[[#Setting up a variable dosing regimen (WDS)|Setting up a variable dosing regimen (WDS) (paragraph 4.1.41)]]
*[[#Changing a variable dosing regimen (WDS) during period of use|Changing a variable dosing regimen (WDS) during period of use (paragraph 4.1.42)]]
*[[#Stopping medication with a variable dosing regimen (WDS)|Stopping medication with a variable dosing regimen (WDS) (paragraph 4.1.43)]]

==Process: dispense==

This paragraph describes the process of dispensing medication, including repeat prescriptions and GDS. This process encompasses all actions a pharmacist must take for the patient to not only receive a medicinal product, but to also receive the associated pharmaceutical care ensuring a safe and effective use of the medicinal product by the patient. The dispense process starts with providing pharmaceutical care. If necessary, a medication administration agreement will be made and if needed, medication is dispensed. Medication dispense (i.e. handing out a medicinal product) does not always take place. This may be the case when the medication agreement is changed (e.g., in case of dose reduction where the patient still has enough supply), when the medication is discontinued or, in an ambulatory situation, the medication is not picked up. When the MA and/or the VV do not comply (see [[#Process step: Informing the prescriber|paragraph 2.3.5]]), the prescriber will be informed. Finally, the recorded data are (actively) made available. See [[#Appendix: General Diagram Medicatioprocess|Chapter 12]] for a diagram of the dispense process.

Medication assessment is the process in which the physician and pharmacist consider all medication of the patient against the background of his condition, applicable treatment guidelines, the well-being of the patient, etc. Medication assessment is defined in this document as a combination of treatment evaluation (as described in the previous paragraphs) and pharmaceutical care. Depending on the findings, the previously described medication verification and prescription processes are followed, after which medication dispense takes place.

For the GDS, many pharmacists collaborate with another organisation that handles part of the pharmacists’ logistics. This then also requires data exchange with that party. Besides, not all medication can be included in the GDS packaging, which adds to the logistical complexity for the pharmacist. The internal logistics and communication between the pharmacist and his subcontractor(s) are outside the scope of this information standard. It has been established however that with the provision of the current building blocks and the underlying data elements, this logistical process can be adequately supported.

===Current situation===
The following deviations (from the desired situation that) are currently observed:
*In the current situation, in the case of GDS, the prescribing physician and other health professionals receive a large quantity of dispense messages. This becomes difficult to manage for these health professionals.
*In the current situation, in the case of GDS, pharmacists and general practitioners communicate via so-called authorisation lists. The pharmacist sends an overview of all the patient’s medication to the general practitioner for authorisation. This complicates matters for a general practitioner because he will need to verify all medication agreements. This should not be necessary, as most medication agreements/dispense requests have already been authorised. It would be much more efficient if the general practitioner only needs to authorise those medication agreements/disprense requests that have not been authorised yet, e.g. a new dispense request on the basis of an existing medication agreement.
*In the current situation, a locum pharmacy often does not inform the regular general practitioner and regular pharmacy when medication is dispensed.
*In the current situation, a proposal for a medication agreement may have been aligned with the prescriber over the phone and/or the pharmacist and prescriber have made an agreement about handling a warning from the medication monitoring system.
*The intention of the return message is not always clear: no distinction can be made in the return/delivery message between displaying a physical delivery and a transmission of information about a medication change.
*In the current situation, pharmacists sometimes register (and communicate) medication dispenses when they are preparing the medication for the patient instead of at the time when the medication is actually dispensed to the patient. This means that medication that has not been picked up, is sometimes erroneously registered as dispensed.

===Precondition===

An MA exists. In an ambulatory situation there may also be a corresponding VV.

===Trigger event===
The pharmacist starts the medication dispense process on the basis of one of the following events:
*Receipt of an order to make an MVE on the basis of a new MA. In an ambulatory situation, this order is always accompanied by a VV.
*Receipt of an order to process a new MA in an ongoing MVE.
*Receipt of a trigger (for example, via a patient or a repeat module of the pharmacist information system) for a repeat MVE under an existing MVE or a new VVV.

===Process step: Providing pharmaceutical care===
Pharmaceutical care is provided by a community, outpatient (i.e. at the hospital) or institutional pharmacy, depending on the health professional who has created the MA:
*MA, possibly with a VV from the general practitioner or specialist: care provided by a community or outpatient pharmacy.
*MA from specialists and other prescribers in hospitals/institutions: care provided by an institutional pharmacy or a community pharmacy that supplies the respective institution.
Medication monitoring is also part of pharmaceutical care.

Based on the received MA or a change in the situation of the patient, the pharmacist decides how to apply this by:
*Making one or more new TAs.
*Continuing, permanently discontinuing, temporarily halting or modifying an existing MA.
*Rejecting the MA.
*Proposing a new MA.
*Proposing a new medication dispense (VVV).

The last three situations are explained in the following paragraph. The first two situations are explained in [[#Process step: Creating a toedieningsafspraak|paragraph 2.3.6]].
In conclusion of provided pharmaceutical care, which may comprise new agreements and medication dispenses, a new up-to-date medication overview may be compiled and made available.

===Process step: Informing the prescriber===

There is a number of situations in which the pharmacist informs the prescriber, including:
*When a new or modified MA is needed
*When a new VV is needed
For more information about informing, see [[#Informing and (actively) making available|paragraph 1.3.5]].

A new or modified MA is needed:
*When a new TA cannot be created based on the received MA because the pharmacist suspects an error in the MA, or
*After a signal from the medication monitoring system as part of pharmaceutical care. The signal may indicate, for example, that the dosage should be lowered or increased, that it is advisable to select another medicinal product, that a product should be temporarily discontinued, that another additional product should be added, etc., or
*Based on medication use as reported by the patient during pharmaceutical care, or
*When the temporarily halted pharmaceutical treatment may be resumed.
*A TA is not yet created or modified in these situations.
Instead, the pharmacist starts by contacting the prescriber by phone, informing him of the suspected error and proposing an alternative. The pharmacist may also send a digital proposition called VMA to the prescriber. He recommends a specific MA in this proposal, together with the reason and arguments for that recommendation. The prescriber may approve the VMA and make it into a final MA (see also [[#Process step: Evaluating a (pharmaceutical) treatment|paragraph 2.2.4]]). 

A new VV is needed when the patient’s medication stock is depleted or nearly used and the treatment may need to be continued (request repeat prescription). The patient either requests a repeat MVE from the pharmacist or has signed up in the past for proactive repeat MVE and a notification signal is generated by the repeat module of the AIS when the patient requires new medication<ref> The patient may also request a repeat directly from the prescriber: see [[#2-5-6|paragraph 2.5.6]].</ref>.
When the existing VV is not adequate, the pharmacist may communicate this request over the phone or send a digital VVV to the prescriber. The VVV may contain indications for the prescriber, such as urgency. The prescriber may approve the received proposal and alter it into a final VV. The prescriber informs the requestor via a AVVV (see also [[#Process step: Evaluating a (pharmaceutical) treatment|paragraph 2.2.4]] and subsequent paragraphs).

===Process step: Creating an administration agreement===

If the MA and, if applicable, the corresponding VV can be processed, a TA will be created. By creating a TA, the pharmacist fulfills the MA. The TA is communicated to the patient or the person administrating the medication. The TA belongs to the same MBH as the MA it fulfills. As is the case with the corresponding MA, a TA may start in the future. The dosage in the TA may deviate from that in the MA, for example because a certain strength is not in stock. This means that another PRK can become part of the MBH when, for example, 1 tablet of 20 mg is changed into 2 tablets of 10 mg.
Before the TA is made (actively) available, medication monitoring will occur in accordance with applicable guidelines, as part of this process step.

On the basis of the TA, an administration list<ref> In this document, the administration list means both the digital and the paper version, unless otherwise indicated. Sublist and checklist are synonyms. </ref> can be compiled for home care or nursing staff, among others.

When creating a TA, the same principle applies as for the MA: each change is recorded in a new TA.

The following paragraphs describe the different situations in which a TA is created: new TA or continuing, permanently discontinuing, temporarily halting or modifying an existing TA.

====New administration agreement====

In case of a new MA, a new TA is always created. A new TA is also created in case of a new preference policy or a change in stock which results in the selection of a different medicinal product.
When creating a new TA, the pharmacist takes into account, among other things:
*Preference policy,
*Inclusion in GDS-packaging,
*Available stock of the institution (‘hospital formulary’) or the pharmacy itself. 

If, in an ambulatory situation, the first provision/dispense to the patient occurs later than agreed, the start date of the TA will be different from the start date of the MA.

====Continuing an administration agreement====

When the existing MA and TA are sufficient to carry out an MVE, the TA will not be adjusted.

====Discontinuing an administration agreement====

An MA in which it has been agreed to discontinue medication permanently, leads to a stop-TA under the same MBH (this also applies in case of a stop-MA as a result of a change) with stop type ‘permanent’. The stop-TA prevents a new MVE of the discontinued medication.
In an ambulatory situation, the prescriber can indicate in the MA that the medication will be discontinued with the next roll (with GDS). In this case, the start date of the stop-TA may be later than indicated in the original stop-TA.

====Temporarily interrupting an administration agreement====

Temporarily interrupting an MA results in a stop-TA (stop type: 'temporary'). Upon resuming, a new TA is created. Both TAs belong to the same MBH as the MA.

====Modifying an administration agreement====

A modified MA (leading to a new MA) leads to a new TA under the same MBH. As with the MA, a change to a TA means the termination of the existing TA (a technical stop-TA) and the creation of a new TA.

===Process step: Dispense===

After creating the TA, the pharmacist prepares the product and dispenses it to:
*The patient in a community setting,
*The patient admitted to a hospital, nursing home or other institution.
The pharmacist records MVE<ref>In a clinical situation, product may be taken from the department’s own supply, after which administration takes place immediately and the administration is recorded.</ref>.

Medication dispense to patients:
*In an ambulatory situation only occurs on the basis of a VV or a repeat VV,
*In a clinical situation occurs on the basis of the MA without the need for a VV.

===Process step: (Actively) making available===

This step involves information exchange. Information can be sent or made available with different intentions:

As a request to the prescriber to create a new medication agreement (VMA) or a new dispense request (VVV).

Informing the prescriber about the processing of the prescription (TA and/or MVE).

Making medication data available (VV and MVE) to allow fellow health professionals and/or patients to access these later.

Making a medication overview available to allow fellow health professionals and/or patients to access these later.

===Post-condition===
*A TA could have been created.
*An MVE could have taken place and, if necessary, the patient has received instructions on how to use the medicinal product.
*Fellow health professionals have been informed or may inform themselves. The prescriber has been informed.
*If necessary, the prescribing physician has been requested to provide a new/modified MA or VV.

===Information systems and transaction groups===

The prescriber and the pharmacist as well as other health professionals and users all make use of an information system, respectively, an electronic prescribing system (EVS), a pharmacist information system (AIS, incl. ZAIS), a XIS and a PGO<ref> XIS is a generic term for a random (health care) information system. PHR=personal health records. </ref>. These information systems each have different system roles which enable the exchange of data between these information systems as part of the prescription process.
[[#Information systems and transactions|Chapter 6]] includes an overview of all information systems, system roles, transactions, etc. The most important elements for the prescription process are included in the overview below.

{{anchor|figuur 6}}
[[Bestand:Uc Ter handstellen.png|Figuur 6 Processeps and transactions - dispense]]

===Use cases===
De volgende specifieke use cases van ter hand stellen zijn uitgewerkt:
*[[#New medicatieafspraak, medicatieverstrekking of the same product|New medicatieafspraak, medicatieverstrekking of the same product (paragraph 4.2.1)]]
*[[#New medicatieafspraak, medicatieverstrekking of the same product|New medicatieafspraak, medicatieverstrekking of the same product (paragraph 4.2.2)]]
*[[#Existing toedieningsafspraak is adequate|Existing toedieningsafspraak is adequate(paragraph 4.2.3)]]
*[[#Medicatieafspraak wanted (informing the prescriber)|Medicatieafspraak wanted (informing the prescriber) (paragraph 4.2.4)]]
*[[#Request and dispense|Request and dispense (paragraph 4.2.5)]]
*[[#Patient requests repeat prescription via physician (reactive repeat)|Patient requests repeat prescription via physician (reactive repeat) (paragraph 4.2.6)]]
*[[#Patient requests repeat prescription via pharmacist (informing prescriber)|Patient requests repeat prescription via pharmacist (informing prescriber) (paragraph 4.2.7)]]
*[[#Proactive repeat prescription by pharmacist (informing prescriber)|Proactive repeat prescription by pharmacist (informing prescriber) (paragraph 4.2.8)]]
*[[#Dispense based on an existing verstrekkingsverzoek|Dispense based on an existing verstrekkingsverzoek (paragraph 4.2.9)]]
*[[#Splitting a prescription|Splitting a prescription (paragraph 4.2.10)]]
*[[#Starting and continuing a GDS|Starting and continuing a GDS (paragraph 4.2.11)]]
*[[#The pharmacist changes commercial product|The pharmacist changes commercial product (paragraph 4.2.12)]]
*[[#Adding medication to a GDS|Adding medication to a GDS (paragraph 4.2.13)]]
*[[#Discontinuing medication in a GDS|Discontinuing medication in a GDS (paragraph 4.2.14)]]
*[[#GDS supplier supplies other commercial product|GDS supplier supplies other commercial product (paragraph 4.2.15)]]
*[[#Parallel administration agreements with GDS- and non-GDS-dispense|Parallel administration agreements with GDS- and non-GDS-dispense (paragraph 4.2.16)]]
*[[#Handling a stop medicatieafspraak|Handling a stop medicatieafspraak (paragraph 4.2.17)]]
*[[#Medication dispense with someone else’s administration agreement|Medication dispense with someone else’s administration agreement (paragraph 4.2.18)]]
*[[#Modification of someone else’s administration agreement|Modification of someone else’s administration agreement (paragraph 4.2.19)]]
*[[#Verstrekkingsverzoek with number of repetitions|Verstrekkingsverzoek with number of repetitions (paragraph 4.1.36)]]

==Process: administer==

 
This paragraph describes the administration process. This process comprises the compilation of the administration list for (professional) administrators and the administration which is carried out by a (professional) administrator, the patient himself or an informal caregiver. Professional administrators are physicians, nurses and caregivers (home care/institution).

In paragraph 2.4.1, the current situation is described, followed by a description of the new, altered situation.

===Current situation===
In the current situation, the (professional) administrator, together with the patient, verifies the medication which should be administered, using the available information (paper and/or digital administration list(s), the dosing schedule for, for example, anticoagulant medication, the information on the label), and, subsequently, administers the medication. In case of uncertain administration instructions, the administrator contacts the prescriber or pharmacist. Uncertainties are more likely to occur with an increasing number of prescribers, suppliers and administrators who are involved in the administration process.
In the current situation, for administrators, there are several challenges in the transfer of medication data:
*Transfer of medication data between inpatient health care or home care, and hospital health care is missing or is not available in time;
*Medication changes are not received (in time), and medication stops are missing;
*Up-to-date data on the administration list is not available in the case of supply by multiple pharmacies during after-hours care (evening, night or weekend);
*Separate dosing schedules, in addition to the administration list, of (highly) variable dosages, for example anticoagulant medication;
*Problems related to a separate dosing schedule of (highly) variable dosages; for example, loss of the dosing schedule, verbal information regarding changes of the dosing schedule;
*Medication as needed, injection schedules (for example, for insulin) are missing on the administration list (the injection schedules will be worked out in the information standard in the future);
*An overview is missing of all health professionals and healthcare providers which are involved.

In the current situation, the pharmacist compiles the administration list for the (professional) administrator or the patient. This administration list comprises the administration times, which are geared to the rounds of the home care organization, with account for the pharmaceutical ranges. A paper or digital administration list is used by the (professional) administrators for the registration of the medication administration. A paper administration list (including the administration registration) is in the patient’s home, and is therefore accessible for all professional administrators (irrespective of organization). The digitally recorded medication administrations are only exchanged with other health professionals in exceptional situations (for example, it may be exchanged in the case of admission or special circumstances). With the transition to an electronic administration registration, the administration list (with the recorded administration times) is no longer physically present; instead the administration is recorded in the E-TDR/E-TRS (electronic administration registration/electronic administration registration system) (see paragraph 2.4.8). The involved professional administrators of different organizations (with possibly different E-TRS applications) cannot consult or can only consult with difficulty the registered administration procedures of other organizations, because of registration in different applications and/or databases.

===Precondition===

The patient administers medication to himself or the patient must be administered medication by a(n) (professional) administrator and, therefore, requires an administration list.

===Trigger event===

The moment the medicinal products must be administered.

===Process step: Administration list===

The (professional) administrator or the patient receives or asks for the (actively) made available medication data that is required for automatic generation of the administration list. For the administration list, the building blocks ‘medicatieafspraak’ (MA), ‘wisselend doseerschema’ (WDS), ‘toedieningsafspraak’(TA), ‘medicatieverstrekking’ (MVE) and ‘medicatietoediening’ (MTD) are needed. In order to compile a complete administration list, the (guide) administration times and dosing instructions are required. The pharmacist and prescriber can enter these data in the TA, and MA or WDS, respectively. In general, pharmacists and prescribers in the ambulatory setting do not register the (guide) administration times and, therefore, they should receive a trigger which indicates that it concerns an ‘administration patient’; a patient who is aided in the medication administration or a patient who requires an administration list. For some medication, it is necessary to provide information on the previous ‘prick and patch locations’ (sites of administration); this is registered in the MTD. In the case of inpatient health care, administration lists are available for all patients, and (guide) administration times are registered by default.

Most (guide) administration times are chosen based on the administration times of other prescribed medication and the rounds of the administrator, especially for MAs and TAs with standard flexible (guide) administration times. Further agreements should be made regarding the (guide) administration times by those concerned in the healthcare field (for example, which deviations from the (guide) administration times are permitted). If the administration of a drug requires a specific time of administration, for example because of medication interactions, this is communicated by entering in the TA and/or MA that the (guide) administration time is not flexible.

The administration list differentiates between GDS medication (GDS: medication distribution system, in Dutch ‘Geneesmiddel Distributie Systeem’) and non-GDS medication based on the distribution type. This information is recorded in the building block MVE. Subsequently, the administrator (administration software) compiles the administration list, based on the MA, WDS, TA and MTD, with differentiation according to administration moment. Prescribers, pharmacists and administrators (PrickPatchLocation) are responsible for providing the medication data which is necessary for generating the administration list.

'''NB.''' It is currently explored in which way information regarding GDS can be best exchanged.

===Process step: Administering===

The (professional) administrator has received the medication data (MA, WDS, TA, MVE and MTD) that is required for the medication administration. These data is presented in the administration list as described above. The (professional) administrator, together with the patient, verifies the available medication and the administration data. If agreed and needed, the professional administrator prepares the medication for administration. The medication is administered and the administrator records the administration in the information system or on the administration list. Deviations in the medication administration (not administered, adjusted dosage, refusal by the patient, swallowing problems, adverse effects, etc.) are recorded as well.

===Process step: (Actively) making available===

In this step, information is exchanged. The administration data can be sent or be made available with the following aims:
*The recorded MTDs and deviations can be sent for information to a fellow health professional;
*The MTD can be made available so that the data can be accessed later by fellow health professionals and/or the patient. For example, the administration data can be retrieved upon transfer of the patient to another department or institution. Also, a health professional can check which medication is administered to a patient.

===Post-condition===

The patient has administered medication by himself or has been administered medication. The MTDs can be recorded in an information system and can be (actively) made available for fellow health professionals and/or the patient.

===Information systems and transaction groups===

The prescriber and the pharmacist as well as other administrators and patients (optional) all make use of an information system, respectively, an electronic prescribing system (‘elektronisch voorschrijfsysteem’ - EVS), an electronic client file (‘elektronisch cliëntendossier’ - ECD), a pharmacist information system (‘apothekersinformatiesysteem’ - AIS), a hospital pharmacist information system (‘ziekenhuisapotheekinformatiesysteem’ - ZAIS), an administration registration system (‘toedieningsregistratiesysteem’ - TRS), a thrombosis service information system (‘trombosedienstinformatiesysteem’ - TrIS) and a personal health environment (‘persoonlijke gezondheidsomgeving’ - PGO). These information systems each have different system roles which enable the exchange of data between these information systems as part of the administration process. The information systems may have a function in compiling an administration list, and in the registration, the exchange and the delivering of an MTD.
Chapter 6 provides an example of compiling an administration list. The most important elements for the administration process are included in the overview below.

{{anchor|figuur 7}}
[[Bestand:Toedienen.png|Figuur 7 Processtappen en transacties - toedienen|800px]]

===Use cases===

The following use cases for medication administration have been worked out:

*[[#Creating an administration list|4.3.1 Creating an administration list]]
*[[#Exact administration times required|4.3.2 Exact administration times required]]
*[[#Missing (guide) administration times|4.3.3 Missing (guide) administration times]]
*[[#Non GDS medication as needed|4.3.4 Non GDS medication as needed]]
*[[#Medication supply by multiple pharmacies|4.3.5 Medication supply by multiple pharmacies]]
*[[#Change in GDS from the next supply or immediately|4.3.6 Change in GDS from the next supply or immediately]]
*[[#Increasing dosage of GDS in new MBH|4.3.7 Increasing dosage of GDS in new MBH]]
*[[#Decreasing dosage of GDS in new MBH|4.3.8 Decreasing dosage of GDS in new MBH]]
*[[#Change processed by the pharmacist|4.3.9 Change processed by the pharmacist]]
*[[#Change not processed by the pharmacist|4.3.10 Change not processed by the pharmacist]]
*[[#Variable-dosing regimen|4.3.11 Variable-dosing regimen]]
*[[#Additional information|4.3.12 Additional information]]
*[[#Medication administration deviates from administration list|4.3.13 Medication administration deviates from administration list]]
*[[#Medication administration without medication agreement and administration agreement|4.3.14 Medication administration without medication agreement and administration agreement]]
*[[#Medication administration of self-care medication|4.3.15 Medication administration of self-care medication]]
*[[#Correction/cancellation of an administration|4.3.16 Correction/cancellation of an administration]]
*[[#Medication administration on hold|4.3.17 Medication administration on hold]]
*[[#Medication administration by a prescriber|4.3.18 Medication administration by a prescriber]]
*[[#Multiple administration organizations|4.3.19 Multiple administration organizations]]

==Process: medication use==
This paragraph describes the process of medication use including registration of medication use by the patient or a health professional. The information recorded by the patient or health professional may be used, among other things, for medication verification by the health professional. During medication verification, medication use is established by the health professional. See [[#Appendix: General Diagram Medicatioprocess|Chapter 12]] for a diagram of this process.

===Current situation===
*There is currently a limited number of information systems available in which the patient can record his own use of medication. Exchange to health professionals is also highly dependent on the information system used and is often limited to one specific health professional via, for example, one specific platform/app.
*The current medication profiles are often incomplete and not up to date.

===Precondition===
The patient has been prescribed medication.

===Trigger event===
The patient has used the medication or does not use it (anymore).

===Process step: Medication use===
The patient uses the prescribed medication, selfcare medication. Medication use may be recorded by
*The patient himself or his informal caregiver,
*A home care or institution nurse and/or
*Another health professional.
This third option often applies in the event of medication verification (see [[#Process: medication verification|paragraph 2.1]]). A variety of information systems is available to record medication use: PHR, XIS, EPF [electronic patient file] / ECF [electronic client file], app, etc.

The following can be recorded as medication use:
*Self-care and other proprietary medication,
*Discrepancies compared to agreements made,
*Confirmation of medication use (promoting compliance),
*Verified medication (see medication verification),
*Changes as a result of, for example, side effects (by the patient himself; a health professional will record this in a different way).

Patients who are being administered medication by a nurse sometimes take the medication by themselves at a later time, depending on the BEM-score (assessment of medication self-management, in Dutch: 'Beoordeling Eigen Beheer Medicatie'); in that case, MTD data may deviate from MGB. 
While medication is being used, pharmaceutical care is provided by the pharmacist (see [[#Process step: Providing pharmaceutical care|paragraph 2.3.4]], e.g. in case of new laboratory values). There may also be follow-up contact during which the pharmaceutical treatment is evaluated (see [[#Process step: Evaluating a (pharmaceutical) treatment|paragraph 2.2.4]]).

====''Recording of medication use by the patient''====
The patients makes use of a medication profile and indicates actual medication use for each medicinal product for which this is relevant. The patient can indicate whether or not he is using the product and/or whether this is ‘medication use according to agreement’ (whereby the MA and/or TA is displayed) or if there were deviations. In case of deviations, it is possible to enter specific deviations (i.e. with regard to the schedule actually followed by the patient), but deviations can also be entered in more general terms (for example, I take the medication: ‘from time to time’, [x] times per [days/week] on average’, ‘1x daily instead of 2x’, ‘not anymore since 22 January 2015’ or ‘not anymore since about a month’). In case of deviation from the agreements, the patient also indicates the reason for changing or discontinuing. 
The patient may also add his own medication to the overview and indicate any side effects as the reason for the changes.

Information about medication use will not always be present. There is also no certainty about the reliability of the information. Sometimes there are agreements between the health professional and the patient about keeping track of medication use, and sometimes the initiative is the patient’s entirely.

====''Recording of medication use by health professionals''====
During the process of medication verification ([[#Process: medication verification|paragraph 2.1]]) or evaluating a pharmaceutical treatment ([[#Process step: Evaluating a (pharmaceutical) treatment|2.2.4]]) the patient (or his informal caregiver) indicates, for example, that he does not use medication or uses it differently than was agreed. He may also indicate that he uses other medication as well (self-care products or foreign medication). The health professional can record these data as MGB. The data about medication use is recorded in addition to the primary medication data with the patient being recorded as the source of the information and the health professional as the author. 
Instead of or in addition to recording the MGB, a prescriber may also choose to make a new or modified MA with the patient (in accordance with the process described in [[#Process step: Creating a medication agreement|paragraph 2.2.5]]). This may occur when the prescriber sees reasons to adjust the agreement in response to the patient’s actual medication use. When the prescriber sees no reasons to adjust the agreement, he may choose to only record the medication use, perhaps with the remark that he has requested the patient to comply with the existing agreements.

In case of deviations in MGB, a pharmacist may create a VMA for the prescriber (see [[#Process step: Informing the prescriber|paragraph 2.3.5]]) and/or advise the patient to inform the prescriber about the deviations.

The assessment of medication use (effect and side effect) will be recorded by the physician in the medical history or used as a reason to modify or discontinue a medication agreement.

===Process step: (Actively) making available===
The recorded medication data (MGB) and possibly the medication overview may be sent for information to a fellow health professionals or be made available so that the data can be accessed later.

{{Anchor|2-5-6}}

===Process step: Informing the prescriber===
The patient may also directly inform the prescriber when a new or modified MA or new VV is needed. The process is similar to the process of the pharmacist informing the prescriber ([[#Process step: Informing the prescriber|paragraph 2.3.5]]).

===Post-condition===
The medication list has been updated by the patient and actual medication use has been added. If necessary, the patient has asked the prescriber for a new or modified MA or VV.

===Information systems and transaction groups===
The ''prescriber'' and the ''pharmacist'' as well as other ''health professionals'' and ''users'' all make use of an information system, respectively, an electronic prescribing system (EVS), a pharmacist information system (AIS, incl. ZAIS), a XIS and a PGO<ref>XIS is a generic term for a random (health care) information system. PHR=personal health records.</ref>. These information systems each have different system roles which enable the exchange of data between these information systems as part of the prescription process. 
[[#6 Information systems and transactions|Chapter 6]] includes an overview of all information systems, system roles, transactions, etc. The most important elements for the prescription process are included in the overview below.

{{anchor|figuur 8}}
[[Bestand:Gebruiken.png|Figuur 8 Processtappen en transacties - gebruiken]]

===Use cases===
The use cases for medication use are described on the basis of registration by the patient. The prescriber may record medication use in the same way but will rather record the assessment of medication use (effect and side effect) in the medical history or use it as a reason to modify or discontinue a medication agreement.

The following specific use cases for medication use have been worked out:
*[[#Self-care product|Self-care product (paragraph 4.4.1)]]
*[[#Medication from abroad|Medication from abroad (paragraph 4.4.2)]]
*[[#Modification on the patient’s initiative|Modification at the patient’s initiative (paragraph 4.4.3)]]
*[[#Discontinuation of medication on the patient’s initiative|Discontinuation of medication at the patient’s initiative (paragraph 4.4.4)]]
*[[#No more supply|No more supply (paragraph 4.4.5)]]
*[[#Feedback to patient through a medication adherence app|Feedback to patient through a medication adherence app (paragraph 4.4.6)]]
*[[#Registration of side effects by the patient|Registration of side effects by the patient (paragraph 4.4.7)]]
*[[#Register usage based on provision|Register usage based on provision (paragraph 4.4.8)]]

=Domain-specific handling of the medication process=

==After Hours General Practice clinics (HAP)==
The after hours general practitioner (AHGP) works on behalf of the regular general practitioner (GP). The AHGP may (among other things) start, modify and discontinue MAs in accordance with the process described in [[#Process: medication verification|paragraph 2.1]]. If necessary, the AHGP will also create the corresponding VVs. 
The AHGP will inform the regular GP about the observation. Currently, it has been agreed that the AHGP does not act as a source of information for other health professionals of this patient. This means that the AHGP will not carry out the process step ‘(actively) making available’. Instead, the regular GP will make the relevant information available to the fellow health professionals. An exception may be made for a prescription created by the AHGP without a specified recipient, see [[#Prescription without specified recipient (ambulatory)|paragraph 8.1]]. 
In principle, the AHGP will follow the generic prescription process, except that a AHGP will carry out certain steps on behalf of the regular GP (‘delegated’).

==Mental health care==
There are only few planned admissions in mental health care (almost only in departments for eating disorders, clinical rehabilitation, etc.). Most admissions are admissions as a result of acute crisis situations and are therefore comparable to admissions via the emergency departments in hospitals (see also [[#Starting with medication before admission|paragraph 4.1.20]]).

===Current situation===
In the current situation, patient or family/informal caregivers are asked which medication the patient is using. In most cases, the patient is unable to give an answer (often the reason for admission). Family/informal caregivers (if known) are also not always able to answer this. If this is the case, the admitting physician/psychiatrists will contact the general practitioner or the pharmacist to find out the medication. This is difficult outside office hours and during weekends. When data do come in, only part of them is retyped in the information system of the health professionals.

===Process===
In the new situation, it will be possible to retrieve the available medication data and medication overviews. On this basis, medication verification, assessment of the medicamenteuze behandeling (as soon as possible) and medication administration (in accordance with [[#Medication process|Chapter 2]]) can be started. Medication dispense is carried out by public pharmacists on an outpatient basis and, in clinical practice, often by a contracted hospital pharmacy. 
As is the case with hospital discharge, medicamenteuze behandeling will be assessed at discharge from a mental health institution ([[#Process step: Evaluating a (pharmaceutical) treatment|paragraph 2.2.4]] and subsequent). Clinical medication is discontinued and, if necessary, new medication is prescribed or temporarily halted outpatient medication is resumed or permanently discontinued. The physician/psychiatrist focuses mainly on psychiatric medication; somatic medication usually remains unaffected. 
Letting the psychiatric patient record his own medicatiegebruik may be experienced as undesirable control instead of it stimulating proper medication use. 
The medication data will be made available.

==Nursing, care and home care (VVT)==
The medication process in a VVT institution (nursing home, care home and home care) is similar to that of the clinical situation. However, in a VVT institution, a geriatrics specialist is responsible for prescribing medication to admitted clients and medication is being dispensed by one or more community pharmacists, possibly as part of GDS if needed. VVT institutions and home care make use of administration lists, which are drawn up based on the toedieningafspraken. The administration list is used to check medication before administering it and to sign off actual medicatiegebruik. Communication of the administration list between pharmacist, prescriber and nursing staff will be explained in more details further on in this information standard.

==Hospital admission and discharge==
A special situation in the transfer of medication data occurs when a patient is admitted to a hospital. At the moment of admission and of discharge, a lot of changes can take place in the medicatieafspraken and toedieningsafspraken. That is why this subject is separately illustrated in this chapter. This process is described in more detail in instruction manuals for caregivers and software suppliers.

===Prior to admission===
Before a patient is admitted to a hospital, changes in medication may be necessary. The medical specialist and patient can agree upon starting new medication or stopping continuous medication a few days before admission. The medical specialist subsequently registers a medicatieafspraak or stop-MA and mentions in the explanatory notes how many days before admission the patient has to start or stop the medication. When this medicatieafspraak is registered, the date of admission is often yet unknown. That is why the medical specialist records that this medicatieafspraak depends upon a hospital admission. This means that the start- or end date are uncertain. Technically, this is solved by registering the explanatory notes in the element ‘Condition’ of the period of use of the medicatieafspraak. If this condition is entered, it is clear to caregivers that the period of use is uncertain.

===During admission and at time of discharge===
When a patient is admitted, the following situations can occur, concerning the outpatient medication:
* Unchanged continuous use,
* Change in dosage,
* Generic substitution (active ingredient remains the same),
* Pharmacological substitution (active ingredient changes, but medication is registered for the same indication),
* (Temporary) stop.

Below, for each situation, an explanation is given for registration of the medication of the patient.

====Unchanged continuous use====
The patient continues using the outpatient medication during admission.

Both medicatieafspraak and toedieningsafspraak continue during admission and after discharge.

====Change in dosage====
The patient uses the outpatient medication during admission, but in a different dosage.

The medicatieafspraak for outpatient medication is stopped at admission. During admission, a new medicatieafspraak is registered with the changed dosage. At discharge, the prescriber decides which dosage will apply for the outpatient medication. Depending on this decision, the medicatieafspraak that applied before admission will be continued, or a new medicatieafspraak will be registered.
The toedieningsafspraak is also stopped at admission. During admission, a new toedieningsafspraak is registered, based on the new medicatieafspraak. At discharge, the toedieningsafspraak that applied before admission will be continued, or a new toedieningsafspraak will be registered.

====Generic substitution====
The patient uses a different medicinal product during admission, but with the same active ingredient and dosage as in the outpatient medication.

The medicatieafspraak for outpatient medication continues during admission and after discharge.
The toedieningsafspraak for outpatient medication is stopped at admission and continued at discharge. During admission, a new toedieningsafspraak is registered. This toedieningsafspraak will be stopped at discharge.

====Pharmacological substitution====
The patient uses a different medicinal product during admission, with a different active ingredient from the outpatient medication. This medicinal product, however, is registered for the same indication as the outpatient medication.

The medicatieafspraak for outpatient medication is stopped at admission and will be continued again at discharge. During admission, a new medicatieafspraak is registered. This medicatieafspraak will be stopped at discharge.
The toedieningsafspraak for outpatient medication is also stopped at admission and continued at discharge. During admission, a new toedieningsafspraak is registered. This toedieningsafspraak will be stopped at discharge.

====(Temporary) stop====
The patient (temporarily) stops using the outpatient medication during admission.

The medicatieafspraak for outpatient medication is (temporarily) stopped at admission. If the medication is stopped temporarily, this medicatieafspraak will be continued at discharge. If the medication is stopped definitively, the medicatieafspraak will not be continued.
The toedieningsafspraak for outpatient medication is also (temporarily) stopped at admission. If the medication is stopped temporarily, this toedieningsafspraak will be continued at discharge. If the medication is stopped definitively, the toedieningsafspraak will not be continued.

=Description of use cases=
This chapter contains a description of various use cases. Specific practical situations have been described for the various subprocesses. A large number of the practical situations are based on general medical practice, but are illustrative of similar situations in a different setting. This chapter assumes the knowledge as previously described in [[#Medication process|Chapter 2]].

==Use cases, Prescribe==

===Short-term medication===
A 35 year old female patient with a history of urinary tract infection brings her urine to the doctor’s assistant and tells her she has the same symptoms as the previous times. The assistant enquires about other symptoms such as fever and pain in the flank and checks the urine. There are no other symptoms and the urine reveals a urinary tract infection. She tells the patient that the general practitioner will prescribe a course of treatment and that she can pick it up from the pharmacist later. The General practitioner checks the previous courses of treatment and any cultures and records a medicatieafspraak. On ''27 January'' it was agreed:
:''Nitrofurantoin CR capsule, 100 mg, 2x daily, 1 capsule, from now on<ref>See also [[#Hard end date for period of use|paragraph 4.1.3]].</ref> for 5 days.''
He records this medicatieafspraak in his information system. The general practitioner then immediately also makes a verstrekkingsverzoek for the pharmacist chosen by the patient:
:''Nitrofurantoin CR capsule, 100 mg; 10 capsules.''
The general practitioner also records this verstrekkingsverzoek in his information system. 
The general practitioner consults with the patient to find out from which pharmacist she wants to pick up the medication. The general practitioner can then inform this pharmacist about the verstrekkingsverzoek and the medicatieafspraak. 
The information system of the general practitioner makes this information (verstrekkingsverzoek and medicatieafspraak) available to the other health professionals of this patient. 
 
[[Bestand:ENG_Voorschrijven_Kortdurende medicatie.png|800px]]

===Continuing medication===
The process for continuing medication is practically the same as for short-term medication (see [[#Short-term medication|paragraph 4.1.1]]), except that in the case of continuing medication the medicatieafspraak is made for an indefinite period of time.

For example: the prescriber agrees with a patient who has hypertension that he should use a diuretic on a continuous basis. On ''30 March 2013'' it was agreed:

:''Hydrochlorothiazide tablet, 12.5 mg; 1x daily, 1 tablet; from now on for an indefinite period.''
''For example, the prescriber chooses in the verstrekkingsverzoek for an initial dispensing quantity of 100 pieces.'' 
 
[[Bestand:ENG_Voorschrijven_Doorlopende medicatie.png|800px]]

===Hard end date for period of medication use===
A start date, end date and/or duration can be included in the period of medication use of a medicatieafspraak. If a hard end date is desired, this must also be explicitly stated in the explanation. Including an end date alone is not sufficient because this does not provide enough clarity about the intention of the prescriber. 
 
[[Bestand:ENG_Voorschrijven_Harde stopdatum gebruiksperiode.png|800px]]

===Medication as needed===
A 31-year-old female patient has had headaches a few times in a year, with migraine now being diagnosed. The general practitioner prescribes:
:''Rizatriptan tablets, 10 mg, as needed 1c1t under the tongue. First tablet at the next clear migraine attack.''
De huisarts legt de medicatieafspraak vast en doet een verstrekkingsverzoek:
:''6 sublingual rizatriptan tablets, 10 mg.''
 
[[Bestand:ENG_Voorschrijven_Zo nodig medicatie.png|800px]]

===Course of treatment as needed starting in future===
A 60-year-old patient with post-thrombotic syndrome experiences erysipelas (severe infection of the leg which can require admission if medication is not started quickly) sometimes every other year, sometimes three times a year. At the request of the patient, the general practitioner prescribes an antibiotic treatment the patient can start immediately in case of a recurrence of erysipelas. The following medicatieafspraak is created:
:''Flucloxacillin capsules, 500 mg, 1 capsule 4x daily, for 10 days. In the medicatieafspraak is indicated (if necessary): start in case of recurrence, as needed.''
The general practitioner immediately creates a verstrekkingsverzoek:
:''Flucloxacilline 500 mg capsules 40 stuks.'' 
 
[[Bestand:ENG_Voorschrijven_Kuur zo nodig startend in de toekomst.png|800px]]

===Two dosages of the same medication at the same time===
A 79-year-old man with metastatic prostate cancer is increasingly suffering from pain and his medication is being changed. The specialist prescribes oxycodone tablets, 10 mg, 1 tablet 4x daily and as needed for pain during the night, 1 tablet 1x daily, on October 9. The specialist records this in one single medicatieafspraak with two dosing instructions and creates a verstrekkingsverzoek for 60 tablets of oxycodone of 10 mg. 
 
[[Bestand:ENG_Voorschrijven_Twee doseringen van hetzelfde geneesmiddel tegelijkertijd.png|800px]]

===The same medicinal product with different strengths at the same time===
The same 79-year-old patient (see [[#Two dosages of the same medication at the same time|paragraph 4.1.6]]) is experiencing even more pain. The specialist discontinues the 10 mg tablets of oxycodone on October 16 and prescribes 20 mg retard tablets of oxycodone, 2 tablets 3x daily, and 20 mg normal release tablets of oxycodone as needed in case of nocturnal pain, 1 tablet 1x daily. The specialist records this in two medicatieafspraken (with, for the time being, two separate medicamenteuze behandelings) and creates a verstrekkingsverzoek for both medicatieafspraken, respectively 45 retard tablets of 20 mg oxycodone and 30 tablets of 20 mg oxycodone (normal release). 
 
[[Bestand:ENG_Voorschrijven_Hetzelfde geneesmiddel met verschillende sterkte tegelijkertijd.png|800px]]

===Explanation in medicatieafspraak with deliberately chosen special characteristic===
This use case is described in the zib medicatieafspraak/additional information. Here it is described for information purposes only. When selecting a medicinal product, it is possible to deviate from what is expected or standard. For example, when a hospital uses a different formulary than a community pharmacy. For reasons of efficiency the hospital has opted for a single gastric acid inhibitor: pantoprazole. 
At admission, a patient with omeprazole is switched to pantoprazole for the duration of the hospitalization. At discharge, the patient returns to omeprazole. 
It is clear that this may sometimes go wrong and that the patient might end up taking both omeprazole and pantoprazole if nothing is done. In the medicatieafspraak of the hospital for pantoprazole, a remark can be made about this deviation in order to make it clear that pantoprazole is the replacement of omeprazole or that it has to be used in addition to omeprazole.
 
 
Half-strengths are another example. The hospital sometimes as tablets available with half the strength of the normal commercial preparation (proprietary production). When a patient enters the hospital with a prescription of 25 mg of chlorthalidone, half a tablet 1x daily, he will receive 12.5 mg of chlorthalidone, 1 tablet 1x daily. In this specific case, this means that nursing staff does not have to break tablets in half. There is a risk that the patient will use the 25 mg again at home, but now a whole tablet at the time. An explanation in the medicatieafspraak (additional information) regarding the last 25 mg of chlorthalidone, makes it possible to indicate whether this was a deliberate increase. 
 
If a prescribed product has to be a very specific commercial product, this can be indicated with ‘medical necessity’.

===New medicatieafspraak, no verstrekkingsverzoek===
A 50-year-old man comes to the general practitioner with back problems. The symptoms have been present for three weeks and he is already using paracetamol. The general practitioner agrees with the patient that he can additionally use diclofenac:

On ''30 January'' it was agreed:
:''Diclofenac tablet, 50 mg, 1 tablet 3x daily, from now on for 3 weeks.''
He records this medicatieafspraak in his information system. The patient indicates there is sufficient supply at home: his wife still has an ample supply of diclofenac left because of a different problem a year ago.

A verstrekkingsverzoek is therefore not needed and the pharmacist also does not dispense any medication. 
The general practitioner makes the new medicatieafspraak available to any fellow health professionals of this patient. This allows the regular pharmacist to inform himself about this new medicatieafspraak. 
 
[[Bestand:ENG_Voorschrijven_Nieuwe medicatieafspraak geen verstrekkingsverzoek_a.png|800px]]

Another example: Mr Simons receives medication from the pharmacy weekly. In the past there were many requests for extra medication, which led to clear agreements about the dispense policy.

This is about:
:''Medicatieafspraak: Diazepam, 5 mg, 1 tablet 4x daily, from 1 January 2012 for an indefinite period''
:''Verstrekkingsverzoek: 28 tablets with 10 repeats; remark: weekly medicatieverstrekking''
The verstrekkingsverzoek is repeated approximately every 11 weeks.
The last verstrekkingsverzoek was on 3 March 2016:
:''one week (28 tablets) with 10 repeats''
This way, the pharmacy can go on for 11 weeks.
 
 
[[Bestand:ENG_Voorschrijven_Nieuwe medicatieafspraak geen verstrekkingsverzoek_b.png|800px]]

The last few years have been quiet. Mr. Simons is no longer asking for extra medication. At the last consultation he indicated that diazepam, 3x daily, is sufficient. This has been recorded in a medicatieafspraak:
:''1 April 2016 Diazepam, 5 mg, 1 tablet 3x daily, from 1 April 2016 for an indefinite period.''

The previous medicatieafspraak will be terminated as of 31 March 2016 (see discontinuation of medication in [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5]]).

In the current situation, the general practitioner would have called the pharmacy to make sure that 21 tablets of diazepam would be given with the following medicatieverstrekking, instead of 28. No new verstrekkingsverzoek would have been needed at the time.

In the new situation, the general practitioner sends the new medicatieafspraak to the pharmacy. Based on the new medicatieafspraak, the pharmacy provides 21 tablets per week, the previous verstrekkingsverzoek is still sufficient.

 
[[Bestand:ENG_Voorschrijven_Nieuwe medicatieafspraak geen verstrekkingsverzoek_c.png|800px]]

===New verstrekkingsverzoek under existing medicatieafspraak===
A prescriber may also create a new verstrekkingsverzoek as part of an existing medicatieafspraak. This medicatieafspraak may have been created by a different prescriber, for example a psychiatrist. This concerns repeat medication. This use case is described in [[#Patient requests repeat prescription via physician (reactive repeat)|paragraph 4.2.6]].

[[Bestand:ENG_Voorschrijven_Nieuw verstrekkingsverzoek onder bestaande medicatieafspraak.png|800px]]

===Dosage change (sufficient supply)===
Patient (37 years old, asthma) visited the pulmonologist on 13 August 2013 for a check-up of his asthma. The pulmonologist has established that patient’s asthma is not adequately controlled. 
The patient is currently using beclomethasone in accordance with a previously made and registered medicatieafspraak: on 10 June 2010 it was agreed:
:''Beclomethasone aerosol, 100 microgram/dose, inhaler; 1 inhalation 2x daily; from 10 June 2010 for an indefinite period.''
On 13 August 2013, the pulmonologist agrees with the patient on a dosage increase:
:''Beclomethasone aerosol, 100 microgram/dose, inhaler; 2 inhalations 2x daily; from 13 August 2013 for an indefinite period; reason for adjustment: insufficient effect.''
The previous medicatieafspraak of 10 June 2010 it is no longer valid: it is terminated (see Changing medication in [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5]]). The patient still has a sufficient supply, a verstrekkingsverzoek is therefore not needed.
 
 
[[Bestand:ENG_Voorschrijven_Wijziging in dosering voldoende voorraad.png|800px]] 
In case the patient has no more supply, a new verstrekkingsverzoek will be created. 
The information system of the pulmonologist makes the new medicatieafspraak available to the other health professionals of this patient. This modification is received by the pharmacist (fellow health professional). The pharmacist processes the modification. The pharmacist may also choose to accept the modifications automatically.

===Prescription no longer needed after first verstrekkingsverzoek===
A 16-year-old woman has a boyfriend and does not want to become pregnant. After explanation she opts for the pill. The general practitioner prescribes ethinylestradiol/levonorgestrel tablets of 20/100 µg, 1 tablet 1x daily for 21 days, then no tablet for 7 days, then another 21 days of taking a tablet once a day. Start on the first day of the next menstruation. The general practitioner records the medicatieafspraak and creates a verstrekkingsverzoek for 63 coated microgynon 20 tablets. He explains to her that if she does not experience any problems, she can continue to get the pill via the pharmacy. 
Three months later, the woman sends a request for repeat supply to the pharmacy. The pharmacy provides the product and communicates the medicatieverstrekking to the general practitioner.

 
[[Bestand:ENG_Voorschrijven_Recept niet meer nodig na eerste verstrekkingsverzoek.png|800px]] 

{{Anchor|4-1-13}}
===Discontinuing medication===
Patient (37 years old, asthma) visits the pulmonologist on 13 August 2013 for a check-up of his asthma. The patient is suffering from a side effect. The patient is currently using Beclomethasone in accordance with a previously made and registered medicatieafspraak. On ''10 June 2010'' it was agreed:
:''Beclometasone aerosol, 100 microgram/dose, inhaler; 1 inhalation 2x daily; from 10 June 2010 for an indefinite period.''
On 13 August 2013, the pulmonologist agrees with the patient to discontinue the medication (medicamenteuze behandeling is discontinued). Medication verification is also applicable here. In addition, medication monitoring may also be relevant here, for example if gastroprotrective drugs are being used because of the use of the medication to be discontinued (the information system will not always signal this automatically). 
The pulmonologist records:
:''Beclometasone aerosol, 100 microgram/dose, inhaler; stoptype ‘definite’; from 13 August 2013. Because of a side effect.''
This modification is received by the pharmacist (fellow health professional). The pharmacist processes the modification. The pharmacist may also choose to accept the modifications automatically. The pulmonologist decides to also actively inform a fellow health professional (such as a specialist) about this (part of the process step (actively) making available). 
The information system of the pulmonologist makes this information (agreement to discontinue) available to the other health professionals of this patient.
 
 
[[Bestand:ENG_Voorschrijven_Stoppen medicatie.png|800px]] 

===Temporarily halting/resuming medication===
A patient is being treated with simvastatin (cholesterol-lowering agent): 40 mg, 1 tablet 1x daily, for an indefinite period. Because of a throat infection in combination with an allergy for the first antibiotic of choice, Clarithromycin, 250 mg, 1 tablet 2x daily (antibiotic) is prescribed for 1 week. During that week, simvastatin is temporarily halted because of an interaction. 
The general practitioner records:
:''Simvastatin 40 mg; halt temporarily; for 1 week; reason: interaction''
:''Clarithromycin, 250 mg; 1 tablet 2x daily; for 1 week (and a corresponding verstrekkingsverzoek)''
The pharmacist is actively informed by the general practitioner about the temporary halt of simvastatin. A new medicatieafspraak is also created with which simvastatin is resumed after one week. The pharmacist will also receive the medicatieafspraak and the corresponding verstrekkingsverzoek for clarithromycin. See also Temporarily halting and resuming medication in [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5]].

 
[[Bestand:ENG_Voorschrijven_Onderbreken hervatten medicatie.png|800px]] 

===Temporarily halting for an intervention===
A 62-year-old man uses acetylsalicylic acid, 100 mg, 1 tablet 1x daily because of coronary disease. He has an intestinal polyp that must be removed. The general practitioner informs him that he should stop using acetylsalicylic acid three days before the intervention and resume the day after the intervention. The general practitioner records the temporary halt in a medicatieafspraak with an enddate 3 days before the intervention; stoptype ‘temporary’; reason for halting: ‘intervention’. In the (second) medicatieafspraak for presuming, 1 day after the intervention is used as the start date. The general practitioner actively informs the pharmacist and the gastroenterologist about the medicatieafspraken. 
When the date of the intervention is unknown or uncertain, the explanation will indicate that the medication should be halted three days before the intervention and resumed one day later. The duration of the temporary halt is then 4 days. See also Temporarily halting and resuming medication in [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5]].

 
[[Bestand:ENG_Voorschrijven_Onderbreken voor een ingreep.png|800px]] 

===Paper prescription===
The physician gives the patient a paper prescription<ref>A similar situation occurs when the pharmacist receives a fax.</ref>. A paper prescription contains a medicatieafspraak and a verstrekkingsverzoek. The patient can use this prescription to pick up the medication from any pharmacist. The general practitioner does not inform the issuing pharmacist in this case. However, the process is actually the same: the activity ‘(actively) making available’ is now only ‘handled’ by the paper prescription in the hands of the patient. The supplying pharmacist will copy this paper medicatieafspraak and verstrekkingsverzoek in his own information system and complete it with a toedieningsafspraak. The pharmacist may also retrieve the medicatieafspraak and verstrekkingsverzoek that were made available digitally and process them in his own information system this way. 
The information system of the general practitioner makes the new medicatieafspraak and verstrekkingsverzoek available for fellow health professionals. When the information system of the general practitioner has not made these available this may be because it concerns a toedieningsafpsraak without digitally available medicatieafspraak and verstrekkingsverzoek. The pharmacist will not make the medicatieafspraak and verstrekkingsverzoek obtained ‘from paper’ available because he is not the owner. Next to that, this could lead to, possibly only in the future, wrongful duplication of medicatieafspraken and verstrekkingsverzoeken.
 
[[Bestand:ENG_Voorschrijven_Papieren recept.png|800px]]
 

===Carrying out medication verification and evaluation of foreign or self-care medication===
When medication cannot be found in the information system (such as foreign medication and self-care medication), this medication will be recorded as medicatiegebruik (see [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5]]).

===Day treatment===
An admission for day treatment is comparable with an outpatient consultation or an emergency admission during which the medication is supplied by the hospital pharmacist. In the case of admission for a day, extensive medication verification does not usually occur. In the case of admission for a day, the medication prescribed is recorded (often on the basis of protocols according to which verification is carried out afterwards) and administered. 
For treatments with cytostatics, for example, there is a medicatieafspraak, but it is not always clear in advance when the medicatieverstrekking/administration takes place. Reason: treatments are often postponed and then supplied and administered later.

===Starting with medication before admission===
Prior to cataract surgery, Nevanac is started three days before the surgery. The eye drops are used until three weeks after surgery (a total duration of medication use of 24 days). The specialist creates a medicatieafspraak for Nevanac, 1 drop in the morning, for 24 days. When the date of the surgery is unknown or uncertain, the explanation may indicate that Nevanac should be started 3 days before surgery takes place.
 [[Bestand:ENG_Voorschrijven_Starten met medicatie voor opname.png|800px]]
 

===Emergency admission===
In the event of an emergency admission, extensive medication verification is not carried out beforehand as would normally be the case with clinical admissions. Agreeing on medication with the patient is also often not possible in the event of an emergency admission. Often, the patient is administered medication as soon as possible and verification only takes place afterward

===Discharge===
When a patient is discharged from the hospital, all clinical medication is discontinued. The medicamenteuze behandeling is evaluated during which it is decided which medication the patient will use after discharge:
*Previous outpatient medication that was discontinued at admission is started again (new medicatieafspraak under previous or new medicamenteuze behandeling) with possible reference to medication from before admission.
*Previous outpatient medication that was temporarily halted at admission (without substitution) is resumed using a new medicatieafspraak under the same medicamenteuze behandeling
*New outpatient medication is agreed upon: as an outpatient replacement of clinical medication or as a new therapy (new medicamenteuze behandeling with possible reference to institutional medication)
See [[#Process step: Evaluating a (pharmaceutical) treatment|Chapter 2.2.4]] for this. The medication overview and the medication data are (actively) made available.

===Interim discharge===
When a patient temporarily leaves the hospital/institution to go home, for example, for weekend leave, the clinical medication continues. In order to keep the patient’s own general practitioner informed, the medication overview is provided to the patient and the medication data are made available.

===Transfer to another institution===
In case of a transfer to another institution, the medicamenteuze behandeling is evaluated (see [[#Process step: Evaluating a (pharmaceutical) treatment|Chapter 2.2.4]] and [[#Process step: Creating a medicatieafspraak|paragraph 2.2.5]]). Medication overview and medication data are (actively) made available. The new attending physician evaluates the medicamenteuze behandeling and determines the institutional medication.

===Do not dispense before===
The prescribing physician creates a verstrekkingsverzoek on 14 April 2017, but wants to indicate in that same verstrekkingsverzoek the medicatieverstrekking may only take place on or from a later date, for example, 23 April 2017. This cannot be recorded in a structured manner in the verstrekkingsverzoek, but is included in the explanation (as free text).
 
[[Bestand:ENG_Voorschrijven_Niet verstrekken voor.png|800px]]
 

===Discontinuation of medication by third parties===
Medication can be discontinued by the prescriber himself (see [[#Discontinuing medication|paragraph 4.1.13]]) but also by another prescriber. For example, the specialist can end medicatieafspraken made by a general practitioner that are up to date according to the information system, but that turn out not to be, for example after medication verification. When a health professional discontinues medication, he creates a new stop-MA. The health professional cannot modify someone else’s medicatieafspraak, only create a stop-MA. He therefore actively informs the health professional of the original medicatieafspraak about this change. The health professional of the original medicatieafspraak modifies the end date in the existing medicatieafspraak. If required, this may also be automated by the information system. This prevents the second health professional from not having to produce data after a period of time because the production period has expired (also no stop-MA), while the health professional of the original medicatieafspraak continues to produce it for no reason (without an end date).
 
 
[[Bestand:ENG_Voorschrijven_Stoppen van medicatie door derden.png|800px]]
 

===Two PRKs in a single medicamenteuze behandeling===
In certain circumstances, the pharmacy is allowed to select a different PRK for the toedieningsafspraak than is indicated in the medicatieafspraak made by a prescriber. If for instance a failure of the prescriber’s information system would result in only the communication of the toedieningsafspraak, a subsequent prescriber will only have this toedieningsafspraak with the new PRK. The next prescriber will then probably assume that this PRK is also the PRK of the medicatieafspraak. A modification of the medicatieafspraak will then also result in a stop-MA (without referring to the original MA) and a new medicatieafspraak on the basis of this PRK. This means that there are now two medicatieafspraken with different PRKs under the same medicamenteuze behandeling. These two medicatieafspraken continue to exist. After any information system failure, (the information system of) the prescriber must check whether there have been changes and implement them, if necessary (see also [[#Discontinuation of medication by third parties|paragraph 4.1.26]]).
 
[[Bestand:ENG_Voorschrijven_Twee PRKs onder een medicamenteuze behandeling.png|800px]]
 

===Creating a medicatieafspraak after the fact===
In emergency situations, for example, it may happen that the medicatieafspraak is only created after the medication has been dispensed or administered. This may lead to conflicting medicatieafspraken. This means that one or more medicatieafspraken must be discontinued in order to prevent the occurrence of parallel medicatieafspraken. The only exception for parallel medicatieafspraken is described in [[#Medicamenteuze behandeling|paragraph 1.3.3]].

===Single medication use( medicatiegebruik)===
For medication meant for single use, only an end date is included in the period of medication use. An example would be a vaccination (for example, a tetanus shot) or a situation in which a patient should take a medication just once, for example 3 weeks before he leaves on holiday.
 
[[Bestand:ENG_Voorschrijven_Eenmalig gebruik.png|800px]]
 

===Provisional and final medication order===
The prescriber at the clinic prescribes medication. This is recorded in a provisional medication order (the medicatieafspraak). The hospital pharmacist verifies this order and records it as a final medication order (the toedieningsafspraak). See also <ref name="MO"/>.

===Inadvertently ‘outstanding’ medication or 'orphans'===
In a transitional situation and in a situation where not every XIS is connected, medicatieafspraken for the same treatment may exist that have been created by different information systems under different medicamenteuze behandelings. These medicatieafspraken should ideally be combined in a single medicamenteuze behandeling. This particularly applies to medication with an open end date, as this medication may have been discontinued under a different medicamenteuze behandeling. The medicatieafspraak therefore remains open, resulting in continued medicatieverstrekking. This is a so-called ‘orphan’ (a building block that has been registered, but in which, at a certain point, the health professional no longer has an active role. However, his information system continues to provide the building block, even if it has already been discontinued elsewhere). For medication with an end date, this problem will solve itself. Therefore, it is not necessary to take any action. When medication verification or medication assessment reveals that the medication is inappropriately still ‘open’, a stop-MA is created under the same medicamenteuze behandeling. The original prescriber is actively informed about this stop-MA and enters an end date for the medicatieafspraak in his own information system. Depending on the supplier and the client’s wishes, setting this end date can be done automatically or through an intervention of the prescriber. See also [[#Discontinuation of medication by third parties|paragraph 4.1.26]] and [[#Modification of someone else's medicatieafspraak|paragraph 4.1.40]].
 
 
[[Bestand:ENG_Voorschrijven_Onterecht openstaande medicatie of weeskinderen.png|800px]]
 

===Missing digital medicatieafspraak at admission===
If no digital medicatieafspraak is available when medication verification is carried out, a new medicamenteuze behandeling is started by recording medicatiegebruik. When this medicatiegebruik has to be discontinued, a stop-medicatieafspraak is created under the same medicamenteuze behandeling that refers to the recorded medicatiegebruik. If possible, the original prescriber (for example, general practitioner) and the pharmacy are actively informed about the discontinuation of this medication.
 
[[Bestand:ENG_Voorschrijven_Ontbreken digitale medicatieafspraak bij opname.png|800px]]
 

===Own articles (90 million numbers)===
It is possible to exchange a 90 million number. The condition is that within an organization a 90 million number once created may never be modified. During the exchange, the root OID (unique technical identification of the organization) in combination with the 90 million number ensures that it is unique compared to all 90 million numbers form other organizations. The substances that make up this article are included as ingredients in the medicatieafspraak (at least one ingredient), as is the case with magistrals.

===Dosing with minimum interval ===
Medication can be prescribed at a fixed interval (for example: 2 tables every 6 hours). Prescribing medication with a minimum interval should be partly in free text. For example, if needed, a maximum of 3 times a day, a minimum of 6 hours between the intake moments: ''if needed, a maximum of 3 times a day'' is recorded in the standard way. The section “''at least 6 hours between intake times''” is recorded in free text as an Additional Instruction.
 
 [[Bestand:ENG_Voorschrijven_Dosering met minimum interval.png|800px]] 
 

===Verstrekkingsverzoek with number of repetitions ===
The prescriber makes a verstrekkingsverzoek with a medicatieafspraak in which she enters the number of repetitions. The prescriber hereby indicates to the provider that it may make additional provisions. The number of repetitions in combination with the quantity to be dispensed results in: (Number of repetitions + 1) X quantity to be dispensed. In case of “number of repetitions =3” and “quantity to be supplied = 30 pieces” the provider may provide 4 times 30 pieces (total 120 pieces). The number of repetitions in combination with the duration of medication usage period results in: (number of repetitions + 1) x duration of medication use. The amount to be dispensed depends on the dosage. In case of “dosage = 3 x per day 2 pieces”, and “Duration of medication usage period = 30 days” the provider may provide 180 pieces 4 times (6 pieces per day X 30 days = 180, 4 times = a total of 720 pieces).
 
 [[Bestand:ENG_Voorschrijven_Verstrekkingsverzoek met aantal herhalingen.png|800px]] 
 

===Prescribing non-medicines===
Non medicines can be prescribed from the G-standard at HPK level. For example, this could be an inhaler (Aerochamber, HPK 1915185) as an aid to prescribed aerosols. Non-medicinal products are not applicable for the medication overview or medication monitoring.

===Send renal function value in the prescription===

'''A) Renal function value with a new prescription:''' 
For the prevention of stroke, a patient (male, 65 years old) is prescribed Dabigatran for the first time. The patient has renal impairment and the prescriber has a recent renal function value available. Based on this renal function value, the prescriber deviates from the standard dose and makes a medicatieafspraak with a lower dosage of Dabigatran twice a day 1 capsule of 110 mg, starting from January 15, 2020. The prescriber also makes a verstrekkingsverzoek and sends the prescription (medicatieafspraak, verstrekkingsverzoek and the laboratory result of the renal function value) to the pharmacist.
 
[[Bestand:ENG_Voorschrijven_Nierfunctiewaarde sturen met het voorschrift_a.png|800px]] 

'''B) Renal function value reason for a change:''' 
A 70-year-old man was prescribed 1 tablet of metformin 500 mg 3 times a day a few days ago (medicatie afspraak and verstrekkingsverzoek). At the same time, the doctor initiated a blood test to determine the renal function value of the patient. The value was not yet known at the time of prescription.
 
[[Bestand:ENG_Voorschrijven_Nierfunctiewaarde sturen met het voorschrift_b1.png|800px]] 

The blood test shows that renal function is impaired and gives reason to adjust the medicatieafspraak. The prescriber adjusts the dose on January 17, 2020 to 2 tablets metformin 500 mg twice a day and discuss this with the patient. The new prescription (the 'technical' stop medicatieafspraak, new medicatieafsrpaak and the laboratory result of the renal function value) is sent to the pharmacy by the prescriber. Because the patient had already collected the medication and therefore has enough stock, no new verstrekkingsverzoek is sent along.
 
[[Bestand:ENG_Voorschrijven_Nierfunctiewaarde sturen met het voorschrift_b2.png|800px]] 

'''C) Renal function value due to drug:''' 
The patient is prescribed Nitrofurantoin 100 mg, 1 capsule twice daily as a 5-day course due to a bladder infection and must start immediately on January 6, 2020. With this drug, the renal function value (if known and not older than 13 months) needs to be sent along. The prescriber has a renal function value available for this patient, but this does not lead to an adjusted dosage. The prescriber sends the prescription (medicatieafspraak, verstrekkingsverzoek and the laboratory result of the renal function value) to the pharmacist.
 
[[Bestand:ENG_Voorschrijven_Nierfunctiewaarde sturen met het voorschrift_c.png|800px]] 
 

===Cancelling a prescription that was sent earlier ===
A patient visits the general practitioner (GP) one morning because of stomach complaints. The GP prescribes pantoprazole and sends the prescription (MA + VV1) to the preferred pharmacy as known to him. In the afternoon the patient calls the GP. He hasn’t picked up the prescription yet and he would like to pick it up at another pharmacy due to a recent move, but forgot to ask this morning. The GP resends the prescription to the old pharmacy, but the VV in the newly send prescription contains a canceled indicator (MA + VV1 “cancelled”), so the pharmacist knows he should not dispense on this prescription. The prescriber then sends a new prescription (MA + VV2) to the patient's new pharmacy. The patient can pick up the medication there. 
In medication building blocks it looks as follows: 
 [[Bestand:ENG_Voorschrijven_Annuleren eerder verstuurd voorschrift_a.png|800px]] 
 
The transactions look as follows: 
[[Bestand:ENG_Voorschrijven_Annuleren eerder verstuurd voorschrift_b.png]] 

===Modification of someone else's medicatieafspraak ===
A patient takes 40 mg Lisinopril once a day because of hypertension. This medicatieafspraak was previously made by the GP with the patient. The patient is admitted to the enters A&E department because of a fall due to dizziness. The specialist notices hypotension and decides to reduce the dose of Lisinopril to 20 mg once a day. The specialist then stops the current medicatieafspraak and starts the new medicatieafspraak with a lower dose. With this he changes the medicationafspraak with the patient. The specialist informs the original prescriber (the general practitioner) about this with a stop medicatieafspraak and the new medicatieafspraak.
The prescriber of the original medicatieafspraak adjusts the stop date in the original medicatieafspraak. If desired, this can also be automated by the information system. This prevents the second care provider no longer having to provide data over time because the delivery period has expired (including no stop MA) while the care provider of the original medication appointment continues to provide this incorrectly (without a stop date).
 
[[Bestand:ENG_Modification of someone else's medicatieafspraak.PNG|800px]]
 
===Setting up a variable dosing regimen (WDS) ===
The prescriber prescribes anticoagulants and states in the MA that the medication is used as recorded by the schedule of the thrombosis service (‘gebruik volgens schema trombosedienst). The prescriber sends a VV to the pharmacist and the patient is registered with the thrombosis service. In order to bridge the period until thrombosis care can take over, the prescriber creates a WDS for the first period. After registration, the thrombosis service creates a dosing regimen that overwrites or succeeds the previous regimen. From this moment on, the thrombosis service takes over creating the dosing regimen from the original prescriber.
[[Bestand:ENG_Uc_setting_up_WDS.png|800px]]

===Changing a variable dosing regimen (WDS) during period of use===
It could be necessary to revise the dosing regimen from a WDS before the scheduled stop date. For example, when the patient unexpectedly has to undergo minor surgery. In this case, the prescriber stops the current WDS with a technical stop (not visible to the user) and creates a new WDS with a few 0 doses the days before the procedure. In the meantime, the MA continues as usual.
[[Bestand:ENG_Uc_Changing_WDS.png|800px]]

===Stopping medication with a variable dosing regimen (WDS) ===
When the patient has to (temporarily) stop using anticoagulants completely, this is recorded at the level of the MA. The thrombosis physician creates a stop-MA. This also stops the underlying WDS and the associated TA. The original prescriber also processes the stop date in his MA.
If the anticoagulants needs to be restarted after several months, the original prescriber of the anticoagulant medication does this by following the process of starting a WDS. So by creating a new MA and a first WDS (see the use case [[#Setting up a variable dosing regimen (WDS)| Setting up a variable dosing regimen (WDS)]]). 
[[Bestand:ENG_Uc_stopping_WDS.png|800px]]

==Use case, Dispense==

===New medicatieafspraak, medicatieverstrekking of the same product===
The patient is at the pharmacist on 27 January 2013 to collect his medication. The pharmacist opens the file of the patient and verifies the medication file. It is a new medicatieafspraak for this patient. The relevant information of the prescribing physician is displayed on the screen of the pharmacist. 
Medicatieafspraak: ''Nitrofurantoin CR capsule, 100 mg, 1 capsule 2x daily, from now on for 5 days.'' 
Verstrekkingsverzoek: ''Nitrofurantoin CR capsule, 100 mg; 10 capsules.'' 
The pharmacist selects a product on the basis of the medicatieafspraak and other factors (such as the pharmacist’s stock and the preference policy of the healthcare insurer): 
''FURABID CR CAPSULE, 100 MG''. The pharmacist carries out medication monitoring using the information system, no (warning) signals are given. 
The pharmacist carries out pharmaceutical care (compliance, education, et cetera) and agrees with the patient on how she will use the medication. This toedieningsafspraak on 27 January 2013 reads: 
''FURABID CR CAPSULE, 100MG; 1 capsule 2x daily; from now on for 5 days''. The pharmacist provides the medication to the patient: 
''on 27 January 2013, FURABID CR CAPSULE, 100 MG; 10 capsules.'' The pharmacist actively informs the prescribing physician about the medicatieafspraak and the medicatieverstrekking. 
The information system of the pharmacist makes the new toedieningsafspraak and medicatieverstrekking available to the other health professionals of this patient.
 
 [[Bestand:ENG_Ter hand stellen_Nieuwe medicatieafspraak medicatieverstrekking zelfde product.png|800px]] 

===New medicatieafspraak, more precise product specification===
Here, the difference when specifying the product is that the toedieningsafpsraak and also the medicatieverstrekking deviates from the medicatieafspraak the patient has made with the prescribing physician. The process is otherwise the same as described in the previous paragraph.

'''Example''' 
''Medicatieafspraak: Nitrofurantoin capsule mga 100 mg, 1 capsule 2 times a day from today for 5 days.''

The pharmacist specifies a different product: 
''Nitrofurantoine MC Actavis capsule 50 mg.''
The pharmacist agrees with the patient on how she will use the medication. This toedieningsafspraak on 27 January 2013 reads: 
''Nitrofurantoin MC CR capsule 50 mg, 1 capsule 2x daily, from now on for 5 days.'' 
The pharmacist provides the medication to the patient: 
''on 27 January 2013, Nitrofurantoin MC Actavis capsule 50 mg; 20 pieces.''
 
 [[Bestand:ENG_Ter hand stellen_Nieuwe medicatieafspraak nadere specificering product.png|800px]] 

===Existing toedieningsafspraak is adequate===
The process of repeat medicatieverstrekking on the basis of an existing medicatieafspraak and possibly existing verstrekkingsverzoek and toedieningsafsrpaak occurs in case of repeat prescriptions and is described in [[#Splitting a prescription|paragraph 4.2.10]], situation 2.

===Medicatieafspraak wanted (informing the prescriber)===
'''Example 1 - adjusting dosage:''' 
For a 70-year-old patient with a creatinine clearance of 45 mL/min, the pharmacist enters a toedieningsafspraak for gabapentin tablets of 600 mg, 1 tablet 3x daily. Renal function has been recorded in the patient’s file at the pharmacy, and based on this a signal appears that the maximum dosage is 900 mg daily. The pharmacist sends the prescriber a proposed medicatieafspraak with an adjusted dosage of 300 mg, 3x daily, and the reason for this proposal (maximum dosage exceeded). The prescriber receives the proposed medicatieafspraak in his EVS. The prescriber sends an adjusted medicatieafspraak and possibly a reply proposed medication agreement (antwoord voorstel medicatieafspraak) back to the pharmacist.
 
 [[Bestand:ENG_Ter hand stellen_Medicatieafspraak gewenst - informeren voorschrijver_a.png|800px]] 
 
'''Example 2 – temporarily halting a medicinal product:''' 
For a 50-year-old patient with on oral fluconazole as part of his current medication, the pharmacist enters a toedieningsafspraak for simvastatin. A message appears with the advice to consider temporarily halting simvastatin. The pharmacist can make a proposed medicatieafspraak for halting the simvastatin (stoptype ‘temporary’). See example 1 for further steps.
 
 [[Bestand:ENG_Ter hand stellen_Medicatieafspraak gewenst - informeren voorschrijver_b.png|800px]] 
 
'''Example 3 – adding a medicinal product:''' 
For a 55-year-old woman, the pharmacist enters a toedieningsafspraak for prednisone, 10 mg daily for three months. The patient is not using osteoporosis prophylaxis. A message appears with the advice to add a biphosphonate drug and to check whether the patient is taking calcium and vitamin D. If the patient is not, the pharmacist can make a proposed medicatieafspraak for these products. See example 1 for further steps.
 
 [[Bestand:ENG_Ter hand stellen_Medicatieafspraak gewenst - informeren voorschrijver_c.png|800px]] 
 
PLEASE NOTE: it will depend on the situation whether it is useful to create an automated proposal for adjustment/addition of a MA. If the advice is complex, it may still be useful to phone and to consult instead of sending a digital proposal. 
The proposed medicatieafspraak may help the prescriber to enter this change in the system. The latter is important when medicatieafspraken are consulted, for example, by service observation general practitioners.

===Request and dispense ===
When a medicatieafspraak and verstrekkingsverzoek arrives at the pharmacy, it is processed by the pharmacy information system as an intended medicatieverstrekking. This is called the request date, which is captured as the request date of the medication dispensing The date of dispensing is only registered at the moment of pick up or hand over of the medication. The pharmacist informs the prescriber about the handling of the prescription (toedieningsafspraak and/or medicatieverstrekking).

It is possible to create multiple dispensings under the same toedieningsafpsraak:
*A verstrekkingsverzoek comes in with a medicatieafspraak with a one-year use period
*There will be a first provision with a new toedieningsafspraak and a medication supply that is sufficient for, for example, a period of 4 months.
 [[Bestand:ENG_Ter hand stellen_Aanschrijven en verstrekken_a.png|800px]] 

*The second dispensing is performed based on the existing medicatieafpsraak, verstrekkingsverzoek and toedieningsafspraak (no new prescription or new administration appointment is needed). The new second medication dispensing (with new write-up date and the pre-existing associated toedieningsafspraak) is sent to the prescriber when the dispensing date is registered.
 [[Bestand:ENG_Ter hand stellen_Aanschrijven en verstrekken_b.png|800px]] 

===Patient requests repeat prescription via physician (reactive repeat)===
A physician has previously diagnosed hypertension in a patient (57 years old) and has prescribed the patient medication for this. The patient uses this medication and the medication is running out. The patient makes a request to repeat the medication, for example through the repeat line, by phone, by email to the practice, counter/boxes, website, app or portal of the physician. The physician approves the repeat. This leads to a new verstrekkingsverzoek. 
For example:
The general practitioner makes, in the context of the medicatieafspraak of 30 March 2010:
:''Nifedipine CR 30 mg; 1 tablet 1x daily, from 30 March 2010 for an indefinite period''
on 13 April 2013 a verstrekkingsverzoek to a pharmacist chosen by the patient:
:''Nifedipine, CR tablet, 30 mg; ‘for three months’.''
In consultation with the patient, the prescriber can send the verstrekkingsverzoek with the corresponding medicatieafspraken and toedieningsafspraken as an order to a pharmacy of the patient’s choice. The prescriber also makes the new verstrekkingsverzoek available to fellow health professionals and the patient. The existing medicatieafspraken had already been made available. 
 [[Bestand:ENG_Ter hand stellen_Patiënt vraagt herhaalrecept via arts - reactief herhalen.png|800px]] 
The pharmacist receives the verstrekkingsverzoek together with the medicatieafspraak and processes it in accordance with the dispense process and starts with the pharmaceutical care process step.

When the patient, on the basis of a toedieningsafspraak or on the basis of his medicatiegebruik asks for a repeat prescription, and the medicatieafspraak is not digitally available, the physician creates a new medicatieafspraak based on this toedieningsafspraak or the patient’s medicatiegebruik of the medication. No reference is made to the existing medicatieafspraak in that case.

===Patient requests repeat prescription via pharmacist (informing prescriber)===
The patient requests a repeat medication from the pharmacist, for example through repeat line, by phone, email, counter/boxes, website, app or portal of the pharmacist. 
The pharmacist sends a proposed verstrekkingsverzoek for authorisation to the prescriber. The physician evaluates the proposed verstrekkingsverzoek and approves it. He informs the pharmacist via the reply proposed verstrekkingsverzoek and sends a new verstrekkingsverzoek together with the current agreements to the pharmacist. The pharmacist continues the dispense process and starts with the pharmaceutical care process step. 
Patiënt vraagt herhaalrecept via arts (reactief herhalen)
 [[Bestand:ENG_Ter hand stellen_Patiënt vraagt herhaalrecept via apotheker - informeren voorschrijver.png|800px]] 
 
If the prescriber does not provide a verstrekkingsverzoek, he informs the pharmacist via the answer proposed verstrekkingsverzoek.

===Proactive repeat prescription by pharmacist (informing prescriber)===
The patient has signed up in the past for proactive repeats and the pharmacist has registered this in his proprietary pharmacist information system (PIS). The repeat module of this information system will generate a signal when a patient needs new medication. When a new verstrekkingsverzoek is needed, this is similar to the process described in the previous paragraph, only the trigger is not the patient but the pharmacist (or his information system). Proactive repeats are also used for GDS, see [[#Starting and continuing a GDS|paragraph 4.2.11]].
 [[Bestand:ENG_Ter hand stellen_Proactief herhaalrecept door apotheker - informeren voorschrijver.png|800px]] 
 

===Dispense based on an existing verstrekkingsverzoek===
The patient submits a repeat prescription to the pharmacist. In this case, it is a request for medicatieverstrekking on the basis of an existing, still valid, verstrekkingsverzoek. See [[#Splitting a prescription|paragraph 4.2.10]] situation (3).

===Splitting a prescription===
The patient has been using the same medication for a number of years, which means that the medicatieafspraak can be created for an indefinite period. The toedieningsafspraak is also valid for an indefinite period. In such a case, the patient can be given a prescription for a year. This single year prescription will be split into several prescriptions by the pharmacist. These split prescriptions are commonly called ‘repeat prescriptions’, even though strictly speaking this is not true.

There are three possible situations: 
1) The patient returns to his attending physician still suffering from the same symptoms. The prescriber prescribes the same medication (in the case of an expired medicatieafspraak, a new medicatieafspraak is created with a new verstrekkingsverzoek and in the case of a medicatieafspraak that is still valid, only a new verstrekkingsverzoek is created). 
 [[Bestand:ENG_Ter hand stellen_Knippen van recept_a.png|800px]] 
 
2) Prescriber and patient initially agree on 90 tablets with 3 repeat prescriptions. The patient receives the first 90 tablets. The next time the patient visits the pharmacist, a medicatieverstrekking is made under the existing agreements. 
 [[Bestand:ENG_Ter hand stellen_Knippen van recept_b.png|800px]] 
 
3) Prescriber and patient initially agree on 360 tablets for one year. The pharmacist splits this into 4 separate occasions of medicatieverstrekking. The patient is initially dispensed 90 tablets and without a new verstrekkingsverzoek, can go to the pharmacist 3 more times to pick up another 90 tablets each time. 
Situation 3 best describes the way in which a pharmacist splits a year prescription. 
 [[Bestand:ENG_Ter hand stellen_Knippen van recept_c.png|800px]] 
 

===Starting and continuing a GDS===
The following example shows the process for one medicinal product used by the patient for an indefinite period of time. The information system of the prescriber and the pharmacist contains (among other things) the following data on a patient:
*The medicatieafspraak of 2 January 2013 reads: Metoprolol, CR tablet, 100 mg (succinate); 1x tablet daily; from 2 January 2013 for an indefinite period.
*The toedieningsafspraak of 2 January 2013 reads: Metoprolol PCH retard, 100 CR tablets of 95 mg; 1x tablet 1x daily; from 2 January 2013 for an indefinite period.
This elderly patient is taking so much medication that he has problems overseeing it all: a potentially dangerous situation. On 6 February, the pharmacist and the prescriber agree that the medicatieverstrekking of medicinal products to this patient will take place via GDS.

The GDS is started: the pharmacist sends a proposed verstrekkingsverzoek (a similar event to the current combined prescription or authorisation form).

The proposed verstrekkingsverzoek of 6 February reads:
*Verstrekkingsverzoek for the medicatieafspraak of 2 January 2013: Metoprolol, CR tablet, 100 mg (succinate), and a period of use to ensure enough stock up to and including 1 May 2013.
The pharmacist sends the proposal to the prescriber. The prescriber approves the proposal on February 6 and sends it unchanged to the pharmacist as a verstrekkingsverzoek. The GDS indicator is switched on in the information system of the prescriber as well as in the pharmacist’s information system.

The pharmacist and the patient select a partial duration for the product. This toedieningsafspraak reads as follows:
*On 7 February it was agreed: Metoprolol PCH retard, 100 CR tablets of 95 mg, 1 tablet in the morning, from 11 February (week 6), for an indefinite period.

Every second week, the pharmacist dispenses a Baxter medication roll containing (among other things) the metoprolol:
*Medicatieverstrekking 1: The pharmacist dispenses, on Friday, 8 February 2013: 14 tablets, scheduled for weeks 6 and 7 (a period of use of 2 weeks).
*Medicatieverstrekking 2: The pharmacist dispenses, on Friday, 22 February: 14 tablets, scheduled for weeks 8 and 9.
*Medicatieverstrekking 3, 4, 5, etc.
With each medicatieverstrekking, it is indicated that medicatieverstrekking was carried out via GDS.
After three months, there is a new proposed verstrekkingsverzoek from the pharmacy to the prescriber, etc.
 
 [[Bestand:ENG_Ter hand stellen_Het opstarten en continueren van GDS.png|800px]] 
'''Consideration ''' 
*The application of a proposed verstrekkingsverzoek instead of an authorisation form makes its meaning unambiguous.
*In the current situation, toedieningsafspraken and medicatieverstrekkingen are registered as a single dispense. This makes it difficult to find useful information in the large number of messages. By dividing the dispense order into two building blocks, the overview is easier to understand: there are no new medicatieafspraken and only one new toedieningsafpsraak is created. There are no hidden surprises in the remaining logistical data and the prescriber does not have to monitor the multiple medicatieverstrekkingen.
*This way of registering and exchanging prevents double registration, and errors caused by this.
*The toedieningsafspraken are the basis for the administration list and checklists of nursing homes and care homes. Signing them corresponds to the administration(s).

===The pharmacist changes commercial product===
This scenario builds on the previous scenario: after half a year a different commercial product is agreed with the patient (toedieningsafspraak), because the original product is not available. No new medicatieafspraak is made, as there is no change needed on that level. The toedieningsafspraak is changed:
*On 1 July it was agreed: Metoprolol Sandoz ret, 100 CR tablets, 95 mg, 1 tablet in the morning; from 3 July, for an indefinite period. Reason: not available.
The toedieningsafspraak is a modification of the toedieningsafspraak of 7 February, which stops on 2 July (11:59 p.m.) and is an actual handling of the medicatieafspraak of 2 January. The pharmacist informs the general practitioner about this. 
 [[Bestand:ENG_Ter hand stellen_De apotheker wijzigt van handelsproduct.png|800px]] 
'''Consideration ''' 
This change in the actual handling of the medicatieafspraak using a toedieningsafspraak, changes nothing to the validity of the medicatieafspraak itself, improving the overall view for all parties. In addition, since the pharmacist records and communicates the reason for the adjustment, the prescriber is better able to assess whether the information is relevant.
 

===Adding medication to a GDS===
When new medication is added to an existing GDS, the prescriber may opt for immediate addition to the current roll (Change in GDS immediately) or for addition starting from the next roll (Change in GDS per change of roll). The prescriber indicates this in the medicatieafspraak (Additional information).

If ‘Change in GDS immediately’ is chosen, the pharmacist will first dispense the medication separately, in addition to the existing GDS. This means that a toedieningsafspraak is created by the pharmacist for the bridging period. Starting with the new roll, the new medication is added to the roll. Starting with the start date of the new roll, a toedieningsafspraak can be made by the pharmacists with specific administration times. If the ‘bridging-toedieningsafspraak’ already includes the correct administration times, no new toedieningsafspraak is created at the date of inclusion in the roll. 
 [[Bestand:ENG_Ter hand stellen_Medicatie toevoegen aan GDS.png|800px]] 
 
If 'Change in GDS per change of roll' is chosen, the pharmacist will start to include the medication in the roll on the start date of the first new roll. In this case, a toedieningsafspraak for the bridging period is not required.

===Discontinuing medication in a GDS===
When medication is discontinued, the prescriber creates a discontinuation-medicatieafspraak. In accordance with the process, the pharmacist is informed about this stop-MA and can adjust the medicatieverstrekking accordingly. The pharmacist will create a staken toedieningsafspraak . See [[#Discontinuing medication|paragraphs 2.2.5.3]] and [[#Discontinuing a toedieningsafspraak|2.3.6.3]].

===GDS supplier supplies other commercial product===
It is possible that a GDS supplier delivers a different commercial product than that which is included in the toedieningsafspraak by the pharmacy. This is therefore a change in the HPK which results in a changed toedieningsafpsraak. This may only be afterwards, after feedback from the GDS supplier of the filling details.
 
 [[Bestand:ENG_Ter hand stellen_GDS leverancier levert ander handelsproduct.png|800px]] 

===Parallel administration agreements with GDS- and non-GDS-dispense===
A patient takes two to three times daily 20 mg pantoprazole because of gastric complaints. The first two tablets are fixed dosages, which are dispensed in GDS. The third tablet, which is prescribed as needed, is dispensed separately. At a certain moment, Sandoz is unable to supply the pantoprazole 20 mg for separate dispenses. Therefore, the pharmacist decides to dispense from Apotex. He stops the current TA and splits the TA in two TA’s, both with the same start date/time. The first TA concerns the fixed dosage in GDS, the second TA involves the as needed tablet. 
''NB. Currently, there is no relationship between medication dispense and TA. Therefore, it is only possible to retrieve which TA is associated with the medication dispense by assessment of the data content. It is evaluated whether the functional design should be adjusted for this use case in the future. 
''
 
[[Bestand:ENG-Uc4.2.16.png|800px]]
 

===Handling a stop medicatieafspraak===
When the prescriber agrees to discontinue medication, a stop medicatieafspraak is created. This stop-MA this processed by the pharmacist by discontinuing the corresponding toedieningsafspraak.

===Medication dispense with someone else’s administration agreement===
A patient takes two times daily 20 mg pantoprazole because of gastric complaints. During the holidays the patient notices that he has forgotten to bring his medication. He visits the after hours general practice clinic and asks for extra tablets for during his holidays. The after hours physician sends a VV to the after hours pharmacy, using an existing MA. 
The after hours pharmacist reads the medication prescription and creates an MVE, using the existing TA, for the ten tablets that the patient needs. The pharmacist notifies the after hours physician about the medication dispense, and sends a copy of the original TA. 
''NB. Although the original prescriber and supplier do not receive an automatic notification, the data will be made available to them.'' 
 
[[Bestand:ENG-Uc4.2.18.png|800px]]
 

===Modification of someone else’s administration agreement===
A patient takes two times daily 20 mg pantoprazole because of gastric complaints. During the holidays the patient notices that he has forgotten to bring his medication. He visits the after hours general practice clinic and asks for extra tablets for during his holidays. The after hours physician sends a VV to the after hours pharmacy, using an existing MA. 
The after hours pharmacist notices that they have no pantoprazole from Sandoz in stock, but they do have pantoprazole from Apotex. Therefore, she stops the current TA, starts a new TA for the Apotex, and creates an MVE for the ten tablets from Apotex. The after hours pharmacist notifies the original pharmacist and, subsequently, the original pharmacist processes the stop-TA. 
 
[[Bestand:ENG-Uc4.2.19.png|800px]]
 

==Use cases, Administer ==

===Creating an administration list===
When an administration list has to be created, for example when a patient starts to receive medication administered by a (professional) administrator, or when GDS medication or non-GDS medication is started, an intake is planned with the patient and the prescriber, pharmacist or administrator (the exact process may differ across institutions). Then, the prescriber, pharmacist, administrator and/or the patient consult on the administration list (which medication is recorded on the administration list, which (guide) administration times are suitable). The pharmacist enters the (guide) administration times in the TA and (actively) makes the relevant medication data available for the administrator and/or the patient.

===Exact administration times required===
When exact administration times are required, for example because of medication interactions, the prescriber or the pharmacist can indicate that an exact administration time is required (the administration time is not a guideline but denotes an exact time). The prescriber or pharmacist can register an exact administration time by indicating that the administration time is not flexible. By default, administration times are flexible. Exact administration times should be presented on the administration list, to ensure that the administrator is informed that it is not allowed to deviate from the entered administration time.

===Missing (guide) administration times===
When (guide) administration times are missing in the MA and TA, an administrator will contact the prescriber or pharmacist to retrieve the (guide) administration time. This is not supported digitally in this information standard.

===Non-GDS medication as needed===
Non-GDS medication as needed is included in the administration list, but is not listed according to the administration moment and/or administration time, because this information is not available beforehand. If relevant (for example because of drug interactions), (guide) administration times can be entered. See the following use cases for practical examples: [[#Medication as needed|4.1.4 Medication as needed]], [[#Course of treatment as needed starting in future|4.1.5 Course of treatment as needed starting in future]], [[#Two dosages of the same medication at the same time|4.1.6 Two dosages of the same medication at the same time]], [[#The same medicinal product with different strengths at the same time|4.1.7 The same medicinal product with different strengths at the same time]].

===Medication supply by multiple pharmacies===
Multiple pharmacies may be involved in the medication supply for one patient, for example in the following situations: medication supply by an outpatient pharmacy, in addition to supplies by a community pharmacy or supplies of add-on medication by a hospital pharmacy. In the case of medication supply by multiple pharmacies, each pharmacist is responsible for the medication data that is required for the administration list, including the (guide) administration times in the TA. It is the responsibility of the prescriber or pharmacist who has made the most recent medication adjustments to determine whether an addition/modification is appropriate with regard to the total of (known) medication data; this concerns both medication monitoring and (guide) administration times. The medication data is (actively) made available, in order to enable that all medication data from different pharmacies are compiled in one administration list.

===Change in GDS from the next supply or immediately===
If GDS medication is altered, it depends on the situation whether this change should occur immediately or from the next supply. The prescriber can indicate in the MA when the change in GDS medication should be implemented. An immediate modification should be immediately shown on the administration list, to ensure that the (professional) administrator administers the correct (amount of) medication. In contrast, a modification that should be implemented from the next supply, should not be processed immediately in the administration list, since previous agreements remain valid until the next supply. Thus, the administration list should not be modified until the change in GDS modification has become effective.

See also use case [[#Adding medication to a GDS|4.2.13 Adding medication to a GDS]].

===Increasing dosage of GDS in new MBH===
A patient is administered 1 tablet propranolol 40 mg 1 time a day. Due to insufficient effects, the prescriber decides to increase the dosage to 80 mg 1 time a day. A new MBH is created for this MA, as there is a change on prescription level. However, the patient still has the 40 mg tablets in the GDS medication roll for the coming days. Therefore, the pharmacists decides to supplement the GDS medication with the administration of 1 tablet propranolol 40 mg, separately from the GDS package, in addition to the tablet in the GDS package, until the next GDS medication roll change in 5 days. The pharmacists creates two TAs: one for the previous GDS medication and one for tiding over the period with medication dispense separately from GDS. In the new GDS supply (medication roll change), the 80 mg tablets are incorporated in this new GDS package. 
 [[Bestand:ENG_Toedienen_Verhogen dosering GDS-medicatie in nieuwe MBH_beta.png|800px]] 

===Decreasing dosage of GDS in new MBH===
A patient is administered 1 tablet propranolol 80 mg 1 time a day. Due to a too strong effect, the prescriber decides to reduce the dosage to 40 mg 1 time a day. A new MBH is created for this MA. The patient still has 80 mg tablets in the GDS medication roll for several days. Because the administrator is not allowed to divide the tablets into halves, the supplier decides that the remaining GDS packages should be collected the same day and be replaced by a new GDS medication roll with 40 mg tablets. 
 [[Bestand:ENG_Toedienen_Verlagen dosering GDS in nieuwe MBH_beta.png|800px]] 
 

===Change processed by the pharmacist===
A change by the prescriber, such as starting new medication, adjusting the dosage, (temporarily) halting medication, is recorded by the prescriber in the MA and/or the VV. Then, the pharmacists processes this change in the TA and/or the MVE. This may be done during the opening hours of the community pharmacist, or after hours when a medication dispense is needed. The after-hours pharmacist dispenses the medication; in this case, multiple pharmacists are supplying medication (see also paragraph 4.3.9). The medication data of the pharmacist(s) and the prescriber(s) are (actively) made available by the prescriber and the after-hours pharmacist to the administrator for the administration list.

===Change not processed by the pharmacist===
When medication is changed by a prescriber after the opening hours of the community pharmacist and medication dispense is not needed, no pharmacist is involved. In that case, the MA is decisive, and the prescriber (actively) makes the MA available. The administrator will be informed of the changed or stopped MA by the administration list; this MA overrules all medication building blocks within the same MBH. This situation also applies if the pharmacist has not processed the modification by the prescriber yet. The pharmacist is responsible for adjusting the TA as soon as possible.

===Variable-dosing regimen===
If a physician prescribes medication with a variable-dosing regimen, the dosing schedule of this medication may be specified by another physician. For example, this applies to thrombosis medication: the prescriber defines the therapeutic INR range (International Normalized Ratio, a measure for the coagulation time of blood), but refers the patient to the thrombosis service for defining the exact dosing schedule. The ‘trombosearts’ (physician affiliated to the thrombosis clinic, who is specialized in the management of anticoagulation therapy) enters the variable-dosing regimen in the medication building block WDS. The prescribing physician remains responsible for the supplies, the ‘trombosearts’ specifies the dosing regimen based on the therapeutic INR range. As the WDS is a separate medication building block, the medication overview remains unchanged (the MA is specified, not altered by the WDS). The WDS is used to compile the administration list, together with the medication data in the MA, TA, MVE and MTD.

===Changing a variable-dosing regimen===
If a dosing schedule is adjusted, the information system closes the current WDS, using a technical stop (not visible to the user). This new WDS is related to the MA and the previous WDS.

===Stop of medication with variable-dosing regimen===
Anticoagulation medication may be (temporality) halted for several reasons; for example, in the case of a medical procedure. Depending on the situation and based on professional judgment, the ‘trombosearts’ can choose one of the following two methods: 

'''A. (temporarily) adjusting the medication regimen''' 
In certain situations, the ‘trombosearts’ may choose to temporarily set the anticoagulation medication to zero, for example, in the period before the planned medical procedure. The MA (and, therefore, the treatment with anticoagulation medication) continues, but in the WDS, the dosage is temporarily adjusted to zero. In such situations, it is advisable to exchange the reason for the WDS change as well. 
 [[Bestand:ENG_Toedienen_Stoppen medicatie met wisselend doseerschema_a_beta.png|800px]] 
'''B. (temporarily) halting the anticoagulation medication''' 
Alternatively, the ‘trombosearts’ may choose to (temporarily) halt the anticoagulation medication. In this case, the ‘trombosearts’ creates a stop-MA. This implies that the underlying WDS and the related TA are stopped as well. If the MA should be restarted or adjusted after a certain period, this is done by the initial prescriber of the anticoagulation medication. In general, the thrombosis service may not be involved any more (temporarily); however, if the thrombosis service is still involved, the ‘trombosearts’ may send a VMA to the initial prescriber who can adopt this proposal in an MA. 
 [[Bestand:ENG_Toedienen_Stoppen medicatie met wisselend doseerschema_b_beta.png|800px]] 
 

===Additional information===
Additional information is an extra explanation about the medication use for the (professional) administrator and/or the patient. An example is the situation when fentanyl patch therapy is stopped; additional information is that the patch has to be removed. Another example is the dosing of half a tablet; the additional information contains the instruction what should be done with the other half. This information can be entered as free text, as a comment in the MA, TA and/or WDS.

See use case [[#Explanation in medicatieafspraak with deliberately chosen special characteristic|4.1.8 Explanation in medicatieafspraak with deliberately chosen special characteristic]] for more information.

===Medication administration deviates from administration list===
It may happen that the administration deviates from the instructions as entered by the prescriber and pharmacist in the MA or TA. This may be a deviation in administration time, administered amount, administration route, administration speed, administered product or no administration. A (professional) administrator can deviate from the rules, in consultation with the prescriber, for valid reasons, and under the condition of safe medical practice and safe working practice. The reason for deviation can be entered in the MTD.

===Medication administration without medication agreement and administration agreement===
In the case of an emergency, the MA and TA may be missing and, therefore, the (professional) administrator has to administer medication on the basis of an MA which is communicated verbally/by telephone. This medication is not incorporated in the administration list. In this situation, the (professional) administrator records the MTD in the information system of the administrator (including ECD, TDR). This is the first building block in a new pharmaceutical treatment; therefore, the administrator creates an MBH.

===Medication administration of self-care medication===
According to the safety principles in the medication chain, the administrator is not concerned with the administration of self-care medication, except for prescribed selfcare medication (a prescriber has created an MA). In that case, the self-care medication is listed on the administration list as GDS medication or non-GDS medication (as needed).

===Correction/cancellation of an administration===
This concerns correcting or cancelling an MTD, because an administrator has made a mistake in the registration and no medication has been administered. If the MTD has not been exchanged with other health professionals, the administrator can adjust the MTD by himself, or remove (cancel) the registration from his own information system. If the MTD has been exchanged with other health professionals, the administrator cancels this erroneous MTD and creates a new MTD under the same MBH with the correct information. The administrator (actively) makes the corrected MTD and the new MTD available.

===Medication administration on hold===
It may happen that the medication administration was unsuccessful, but that is still possible to administer the medication on a later moment, in consultation with a prescriber or pharmacist. If the medication administration is in keeping with the agreements on flexible administration times, the administrator is allowed to deviate from the (guide) administration time.

An example of suspending the medication administration:
* Medication administration is unsuccessful, but the medication can be administered on a later (or, in some cases, earlier) moment of the day. In this situation, the medication administration is suspended, and there is a deviation from the administration list.

===Medication administration by a prescriber===
A prescriber, similarly to a (professional) administrator, is able to administer medication to a patient, and record this procedure in an MTD.

===Multiple administration organizations===
Multiple administration organizations may be involved in a patient’s medication administration. For example, medication may be administered by another organization during the evening/night than during the day. If multiple administration organizations are involved in providing patient care, these health professionals can consult each other’s MTDs to track the process of medication administration. The acts of one organization can affect the process of another organization (for example, has medication been administered, have there been deviations from the administration list, etc.).

===Feedback to patient through a medication adherence app===
In this example the patient uses an app on his mobile phone to help manage his medication. The patient or the pharmacist has created an administration schedule with reminder times (where possible using the app to obtain the toedieningsafspraken from the medicatietoediening). When it is time to take his medication, the patient receives a reminder signal from the app. The patient registers the medication administration and thus indicates whether he has taken the medicine or not (for instance because he forgot to bring it along with him). If the app is linked, for example, to the patient’s PGO (personal health file), medication adherence is tracked automatically.
 
[[Bestand:ENG_Feedback_to_patient_through_a_medication_adherence_app.PNG|800px]] 
 


==Use cases, Medicatiegebruik==

===Self-care product===
A patient has acquired Ibuprofen from the drugstore and takes 1200 mg every day. The patient enters this product as gebruik, with such data as starting dates and dosage, and possibly the reason for medicatiegebruik.
 [[Bestand:ENG_Gebruik_Zelfzorgmiddel.png|800px]] 

===Medication from abroad===
A patient has been prescribed medication on holiday and is taking this. The patient enters the medication as gebruik, with data such as start date and dosage, and possibly the reason for medicatiegebruik. If known, the name of the prescriber is also recorded.
 [[Bestand:ENG_Gebruik_Medicatie uit buitenland.png|800px]] 

===Modification on the patient’s initiative===
The patient has been prescribed propranolol. The patient is having severe problems sleeping because of this and has reduced the medication herself. The patient records gebruik with the modified dosage and the start date for this lower dose. The patient also indicates that she initiated this change herself. In the case where a patient initiates a dose reduction, the patient can keep on using the medication for a longer period than initially agreed because she still has a supply. The patient can indicate this as additional gebruik. 
In the case where a patients initiates a dosage increase, the patient’s supply may run out sooner. The patient may then have to return to the physician earlier than expected.
 [[Bestand:ENG_Gebruik_Wijziging op initatief patiënt.png|800px]] 

===Discontinuation of medication on the patient’s initiative===
Since he started using propranolol, the patient suffers from insomnia. He decides to stop without immediately informing the prescribing physician. The patient himself records that he has discontinued medication, indicating the date and giving insomnia as the reason for discontinuing. 
[[Bestand:ENG_Gebruik_Stoppen medicatie op initatief patiënt.png|800px]] 

===No more supply===
A patient has received medication ‘as needed’ for his skin problems. The medication is still active in the medication profile, but is no longer available at the pharmacist. The patient indicates that the medication has been discontinued because it is no longer available, possibly with the addition that the symptoms have disappeared.
 
[[Bestand:ENG_Gebruik_Geen voorraad meer_a.png|800px]] 
 
The patient may also make a proposed verstrekkingsverzoek to replenish his supply In this case, the reply proposed verstrekkingsverzoek comes back to the patient (and if approved, a verstrekkingsverzoek is also sent from the prescriber to the pharmacist). 
[[Bestand:ENG_Gebruik_Geen voorraad meer_b.png|800px]] 

===Registrations of abnormal medicatiegebruik by patient due to adverse drug reactions===
Since he started taking propranolol, a patient has been suffering from insomnia. The patient records this side effect in the explanatory notes to the medicatiegebruik. When the patient changes the medicatiegebruik of this medication from what was previously agreed, for example when he takes less tablets, he can give the side effect as a reason for this change. When his symptoms diminish or cease, the patient records this in the explanation for medicatiegebruik. 
It is possible that the patient is suffering from side effects without exactly knowing which medicinal products cause them. There is no provision within medication process to record this (yet).

===Register medicatiegebruik based on provision===
This applies in the transition period from the old medication process standard 6.12 to this medication process information standard.

Only verstrekking (dispensing) is available digitally (according to medication process version 6.12). However, the user's information system offers the possibility to record all medicatiegebruik. In that case, the medicatiegebruik can be recorded with reference to the ID of the version 6.12 verstrekking.
 
[[Bestand:ENG_Gebruik_Gebruik registreren op basis van verstrekking.png|800px]] 

=Medication overview and inference rules=
This chapter shows a sample medication overview and also specifies inference rules for 'The most current relevant building block', Verification for each medicamenteuze behandeling, etc.

==Introduction==
The term 'current medication overview' has been replaced by the term 'basisset medicatiegegevens’ (basic set of medication data): the medication overview in combination with additional information that is required (at least) to be able to prescribe, change, stop or safely provide medication in a safe and responsible manner in the Transfer of Medication Data in the Chain (Leidraad Overdracht van Medicatiegegevens in de keten, final draft 2017).

This page contains an example of a medication overview. This example was developed in the Medication Process Information Standard program and serves as an example of how data can be displayed in an application. The data numbered in the pictures below are normative, they are mandatory to show. The other (unnumbered) data in the example is optional and may be added as normative in the future. The layout of the overview in a information system can differ per target group and per device. For pharmacists, for example, only toedieningsafspraken are initially visible, after which it is possible to click further to get to the corresponding medicatieafspraak and the medicatiegebruik. If only medicatiegebruik or a medicatieafspraak is known, this will of course be shown immediately. The basic principle is that the overview shows all medication of the patient, not just the medication that is registered in the patient's own information system.

The overview is described generically and therefore the same for all suppliers. The requirements of the end users are included on this page and no statements are made about the technical realization or implementation. The existing KNMP specification “User requirements specification Medication overview 2.0”, final concept “Guidance Transfer of Medication data in the chain (Leidraad OVerdracht van Medicatiegegevens in de keten)” and the new insights from the Medication process program have been incorporated in this.

Principles for the overview are:
*Health professionals want to see a distinction between the therapeutic building blocks on a medication overview:
**Medicatieafspraak
**Toedieningsafpsraak
**Medicatiegebruik
*Logistical building blocks (verstrekkingsverzoek, dispensing) and the medicatietoedieningbuilding block are not relevant for the medication overview.

[[Bestand:Medicatieoverzicht_1_v0.5.PNG|Medicatieoverzicht v0.5]]
[[Bestand:Medicatieoverzicht_2_v0.5.PNG|Medicatieoverzicht v0.5]]

==Functional specification==
In the figures below the parts with normative data are included. The other parts are not yet normative. The numbered elements in the table are normative, other elements are optional for the time being.

===Heading and General===
[[Bestand:Medicatieoverzicht_KopAlgemeen_v0.5.PNG]]

Filter: N/A

Sort: N/A

Medication Overview Date: This is the date that the last change to a medicatieafspraak, toedieningsafspraak or medicatiegebruik was recorded within the information system providing the medication overview.

NOTE: In the viewer, all dates are shown with the month in characters, so that there is no confusion between day-month and month-day (American format).

{| class="wikitable"
|-
! No !! Header !! Dataset !! Explanation
|-
| 1 || Name || Patient – Name data (Initials, Surname, PartnerSurname), Date of Birth, Gender ||
|-
| 2 || Telephone || Patient – Contact data – Telephone numbers || Primary telephone number of patient
|-
| 3 || BSN || Patient – Patient identification number || Always BSN
|-
| 4 || Adress || Patient – Address data ||
|-
| 5 || Healthcare Provider Name || Healthcare Provider – Organization name || Healthcare Provider who has compiled the medication overview
|-
| 6 || Healthcare Provider Adress || Healthcare Provider – Address – Address data || Healthcare Provider who has compiled the medication overview
|-
| 7 || Healthcare Provider Telephone || Healthcare Provider – TelephoneMail – Contact data – Telephone numbers || Healthcare Provider who has compiled the medication overview
|-
| 8 || Healthcare Provider Email || Healthcare Provider – TelephoneMail – Contact data – Email addresses || Healthcare Provider who has compiled the medication overview
|-
| 9 || Date of Medication Overview || Document data – Document date ||
|-
| || Height|| Body height – HeightValue, HeightDateTime ||
|-
| || Weight|| Bodyweight – WeightValue, WeightDateTime ||
|-
| || Checked by Health professional || Document data – Verification by health professional ||
|-
| || Verified with Patient/Informal Caregiver || Document data – Verification by patient ||
|}
Elements 5 through 8 are not shown if the patient is the creator of the medication summary.

===Contraindications and hypersensitivities (CiO)===
[[Bestand:Medicatieoverzicht_ICA_v0.5.PNG]]

Active contraindications and hypersensitivities (intolerances, allergies/adverse reactions) (in Dutch: 'contraindicaties en overgevoeligheden' - CiO).

Filter: end date is not filled, is in the future or was less than a year ago when compiling the overview.

Sort: most recent effective date at the top.

This part will be elaborated at a later time and is not yet normative.

===Current medication===
[[Bestand:Medicatieoverzicht_HuidigeMedicatie_v0.5.PNG]]

Filter: all current medication, i.e. all medicatieafspraken and toedieningsafspraken that apply at the time the overview is compiled and the associated medicatiegebruik per source. The temporarily interrupted medication is also shown in this category. When only medicatiegebruik is known, it is shown if it is not older than 13 months. When medicatiegebruik is recorded by both a health professional and a patient, the last registered medicatiegebruik is shown for both.

Sorting: by medicamenteuze behandeling (MBH): medicatieafspraak, toedieningsafspraak, medicatiegebruik (recorded by patient, care provider). Medicamenteuze behandelingen are sorted in descending order by startdate medicatieafspraak, toedieningsafspraak, medicatiegebruik.

{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| '''No'''
! style="text-align:left;"| '''Header'''
! style="text-align:left;" colspan="3"| '''Dataset'''
|-
|style="background-color: white;vertical-align:top;"|1
|style="background-color: white;vertical-align:top;"|Type
|style="background-color: white;vertical-align:top; text-align:center;"|Medicatieafspraak
|style="background-color: white;vertical-align:top; text-align:center;"|Toedieningsafspraak
|style="background-color: white;vertical-align:top; text-align:center;"|Medicatiegebruik
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|2
|style="background-color: white;vertical-align:top;" rowspan="2"|Medicinal product
|style="background-color: white;vertical-align:top; text-align:center;"|Agreed medicinal product-
|style="background-color: white;vertical-align:top; text-align:center;"|Medicinal product belonging to Toedieningsafspraak-
|style="background-color: white;vertical-align:top; text-align:center;"|Device-
|-
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Product – ProductCode (if absent: ProductSpecification, ProductName)
|-
|style="background-color: white;vertical-align:top;"|3
|style="background-color: white;vertical-align:top;"|Start date
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Start date
|-
|style="background-color: white;vertical-align:top;"|4
|style="background-color: white;vertical-align:top;"|End date/duration
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|End date (if not available: Duration)
|-
|style="background-color: white;vertical-align:top;"|5
|style="background-color: white;vertical-align:top;"|Dosage
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Instructions for medicatiegebruik – Description
|-
|style="background-color: white;vertical-align:top;"|6
|style="background-color: white;vertical-align:top;"|Route of toediening
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Instructions for medicatiegebruik – Route of toediening
|-
|style="background-color: white;vertical-align:top;"|7
|style="background-color: white;vertical-align:top;"|Reason
|style="background-color: white;vertical-align:top; text-align:center;"|Reason for prescribing &
if applicable reason for discontinuing/suspending medication
|style="background-color: white;vertical-align:top; text-align:center;"|Reason for discontinuing/suspending medication
|style="background-color: white;vertical-align:top; text-align:center;"|Reason for discontinuing/suspending medication
|-
|style="background-color: white;vertical-align:top;"|8
|style="background-color: white;vertical-align:top;"|Explanation
|style="background-color: white;vertical-align:top; text-align:center;" colspan="2"|Explanation & additional information
|style="background-color: white;vertical-align:top; text-align:center;"|Explanation
|-
|style="background-color: white;vertical-align:top;" rowspan="3"|9
|style="background-color: white;vertical-align:top;" rowspan="3"|Source
|style="background-color: white;vertical-align:top; text-align:center;"|Prescriber-
|style="background-color: white;vertical-align:top; text-align:center;"|Provider-
|style="background-color: white;vertical-align:top; text-align:center;"|Author-
|-
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Health professional – Name healthcare provider, specialty
|-
|style="background-color: white;vertical-align:top; text-align:center;"|n/a
|style="background-color: white;vertical-align:top; text-align:center;"|n/a
|style="background-color: white;vertical-align:top; text-align:center;"|or “Patient”
|}

===Future medication===
[[Bestand:Medicatieoverzicht_ToekomstigeMedicatie_v0.5.PNG]]

Filter: all medication that will become actual in the next 3 months. This includes intended medicatiegebruik.
For a description of the mapping, the same applies as with the current medication, see [[#Current medication|Current medication]].

===Recently discontinued medication===
[[Bestand:Medicatieoverzicht_RecentBeeindigde_v0.5.PNG]]

Filter: any medication that has ended or stopped in the past 2 months.

For a description of the mapping, the same applies as with the current medication, see [[#Current medication|Current medication]].

===Additional lab values ===
[[Bestand:Medicatieoverzicht_Labwaarden_v0.5.PNG]]

Most recent lab values and abnormal renal function values.

This part will be elaborated at a later time and is not yet normative.

===Remarks ===
[[Bestand:Medicatieoverzicht_Opmerkingen_v0.5.PNG]]

For example, relevant (limited) health skills (competences: literacy, calculation and digital skills) that can have an impact on medicatiegebruik / treatment.

This part will be elaborated at a later time and is not yet normative.

==Building block instantiations==
This section describes which instantiations of the building blocks belong to the medication overview. This concerns 'own' and 'other people's' building blocks ([[#GP observation service (HAP)|section 3.1]]) and then only the latest, relevant instantiations of this ([[#Thrombosis service|section 3.2]]).

===Own and other people===
Both the own and a copy of (known to the sender) building blocks from other sources are included in the medication overview. This so that the medication overview is as complete as possible for the recipient. This ensures that recipients can start using it immediately and that they are not dependent on other sources. The technical representation of someone else's building block may differ from that of the real source. It is important that the recipient is aware of this. The original OID of someone else's building block should simply be given. The recipient can then choose to also collect the building block from its source in its original form.

The medicatieafspraak, toedieningsafspraak and medicatiegebruik building blocks have been extended with a feature that indicates whether:
*there is an 'own' building block or
*that of "someone else" (an ''accent'' building block: MA’, TA’, MGB’)
This attribute only applies in the medication overview transaction, because that is the only transaction where other people's building blocks may be delivered.

The 'building block of someone else' attribute is on two levels:
*The template ID of an MA’, TA’, MGB’ differs from an MA, TA and MGB.
*In addition, the element copy indicator is always sent with value '''true''' in MA’, TA’, MGB’.
For the medication overview, it is permitted to offer the medicatieafspraken, toedieningsafspraken and medicatiegebruik via a information system-generated MGB or MGB '(Healthcare provider is author MGB). This must have a reference to an MA, TA or MGB.

====Medication overview and derivation rules====
An overview of medication that the patient is using (or should be using) can be put together in a information system in two ways: 
1) displaying a current medication overview (or overviews) obtained from another source (or sources) 
2) showing coherent medication building blocks obtained from one's own information system and from other sources. 
In both cases, this overview of medication consists of the information as included in the building blocks medicatieafspraak, toedieningsafspraak and medicatiegebruik.

Re 1) When this document refers to a current medication overview, this means a coherent overview in which current medicatieafspraken, toedieningsafspraken and medicatiegebruik are included. This current medication overview is built up by the source on the basis of the data known at that time at the source. This overview can be exchanged with the transaction group Medicatieoverzicht (Medication overview) (PULL or PUSH).

The data and building blocks that are known at the source, but originating from another source, are supplied in the transaction with the 'accent' indicator so that they are recognizable as building blocks from someone else (MA accent, TA accent, MGB accent).

Re 2) It is also possible for a information system to compile an overview by combining own and other people's separate individual medication building blocks. The transaction group Medicatiegegevens (medication data) (PULL) is used to request individual building blocks.

With the transaction group Medicatiegegevens (medication data) (PUSH), separate building blocks can also be sent directly to another health professional or the patient (so without requests). This happens, for example, at discharge or at the request of a co-practitioner who has the patient in front of him (e.g. patient appears to a GP or pharmacist outside the region, where this GP or pharmacist requests the data by telephone from the patient's own GP and receives it digitally).

Both Medicatiegegevens (medication data) PUSH and PULL should not provide data obtained from other sources.

===Last relevant===
Only the last relevant building blocks (per medicamenteuze behandeling) are part of the medication overview. This section describes what exactly those last relevant building blocks are for a medication overview. Firstly for prescription medication (section 3.2.1), then for "over the counter" medication (section 3.2.2). The following section 3.2.3 further discusses the special situation that, in addition to a current, a future medicatieafspraak within the same medicamenteuze behandeling is valid. Finally, the last paragraph summarizes the rules to be applied. 
Note: The (technical) stop-medicatieafspraken are not shown in the examples, but are implicitly assumed.

====Prescription medication====
=====Most simple "happy flow"=====
In a medicamenteuze behandeling, the simplest "happy flow" results in a sequence of:
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik''.
Usually, medicamenteuze behandeling (drug treatment) starts with a medicatieafspraak. A toedieningsafspraak concretely completes the medicatieafspraak. medicatiegebruik says something about the actual medication use of the patient in this medicamenteuze behandeling. All three building blocks are relevant in such a case and are part of the delivery of a medication overview, as indicated in green below.
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik.
A toedieningsafspraak refers to the medicatieafspraak he enters. If no referral is available in the toedieningsafspraak, the appointment date (administration appointment) must be later than that of the medicatieafspraak to be relevant to delivery. 
Medicatiegebruik can refer to a medicatieafspraak or toedieningsafspraak. If no referral is available in the medicatiegebruik, the registration date (medicatiegebruik) must be later than that of the medicatieafspraak to be relevant for delivery.

=====New medicatieafspraak in medicamenteuze behandeling=====
If you create a new medicatieafspraak in an existing medicamenteuze behandeling (drug treatment), the currently existing medicatieafspraken, toedieningsafspraken and records of medicatiegebruik are no longer relevant for the medication overview. The idea is that all older building blocks than the current medicatieafspraak are by definition "overruled" by this new medicatieafspraak and consequently no longer relevant for the medication overview.
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik'' - stop-Medicatieafspraak – Medicatieafspraak – stop-Toedieningsafspraak

If a toedieningsafspraak and possibly also medicatiegebruik are created and available following such a medicatieafspraak medication appointment, these will be included in the medication overview.
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik'' – stop-Medicatieafspraak – Medicatieafspraak – stop-Toedieningsafspraak - Toedieningsafspraak
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik'' – stop-Medicatieafspraak - Medicatieafspraak - stop-Toedieningsafspraak – Toedieningsafspraak – Medicatiegebruik 

The new MA can also be a stop-MA, if the patient has to stop medication permanently. This stop-MA remains relevant for the medication overview for 2 months. 
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – stop-Medicatieafspraak - stop-Toedieningsafspraak

=====Medicatiegebruik earlier than toedieningsafspraak =====
It is possible that you have registered medicatiegebruik before the toedieningsafspraak has been made. Here too, the idea is that the newer toedieningsafspraak "overrules" the older registration of toedieningsafspraak and medicatiegebruik. The older medicatiegebruik is therefore no longer relevant for the medication overview.
* Medicatieafspraak – Medicatiegebruik
* Medicatieafspraak – ''Medicatiegebruik'' – Toedieningsafspraak

Of course, a new record of medicatiegebruik can then be made, which is also relevant for the medication overview.
* Medicatieafspraak – ''Medicatiegebruik'' – Toedieningsafspraak - Medicatiegebruik

=====New toedieningsafspraak =====
Sometimes you make a new toedieningsafspraak under an existing medicatieafspraak. For example, because another product must be provided (as a result of preference policy or stock). In that case, too, such a new toedieningsafspraak may overrule older medicatieafspraken and medicatiegebruik.
* Medicatieafspraak – ''Toedieningsafspraak – Medicatiegebruik''- stop-Toedieningsafspraak - Toedieningsafspraak

Of course you can then record medicatiegebruik, which is also relevant for the medication overview.
* Medicatieafspraak – ''Toedieningsafspraak – Medicatiegebruik'' - stop-Toedieningsafspraak – Toedieningsafspraak - Medicatiegebruik

====Over the counter====
Sometimes a patient uses medication for which there is no prescription. This applies, for example, to painkillers such as paracetamol or ibuprofen, which are available without a prescription. We call this “over the counter” medication. Such use of "over the counter" medication can be recorded with the medicatiegebruik building block. This is also relevant for the medication overview.
* Medicatiegebruik

A new record of medicatiegebruik by the same type of author (type of author is patient or health professional) "overrules" any older records of medicatiegebruik. Elaborated below, in order of registration date:
* ''Medicatiegebruik'' - Medicatiegebruik

When a prescriber decides to formalize this medicamenteuze behandeling with a medicatieafspraak the rules as described above apply. Elaborated below, in order of appointment date (medicatieafspraak or toedieningsafspraak) / registration date (medicatiegebruik):
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak - Medicatiegebruik
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak – Toedieningsafspraak - Medicatiegebruik
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak – ''Medicatiegebruik'' - Toedieningsafspraak - Medicatiegebruik
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak - ''Medicatiegebruik'' - Medicatiegebruik

====Future medicatieafspraken and toedieningsafspraken====
A medicamenteuze behandeling may include more than one topical medicatieafspraak and toedieningsafspraak. Namely one for the current situation and one or more for the future situation. This section describes an example with one current and one future. For clarity, the future building blocks have a “T-” in the examples. Both current and future building blocks are relevant for the medication overview. The building blocks for toedieningsafspraak and medicatiegebruik must have adequate references to either the current or future appointments. Below are three examples, in order of appointment date / registration date (if these are equal, then sorted by period of use):
* Medicatieafspraak – T Medicatieafspraak
* Medicatieafspraak – Toedieningsafspraak – T Medicatieafspraak – T Toedieningsafspraak
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – T Medicatieafspraak – T Toedieningsafspraak – T Medicatiegebruik
Suppose that the toedieningsafspraak changes because the provider provides a different strength (2x 500mg tablets instead of 1x 1000mg tablets) and the patient still has enough stock for two weeks based on the first toedieningsafspraak:
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – T Toedieningsafspraak – T Medicatiegebruik

=====New medicatieafspraak =====
If you make a new medicatieafspraak in this situation, you always make a (technical) stop-medicatieafspraak. This stop-medicatieafspraak has two manifestations: 
1) with reference to a specific medicatieafspraak that you stop 
2) without a referral, and with that you stop the entire medicamenteuze behandeling (drug treatment)

Ad 1) Stop medicatieafspraak for one current medicatieafspraak. With this stop medicatieafspraak you stop one specific medicatieafspraak. You also make a new one for that medicatieafspraak. Suppose you only want to change the current medicatieafspraak, then this applies to the examples above, in order of appointment date:
* ''Medicatieafspraak'' – T Medicatieafspraak - stop-Medicatieafspraak – Medicatieafspraak 
* ''Medicatieafspraak – Toedieningsafspraak'' – T Medicatieafspraak – T Toedieningsafspraak - stop-Medicatieafspraak – Medicatieafspraak
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik'' – T Medicatieafspraak – T Toedieningsafspraak – T Medicatiegebruik - stop-Medicatieafspraak – Medicatieafspraak

Suppose you only want to change the future medicatieafspraak, then this applies to the examples above, in order of appointment date:
* Medicatieafspraak – ''T Medicatieafspraak'' - stop- T Medicatieafspraak – T Medicatieafspraak
* Medicatieafspraak – Toedieningsafspraak – ''T Medicatieafspraak – T Toedieningsafspraak'' - stop- T Medicatieafspraak – T Medicatieafspraak
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – ''T Medicatieafspraak – T Toedieningsafspraak – T Medicatiegebruik'' - stop- T Medicatieafspraak – T Medicatieafspraak 

 Ad 2) Stop medicatieafspraak for the entire medicamenteuze behandeling. With this stop medicatieafspraak you stop all existing (current and future) medicatieafspraken in the medicamenteuze behandeling. If you now want to make a medicatieafspraak for the future in addition to a current one, you must also make it again. Elaborated below for the same three examples as above, in order of appointment date.
* ''Medicatieafspraak – T-Medicatieafspraak'' – stop-Medicatieafspraak (zonder referentie) - Medicatieafspraak 
* ''Medicatieafspraak – Toedieningsafspraak – T-Medicatieafspraak – T-Toedieningsafspraak'' - stop-Medicatieafspraak (zonder referentie) – Medicatieafspraak – T Medicatieafspraak
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – T-Medicatieafspraak – T-Toedieningsafspraak – T Medicatiegebruik'' - stop-Medicatieafspraak (zonder referentie) – stop-Toedieningsafspraak -Medicatieafspraak – stop- T Toedieningsafspraak - T Medicatieafspraak 

=====New toedieningsafspraak=====
 However, you can also make a new toedieningsafspraak for the current medicatieafspraak only. This new toedieningsafspraak must then have a reference to that current medicatieafspraak. Elaborated below for three examples, in order of appointment date.
* Medicatieafspraak – T Medicatieafspraak – Toedieningsafspraak
* Medicatieafspraak – ''Toedieningsafspraak''– T-Medicatieafspraak – T Toedieningsafspraak - stop-Toedieningsafspraak – Toedieningsafspraak
* Medicatieafspraak – ''Toedieningsafspraak – Medicatiegebruik'' – T Medicatieafspraak – T-Toedieningsafspraak – T Medicatiegebruik – - stop-Toedieningsafspraak – Toedieningsafspraak

A new toedieningsafspraak with a reference to the future medicatieafspraak looks like this.
* Medicatieafspraak – T Medicatieafspraak – Toedieningsafspraak – T-Toedieningsafspraak
* Medicatieafspraak –Toedieningsafspraak – T-Medicatieafspraak – ''T Toedieningsafspraak'' – stop-T Toedieningsafspraak - T Toedieningsafspraak
* Medicatieafspraak –Toedieningsafspraak – Medicatiegebruik – T Medicatieafspraak – ''T Toedieningsafspraak – T Medicatiegebruik'' - stop- T Toedieningsafspraak – T-Toedieningsafspraak

====Rules of overruling listed====
Based on the above description / examples, the following general rules for overruling can be derived. This concerns the rules for determining whether a building block is relevant for delivery in the medication overview. Within a medicamenteuze behandeling:
*A new medicatieafspraak overrules all older building blocks (medicatieafspraak, toedieningsafspraak, medicatiegebruik) belonging to the medicatieafspraak /medicatieafspraken that this medicatieafspraak has stopped.
*A new toedieningsafspraak overrules all older building blocks of the type of toedieningsafspraak or medicatiegebruik that belong to the same medicatieafspraak as the new toedieningsafspraak.
*In principle, a new record of medicatiegebruik overrules (see exception below) older records of medicatiegebruik that belong to the same medicatieafspraak as the new medicatiegebruik.
**Exception to this rule: medicatiegebruik with the author as a patient DOES NOT overrule an older record of medicatiegebruik with the care provider as author and vice versa. Both are therefore relevant to the medication overview.
The latter exception applied to a number of situations:

Deze laatste uitzondering toegepast op een aantal situaties:
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik-ZVL – Medicatiegebruik-PAT
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik-PAT – Medicatiegebruik-ZVL
* Medicatieafspraak – Toedieningsafspraak – ''Medicatiegebruik-PAT'' – Medicatiegebruik-PAT
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik-ZVL – ''Medicatiegebruik-PAT'' – Medicatiegebruik-PAT
* Medicatieafspraak – Toedieningsafspraak – ''Medicatiegebruik-ZVL – Medicatiegebruik-PAT'' – Medicatiegebruik PAT – Medicatiegebruik-ZVL

==Verification by medicamenteuze behandeling ==
A health professional records verification per medicamenteuze behandeling with the medicatiegebruik building block:
*Author = Health professional
*Possible informant: the patient, a care provider or another person
*Possible characteristic "according to agreement": according to the author, is the medicatiegebruik in accordance with the medicatieafspraak or toedieningsafspraak?
*Possible link to medicatieafspraak or toedieningsafspraak:
**Medicatieafspraak or toedieningsafspraak that has been the reference for recording this medicatiegebruik.
**When it is indicated "by appointment", this is the medicatieafspraak or toedieningsafspraak according to which the patient uses.
Such a record of medicatiegebruik means: "I think the patient uses this drug as follows: ... ..".

Known: it is not currently provided in the information standard to indicate that a medicatieafspraak or toedieningsafspraak is correct, regardless of whether the patient uses it as such.

==Process of the medication overview exchange==
In addition to the content and verification, the process surrounding the medication overview is also important.

===Who, when, with what information===
The reliability and completeness of a medication overview depends on:
*who composed it,
*at what time and
*with what basic information.
We can make agreements about this, for example:
*only exchange/make available a medication overview once it has some form of reliability
**after an explicit action by a health professional or
**automatically if certain conditions are met.
*fully automatically exchange/make available medication overview without conditions
*make medication overview fully automatically available without the need for a new data type (so when registering one of the other medication data types you are automatically also the source of a medication overview).

====Decision====
The above questions have not yet been answered. It has been decided that during the Proof-Of-Concept all parties that can provide a medication overview will do the same.

===Responsibilities applicant and source===
The applicant receives medication overviews from multiple sources. Processing this is the responsibility of the recipient. The topicality of a medication overview is important here.

'''Action''': the transaction Medicatieoverzicht (medication record) must contain the most recent date of the collection of available appointment dates / registration dates of the delivered building block instantiations. The compiler (source) of the medication overview must therefore provide this date. This helps the recipient to better estimate the topicality of the medication overview.

===Agreements continued===
We continue the analysis with the results of the Proof-Of-Concept to arrive at a good process for the medication overview.

==Inference rules==
It is important that all parties, physician, pharmacist, nurse as well as patient can infer from the medication building blocks what is intended (i.e. what the current agreements are) and that this should be the same for all information systems. For that reason, information systems must be able to calculate the current situation using the same inference rules.

The current therapeutic situation is calculated on the basis of medicatieafspraken and toedieningsafspraken. Toedieningsafspraken have a relationship with the medicatieafspraak that they were added to. For this reason, toedieningsafspraken can be linked to the medicatieafspraak that they belong to. 
Of course it is also useful to have information about medicatiegebruik. However, this does not indicate the aim of the health professional, only what medication the patient has used. For that reason, the rules below do not take ‘medicatiegebruik’ in consideration. However, ‘gebruik’ is part of a medication profile but is shown separately under the medicamenteuze behandeling concerned.

===Effective period===
The effective period lies between an ''effective start date'' and an ''effective end date''. 
:''The effective period describes the period to which a medicatieafspraak or toedieningsafspraak (ultimately) applies.'' 
The effective period depends on adjustments (modifying/discontinuing/halting/resuming) of medication and by the ‘actual handling of a medicatieafspraak by a toedieningsafspraak. The effective period is not described in the dataset, because it is inferred which is only used to determine the current situation. The ''effective start date, effective end date'' and ''effective period'' are not data to be shown to the end user. Medication for an indefinite period has an effective end date that is in the future, but at a time that cannot be distracted (yet). It is only known that it is 'somewhere' in the future.

===Actual and current medication===
*''Actual (medicatieafspraken en toedieningsafspraken)'': the agreements of which the effective end date lies in the future.
*''Current (medicatieafspraken en toedieningsafspraken) agreements'': the agreements for which the present date lies between their effective start date and the effective end date.
*''Actual medication'': the collection of actual (current and future) medication and toedieningsafspraaks as well as current medicatiegebruik. It should be taken into account that it is never possible to say with certainty to what extent the patient complies with the agreements and/or reports actual gebruik.

===Details===
'''Approach''' 
Using a number of different situations the inference rules are described for arriving at the effective therapeutic period in a medication profile: 
:1) Starting medication
:2) Creating a toedieningsafspraak
:3) Changing medication
:4) Discontinuing medication
:5) Temporarily halting and resuming medication

The inference rules are described below. The number for each inference rule indicates the order in which the rules must be executed.

'''1) Starting medication''' 
Medication is started by creating a new medicatieafspraak. The medicatieafspraak has:
*An agreement date - the date on which the agreement was made with the patient.
*A period of use - this period is consists of:
**A start date - the start date of the medicatieafspraak may be in the future;
**The duration of medicatiegebruik;
**The end date – the date until which the medicatieafspraak is valid.

1a: The effective period of a new medicatieafspraak is equal to its period of medication use.

'''2) Creating a toedieningsafspraak ''' 
A toedieningsafspraak specifically fulfils a medicatieafspraak. From a patient perspective, the toedieningsafspraak, in a way, replaces a medicatieafspraak, as the toedieningsafspraak is a more specific indication of what the patient should be using.

Inference rule 1 is extended:

1b: The effective period of a new toedieningsafspraak is equal to its period of medication use

Inference rule 2 is applicable when a medicatieafspraak has underlying toedieningsafspraken (see inference rule 2b for further explanation):

2a: The effective period of a medicatieafspraak is equal to the effective period of the toedieningsafspraak.

'''3) Changing medication'''
:'''a) By means of a medicatieafspraak'''
The prescriber changes the medication (or the medicamenteuze behandeling) by creating a new medicatieafspraak (and discontinuing the existing one) within an existing medicamenteuze behandeling.
Because the start date of a medicatieafspraak may lie in the future, several medicatieafspraken may be actual at the same time. For example, when a medicatieafspraak applies ‘for an indefinite period’ (ma1) and it is agreed to change the dosage in two weeks (ma2), the first medicatieafspraak (ma1) remains valid for two weeks, after which the second medicatieafspraak (ma2) becomes effective. The previous inference rules do not change because of this.

:'''b) By means of a toedieningsafspraak '''
An toedieningsafspraak specifically fulfils a medicatieafspraak. This toedieningsafspraak may be modified. For example, when administration schedules are changed (when GDS is initiated), or when a commercial product is changed (for example, as a result of a preference policy). Several successive toedieningsafspraken can therefore be created under a single medicatieafspraak. Hence, rule 2 is expanded so that the effective period of the medicatieafspraak is determined by the entire series of underlying toedieningsafspraken.

2b: When several toedieningsafspraken are made under a single medicatieafspraak, the effective start date of the medicatieafspraak is then equal to the earliest start date of the underlying toedieningsafspraak and the end date of the last toedieningsafspraak.

Parallel toedieningsafspraken may exist under a single medicatieafspraak of which the agreement date and the start date are the same. Both are then valid at the same time and this does not change rule 2b.

The diagram below includes a simplified example of an actual profile composed of different building blocks. The patient, verification, CiO and lab data have been excluded from this overview. Only limited data has been included, mainly to demonstrate the way in which the effective period works. Lines starting with ‘-’ are detail lines which can be hidden in the medication profile, if required. The first line shows the effective period for the underlying MAs and TAs. The ‘medicatiegebruik” is also displayed, but this does not influence the calculation of the effective therapeutic period on the first line.

{{anchor|figuur 9}}
[[Bestand:Voorbeeldeffectieveperioden.png|Figuur 9 Voorbeeld effectieve periode]]

'''4) Discontinuing medication''' 
Discontinuing medication (i.e medicamenteuze behandeling) is done by creating a new medicatieafspraak in which stoptype ‘definite’ is indicated. The start date of this medicatieafspraak is the date on which the original medicatieafspraak started. The end date is the date on which the medication is discontinued. The effective period of the original medicatieafspraak is so replaced by the effective period of this new stop-MA.

1c: When a medicatieafspraak is discontinued, the effective period of the medicatieafspraak is then the effective period of the stop-MA.

An stop-toedieningsafspraak fulfils the stop-medicatieafspraak. In this way, for example, it is possible to indicate that the discontinuation starts when the next GDS roll is dispensed.

'''5) Temporarily halting and resuming medication''' 
Temporarily halting medication is carried out in the same way as discontinuing medication. A stop-MA is created (stoptype ‘temporary’) with the same start date as that of the original medicatieafspraak. The end date of the stop-MA is the timing of the temporary halt, the stop type is ‘temporary’. Resuming medication is done by creating a new medicatieafspraak with the old (or adjusted) dosage with the date of resuming as the start date. A meaningful reason (example: resume previous policy) may serve to clarify matters. If the medication is not resumed, ‘discontinue medication’ (stoptype ‘definite’) can be executed in order to permanently end the medicamenteuze behandeling, which means the medication is no longer valid. Medication that is halted remains valid, and so remains visible in the medication profile.

1d: When medication is temporarily halted, the effective period is not affected. The effective period is determined by the effective period of the original medicatieafspraak.

These inference rules are the basis for determining the current agreements. It is possible to conceive exceptional situations relating to a partial availability of medication data. These situations have not been elaborated. All inference rules are included and implemented in the open source medication viewer.

==Data that need not be shown==
Various data are important for the correct processing of information, but are not relevant to the end user:
*An application does not have to show the (technical) identification of a medicamenteuze behandeling (MBH) (nor that of the building blocks themselves), but the elaboration thereof: namely, building blocks shown in coherence.
*The copy indicator with the medicatieafspraak (MA), toedieningsafspraak (TA) and medicatiegebruik (MGB) when consulting the medication overview. Whether a building block is a copy is not that important to a user and can be deduced by other data from that building block (such as the author of the building block). So it is not so important that a user can see that this has been delivered 'as a copy' and is probably only confusing. However, this information is important for suppliers, for example because they sometimes want to perform calculations with the data and it is then safer to collect the data from the real source. It is therefore obvious to keep track of whether you have received data from the real source in your information system.
*An application does not have to show the stop type (temporary / definite) of a stop appointment, but the elaboration thereof: namely the processing of the meaning, so that an entire MBH is shown as stopped medication or as interrupted medication (remains clear under current medication) or as a change in the case of a 'technical stop appointment'.

=Administration list and inference rules=

This chapter shows a possible presentation/view of the administration list and, additionally, specifies the inference rules to identify the relevant medication building blocks within a pharmaceutical treatment, for the generation of an administration list.

==Introduction==
This paragraph contains an example of an administration list. The administration list shows the most recent medication data at any time of the day, to facilitate adequate medication administration. To ensure safe circumstances in which correct and up-to-date medication data is presented to the (professional) administrator, the administration software must be able to process the medication building blocks and to correlate the medication building blocks, as described in this information standard.

The term ‘administration list’ is defined as a digital list including all medicaments that are prescribed by a prescriber and that have to be administered to a patient/client. This list is generated based on the following medication building blocks: medication agreement (MA), administration agreement (TA), medication dispense (MVE), medication administration (MTD) and variable-dosing regimen (WDS).

The process of (actively) making medication data available to (professional) administrators enables the generation of a total overview of all medication which has to be administered. Importantly, this implies that information regarding discontinuation and change of medication with or without medication dispense is available at any time. Change in medication and variable-dosing regimens, for example as prescribed by the thrombosis service, are immediately available for administrators.

In the figures below, the numbered elements are normative; it is mandatory to show those components. The lay-out of the administration list in an information system may differ depending on the type of users or the type of device; this is dependent on the user requirements.

The administration list in this example is described generally. The chapter entails the general end user requirements for the administration list; this chapter does not comprise details on the technical requirements or implementation.

The project ‘Veilige principes in the medication’ comprises the sectors nursing care, nursing aid and home care. The specifications as described in ‘Veilige principes in de medicatieketen 2016’ and ‘Richtlijn overdracht van medicatiegegevens in de keten herziening 2018/2019’ as well as new insights from the program ‘Medicatieoverdracht’ are incorporated in this chapter.

The basis for the administration list entails:
*Medication building blocks
**Medication agreement (MA)
**Administration agreement (TA)
**Variable-dosing regimen (WDS)
**Medication administration (MTD)
**Medication dispense (MVE)
*All current medication; this comprises all MAs, TAs and WDSs which are available and applicable when the medication is administered. The PeriodOfUse defines whether medication should be considered current medication.
*The PrickPatchLocation is consulted based on the AdministrationDateTime.
*(Professional) administrators can distinguish the types of medication (in GDS package or separately) which should be administered to the patient by the data element DistributionForm (medication building block MVE) and the data element AsNeeded/Condition in the dosage (medication building blocks MA, TA or WDS). The different types of medication may be presented according to the following categories:
**GDS medication (including discontinued medication in order to show a notification/warning)
**Non-GDS medication
**Non-GDS medication as needed
*The remaining building blocks (dispense request (VV), medication use (MGB) and medication consumption (MVB)) are not relevant for the administration list.

{{anchor|figuur 1}}
[[Bestand:Toedienlijst_figuur_1a.PNG|Figuur 1: Voorbeeldweergave toedienlijst]]
[[Bestand:Toedienlijst_figuur_1b.PNG|Figuur 1: Voorbeeldweergave toedienlijst]]
[[Bestand:Toedienlijst_figuur_1c.PNG|Figuur 1: Voorbeeldweergave toedienlijst]]
 
''Figure 1: Example administration list.''
 
 
{| class="wikitable"
|-
! Nr
! style="text-align:left;"|Heading
! style="text-align:left;" colspan="3"|Dataset
|-
| 1 || Type || Medication Agreement || Administration Agreement || Variable-Dosing Regimen
|-
| 2 || Medicine || Agreed Medicine || Medicine To Be Dispensed ||
|-
| 3 || Prescriber
|style="text-align:left;" colspan="3"| Medication Agreement – Prescriber – Health Professional
|-
| 4 || Supplier
|style="text-align:left;" colspan="3"| Administration Agreement – Supplier – Healthcare Provider
|-
| || Author
|style="text-align:left;" colspan="3"| Variable-Dosing Regimen – Author – Health Professional (conditional)
|-
| 5 || Start Date || Medication Agreement – Period Of Use || Administration Agreement – Period Of Use || Variable-Dosing Regimen – Period Of Use
|-
| 6 || End Date/Duration || Medication Agreement – Period Of Use || Administration Agreement – Period Of Use || Variable-Dosing Regimen – Period Of Use
|-
| 7 || Description
|style="text-align:left;" colspan="3"| Instructions For Use – Description
|-
| || Route Of Administration
|style="text-align:left;" colspan="3"| Instructions For Use – Route Of Administration

|-
| || Additional Instructions
|style="text-align:left;" colspan="3"| Instructions For Use – Additional Instructions
|-
| || Dose
|style="text-align:left;" colspan="3"| Instructions For Use – Dosing Instructions – Dosage – Dose
|-
| || Administration Time
|style="text-align:left;" colspan="3"| Period Of Use – Dosing Instructions – Dosage – Administering Schedule – Administration Time
|-
| || Administration Speed
|style="text-align:left;" colspan="3"| Period Of Use – Dosing Instructions – Dosage – Administration Speed
|-
| || Duration Of Administration
|style="text-align:left;" colspan="3"| Period Of Use – Dosing Instructions – Dosage – Duration Of Administration
|-
| 8 || Prick-Patch Location
|style="text-align:left;" colspan="3"|Medication Administration – Prick-Patch Location
|-
| 9 || Comment
|style="text-align:left;" colspan="3"|Comment & Additional Information
|}
''Table 1: Normative medication data in the administration list.''


==Functional specification==
In the figures below the elements with normative data are presented. The other elements are not normative (not yet). The numbered elements in the table are normative; the other elements are optional (until further notice).

===Heading and general===

[[Bestand:Toedienlijst_Functionele_specificatie.png]]

===Remarks===

[[Bestand:Toedienlijst_Kop en algemeen.png]]

In the comment field, for example, (limiting) health literacy competences (competences: literacy, calculation and digital skills) can be recorded, which may affect the medication administration. This part is for internal use and is not exchanged (not yet).

'''NB.''' This part is not normative yet. This data is derived from the internal information system of the organization.

===GDS medication===

[[Bestand:Toedienlijst_Opmerkingen.png]]

GDS (medication distribution system, in Dutch: 'Geneesmiddel Distributie Systeem') is defined as a package in which medicaments are distributed in units per administration moment, labelled with the name of an individual patient/client ([https://www.knmp.nl/praktijkvoering/richtlijnen/knmp-richtlijnen-praktijkvoering/knmp-richtlijn-voor-geautomatiseerd-geneesmiddeldistributiesysteem-gds-september-2011 KNMP, 2011]). If medication is discontinued or changed, it is desired that a warning signal is shown, with the comment that, possibly, the medication is in the GDS package, and an additional act may be required. Further elaboration is needed.

===Non-GDS medication===

[[Bestand:Toedienlijst_Niet-GDS-medicatie.png]]

Non-GDS medication is medication which, for various reasons, cannot be included in an automated medication distribution system. The distribution type 'non-GDS' is specified in the data element DistributionForm in the corresponding MVE. Furthermore, for non-GDS medication, the condition AsNeeded remains empty.

===Non-GDS medication – as needed===

[[Bestand:Toedienlijst_Niet-GDS-medicatie_zo_nodig.png]]

Non-GDS medication as needed comprises separate medication which should be administered only in specific circumstances. The condition for administration of such medicament can be:
*a measured physiological value (plasma glucose level, body temperature, blood pressure);
*a symptom or other condition (headache, itching).
The distribution type 'non-GDS' is specified in the data element DistributionForm in the corresponding MVE. Furthermore, the condition AsNeeded is filled.

==Building block instantiations==
This paragraph describes which building block instantiations are related to the administration list. This includes only the ‘own’ building blocks (see [[#Own and other people|5.3.1]]) and only the latest, relevant instantiations (see [[#Last relevant|6.3.2]]).

===Therapeutic and logistical building blocks===
Compiling an administration list involves both therapeutic and logistical medication building blocks. Building blocks can be ‘overruled’ based on inference rules. All inference rules as described in [[#Medication overview and inference rules|Chapter 5]] are applicable. In addition, in this paragraph, the inference rules for WDS are described. The inference rules do not apply to MTD, as medication administration is a procedure at a certain time point; in contrast, the MA, TA and MBG comprise agreements valid for a certain period of time. The logistical medication building block MVE is part of compiling the administration list, as this building block is needed to derive the type of distribution of the medication.

====Administration list and inference rules====
An administration list can be compiled, for example in the administrator’s information system, based on separate medication building blocks.
The medication building blocks may be retrieved from the own information system or from other sources. The transaction Medication data (consulting/making available) is used for consulting and making available individual medication building blocks.
In the transaction group Medication data (sending/receiving), separate medication building blocks can be send to another health professional or patient directly (without prior consultation); for example, in the case of discharge or on request of a fellow health professional (for example, a patient sees a GP or pharmacist outside the region; the GP or pharmacist requests the data by telephone and receives the data digitally).
Both for Medication data sending/receiving and Medication data consulting/making available, data obtained from other sources is not allowed to be presented in the administration list.

===Last relevant===
Only the latest relevant medication building blocks (per pharmaceutical treatment) are part of the administration list. This paragraph provides a description of the latest relevant building blocks for an administration list comprising medication on prescription. [[#Medication with prescription with a variable-dosing regimen|Paragraph 6.3.2.1]] describes the situation in which a variable-dosing regimen (WDS) is applicable. For WDS, the same inference rules apply as for MA. For compiling an administration list, the presence of a WDS is decisive for the instructions for use. All other situations in which WDS is not applicable, as described in [[#Last relevant|paragraph 5.3.2]], are applicable as well.

Query to identify the correct, relevant and future medication building blocks:
{| class="wikitable"
|-
! Nr
! style="text-align:left;"|Medication building block
! style="text-align:left;"|Query Parameter
! style="text-align:left;"|What should be filled in specifically?
|-
| 1 || MA, TA, WDS || Period Of Use || All medication that should be administered today and, therefore, is applicable: Day = T, startDate = T: 00:00:00 h, endDate = T: 23:59:59 h
|-
| 2 || MTD || Administration Period || Depending on medical relevance (for example, historical information on prick and patch locations may be relevant back to one week ago). For example, is one week is sufficient (another period may be chosen): Day = T, startDate = T-7 day
|-
| 3 || MVE || Dispense Period || Broad request (+/- one month)
|}

If all medication building blocks are collected, the following medication data, depending on the situation, can be used:
{| class="wikitable"
|-
! style="text-align:left;"|Medication building block
! style="text-align:left;"|Situation: only MA*
! style="text-align:left;"|Situation: MA + TA
! style="text-align:left;"|Situation: MA + TA + WDS
|-
| MA || Decisive** for compiling the administration list (number: 2, 5, 6, 7, 9, 10) || Data from the prescriber || Data from the prescriber
|-
| TA || - || Decisive** for compiling the administration list (number 2, 5, 6, 7, 9, 10) || Data from the supplier and medicine
|-
| WDS || - || - || Decisive** for compiling the administration list (number 5, 6, 7, 10)
|}

* Situation in which the pharmacist has not processed the MA yet.
** ‘Decisive’ indicates the data elements which are included in the functional requirements (numbers of the elements are provided between brackets).

====Medication with prescription with a variable-dosing regimen====

=====Most simple ‘happy flow’=====
The most simple ‘happy flow’ in a pharmaceutical treatment is stated below.

*''MA – WDS – TA''

In general, a pharmaceutical treatment starts with an MA. A TA specifies the MA. In the WDS, it is defined whether a variable-dosing regimen applies. In both the MA and the TA, the instruction ‘according to schedule thrombosis service’ is recorded. Then, in the WDS, the dosing schedule is specified. The three medication building blocks MA, TA and WDS are relevant and are part of compiling an administration list, as indicated in green below.


*MA – WDS– TA


A TA refers to the MA, which is specified by the TA. Also, a WDS refers to the MA, which is specified by the WDS. A WDS is always related to an MA.

====New WSD====
*MA – WDS – TA – WDS

The period of use of the WDS has ended and a new dosing schedule is created.

=====Change of WDS=====

*MA – WDS– TA – stop-WDS – WDS

The variable-dosing regimen (WDS) is changed.

=====Discontinuation of medication=====
*MA – WDS – TA – stop-MA

Medication with a WDS is discontinued by a stop of the MA.

=====Change of trade product=====

*MA – WDS – TA – stop-TA – TA

The trade product is changed; this affects the WDS.

====Rules of overruling listed====
Based on the descriptions/examples above, the following general rules for overruling apply. Those rules indicate which medication building block is relevant to incorporate and present in the administration list. Within a pharmaceutical treatment:
*A new MA overrules all previous, older therapeutical medication building blocks (MA, TA, WDS) related to the MA(s) which is/are stopped by the new MA.
*A new TA overrules the previous, older TA related to the same MA as the new TA.
*A new WDS overrules all previous, older WDSs related to the same MA as the new WDS.



=Information systems and transactions=
This chapter contains a list of all system roles and transactions that are referred to in the various process chapters.

The figure below ([[#figuur 10|Figure 10]]) contains an overview of all information systems with their corresponding system roles. The system roles have been described in [[#tabel 3|Table 3]]. The system roles associated with consulting/making available medication data and the medication overview are important for all information systems depending on the process in which they are used. The electronic prescribing system (EPS) also includes the system roles for receiving a voorstel verstrekkingsverzoek, sending a reply voorstel verstrekkingsverzoek and receiving a voorstel medicatieafspraak and, in an outpatient situation, for sending a prescription and receiving data on the processing of a prescription. In addition to the basic system roles, a XIS and PGD also include the system roles for sending a voorstel medicatieafspraak and a voorstel verstrekkingsverzoek, for sending data on gebruik and for receiving a reply voorstel verstrekkingsverzoek. The pharmacist information system (PIS) also includes, in addition to the basic system roles, the roles for sending a voorstel medicatieafspraak, sending a voorstel verstrekkingsverzoek and data on processing of the prescription, and receiving a prescription and reply voorstel verstrekkingsverzoek. [[#Medication process|Chapter 2]] lists the main system roles per process.

{{anchor|figuur 10}}
[[Bestand:Systemen.png|Figuur 10 Overzicht systemen en systeemrollen]]

{{anchor|tabel 3}}
{| class="wikitable" "cellpadding="10"
!style="text-align:left;"|System role name
!style="text-align:left;"|Abbr.
!style="text-align:left;"|Description
|-
| style="background-color: white;"| MedicatieGegevensBeschikbaarstellend
| style="background-color: white;"| MP-MGB
| style="background-color: white;"| Making medication data available to fellow health professionals/patient
|-
| style="background-color: white;"| MedicatieGegevensRaadplegend
| style="background-color: white;"| MP-MGR
| style="background-color: white;"| Consulting medication data at fellow health professionals/patient
|-
| style="background-color: white;"| MedicatieGegevensSturend
| style="background-color: white;"| MP-MGS
| style="background-color: white;"| Sending data to fellow health professional/patient
|-
| style="background-color: white;"| MedicatieGegevensOntvangend
| style="background-color: white;"| MP-MGO
| style="background-color: white;"| Receiving medication data from fellow health professional/patient
|-
| style="background-color: white;"| MedicatieOverzichtBeschikbaarstellend
| style="background-color: white;"| MP-MOB
| style="background-color: white;"| Making medication overview available to fellow health professionals/patient
|-
| style="background-color: white;"| MedicatieOverzichtRaadplegend
| style="background-color: white;"| MP-MOR
| style="background-color: white;"| Consulting medication overview at fellow health professionals/patient
|-
| style="background-color: white;"| MedicatieOverzichtSturend
| style="background-color: white;"| MP-MOS
| style="background-color: white;"| Sturen medicatieoverzicht aan medebehandelaar/patiënt
|-
| style="background-color: white;"| MedicatieOverzichtOntvangend
| style="background-color: white;"| MP-MOO
| style="background-color: white;"| Receiving medication overview from fellow health professional/patient
|-
| style="background-color: white;"| VoorschriftSturend
| style="background-color: white;"| MP-VOS
| style="background-color: white;"| Sending a request to dispense medication (verstrekkingsverzoek) or process modifications to medicatieafspraak.
|-
| style="background-color: white;"| VoorschriftOntvangend
| style="background-color: white;"| MP-VOO
| style="background-color: white;"| Receiving verstrekkingsverzoek or request for processing of modifications to medicatieafspraak.
|-
| style="background-color: white;"| VoorschriftAfhandelingSturend
| style="background-color: white;"| MP-VAS
| style="background-color: white;"| Sending data on processing of medicatieafspraak and possibly verstrekkingsverzoek in toedieningsafspraak and/or medicatieverstrekking
|-
| style="background-color: white;"| VoorschriftAfhandelingOntvangend
| style="background-color: white;"| MP-VAO
| style="background-color: white;"| Receiving data on processing of medicatieafspraak and possibly verstrekkingsverzoek in toedieningsafspraak and/or medicatieverstrekking
|-
| style="background-color: white;"| VoorstelVerstrekkingsverzoekSturend
| style="background-color: white;"| MP-VVS
| style="background-color: white;"| Informing prescriber about voorstel new verstrekkingsverzoek, receiving reply to proposed verstrekkingsverzoek
|-
| style="background-color: white;"| VoorstelVerstrekkingsverzoekOntvangend
| style="background-color: white;"| MP-VVO
| style="background-color: white;"| Receiving new voorstel verstrekkingsverzoek, sending reply to voorstel verstrekkingsverzoek
|-
| style="background-color: white;"| VoorstelMedicatieafspraakSturend
| style="background-color: white;"| MP-VMS
| style="background-color: white;"| Informing prescriber about new voorstel or modified medicatieafspraak, receiving reply to proposed medicatieafspraak
|-
| style="background-color: white;"| VoorstelMedicatieafspraakOntvangend
| style="background-color: white;"| MP-VMO
| style="background-color: white;"|Receiving voorstel for new or modified medicatieafspraak, sending reply to voorstel medicatieafspraak
|}Table 3 Overview system roles

Table 4 gives an overview of all transaction groups, transactions, corresponding system roles and building blocks exchanged with this transaction group. The names of the transaction groups and transactions link to the ART-DECOR publication which details per scenario which data elements are used.

{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| '''Transaction group'''
! style="text-align:left;"| '''Transaction'''
! style="text-align:left;"| '''System role'''
! style="text-align:left;"| '''Building blocks'''
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.131-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.299_20220207000000 Medication data (PULL)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.301-2022-02-07T000000.html Making medication data available]
|style="background-color: white;vertical-align:top;"|MP-MGB
|style="background-color: white;vertical-align:top;" rowspan="2"|One or more: MA, VV, TA, MVE, MTD, MGB, WDS
|-
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.300-2022-02-07T000000.html Consulting medication data]
|style="background-color: white;vertical-align:top;"|MP-MGR
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.131-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.302_20220207000000 Medication data (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.303-2022-02-07T000000.html Sending medication data]
|style="background-color: white;vertical-align:top;"|MP-MGS
|style="background-color: white;vertical-align:top;" rowspan="2"|One or more: MA, VV, TA, MVE, MTD, MGB, WDS
|-
|style="background-color: white;vertical-align:top;"|Receiving medication data
|style="background-color: white;vertical-align:top;"|MP-MGO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.132-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.315_20220207000000 Medication overview (PULL)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.317-2022-02-07T000000.html Making medication overview available]
|style="background-color: white;vertical-align:top;"|MP-MOB
|style="background-color: white;vertical-align:top;" rowspan="4"|MA, TA, MGB
|-
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.316-2022-02-07T000000.html Consulting medication overview]
|style="background-color: white;vertical-align:top;"|MP-MOR
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.132-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.318_20220207000000 Medication overview (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.319-2022-02-07T000000.html Sending medication overview]
|style="background-color: white;vertical-align:top;"|MP-MOS
|-
|style="background-color: white;vertical-align:top;"|Receiving medication overview
|style="background-color: white;vertical-align:top;"|MP-MOO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.133-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.321_20220207000000 Medication prescription (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.322-2022-02-07T000000.html Sending medication prescription]
|style="background-color: white;vertical-align:top;"|MP-VOS
|style="background-color: white;vertical-align:top;" rowspan="2"|MA with or without VV, height, weight, renal function value
|-
|style="background-color: white;vertical-align:top;"|Receiving medication prescription
|style="background-color: white;vertical-align:top;"|MP-VOO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.135-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.333_20220207000000 Medication prescription processing (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.334-2022-02-07T000000.html Sending data on processing of medication prescription]
|style="background-color: white;vertical-align:top;"|MP-VAS
|style="background-color: white;vertical-align:top;" rowspan="2"|TA with or without MVE
|-
|style="background-color: white;vertical-align:top;"|Receiving data on processing of medication prescription
|style="background-color: white;vertical-align:top;"|MP-VAO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.134-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.327_20220207000000 Proposal dispense request (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.328-2022-02-07T000000.html Sending proposal dispense request]
|style="background-color: white;vertical-align:top;"|MP-VVS
|style="background-color: white;vertical-align:top;" rowspan="2"|VVV
|-
|style="background-color: white;vertical-align:top;"|Receiving proposal dispense request
|style="background-color: white;vertical-align:top;"|MP-VVO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.134-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.330_20220207000000 Reply proposal dispense request (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.331-2022-02-07T000000.html Sending reply proposal dispense request]
|style="background-color: white;vertical-align:top;"|MP-VVO
|style="background-color: white;vertical-align:top;" rowspan="2"|AVVV
|-
|style="background-color: white;vertical-align:top;"|Receiving reply proposal dispense request
|style="background-color: white;vertical-align:top;"|MP-VVS
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.134-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.324_20220207000000 Proposal medication agreement (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.325-2022-02-07T000000.html Sending proposal medication agreement]
|style="background-color: white;vertical-align:top;"|MP-VMS
|style="background-color: white;vertical-align:top;" rowspan="2"|VMA with or without height, weight
|-
|style="background-color: white;vertical-align:top;"|Receiving proposal medication agreement
|style="background-color: white;vertical-align:top;"|MP-VMO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.134-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.372_20220302000000 Reply proposal medicationagreement (PUSH)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.373-2022-03-02T000000.html Sending reply proposal medicationagreement]
|style="background-color: white;vertical-align:top;"|MP-VMO
|style="background-color: white;vertical-align:top;" rowspan="2"|AVMA
|-
|style="background-color: white;vertical-align:top;"|Receiving reply proposal medicationagreement
|style="background-color: white;vertical-align:top;"|MP-VMS
|}Table 4 Overview transaction groups

[[#Medication process|Chapter 2]] lists for each process only the relevant transactions per process step. The transaction groups are not included in this. Table 4 includes all transaction groups and transactions.

=Functionality=
This chapter describes indications for the functionality of an information system.

==Filtering medication from 2nd/3rd line (all information systems)==
An institution makes all its medication data (all building blocks) available. Not all data may be relevant for the receiving health professionals. Receiving information systems may therefore include a filter depending on the requirements of the specific health professional/patient. The list below (Table 5) includes medication types of which it has been determined that medicatietoediening during admission is relevant for health professionals outside the institution.

{{anchor|tabel 5}}
{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| ATC-code
! style="text-align:left;"| Name
|-
| style="background-color: white;vertical-align:top;"|L01
| style="background-color: white;vertical-align:top;"|Cytostatics
|-
| style="background-color: white;vertical-align:top;"| L03AX03
| style="background-color: white;vertical-align:top;"|BCG vaccine, urology
|-
| style="background-color: white;vertical-align:top;"|L04AA23; L04AA25; L04AA26; L04AA33; L04AA34; L04AB; L04AC
| style="background-color: white;vertical-align:top;"|Immunosuppressive agents
|-
| style="background-color: white;vertical-align:top;"|B03AC; B03XA; B06AC
| style="background-color: white;vertical-align:top;"|Iron, erythropoietin, drugs used in angioedema
|-
| style="background-color: white;vertical-align:top;"|G03GA; G03GB02
| style="background-color: white;vertical-align:top;"|Gonadotropins (HCG, etc.), clomiphene
|-
| style="background-color: white;vertical-align:top;"|H01CA; H01CC; L02AE04
| style="background-color: white;vertical-align:top;"|Gonadorelin, hypothalamic hormones, triptorelin
|-
| style="background-color: white;vertical-align:top;"|J06; J07
| style="background-color: white;vertical-align:top;"|Immunoglobulins, vaccines
|-
| style="background-color: white;vertical-align:top;"|M03AX01
| style="background-color: white;vertical-align:top;"|Botulinum toxin
|-
| style="background-color: white;vertical-align:top;"|R03DX05
| style="background-color: white;vertical-align:top;"|Omalizumab
|-
| style="background-color: white;vertical-align:top;"|S01LA04; S01LA05; S01LA
| style="background-color: white;vertical-align:top;"|OOphthalmological antineovascularisation agents
|}Table 5 Types of clinical medication relevant for external health professionals

==Making medication data available (all information systems)==
All proprietary medication data may be made available when the patient has given his consent (in accordance with applicable laws and regulations). Data received from third parties copied (health care provider/patient) in one’s own information system and marked as ‘copy’, are not made available. The only exception is the transaction Medicatiegegevens (Medication data) PUSH and PULL and Medication overview PUSH and PULL, in which case third parties’ building blocks are made available on the condition that they include the original identification label (see also [[#Inference rules|paragraph 5.6]]).

==Notification date or dispense date (pharmacist information system)==
The notification date and the actual dispense date may be recorded in the medicatieverstrekking. When a verstrekkingsverzoek is processed immediately and the patient picks up the medication that same day, both dates will be the same. When the patient picks up the medication one or several days later, different dates must be entered. The dispense date is the date on which the medicatieverstrekking has actually taken place. The request date is the time at which a pharmacy records an intended medicatieverstrekking. When medication is dispensed on several occasions as part of the same verstrekkingsverzoek (for example, when prescriptions are split), each medicatieverstrekking has its own request date. When an automated dispense system is being used, the dispense date is the time at which the patient picks up the medication from the dispense system. Until this time is available in the PIS, the time at which the medication is deposited in the automated dispense system may be used. See also [[#Request and dispense|paragraph 4.2.5]].

==Updating after system malfunction==
After a system malfunction, the prescriber’s information system needs to determine whether changes have been made to medicatieafspraken. For use cases and rationale, see [[#Discontinuation of medication by third parties|paragraph 4.1.26]] and [[#Two PRKs in a single medicamenteuze behandeling|paragraph 4.1.27]].

==Construction for ‘once every 36 hours’ interval==
When the dosing instruction reads ‘1 tablet every 36 hours’, this may normally be recorded in one medicatieafspraak (dose: 1 tablet, interval: 36 hours). However, when a information system does not go beyond an interval of, for example, 24 hours, another solution needs to be found.

''Variation 1:''
Making use of an ‘as needed’ instruction with the criterion: ‘36 hours have passed since the last medicatietoediening’. This does however come with a certain amount of freedom that may not be desirable.

''Variation 2:''
A repeating dosing schedule can be created, with alternation between administration in the morning, administration in the evening and a day without medicatietoediening:
Repeat period: 3 days
Dosage instruction
Sequence number: 1
Dosage duration: 1 day
Dosage
Dose per administration: 1 tablet
Administration time: 9 am (per example, this could also be a part of the day)
Sequence number: 2
Dosage duration: 1 day
Dosage
Dose per administration: 1 tablet
Administration time: 9 pm (per example, this could also be a part of the day)

If it is not technically possible to choose a 36 hours interval, variation 2 applies.

==EVS / HIS processing Regulation processing==
The prescribing information system is informed by the pharmacist of all dispensings and changes in toedieningsafspraken through the transaction Afhandeling voorschrift (settlement prescription). This handling must be automatically processed in the prescribing information system. The prescriber only assesses the toedieningsafspraken and does not have to assess all the dispensings (verstrekkingen).

==Examples dosages==
See [[mp:V9.1 Voorbeelden doseringen|examples dosages 9.1.0]] (both functional and technical effect in HL7v3 CDA and in FHIR)

==Medicatiegebruik: use indicator, according to agreement indicator, stop type, period of use and dosing instructions==
{| class="wikitable"
|-
|style="text-align:center;" |Situation || 1. Medication is/will be used during period of use according to agreement|| 2. Medication is/will be used during period of use, but not according to agreement || 3. Contrary to agreement, medication is/will not be used during period of use || 4. Medication is/will not be used during period of use, which is according to agreement || 5.Medication is used during period of use but it is unknown if this is according to agreement (selfmedication)
|-
! Use indicator (is this product being used) !! Yes!! Yes !! No !! N/A (because this would lead to a double negative otherwise) !! Yes
|-
! According to agreement indicator !! No!! No !! No!! Yes!! -
|-
! Stoptype!! N/A!! N/A!! Discontinuation or Stop !! Definitve of Temporary !! N/A
|-
| || || || Stoptype depends if agreement is being stoped or dicontinued || Stoptype in acoordance with stop-agreement ||
|-
! Period of use!! In accordance with MA or TA !! Max. 2 out of 3 !! Max. 2 out of 3 !! Max. 2 out of 3 !! Max. 2 out of 3
|-
|style="text-align:right;" | start date || The time at which the medicatiegebruik was started. ||The time at which the deviating medicatiegebruik was/will be started. . || Contrary to agreement, medication is/will not be used during period of use || The time at which the medicatiegebruik was/will be discontinued. || The time at which the medicatiegebruik was started.
|-
|style="text-align:right;" | duration of medicatiegebruik|| The intended duration of medicatiegebruik. || The intended duration of deviating medicatiegebruik. || The (intended) duration of non-use||The (intended) duration of non-use. || The intended duration of medicatiegebruik.
|-
|style="text-align:right;" | end date || The time at which the period of use ends (or has ended or will end). || The time at which the period of deviating use ends (or has ended or will end). || The time at which the use was/will be resumed (or is intended to resume).|| The time at which the medicatiegebruik was/will be resumed (or is intended to resume). || The time at which the period of use ends (or has ended or will end).
|-
! Dosing instructions!! In accordance with MA or TA!! Required!! N/A !! N/A!! Required
|-
| || Medication was/will be used during the period of use according to the agreement, therefore dosage is known. || Medication was/will not be used according to the agreement, the actual dosage used must be communicated. || The medication was/will not be used, there is no dosage. || The medication was/will not be used, there is no dosage. || Dosage tha the patient has agreed upon himself
|}
'''Examples:''' 
'''Situation 1a: Medication is / is used during the period of use according to agreement''' 
Patient has been prescribed Ferrofumarate for anemia. Dosage is 1 tablet 3 times a day half a hour before eating, with a start date of June 4, 2018 and no end date. 
On 10 June, the patient registers the medicatiegebruik for the past period (from 4 to 10 June). 
{| class="wikitable"
|-
! Situation 1a !!
|-
| Medication || FERROFUMARATE 100MG TABLET
|-
| Use indicator || Yes
|-
| According to indicator agreement || Yes
|-
| Stoptype || Not applicable
|-
| Start date|| 4 June 2018
|-
| End date || 10 June 2018
|-
| Dosing instruction || ''According agreement''
|}

'''Situation 1b: Medication is / is used during the period of use according to agreement''' 
Patient has been prescribed Ferrofumarate for anemia. Dosage is 1 tablet 3 times a day half an hour before eating, with a start date of June 4, 2018 and no end date. 
On 10 June, the patient registers the medicatiegebruik for the past period (from 4 to 10 June).
 
{| class="wikitable"
|-
! Situation 1b !!
|-
| Medication || FERROFUMARATE 100MG TABLET
|-
| Use indicator || Yes
|-
| According to indicator agreement || Yes
|-
| Stoptype || Not applicable
|-
| Start date|| 4 June 2018
|-
| End date || -
|-
| Dosing instruction || ''According agreement''
|}

'''Situation 2: Medication is / is used during the period of use, but not by agreement''' 
Patient has been prescribed Ferrofumarate for anemia. Dosage is 1 tablet 3 times a day half an hour before eating, with a start date of June 4, 2018 and no end date. 
The patient is on the road a lot during the day and forgets for a week to take the medicines for lunch. However, the tablets are taken in the morning and evening before eating. 
{| class="wikitable"
|-
! Situation 2 !!
|-
| Medication || FERROFUMARATE 100MG TABLET
|-
| Use indicator || Yes
|-
| According to indicator agreement || No
|-
| Stoptype || Not applicable
|-
| Start date|| 11 June
|-
| End date || 15 June
|-
| Dosing instruction || 1 tablet 2 times a day
|}
'''Situation 3: Contrary to the agreement, the medication is / is not used during the period of use''' 
Patient has been prescribed Ferrofumarate for anemia. Dosage is 1 tablet 3 times a day half an hour before eating, with a start date of June 4, 2018 and no end date. 
The patient goes on vacation for a long weekend and finds out too late that the medication is not packed. The patient will not take the tablets for the next few days and wants to record it. 
{| class="wikitable"
|-
! Situation 3 !!
|-
| Medication || FERROFUMARATE 100MG TABLET
|-
| Use indicator || No
|-
| According to indicator agreement || No
|-
| Stoptype || Temporary
|-
| Start date|| 20 July
|-
| End date || 23 July
|-
| Dosing instruction || Not applicable
|}
'''Situation 4: Medication is / is not used during the period of use and that is also by agreement''' 
Patient has been prescribed Ferrofumarate for anemia. Dosage is 1 tablet 3 times a day half an hour before eating, with a start date of June 4, 2018. 
On August 12, it turns out after checking that there is no longer anemia and the doctor stops the medication. The patient wants to register that she has stopped taking the medication and registers this herself on August 15. 
{| class="wikitable"
|-
! Situation 4 !!
|-
| Medication || FERROFUMARATE 100MG TABLET
|-
| Use indicator || No
|-
| According to indicator agreement || Yes
|-
| Stoptype || Definite
|-
| Start date|| 12 August 2018
|-
| End date || -
|-
| Dosing instruction || Not applicable
|}
'''Situation 5: Medication is used during the period of use, but it is unknown whether this is by appointment or there is no appointment (self-care medication)''' 
Patient has the flu and he takes paracetamol 500 mg from the local drug store for fever and pain. He has been taking 4 to 6 tablets a day for four days and expects to do this for another three days. He registers this on August 12 as medicatiegebruik. 
{| class="wikitable"
|-
! Situation 5 !!
|-
| Medication || Paracetemol 500mg
|-
| Use indicator || Yes
|-
| According to indicator agreement || -
|-
| Stoptype || Not applicable
|-
| Start date|| 9 August 2018
|-
| End date || 7 days
|-
| Dosing instruction || 4 to 6 tablets a day
|}

==Implementation of medication distribution system (GDS) fields==

===Background===
More and more patients are receiving their medication through Individualized Distribution Forms (In dutch geindividualiseerde distributie vorm), with the pharmacist providing patients overview and organization of their drugs by preparing them in separate compartment units. This form of delivery took off when the Medicines Act in 2007 stipulated that in healthcare institutions without a pharmacy, the medication should be individually registered for the patients.

It is important for health professionals to know whether a patient is using GDS. In 2018, an analysis was conducted (under the direction of Z-Index, with health professionals) of the bottlenecks and wishes regarding the recording of a patient using GDS. Overall, it has emerged that it is desirable to be able to see whether a patient is using GDS at both the medication level and the patient level. For details see next paragraph.

The directions below provide guidance on how the Medication Process can support these needs.

===Wishes of care providers===
In 2018, an inventory was made with the user councils of Z-Index about the wishes regarding the recording and exchange of GDS. Below is an overview of these wishes. 

'''Who'''
*All healthcare parties (from prescriber to operator)
'''What'''
*Determines which pharmacy delivers
*Pharmacy must know whether the change applies to the current roll or not
*Important for stopping previous medication at the start of GDS
*Evaluation of GDS patients for health insurer
*Other logistics processes towards home care / informal care

'''Why'''
*Determines which pharmacy delivers
*Pharmacy must know whether the change applies to the current roll or not
*Important for stopping previous medication at the start of GDS
*Evaluation of GDS patients for health insurer
*Other logistics processes towards home care / informal care

'''When'''
*When starting medication, in a pharmacy already before notification of prescription
*When transferring 1st / 2nd line
*When changing (incl. Stopping) medication
*When changing CiO data

'''Where'''
*When working in the patient's file, it should be clear that this characteristic applies to the patient concerned. This can be different for each type of care provider (patient file, medication file). The wish of public pharmacists is that they always have this characteristic available for a specific patient.
*On medication overview

===Data elements Medication process===
The building blocks for the Medication Process have the following fields that play a role in recording GDS. 

{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| '''Buildingblock '''
! style="text-align:left;"| '''Data-element nr'''
! style="text-align:left;"| '''Description'''
! style="text-align:left;"| '''Type of content '''
|-
|style="background-color: white;vertical-align:top;"| Medicatieafspraak
|style="background-color: white;vertical-align:top;"|23283
|style="background-color: white;vertical-align:top;"|Additional information
|style="background-color: white;vertical-align:top;"|Additional information contains a list of details of the medicatieafsrpaak that are important for pharmacovigilance monitoring and completion by a pharmacist.

For example: "change in GDS immediately"..
|-
|style="background-color: white;vertical-align:top;"| Verstrekkingsverzoek
|style="background-color: white;vertical-align:top;"|22759
|style="background-color: white;vertical-align:top;"|Supplementary wishes
|style="background-color: white;vertical-align:top;"|Logistical instructions important for the completion of the dispensing request by the pharmacist.

For example: "do not include in GDS"
|-
|style="background-color: white;vertical-align:top;" rowspan="4"| Verstrekking
|style="background-color: white;vertical-align:top;"|20927
|style="background-color: white;vertical-align:top;"|Distribution form
|style="background-color: white;vertical-align:top;"|Distribution form.

For example: GDS
|-
|style="background-color: white;vertical-align:top;"|20924
|style="background-color: white;vertical-align:top;"|Consumption period
|style="background-color: white;vertical-align:top;"|Stock for this duration
|-
|style="background-color: white;vertical-align:top;"|22500
|style="background-color: white;vertical-align:top;"|Registration date
|style="background-color: white;vertical-align:top;"|The registration date is the time when a pharmacist records an intended dispensing
|-
|style="background-color: white;vertical-align:top;"|20272
|style="background-color: white;vertical-align:top;"|Date
|style="background-color: white;vertical-align:top;"|The time of the dispensing. The date when the medicine is made available to the patient
|}

===Application of data elements to support desired functionality for GDS patients===
====Recording that someone uses GDS====
When working in the patient's file it is important to see that someone is using GDS. This applies to the pharmacy that supplies the GDS, as well as other care providers of the patient. It is therefore important that this information can be communicated with and shown to other health professionals.

As long as there is no patient characteristic with which GDS can be registered, it can be decided to derive this information from the GDS data that have been recorded with the medication. A possible handle for this is the fact that medication is included in the distribution module together with the Distribution form field in the verstrekking (dispensing).
*Step 1: if medication is included in the distribution module: fill in the Distribution form field in the verstrekking with 'GDS'.
*Step 2: Based on the Distribution form field, deduce that a patient is using GDS. The fact that a patient has a dispensing (vertrekking) where the Distribution form field is filled with "GDS" indicates that the patient is using GDS. This dispensing can be a private dipsenisn, or it can be dispensed from another pharmacy (insofar as this data is collected and recorded in such a way that the contents of the Distribution form field are reusable). The fact that a patient uses GDS can then be shown when working in the medication file or the patient file. In consultation with end users, it should be further determined where and how this is shown.

====Recording why someone uses GDS====
Users have indicated that it is desirable to be able to record why someone uses GDS. There are currently no structural fields available for this.

====Record for medication that this must be in the GDS====
Prescribers want to be able to indicate whether or not a medicine should be provided via GDS. This can be done as follows:
*Verstrekkingsverzoek, Additional wishes (aanvullende wensen) field. The code list for this field contains the item "not in GDS". This code list is thesaurus 2051 from file 902 in the G-Standard.

====Establishing / exchanging the duration of a medication roll====
The duration of the medication roll can be determined on the basis of the "duration of use" of the provision: the "duration of use" indicates the duration of a medication roll.

====Establishing / exchanging whether a change in the medication should be effective immediately or not====
It is desirable that a prescriber can indicate whether changes in the medication should be implemented immediately or that they can wait until the next roll change. The handles for this are as follows:
*Medicatieafspraak, Additional information (aanvullende informatie) field. The code list for this field contains two items that relate to changes in the GDS, namely "Change in GDS immediately" and "Change in GDS per roll change". This code list is thesaurus 2050 from file 902 in the G-Standard.
*It is important that the prescriber has insight into the duration of the roll and how long it will take before the current medication roll is used up. This can be deduced from:
**The verstrekking, period of use (verbruiksduur), see above. For this, the prescribing system must have access to the verstrekking data of previous verstrekkingen (dispensings).
**Verstrekking (dispensing), Registration Date (aanschrijfdatum) or Date (datum) field (or if this field is not filled but the Registration date field is, then the registration date.; if both are filled, Date is preferred). Based on this date and the consumption period, it is possible to calculate the date on which the current medication roll is used.

=Reflections=
==Prescription without specified recipient (ambulatory)==
In this paragraph, the term ‘prescription’ is used to indicate the message through which a patient may pick up a medicinal product from a supplier. A prescription contains a medicatieafspraak and a verstrekkingsverzoek.

In the Netherlands it is customary to digitally send prescriptions to a receiving pharmacy instead of having to collect prescriptions. This requires that the pharmacy is already known. 

This paragraph considers whether more flexibility can be achieved in the logistical processing of prescriptions, without canceling out current advantages. This paragraph may be seen as a long-term vision that we aim towards.

===Basic principles===
When considering how to achieve flexibility in the processing of prescriptions, these basic principles have been formulated:
*The patient is free to choose where prescriptions are handled
*The current option for sending prescriptions remains possible.
*The information system must reuse the same functionality as much as possible.
*A prescription may only be dispensed once.
Since the methodology described below uses the existing method of sending prescriptions, the same legal rules and regulations apply to prescription validity. All discussions about electronic signatures are equally applicable to the current method of communicating prescriptions.

===Details===
A patient may choose from 3 options:
#A prescription is always sent to the same regular pharmacist.
#The patient indicates each time where the prescription has to be sent.
#The patient does not give any indication, and goes to a pharmacy which subsequently requests and processes the prescription.
Options 1 and 2 require a patient portal, in which the patient indicates his preference. For option 2, a patient may define a preferred pharmacy which would be at the top of the selection screen when the patient is asked where the prescription must be sent. If the patient does not give any indication, option 3 can be the only procedure.

The method partly uses a concept called “publish and subscribe”.

It is important that the pharmacist explains this principle to his customers.

===Work process===
A physician decides to create a prescription for a patient. This may be during a consultation or even when repeat prescriptions are requested. The physician registers the prescription in his prescribing system (EPS). The physician does not need to consider the pharmacy as the patient handles this through the portal.

After approval of the prescription, a central prescription index is updated. The EVS automatically sends a notification to this prescription registry to facilitate this. Here, the prescription index is seen as a separate registry with the data type “prescriptions”. It is always possible to consider whether or not this can be merged at a later time. Initially, atomic registration in the registry is being considered. However, at a later date, consideration could be given as to whether categorical registration would be sufficient.

It is important to realise that currently only a notification is given when a prescription is ready. After all, the prescription is still in the EVS database with the status “is available”. There is no prescription message yet.

The prescription registry knows from the patient’s preference settings what needs to be done with the notification:
#With the option ‘send to regular pharmacy’, a notification is sent to the subscription holder of the patient with the message that a prescription can be retrieved.
#With the option ‘patient indicates pharmacy’, the prescription registry sends a notification (e.g., SMS) to the patient. The prescription registry then waits until the patient uses a smartphone app or the patient portal to indicate to which pharmacy the notification should be sent.
#With the option ‘no indication’, the prescription registry does nothing. The patient does not have a regular subscription holder.

===Processing by pharmacy===
A receiving pharmacy can deduce from the transmitted notification signal (data type) that it refers to an open prescription. The signal also identifies who the patient is as well as the source of the prescription.

For patients who selected option 3 (no indication), the process starts now. The patient identifies himself and notifies the pharmacy that a prescription is ready at a certain institution. The pharmacist may look in the prescription registry to find out which EVS is involved.

The pharmacy information system asks the EVS source system to send the prescription of the respective patient. Since this is a request without medical content, it may even be submitted at lower trust levels.

===Sending via EVS===
If an EVS receives a request for “sending outstanding prescriptions”, the EVS will check whether prescriptions are indeed outstanding. This prevents a prescription from being retrieved several times. The address of the pharmacy is entered and the prepared prescription message is finally created. The prescription message is sent to the respective pharmacy.

If the prescription has been retrieved before, an error message is sent to the retrieving pharmacy announcing that the prescription is no longer available.

'''Sending prescriptions is the standard process and already customary for pushing prescriptions.''' The advantage of this is that the receiving pharmacy only needs to maintain one method for processing received prescriptions. It is noted again that the same legal rules and regulations continue to apply.

After sending a prescription, the EVS also sends a notification to the prescription registry to remove the entry of the outstanding prescription. This indicates that the respective prescription can no longer be retrieved.

{{anchor|figuur 11}}
[[Bestand:Interactiediagramvoorschrijven.png|Figuur 11 Interactiediagram Ongeadresseerd voorschrijven]]

=Appendix References=

==General references==
{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| Author(s)
! style="text-align:left;"| Title
! style="text-align:left;"| Version
! style="text-align:left;"| Date (consultation)
! style="text-align:left;"| Source
! style="text-align:left;"| Organisation
|-
| style="background-color: white;vertical-align:top;"| NHG, KNMP, Z-index
| style="background-color: white;vertical-align:top;"| Building blocks of the medication process
| style="background-color: white;vertical-align:top;"| 2014
| style="background-color: white;vertical-align:top;"| Augustus 2015
| style="background-color: white;vertical-align:top;"| https://www.nhg.org/bouwstenen
| style="background-color: white;vertical-align:top;"| NHG, KNMP, Z-index
|-
| style="background-color: white;vertical-align:top;"| ActiZ, KNMP, NVZA a.o
| style="background-color: white;vertical-align:top;"| Safe principles in the medication chain
| style="background-color: white;vertical-align:top;"| 2014
| style="background-color: white;vertical-align:top;"| August 2015
| style="background-color: white;vertical-align:top;"| http://www.knmp.nl/patiëntenzorg/samenwerking/brochure-veilige-principes-in-de-medicatieketen
| style="background-color: white;vertical-align:top;"| ActiZ, KNMP, NVZA a.o.
|-
| style="background-color: white;vertical-align:top;"| Miscellaneous
| style="background-color: white;vertical-align:top;"| Guideline on exchange of medication data in the medication chain
| style="background-color: white;vertical-align:top;"| 25 April 2008
| style="background-color: white;vertical-align:top;"| August 2015
| style="background-color: white;vertical-align:top;"| Website KNMP
| style="background-color: white;vertical-align:top;"| Miscellaneous
|-
| style="background-color: white;vertical-align:top;"| Paul Geels
| style="background-color: white;vertical-align:top;"| Assessment of medication self-management (BEM) in care homes, Institute for Responsible Medication Use
| style="background-color: white;vertical-align:top;"| February 2009
| style="background-color: white;vertical-align:top;"|
| style="background-color: white;vertical-align:top;"| http://www.instellingsapotheek.nl/downloads/rapporten/beoordeling_eigen_beheer_van_medicatie_in_verzorgingshuizen.pdf
| style="background-color: white;vertical-align:top;"| Institute for responsible medicatiegebruik
|-
| style="background-color: white;vertical-align:top;"| ActiZ
| style="background-color: white;vertical-align:top;"| Safety in the medication chain
| style="background-color: white;vertical-align:top;"| March 2012
| style="background-color: white;vertical-align:top;"|
| style="background-color: white;vertical-align:top;"| https://www.knmp.nl/downloads/brochure-veiligheid-in-de-medicatieketen.pdf
| style="background-color: white;vertical-align:top;"| ActiZ, Miscellaneous
|-
| style="background-color: white;vertical-align:top;"| KNMG
| style="background-color: white;vertical-align:top;"| Guideline on electronic prescription
| style="background-color: white;vertical-align:top;"| September 2013
| style="background-color: white;vertical-align:top;"|
| style="background-color: white;vertical-align:top;"| Website KNMG
| style="background-color: white;vertical-align:top;"| KNMG
|}

==Qualification scripts==
[[mp:Vdraft Kwalificatie|Qualification scripts]]

=Attachment: Document history=

{{anchor|tabel 6}}
{| class="wikitable" "cellpadding="10"
!style="text-align:left;"|Version
!style="text-align:left;"|Date
!style="text-align:left;"|Description
|-
| style="background-color: white;"| 0.95
| style="background-color: white;"| 15 July 2016
| style="background-color: white;"| Pilot version
|-
| style="background-color: white;"| 0.96
| style="background-color: white;"| 1 December 2016
| style="background-color: white;"| Paragraph 2.4 Process: Administer was adapted and C6: Sending/receiving administration data was added as a result.
|-
| style="background-color: white;vertical-align:top;"| 0.97
| style="background-color: white;vertical-align:top;"| 22 December 2016
| style="background-color: white;"| Paragraph 2.4, 4.3.1 review remarks incorporated. 
Paragraph 4.2.11 text made more precise.
|-
| style="background-color: white;vertical-align:top;"| 9.0.2
| style="background-color: white;vertical-align:top;"| 18 June 2017
| style="background-color: white;"| Conversion of the document to wiki.
|-
| style="background-color: white;vertical-align:top;"| 9.0.4
| style="background-color: white;vertical-align:top;"| September 2017
| style="background-color: white;vertical-align:top;"|
*Processed [[mp:V9.0_Ontwerpbeslissingen|Design decisions]] in functional design. This means the design decisions have become obsolete. The current Functional Design is now leading.
*Par. 1.3.1. Definitions of building blocks have been adapted and the abbreviation for medicatieverstrekking has changed to MVE.
*Par. 1.3.3. Medicamenteuze behandeling is now based on PRK, rewritten and introduced PT as well as added text on handling parallel MAs.
*Par. 1.3.4. New data model diagram, various relations added and adapted on the basis of design decisions.
*Par. 1.5 Glossary removed.
*C2 Medication process diagram changed: MO added to actively making available by the user; lines in swimlane of administrator/use adapted.
*C4.1 New use cases added: Do not dispense before, Two PRKs in a single medicamenteuze behandeling, Discontinuation of medication by third parties, Creating a medicatieafspraak after the fact, Parallel medicatieafspraken.
*C4.2 New use case: Discontinuing medication in a GDS; modified use case: Request, dispense and not picked up.
*C5: Differences between medication profile and medication overview were described; inference rules adapted on the basis of the new design decisions.
*Where necessary, references from ART-DECOR to FD C7 were added.
*Various grammatical and minor textual changes.
|-
| style="background-color: white;vertical-align:top;"| 9.0.5
| style="background-color: white;vertical-align:top;"| January 2018
| style="background-color: white;vertical-align:top;"|
*Terminology: Stop-MA was changed to stop-MA in accordance with earlier project agreements (in Dutch different terminology Stop changed to staken)
*Par. 1.3.4 Addition to indicate that MA may also refer to a building block under a different medicamenteuze behandeling.
*Par. 4.1.22 Discharge was adapted because outpatient medication that was discontinued earlier may be started again at discharge.
*Par. 4.1.26 Discontinuation of medication by third parties was adapted.
*Par. 4.1.27 Two PRKs under a single medicamenteuze behandeling.
*Par. 2.2.5.3 Medication discontinuation agreement was adapted to clarify the impact on previously entered future medicatieafspraken.
*Footnote 3 Provisional and final medication order clarified and use case Provisional and final medication order (par. 4.1.31) added.
*Par. 4.1.30 Use case Single use added.
*Paragraphs 2.2.4, 2.2.5.2, 2.2.5.4, 4.1.16, 4.1.22 were adapted for substitution. In case of substitution, a medicamenteuze behandeling is not temporarily halted but effectively discontinued. The substitution is started under a new medicamenteuze behandeling.
*Paragraph 4.1.33 Missing digital medicatieafspraak at admission was added.
*C5 Medication overview was adapted with a reference to a new content page with functional elaboration.
*Paragraph 7.10 Medicatiegebruik: use indicator, according to agreement indicator and stop type added as agreed.
*C6 Building blocks of medication overview were changed to MA, TA and MGB.
*Figure 2 Colours in data model in accordance with Figure 1.
*Various abbreviations explained.
|-
| style="background-color: white;vertical-align:top;"| 9.0.6
| style="background-color: white;vertical-align:top;"| May 2018
| style="background-color: white;vertical-align:top;"|
*Addition to proposed verstrekkingsverzoek and addition of reply proposed verstrekkingsverzoek
*Chapter 6 table 4 addition of links to ART-DECOR transactions
*Removed: chapter about LSP
*Par. 7.10 table was extended with period of use and dosing instructions
*Various paragraphs were made more precise
*Addition of the property ‘third parties’ building block’ for MA, TA and MGB in medication overview
|-
| style="background-color: white;vertical-align:top;"| 9.0.7
| style="background-color: white;vertical-align:top;"| December 2018
| style="background-color: white;vertical-align:top;"|
*Par 1.3.3. MBH at HPK level in case of 'non medicines' without a PRK level
*Par 1.3.3. MBH for medicines without PRK (magistrals, infusions, etc.)
*Par 2.2.5.5. Changing medication: Technical stop-ma: appointment date for stop-ma and new ma must be the same. Change on MA that has already been stopped explained (no extra Stop-ma needed)
*Par 2.2.6. Added: VV under MA of someone else
*Par 4.2.15. Explanation GDS supplier supplies different HPK
*Par 7.10: Medication use indicator, according to appointment indicator, stop type, period of use and dosing instruction: table adapted and examples added
*Par 4.1.34: Own articles explanation added
*Chapter 5: example medication overview inserted in this wiki page instead of a separate wiki page (to simplify searching within the FO).
*Various textual tightening / improvements
|-
| style="background-color: white;vertical-align:top;"| 9.0.7
| style="background-color: white;vertical-align:top;"| July 2019
| style="background-color: white;vertical-align:top;"|
*Removed examples of specific infrastructures
|-
| style="background-color: white;vertical-align:top;"| 9.1.0
| style="background-color: white;vertical-align:top;"| 29 January 2020
| style="background-color: white;vertical-align:top;"|
*Stop textual adjustments
*Par 7.11 added: Implementation of medication distribution system (GDS) fields
*[https://bits.nictiz.nl/browse/MP-85 BITS MP-85], [https://bits.nictiz.nl/browse/MP-93 BITS MP-93], [https://bits.nictiz.nl/browse/MP-122 BITS MP-122] Use cases added (Register usage based on verstrekkingn, Verstrekkingsverzoek with number of repetitions, Prescribe non-drug)
*Chapter 4: Added pictures of use cases
*Renal function value in the prescription
*[https://bits.nictiz.nl/browse/MP-48 BITS MP-48] Medication Overview: Par 5.7 added 'Fields not to be shown'
*Various textual specifications/ improvements, including [https://bits.nictiz.nl/browse/MP-131 o.a. BITS MP-131]
*Paragraph 'Unaddressed prescription' moved to chapter 'Considerations'
*[https://bits.nictiz.nl/browse/MP-151 BITS MP-151] Removed draft TA creation process
*[https://bits.nictiz.nl/browse/MP-128 BITS MP-128] Par 4.1.8: Explanation 'Medical necessity'
*[https://bits.nictiz.nl/browse/MP-129 BITS MP-129] Par 4.1.35: Use case added
|-
| style="background-color: white;vertical-align:top;"| 9.1.0
| style="background-color: white;vertical-align:top;"| September 2020
| style="background-color: white;vertical-align:top;"|
*[https://bits.nictiz.nl/browse/MP-167 BITS MP-167] FO Translated in English
|-
| style="background-color: white;vertical-align:top;"| 9 2.0.0 bèta
| style="background-color: white;vertical-align:top;"| 01 october 2021
| style="background-color: white;vertical-align:top;"| all changes see: *[https://informatiestandaarden.nictiz.nl/wiki/mp:V9_2.0.beta_releasenotes Releasenotes]
|}

=Appendix: Figures and tables=
[[#figuur 1|Figure 1 Building blocks - overview]] 
[[#figuur 2|Figure 2 Building blocks - coherence]] 
[[#figuur 3|Figure 3 Activity diagram - Medication process in general]] 
[[#figuur 4|Figure 4 Process steps and transactions - medication verification]] 
[[#figuur 5|Figure 5 Process steps and transactions - prescribing]] 
[[#figuur 6|Figure 6 Process steps and transactions - make available]] 
[[#figuur 7|Figure 7 Process steps and transactions - administer]] 
[[#figuur 8|Figure 8 Process steps and transactions - use]] 
[[#figuur 9|Figure 9 Example effective period]] 
[[#figuur 10|Figure 10 Overview of systems and system roles]] 
[[#figuur 11|Figure 11 Interaction diagram Prescribing without address]] 

[[#tabel 1|Table 1 Building blocks - description]] 
[[#tabel 2|Table 2 Informing versus (Active) making available]] 
[[#tabel 3|Table 3 Overview of system roles]] 
[[#tabel 4|Table 4 Overview of transaction groups]] 
[[#tabel 5|Table 5 Types of clinical medication relevant for outpatient care providers]]

mp:V2.0.0 Ontwerp medicatieproces 9

2022-04-04T14:47:41Z

Petra van Deursen: /* Starten met medicatie voor opname */

{{IssueBox|'''LET OP: Dit is een ontwikkel versie. Voor een overzicht van relevante en gepubliceerde wiki-pagina's voor Medicatieproces zie [[Landingspagina_Medicatieproces]].'''}}

__NUMBEREDHEADINGS__
{{DISPLAYTITLE: Functioneel Ontwerp Medicatieproces 9 versie 2.0.0 ONTWIKKELVERSIE definitieve publicatie}}
[[Bestand:NL.jpg|50px]] [[mp:V2.0.0_Ontwerp_medicatieproces_9|Dit is de NL versie]] 
[[Bestand:ENG.jpg|50px]] [[mp:V2.0.0_Ontwerp_medicatieproces_9_ENG|Click here for the ENG version]] 
Voor een overzicht van relevante wiki-pagina's voor Medicatieproces zie [[Landingspagina_Medicatieproces]]

=Inleiding=

Dit document is het functioneel ontwerp van de informatiestandaard Medicatieproces. Het beschrijft de algemene werking en specifieke praktijksituaties. Daarbij is voor een concrete situatie het vastleggen en uitwisselen van informatie beschreven aan de hand van actoren (mensen, informatiesystemen) en transacties (welke informatie wordt wanneer uitgewisseld).

Doelgroep voor dit document zijn:
* zorgverleners;
* informatieanalisten en -architecten;
* softwareleveranciers.

==Scope en visie==

Dit document is tot stand gekomen binnen het programma Medicatieproces. Het programma Medicatieproces beoogt allereerst om bestaande knelpunten in het medicatieproces op te lossen, rekening houdend met de huidige wetgeving en de haalbaarheid van concrete resultaten binnen afzienbare termijn.

Een van de belangrijkste knelpunten betreft het onvoldoende zicht hebben op de medicatie die de patiënt gebruikt. Dit heeft onder andere te maken met het vermengen van therapeutische en logistieke informatie wat leidt tot een onoverzichtelijke medicatiehistorie. Het onderscheid tussen therapie en logistiek is als volgt gemaakt:
* '''Therapie''' omvat de ‘medisch-inhoudelijke’ aspecten. Het omvat onder andere de medicamenteuze (behandelings-)afspraken, de begeleiding en de uitvoering ervan. Ook de therapeutische intentie, het (werkelijk) gebruik, zelfmedicatie en farmacotherapie zijn termen die passen onder de paraplu van ‘therapie’, zoals in dit document is bedoeld.
* '''Logistiek''' omvat de aspecten rondom de fysieke goederenstroom van geneesmiddelen, inclusief aanvragen, planning en afleveringen. Ook de medicatievoorraad en het verbruik ervan vallen onder dit begrip.

Het programma heeft rekening gehouden met huidige wetgeving en haalbaarheid binnen een afzienbare termijn. De visie gaat wel verder dan de scope van het programma Medicatieproces en legt het fundament voor een situatie waarin het verstrekkingsverzoek verdwijnt. Het uiteindelijke doel is dat voorschrijvers zich uitsluitend bezig houden met therapeutische aspect (welk geneesmiddel, welke sterkte, welke dosering, wanneer starten, etc.). Daardoor is het maken van een verstrekkingsverzoek niet meer nodig. In plaats daarvan maakt de voorschrijver medicatieafspraken met de patiënt. Op basis van deze medicatieafspraken verzorgt de apotheker het logistieke proces en daarmee kan het verstrekkingsverzoek verdwijnen.
Dit is echter (nog) niet mogelijk vanwege wetgeving. Het programma Medicatieproces zet wel de eerste noodzakelijke stap in die richting.

==Leeswijzer==

De volgende paragraaf bevat een introductie van de belangrijkste bouwstenen en termen die in dit document gebruikt worden.
In [[#Medicatieproces|hoofdstuk 2]] zijn de verschillende processen (voorschrijven, ter hand stellen, toedienen, gebruiken) uitgewerkt. Het doel van de beschrijving is helder te maken hoe het zorgproces in de gewenste situatie loopt, welke processtappen nodig zijn, welke actoren daaraan deelnemen, welke informatie daarbij van toepassing is en welke uitwisselingsmomenten er zijn.
De processen zijn volgens een vaste indeling beschreven:

* Huidige situatie Deze paragraaf beschrijft de relevante verschillen van de huidige situatie ten opzichte van de gewenste situatie (“soll”, volgens deze informatiestandaard). Hier vindt u dus knelpunten terug.
* Procesbeschrijving met de paragrafen:
** ''Preconditie'' De voorwaarden waaraan voldaan moet zijn vóór het starten van het proces.
** ''Trigger Event'' De gebeurtenis die het proces start.
** ''Een of meerdere processtappen'' Beschrijving van een onderdeel van het proces.
** ''Postconditie'' De voorwaarden waaraan voldaan is nadat de processtappen van het proces zijn uitgevoerd.
* Use cases Opsomming van de use cases die horen bij dit deelproces. De uitwerking van de use cases is opgenomen in [[#Beschrijving use cases|Hoofdstuk 4]].
* Informatiesystemen en transactiesgroepen Deze paragraaf beschrijft de betrokken informatiesystemen, systeemrollen, transacties en transactiegroepen in relatie tot de processtappen. Alle informatie rond informatiesystemen en transactiegroepen is ook opgenomen in [[#Systemen en transacties|Hoofdstuk 7]].

In [[#Domeinspecifieke invulling medicatieproces|hoofdstuk 3]] zijn enkele domeinspecifieke invullingen van het medicatieproces beschreven bijvoorbeeld die bij de dienstwaarneming in de ambulante situatie. In [[#Beschrijving use cases|Hoofdstuk 4]] zijn verschillende use cases in meer detail beschreven. De praktijk situaties zijn in een groot aantal gevallen ontleent aan de huisartsenpraktijk maar zijn illustratief voor vergelijkbare situaties in een andere setting. De use cases zijn onderverdeeld naar deelproces, zoals aangegeven in Hoofdstuk 2. 
[[#Medicatieoverzicht en afleidingsregels|Hoofdstuk 5]] beschrijft hoe een medicatieprofiel kan worden opgebouwd uit de verschillende bouwstenen. In [[#Systemen en transacties|Hoofdstuk 7]] is een overzicht opgenomen van alle informatiesystemen, systeemrollen, transacties en transactiegroepen. Aanwijzingen voor de functionaliteit van verschillende informatiesystemen zijn uitgewerkt in [[#Functionaliteit|Hoofdstuk 8]].

==Introductie van relevante termen==
===Therapeutische en logistieke bouwstenen===
De use cases bevatten een beschrijving van het proces en de gegevenselementen die daarin een rol spelen. Daarbij wordt gebruik gemaakt van groepen van bij elkaar horende gegevenselementen: zorginformatiebouwstenen (zib), de zorginformatiebouwstenen zijn in sommige gevallen aangevuld met elementen die nodig zijn voor de context en/ of het werkproces. In de dataset is uitgewerkt uit welke gegevenselementen deze bouwstenen bestaan. De dataset bevat de complete set van definities van de gegevenselementen in de bouwstenen. De bouwstenen met hun gegevenselementen worden gebruikt in verschillende scenario’s waarmee zorgtoepassingen kunnen worden ingericht/gemodelleerd of waarmee koppelvlakken voor gegevensuitwisseling worden gedefinieerd.

Onderstaande figuur geeft de bouwstenen weer. Zij zijn gerangschikt naar (deel)proces en naar therapie versus logistiek.

{{anchor|figuur 1}}
[[Bestand:Figuur 1 Bouwstenen - overzicht.png|Figuur 1 Bouwstenen - overzicht]]

Onderstaande tabel geeft een beschrijving van deze bouwstenen. Ook de vier aanvullende concepten ‘voorstel medicatieafspraak’ (therapeutisch), 'antwoord voorstel medicatieafspraak' (therapeutisch), 'voorstel verstrekkingsverzoek’ (logistiek) en ‘antwoord voorstel verstrekkingsverzoek’ (logistiek) zijn beschreven.

{{anchor|tabel 1}}
{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| Bouwsteen
! style="text-align:left;"| Afk.
! style="text-align:left;"| Beschrijving
|-
| style="background-color: white;vertical-align:top;"| medicatieafspraak
|style="background-color: white;vertical-align:top;"| MA
| style="background-color: white;vertical-align:top;"| Een medicatieafspraak is het voorstel van een voorschrijver tot gebruik van medicatie waarmee de patiënt akkoord is. Ook de afspraak om het medicatiegebruik te stoppen is een medicatieafspraak<ref>In dit document wordt alleen medicatieafspraak gebruikt waarmee dus ook het klinische equivalent voorlopige medicatie-opdracht wordt aangeduid</ref>.
|-
| style="background-color: white;vertical-align:top;"| wisselend doseerschema
| style="background-color: white;vertical-align:top;"| WDS
| style="background-color: white;vertical-align:top;"| Een wisselend doseerschema is het doseerschema van een (externe) voorschrijver, waarbij het onderdeel gebruiksinstructie van een medicatieafspraak concreet wordt ingevuld. Het doseerschema kan tussentijds aangepast worden zonder dat de medicatieafspraak gewijzigd hoeft te worden.
|-
| style="background-color: white;vertical-align:top;"| verstrekkingsverzoek
| style="background-color: white;vertical-align:top;"| VV
| style="background-color: white;vertical-align:top;"| Een verstrekkingsverzoek is het verzoek van een voorschrijver aan de apotheker om medicatieverstrekking(en) te doen aan de patiënt, ter ondersteuning van de geldende medicatieafspraken<ref>De bouwsteen verstrekkingsverzoek is in de klinische situatie niet van toepassing. Verstrekken van medicatie wordt in de klinische situatie op verschillende manieren ingevuld. Het aanvullen van bijvoorbeeld een afdelingsdepot wordt hier niet als medicatieverstrekking gezien maar als verlengde voorraad van de apotheker. Er is pas sprake van een medicatieverstrekking als de koppeling tussen het geneesmiddel en de patiënt gelegd is. In de klinische situatie wordt daarna vaak gelijk toegediend.
</ref>.
|-
| style="background-color: white;vertical-align:top;"| toedieningsafspraak
| style="background-color: white;vertical-align:top;"| TA
| style="background-color: white;vertical-align:top;"| Een toedieningsafspraak is de gebruiks- (of toedienings-)instructie van de apotheker aan de patiënt (of zijn vertegenwoordiger of toediener), waarbij een medicatieafspraak concreet wordt ingevuld<ref name="MO">Een voorlopige medicatieopdracht, zoals die in ziekenhuizen wordt gebruikt, is zowel het verzoek van de arts aan de toediener om medicatie toe te dienen aan de patiënt als een verstrekkingsverzoek aan de apotheker om ervoor te zorgen dat de medicatie beschikbaar is voor de toediener. Dit laatste komt overeen met de medicatieafspraak en verstrekkingsverzoek uit de eerste lijn. De apotheker in het ziekenhuis voert in de regel bovendien een validatie van het toedieningsverzoek uit (zo ontstaat de definitieve medicatieopdracht en dit wordt hier de toedieningsafspraak genoemd). Met voorlopige medicatieopdracht wordt dus niet bedoeld een voorstel van bijvoorbeeld de verpleegkundige op basis van protocol welke nog niet geaccordeerd is door een arts.</ref>.
|-
| style="background-color: white;vertical-align:top;"| medicatieverstrekking
| style="background-color: white;vertical-align:top;"| MVE
| style="background-color: white;vertical-align:top;"| Een medicatieverstrekking is de ter handstelling van een hoeveelheid van een geneesmiddel aan de patiënt, zijn toediener of zijn vertegenwoordiger.
|-
| style="background-color: white;vertical-align:top;"| medicatietoediening
| style="background-color: white;vertical-align:top;"| MTD
| style="background-color: white;vertical-align:top;"| Medicatietoediening is de registratie van de afzonderlijke toedieningen van het geneesmiddel aan de patiënt door de toediener (zoals een verpleegkundige of patiënt zelf), in relatie tot de gemaakte afspraken.
|-
| style="background-color: white;vertical-align:top;"| medicatiegebruik
| style="background-color: white;vertical-align:top;"| MGB
| style="background-color: white;vertical-align:top;"| Medicatiegebruik is een uitspraak over historisch, huidig of voorgenomen gebruik van een geneesmiddel<ref>Gebruik kan voorafgegaan zijn door een medicatietoediening. Registratie van gebruik na bijvoorbeeld medicatietoediening van rabiës vaccinatie of infuus ligt niet voor de hand.</ref>.
|-
| style="background-color: white;vertical-align:top;"| medicatieverbruik
| style="background-color: white;vertical-align:top;"| MVB
| style="background-color: white;vertical-align:top;"| Het verbruik is de logistieke invalshoek van het gebruik. Het beschrijft tot wanneer een patiënt heeft gedaan of nog kan doen met een (deel)voorraad geneesmiddelen<ref>Van eenmalig tot een bepaalde periode. De bouwsteen Medicatieverbruik is niet verder uitgewerkt in deze informatiestandaard.</ref>.
|-
| style="background-color: white;vertical-align:top;"| voorstel medicatieafspraak
| style="background-color: white;vertical-align:top;"| VMA
| style="background-color: white;vertical-align:top;"| Het voorstel medicatieafspraak is een advies of verzoek van de apotheker of de patiënt aan de voorschrijver over de afgesproken medicatie. Het adviesverzoek kan bijvoorbeeld inhouden medicatie te evalueren, te stoppen, te starten of te wijzigen.
|-
| style="background-color: white;vertical-align:top;"| antwoord voorstel medicatieafspraak
| style="background-color: white;vertical-align:top;"| AVMA
| style="background-color: white;vertical-align:top;"| Het antwoord voorstel medicatieafspraak is een antwoord van de voorschrijver op de voorstel medicatieafspraak. Hierin geeft de voorschrijver aan akkoord te gaan (waarna een (aangepaste) medicatieafspraak zal volgen) of niet (en de reden daarvoor).
|-
| style="background-color: white;vertical-align:top;"| voorstel verstrekkingsverzoek
| style="background-color: white;vertical-align:top;"| VVV
| style="background-color: white;vertical-align:top;"| Het voorstel verstrekkingsverzoek is een voorstel van de apotheker aan de voorschrijver om (een) medicatieverstrekking(en) te fiatteren ten behoeve van geldende medicatieafspr(a)ak(en). Dit is vergelijkbaar met de huidige situatie van het aanbieden van het autorisatieformulier of verzamelrecept of het ter ondertekening aanbieden van een herhaalrecept. Ook de patiënt kan een voorstel verstrekkingsverzoek indienen bij de voorschrijver.
|-
| style="background-color: white;vertical-align:top;"| antwoord voorstel verstrekkingsverzoek
| style="background-color: white;vertical-align:top;"| AVVV
| style="background-color: white;vertical-align:top;"| Het antwoord voorstel verstrekkingsverzoek is een antwoord van de voorschrijver op het voorstel verstrekkingsverzoek. Hierin geeft de voorschrijver aan akkoord te gaan (waarna een verstrekkingsverzoek zal volgen) of niet (en de reden daarvoor).
|}Tabel 1 Bouwstenen – beschrijving

===Medicatieoverzicht===
Zie [[#Medicatieoverzicht en afleidingsregels|hoofdstuk 5]] voor meer informatie over deze overzichten, welke bouwstenen daarbij van toepassing zijn en hoe een medicatieprofiel/actueel overzicht kan worden samengesteld.

===Medicamenteuze behandeling===
De verschillende medicatiebouwstenen representeren stappen in het medicatieproces, van het voorschrijven van een geneesmiddel (medicatieafspraak en/of verstrekkingsverzoek), gevolgd door het ter hand stellen (toedieningsafspraak en/of medicatieverstrekking) tot en met het toedienen en gebruik. Het model is zo ingericht dat therapeutische bouwstenen en logistieke bouwstenen van elkaar gescheiden zijn. 
'''Scope''' 
Om de onderlinge samenhang tussen de medicatiebouwstenen te kunnen benoemen, is het begrip ‘medicamenteuze behandeling’ geïntroduceerd. 
:''Medicamenteuze behandeling is in de informatiestandaard een '''technisch begrip'''. Het heeft als doel om: 
:#'' de verzameling van samenhangende medicatiebouwstenen eenduidig te identificeren, en'' 
:#'' regels op toe te passen waarmee de actuele situatie eenduidig wordt bepaald.''
 
De functionele toepassing van het begrip medicamenteuze behandeling is als volgt:
*Het starten van medicatie (c.q. medicamenteuze behandeling) wordt gedaan door het maken van een eerste medicatieafspraak binnen een nieuwe medicamenteuze behandeling.
*Het stoppen van medicatie (c.q. medicamenteuze behandeling) gebeurt door een nieuwe medicatieafspraak te maken binnen dezelfde medicamenteuze behandeling (een stop-medicatieafspraak).
*Het wijzigen van de medicatie (c.q. medicamenteuze behandeling) gebeurt door:
#de bestaande medicatieafspraak te stoppen en
#een nieuwe medicatieafspraak met de wijziging te maken binnen dezelfde medicamenteuze behandeling. De ingangsdatum van deze nieuwe medicatieafspraak kan ook in de toekomst liggen.

Het voorschrijven van een nieuw geneesmiddel resulteert altijd in een nieuwe medicatieafspraak. Een medicatieafspraak hoort altijd bij één medicamenteuze behandeling. Vooralsnog bepaalt het PRK-niveau (Prescriptie Kode uit de G-standaard) van het geneesmiddel of de medicatieafspraak bij een nieuwe of bestaande medicamenteuze behandeling hoort. In de toekomst wordt dit mogelijk verruimd naar SNK-niveau (Stam Naam Kode uit de G-standaard) zodat sterktewijzigingen en geneesmiddelen uit dezelfde groep niet meer leiden tot een nieuwe medicamenteuze behandeling. Een nadere beschrijving is te vinden in [[#Processtap: Maken medicatieafspraak| paragraaf 2.2.5 Processtap: Maken Medicatieafspraak]]. 
Uitzonderingen: 
*Middelen zonder PRK (een niet geneesmiddel zoals krukken of verbandmiddelen). In dit geval bepaalt het HPK niveau (Handels Product Kode uit de G-standaard) of deze tot een nieuwe medicamenteuze behandeling leidt.
*Medicatie zonder PRK (magistralen bestaan veelal uit meerdere stoffen die niet onder eenzelfde PRK vallen, deze stoffen worden afzonderlijk als ingrediënten opgenomen in de medicatieafspraak). Elk magistraal of aanpassing daarop valt onder een nieuwe medicamenteuze behandeling.
*Eigen artikelen zonder PRK (artikelen die in het interne informatiesysteem onder de 90 miljoen nummers opgeslagen staan, zoals bijvoorbeeld halve tabletten, veel gebruikte magistralen). Elk artikel of aanpassing daarop valt onder een nieuwe medicamenteuze behandeling.
*Infusen (wordt nog uitgezocht)

 
'''Voorbeelden''' 
Een vijftal voorbeelden lichten de reikwijdte van een medicamenteuze behandeling toe: 
*Diazepam 5 mg 4x daags 1 tablet wordt gewijzigd naar diazepam 5 mg 3x daags 1 tablet. Het PRK van beide middelen is gelijk, ze vallen beide onder dezelfde medicamenteuze behandeling.
*Paroxetine tablet 10 mg 1 maal per dag 1 tablet wordt gewijzigd naar paroxetine tablet 20 mg 1 maal per dag 1 tablet. Het betreft hierbij een wijziging van een medicatieafspraak met twee verschillende geneesmiddelen op PRK-niveau. Bij deze wijziging dient dus de eerste medicamenteuze behandeling te worden beëindigd en een nieuwe medicamenteuze behandeling te worden gestart.
*Uit voorzorg is een maagbeschermer afgesproken bij een behandeling met prednison: prednison en maagbeschermer zijn hier twee verschillende geneesmiddelen, die parallel aan elkaar lopen en apart van elkaar gewijzigd en gestopt kunnen worden. Daarmee vallen zij niet onder dezelfde medicamenteuze behandeling.
*Het wisselen van bètablokker naar een ACE-remmer betekent een andere PRK en wordt dan ook ingevuld met het stoppen van de medicamenteuze behandeling van de bètablokker én het starten van een nieuwe medicamenteuze behandeling voor de ACE-remmer.
*Wanneer er geen PRK is en de samenstelling van de geneesmiddelen in de medicatieafspraak verandert (elke wijziging in de ingrediënten), wordt de bestaande medicamenteuze behandeling beëindigd en wordt een nieuwe medicamenteuze behandeling gestart. Dit geldt bijvoorbeeld voor magistralen, infusen en eigen artikelen.

 
'''Ontstaan medicamenteuze behandeling''' 
In onderstaande figuur is het ontstaan van de medicamenteuze behandeling (MBH) schematisch weergegeven. Bij het ontstaan van een nieuwe bouwsteen (MA, TA, VV, MVE, MTD of MGB) wordt eerst gecontroleerd of het nieuwe medicatie betreft of dat er al een bouwsteen met hetzelfde product bestaat en actueel is. Hiervoor worden zowel de eigen als andermans bouwstenen beschouwd. In de meeste informatiesystemen zal de gebruiker van het informatiesysteem aangeven een wijziging te willen uitvoeren op één van de bestaande medicatiebouwstenen of nieuwe medicatie op te willen voeren. In dat geval is het eenvoudig om te ontdekken of er al een medicamenteuze behandeling is waar de bouwsteen bij hoort.
*Wanneer er geen bestaande bouwsteen voor deze medicatie is dan wordt een nieuwe bouwsteen gemaakt met een nieuwe medicamenteuze behandeling.
*Wanneer er een bouwsteen bestaat met een medicamenteuze behandeling dan wordt de gebruiker van het informatiesysteem gevraagd of de nieuwe bouwsteen en de bestaande bouwsteen bij dezelfde behandeling horen. Wanneer dit het geval is dan wordt dezelfde medicamenteuze behandeling gebruikt. Wanneer de bouwstenen niet bij dezelfde behandeling horen dan wordt een nieuwe medicamenteuze behandeling gemaakt.
{{anchor|figuur 2}}
[[Bestand:Ontstaan_MBH.png|500px|Figuur 2 Ontstaan medicamenteuze behandeling]]

 
'''Parallelle medicatieafspraken''' 
Binnen een medicamenteuze behandeling kunnen meerdere medicatieafspraken gelijktijdig actueel zijn. Dit zijn alle medicatieafspraken die op dit moment geldig zijn (“huidig”) of in de toekomst geldig worden. Binnen een medicamenteuze behandeling is in principe op enig moment één medicatieafspraak geldig. Maar er is een aantal situaties waarin parallelle medicatieafspraken denkbaar zijn:
#Zelfde geneesmiddel, andere sterkte waarbij eigenlijk in één afspraak de totale sterkte voorgeschreven wordt.
#Aan elkaar gerelateerde (andere) geneesmiddelen die samen gegeven worden en je ook als één geheel wilt beschouwen bij evaluatie van de therapie.
#Technische omissies in informatiesystemen bij bijvoorbeeld complexe doseerschema’s of combinatie-infusen.
'''Situatie 1''' kan worden opgelost door op een hoger niveau (SNK) voor te schrijven. G-standaard/Zindex werkt hieraan, maar dit is nog niet mogelijk. Tot die tijd wordt gekozen voor het combineren van 1 of meer producten in dezelfde medicatieafspraak door de producten als ingrediënt op te nemen. Dit is vergelijkbaar met magistrale producten. De gebruiksinstructie voor al deze producten moet dan wel identiek zijn.<ref>In de praktijk worden vaak meerdere medicatieafspraken (met verschillende PRK's) gecombineerd tot één product in plaats van één medicatieafspraak met daaronder de samenstelling.</ref> 
'''Situatie 2''' wordt in informatiesystemen op verschillende wijze opgelost, met eigen groeperingsmechanismen. Het betreft hier het relateren van verschillende medicamenteuze behandelingen. De informatiestandaard laat dit vrij en heeft hiervoor dus geen universeel groeperingsmechanisme. 
'''Situatie 3''' is de enige situatie waarin parallelle medicatieafspraken onder één medicamenteuze behandeling toegestaan zijn. Complexe op- en afbouwschema’s en combinatie infusen kunnen in één medicatieafspraak worden opgenomen maar niet alle informatiesystemen ondersteunen dit. Voor die informatiesystemen is het toegestaan om parallelle medicatieafspraken in één medicamenteuze behandeling te maken.

===Samenhang tussen de bouwstenen en medicamenteuze behandeling===
In onderstaande figuur is de samenhang tussen de bouwstenen en de medicamenteuze behandeling schematisch weergegeven. Hier volgt een beschrijving van de relaties tussen de bouwstenen onderling en met medicamenteuze behandeling:
*De bouwstenen horen bij één medicamenteuze behandeling. Een medicamenteuze behandeling heeft tenminste één medicatieafspraak en kan 0 of meer van de bouwstenen verstrekkingsverzoeken, wisselend doseerschema's, toedieningsafspraken, medicatieverstrekkingen, gebruik en medicatietoediening hebben. Tenzij bijvoorbeeld zelfmedicatie met gebruik is vastgelegd of er een papieren recept is aangeleverd, dan kan een medicamenteuze behandeling bestaan zonder medicatieafspraak, maar met medicatiegebruik, medicatietoediening of een toedieningsafspraak. Een MBH blijft altijd bestaan, het kan alleen zijn dat hij niet meer effectief is, omdat er geen actuele bouwstenen meer onder hangen. Een voorstel medicatieafspraak, antwoord voorstel medicatieafspraak, voorstel verstrekkingsverzoek en antwoord voorstel verstrekkingsverzoek vallen nog buiten de medicamenteuze behandeling omdat het gaat om een concept/voorstel dat al dan niet leidt tot een definitieve medicatieafspraak of verstrekkingsverzoek met een relatie naar een medicamenteuze behandeling. Een voorstel medicatieafspraak kan leiden tot nul (wanneer het advies niet opgevolgd wordt), één of meerdere medicatieafspraken en een voorstel verstrekkingsverzoek kan leiden tot nul (wanneer het voorstel niet gehonoreerd wordt), één of meerdere verstrekkingsverzoeken.
*Een MBH kan ook alleen een stop-MA hebben naast bijvoorbeeld een gebruiksbouwsteen. Bijvoorbeeld in het geval dat de zorgverlener de patiënt verzoekt om het gebruik van een vrij verkrijgbaar geneesmiddel (ook wel zelfzorgmedicatie of Over-The-Counter (OTC) medicatie genoemd) te stoppen. Dan legt de zorgverlener het gebruik van de zelfzorgmedicatie vast in een gebruiksbouwsteen en stopt het gebruik door het maken van een stop-afspraak (stop-MA die onder dezelfde MBH hangt).
*Een MA kan verwijzen naar de vorige MA of een TA of MGB waarop deze gebaseerd is. Dit mag ook een MA, TA of MGB onder een andere medicamenteuze behandeling zijn. Het kan zijn dat er geen digitale MA beschikbaar is (bijvoorbeeld [[#Papieren recept|Papieren recept (paragraaf 4.1.17)]]), deze MA moet dan worden aangemaakt. Die MA mag verwijzen naar de TA of MGB. Een apotheker is nooit de bron van een MA; hij kan wel een kopie hebben.
*Binnen een medicamenteuze behandeling is in principe op enig moment één medicatieafspraak geldig. Alleen vanwege technische omissies in informatiesystemen bij bijvoorbeeld complexe doseerschema’s of combinatie-infusen, zijn parallelle medicatieafspraken toegestaan (zie ook vorige paragraaf).
*Een medicatieafspraak wordt ondersteund door nul (wanneer er nog voldoende voorraad is of wanneer er geen medicatieverstrekking nodig is), één of meerdere (wanneer er bijvoorbeeld sprake is van doorlopende medicatie) verstrekkingsverzoeken.
*Een verstrekkingsverzoek is gebaseerd op de actuele medicatieafspraken en eventueel reeds bestaande bijbehorende toedieningsafspraken in een behandeling. Dit kunnen er meerdere zijn.
*Een verstrekkingsverzoek verwijst naar één of meerdere MA’s (bij bijvoorbeeld een tussentijdse doseringsverhoging kan er een Verstrekkingsverzoek gedaan worden die zowel de voorraad voor de bestaande MA aanvult als de voorraad voor de toekomstige MA start).
*Een verstrekkingsverzoek kan resulteren in nul (bijvoorbeeld wanneer de patiënt de medicatie niet afhaalt) tot meerdere medicatieverstrekkingen.
*Een medicatieafspraak kan leiden tot nul, één of meerdere wisselend doseerschema’s.
*Er kunnen meerdere (evt. parallelle) toedieningsafspraken gebaseerd zijn op dezelfde medicatieafspraak (bijvoorbeeld wanneer een apotheker wisselt van handelsproduct of wanneer het geneesmiddel geleverd wordt in twee of meer geneesmiddelen met andere sterkte waarbij de totale sterkte gelijk blijft). Wanneer er een papieren recept wordt aangeleverd en de medicatieafspraak en het verstrekkingsverzoek niet digitaal beschikbaar zijn, is er een toedieningsafspraak zonder medicatieafspraak.
*Een medicatieafspraak hoeft niet altijd te leiden tot een toedieningsafspraak. Bijvoorbeeld wanneer er geen verstrekkingsverzoek nodig is bij een MA met korte gebruiksperiode, waarbij de patiënt nog voldoende voorraad heeft.
*Een toedieningsafspraak wordt ondersteund door nul (wanneer er voldoende voorraad is), één of meerdere medicatieverstrekkingen.
*Een medicatieverstrekking is gebaseerd op een medicatieafspraak (en een toedieningsafspraak) en in de ambulante situatie op een verstrekkingsverzoek. De uitzondering hierop is de verkoop ten behoeve van zelfzorgmedicatie: deze heeft geen medicatieafspraak en geen verstrekkingsverzoek. Zelfzorgmedicatie verstrekt door de apotheker kan wel door die apotheker worden vastgelegd als toedieningsafspraak met medicatieverstrekking of door een willekeurige zorgverlener of de patiënt zelf als gebruik.
*Een medicatieverstrekking kan meerdere toedieningsafspraken ondersteunen.
*Een medicatie- of toedieningsafspraak kan opgevolgd worden door een nieuwe medicatie- of toedieningsafspraak. Dit kan het geval zijn bij een wijziging van de bestaande medicatie (wijziging MA en/of TA) of bij het stoppen van het medicatiegebruik (stoppen MA/TA).

{{anchor|figuur 2}}
[[Image: Datamodel_MP92.PNG|800px|Figuur 2 - Datamodel Medicatieproces]]

===Informeren en (actief) beschikbaar stellen===
[[#Medicatieproces|Hoofdstuk 2]] beschrijft het medicatieproces. Daarbij zijn processtappen opgenomen met de tekst 'Informeren' of '(Actief) beschikbaar stellen'. Onderstaande tabel bevat een nadere omschrijving van de betekenis hiervan. In [[#Medicatieproces|hoofdstuk 2]] is verder uitgewerkt in welke situatie er sprake is van actief versturen danwel beschikbaar stellen.

{{anchor|tabel 2}}
{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| Term
! style="text-align:left;"| Toelichting
|-
| style="background-color: white;vertical-align:top;"| Informeren
| style="background-color: white;vertical-align:top;"| Informeren betekent het geadresseerd sturen van een opdracht of verzoek aan een andere actor. Het gaat hier om een zogenaamde 'push' van informatie: de actor stuurt de informatie gericht naar de ander. Dit kan bijvoorbeeld met
*een elektronisch bericht via een digitaal netwerk,
*papier (bijvoorbeeld door een recept bestemd voor een apotheker mee te geven met de patiënt),
*een fax,
*een combinatie van bovengenoemde opties.
|-
| style="background-color: white;vertical-align:top;"| (Actief) beschikbaar stellen
| style="background-color: white;vertical-align:top;"| De zorgverlener stelt de informatie (actief) beschikbaar voor een andere actor. Het gaat in deze processtap om:
*actief versturen ofwel informeren (‘push’) zoals hierboven beschreven of
*geautomatiseerd beschikbaar stellen aan zorgverleners en/of de patiënt wanneer deze daarom vragen op basis van vooraf verleende toestemming of
*een combinatie van beide voorgaande bullets.
Gegevens worden altijd beschikbaar gesteld en daarnaast heeft de zorgverlener de keus om medebehandelaars en/of de patiënt op enig moment in het proces ook geadresseerd te informeren. Gegevens kunnen in overleg met de patiënt naar een door de patiënt gewenste zorgverlener worden verstuurd (informeren).
|} Tabel 2 Informeren versus (Actief) beschikbaarstellen

Het technisch mechanisme (‘pull’, ‘publish and subscribe’, ‘push’, etc.) waarmee gegevens (actief) beschikbaar worden gesteld is infrastructuur afhankelijk en daarom niet in dit document uitgewerkt.

Artsenfederatie KNMG beschrijft in zijn publicatie “Van wet naar praktijk: implementatie van de WGBO Deel 4. Toegang tot patiëntengegevens” wanneer er sprake is van veronderstelde toestemming en expliciete toestemming. Op de uitwisseling beschreven in deze informatiestandaard zijn de vigerende wettelijke kaders en richtlijnen rond toestemming en opt-in van toepassing en derhalve niet expliciet beschreven.

==Legenda/Uitleg==
Een handleiding bij deze Nictiz wiki documentatie is te vinden op: 
http://informatiestandaarden.nictiz.nl/wiki/Handleiding_Wiki_documentatie 
Daarin is ook een legenda opgenomen bij de verschillende diagrammen die in dit document voorkomen.

=Medicatieproces=
Dit hoofdstuk beschrijft het medicatieproces in relatie tot de bouwstenen voor zowel de 1e, 2e als 3e lijnszorg. In de kern is het proces in al deze lijnen hetzelfde. Het belangrijkste verschil is welke apotheek de medicatie levert: de openbare apotheek (incl. poliklinische apotheek) of de ziekenhuisapotheek. 
Daarnaast is het verschil dat in de ambulante setting een verstrekkingsverzoek nodig is om medicijnen geleverd te krijgen. In de klinische setting is dit niet nodig: de (ziekenhuis)apotheker zorgt dat de medicijnen er zijn zolang de medicatieafspraak loopt.

Het medicatieproces is een cyclisch proces dat bestaat uit voorschrijven, ter hand stellen, toedienen en gebruiken. Het proces start op het moment dat de patiënt/cliënt bij de zorgaanbieder (huisarts, ziekenhuis of andere instelling) komt voor een behandeling met een geneesmiddel en eindigt wanneer de medicatie niet meer gebruikt hoeft te worden. Het proces is weergegeven in onderstaande figuur. De gele balk betreft het proces van medicatieverificatie, groen voorschrijven, paars ter hand stellen, oranje toedienen en gebruiken. De blauwe balk geeft het ontvangen of opvragen van beschikbaar gestelde gegevens aan, dit kan in elk van de deelprocessen plaats vinden. Een verdere uitwerking hiervan is in het vervolg van dit hoofdstuk bij het betreffende deelproces beschreven. 
In de volgende paragrafen zijn de processen medicatieverificatie, voorschrijven, ter hand stellen, toedienen en gebruiken beschreven.

{{anchor|figuur 3}}
[[Bestand:ActiviteitendiagramMP.png|1600px|Figuur 3 Activiteitendiagram - Medicatieproces algemeen]] 

==Proces: medicatieverificatie==
Voorafgaande aan het proces van voorschrijven wordt het werkelijke medicatiegebruik van de patiënt vastgesteld. Dit gebeurt<ref>De patiënt kan ook zijn eigen medicatie verifiëren. Hij legt dan gebruik vast, zie [[#Vastleggen medicatiegebruik door de patiënt|paragraaf 2.5.4.1]].</ref>:
*in de huisartsenpraktijk door de huisarts tijdens het consult,
*op de huisartsenpost, SEH (Spoedeisende Hulp), crisisdienst GGZ (Geestelijke gezondheidszorg) door bijvoorbeeld de triagist of de behandelaar zelf, zo snel mogelijk, bij aankomst of opname,
*bij klinische of dagopname in een ziekenhuis of andere instellingen door bijvoorbeeld de verpleging, apothekersassistent of poliklinische/ziekenhuisapotheker,
*bij poliklinisch consult door bijvoorbeeld de verpleging, doktersassistent of behandelaar zelf.

===Huidige situatie===
*In de huidige situatie wordt aan de patiënt of de familie/mantelzorgers gevraagd welke medicatie zij gebruiken. Soms is de patiënt niet in staat om hier antwoord op te geven. Familie/mantelzorgers (indien bekend) kunnen hier vaak ook geen antwoord op geven. De arts neemt dan contact op met huisarts of apotheek om de medicatie te achterhalen. Buiten kantooruren en in het weekend lukt dit slecht.

===Preconditie===
De patiënt komt op (poliklinisch) consult of wordt (in de toekomst) opgenomen.

===Trigger event===
*Ambulante setting: consult van en/of voorschrijven aan ambulante patiënten en patiënten die in een andere zorginstelling<ref>Het gaat om patiënten uit een verpleeghuis of GGZ-instelling die naar de polikliniek van een ziekenhuis gaan.</ref> verblijven. Medicatieverificatie gebeurt dan vaak tijdens het evalueren van de behandeling (zie [[#Processtap: Evalueren (medicamenteuze) behandeling|paragraaf 2.2.4]]).
*Klinische setting: voorbereiding bij opname van patiënt.

===Proces===
De zorgverlener verzamelt de medicatiegegevens uit verschillende bronnen. Bronnen kunnen zijn:
*verhaal van patiënt,
*afleveroverzichten van apotheken,
*digitaal beschikbare medicatiegegevens van zorgverleners of PGO (Persoonlijke GezondheidsOmgeving),
*meegenomen medicatie,
*indien nodig telefonische informatie van eigen apotheker of huisarts.

De zorgverlener voert de medicatieverificatie uit met de patiënt en legt daarbij de geverifieerde medicatie als medicatiegebruik (MGB, incl. zelfzorgmedicatie) vast. Er ontstaat een geactualiseerd medicatieprofiel; zie ook [[#paragraaf5.1|paragraaf 5.1]].

In de praktijk zal alleen wanneer dit klinisch relevant is de medicatieverificatie leiden tot het vastleggen van gebruik en het actualiseren van het medicatieprofiel. Hierbij kan vooral gedacht worden aan opname en ontslag. 
De vastgelegde gegevens rond medicatiegebruik worden ter beschikking gesteld voor medebehandelaars en patiënt zodat deze de gegevens kunnen opvragen.

===Postconditie===
Het medicatiegebruik van de patiënt is vastgelegd. Medicatiegegevens (gebruik) zijn beschikbaar gesteld.

===Informatiesystemen en transactiegroepen===
[[#Systemen en transacties|Hoofdstuk 7]] geeft een overzicht van alle informatiesystemen, systeemrollen, transacties, etc. De belangrijkste voor het proces van medicatieverificatie zijn in onderstaand overzicht opgenomen.

{{anchor|figuur 4}}
[[Bestand:Medicatieverificatie.png|Figuur 4 Processtappen en transacties - medicatieverificatie]]

==Proces: voorschrijven==
Deze paragraaf beschrijft het proces van voorschrijven. Het gaat hierbij om alle voorschrijvers; denk bijvoorbeeld aan: huisarts, specialist, andere arts of specialistisch verpleegkundige met een voorschrijfbevoegdheid. Het proces van voorschrijven bestaat uit het evalueren van de eventueel reeds bestaande medicamenteuze behandeling. Zo nodig wordt er een medicatieafspraak gemaakt en, alleen in de ambulante situatie, eventueel een verstrekkingsverzoek. Ten slotte worden de vastgelegde gegevens (actief) beschikbaar gesteld. Voor een plaat van dit proces zie [[#Bijlage: Diagram Medicatieproces algemeen|hoofdstuk 13]].

===Huidige situatie===
Afwijkingen in de huidige situatie (ten opzicht van de gewenste) betreffen:
*Het logistieke proces bepaalt vaak de registratie (en zeker de communicatie). Het wijzigen en stoppen van medicatie wordt onvoldoende vastgelegd en/of gecommuniceerd. Dit leidt onder andere tot onnauwkeurige medicatiebewaking, onjuist gebruik en onjuiste medicatieprofielen. In plaats van het logistieke proces zou het farmacotherapeutisch beleid bepalend moeten zijn.
*Doordat de therapeutische intentie niet gecommuniceerd wordt naar de apotheker, is uit de beschikbare gegevens niet af te leiden of een aanvraag voor een herhaalrecept binnen die therapeutische intentie valt. Hierdoor kan onterecht een geneesmiddel hervat of gecontinueerd worden.
*Wanneer een wijziging niet wordt gecommuniceerd kan een aanvraag voor een herhaalrecept (via de apotheker) gebaseerd zijn op een verouderde gebruiksinstructie. Dit kan gemakkelijk leiden tot fouten.
*Vanuit de poliklinische setting wordt een medicatieafspraak en/of een verstrekkingsverzoek nu meestal niet (elektronisch) verstuurd naar de apotheker.

===Preconditie===
Er is een bepaalde reden waarom een voorschrijver een medicamenteuze behandeling wil starten of evalueren/herzien.

===Trigger event===
De trigger voor het proces is het starten van een nieuwe medicamenteuze behandeling of evalueren van een lopende behandeling of het ontvangen van een voorstel verstrekkingsverzoek of voorstel medicatieafspraak of het ontvangen van een afhandeling voorschrift van een apotheker of opname in of ontslag van een patiënt uit een instelling.

===Processtap: Evalueren (medicamenteuze) behandeling===
Om de behandeling te kunnen evalueren is er behoefte aan een actueel overzicht van medicatiegegevens. Het dossier van de zorgverlener wordt zo mogelijk en indien nodig aangevuld met gegevens uit externe bronnen en eventueel wordt aan de patiënt gevraagd welke geneesmiddelen hij gebruikt. Dit gebruik kan door de zorgverlener worden vastgelegd. Desgewenst vindt er eerst uitgebreidere medicatieverificatie plaats (zie [[#Proces: medicatieverificatie|paragraaf 2.1]]).

De behandelend arts<ref>Hiertoe behoren alle zorgverleners die bevoegd zijn tot voorschrijven: naast artsen zijn dat bijvoorbeeld ook verpleegkundig specialisten en physician assistants.</ref> evalueert de (medicamenteuze) behandeling en besluit tot:
*het starten van een nieuwe medicamenteuze behandeling door het maken van een eerste medicatieafspraak en/of
*het continueren, stoppen (definitief of tijdelijk) of wijzigen van een bestaande medicatieafspraak (1 of meerdere)<ref>Bij substitutie is er sprake van het staken van de bestaande medicatieafspraak en het maken van een nieuwe medicatieafspraak onder een nieuwe medicamenteuze behandeling.</ref> en/of
*het corrigeren/annuleren van een bestaande medicatieafspraak en/of
*accorderen voorstel verstrekkingsverzoek (en antwoorden via het antwoord voorstel verstrekkingsverzoek) of voorstel medicatieafspraak.
In de volgende paragraaf worden deze situaties nader toegelicht. Zie ook [[#Medicamenteuze behandeling|paragraaf 1.3.3]] voor meer informatie over het begrip medicamenteuze behandeling. 

===Processtap: Maken medicatieafspraak===
Bij het maken van een medicatieafspraak geldt het uitgangspunt: elke wijziging wordt vastgelegd in een nieuwe medicatieafspraak.
Een wijziging wordt technisch ingevuld door het beëindigen van de bestaande medicatieafspra(a)k(en) door de stopdatum (einddatum van de gebruiksperiode) in te vullen én het maken van een nieuwe medicatieafspraak met de wijzigingen <ref>Informatiesystemen houden een audittrail bij. Bij een wijziging wordt de bestaande MA gestopt (nieuw record) en vervolgens wordt een nieuwe MA met daarin de wijziging aangemaakt (nieuw record). Door gebruik te maken van de records in de audittrail zijn er voor het stoppen van een MA in de meeste informatiesystemen geen grote aanpassingen nodig.</ref>. 
Medicatieafspraken kunnen ook gemaakt worden om te starten in de toekomst. Ze krijgen dan een gebruiksperiode met een toekomstige ingangsdatum die dus later is dan de datum van de afspraak. Een eventuele voorgaande medicatieafspraak heeft dan een stopdatum pas net voor de ingangsdatum/tijd van de toekomstige.
In de gebruiksperiode kan ook enkel een ingangsdatum aangegeven worden (zonder duur of stopdatum), dit is het geval bij doorlopende medicatie. Om verwarring te voorkomen tussen 'tot' en 'tot en met' is het meegeven van de tijd altijd verplicht bij de stopdatum. 'Tot en met' datum (bij een gehele dag) is tijdstip 23:59:59 van toepassing.

Voordat de medicatieafspraak (actief) beschikbaar wordt gesteld, vindt medicatiebewaking plaatst conform de geldende richtlijnen. Dit is onderdeel van deze processtap.

In de volgende paragrafen zijn de verschillende situaties beschreven waarin een medicatieafspraak wordt gemaakt: eerste medicatieafspraak, continueren medicatie, stoppen medicatie, tijdelijk onderbreken medicatie, wijzigen medicatie of het corrigeren/annuleren van een medicatieafspraak. Informatie over de Medicamenteuze behandeling wordt bekend verondersteld (zie [[#Medicamenteuze behandeling|paragraaf 1.3.3]]).

====''Nieuwe medicatieafspraak''====
Een nieuwe medicatieafspraak wordt gemaakt bij de start van een medicamenteuze behandeling of een wijziging daarvan. Wanneer er een nieuwe medicamenteuze behandeling gestart wordt dient de voorschrijver te overwegen of een bestaande medicamenteuze behandeling gestopt moet worden.
De beschrijving in [[#Medicamenteuze behandeling|paragraaf 1.3.3]] gaat uit van het meest gangbare proces van voorschrijven tot toedienen of gebruiken. In de overgangssituatie of bij het ontbreken van digitale gegevens kan het ook gebeuren dat een medicamenteuze behandeling systeemtechnisch gezien begint met bijvoorbeeld een toedieningsafspraak. Dit treedt bijvoorbeeld op wanneer de apotheker de medicatieafspraak met bijbehorende medicamenteuze behandeling niet digitaal heeft ontvangen. De apotheker start dan een nieuwe medicamenteuze behandeling bij het maken van de toedieningsafspraak. Dit kan met elke andere bouwsteen ook het geval zijn. Zo kan ook de patiënt bijvoorbeeld een medicamenteuze behandeling starten door het vastleggen van medicatiegebruik zonder daarbij de oorspronkelijke medicamenteuze behandeling te hebben.

====''Continueren medicatie''====
In een aantal gevallen blijft de therapeutische intentie van de voorschrijver gelijk en hoeft de medicatieafspraak niet aangepast te worden. Dit gebeurt bijvoorbeeld
*in de ambulante situatie wanneer er alleen een nieuw verstrekkingsverzoek gewenst is ingeval van een herhaling, of
*bij opname in een instelling waarbij de thuismedicatie wordt doorgebruikt, al dan niet gecombineerd met ‘Medicatie in Eigen Beheer’
In deze beide gevallen wordt de bestaande medicatieafspraak niet aangepast. 
Wanneer, bijvoorbeeld bij een opname of ontslag, sprake is van een wijziging in PRK wordt in alle gevallen de bestaande medicamenteuze behandeling beëindigd door het maken van een stop-MA (zie [[#Stoppen medicatie|Stoppen medicatie (paragraaf 2.2.5.3)]]) en een nieuwe medicamenteuze behandeling gestart (zie [[#Nieuwe medicatieafspraak|Nieuwe medicatieafspraak (paragraaf 2.2.5.1.)]]).

====''Stoppen medicatie''====
Medicatie wordt gestopt door het maken van een nieuwe medicatieafspraak (stop-MA) binnen dezelfde medicamenteuze behandeling. De reden van het stoppen wordt in deze medicatieafspraak vastgelegd. De medicatie kan per direct of in de toekomst gestopt worden. 
De nieuwe stop-medicatieafspraak is een kopie van de bestaande medicatieafspraak met:
*in de gebruiksperiode als stopdatum de datum waarop de medicatieafspraak eindigt (kan ook in de toekomst liggen),
*een stopdatum die ook moet terugkomen in de tekstuele omschrijving van de gebruiksinstructie,
*een eigen auteur,
*een eigen afspraakdatum,
*stoptype 'definitief',
*verwijzing naar de specifieke medicatieafspraak die gewijzigd wordt (toekomstige medicatieafspraken blijven bestaan). Het is niet mogelijk om een stop-MA aan te maken zonder verwijzing naar de MA die gestopt moet worden, behalve als er geen MA beschikbaar is in de MBH om naar te verwijzen. Wanneer er alleen TA('s) en/of MGB('s) beschikbaar zijn in de MBH moet de voorschrijver deze kunnen stoppen met een stop-MA zonder relatie naar MA.
Voor een medicatieafspraak waarin al direct een stopdatum is afgesproken, bijvoorbeeld in geval van een kuur, is geen aanvullende stop-MA nodig. Wanneer een medicatieafspraak met een stopdatum die nog in de toekomst ligt wordt verlengd, is dat een gewone wijziging (zie [[#Wijzigen medicatie|Wijzigen medicatie (paragraaf 2.2.5.5)]]). Een stop-MA heeft ook het stoptype 'definitief' als het een stop-MA is als gevolg van een wijziging. Bij een wijziging wordt de stop-MA opgevolgd door een nieuwe medicatieafspraak. Voor de eindgebruikers is de stop-MA als gevolg van een wijziging minder relevant. Een stop-MA als gevolg van een wijziging wordt ook wel een technische stop-MA genoemd. De user-interface dient hierbij adequaat te ondersteunen. Een voorschrijver zal hier minder behoefte aan hebben dan een apotheker die zijn logistieke proces mogelijk moet aanpassen vanwege de wijziging.

====''Tijdelijk onderbreken en hervatten van medicatie''====
Tijdelijk onderbreken is het stoppen van het medicatiegebruik gedurende een bepaalde, vooraf bekende of onbekende, periode. Tijdelijk onderbreken kan per direct of in de toekomst plaatsvinden. In de periode van onderbreken blijft de medicatie relevant voor medicatiebewaking in verband met het mogelijk hervatten in de toekomst. Tijdelijke substitutie met een ander middel is dus geen onderbreking maar daadwerkelijk stoppen van het eerste middel en het starten van een nieuwe medicamenteuze behandeling met het substituut. Tijdelijk onderbreken bestaat uit twee medicatieafspraken<ref>Dit betekent niet dat eindgebruikers ook daadwerkelijk twee afspraken moeten maken. Een gebruikersvriendelijke presentatie door het informatiesysteem is gewenst. </ref>: als start van de onderbreking wordt een medicatieafspraak (stop-MA) vastgelegd overeenkomstig de stop-MA (zie vorige paragraaf), maar met stoptype 'tijdelijk' en voor het hervatten van de medicatie wordt een nieuwe medicatieafspraak (met eventueel reden van hervatting) vastgelegd. Al deze medicatieafspraken vallen onder dezelfde medicamenteuze behandeling. De reden van de onderbreking wordt in de stop-MA vastgelegd. De stop-MA verwijst naar de originele medicatieafspraak om deze tijdelijk te onderbreken. Het stoptype voor het tijdelijk onderbreken van medicatie is 'tijdelijk'.

====''Wijzigen medicatie''====
Het wijzigen van een medicatieafspraak kan onder andere betrekking hebben op:
:a) de dosering,
:b) de sterkte van het geneesmiddel,
:c) toedieningswijze,
:d) de duur (bijvoorbeeld een verlenging van de therapie);
:e) de verantwoordelijk voorschrijver.
Bij een overstap naar een geheel ander geneesmiddel is er in principe sprake van het overstappen op een andere medicamenteuze behandeling (zie ook [[#Medicamenteuze behandeling|paragraaf 1.3.3]]). In dat geval stopt de arts de bestaande behandeling (zie [[#Stoppen medicatie|paragraaf 2.2.5.13]]) en start een nieuwe (zie [[#Nieuwe medicatieafspraak|paragraaf 2.2.5.1]]). 
Wijzigingen worden, bij gelijkblijvende PRK, vastgelegd onder dezelfde medicamenteuze behandeling. Bij een wijziging wordt er een technische stop-MA gemaakt (zie [[#Stoppen medicatie|paragraaf 2.2.5.3]]) en een nieuwe medicatieafspraak met de wijziging. De afspraak datum van de technisch stop-MA en de nieuwe medicatieafspraak moeten altijd hetzelfde zijn. In de nieuwe medicatieafspraak wordt de reden van de wijziging opgenomen en (zo mogelijk) een verwijzing naar de oorspronkelijke medicatieafspraak. Wijzigingen kunnen per direct of in de toekomst ingaan. Een technische stop-MA en bijbehorende nieuwe medicatieafspraak worden gelijktijdig ter beschikking gesteld.
Ingeval van het verlengen van een medicatieafspraak waarvan de duur al is verlopen of de ingevulde stopdatum al voorbij is, dan wordt dit niet gezien als een wijziging (een stop-MA op de reeds automatisch gestopte medicatieafspraak is overbodig). In dit geval kan er onder de betreffende medicamenteuze behandeling een nieuwe MA worden gemaakt.

====''Corrigeren / annuleren medicatieafspraak''<ref>Het corrigeren/annuleren van toedieningsafspraken vindt op gelijke wijze plaats.
XIS is een generieke term voor een willekeurig (zorg)informatiesysteem. PGO=Persoonlijke GezondheidsOmgeving.</ref>====
Dit betreft het corrigeren of annuleren van een medicatieafspraak omdat een voorschrijver een fout maakte. Dit kan ontdekt zijn door de voorschrijver zelf of door een medebehandelaar. 
Bijvoorbeeld een arts die een typefout maakt in de dosering van een medicatieafspraak: 2 maal daags 10 inhalaties in plaats van 2 maal daags 1 inhalatie. Indien de medicatieafspraak nog niet gedeeld is met andere zorgverleners, dan kan de voorschrijver die medicatieafspraak zelf aanpassen of schrappen (annuleren) uit het eigen informatiesysteem. Indien de afspraak al wel gedeeld is met andere zorgverleners dan stopt hij deze foutieve medicatieafspraak met een stop-MA en als reden 'foutieve registratie' en maakt een nieuwe medicatieafspraak onder dezelfde medicamenteuze behandeling met de juiste informatie. De arts informeert de apotheker en eventuele medebehandelaren actief hierover en stelt de stop-MA en nieuwe medicatieafspraak beschikbaar (zie [[#Processtap: (Actief) beschikbaarstellen|paragraaf 2.2.10]]).

====''Stoppen toekomstige medicatieafspraak''====
Dit betreft alleen medicatieafspraken waarvan de startdatum in de toekomst ligt. Een voorschrijver kan deze toekomstige MA om wat voor reden dan ook willen beëindigen. Hiervoor wordt geen stop-MA aangemaakt maar annuleert de voorschrijver de toekomstige MA. Dit doet de voorschrijver door gebruik te maken van de geannuleerd indicator. Hier kan de voorschrijver alleen gebruik van maken als de startdatum van de MA in toekomst ligt. Als deze voorschrijver de toekomstige MA wil beëindigen dan verandert hij/zij de status van de originele MA naar ‘geannuleerd’. Hier wordt dan dus geen gebruik meer gemaakt van de stop-MA.

In het scenario waarbij niet de originele voorschrijver van de MA maar een andere voorschrijver de toekomstige MA wil beëindigen werkt het proces op de volgende manier. Deze voorschrijver maakt een nieuwe MA aan met daarin geannuleerd indicator geactiveerd. Deze ‘geannuleerd-MA’ stuurt de voorschrijver op naar de originele voorschrijver van de MA. De originele voorschrijver van de MA wijzigt dan ook in de originele MA de status naar geannuleerd.

===Processtap: Maken wisselend doseerschema===
Als een voorschrijver medicatie met een wisselend doseerschema voorschrijft, kan de dosering van deze medicatie tussentijds aangepast worden door een (andere) voorschrijver, zonder dat de medicatieafspraak iedere keer gewijzigd moet worden. Dit is het geval bij antistollingsmedicatie. Bij deze medicatie bepaalt de voorschrijver de therapeutische INR-range (International Normalized Ratio, maat voor de stollingstijd van het bloed) waarbinnen de behandeling plaats dient te vinden.
De invulling van de wisselende doseerschema’s wordt gedaan door de trombosedienst. Het doseerschema wordt in de medicatiebouwsteen wisselend doseerschema (WDS) ingevuld door een voorschrijver, vaak de trombosearts. De voorschrijvend arts, die de medicatieafspraak heeft gemaakt, blijft verantwoordelijk voor de verstrekkingsverzoeken, de trombosearts stelt het specifieke doseerschema op binnen de afgesproken INR-range en op basis van de gemeten INR-waarde. 

====Opstarten wisselend doseerschema ====
De voorschrijver schrijft antistollingsmedicatie voor en geeft in de medicatieafspraak aan:
* Welk geneesmiddel (PRK) de patiënt voorgeschreven krijgt. In het wisselend doseerschema is altijd hetzelfde geneesmiddel opgenomen als in de medicatieafspraak.
* Dat de medicatie wordt gebruikt volgens schema trombosedienst. Dit wordt geregistreerd onder ‘aanvullende instructie’, er wordt in de medicatieafspraak dus geen doseerschema opgenomen;
* Binnen welke INR-range de behandeling plaats dient te vinden (in ‘toelichting’)
Om de periode tot de trombosezorg betrokken is te overbruggen, maakt de voorschrijver een eerste wisselend doseerschema aan voor de eerste periode (vaak tussen de 4 en 7 dagen). Na aanmelding bij de trombosedienst, wordt meestal een controledatum afgesproken waarbij de INR-waarde gemeten wordt. Op basis van de INR-waarde en/ of de professionele inschatting van de trombosearts stelt de trombosedienst een doseerschema op dat het schema van de voorschrijver wijzigt of opvolgt. Vanaf dit moment neemt de trombosedienst het opstellen van de doseerschema’s over van de oorspronkelijke voorschrijver.

''INR-waarde bij het WDS'' 
Het wisselend doseerschema is vaak gebaseerd op een INR-waarde. Voor andere betrokkenen in de keten is het belangrijk om te kunnen achterhalen op welke waarde een bepaald wisselend doseerschema gebaseerd is. Daarom kan bij het beschikbaarstellen (of gericht sturen) van een wisselend doseerschema ook de bijbehorende INR-waarde beschikbaar gesteld worden. De INR-waarde wordt opgenomen in vrije tekst onder ‘toelichting’ in het wisselend doseerschema.

====Wijzigen wisselend doseerschema ====
Wanneer het wisselend doseerschema gebruikt wordt tot de stopdatum van het schema, kan het doseerschema opgevolgd worden door een nieuw schema. In het wisselend doseerschema staat een relatie naar de medicatieafspraak en naar het vorige wisselend doseerschema.
Het is ook mogelijk om een doseerschema tussentijds aan te passen. In dat geval sluit het informatiesysteem het huidige wisselend doseerschema af met een technische stop-WDS (niet zichtbaar voor de gebruiker). Het nieuwe wisselend doseerschema volgt daarop en heeft een reden van wijzigen en een relatie naar de medicatieafspraak en het vorige wisselend doseerschema.
Alle wijzigingen die gaan over het doseerschema, kunnen in het wisselend doseerschema opgenomen worden. Wijzigingen die gaan over het verdere behandelbeleid (bijv. het geneesmiddel, de toedieningsweg of de INR-range) worden opgenomen in de medicatieafspraak.

====Stoppen wisselend doseerschema ====
Antistollingsmedicatie kan om verschillende redenen (tijdelijk) gestopt worden. Bijvoorbeeld in geval van een ingreep, of omdat er tijdelijk sprake is van co-medicatie. Er zijn twee situaties te onderscheiden, afhankelijk van de situatie en de inschatting van de trombosearts kan voor een van beide werkwijzen gekozen worden.
# ''(tijdelijk) aanpassen van beleid:'' De trombosearts kan kiezen om de dosering voor de antistollingsmedicatie tijdelijk aan te passen naar 0. Bijvoorbeeld in aanloop naar een geplande ingreep. De medicatieafspraak (en daarmee de behandeling met antistollingsmedicatie) en de toedieningsafspraak lopen in dit geval door, maar in het wisselend doseerschema wordt de dosering tijdelijk aangepast naar 0. Op het medicatieoverzicht zal de medicatieafspraak van de antistollingsmedicatie te zien zijn onder ‘actuele medicatie’. Bij een dergelijke aanpassing in het wisselend doseerschema is het wenselijk om de reden voor deze wijziging mee te sturen.
# ''staken of stoppen antistollingsmedicatie:'' De trombosearts (of een andere voorschrijver) kan er ook voor kiezen om de behandeling met antistollingsmedicatie (tijdelijk) te stoppen. Dit betekent dat er geen dosering meer plaats mag vinden. In dat geval maakt de trombosearts een stop-MA aan (of stuurt deze een voorstel-MA aan de voorschrijver). Met het stoppen van de medicatieafspraak wordt ook het onderliggende WDS en de bijbehorende TA gestopt. Op het medicatieoverzicht zal de medicatieafspraak van de antistollingsmedicatie te zien zijn onder ‘recent gestopte medicatie’.
Als de MA na een bepaalde periode weer opgestart of gewijzigd moet worden, doet de oorspronkelijke voorschrijver van de antistollingsmedicatie dit door een nieuwe MA aan te maken. In veel gevallen is de trombosedienst ook (tijdelijk) niet meer betrokken bij de patiënt, mocht dit wel het geval zijn dan kan de trombosearts een voorstel-MA sturen naar de oorspronkelijke voorschrijver en kan deze dit voorstel overnemen in een MA.

===Processtap: Maken verstrekkingsverzoek===
Een verstrekkingsverzoek (naast een medicatieafspraak) is alleen van toepassing in de ambulante situatie. Er kan een verstrekkingsverzoek worden gedaan als de voorraad medicatie van de patiënt moet worden aangevuld. Dit hoeft niet tegelijk met een medicatieafspraak plaats te vinden. Bij de start van een medicamenteuze behandeling waarbij de patiënt nog voldoende voorraad thuis heeft van een vorige keer is een verstrekkingsverzoek niet nodig. Ook wanneer de dosering verlaagd wordt, kan de patiënt nog genoeg op voorraad hebben. Bij een geneesmiddel dat lang loopt (bijvoorbeeld een bloeddrukverlager waarbij er een doorlopende medicatieafspraak is gemaakt, dus een gebruiksperiode met enkel een ingangsdatum), kunnen er in de loop van de tijd meerdere verstrekkingsverzoeken worden gedaan onder deze bestaande medicatieafspraak. Het is ook mogelijk dat een andere voorschrijver dan degene die de medicatieafspraak heeft gemaakt, een verstrekkingsverzoek onder deze medicatieafspraak doet. 
In het verstrekkingsverzoek kunnen logistieke en urgentie aanwijzingen worden meegegeven, zoals afleverlocatie, niet opnemen in GDS (Geneesmiddel Distributie Systeem), etc.

Bij een verstrekkingsverzoek kan de te verstrekken hoeveelheid opgegeven worden óf de verbruiksperiode. Bij een verbruiksperiode moet de hoeveelheid wel eenduidig afleidbaar zijn uit de doseerinstructie van de medicatieafspraak. Let op: een verbruiksperiode einddatum heeft een andere betekenis dan de gebruiksperiode stopdatum uit de medicatieafspraak en kunnen ongelijk zijn.
* verbruiksperiode einddatum: datum tot wanneer de apotheker toestemming heeft om verstrekkingen te doen (en daarmee voldoende voorraad aan de patiënt mee te geven voor gebruik tot aan die datum).
* gebruiksperiode stopdatum: datum waarop de patiënt moet stoppen met de medicatie (deze kan gelijk zijn aan de verbruiksperiode einddatum of verder in de toekomst liggen).

===Processtap: Nierfunctiewaarde meesturen met het voorschrift ===

Voor sommige geneesmiddelen is het functioneren van de nieren van belang. De nierfunctiewaarde bepaalt dan de keuze van het geneesmiddel en/of de geneesmiddeldosering. Wettelijk is vastgelegd dat indien een beroepsbeoefenaar bij een patiënt nader onderzoek heeft laten uitvoeren naar de nierfunctie, hij afwijkende nierfunctiewaarden deelt met de daartoe door patiënt aangewezen apotheker (artikel 6.10, regeling geneesmiddelenwet).

De nierfunctiewaarde wordt altijd met het voorschrift meegestuurd (m.b.v. de bouwsteen laboratoriumuitslag) voor geneesmiddelen waarvoor dit van belang is (kenmerk in de G-standaard), zodat de apotheker goede medicatiebewaking kan uitvoeren. De nierfunctiewaarde mag niet ouder zijn dan 13 maanden, omdat bij een stabiele chronische verminderde nierfunctie de nierfunctie 1x per jaar gecontroleerd moet worden. Hier is 1 maand aan toegevoegd, zodat er voor de praktijk enige speling is.

Als op het moment van het sturen van een medicatieafspraak en/of verstrekkingsverzoek geen nierfunctie bekend is, betreft dat het voorschrijfbeleid van dat moment.
Het los sturen van de laboratoriumuitslag nierfunctiewaarde zonder medicatieafspraak en/of verstrekkingsverzoek valt buiten scope van deze informatiestandaard.

===Processtap: Lengte en gewicht meesturen in het voorschrift ===

De voorschrijver kan bij het versturen van het medicatievoorschrift ook de lichaamslengte en het lichaamsgewicht van de patiënt meesturen. Het gaat om de lengte en het gewicht dat de voorschrijver heeft aangehouden voor het bepalen van de medicatieafspraak. Deze kan dus afwijken (nauwkeuriger zijn) van de lengte of het gewicht dat algemeen is vastgelegd over de patiënt. Dit kan bijvoorbeeld gedaan worden bij het voorschrijven aan kinderen, of het voorschrijven van medicatie waarbij gewicht (bepaalde stollingsmedicatie) of lichaamsoppervlak (bijv. bij sommige oncolytica) van belang zijn.

Lichaamslengte en lichaamsgewicht zijn losse bouwstenen en kunnen alleen worden meegestuurd bij het versturen van het medicatievoorschrift en bij het versturen van een voorstel medicatieafspraak. Deze informatie is verder niet opvraagbaar.

===Processtap: (Actief) beschikbaarstellen===
In deze stap vindt informatie-uitwisseling plaats. De informatie kan met verschillende intenties gestuurd of beschikbaar gesteld worden:
:A. Als opdracht aan de apotheker om medicatie ter hand te stellen. De voorschrijver verstuurt de medicatieafspraak aan de apotheker. In de ambulante situatie wordt daarbij ook het verstrekkingsverzoek naar de apotheker van keuze van de patiënt gestuurd. Wanneer de apotheker niet bekend is kan deze processtap ook worden vervuld met een papieren recept en/of het (reactief) beschikbaarstellen van de gegevens (zie C). Wanneer de apotheker de opdracht heeft ingevuld dan ontvangt de voorschrijver daarvan bericht (zie [[#Processtap:_.28Actief.29_beschikbaarstellen_2|paragraaf 2.3.8]]).
:B. Als opdracht aan de apotheker om een wijziging in medicatie (incl. stop-MA met stoptype definitief of tijdelijk) door te voeren dat impact heeft of kan hebben op een lopende ter hand stelling van deze apotheker. Een lopende ter hand stelling houdt in dat er een opdracht (als bij A) is aangenomen die nog niet volledig is ingevuld. Er vinden bijvoorbeeld nog uitgiftes plaats of er is sprake van meerdere uitgiftes op basis van een verstrekkingsverzoek waarvan nog niet alle uitgiftes hebben plaatsgevonden. Dit komt bijvoorbeeld bij GDS voor.
:C. Het beschikbaarstellen van de medicatiegegevens (MA, WDS, VV (aan patiënt), MGB) zodat medebehandelaren en/of patiënt deze later kunnen opvragen eventueel in combinatie met ongeadresseerd voorschrijven (zie [[#Ongeadresseerd voorschrijven (ambulant)|paragraaf 9.1]]).
:D. Het geadresseerd sturen (informeren) van medicatiegegevens (één of meerdere bouwstenen) aan een andere zorgverlener op verzoek van de patiënt die bij deze zorgverlener aanwezig is of bij ontslag.

Bij gecorrigeerde gegevens schat de voorschrijver in wie hij actief op de hoogte moet stellen van deze correctie bijvoorbeeld door het sturen van de nieuwe afspraak (optie A of B hierboven) of door middel van telefonisch overleg. 
In de ambulante setting (huisarts/polikliniek) worden gegevens meestal direct gestuurd of beschikbaar gesteld, in de klinische setting meestal bij ontslag of tussentijds verlof uit de instelling. 
In dit hoofdstuk wordt uitgegaan van geadresseerd voorschrijven; in [[#Ongeadresseerd voorschrijven (ambulant)|paragraaf 7.5]] is het ongeadresseerd voorschrijven uitgewerkt. 
Zie ook [[#Informeren en (actief) beschikbaar stellen|paragraaf 1.3.5]] voor een nadere toelichting op informeren (situatie A, B, D) en beschikbaar stellen (situatie C).

===Postconditie===
*Er kan een nieuwe medicatieafspraak gemaakt zijn (starten, wijzigen of stoppen van medicatie)
*Er kan een verstrekkingsverzoek gedaan zijn (alleen ambulant)
*Er kan een opdracht gestuurd zijn naar de apotheker om een ter hand stelling uit te voeren
*Er kan een opdracht gestuurd zijn naar de apotheker om een ter hand stelling aan te passen
*Medebehandelaars en de patiënt zijn geïnformeerd of kunnen zich informeren over de nieuwe medicatiegegevens: medicatieafspraak, verstrekkingsverzoek, gebruik.

===Informatiesystemen en transactiegroepen===
Zowel de ''voorschrijver'' als de ''apotheker'' als andere ''medebehandelaars'' en ''gebruikers'' maken ieder gebruik van een informatiesysteem, respectievelijk een elektronisch voorschrijfsysteem (EVS), een apothekersinformatiesysteem (AIS, incl. ZAIS), een XIS en een PGO<ref>XIS is een generieke term voor een willekeurig (zorg)informatiesysteem. PGO=Persoonlijke GezondheidsOmgeving.</ref>. Deze informatiesystemen kennen ieder verschillende systeemrollen, die het uitwisselen van gegevens tussen deze informatiesystemen in het kader van het voorschrijfproces mogelijk maken. 
[[#Systemen en transacties|Hoofdstuk 7]] geeft een overzicht van alle informatiesystemen, systeemrollen, transacties, etc. De belangrijkste voor het proces van voorschrijven zijn in onderstaand overzicht opgenomen.

{{anchor|figuur 5}}
[[Bestand:Uc Voorschrijven.png|Figuur 5 Processtappen en transacties - voorschrijven]]

===Use cases===
De volgende specifieke use cases van voorschrijven zijn uitgewerkt:
*[[#Kortdurende_medicatie|Kortdurende medicatie (paragraaf 4.1.1)]]
*[[#Doorlopende medicatie|Doorlopende medicatie (paragraaf 4.1.2)]]
*[[#Harde stopdatum gebruiksperiode| Harde stopdatum gebruiksperiode (paragraaf 4.1.3)]]
*[[#Zo nodig medicatie|Zo nodig medicatie (paragraaf 4.1.4)]]
*[[#Kuur zo nodig startend in de toekomst|Kuur zo nodig startend in de toekomst (paragraaf 4.1.5)]]
*[[#Twee doseringen van hetzelfde geneesmiddel tegelijkertijd|Twee doseringen van hetzelfde geneesmiddel tegelijkertijd (paragraaf 4.1.6)]]
*[[#Hetzelfde geneesmiddel met verschillende sterkte tegelijkertijd|Hetzelfde geneesmiddel met verschillende sterkte tegelijkertijd (paragraaf 4.1.7)]]
*[[#Toelichting in medicatieafspraak bij bewust gekozen bijzonderheid|Toelichting in medicatieafspraak bij bewust gekozen bijzonderheid (paragraaf 4.1.8)]]
*[[#Nieuwe medicatieafspraak, geen verstrekkingsverzoek|Nieuwe medicatieafspraak, geen verstrekkingsverzoek (paragraaf 4.1.9)]]
*[[#Nieuw verstrekkingsverzoek onder bestaande medicatieafspraak|Nieuw verstrekkingsverzoek onder bestaande medicatieafspraak (paragraaf 4.1.10)]]
*[[#Wijziging in dosering (voldoende voorraad)|Wijziging in dosering (voldoende voorraad) (paragraaf 4.1.11)]]
*[[#Recept niet meer nodig na eerste verstrekkingsverzoek|Recept niet meer nodig na eerste verstrekkingsverzoek (paragraaf 4.1.12)]]
*[[#Stoppen medicatie|Stoppen medicatie (paragraaf 4.1.13)]]
*[[#Onderbreken / hervatten medicatie|Onderbreken / hervatten medicatie (paragraaf 4.1.14)]]
*[[#Onderbreken voor een ingreep|Onderbreken voor een ingreep (paragraaf 4.1.15)]]
*[[#Substitutie|Substitutie (paragraaf 4.1.16)]]
*[[#Papieren recept|Papieren recept (paragraaf 4.1.17)]]
*[[#Uitvoeren medicatieverificatie en evaluatie bij buitenlandse of zelfzorgmedicatie|Uitvoeren medicatieverificatie en evaluatie bij buitenlandse of zelfzorgmedicatie (paragraaf 4.1.18)]]
*[[#Dagbehandeling|Dagbehandeling (paragraaf 4.1.19)]]
*[[#Starten met medicatie voor opname|Starten met medicatie voor opname (paragraaf 4.1.20)]]
*[[#Spoedopname|Spoedopname (paragraaf 4.1.21)]]
*[[#Ontslag|Ontslag (paragraaf 4.1.22)]]
*[[#Tussentijds ontslag|Tussentijds ontslag (paragraaf 4.1.23)]]
*[[#Ontslag naar andere instelling|Ontslag naar andere instelling (paragraaf 4.1.24)]]
*[[#Niet verstrekken voor|Niet verstrekken voor (paragraaf 4.1.25)]]
*[[#Stoppen van medicatie door derden|Stoppen van medicatie door derden (paragraaf 4.1.26)]]
*[[#Verschillende PRKs onder dezelfde medicamenteuze behandeling|Verschillende PRKs onder dezelfde medicamenteuze behandeling (paragraaf 4.1.27)]]
*[[#Achteraf vastleggen medicatieafspraak|Achteraf vastleggen medicatieafspraak (paragraaf 4.1.28)]]
*[[#Eenmalig gebruik|Eenmalig gebruik (paragraaf 4.1.30)]]
*[[#Voorlopige en definitieve medicatieopdracht|Voorlopige en definitieve medicatieopdracht (paragraaf 4.1.31)]]
*[[#Onterecht openstaande medicatie of 'weeskinderen'|Onterecht openstaande medicatie of 'weeskinderen' (paragraaf 4.1.32)]]
*[[#Ontbreken digitale medicatieafspraak bij opname|Ontbreken digitale medicatieafspraak bij opname (paragraaf 4.1.33)]]
*[[#Eigen artikelen (90 miljoen nummers)|Eigen artikelen (90 miljoen nummers) (paragraaf 4.1.34)]]
*[[#Dosering met minimum interval|Dosering met minimum interval (paragraaf 4.1.35)]]
*[[#Verstrekkingsverzoek met aantal herhalingen|Verstrekkingsverzoek met aantal herhalingen (paragraaf 4.1.36)]]
*[[#Voorschrijven van niet geneesmiddelen (verbandmiddelen, krukken of andere hulpmiddelen)|Voorschrijven van niet geneesmiddelen (verbandmiddelen, krukken of andere hulpmiddelen) (paragraaf 4.1.37)]]
*[[#Nierfunctiewaarde sturen met het voorschrift|Nierfunctiewaarde sturen met het voorschrift (paragraaf 4.1.38)]]
*[[#Annuleren eerder verstuurd voorschrift|Annuleren eerder verstuurd voorschrift (paragraaf 4.1.39)]]
*[[#Wijzigen van andermans medicatieafspraak|Wijzigen van andermans medicatieafspraak (paragraaf 4.1.40)]]
*[[#Opstarten van een wisselend doseerschema|Opstarten van een wisselend doseerschema (paragraaf 4.1.41)]]
*[[#Tussentijds wijzigen wisselend doseerschema|Tussentijds wijzigen wisselend doseerschema (paragraaf 4.1.42)]]
*[[#Stoppen medicatie met een wisselend doseerschema|Stoppen medicatie met een wisselend doseerschema (paragraaf 4.1.43)]]

==Proces: ter hand stellen==
Deze paragraaf beschrijft het proces van het ter hand stellen, inclusief herhaling en GDS. Het proces omvat het geheel van handelingen die de apotheker uitvoert opdat de patiënt niet alleen een farmaceutisch product ontvangt, maar ook de daarbij behorende farmaceutische zorg, zodat hij het product veilig en effectief kan gebruiken. Het proces van ter hand stellen start met het uitvoeren van farmaceutische zorg. Vervolgens wordt er zo nodig een toedieningsafspraak gemaakt en vindt er (indien nodig) een verstrekking plaats. Er hoeft niet altijd een medicatieverstrekking (d.w.z uitgifte van een geneesmiddel) plaats te vinden. Dit is het geval bij sommige wijzigingen in de medicatieafspraak (bijv. dosisverlaging waarbij de patiënt nog genoeg voorraad heeft), het stoppen van de medicatie of, in de ambulante situatie, het niet afhalen van de medicatie. Wanneer de medicatieafspraak en/of het verstrekkingsverzoek niet voldoen (zie [[#Processtap: Informeren schrijver|paragraaf 2.3.5]]) wordt de voorschrijver daarover ingelicht. Ten slotte worden de vastgelegde gegevens (actief) beschikbaar gesteld. Voor een plaat van dit proces zie [[#Bijlage: Diagram Medicatieproces algemeen|hoofdstuk 13]].

Medicatiebeoordeling is het proces waarbij arts en apotheker de complete medicatie van de patiënt beschouwen tegen de achtergrond van zijn aandoening, de geldende richtlijnen voor behandeling, het welbevinden van de patiënt, etc. Medicatiebeoordeling wordt in dit document gezien als een combinatie van evalueren medicamenteuze behandeling (zoals in de vorige paragrafen beschreven) en het verlenen van farmaceutische zorg. Afhankelijk van de bevindingen worden de eerder beschreven processen van medicatieverificatie en voorschrijven doorlopen en opgevolgd door ter hand stellen.

Veel apothekers werken voor GDS samen met een andere organisatie die een deel van de logistiek van de apotheker overneemt. Daarbij is ook informatie-uitwisseling met die partij nodig. Daarnaast is niet alle medicatie 'rolgeschikt'. Dit zorgt voor extra logistieke complexiteit bij de apotheker.
De interne logistieke activiteiten en communicatie tussen de apotheker en zijn 'onderaannemer(s)' zijn buiten scope van deze informatiestandaard. Wel is geconstateerd dat met het aanbieden van de huidige bouwstenen en onderliggende dataelementen dit logistieke proces voldoende ondersteund kan worden.

===Huidige situatie===
Afwijkingen in de huidige situatie (ten opzicht van de gewenste situatie) betreffen:
*In de huidige situatie, bij GDS, ontvangen de voorschrijvend arts en andere medebehandelaars een grote hoeveelheid afleverberichten. Dit is voor deze zorgverleners moeilijk te overzien.
*In de huidige situatie is er, bij geneesmiddel distributiesystemen, communicatie tussen apothekers en huisartsen via zogenaamde autorisatielijsten. Hierbij stuurt de apotheker een overzicht van alle medicatie van de patiënt naar de huisarts om deze in zijn geheel te autoriseren. Dit is lastig voor een huisarts omdat hij dan alle medicatieafspraken opnieuw moet verifiëren. Dit zou eigenlijk ook niet nodig moeten zijn, omdat de meeste medicatieafspraken/verstrekkingsverzoeken al geautoriseerd zijn. Het is dan ook veel efficiënter voor de huisarts om alleen die medicatieafspraken/verstrekkingsverzoeken te autoriseren die ook daadwerkelijk nog geautoriseerd moeten worden. Bijvoorbeeld een nieuw verstrekkingsverzoek op basis van een bestaande medicatieafspraak.
*Een dienstapotheek informeert de vaste huisarts en vaste apotheker in de huidige situatie vaak niet over uitgevoerde terhandstellingen.
*In de huidige situatie wordt een voorstel medicatieafspraak meestal per telefoon met de voorschrijver afgestemd en/of de apotheker en voorschrijver hebben een afspraak gemaakt over de afhandeling van een medicatiebewakingssignaal.
*De bedoeling van het retourbericht is niet altijd duidelijk: in het retour-/afleverbericht is geen onderscheid te maken tussen weergave van de fysieke aflevering en het doorgeven van informatie over een aanpassing in de medicatie.
*In de huidige situatie registreren (en communiceren) apothekers soms al medicatieverstrekkingen bij het gereed maken van de medicatie voor de patiënt in plaats van bij de daadwerkelijke uitgifte aan de patiënt. Dit betekent dat er soms ten onrechte medicatieverstrekkingen zijn geregistreerd voor niet afgehaalde medicatie.

===Preconditie===
Er is een medicatieafspraak en in de ambulante situatie eventueel een bijbehorend verstrekkingsverzoek.

===Trigger event===
De apotheker start het proces van ter hand stellen op basis van één van de volgende gebeurtenissen:
*Ontvangen van een opdracht om op basis van een nieuwe medicatieafspraak een medicatieverstrekking te doen. In de ambulante situatie gaat deze opdracht altijd gepaard met een verstrekkingsverzoek.
*Ontvangen van een opdracht om een nieuwe medicatieafspraak te verwerken in een lopende ter hand stelling.
*Ontvangen van een trigger (via bijvoorbeeld patiënt of herhaalmodule van het apotheekinformatiesysteem) voor een herhaalde terhandstelling onder een bestaande of nieuw voor te stellen verstrekkingsverzoek.

===Processtap: Uitvoeren farmaceutische zorg===
Het uitvoeren van de farmaceutische zorg gebeurt door de openbare, poliklinische of ziekenhuisapotheek, afhankelijk vanuit welke zorgaanbieder de medicatieafspraak afkomstig is:
*medicatieafspraken evt. met verstrekkingsverzoek van de huisarts of specialist door de openbare of poliklinische apotheek,
*medicatieafspraken van specialisten en andere voorschrijvers in ziekenhuizen/instellingen door de ziekenhuisapotheek of de openbare apotheek die levert aan de betreffende instelling.
Medicatiebewaking is ook een onderdeel van de farmaceutische zorg.

De apotheker besluit op basis van de ontvangen medicatieafspraak of wijziging in de situatie van de patiënt hoe hij deze kan invullen door:
*het maken van een of meerdere nieuwe toedieningsafspraken,
*het continueren, definitief stoppen, tijdelijk onderbreken of wijzigen van een bestaande toedieningsafspraak,
*het afwijzen van de medicatieafspraak,
*het voorstellen van een nieuwe medicatieafspraak,
*het voorstellen van een nieuw verstrekkingsverzoek.
De laatste drie situaties zijn in de volgende paragraaf toegelicht. De eerste twee situaties zijn toegelicht in [[#Processtap: Maken toedieningsafspraak|paragraaf 2.3.6.]] 

===Processtap: Informeren voorschrijver===
Er is een aantal situaties waarin de apotheker de voorschrijver informeert waaronder:
*omdat er mogelijk een nieuwe of gewijzigde medicatieafspraak nodig is
*omdat er een nieuw verstrekkingsverzoek nodig is.
Voor meer informatie over Informeren zie [[#Informeren en (actief) beschikbaar stellen|paragraaf 1.3.5.]]

Een nieuwe of gewijzigde medicatieafspraak is nodig:
*wanneer op basis van de ontvangen medicatieafspraak geen toedieningsafspraak kan worden gemaakt omdat de apotheker een fout in de medicatieafspraak vermoedt, of
*na een medicatiebewakingssignaal als onderdeel van de farmaceutische zorg. Daaruit blijkt bijvoorbeeld dat de dosering moet worden verlaagd of verhoogd, dat het raadzaam is een ander middel te kiezen, dat een middel tijdelijk gestopt dient te worden, dat een ander middel moet worden toegevoegd, et cetera, of
*op basis van het medicatiegebruik zoals verwoord door de patiënt tijdens het uitvoeren van de farmaceutische zorg, of
*wanneer de tijdelijk onderbroken medicamenteuze behandeling mogelijk kan worden hervat.
Er wordt in deze situaties dus nog geen toedieningsafspraak gemaakt of gewijzigd. 
In deze situaties belt in eerste instantie de apotheker de voorschrijver, informeert deze over de vermoede fout en stelt een alternatief voor. De apotheker kan ook een digitaal voorstel medicatieafspraak sturen naar de voorschrijver. Hij adviseert daarin een concrete medicatieafspraak, met de aanleiding en de argumenten voor dat advies. Vervolgens kan de voorschrijver de voorstel medicatieafspraak accorderen tot een definitieve medicatieafspraak (zie ook [[#Processtap: Evalueren (medicamenteuze) behandeling|paragraaf 2.2.4]]).

Er is een nieuw verstrekkingsverzoek nodig wanneer de medicatie op of bijna op is voor de patiënt en de behandeling mogelijk moet worden voortgezet (herhaling aanvragen). De patiënt vraagt herhaling van medicatie aan bij apotheker of de patiënt heeft zich in het verleden aangemeld voor proactief herhalen en de herhaalmodule van het AIS genereert een signaal wanneer een patiënt nieuwe medicatie nodig heeft<ref>De patiënt kan ook een herhaling rechtstreeks bij de voorschrijver aanvragen: zie [[#Processtap: Informeren voorschrijver|paragraaf 2.5.6]].</ref>. 
Wanneer het bestaande verstrekkingsverzoek niet voldoet kan de apotheker dit verzoek telefonisch doorgeven of een digitaal voorstel verstrekkingsverzoek naar de voorschrijver sturen. Het voorstel verstrekkingsverzoek kan aanwijzingen bevatten voor de voorschrijver zoals urgentie. De voorschrijver ontvangt het voorstel en kan deze accorderen tot een definitief verstrekkingsverzoek. De voorschrijver informeert de verzoeker via een antwoord voorstel verstrekkingsverzoek. (zie ook [[#Processtap: Evalueren (medicamenteuze) behandeling|paragraaf 2.2.4]] en volgende).

===Processtap: Maken toedieningsafspraak===
Indien de medicatieafspraak en eventueel het bijbehorende verstrekkingsverzoek verwerkt kunnen worden dan wordt er een toedieningsafspraak gemaakt. Met het maken van een toedieningsafspraak vult de apotheker een medicatieafspraak concreet in. De toedieningsafspraak wordt gecommuniceerd met de patiënt of diens toediener. De toedieningsafspraak hoort bij dezelfde medicamenteuze behandeling als de medicatieafspraak die hij vervult. Een toedieningsafspraak kan net als de bijbehorende medicatieafspraak ook in de toekomst starten. De dosering in de toedieningsafspraak kan afwijken van die in de medicatieafspraak omdat bijvoorbeeld een bepaalde sterkte niet op voorraad is. Daarmee kan er dus ook een andere 'PRK' onder de medicamenteuze behandeling vallen wanneer bijvoorbeeld gewijzigd wordt van 1x 20 mg naar 2x 10 mg tabletten. 
Voordat de toedieningsafspraak (actief) beschikbaar wordt gesteld, vindt medicatiebewaking plaatst conform de geldende richtlijnen van ter hand stellen. Dit is onderdeel van deze processtap.

Op basis van de toedieningsafspraken kan voor o.a. de thuiszorg of de verpleging in een instelling een toedienlijst<ref>In dit document wordt met toedienlijst zowel de digitale als papieren variant bedoeld, tenzij anders aangeduid. Synoniem zijn deellijst, aftekenlijst.</ref> worden samengesteld.

Bij het maken van een toedieningsafspraak geldt hetzelfde uitgangspunt als bij de medicatieafspraak: elke wijziging wordt vastgelegd in een nieuwe toedieningsafspraak.

In de volgende paragrafen zijn de verschillende situaties beschreven waarin een toedieningsafspraak wordt gemaakt: nieuwe toedieningsafspraak of continueren, definitief stoppen, tijdelijk onderbreken of wijzigen van een bestaande toedieningsafspraak.

====''Nieuwe toedieningsafspraak''====
Bij een nieuwe medicatieafspraak wordt altijd een nieuwe toedieningsafspraak gemaakt. Een nieuwe toedieningsafspraak wordt ook gemaakt bij nieuw preferentiebeleid of een wijziging in assortiment die leidt tot de keus voor een ander geneesmiddel. 
Bij het maken van een nieuwe toedieningsafspraak houdt de apotheker onder andere rekening met:
*preferentiebeleid,
*levering in GDS-verpakking,
*beschikbaar assortiment van de instelling (‘ziekenhuisformularium’) of de apotheek zelf.

''Toedieningsafspraak bij antistollingsmedicatie'' 
Bij medicatie met een wisselend doseerschema is ook een toedieningsafspraak en/ of medicatieverstrekking nodig. Hiervoor wordt het reguliere proces gevolgd. Alleen wordt in de toedieningsafspraak, net als in de medicatieafspraak geen doseerschema opgenomen maar de aanvullende instructie: 'gebruik volgens schema trombosedienst'. Zie [[#Processtap:_Maken_wisselend_doseerschema|paragraaf 2.2.6]] voor meer informatie over het wisselend doseerschema.

====''Continueren toedieningsafspraak''====
Wanneer de bestaande medicatieafspraak en toedieningsafspraak voldoende zijn om een medicatieverstrekking te doen dan wordt de toedieningsafspraak niet aangepast.

====''Stoppen toedieningsafspraak''====
Een medicatieafspraak waarin afgesproken is om de medicatie definitief te stoppen leidt tot een stop-toedieningsafspraak onder dezelfde medicamenteuze behandeling met als stoptype 'definitief' (dit geldt ook voor de stop-MA als gevolg van een wijziging). Daarmee wordt een nieuwe medicatieverstrekking van de medicatie voorkomen. 
In de ambulante situatie kan de voorschrijver in de medicatieafspraak aangeven dat de medicatie gestopt wordt met ingang van de volgende rol (GDS). Dit kan betekenen dat de ingangsdatum van de stop-toedieningsafspraak later is dan in de oorspronkelijke stop-medicatieafspraak is aangegeven.

====''Tijdelijk onderbreken toedieningsafspraak''====
Een tijdelijk onderbreken medicatieafspraak leidt tot een stop-toedieningsafspraak (stoptype: tijdelijk). Bij hervatting wordt er een nieuwe toedieningsafspraak gemaakt. Beide toedieningsafspraken horen bij dezelfde medicamenteuze behandeling als de medicatieafspraak.

====''Wijzigen toedieningsafspraak''====
Een gewijzigde medicatieafspraak (bestaande uit een technische stop-MA en een nieuwe medicatieafspraak) leidt tot een nieuwe toedieningsafspraak onder dezelfde medicamenteuze behandeling. Net als bij de medicatieafspraak betekent een wijziging in een toedieningsafspraak het stoppen van de bestaande toedieningsafspraak (een technische stop-TA) en het maken van een nieuwe toedieningsafspraak.

===Processtap: Verstrekken===
Na het maken van de toedieningsafspraak maakt de apotheker het product gereed en levert deze af voor:
*de patiënt in de thuissituatie,
*de patiënt die is opgenomen in een ziekenhuis, verpleeghuis of andere instelling.
De apotheker registreert de medicatieverstrekking<ref>In de klinische situatie wordt eventueel vanuit de afdelingsvoorraad gehaald waarna direct toediening plaatsvindt en de toediening wordt vastgelegd.</ref>.

Levering aan patiënten:
*in de ambulante situatie gebeurt alleen op basis van een verstrekkingsverzoek of een herhaling van dat verzoek,
*in de klinische situatie gebeurt op basis van de medicatieafspraak zonder dat een verstrekkingsverzoek nodig is.

===Processtap: (Actief) beschikbaarstellen===
In deze stap vindt informatie-uitwisseling plaats. De informatie kan met verschillende intenties gestuurd of beschikbaar gesteld worden:
*Als verzoek aan de voorschrijver om een nieuwe medicatieafspraak (VMA) of verstrekkingsverzoek (VVV) te maken.
*Het informeren van de voorschrijver over de afhandeling van het voorschrift (toedieningsafspraak en/of medicatieverstrekking).
*Het beschikbaarstellen van de medicatiegegevens (toedieningsafspraak en medicatieverstrekking) zodat medebehandelaren en/of patiënt deze later kunnen opvragen.

===Postconditie===
*Er kan toedieningsafspraak zijn gemaakt.
*Er kan een medicatieverstrekking zijn gedaan en de patiënt heeft zo nodig uitleg gekregen hoe hij het geneesmiddel moet gebruiken.
*Medebehandelaars zijn op de hoogte gesteld of kunnen zich op de hoogte stellen. De voorschrijver is op de hoogte gesteld.
*De voorschrijvend arts is zo nodig verzocht om een nieuwe/gewijzigde medicatieafspraak of verstrekkingsverzoek.

===Informatiesystemen en transactiegroepen===
Zowel de ''voorschrijver'' als de ''apotheker'' als andere ''medebehandelaars'' en ''gebruikers'' maken ieder gebruik van een informatiesysteem, respectievelijk een elektronisch voorschrijfsysteem (EVS), een apothekersinformatiesysteem (AIS, incl. ZAIS), een XIS en een PGO<ref>XIS is een generieke term voor een willekeurig (zorg)informatiesysteem. PGO=Persoonlijke GezondheidsOmgeving.</ref>. Deze informatiesystemen kennen ieder verschillende systeemrollen, die het uitwisselen van gegevens tussen deze informatiesystemen in het kader van het ter handstellingsproces mogelijk maken. 
[[#Systemen en transacties|Hoofdstuk 7]] geeft een overzicht van alle informatiesystemen, systeemrollen, transacties, etc. De belangrijkste voor het proces van ter hand stellen zijn in onderstaand overzicht opgenomen.

{{anchor|figuur 6}}
[[Bestand:Uc Ter handstellen.png|Figuur 6 Processtappen en transacties - ter hand stellen]]

===Use cases===
De volgende specifieke use cases van ter hand stellen zijn uitgewerkt:
*[[#Nieuwe medicatieafspraak, medicatieverstrekking zelfde product|Nieuwe medicatieafspraak, medicatieverstrekking zelfde product (paragraaf 4.2.1)]]
*[[#Nieuwe medicatieafspraak, nadere specificering product|Nieuwe medicatieafspraak, nadere specificering product (paragraaf 4.2.2)]]
*[[#Bestaande toedieningsafspraak voldoet|Bestaande toedieningsafspraak voldoet (paragraaf 4.2.3)]]
*[[#Medicatieafspraak gewenst (Informeren voorschrijver)|Medicatieafspraak gewenst (Informeren voorschrijver) (paragraaf 4.2.4)]]
*[[#Aanschrijven en verstrekken|Aanschrijven en verstrekken (paragraaf 4.2.5)]]
*[[#Patiënt vraagt herhaalrecept via arts (reactief herhalen)|Patiënt vraagt herhaalrecept via arts (reactief herhalen) (paragraaf 4.2.6)]]
*[[#Patiënt vraagt herhaalrecept via apotheker (Informeren voorschrijver)|Patiënt vraagt herhaalrecept via apotheker (Informeren voorschrijver) (paragraaf 4.2.7)]]
*[[#Proactief herhaalrecept door apotheker (Informeren voorschrijver)|Proactief herhaalrecept door apotheker (Informeren voorschrijver) (paragraaf 4.2.8)]]
*[[#Verstrekken op basis van bestaand verstrekkingsverzoek|Verstrekken op basis van bestaand verstrekkingsverzoek (paragraaf 4.2.9)]]
*[[#Knippen van recept|Knippen van recept (paragraaf 4.2.10)]]
*[[#Het opstarten en continueren van GDS|Het opstarten en continueren van GDS (paragraaf 4.2.11)]]
*[[#De apotheker wijzigt van handelsproduct|De apotheker wijzigt van handelsproduct (paragraaf 4.2.12)]]
*[[#Medicatie toevoegen aan GDS|Medicatie toevoegen aan GDS (paragraaf 4.2.13)]]
*[[#Medicatie in GDS stoppen|Medicatie in GDS stoppen (paragraaf 4.2.14)]]
*[[#GDS leverancier levert ander handelsproduct|GDS leverancier levert ander handelsproduct (paragraaf 4.2.15)]]
*[[#Parallelle toedieningsafspraken bij GDS- en niet-GDS-verstrekking|Parallelle toedieningsafspraken bij GDS- en niet-GDS-verstrekking (paragraaf 4.2.16)]]
*[[#Afhandelen stop medicatieafspraak|Afhandelen stop medicatieafspraak (paragraaf 4.2.17)]]
*[[#Verstrekken onder andermans toedieningsafspraak|Verstrekken onder andermans toedieningsafspraak (paragraaf 4.2.18)]]
*[[#Wijzigen van andermans toedieningsafspraak|Wijzigen van andermans toedieningsafspraak (paragraaf 4.2.19)]]
*[[#Verstrekkingsverzoek met aantal herhalingen|Verstrekkingsverzoek met aantal herhalingen (paragraaf 4.1.36)]]

==Proces: toedienen==

Deze paragraaf beschrijft het proces van toedienen. Dit proces bestaat uit het samenstellen van de toedienlijst voor (professionele) toedieners en de toediening die wordt gedaan door een (professionele) toediener, de patiënt zelf of een mantelzorger. Professionele toedieners zijn artsen, verpleegkundigen en verzorgenden.

In [[#Huidige_situatie_.28b.C3.A8ta-versie.29|paragraaf 2.4.1]] wordt de huidige situatie omschreven en in de paragrafen die volgen zal de nieuwe situatie met aanpassingen omschreven worden.

===Huidige situatie===

In de huidige situatie controleert de (professionele) toediener samen met de patiënt de toe te dienen medicatie aan de hand van de aanwezige informatie: papieren en/of digitale toedienlijst(en), een doseerschema van bijvoorbeeld antistollingsmedicatie en etiketinformatie, en dient toe. Bij onduidelijkheden neemt de toediener contact op met voorschrijver of apotheker. Mogelijke onduidelijkheden nemen toe naarmate er meer voorschrijvers, verstrekkers en toedieners betrokken zijn in het toedienproces.

In de huidige situatie is er een aantal knelpunten in de overdracht van medicatiegegevens voor de toediener:
*ontbreken van of geen tijdige overdracht van medicatiegegevens tussen intramurale zorginstelling en thuiszorg enerzijds en ziekenhuis anderzijds;
*het niet of niet tijdig doorkrijgen van wijzigingen en ontbrekende stops;
*het niet op een veilige manier beschikbaar hebben van actuele gegevens op de toedienlijst bij verstrekkingen door meerdere apothekers en tijdens ANW-uren (avond, nacht, weekend);
*naast de toedienlijst een apart doseerschema van (snel) wisselende doseringen, zoals antistollingsmedicatie.
*gerelateerde problemen aan apart doseerschema, zoals het kwijtraken van het doseerschema, mondeling doorgeven van wijzigingen van het doseerschema;
*ontbreken van zo nodig medicatie en bijspuitschema’s (bijvoorbeeld bij insuline) op de toedienlijst (in de toekomst zal dit opgepakt worden);
*ontbreken van inzicht in alle betrokken zorgverleners en zorgaanbieders.

In de huidige situatie zorgt de apotheker voor de toedienlijst voor de (professionele) toediener of de patiënt. Op de toedienlijst staan toedientijden en de toediener en apotheker stemmen deze toedientijden af op de logistieke ronde van de thuiszorgorganisatie en de farmaceutische mogelijkheden.
Aan de hand van de papieren of digitale toedienlijst registreren (professionele) toedieners de medicatietoediening. Een papieren toedienlijst ligt achter de voordeur van de patiënt (inclusief toedieningsregistratie). Elke betrokken professionele toediener (ongeacht van welke organisatie) heeft in principe achter de voordeur toegang tot deze toedienlijst en registratie van voorgangers. De vastgelegde medicatietoedieningen in digitale vorm worden in de huidige situatie alleen bij uitzonderlijke situaties (soms in geval van opname of bijzonderheden) met andere zorgverleners uitgewisseld. Met de overstap van elektronische toedienregistratie is de toedienlijst (met geregistreerde toedienmomenten) niet meer fysiek aanwezig bij de patiënt, maar is deze vastgelegd in de E-TDR/E-TRS (elektronische toedienregistratie/elektronisch toedienregistratiesysteem) oplossing ([[#Systemen_en_transactiegroepen_.28b.C3.A8ta-versie.29|zie paragraaf 2.4.8]]). Betrokken professionele toedieners van verschillende organisatie (met al dan niet verschillende E-TRS applicaties) kunnen niet of moeizaam elkaars geregistreerde toedienmomenten inzien omdat deze in verschillende applicaties c.q. databases vastgelegd worden.

===Preconditie===

De patiënt dient zichzelf medicatie toe of de patiënt krijgt hulp bij de medicatietoediening door een (professionele) toediener en heeft hiervoor een toedienlijst nodig.

===Trigger event===

Het moment dat de geneesmiddelen zouden moeten worden toegediend.

===Processtap: Toedienlijst===

De (professionele) toediener of patiënt ontvangt of vraagt de (actief) beschikbaar gestelde medicatiegegevens op die nodig zijn voor het geautomatiseerd genereren van de toedienlijst. Voor de toedienlijst zijn hiervoor de bouwstenen medicatieafspraak (MA), wisselend doseerschema (WDS), toedieningsafspraak (TA), medicatieverstrekking (MVE) en medicatietoediening (MTD) nodig. Om een complete toedienlijst te kunnen genereren zijn de (richt)toedientijden en doseerinstructies noodzakelijk. Deze gegevens kunnen door de apotheker in de TA vastgelegd worden of door de voorschrijver in de MA of WDS. Apothekers en voorschrijvers in de ambulante setting leggen niet standaard de (richt)toedientijden vast en zullen dan ook een trigger moeten ontvangen dat het hier gaat om een ‘toedienpatiënt’, een patiënt die hulp krijgt bij de medicatietoediening of zelf een toedienlijst nodig heeft. Voor sommige medicatie is het noodzakelijk om te weten wat de prik- en plakplekken (toedienlocatie) zijn, dit wordt vastgelegd in de MTD. In de klinische setting is voor alle patiënten een toedienlijst aanwezig en worden de (richt)toedientijden standaard vastgelegd.

De meeste (richt)toedientijden zullen bepaald worden op basis van de toedientijden van andere voorgeschreven medicatie en de logistieke rondes van de toediener. Dit is vooral het geval bij MA’s en TA’s waarbij de (richt)toedientijd standaard flexibel is. Over de (richt)toedientijden zullen nog verdere afspraken in het zorgveld gemaakt moeten worden (o.a. hoeveel de patiënt of toediener mag afwijken van de (richt)toedientijd). Als een toediening van medicatie een specifieke tijd vereist, bijvoorbeeld door een wisselwerking tussen medicaties, wordt dit gecommuniceerd door de (richt)toedientijd als niet flexibel aan te geven in de TA en/of MA.

Op de toedienlijst wordt op basis van de distributievorm een onderscheid gemaakt tussen GDS-medicatie en niet-GDS-medicatie. Deze gegevens worden in de bouwsteen MVE en TA vastgelegd. Vervolgens stelt de toediener (toedieningssoftware) op basis van de MA, het WDS, de TA en de MTD de toedienlijst samen, met een uitsplitsing naar toedieningen per toedienmoment. Voorschrijvers, apothekers en toedieners (PrikPlakLocatie) zijn verantwoordelijk voor het aanleveren van de medicatiegegevens die noodzakelijk zijn voor het samenstellen van een toedienlijst.

===Processtap: Medicatietoediening===

De (professionele) toediener heeft de medicatiegegevens (MA, WDS, TA, MVE en MTD), die nodig zijn voor de medicatietoediening, ontvangen. Deze gegevens worden in de hierboven beschreven toedienlijst voor de toedienpatiënten weergegeven. De (professionele) toediener controleert samen met de patiënt de aanwezige medicatie en de toediengegevens. Indien afgesproken en nodig maakt de toediener het geneesmiddel voor medicatietoediening gereed. De medicatie wordt toegediend en de toediener legt de medicatietoediening in het informatiesysteem of op de toedienlijst vast. Afwijkingen in de medicatietoediening (niet toedienen, gewijzigde dosering, weigering van de patiënt, slikproblemen, bijwerkingen, etc.) worden daarbij vastgelegd.

===Processtap: (Actief) beschikbaarstellen===

In deze stap vindt informatie-uitwisseling plaats. De informatie kan met verschillende intenties gestuurd of beschikbaar gesteld worden:
*De vastgelegde MTD’s en afwijkingen kunnen ter kennisgeving worden gestuurd naar een medebehandelaar;
*Het beschikbaarstellen van de MTD zodat medebehandelaars en/of patiënt deze later kunnen opvragen. Dit kan bijvoorbeeld van belang zijn bij de verplaatsing van een patiënt naar een andere afdeling of instelling. Daarnaast kan een zorgverlener controleren welke medicatie bij een patiënt toegediend is.

===Postconditie ===

De patiënt heeft geneesmiddelen zelf toegediend of toegediend gekregen. De MTD’s kunnen zijn vastgelegd in een informatiesysteem en worden (actief) beschikbaar gesteld voor medebehandelaars en/of patiënt.

===Systemen en transactiegroepen===

Zowel de voorschrijver en apotheker als de toedieners en patiënten (optioneel) maken ieder gebruik van een informatiesysteem, respectievelijk een elektronisch voorschrijfsysteem (EVS), een elektronisch cliëntendossier (ECD), een apothekersinformatiesysteem (AIS), ziekenhuisapotheekinformatiesysteem (ZAIS), een toedieningsregistratiesysteem (TRS), trombosedienstinformatiesysteem (TrIS) en een persoonlijke gezondheidsomgeving (PGO). Deze informatiesystemen kennen ieder verschillende systeemrollen, die het uitwisselen van gegevens tussen deze informatiesystemen in het kader van het proces toedienen mogelijk maken. Deze informatiesystemen kunnen een systeemrol spelen bij het opstellen van een toedienlijst en bij het vastleggen, versturen en opleveren van een MTD.
[[#Systemen_en_transacties|Hoofdstuk 7]] geeft een voorbeeld van het opstellen van een toedienlijst. De belangrijkste processtappen voor het proces van toedienen zijn in het onderstaande overzicht opgenomen.

{{anchor|figuur 7}}
[[Bestand:Toedienen.png|Figuur 7 Processtappen en transacties - toedienen|800px]]

===Use cases ===

De volgende specifieke use cases van het proces toediening zijn uitgewerkt:

*[[#Toedienlijst opstarten|4.3.1 Toedienlijst opstarten]]
*[[#Exacte toedientijden nodig|4.3.2 Exacte toedientijden nodig]]
*[[#Ontbreken (richt)toedientijden|4.3.3 Ontbreken (richt)toedientijden]]
*[[#Niet-GDS-medicatie zo nodig|4.3.4 Niet-GDS-medicatie zo nodig]]
*[[#Meerdere apotheken leveren medicatie|4.3.5 Meerdere apotheken leveren medicatie]]
*[[#Wijziging in GDS vanaf volgende levering of per direct|4.3.6 Wijziging in GDS vanaf volgende levering of per direct]]
*[[#Verhogen dosering GDS in nieuwe MBH|4.3.7 Verhogen dosering GDS in nieuwe MBH ]]
*[[#Verlagen dosering GDS in nieuwe MBH|4.3.8 Verlagen dosering GDS in nieuwe MBH]]
*[[#Wijziging verwerkt door de apotheker|4.3.9 Wijziging verwerkt door de apotheker ]]
*[[#Wijziging niet verwerkt door de apotheker|4.3.10 Wijziging niet verwerkt door de apotheker]]
*[[#Aanvullende informatie|4.3.11 Aanvullende informatie]]
*[[#Medicatietoediening afwijkend ten opzichte van toedienlijst|4.3.12 Medicatietoediening afwijkend ten opzichte van toedienlijst]]
*[[#Medicatietoediening zonder medicatieafspraak en toedieningsafspraak|4.3.13 Medicatietoediening zonder medicatieafspraak en toedieningsafspraak]]
*[[#Medicatietoediening van zelfzorgmedicatie|4.3.14 Medicatietoediening van zelfzorgmedicatie]]
*[[#Corrigeren/annuleren van toediening|4.3.15 Corrigeren/annuleren van toediening]]
*[[#Opschorten van toediening|4.3.16 Opschorten van toediening ]]
*[[#Medicatietoediening door voorschrijver|4.3.17 Medicatietoediening door voorschrijver ]]
*[[#Meerdere toedienorganisaties|4.3.18 Meerdere toedienorganisaties ]]
*[[#Feedback aan patiënt via medicatiesignalering|4.3.19 Feedback aan patiënt via medicatiesignalering]]

==Proces: gebruiken==
Deze paragraaf beschrijft het proces van gebruiken van de medicatie inclusief de registratie van het gebruik door de patiënt of een zorgverlener. De door de patiënt of zorgverlener vastgelegde informatie kan onder andere worden gebruikt bij medicatieverificatie door de zorgverlener. Tijdens medicatieverificatie wordt het gebruik vastgelegd door de zorgverlener. Voor een plaat van dit proces zie [[#Bijlage: Diagram Medicatieproces algemeen|hoofdstuk 13]].

===Huidige situatie===
*Er is op dit moment een beperkt aantal informatiesystemen beschikbaar waarin de patiënt zelf het gebruik van medicatie kan vastleggen. Ook de uitwisseling naar zorgverleners is sterk afhankelijk van het gebruikte informatiesysteem en beperkt zich veelal tot één specifieke zorgaanbieder via bijvoorbeeld één specifiek zorgaanbiedersplatform/app.
*De huidige medicatieprofielen zijn vaak onvolledig en niet actueel.

===Preconditie===
De patiënt heeft medicatie voorgeschreven gekregen.

===Trigger event===
De patiënt heeft de medicatie gebruikt of gebruikt deze niet (meer).

===Processtap: Gebruiken===
De patiënt gebruikt de voorgeschreven medicatie of zelfzorgmedicatie. Het medicatiegebruik kan worden vastgelegd door
*de patiënt zelf of zijn mantelzorger,
*een thuiszorg- of instellingsverpleegkundige en/of
*een andere zorgverlener.
Dit laatste vindt vaak plaats bij medicatieverificatie (zie [[#Proces: medicatieverificatie|paragraaf 2.1]]). Er zijn allerlei informatiesystemen beschikbaar om het gebruik vast te leggen: PGO, XIS, EPD/ECD, app, etc.

Als medicatiegebruik kunnen worden vastgelegd:
*zelfzorg en andere eigen medicatie,
*het aangeven van afwijkingen ten opzichte van de gemaakte afspraken,
*bevestiging van gebruik (bevorderen therapietrouw),
*geverifieerde medicatie (zie [[#Proces: medicatieverificatie|paragraaf 2.1]]),
*wijzigingen als gevolg van bijvoorbeeld bijwerkingen (door de patiënt zelf; een zorgverlener zal dit op een andere wijze registreren).

Patiënten die medicatie krijgen toegediend door een verpleegkundige nemen afhankelijk van de BEM score (Beoordeling Eigen beheer Medicatie) soms zelf later de medicatie in; de gegevens van de medicatietoediening kunnen dan afwijken van het medicatiegebruik. 
Gedurende het gebruik wordt farmaceutische zorg uitgevoerd door de apotheker (zie [[#Processtap: Uitvoeren farmaceutische zorg|paragraaf 2.3.4]] bijv. in geval van nieuwe laboratoriumwaarden). Ook kan er een vervolgcontact plaatsvinden waarin de medicamenteuze behandeling wordt geëvalueerd (zie [[#Processtap: Evalueren (medicamenteuze) behandeling|paragraaf 2.2.4]]).

====''Vastleggen medicatiegebruik door de patiënt''====
De patiënt maakt gebruik van een medicatieprofiel en geeft per medicijn, waarvoor dit relevant is, het daadwerkelijk gebruik aan. Daarbij kan de patiënt aangeven of hij het product wel of niet gebruikt en of dit 'gebruik volgens afspraak' is (waarbij de medicatieafspraak en/of toedieningsafspraak getoond is) en afwijkingen daarvan. Bij afwijkingen kan ingevoerd worden welke afwijking het betreft, dus volgens het werkelijk door de patiënt gevolgde schema, maar ook in algemenere termen (bijvoorbeeld ik neem de medicatie: 'af en toe', 'gemiddeld [x] keer per [dag/week]', '1x per dag in plaats van 2x', 'niet meer sinds 22-1-2015' of 'niet meer sinds ongeveer een maand'). Bij afwijking van de afspraken geeft de patiënt ook de reden van wijzigen of stoppen aan. 
Daarnaast kan de patiënt zijn eigen medicatie toevoegen aan het overzicht en eventuele bijwerkingen als reden voor wijzigingen opgeven.

Informatie over gebruik zal niet altijd aanwezig zijn. Daarnaast is er geen zekerheid over de betrouwbaarheid van de informatie. Soms zijn er afspraken tussen zorgverlener en patiënt over het bijhouden van medicatiegebruik, soms ligt het initiatief geheel bij de patiënt zelf.

====''Vastleggen medicatiegebruik door zorgverlener''====
Tijdens het proces van medicatieverificatie ([[#Proces: medicatieverificatie|paragraaf 2.1]]) of Evalueren van de medicamenteuze behandeling ([[#Processtap: Evalueren (medicamenteuze) behandeling|2.2.4]]) geeft de patiënt (of zijn mantelzorger) bijvoorbeeld aan dat hij medicatie niet of anders gebruikt dan afgesproken. Of dat hij ook nog andere medicatie gebruikt (zelfzorgmiddelen of buitenlandse medicatie). De zorgverlener kan deze gegevens vastleggen als medicatiegebruik. De gegevens over gebruik worden naast de primaire medicatiegegevens vastgelegd, de patiënt wordt daarbij als bron van de informatie vastgelegd, de zorgverlener als auteur. 
In plaats van of naast het vastleggen van het gebruik kan een voorschrijver er ook voor kiezen om een nieuwe of gewijzigde medicatieafspraak te maken met de patiënt (conform proces beschreven in [[#Processtap: Maken medicatieafspraak|paragraaf 2.2.5]]). Dit gebeurt wanneer de voorschrijver reden ziet om de afspraak bij te stellen naar aanleiding van het gebruik door de patiënt. Wanneer de voorschrijver geen reden ziet de afspraak bij te stellen kan hij er voor kiezen alleen het gebruik vast te leggen, met eventueel de opmerking dat hij de patiënt heeft verzocht zich te houden aan de eerder gemaakte afspraken.

Bij afwijkend gebruik zal een apotheker mogelijk een voorstel medicatieafspraak opstellen ten behoeve van de voorschrijver (zie [[#Processtap: Informeren voorschrijver|paragraaf 2.3.5]]) en/of de patiënt aanraden de voorschrijver te informeren over het afwijkende gebruik.

De verslaglegging rondom de evaluatie van gebruik (werking en bijwerking) zal de arts in de anamnese vastleggen of gebruiken als reden om een medicatieafspraak te wijzigen of te stoppen.

===Processtap: (Actief) beschikbaarstellen===
De vastgelegde medicatiegegevens (gebruik) kunnen ter kennisgeving worden verstuurd naar een medebehandelaar of beschikbaar worden gesteld zodat zij later opgevraagd kunnen worden.

===Processtap: Informeren voorschrijver===
De patiënt kan de voorschrijver ook zelf informeren wanneer er een nieuwe of gewijzigde medicatieafspraak of een nieuw verstrekkingsverzoek nodig is. Het proces is analoog aan het proces van Informeren voorschrijver door de apotheker ([[#Processtap: Informeren voorschrijver|paragraaf 2.3.5]]).

===Postconditie===
De lijst met medicatie is door de patiënt bijgewerkt en het daadwerkelijk gebruik is toegevoegd. De patiënt heeft zo nodig de voorschrijver verzocht om een nieuwe of gewijzigde medicatieafspraak of verstrekkingsverzoek.

===Informatiesystemen en transactiegroepen===
Zowel de ''voorschrijver'' als de ''apotheker'' als andere ''medebehandelaars'' en ''gebruikers'' maken ieder gebruik van een informatiesysteem, respectievelijk een elektronisch voorschrijfsysteem (EVS), een apothekersinformatiesysteem (AIS, incl. ZAIS), een XIS en een PGO<ref>XIS is een generieke term voor een willekeurig (zorg)informatiesysteem. PGO=Persoonlijke GezondheidsOmgeving.</ref>. Deze informatiesystemen kennen ieder verschillende systeemrollen, die het uitwisselen van gegevens tussen deze informatiesystemen in het kader van het gebruiksproces mogelijk maken.
[[#Systemen en transacties|Hoofdstuk 7]] geeft een overzicht van alle informatiesystemen, systeemrollen, transacties, etc. De belangrijkste voor het proces van gebruiken zijn in onderstaand overzicht opgenomen.

{{anchor|figuur 8}}
[[Bestand:Gebruiken.png|Figuur 8 Processtappen en transacties - gebruiken]]

===Use cases===
De use cases voor Gebruiken zijn beschreven vanuit registratie door de patiënt. De voorschrijver kan het medicatiegebruik op dezelfde wijze vastleggen maar zal de verslaglegging rondom de evaluatie van gebruik (werking en bijwerking) eerder in de anamnese vastleggen of gebruiken als reden om een medicatieafspraak te wijzigen of te stoppen.

De volgende specifieke use cases van gebruik zijn uitgewerkt:
*[[#Zelfzorgmiddel|Zelfzorgmiddel (paragraaf 4.4.1)]]
*[[#Medicatie uit buitenland|Medicatie uit buitenland (paragraaf 4.4.2)]]
*[[#Wijziging op initiatief patiënt|Wijziging op initiatief patiënt (paragraaf 4.4.3)]]
*[[#Stoppen medicatie op initiatief patiënt|Stoppen medicatie op initiatief patiënt (paragraaf 4.4.4)]]
*[[#Geen voorraad meer|Geen voorraad meer (paragraaf 4.4.5)]]
*[[#Registreren van afwijkend medicatiegebruik door patiënt vanwege een bijwerking|Registreren van afwijkend medicatiegebruik door patiënt vanwege een bijwerking (paragraaf 4.4.6)]]
*[[#Gebruik registreren op basis van verstrekking|Gebruik registreren op basis van verstrekking (paragraaf 4.4.7)]]

=Domeinspecifieke invulling medicatieproces=

==Dienstwaarneming door HAP==
De huisartsenpost (HAP) werkt in opdracht van de vaste huisarts. De huisartsenpost kan (onder andere) medicatieafspraken starten, wijzigen en stoppen conform het proces beschreven in [[#Proces: medicatieverificatie|paragraaf 2.1]]. De HAP zal zo nodig ook de bijbehorende verstrekkingsverzoeken doen. 
De HAP informeert de vaste huisarts over de waarneming. Bestaande afspraak is dat de HAP zelf geen bron is van informatie voor andere medebehandelaars van deze patiënt. Dit betekent dat de HAP de processtap ‘(Actief) beschikbaar stellen’ niet zal vervullen. In plaats daarvan stelt de vaste huisarts de betreffende informatie beschikbaar voor de medebehandelaars. Uitzondering hierop is het eventueel ongeadresseerd voorschrijven door een HAP, zie hiervoor [[#Ongeadresseerd voorschrijven (ambulant)|paragraaf 7.5]]. 
Dienstwaarneming volgt daarmee in principe het generieke proces van voorschrijven. Het verschil is dat een waarnemend arts sommige stappen uitvoert in opdracht van de vaste huisarts ('gedelegeerd').

==GGZ==
In de GGZ komen maar weinig geplande opnames voor (eigenlijk alleen bij afdelingen als eetstoornissen, klinisch herstel, e.d.). De meeste opnames betreffen opnames t.g.v. acute crisissituaties en zijn daarmee vergelijkbaar met opnames via de SEH in ziekenhuizen (zie ook [[#Starten met medicatie voor opname|paragraaf 4.1.20]]).

===Huidige situatie===
In de huidige situatie wordt aan de patiënt of de familie/mantelzorgers gevraagd welke medicatie zij gebruiken. In de meeste gevallen is de patiënt niet in staat om hier antwoord op te geven (dat is namelijk ook de reden voor opname). Familie/mantelzorgers (indien bekend) kunnen hier ook niet altijd antwoord op geven. De opnemend arts/psychiaters nemen contact op met huisarts of apotheek om de medicatie te achterhalen. Buiten kantooruren en in het weekend lukt dit slecht. En wanneer er gegevens binnen komen worden deze maar deels overgetypt in het informatiesysteem van de zorgverleners.

===Proces===
In de nieuwe situatie kunnen de beschikbaargestelde medicatiegegevens worden opgevraagd. Op basis daarvan wordt gestart met medicatieverificatie en het evalueren van de medicamenteuze behandeling (zodra mogelijk) en het toedienen van medicatie (conform [[#Medicatieproces|hoofdstuk 2]]). De medicatieverstrekking wordt poliklinisch door de openbare apothekers gedaan en klinisch vaak door een gecontracteerde ziekenhuisapotheek. 
Bij ontslag uit een GGZ-instelling wordt, net als in de ziekenhuizen, de medicamenteuze behandeling geëvalueerd ([[#Processtap: Evalueren (medicamenteuze) behandeling|paragraaf 2.2.4]]). Daarin wordt de klinische medicatie gestopt en wordt zo nodig nieuwe medicatie voorgeschreven of eerder tijdelijk onderbroken ambulante medicatie definitief gestopt of hervat. De arts/psychiater richt zich vooral op de psychiatrische medicatie, somatische medicatie blijft meestal ongemoeid. 
Het vastleggen van medicatiegebruik door de psychiatrische patiënt kan ervaren worden als ongewenste controle in plaats van dat dit het gebruik stimuleert. 
De medicatiegegevens worden beschikbaargesteld.

==VVT==
Het medicatieproces in een VVT-instelling (Verpleeg-, Verzorgingshuizen en Thuiszorg) verloopt analoog aan die van de klinische situatie echter in de VVT-instelling is een specialist ouderengeneeskunde als voorschrijver verantwoordelijk voor de medicatie van de opgenomen cliënten en wordt de levering van medicatie door één of meerdere openbare apothekers gedaan, zo nodig in de vorm van GDS.
In de VVT-instelling en in de thuiszorg wordt met een toedienlijst gewerkt. Deze wordt samengesteld op basis van de toedieningsafspraken. De toedienlijst wordt gebruikt om controle te doen op de medicatie voorafgaand aan de medicatietoediening en om de daadwerkelijke medicatietoediening op af te tekenen. Het communiceren van de toedienlijst tussen apotheker, voorschrijver en verpleegkundige wordt in een later stadium in deze informatiestandaard uitgewerkt.

==Opname en ontslag==
Een bijzondere situatie bij medicatieoverdracht ontstaat wanneer een patiënt wordt opgenomen in een instelling en vanuit een ambulante situatie in een klinische situatie terecht komt.
Omdat op het moment van opname in de instelling en bij ontslag uit de instelling veel wijzigingen in medicatie- en toedieningsafspraken kunnen plaatsvinden, wordt dit onderwerp hier apart genoemd. In handleidingen voor zorgverleners en leveranciers worden de werking van proces en systeem in de verschillende voorkomende situaties gedetailleerd beschreven.

===Voorafgaand aan opname===
Voordat de patiënt wordt opgenomen, kan al sprake zijn van een aanpassing in de medicatie. De medisch specialist kan met de patiënt afspreken dat deze een aantal dagen voor opname start met nieuwe medicatie of stopt met lopende medicatie.
De medisch specialist maakt in zo’n geval een medicatieafspraak of een stop-MA, waarbij hij in de toelichting aangeeft hoeveel dagen voor opname de patiënt met de medicatie moet starten of stoppen. Op het moment dat deze afspraak wordt gemaakt, is de opnamedatum vaak nog niet bekend. De medisch specialist geeft daarom bij het maken van de medicatieafspraak of stop-MA aan dat deze afhankelijk is van een opname, waardoor de gebruiksperiode onzeker is. Technisch wordt dit ingevuld door de gevulde toelichting op te nemen in element ‘Criterium’ bij de gebruiksperiode in de medicatieafspraak. Wanneer dit element bij een medicatieafspraak is gevuld, moet voor alle zorgverleners in de keten duidelijk zijn dat de gebruiksperiode onzeker is.

===Tijdens opname en bij ontslag===
Wanneer een patiënt wordt opgenomen in een instelling, kunnen voor de medicatie die de patiënt in de ambulante situatie gebruikt de volgende situaties van toepassing zijn:
* Ongewijzigd doorgebruiken,
* Wijziging dosering,
* Generieke substitutie (werkzame stof blijft gelijk),
* Farmacotherapeutische substitutie (werkzame stof wijzigt, maar middel is geregistreerd voor dezelfde indicatie),
* (Tijdelijke) stop.

Hieronder volgt per situatie een toelichting op de gevolgen voor de registratie van de medicatie van de patiënt.

====Ongewijzigd doorgebruiken====
De patiënt blijft de medicatie uit de ambulante situatie ongewijzigd doorgebruiken tijdens opname.

De medicatieafspraak en toedieningsafspraak uit de ambulante situatie blijven doorlopen tijdens opname en na ontslag.

====Wijziging dosering====
De patiënt gebruikt tijdens opname hetzelfde geneesmiddel als in de ambulante situatie, echter met een andere dosering.

De medicatieafspraak uit de ambulante situatie wordt gestopt bij opname. Tijdens opname wordt een nieuwe medicatieafspraak gemaakt met de aangepaste dosering. Bij ontslag bepaalt de voorschrijver welke dosering gaat gelden voor de ambulante situatie. Afhankelijk hiervan wordt de medicatieafspraak uit de ambulante situatie voortgezet of wordt een nieuwe medicatieafspraak gemaakt voor de ambulante situatie.
Ook de toedieningsafspraak uit de ambulante situatie wordt gestopt bij opname. Tijdens opname wordt een nieuwe toedieningsafspraak gemaakt op basis van de nieuwe medicatieafspraak. Bij ontslag wordt de toedieningsafspraak uit de ambulante situatie voortgezet of wordt een nieuwe toedieningsafspraak gemaakt voor de ambulante situatie.

====Generieke substitutie====
De patiënt gebruikt tijdens opname een ander geneesmiddel dan in de ambulante situatie, echter met dezelfde werkzame stof en in dezelfde hoeveelheid en farmaceutische vorm.

De medicatieafspraak uit de ambulante situatie blijft doorlopen tijdens opname en na ontslag. De toedieningsafspraak uit de ambulante situatie wordt bij opname gestopt en na ontslag weer voortgezet. Tijdens opname wordt een nieuwe toedieningsafspraak gemaakt die bij ontslag wordt gestopt.

====Farmacotherapeutische substitutie====
De patiënt gebruikt tijdens opname een ander geneesmiddel dan in de ambulante situatie, dit middel is echter geregistreerd voor dezelfde indicatie (bijvoorbeeld omeprazol/pantoprazol).

De medicatieafspraak uit de ambulante situatie wordt gestopt bij opname en na ontslag weer voortgezet. Tijdens opname wordt een nieuwe medicatieafspraak gemaakt die bij ontslag wordt gestopt.
Ook de toedieningsafspraak uit de ambulante situatie wordt gestopt bij opname en na ontslag weer voortgezet. Tijdens opname wordt een nieuwe toedieningsafspraak gemaakt die bij ontslag wordt gestopt.

====(Tijdelijke) stop====
De patiënt stopt tijdens opname (tijdelijk) met de ambulante medicatie.

De medicatieafspraak uit de ambulante situatie wordt (tijdelijk) gestopt bij opname. Indien het gaat om een tijdelijke stop, wordt de medicatieafspraak na ontslag weer voortgezet. Bij een definitieve stop volgt er geen medicatieafspraak meer voor de ambulante situatie.
Ook de toedieningsafspraak uit de ambulante situatie wordt (tijdelijk) gestopt. Indien het gaat om een tijdelijke stop, wordt de toedieningsafspraak na ontslag weer voortgezet. Bij een definitieve stop volgt er geen toedieningsafspraak meer voor de ambulante situatie.

=Beschrijving use cases=
Dit hoofdstuk bevat een beschrijving van verschillende use cases. Er zijn concrete praktijksituaties beschreven voor de verschillende deelprocessen. De praktijksituaties zijn in een groot aantal gevallen ontleend aan de huisartsenpraktijk maar zijn illustratief voor vergelijkbare situaties in een andere setting. Dit hoofdstuk veronderstelt voorkennis zoals beschreven in [[#Medicatieproces|hoofdstuk 2]].

==Use cases Voorschrijven==

===Kortdurende medicatie===
Een 35-jarige vrouwelijke patiënt met urineweginfectie in de voorgeschiedenis, brengt haar urine naar de assistente aan de balie en vertelt dezelfde klachten als de vorige keren te hebben. De assistente vraagt nog naar andere klachten zoals koorts en pijn in de flank en kijkt de urine na. Er zijn geen andere klachten en uit de urine blijkt een urineweginfectie. Zij vertelt de patiënt dat de huisarts een kuur zal voorschrijven en dat ze die later bij de apotheker op kan halen. De huisarts kijkt naar de vorige kuren en een eventuele kweek en legt een medicatieafspraak vast. Op ''27 januari'' is afgesproken:
:''Nitrofurantoïne capsule mga 100 mg, 2 maal daags 1 capsule, vanaf heden<ref>Zie ook [[#Harde einddatum gebruiksperiode|paragraaf 4.1.3]].</ref> gedurende 5 dagen.''
Hij legt deze medicatieafspraak vast in zijn informatiesysteem. Vervolgens maakt de huisarts direct ook een verstrekkingsverzoek voor de apotheker naar keuze van de patiënt:
:''Nitrofurantoïne capsule mga 100 mg; 10 stuks.''
De huisarts legt ook dit verstrekkingsverzoek vast in zijn informatiesysteem. 
De huisarts overlegt met de patiënt bij welke apotheker zij de medicatie wil afhalen. De huisarts kan deze apotheker vervolgens informeren over het verstrekkingsverzoek én de medicatieafspraak. 
Het informatiesysteem van de huisarts maakt de informatie (verstrekkingsverzoek en medicatieafspraak) beschikbaar voor de medebehandelaars van deze patiënt. 
 
[[Bestand:Uc4.1.1.PNG|800px]]

===Doorlopende medicatie===
Het proces bij doorlopende medicatie is hetzelfde als bij kortdurende medicatie (zie [[#Kortdurende medicatie|paragraaf 4.1.1]]). Het verschil is dat bij doorlopende medicatie de medicatieafspraak voor onbepaalde tijd wordt gemaakt.

Bijvoorbeeld: de voorschrijver spreekt met een patiënt met hypertensie af een diureticum doorlopend te gebruiken. Op ''30 maart 2013'' is afgesproken:
:''Hydrochloorthiazide tablet 12,5 mg; eenmaal daags een tablet; vanaf heden voor onbepaalde duur.''
De voorschrijver kiest bijvoorbeeld in het verstrekkingsverzoek voor initieel een te verstrekken hoeveelheid van 100 stuks. 
 
[[Bestand:Uc4.1.2.PNG|800px]]

===Harde stopdatum gebruiksperiode===
In de gebruiksperiode van een medicatieafspraak kan een ingangsdatum, stopdatum en/of duur worden meegegeven. Wanneer er een harde stopdatum gewenst is, dient dit ook expliciet in de Toelichting te worden aangegeven. Het enkel opnemen van een stopdatum is niet voldoende omdat dit niet genoeg duidelijkheid geeft over de intentie van de voorschrijver. 
 
[[Bestand:Uc4.1.3.PNG|800px]]

===Zo nodig medicatie===
Een 31 jarige vrouwelijke patiënt heeft in een jaar een paar keer hoofdpijnaanvallen gehad, waarbij nu de diagnose migraine wordt gesteld. De huisarts schrijft voor:
:''Rizatriptan 10 mg tabletten zo nodig 1c1t onder de tong. Eerste tablet bij eerstvolgende duidelijke migraine aanval.''
De huisarts legt de medicatieafspraak vast en doet een verstrekkingsverzoek:
:''6 Tabletten rizatriptan s.l. 10 mg.'' 
 
[[Bestand:Uc4.1.4.png|800px]]

===Kuur zo nodig startend in de toekomst===
Een zestigjarige patiënt met een status na een trombosebeen heeft soms om het jaar, soms driemaal per jaar een erysipelas (ernstige infectie aan het been waarvoor als de medicatie niet snel begint opname nodig kan zijn). Op verzoek van de patiënt schrijft de huisarts een antibioticumkuur voor waar hij meteen mee kan beginnen bij een recidief erysipelas. De volgende medicatieafspraak wordt gemaakt:
:''Flucloxacilline 500 mg capsules, 4d1 capsule, gedurende 10 dagen. In de medicatieafspraak wordt aangegeven (zo nodig): start zo nodig bij recidief.''
De huisarts doet meteen een verstrekkingsverzoek:
:''Flucloxacilline 500 mg capsules 40stuks.'' 
 
[[Bestand:Uc4.1.5.PNG|800px]]

===Twee doseringen van hetzelfde geneesmiddel tegelijkertijd===
Een 79 jarige man met uitgezaaide prostaatkanker heeft meer pijn en zijn medicatie wordt gewijzigd. De specialist schrijft (op 9 oktober) oxycodon 10 mg tabletten voor 4d1t en zo nodig bij pijn ’s nachts 1d1t. De specialist legt dit in één medicatieafspraak met twee doseerinstructies vast en doet een verstrekkingsverzoek voor 60 tabletten oxycodon 10 mg. 
 
[[Bestand:Uc4.1.6.PNG|800px]]

===Hetzelfde geneesmiddel met verschillende sterkte tegelijkertijd===
Dezelfde 79 jarige patiënt (zie [[#Twee doseringen van hetzelfde geneesmiddel tegelijkertijd|paragraaf 4.1.6]]) krijgt toch weer meer pijn. De specialist stopt op 16 oktober de oxycodon 10 mg tabletten en schrijft oxycodon 20 mg retard tabletten voor 3d2t en oxycodon 20 mg tabletten (normale afgifte) zo nodig bij pijn ’s nachts 1d1t. De specialist legt dit in twee medicatieafspraken (bij vooralsnog twee separate medicamenteuze behandelingen) vast en doet voor beide medicatieafspraken een verstrekkingsverzoek, respectievelijk 45 retardtabletten oxycodon 20 mg en 30 tabletten oxycodon 20 mg (normale afgifte). 
 
[[Bestand:Uc4.1.7.PNG|800px]]

===Toelichting in medicatieafspraak bij bewust gekozen bijzonderheid===
Bij het kiezen van een geneesmiddel kan er worden afgeweken van wat er verwacht wordt of van wat de standaard is. Bijvoorbeeld wanneer het ziekenhuis een ander formularium hanteert dan de openbare apotheek. Uit efficiencyoverwegingen is in het ziekenhuis bijvoorbeeld gekozen voor één maagzuurremmer: pantoprazol. 
Bij opname wordt een patiënt met omeprazol omgezet naar pantoprazol voor de duur van het verblijf. Bij ontslag gaat de patiënt weer terug naar omeprazol. 
Het is duidelijk dat hier nog wel eens wat mis kan gaan en dat de patiënt zowel omeprazol als pantoprazol slikt als er niet ingegrepen wordt. In de medicatieafspraak van het ziekenhuis voor pantoprazol kan een opmerking worden gemaakt (in de toelichting) over de afwijking zodat duidelijk is dat pantoprazol de vervanger is van omeprazol of juist naast omeprazol moet worden gebruikt. 
Zie ook voorbeeld [[mp:V9_2.0.0_Ontwerp_medicatieproces#Substitutie|substitutie]]. 
 
Ander voorbeeld zijn de halve sterktes. Het ziekenhuis heeft soms de beschikking over tabletten met de halve sterkte van het normale handelspreparaat (eigen productie). Waar de patiënt het ziekenhuis ingaat met chlortalidon 25 mg, een maal daags een halve tablet krijgt hij intramuraal chlortalidon 12,5 mg, eenmaal daags één tablet. Dan hoeft de verpleging in dit geval geen tabletten te breken. Hier bestaat het risico dat de patiënt bij thuiskomst weer de 25 mg gaat gebruiken, maar dan een hele tablet per keer. In de medicatieafspraak (Aanvullende informatie) van de laatste chlortalidon 25 mg kan worden aangegeven of dit een bewuste verhoging is geweest. 
 
Indien een voorgeschreven middel heel specifiek een bepaald handelsproduct dient te zijn (HPK), dan kan dit worden aangegeven met (Aanvullende informatie) 'Medische noodzaak'.

===Nieuwe medicatieafspraak, geen verstrekkingsverzoek===
Een 50-jarige man komt bij de huisarts met rugklachten. De klachten bestaan al 3 weken en hij gebruikt al paracetamol. De huisarts spreekt met de patiënt af aanvullend diclofenac te gebruiken:

Op ''30 januari'' is afgesproken:
:''Diclofenac tablet 50 mg, 3 maal daags 1 tablet, vanaf heden gedurende 3 weken.''
Hij legt deze medicatieafspraak vast in zijn informatiesysteem. De patiënt geeft aan voldoende voorraad thuis te hebben: zijn vrouw heeft nog een ruime voorraad diclofenac over vanwege een ander probleem een jaar geleden.

Er is dus geen verstrekkingsverzoek nodig en de apotheker stelt dus ook geen medicatie ter hand. 
De huisarts stelt de nieuwe medicatieafspraak beschikbaar voor eventuele medebehandelaars van deze patiënt. De vaste apotheker kan zich informeren over deze nieuwe medicatieafspraak. 
 
[[Bestand:Uc4.1.9a.PNG|800px]]

Een ander voorbeeld:
Dhr Simons krijgt wekelijks zijn medicatie verstrekt door de apotheek. In het verleden waren er namelijk veel verzoeken om extra medicatie, wat leidde tot duidelijke afspraken over het afgiftebeleid.

Het gaat om:
:''Medicatieafspraak: Diazepam 5 mg 4 maal daags 1 tablet vanaf 1-1-2012 tot voor onbepaalde duur''
:''Verstrekkingsverzoek: 28 stuks iter 10; toelichting: wekelijkse medicatieverstrekkingen''
Het verstrekkingsverzoek wordt ongeveer iedere 11 weken herhaald.

Het laatste verstrekkingsverzoek was op 3-3-2016:
:''een week (28 tabletten) met iter 10x ''
zodat de apotheek er 11 weken mee vooruit kan. 
 
[[Bestand:Uc4.1.9b.PNG|800px]]

De laatste jaren is het rustig. Hij vraagt niet meer om extra medicatie. Bij het laatste gesprek vertelde hij dat hij toe kan met 3 x daags diazepam. Dit wordt in een medicatieafspraak vastgelegd:
:''1-4-2016 Diazepam 5 mg 3x daags 1 tablet vanaf 1-4-2016 tot voor onbepaalde duur.''
De vorige medicatieafspraak wordt beëindigd per 31-3-2016 (zie stoppen van medicatie in [[#Processtap: Maken medicatieafspraak|paragraaf 2.2.5]]).

In de huidige situatie belde de huisarts de apotheek om te zorgen dat er bij de volgende medicatieverstrekkingen 21 tabletten diazepam worden meegegeven i.p.v. 28. Er was toen geen nieuwe verstrekkingsverzoek nodig.

In de nieuwe situatie stuurt de huisarts de nieuwe medicatieafspraak naar de apotheek. Op basis van de nieuwe medicatieafspraak verstrekt de apotheek 21 tabletten per week, het vorige verstrekkingsverzoek volstaat nog. 
 
[[Bestand:Uc4.1.9c.png|800px]]

===Nieuw verstrekkingsverzoek onder bestaande medicatieafspraak===
Een voorschrijver kan ook een nieuw verstrekkingsverzoek doen onder een bestaande medicatieafspraak. Deze medicatieafspraak kan gemaakt zijn door een andere voorschrijver bijvoorbeeld een psychiater of in geval van waarneming de vaste huisarts. Het betreft hier herhaalmedicatie. Deze use case is beschreven in [[#Patiënt vraag herhaalrecept via arts (reactief herhalen)|paragraaf 4.2.6]]. 
 
[[Bestand:Uc4.1.10.png|800px]]

===Wijziging in dosering (voldoende voorraad)===
Patiënt (37 jaar, astma) is op 13 augustus 2013 bij de longarts voor controle van zijn astma. De longarts heeft vastgesteld dat de astma onvoldoende gereguleerd is. 
De patiënt gebruikt op dit moment Beclometason volgens een eerder gemaakte en geregistreerde medicatieafspraak: op 10 juni 2010 is afgesproken
:''Beclometason aerosol 100 microg/dosis inh; 2 maal daags 1 inhalatie; vanaf 10 juni 2010 voor onbepaalde duur.''
De longarts spreekt op 13 augustus 2013 met de patiënt een verhoging van de dosering af:
:''Beclometason aerosol 100 microg/dosis inh; 2 maal daags 2 inhalaties; van 13 augustus 2013 tot voor onbepaalde duur; reden van aanpassing: onvoldoende werking.''
De voorgaande medicatieafspraak van 10 juni 2010 geldt niet meer: deze wordt beëindigd (zie wijzigen van medicatie in [[#Processtap: Maken medicatieafspraak|paragraaf 2.2.5]]) . De patiënt heeft nog voldoende voorraad, er is dus geen verstrekkingsverzoek nodig. 
 
[[Bestand:Uc4.1.11.PNG|800px]] 
In het geval de patiënt geen voorraad meer zou hebben dan wordt er ook een nieuw verstrekkingsverzoek gemaakt. 
Het informatiesysteem van de longarts maakt de nieuwe medicatieafspraak beschikbaar voor de medebehandelaars van deze patiënt. Deze wijziging komt binnen bij de apotheker (medebehandelaar). De apotheker verwerkt de wijziging. De apotheker kan er ook voor kiezen om wijzigingen automatisch te accepteren.

===Recept niet meer nodig na eerste verstrekkingsverzoek===
Een 16 jarige vrouw heeft een vriend en wil niet zwanger worden. Na uitleg kiest zij voor de pil. De huisarts schrijft ethinylestradiol/levonorgestrel tablet 20/100ug voor, 1d1t gedurende 21 dagen, vervolgens 7 dg geen pil nemen, dan weer 21 dagen wel. Start op de 1e dag van de volgende menstruatie. De huisarts legt de medicatieafspraak vast en doet een verstrekkingsverzoek voor 63 tabletten microgynon 20 tablet omhuld. Hij legt haar uit dat indien zij geen klachten heeft, zij de pil verder via de apotheek kan krijgen. 
Drie maanden later doet de vrouw een voorstel tot herhaalverstrekking aan de apotheek. De apotheek verstrekt het middel en communiceert de medicatieverstrekking aan de huisarts. 
[[Bestand:Uc4.1.12.png|800px]] 

===Stoppen medicatie===
Patiënt (37 jaar, astma) is op 13 augustus 2013 bij de longarts voor controle van zijn astma. De patiënt heeft last van een bijwerking.
De patiënt gebruikt op dit moment Beclometason volgens een eerder gemaakte en geregistreerde medicatieafspraak. Op ''10 juni 2010'' is afgesproken:
:''Beclometason aerosol 100 microg/dosis inh; 2 maal daags 1 inhalatie; vanaf 10 juni 2010 voor onbepaalde duur.''
De longarts spreekt op 13 augustus 2013 met de patiënt af om de medicatie te stoppen (medicamenteuze behandeling wordt gestopt). Medicatieverificatie is ook hier van toepassing. Verder kan ook medicatiebewaking hierbij relevant zijn, bijvoorbeeld wanneer maagbeschermers geslikt worden vanwege gebruik van de te stoppen medicatie (het informatiesysteem zal dit niet altijd automatisch signaleren). 
De longarts legt vast:
:''Beclometason aerosol 100 microg/dosis inh; stoptype 'definitief'; vanaf 13 augustus 2013. Vanwege een bijwerking.''
Deze wijziging komt binnen bij de apotheker (medebehandelaar). De apotheker verwerkt de wijziging. De apotheker kan er ook voor kiezen om wijzigingen automatisch te accepteren.
De longarts besluit ook om een medebehandelaar (bijv. de huisarts) hierover actief te informeren (onderdeel van de processtap (Actief) Beschikbaarstellen). 
Het informatiesysteem van de longarts maakt deze informatie (afspraak om te stoppen) beschikbaar voor alle medebehandelaars van deze patiënt. 
[[Bestand:Uc4.1.13.png|800px]] 

===Onderbreken / hervatten medicatie===
De patiënt wordt behandeld met Simvastatine (cholesterolverlager): 40 mg 1D1T voor onbepaalde duur.
Vanwege een keelontsteking in combinatie met een allergie voor het eerste keuze antibioticum wordt gedurende 1 week Claritromycine 250 mg 2D1T (antibioticum) voorgeschreven. Gedurende die week wordt de simvastatine onderbroken vanwege een interactie. 
De huisarts legt vast:
:''Simvastatine 40 mg; tijdelijk onderbreken; gedurende 1 week; reden: interactie''
:''Claritromycine 250 mg; 2D1T; gedurende 1 week (en een bijbehorend verstrekkingsverzoek)''
De apotheker wordt over het tijdelijk onderbreken van de simvastatine door de huisarts actief geïnformeerd. Er wordt ook een nieuwe medicatieafspraak gemaakt waarmee de simvastatine na een week wordt hervat. Ook ontvangt de apotheker de medicatieafspraak en het bijbehorende verstrekkingsverzoek voor de claritromycine. Zie ook Tijdelijk onderbreken en hervatten van medicatie in [[#Processtap: Maken medicatieafspraak|paragraaf 2.2.5]]. 
[[Bestand:Uc4.1.14.png|800px]] 

===Onderbreken voor een ingreep===
Een 62 jarige man gebruikt acetylsalicylzuur 100 mg 1d1t wegens coronairlijden. Hij moet een darmpoliep laten verwijderen. De huisarts bespreekt met hem dat hij de acetylsalicylzuur drie dagen voor de ingreep moet stoppen en de dag na de ingreep moet hervatten. De huisarts legt het tijdelijk onderbreken in een stop-medicatieafspraak vast met als stopdatum 3 dagen voor de ingreep; stoptype 'tijdelijk'; reden onderbreken ‘ingreep’. In de (tweede) medicatieafspraak voor het hervatten wordt als ingangsdatum 1 dag na de ingreep opgenomen. De huisarts informeert actief de apotheker en de maag-darm-leverarts over de medicatieafspraken. 
Wanneer de datum van de ingreep niet bekend of onzeker is wordt in de toelichting aangegeven dat er 3 dagen voor de ingreep moet worden gestopt en na 1 dag wordt hervat. De duur van de onderbreking is dan 4 dagen. Zie ook Tijdelijk onderbreken en hervatten van medicatie in [[#Processtap: Maken medicatieafspraak|paragraaf 2.2.5]] en Voorafgaand aan opname in [[#Voorafgaand aan opname|paragraaf 3.4.1]]. 
[[Bestand:Uc4.1.15.png|800px]] 

===Papieren recept===
De arts geeft een papieren recept mee aan de patiënt<ref>Eenzelfde situatie doet zich voor wanneer de apotheker een fax ontvangt.</ref>. Een papieren recept bevat een medicatieafspraak en een verstrekkingsverzoek. De patiënt kan met dit recept bij een willekeurige apotheker de medicatie afhalen. De huisarts informeert de verstrekkende apotheker in dit geval niet zelf. Het proces is echter eigenlijk toch hetzelfde: de activiteit '(Actief) beschikbaar stellen' wordt nu alleen 'vervuld' door het papieren recept in handen van de patiënt. De verstrekkende apotheker zal deze papieren medicatieafspraak en verstrekkingsverzoek overnemen in het eigen informatiesysteem en deze invullen met een toedieningsafspraak. Ook kan de apotheker mogelijk de beschikbaar gestelde medicatieafspraak en verstrekkingsverzoek digitaal opvragen en zo verwerken in het eigen informatiesysteem. 
Het informatiesysteem van de huisarts stelt de nieuwe medicatieafspraak en het verstrekkingsverzoek beschikbaar voor medebehandelaars. 
Wanneer het informatiesysteem van de huisarts deze niet beschikbaar heeft gesteld kan er dus sprake zijn van een toedieningsafspraak zonder digitaal beschikbare medicatieafspraak en verstrekkingsverzoek. De apotheker stelt de ‘van papier’ verkregen medicatieafspraak en verstrekkingsverzoek niet beschikbaar omdat hij daar zelf geen eigenaar van is. Daarnaast zou dit er toe kunnen leiden dat er anders, mogelijk pas in de toekomst, onterecht dubbele medicatieafspraken en verstrekkingsverzoeken kunnen voorkomen. 
[[Bestand:Uc4.1.17.png|800px]] 

===Uitvoeren medicatieverificatie en evaluatie bij buitenlandse of zelfzorgmedicatie===
Wanneer medicatie niet in het informatiesysteem gevonden kan worden (bijvoorbeeld buitenlands medicatie en zelfzorgmedicatie) dan wordt deze medicatie vastgelegd als medicatiegebruik (zie [[#Proces: gebruiken|paragraaf 2.5]]).

===Dagbehandeling===
Een dagopname is te vergelijken met een poliklinisch consult of een spoedopname waarbij de medicatie door de ziekenhuisapotheker wordt geleverd. Bij dagopname vindt niet altijd uitgebreide medicatieverificatie plaats. Bij dagopname wordt vastgelegd welke medicatie wordt voorgeschreven (gebeurt vaak op basis van protocollen waarbij achteraf verificatie plaatsvindt) en toegediend. 
Bij bijvoorbeeld cytostatica kuren is er wel een medicatieafspraak maar is niet altijd van te voren duidelijk wanneer de medicatieverstrekking/toediening plaatsvindt. Reden: vaak worden kuren uitgesteld en dan wordt pas later verstrekt en toegediend.

===Starten met medicatie voor opname===
Bij een cataractoperatie wordt 3 dagen voor de behandeling gestart met Nevanac. Deze worden gebruikt tot 3 weken na de operatie (een totale gebruiksduur van 24 dagen). Er wordt door de specialist een medicatieafspraak gemaakt voor Nevanac, 1 druppel ’s morgens, gedurende 24 dagen. Wanneer de datum van de operatie niet bekend of onzeker is kan in de toelichting worden aangegeven dat er 3 dagen voor de operatie moet worden gestart. Zie ook Voorafgaand aan opname in [[#Voorafgaand aan opname|paragraaf 3.4.1]]. 
[[Bestand:Uc4.1.20.png|800px]] 

===Spoedopname===
Bij een spoedopname vindt vooraf geen uitgebreide medicatieverificatie plaats zoals dat bij een klinische opname wel gebeurt. Ook het afspreken van medicatie met de patiënt is vaak niet mogelijk. De patiënt krijgt zo snel mogelijk de medicatie toegediend waarbij verificatie vaak achteraf plaatsvindt.

===Tussentijds ontslag===
Wanneer een patiënt tussentijds uit het ziekenhuis/de instelling naar huis gaat, bijvoorbeeld met weekendverlof, loopt de klinische medicatie door. Om de vaste huisarts op de hoogte te houden wordt het medicatieoverzicht meegegeven met de patiënt en worden de medicatiegegevens beschikbaar gesteld.

===Ontslag naar andere instelling===
Bij ontslag naar een andere instelling wordt de medicamenteuze behandeling geëvalueerd (zie [[#Processtap: Evalueren (medicamenteuze) behandeling|hoofdstuk 2.2.4]] en [[#Processtap: Maken medicatieafspraak|2.2.5]]). De medicatiegegevens worden (actief) beschikbaar gesteld. De nieuwe behandelend arts evalueert de medicamenteuze behandeling en bepaalt de instellingsmedicatie.

===Niet verstrekken voor===
De voorschrijvend arts doet op 14 april 2017 een verstrekkingsverzoek, maar wil in datzelfde verstrekkingsverzoek aangeven dat er pas verstrekt mag worden op of vanaf een latere datum, bijvoorbeeld 23 april 2017. In het verstrekkingsverzoek kan dit niet gestructureerd worden vastgelegd maar wordt dit opgenomen in de toelichting (vrije tekst). 
[[Bestand:Uc4.1.25.png|800px]] 

===Stoppen van medicatie door derden===
Medicatie kan door de voorschrijver zelf gestopt worden (zie [[#Stoppen medicatie|Paragraaf 2.2.5.3]]) maar ook door een andere voorschrijver. Bijvoorbeeld de specialist kan medicatieafspraken gemaakt door een huisarts stoppen die volgens het informatiesysteem weliswaar actueel zijn, maar - na bijvoorbeeld medicatieverificatie - dat toch niet blijken te zijn. Wanneer een zorgverlener medicatie stopt maakt hij een nieuwe stop-MA. De zorgverlener kan de medicatieafspraak van een ander niet aanpassen, alleen een stop-MA maken. Hij informeert daarom de zorgverlener van de originele medicatieafspraak actief over deze wijziging (zie [[#Informeren en (actief) beschikbaar stellen|Paragraaf 1.3.5]]). De zorgverlener van de originele medicatieafspraak past de stopdatum aan in de bestaande medicatieafspraak. Dit kan desgewenst ook geautomatiseerd worden door het informatiesysteem. Hiermee wordt voorkomen dat na verloop van tijd de tweede zorgverlener geen gegevens meer hoeft op te leveren omdat de oplevertermijn is verstreken (ook geen stop-MA) terwijl de zorgverlener van de originele medicatieafspraak deze onterecht (zonder stopdatum) wel blijft opleveren. 
[[Bestand:Uc4.1.26.png|800px]] 

===Twee PRK's onder één medicamenteuze behandeling===
Het is een apotheek, binnen bepaalde kaders, toegestaan om een andere PRK te kiezen voor de toedieningsafspraak dan is aangegeven in de medicatieafspraak gemaakt door een voorschrijver. Wanneer vervolgens alleen de toedieningsafspraak kan worden gecommuniceerd vanwege bijvoorbeeld een storing in het informatiesysteem bij de voorschrijver dan heeft een volgende voorschrijver alleen deze toedieningsafspraak met nieuwe PRK. De volgende voorschrijver gaat er dan waarschijnlijk vanuit dat deze PRK ook de PRK van de medicatieafspraak is. Een wijziging in de medicatieafspraak zal dan ook een stop-MA (zonder verwijzing naar originele MA) en een nieuwe medicatieafspraak op basis van deze PRK tot gevolg hebben. Dit betekent dat er twee medicatieafspraken met verschillende PRK's voorkomen onder dezelfde medicamenteuze behandeling. Deze twee medicatieafspraken blijven bestaan. (Het informatiesysteem van) de voorschrijver moet na uitval controleren of er wijzigingen zijn geweest en deze zo nodig doorvoeren (zie ook [[#Stoppen van medicatie door derden|paragraaf 4.1.26]]). 
[[Bestand:Uc4.1.27.png|800px]] 

===Achteraf vastleggen medicatieafspraak===
In bijvoorbeeld spoedsituaties kan het voorkomen dat de medicatieafspraak pas wordt vastgelegd na het verstrekken of toedienen van de medicatie. Dit kan leiden tot conflicterende medicatieafspraken. Op basis hiervan moeten één of meerdere medicatieafspraken gestopt worden zodat er geen parallelle medicatieafspraken voorkomen. De enige uitzondering voor parallelle medicatieafspraken is beschreven in [[#Medicamenteuze behandeling|Paragraaf 1.3.3]].

===Eenmalig gebruik===
Bij medicatie die eenmalig moet worden gebruikt wordt in de gebruiksperiode alleen een stopdatum opgenomen.
Denk aan vaccinaties (bijv. tetanusprik) of de situatie waarin gezegd wordt neem dit eenmalig 3 weken voordat je op vakantie gaat. 
[[Bestand:Uc4.1.30.png|800px]] 

===Voorlopige en definitieve medicatieopdracht===
In de kliniek schrijft de voorschrijver medicatie voor. Dit wordt vastgelegd in een voorlopige medicatieopdracht oftewel, in termen van deze informatiestandaard, de medicatieafspraak. De ziekenhuisapotheker verifieert deze opdracht en legt dit vast als definitieve medicatieopdracht oftewel, in termen van deze informatiestandaard, de toedieningsafspraak.
Zie ook <ref name="MO"/>.

===Onterecht openstaande medicatie of 'weeskinderen'===
In de overgangssituatie en in een situatie waarin niet elk XIS is aangesloten kunnen er medicatieafspraken zijn bij dezelfde behandeling die door verschillende informatiesystemen zijn vastgelegd onder verschillende medicamenteuze behandelingen. Deze medicatieafspraken wil je eigenlijk samenvoegen onder één medicamenteuze behandeling. Dit probleem dient in ieder geval opgelost te worden voor medicatie met een open stopdatum. Die medicatie kan namelijk onder een andere medicamenteuze behandeling zijn gestopt en daardoor open blijven staan en dus blijvend opgeleverd worden. Het betreft hier een ‘weeskind’ (dat wil zeggen: een bouwsteen die is vastgelegd, maar waarbij de zorgverlener op een gegeven moment geen actieve rol meer heeft en zijn informatiesysteem de bouwsteen dus blijft opleveren ook als deze elders al gestopt is). Voor medicatie met stopdatum, sterft dit probleem vanzelf uit en wordt geen koppelingsactie ondernomen.
Wanneer bij medicatieverificatie of -beoordeling wordt geconstateerd dat medicatie onterecht nog open staat wordt er een stop-MA gemaakt onder dezelfde medicamenteuze behandeling. De originele voorschrijver wordt actief geïnformeerd over deze stop-MA en voorziet de medicatieafspraak in zijn eigen informatiesysteem van een stopdatum. Het zetten van de stopdatum kan, afhankelijk van de leverancier en wensen van de klant, automatisch of met tussenkomst van de voorschrijver gebeuren.
Zie ook [[#Staken van medicatie door derden|paragraaf 4.1.26]] en [[#Wijzigen van andermans medicatieafspraak|paragraaf 4.1.40]]. 
[[Bestand:Uc4.1.32.png|800px]] 

===Ontbreken digitale medicatieafspraak bij opname===
Wanneer bij medicatieverificatie geen digitale medicatieafspraak beschikbaar is wordt een nieuwe medicamenteuze behandeling gestart met het vastleggen van medicatiegebruik. Wanneer dit gebruik gestopt moet worden, wordt vervolgens een stop-medicatieafspraak gemaakt onder deze zelfde medicamenteuze behandeling die verwijst naar het vastgelegde medicatiegebruik. 
[[Bestand:Uc4.1.33.png|800px]] 

Zo mogelijk worden oorspronkelijke voorschrijver (bijv. huisarts) en apotheek actief geïnformeerd over het stoppen van deze medicatie.

===Eigen artikelen (90 miljoen nummers)===
Het is mogelijk om een 90 miljoen nummer uit te wisselen. Voorwaarde is dat binnen een organisatie een eenmaal aangemaakt 90 miljoen nummer nooit aangepast mag worden. Bij de uitwisseling zorgt de root oid (unieke technische identificatie van de organisatie) in combinatie met het 90 miljoen nummer ervoor dat deze uniek is ten opzichte van alle 90 miljoen nummers vanuit andere organisaties. 
De stoffen waaruit dit artikel bestaat worden als ingrediënten in de medicatieafspraak meegegeven (minimaal één ingrediënt) zoals dit ook het geval is bij magistralen.

===Dosering met minimum interval===
Medicatie kan voorgeschreven worden met een vast interval (bijvoorbeeld: elke 6 uur 2 tabletten). Het voorschrijven van medicatie met een minimum interval dient gedeeltelijk in vrije tekst te gebeuren. 
Bijvoorbeeld zo nodig maximaal 3x per dag, minimaal 6 uur tussen de innamemomenten: 
Hierbij wordt ''zo nodig'' en ''maximaal 3x per dag'' op de standaard manier vastgelegd. Het onderdeel ''"minimaal 6 uur tussen de innamemomenten"'' wordt in vrije tekst als ''Aanvullende instructie'' vastgelegd. 
 
[[Bestand:Uc4.1.35.png|800px]]

===Verstrekkingsverzoek met aantal herhalingen===
De voorschrijver maakt een verstrekkingsverzoek bij een medicatieafspraak waarin zij het aantal herhalingen invult.
Hiermee geeft de voorschrijver bij de verstrekker aan dat deze additionele verstrekkingen mag doen.

Het aantal herhalingen in combinatie met de te verstrekken hoeveelheid resulteert in: (Aantal herhalingen + 1) x te verstrekken hoeveelheid.
In geval van "Aantal herhalingen = 3" en "Te verstrekken hoeveelheid = 30 stuks", mag de verstrekker 4 maal 30 stuks verstrekken (in totaal 120 stuks).

Het aantal herhalingen in combinatie met de verbruiksperiode duur resulteert in: (Aantal herhalingen + 1) x verbruiksperiode duur.
De te verstrekken hoeveelheid is hierbij afhankelijk van de dosering.
In geval van "Dosering = 3x per dag 2 stuks", "Aantal herhalingen = 3" en "Verbruiksperiode duur = 30 dagen", mag de verstrekker 4 maal (6 stuks per dag x 30 dagen=) 180 stuks verstrekken (in totaal 720 stuks). 
 
[[Bestand:Uc4.1.36.png|800px]]

===Voorschrijven van niet geneesmiddelen (verbandmiddelen, krukken of andere hulpmiddelen)===
Niet geneesmiddelen kunnen vanuit de G-standaard voorgeschreven worden op HPK niveau.
Dit kan bijvoorbeeld een inhalator (Aerochamber, HPK 1915185) als hulpmiddel voor voorgeschreven aerosolen zijn.
Niet geneesmiddelen zijn niet van toepassing voor het medicatieoverzicht of medicatiebewaking.

===Nierfunctiewaarde sturen met het voorschrift ===

'''A) Nierfunctiewaarde met een nieuw voorschrift:''' 
Ter preventie van een beroerte krijgt een patiënt (man, 65 jaar) voor het eerst Dabigatran voorgeschreven.
De patiënt heeft een verminderde nierfunctie en de voorschrijver heeft een recente nierfunctiewaarde beschikbaar.
Op basis van deze nierfunctiewaarde wijkt de voorschrijver af van de standaard dosering en maakt een medicatieafspraak aan met een lagere dosering van Dabigatran 2x daags 1 capsule van 110 mg vanaf 15 januari 2020.
De voorschrijver maakt ook een verstrekkingsverzoek en stuurt het voorschrift (medicatieafspraak, verstrekkingsverzoek) met de laboratoriumuitslag nierfunctiewaarde aan de apotheker. 
[[Bestand:Uc4.1.38A.PNG|800px]]

'''B) Nierfunctiewaarde reden voor een wijziging:''' 
Een man van 70 jaar heeft enkele dagen geleden 3x daags 1 tablet metformine 500 mg voorgeschreven gekregen (medicatieafspraak met verstrekkingsverzoek). De arts heeft tegelijkertijd een bloed onderzoek in gang gezet om de nierfunctiewaarde te bepalen van de patiënt. De waarde was nog niet bekend op het moment van voorschrijven. 
[[Bestand:Uc4.1.38B1.PNG|800px]]

Uit het onderzoek blijkt dat de nierfunctie verminderd is en reden geeft tot aanpassing van de medicatieafspraak.
De voorschrijver past de dosering op 17 januari 2020 aan naar 2x daags 1 tablet metformine 500 mg en bespreekt dit met de patiënt.
Het nieuwe voorschrift (de 'technische' stop-medicatieafspraak, nieuwe medicatieafspraak) wordt met de laboratoriumuitslag nierfunctiewaarde door de voorschrijver aan de apotheek gestuurd.
Omdat de patiënt de medicatie al had opgehaald en daardoor voldoende voorraad heeft, wordt er geen nieuw verstrekkingsverzoek meegestuurd. 
[[Bestand:Uc4.1.38B2.PNG|800px]]

'''C) Nierfunctiewaarde van toepassing vanwege geneesmiddel:''' 
Patiënte krijgt vanwege een blaasontsteking Nitrofurantoine 100 mg, 2x daags 1 capsule voorgeschreven als kuur van 5 dagen en moet meteen starten op 6 januari 2020. Bij dit geneesmiddel moet de nierfunctie waarde (indien bekend en niet ouder dan 13 maanden) meegestuurd worden. De voorschrijver heeft voor deze patiënte een nierfunctie waarde beschikbaar, welke echter geen aanleiding geeft tot een aangepaste dosering.
De voorschrijver stuurt het voorschrift (medicatieafspraak, verstrekkingsverzoek) met de laboratoriumuitslag nierfunctiewaardenaar de apotheker. 
[[Bestand:Uc4.1.38C.PNG|800px]]

===Annuleren eerder verstuurd voorschrift ===
Patiënt komt 's ochtends bij huisarts in verband met maagklachten. De huisarts schrijft pantoprazol voor en stuurt het voorschrift (MA + VV1) naar de voorkeursapotheek zoals bij de huisarts bekend is. Patiënt belt ’s middags op dat hij de medicatie nog niet heeft opgehaald en dat hij dit graag bij een andere apotheek wil doen i.v.m. een recente verhuizing, maar dat hij dit ’s ochtends is vergeten aan te geven. De huisarts stuurt de apotheek waar het eerdere voorschrift naartoe is gestuurd opnieuw het voorschrift, maar waarbij het VV de geannuleerd indicator bevat (MA + VV1”geannuleerd”), zodat de apotheker weet dat hij op dit voorschrift niet moet verstrekken.
Daarna stuurt de voorschrijver een nieuw voorschrift (MA + VV2) naar de nieuwe apotheek van de patiënt. De patiënt kan de medicatie daar ophalen. 
In medicatiebouwstenen ziet dit er als volgt uit: 
[[Bestand:Uc4.1.39A.png|800px]] 
De transacties zien er zo uit: 
[[Bestand:Uc4.1.39B.png|600px]] 

===Wijzigen van andermans medicatieafspraak ===
Een patiënt slikt een keer per dag 40 mg Lisinopril in verband met hypertensie. Deze medicatieafspraak is eerder door de huisarts met de patiënt gemaakt. De patiënt komt binnen op de spoedeisende hulp in verband met een val door duizeligheid. De specialist constateert hypotensie en besluit om de dosering van de Lisinopril te verlagen naar een keer per dag 20 mg. Hierop stopt de specialist de huidige MA, en start de nieuwe MA met een lagere dosering. Hiermee wijzigt hij de medicatieafspraak met de patiënt. De specialist informeert de oorspronkelijke voorschrijver(de huisarts) hierover met een stop-MA en de nieuwe MA.
De zorgverlener van de originele medicatieafspraak past de stopdatum aan in de bestaande medicatieafspraak. Dit kan desgewenst ook geautomatiseerd worden door het informatiesysteem. Hiermee wordt voorkomen dat na verloop van tijd de tweede zorgverlener geen gegevens meer hoeft op te leveren omdat de oplevertermijn is verstreken (ook geen stop-MA) terwijl de zorgverlener van de originele medicatieafspraak deze onterecht (zonder stopdatum) wel blijft opleveren.
 
[[Bestand:Uc4.1.40.PNG|800px]]
 
===Opstarten van een wisselend doseerschema ===
De voorschrijver schrijft bij een patiënt antistollingsmedicatie voor en geeft in de MA aan dat de medicatie gebruikt wordt volgens het schema van de trombosedienst. De voorschrijver stuurt een VV naar de apotheker en de patiënt wordt aangemeld bij de trombosedienst. Om de periode tot de trombosezorg betrokken is te overbruggen, maakt de voorschrijver een wisselend doseerschema aan voor de eerste periode. Na de aanmelding stelt de trombosedienst een doseerschema op dat het schema van de voorschrijver overschrijft of opvolgt. Vanaf dit moment neemt de trombosedienst de doseerschema’s over van de oorspronkelijke voorschrijver.

[[Bestand:Opstarten wisselend doseerschema.png|800px]]

===Tussentijds wijzigen wisselend doseerschema ===
Het kan nodig zijn om het doseerschema uit een WDS te herzien voor de stopdatum uit het schema. Bijvoorbeeld wanneer de patiënt onverwacht een kleine ingreep moet ondergaan. In dit geval stopt de voorschrijver het lopende WDS met een technische stop (niet zichtbaar voor de gebruiker) en maakt de voorschrijver een nieuw WDS aan met enkele 0-doseringen de dagen voorafgaand aan de ingreep. De MA loopt in de tussentijd gewoon door.
[[Bestand:Uc_Tussentijds_wijzigen_WDS.png|800px]]

===Stoppen medicatie met een wisselend doseerschema ===
Wanneer de patiënt (tijdelijk) helemaal moet stoppen met het gebruik van antistollingsmedicatie, wordt dit vastgelegd op het niveau van de MA. De trombosearts maakt dan een stop-MA aan. Daarmee wordt ook het onderliggende WDS en de bijbehorende TA gestopt. De originele voorschrijver verwerkt de stopdatum ook in zijn MA.
Als de antistollingsmedicatie na een aantal maanden weer opgestart moet worden, doet de oorspronkelijke voorschrijver van de antistollingsmedicatie dit door het proces van het opstarten van een WDS te volgen. Dus door een nieuwe MA te maken en een eerste WDS (zie de use case [[#Opstarten van een wisselend doseerschema|opstarten van een wisselend doseerschema]]).
[[Bestand:Uc_Stoppen_WDS.png|800px]]

==Use cases Ter hand stellen==

===Nieuwe medicatieafspraak, medicatieverstrekking zelfde product===
De patiënt is op 27 januari 2013 bij de apotheker om medicatie af te halen. De apotheker opent het dossier van de patiënt en verifieert het medicatiedossier. Het betreft een nieuwe medicatieafspraak voor deze patiënt. De relevante informatie van de voorschrijvende arts is weergegeven op het scherm van de apotheker: 
Medicatieafspraak: ''Nitrofurantoïne capsule mga 100 mg, 2 maal daags 1 capsule, vanaf heden gedurende 5 dagen.'' 
Verstrekkingsverzoek: ''Nitrofurantoïne capsule mga 100 mg; 10 stuks.''

De apotheker kiest een product op basis van de medicatieafspraak en andere factoren (zoals bijvoorbeeld de voorraad van de apotheker, preferentiebeleid zorgverzekeraar): 
''FURABID CAPSULE MGA 100 MG'' 
De apotheker voert medicatiebewaking uit met behulp van het informatiesysteem, er zijn geen signalen. 
De apotheker voert farmaceutische zorg (therapietrouw, voorlichting, etcetera) uit en spreekt met de patiënt af hoe zij de medicatie zal gebruiken. Deze toedieningsafspraak op 27 januari 2013 luidt: 
''FURABID CAPSULE MGA 100 MG; 2 maal daags 1 capsule; vanaf heden gedurende 5 dagen.''
De apotheker verstrekt de medicatie aan de patiënt: 
''op 27 januari 2013, FURABID CAPSULE MGA 100 MG; 10 stuks.''
De apotheker informeert de voorschrijvende arts actief over de toedieningsafspraak en de medicatieverstrekking. 
Het informatiesysteem van de apotheker maakt de nieuwe toedieningsafspraak en medicatieverstrekking beschikbaar voor de medebehandelaars van deze patiënt. 
 
[[Bestand:Uc4.2.1.PNG|800px]]

===Nieuwe medicatieafspraak, nadere specificering product===
Het verschil bij het specificeren van het product is dat de afspraak over toediening en ook de medicatieverstrekking afwijkt van de afspraak die de patiënt met de voorschrijvende arts heeft gemaakt. Verder is het proces hetzelfde als beschreven in de voorgaande paragraaf.

'''Voorbeeld''' 
Medicatieafspraak: ''Nitrofurantoïne capsule mga 100 mg, 2 maal daags 1 capsule, vanaf heden gedurende 5 dagen.'' 

De apotheker specificeert een ander product:
:''Nitrofurantoïne MC Actavis capsule 50 mg.''
De apotheker spreekt met de patiënt af hoe zij de medicatie zal gebruiken. Deze toedieningsafspraak op 27 januari 2013 luidt:
:''Nitrofurantoïne MC Actavis capsule 50 mg; 4 maal daags 1 capsule; vanaf heden gedurende 5 dagen.''
De apotheker verstrekt de medicatie aan de patiënt:
:''op 27 januari 2013, Nitrofurantoïne MC Actavis capsule 50 mg; 20 stuks.'' 
 
[[Bestand:Uc4.2.2.PNG|800px]]

===Bestaande toedieningsafspraak voldoet===
Het proces van het doen van een nieuwe medicatieverstrekking op basis van een bestaande medicatieafspraak, evt. bestaand verstrekkingsverzoek én toedieningsafspraak komt voor bij herhalen en is beschreven in paragraaf [[#Knippen van recept|4.2.10]], situatie 2.

===Medicatieafspraak gewenst (Informeren voorschrijver)===
'''Voorbeeld 1 - dosering aanpassen:''' 
De apotheker voert bij een patiënt van 70 jaar met creatinineklaring 45 ml/min een toedieningsafspraak in voor gabapentine tablet 600 mg 3x per dag 1 tablet. In de apotheek is de nierfunctie vastgelegd in het patiëntendossier, en op basis daarvan verschijnt er een signaal dat de maximale dosering 900 mg per dag is. De apotheker stuurt een voorstel medicatieafspraak met een aangepaste dosering van 300 mg 3x per dag en de reden voor dit voorstel (maximale dosering overschreden) naar de voorschrijver. De voorschrijver ontvangt het voorstel medicatieafspraak in zijn EVS. Hierop verstuurt de voorschrijver een aangepaste medicatieafspraak en optioneel een antwoord voorstel medicatieafspraak terug naar de apotheker. 
[[Bestand:Uc4.2.4.1.png|800px]] 

'''Voorbeeld 2 – geneesmiddel tijdelijk stoppen:''' 
De apotheker voert bij een patiënt van 50 jaar met een kuur fluconazol oraal in de actuele medicatie, een toedieningsafspraak in voor simvastatine. Er verschijnt een melding met het advies om te overwegen simvastatine tijdelijk te stoppen. De apotheker kan een voorstel medicatieafspraak voor het stoppen van simvastatine maken (stoptype 'tijdelijk'). Voor verdere stappen zie voorbeeld 1. 
[[Bestand:Uc4.2.4.2.png|800px]] 

'''Voorbeeld 3 – geneesmiddel toevoegen:''' 
De apotheker voert bij een vrouw van 55 jaar een toedieningsafspraak in voor prednison 10 mg per dag gedurende 3 maanden. De patiënt gebruikt geen osteoporoseprofylaxe. Er verschijnt een melding met het advies om een bisfosfonaat toe te voegen en na te gaan of de patiënt calcium en vitamine D gebruikt. Wanneer de patiënt deze middelen niet gebruikt kan de apotheker een voorstel medicatieafspraak voor deze middelen maken. Voor verdere stappen zie voorbeeld 1. 
[[Bestand:Uc4.2.4.3.png|800px]] 

LET OP: het zal van de situatie afhangen of het zinvol is geautomatiseerd een voorstel voor aanpassing/toevoeging van een MA te doen. Als het advies complex is, kan het nog steeds zinvol zijn om te bellen en te overleggen, i.p.v. een digitaal voorstel te sturen. 
De voorstel medicatieafspraak kan de voorschrijver helpen deze wijziging in de registratie door te voeren. Dit laatste is van belang wanneer medicatieafspraken worden geraadpleegd zoals in de dienstwaarneming huisartsen.

===Aanschrijven en verstrekken===
Wanneer een medicatieafspraak met verstrekkingsverzoek bij de apotheek binnen komt wordt deze verwerkt in het apotheek informatiesysteem tot een voorgenomen uitgifte. Dit wordt het moment van aanschrijven genoemd, welke als aanschrijfdatum in de medicatieverstrekking wordt vastgelegd. De verstrekkingsdatum wordt gevuld bij afhalen of overhandigen. De apotheker informeert de voorschrijver over de afhandeling van het voorschrift (toedieningsafspraak en/of medicatieverstrekking).

Het is mogelijk om meerdere verstrekkingen onder dezelfde TA aan te maken:
*Er komt een verstrekkingsverzoek binnen met een medicatieafspraak met een gebruiksperiode van een jaar.
*Er vindt een eerste verstrekking plaats met een nieuwe TA en een medicatieverstrekking welke voldoende is voor bijvoorbeeld een periode van 4 maanden.
 
[[Bestand:Uc4.2.5a.PNG|800px]]
 
*De tweede verstrekking wordt op basis van de bestaande medicatieafspraak, verstrekkingsverzoek en toedieningsafspraak uitgevoerd (er is geen nieuw voorschrift of een nieuwe toedieningsafspraak nodig). De nieuwe tweede medicatieverstrekking (met nieuwe aanschrijfdatum en de reeds bestaande bijbehorende toedieningsafspraak) wordt verstuurd naar de voorschrijver wanneer de verstrekkingsdatum geregistreerd is.
 
[[Bestand:Uc4.2.5b.PNG|800px]]

===Patiënt vraagt herhaalrecept via arts (reactief herhalen)===
Een arts heeft eerder hypertensie geconstateerd bij een patiënt (57 jaar) en heeft de patiënt hiervoor medicatie voorgeschreven. De patiënt gebruikt deze medicatie en de medicatie raakt op. De patiënt doet een verzoek om de medicatie te herhalen via bijvoorbeeld de herhaallijn, telefonisch, per e-mail aan de praktijk, balie/doosjes, website, app of portaal van de arts. De arts geeft toestemming voor herhaling. Dit leidt tot een nieuw verstrekkingsverzoek. 
Bijvoorbeeld:
:De huisarts doet, in het kader van de medicatieafspraak van 30 maart 2010:
:''Nifedipine mga 30 mg; 1 maal daags 1 tablet vanaf 30 maart 2010 tot voor onbepaalde duur''
:op 13 april 2013 een verstrekkingsverzoek aan een apotheker naar keuze van de patiënt:
:''Nifedipine tablet mga 30 mg; ‘voor drie maanden’.''
In overleg met de patiënt kan de voorschrijver het verstrekkingsverzoek met de bijbehorende medicatieafspraken als opdracht versturen naar de apotheker naar keuze van de patiënt. Daarnaast stelt de voorschrijver het nieuwe verstrekkingsverzoek beschikbaar aan medebehandelaars en patiënt. De bestaande medicatieafspraken waren reeds eerder beschikbaar gesteld. 
[[Bestand:Uc4.2.6.png|800px]] 
De apotheker ontvangt het verstrekkingsverzoek tezamen met de medicatieafspraak en handelt het af conform het proces van ter hand stellen en start met de processtap farmaceutische zorg. 
Wanneer de patiënt op basis van een toedieningsafspraak of op basis van zijn gebruik om een herhaalrecept vraagt, waarbij de medicatieafspraak niet digitaal beschikbaar is, maakt de arts een nieuwe medicatieafspraak die gebaseerd is op deze toedieningsafspraak of gebruik van de patiënt. Er vindt dan geen verwijzing plaats naar de bestaande medicatieafspraak.

===Patiënt vraagt herhaalrecept via apotheker (Informeren voorschrijver)===
De patiënt vraagt herhaling van medicatie aan bij apotheker, bijvoorbeeld via herhaallijn, telefonisch, e-mail, balie/doosjes, website, app of portaal van de apotheker. 
De apotheker stuurt een voorstel verstrekkingsverzoek ter autorisatie aan de voorschrijver. De arts beoordeelt het voorstel verstrekkingsverzoek en accordeert deze. Hij informeert de apotheker via het antwoord voorstel verstrekkingsverzoek en stuurt een nieuw verstrekkingsverzoek samen met de actuele afspraken naar de apotheker. De apotheker vervolgt het proces van ter hand stellen en start met de processtap farmaceutische zorg. 
[[Bestand:Uc4.2.7.png|800px]] 
Als de voorschrijver geen verstrekkingsverzoek afgeeft informeert hij de apotheker via het antwoord voorstel verstrekkingsverzoek hierover.

===Proactief herhaalrecept door apotheker (Informeren voorschrijver)===
De patiënt heeft zich in het verleden aangemeld voor proactief herhalen en de apotheker heeft dit geregistreerd in het eigen apotheek informatiesysteem (AIS). De herhaalmodule van dit informatiesysteem zal een signaal genereren wanneer een patiënt nieuwe medicatie nodig heeft. Als er een nieuw verstrekkingsverzoek nodig is komt dit overeen met het proces beschreven in de vorige paragraaf, alleen de trigger is niet de patiënt maar de apotheker (of zijn informatiesysteem) zelf. Proactief herhalen wordt ook gebruikt voor GDS, zie [[#Het opstarten en continueren van GDS|paragraaf 4.2.11]]. 
[[Bestand:Uc4.2.8.png|800px]] 

===Verstrekken op basis van bestaand verstrekkingsverzoek===
De patiënt levert een herhaalrecept in bij de apotheker. Het betreft in dit geval een verzoek tot medicatieverstrekking op basis van een bestaand, nog geldig, verstrekkingsverzoek. Zie hiervoor [[#Knippen van recept|paragraaf 4.2.10 situatie (3)]].

===Knippen van recept===
Een patiënt gebruikt al jaren dezelfde medicatie. De medicatieafspraak kan voor onbepaalde duur worden gemaakt. Ook de toedieningsafspraak volstaat voor onbepaalde duur. De patiënt komt dan in aanmerking voor een jaarrecept. Wanneer de patiënt een jaarrecept krijgt dan moet er geknipt worden door de apotheker. De geknipte recepten zijn feitelijk geen 'herhaalrecept' maar we noemen het in de wandelgangen wel zo. 
Er zijn drie situaties: 
1) Patiënt komt terug bij behandelend arts en de klachten zijn nog niet over. De voorschrijver schrijft hetzelfde voor (bij een verlopen medicatieafspraak wordt een nieuwe medicatieafspraak met nieuw verstrekkingsverzoek gemaakt en bij een nog lopende medicatieafspraak wordt alleen een nieuw verstrekkingsverzoek gemaakt). 
[[Bestand:Uc4.2.10A.png|800px]] 

2) Voorschrijver en patiënt spreken initieel af: 90 stuks met 3x herhalen. De patiënt krijgt initieel 90 stuks verstrekt. De volgende keer dat de patiënt bij de apotheker komt wordt er een medicatieverstrekking gedaan onder de bestaande afspraken. 
[[Bestand:Uc4.2.10B.png|800px]] 
3) Voorschrijver en patiënt spreken initieel af: 360 stuks gedurende een jaar. De apotheker knipt dit in 4 deelverstrekkingen. De patiënt krijgt dan initieel 90 stuks verstrekt en kan zonder nieuw verstrekkingsverzoek daarna nog 3x bij de apotheker een medicatieverstrekking afhalen van 90 stuks. 
[[Bestand:Uc4.2.10C.png|800px]] 
Deze laatste situatie beschrijft feitelijk de situatie van het knippen van een jaarrecept door de apotheker.

===Het opstarten en continueren van GDS===
Het voorbeeld hierna toont het proces rondom één geneesmiddel dat door de patiënt voor onbepaalde duur wordt gebruikt. In het informatiesysteem van de voorschrijver en de apotheker staan (onder andere) de volgende gegevens over een patiënt:
*De medicatieafspraak op 2 januari 2013 luidt: Metoprolol tablet mga 100 mg (succinaat); een maal daags een tablet; van 2 januari 2013 voor onbepaalde duur.
*De toedieningsafspraak op 2 januari 2013 luidt: Metoprolol PCH retard 100 tablet mga 95 mg; een maal daags een tablet; van 2 januari 2013 voor onbepaalde duur.
Deze bejaarde patiënt heeft zoveel medicatie dat hij geen overzicht meer heeft: een potentieel gevaar. Op 6 februari spreken de apotheker en de voorschrijver af dat de medicatieverstrekking van geneesmiddelen aan deze patiënt gebeurt via GDS.

De GDS wordt opgestart: de apotheker stuurt een voorstel verstrekkingsverzoek (qua gebeurtenis vergelijkbaar met het huidige verzamelrecept of autorisatieformulier).

Het voorstel verstrekkingsverzoek van 6 februari luidt:
*Verstrekkingsverzoek ten behoeve van de medicatieafspraak van 2 januari 2013: Metoprolol tablet mga 100 mg (succinaat), en een verbruiksperiode voor voldoende voorraad tot en met 1 mei 2013.
De apotheker stuurt het voorstel naar de voorschrijver. De voorschrijver fiatteert het voorstel op 6 februari en stuurt het als verstrekkingsverzoek ongewijzigd naar de apotheker. In zowel het informatiesysteem van de voorschrijver als de apotheker wordt bij de patiënt het kenmerk GDS aangezet.

De apotheker kiest met de patiënt een deeltijd voor het middel. Deze toedieningsafspraak luidt als volgt:
*Op 7 februari is afgesproken: Metoprolol PCH retard 100 tabl mga 95 mg; 1 tablet ‘s morgens; vanaf 11 februari (week 6) voor onbepaalde duur.
De apotheker verstrekt iedere tweede week een baxterrol medicatie met (onder andere) de Metoprolol:
*Verstrekking 1: De apotheker verstrekt op vrijdag 8 februari 2013: 14 tabletten; gepland voor week 6 en 7 (een verbruiksduur van 2 weken).
*Verstrekking 2: De apotheker verstrekt op vrijdag 22 februari: 14 tabletten; gepland voor week 8 en 9.
*Verstrekking 3, 4, 5, enzovoorts...
Bij elke medicatieverstrekking wordt aangegeven dat deze via GDS geleverd is. 
Na drie maanden volgt opnieuw een voorstel verstrekkingsverzoek van de apotheek aan de voorschrijver, enzovoorts. 
[[Bestand:Uc4.2.11.png|800px]] 

'''Beschouwing''' 
*Het toepassen van een voorstel verstrekkingsverzoek in plaats van een autorisatieformulier maakt de betekenis ervan eenduidig.
*Doordat in de huidige situatie toedieningsafspraken en medicatieverstrekkingen als één aflevering wordt geregistreerd, is het moeilijk om in de grote hoeveelheid berichten zinvolle informatie te vinden. Het scheiden van het afleverbericht in twee bouwstenen maakt het overzicht eenvoudiger te overzien: er zijn géén nieuwe medicatieafspraken en er is één nieuwe toedieningsafspraak gemaakt. De resterende logistieke gegevens bevatten geen verrassingen. De medicatieverstrekkingen hoeven in dit scenario niet onder de aandacht van de huisarts te komen.
*Deze wijze van registreren en uitwisselen voorkomt dubbele registratie, en fouten ten gevolge daarvan.
*De toedieningsafspraken vormen de basis voor toedienlijst en aftekenlijsten van verpleeg- en verzorgingshuizen. Het aftekenen ervan komt overeen met de toediening(en).

===De apotheker wijzigt van handelsproduct===
Dit scenario bouwt voort op het vorige scenario: na een half jaar wordt een ander handelsproduct afgesproken met de patiënt (toedieningsafspraak), omdat het andere product niet leverbaar is. Er wordt geen nieuwe medicatieafspraak gemaakt, op dat niveau vindt geen wijziging plaats. De toedieningsafspraak wordt gewijzigd:
*Op 1 juli is afgesproken: Metoprolol Sandoz ret 100 tabl mga 95 mg; 1 tablet ‘s morgens; vanaf 3 juli voor onbepaalde duur. Reden: niet leverbaar.
De toedieningsafspraak is een wijziging van de toedieningsafspraak van 7 februari (welke stopt op 2 juli (23.59u)) en is een concrete invulling van de medicatieafspraak van 2 januari. De apotheker informeert de huisarts over deze gegevens.
[[Bestand:Uc4.2.12.PNG|800px]] 

'''Beschouwing''' 
Deze wijziging in de concrete invulling van de medicatieafspraak door middel van een toedieningsafspraak, verandert niets aan de geldigheid van de medicatieafspraak. Dit komt het overzicht ten goede. Aanvullend kan, doordat de apotheker de reden van aanpassing vastlegt en uitwisselt, de voorschrijver beter inschatten of de informatie relevant is.

===Medicatie toevoegen aan GDS===
Wanneer nieuwe medicatie wordt toegevoegd aan bestaande GDS kan de voorschrijver kiezen voor directe toevoeging aan de rol (Wijziging in GDS per direct) of met ingang van de volgende rol (Wijziging in GDS per rolwissel). Dit geeft de voorschrijver aan in de medicatieafspraak (Aanvullende informatie).
Wanneer gekozen wordt voor ‘Wijziging in GDS per direct’ zal de apotheker de medicatie eerst los, naast de bestaande GDS leveren. Dit betekent dat er een toedieningsafspraak door de apotheker wordt gemaakt voor de overbruggingsperiode. Met ingang van de nieuwe rol wordt de nieuwe medicatie toegevoegd aan de rol. Met ingang van de ingangsdatum van de nieuwe rol kan er een toedieningsafspraak worden gemaakt door de apotheker met specifieke toedientijden. Wanneer de 'overbruggings-toedieningsafspraak' al de juiste toedientijden bevat wordt er geen nieuwe toedieningsafspraak gemaakt bij opname in de rol. 
[[Bestand:Uc4.2.13.png|800px]] 
Wanneer gekozen wordt voor 'Wijziging in GDS per rolwissel' zal de apotheker de medicatie opnemen in de eerstvolgende rol die wordt uitgegeven aan de patiënt. Er hoeft geen toedieningsafspraak gemaakt te worden voor de overbruggingsperiode.

===Medicatie in GDS stoppen===
Wanneer medicatie wordt gestopt wordt er een stop-medicatieafspraak gemaakt door de voorschrijver. De apotheker wordt conform het proces geïnformeerd over deze stop-medicatieafspraak en kan de levering daarop aanpassen. De apotheker zal een stop-toedieningsafspraak maken. Zie hiervoor paragraaf [[#Stoppen medicatie|2.2.5.3]] en [[#Stoppen toedieningsafspraak|2.3.6.3]].

===GDS leverancier levert ander handelsproduct===
Het kan zijn dat een GDS leverancier een ander handelsproduct levert dan door de apotheek in de TA is opgenomen.
Hier is dus sprake van een wijziging in de HPK welke zorgt voor een gewijzigde TA.
Eventueel is dit pas achteraf, na terugkoppeling van de GDS leverancier van de definitieve invulling. 
[[Bestand:Uc4.2.15.png|800px]] 
 
===Parallelle toedieningsafspraken bij GDS- en niet-GDS-verstrekking===
Een patiënt slikt twee tot drie keer per dag 20 mg pantoprazol in verband met maagklachten. De eerste twee tabletten zijn vaste dosering en worden geleverd in GDS. De derde tablet neemt hij zo nodig en is los verpakt. Op een bepaald moment is de pantoprazol 20 mg van Sandoz niet leverbaar voor losse verstrekkingen. Daarop besluit de apotheker om Apotex te verstrekken. Hiervoor stopt hij de bestaande TA en splitst deze (onder de bestaande MA) op in twee TA’s, beide met dezelfde startdatum/tijd. De eerste TA heeft betrekking op de vaste dosering in GDS, de tweede gaat over de zo nodig tablet. 
''NB. Er is op dit moment nog geen relatie tussen de verstrekking en een specifieke TA. Daarom is nu niet te zien bij welke TA een verstrekking hoort zonder de inhoud te checken. Er wordt gekeken of dit in de toekomst anders moet.'' 
 
[[Bestand:Uc4.2.16.png|800px]] 

===Afhandelen stoppen medicatieafspraak===
Wanneer er door de voorschrijver afgesproken wordt medicatie te stoppen wordt een stop-MA gemaakt. Deze stop-MA wordt bij de apotheker ingevuld door het stoppen van de toedieningsafspraak.

===Verstrekken onder andermans toedieningsafspraak===
Een patiënt slikt twee keer per dag 20 mg pantoprazol in verband met maagklachten. Tijdens een vakantie komt de patiënt erachter dat hij zijn medicatie vergeten is. Hij gaat naar een HAP bij hem in de buurt en vraagt om extra tabletten voor tijdens zijn vakantie. De dienstdoende arts stuurt een VV aan de dienstapotheek onder de bestaande MA. 
De apotheker van de dienstapotheek ziet het medicatievoorschrift en maakt een MVE aan onder de reeds bestaande TA voor de 10 tabletten die de patiënt nodig heeft en informeert de dienstdoende arts over deze verstrekking. Daarbij stuurt de apotheker een kopie van de oorspronkelijke TA mee. 
''NB. De oorspronkelijke voorschrijver en verstrekker worden niet automatisch geïnformeerd, maar de gegevens zijn voor hen wel beschikbaar.'' 
 
[[Bestand:Uc4.2.18A.png|800px]] 
 
===Wijzigen van andermans toedieningsafspraak===
Een patiënt slikt twee keer per dag 20 mg pantoprazol in verband met maagklachten. Tijdens een vakantie komt de patiënt erachter dat hij zijn medicatie vergeten is. Hij gaat naar een HAP bij hem in de buurt en vraagt om extra tabletten voor tijdens zijn vakantie. De dienstdoende arts stuurt een VV aan de dienstapotheek onder de bestaande MA. 
De apotheker van de dienstapotheek constateert dat zij geen voorraad pantoprazol van Sandoz hebben, maar van Apotex. Hierop stopt ze de huidige TA, start ze de nieuwe TA voor de Apotex en maakt ze de MVE voor de 10 tabletten Apotex aan. De dienstapotheker informeert de oorspronkelijke apotheker hierover en de oorspronkelijke apotheker verwerkt de stop-TA.
 
[[Bestand:Uc4.2.18B.png|800px]] 
 

==Use cases Toedienen==

===Toedienlijst opstarten===
Wanneer gestart wordt met het gebruik van een toedienlijst, bijvoorbeeld wanneer de patiënt in zorg komt bij een (professionele) toediener, start met GDS-medicatie of niet-GDS-medicatie, vindt een intake plaats met de patiënt en voorschrijver, apotheker of toediener (proces verschilt per zorginstelling). Vervolgens vindt er overleg plaats tussen voorschrijver, apotheker, toediener en/of patiënt waarbij afgestemd wordt welke medicatie op de toedienlijst komt en welke (richt)toedientijden geschikt zijn. De apotheker registreert de (richt)toedientijden in de TA en stelt de benodigde medicatiegegevens voor de toedienlijst (actief) beschikbaar aan toediener en/of patiënt.

===Exacte toedientijden nodig ===
Wanneer er exacte toedientijden nodig zijn, bijvoorbeeld in geval van een wisselwerking tussen medicatie kan de voorschrijver of apotheker aangeven dat een exacte toedientijd nodig is en dat de toedientijd geen richttijd is. De voorschrijver of apotheker kan dit vastleggen door aan te geven dat de toedientijd niet flexibel is. Standaard wordt uitgegaan van flexibele (richt)toedientijden. Een exacte toedientijd moet vermeld worden op de toedienlijst, zodat de toediener weet dat van deze toedientijd niet afgeweken mag worden.

===Ontbreken (richt)toedientijden ===
Wanneer (richt)toedientijden ontbreken in zowel MA als TA zoeken toedieners contact met de voorschrijver of apotheker om de (richt)toedientijd te achterhalen. Dit wordt niet digitaal ondersteund in deze informatiestandaard.

===Niet-GDS-medicatie zo nodig ===
Niet-GDS-medicatie zo nodig staat op de toedienlijst, maar niet per toedienmoment en/of tijd, omdat dit van te voren niet bekend is. Wanneer het relevant is (bijv. bij interactie met andere medicatie) kunnen er wel (richt)toedientijden meegegeven worden.

Zie de volgende use cases voor praktische voorbeelden: [[mp:V9_2.0.0_Ontwerp_medicatieproces#Zo nodig medicatie|4.1.4 Zo nodig medicatie]], [[mp:V9_2.0.0_Ontwerp_medicatieproces#Kuur zo nodig startend in de toekomst|4.1.5 Kuur zo nodig startend in de toekomst]], [[mp:V9_2.0.0_Ontwerp_medicatieproces#Twee doseringen van hetzelfde geneesmiddel tegelijkertijd|4.1.6 Twee doseringen van hetzelfde geneesmiddel tegelijkertijd]],
[[mp:V9_2.0.0_Ontwerp_medicatieproces#Hetzelfde geneesmiddel met verschillende sterkte tegelijkertijd|4.1.7 Hetzelfde geneesmiddel met verschillende sterkte tegelijkertijd]].

===Meerdere apotheken leveren medicatie ===
Meerdere apothekers kunnen betrokken zijn bij medicatieverstrekkingen voor één patiënt. Dit gaat bijvoorbeeld om verstrekkingen door een poliklinische apotheker, naast de verstrekkingen door een openbare apotheker of verstrekkingen van add-on medicatie door een ziekenhuisapotheker, naast verstrekkingen door een openbare apotheker. Wanneer meerdere apothekers medicatie leveren, is iedere apotheker zelf verantwoordelijk voor de medicatiegegevens die nodig zijn voor de toedienlijst. Dit omvat dus ook de (richt)toedientijden in de TA. De verantwoordelijkheid om te bepalen of een toevoeging/wijziging past bij het totaal van (bekende) medicatiegegevens ligt bij de voorschrijver of apotheker van de laatst toegevoegde/gewijzigde medicatie. Dit gaat dan om zowel medicatiebewaking als om (richt)toedientijden. De medicatiegegevens worden (actief) beschikbaar gesteld, zodat alle medicatiegegevens vanuit de verschillende apothekers op één toedienlijst kunnen komen.

===Wijziging in GDS-medicatie vanaf volgende levering of per direct ===
Indien GDS-medicatie gewijzigd wordt, is het situatieafhankelijk of deze wijziging per direct of pas vanaf de eerstvolgende levering kan ingaan. De voorschrijver kan dit aangeven in de MA. Indien het gaat om een directe wijziging, moet dit direct zichtbaar zijn op de toedienlijst, zodat de (professionele) toediener de juiste (hoeveelheid) medicatie toedient. Bij een wijziging die pas bij de eerstvolgende levering ingaat, moet dit niet direct op de toedienlijst worden aangepast, omdat de oude afspraken op dat moment nog geldig zijn. De toedienlijst moet pas worden aangepast op het moment dat de wijziging ook daadwerkelijk ingaat.

Zie ook use case [[mp:V9_2.0.0_Ontwerp_medicatieproces#Medicatie toevoegen aan GDS|4.2.13 Medicatie toevoegen aan GDS]].

===Verhogen dosering GDS-medicatie in nieuwe MBH ===
Patiënt krijgt iedere dag 1 tablet propranolol 40 mg toegediend. Wegens onvoldoende effect besluit de voorschrijver de dosis te verhogen naar 80 mg 1x daags. Er wordt voor deze MA een nieuwe MBH aangemaakt, want het voorschrijven op prescriptieniveau wijzigt. Echter, de patiënt heeft nog voor enkele dagen voorraad van de 40 mg tabletten in haar GDS-rol zitten. Daarom besluit de apotheker om tot de rolwissel over 5 dagen de GDS-medicatie aan te vullen met het toedienen van 1 tablet propranolol 40 mg buiten de GDS, naast de tablet uit de GDS. De apotheker maakt twee TA’s aan, namelijk één voor de oude GDS-medicatie en één voor de overbrugging een niet-GDS bij de medicatieverstrekking. Bij de nieuwe rol GDS (rolwissel) worden de 80 mg tabletten in haar GDS opgenomen.

[[Bestand:Usecase verhogen dosering losse levering nieuwe MBH.png|800px]]

===Verlagen dosering GDS in nieuwe MBH ===
Patiënt krijgt iedere dag 1 tablet propranolol 80 mg toegediend. Wegens een te sterk effect besluit de voorschrijver de dosis zo snel mogelijk te verlagen naar 40 mg 1x daags. Er wordt voor deze MA een nieuwe MBH aangemaakt. Patiënt heeft nog voor enkele dagen voorraad van de 80 mg tabletten in haar GDS-rol zitten. Omdat de toediener tabletten niet mag halveren besluit de verstrekker dat de overgebleven GDS-zakjes dezelfde dag nog worden opgehaald en worden vervangen door een nieuwe GDS-rol met de 40 mg tabletten.

[[Bestand:Verlagen dosering GDS in nieuwe MBH.png|800px]]

===Wijziging verwerkt door de apotheker ===
Wijziging door de voorschrijver, zoals het starten van nieuwe medicatie, het wijzigen van de dosering, het (tijdelijk) stoppen van medicatie, legt de voorschrijver vast in de MA en/of het VV. De apotheker verwerkt deze in de TA en/of MVE. Dit vindt plaats tijdens openingstijden van de openbare apotheker, maar ook wanneer er een wijziging plaatsvindt buiten de openingstijden en er een medicatieverstrekking nodig is. De dienstapotheker verstrekt in dit geval de medicatie en er zijn dan meerdere apotheken die medicatie leveren (zie ook paragraaf 2.5.9.4). De medicatiegegevens van de apotheker(s) en de voorschrijver(s) worden door de voorschrijver en dienstapotheker (actief) beschikbaar gesteld aan de toediener voor de toedienlijst.

===Wijziging niet verwerkt door de apotheker ===
Wanneer een wijziging in de medicatie van een patiënt plaatsvindt door toedoen van de voorschrijver buiten de openingstijden van de openbare apotheker en er geen medicatieverstrekking nodig is, is er geen tussenkomst van een apotheker. In dit geval is de MA leidend en stelt de voorschrijver deze(actief) beschikbaar. De toediener ziet op de toedienlijst de gewijzigde of gestopte MA en deze overrulet alle medicatiebouwstenen binnen dezelfde medicamenteuze behandeling. Deze situatie is ook van toepassing als de apotheker de wijziging van de voorschrijver nog niet heeft verwerkt. De apotheker zorgt zo snel mogelijk alsnog voor aanpassing van de TA.

===Aanvullende informatie ===
Aanvullende informatie is een aanvullende uitleg over het gebruik voor de (professionele) toediener en/of patiënt. Een voorbeeld hiervan is dat bij het stoppen van een fentanylpleister er een extra instructie is dat de pleister verwijderd moet worden. Een ander voorbeeld is dat bij dosering van een halve tablet een instructie is bijgevoegd wat er met de andere halve tablet moet gebeuren. Deze gegevens kunnen vastgelegd worden in vrije tekst in de toelichting van de MA, TA en/of WDS.

Zie use case [[mp:V9_2.0.0_Ontwerp_medicatieproces#Toelichting in medicatieafspraak bij bewust gekozen bijzonderheid|4.1.8 Toelichting in medicatieafspraak bij bewust gekozen bijzonderheid]] van de informatiestandaard MP9 voor meer informatie.

===Medicatietoediening afwijkend ten opzichte van toedienlijst===
Er kan een afwijking zijn geweest in de toediening ten opzichte van wat door de voorschrijver en apotheker is vastgelegd in de MA of TA. Dit kan een afwijking betreffen in tijdstip, hoeveelheid, toedieningsweg, toedieningssnelheid, product of het in het geheel niet toedienen. Een (professionele) toediener kan in overleg met de voorschrijver van de regels afwijken als deze goede argumenten heeft en veilige zorg en veilig werken wordt gerealiseerd. De reden van de afwijking wordt in de MTD vastgelegd.

===Medicatietoediening zonder medicatieafspraak en toedieningsafspraak ===
Bij een spoedsituatie kan er mogelijk (nog) geen MA en TA beschikbaar zijn, maar moet de (professionele) toediener op basis van een mondelinge/telefonische MA medicatie toedienen. Deze medicatie staat dan niet op de toedienlijst. De (professionele) toediener legt een dergelijke MTD vast in het informatiesysteem van de toediener (o.a. ECD, TDR). Dit is de eerste bouwsteen in een nieuwe medicamenteuze behandeling (MBH) en dus start de toediener hier een MBH.

===Medicatietoediening van zelfzorgmedicatie ===
Volgens de veilige principes in de medicatieketen heeft de toediener geen taak in het toedienen van zelfzorgmedicatie, behalve als deze uiteindelijk wordt voorgeschreven door een voorschrijver (MA wordt aangemaakt). Dan komt de zelfzorgmedicatie als GDS- of als niet-GDS-medicatie (zo nodig) op de toedienlijst.

===Corrigeren/annuleren van toediening ===
Dit betreft het corrigeren of annuleren van een MTD omdat een toediener een fout in de registratie maakte en er geen medicatietoediening heeft plaatsgevonden. Indien de MTD nog niet gedeeld is met andere zorgverleners, dan kan de toediener die MTD zelf aanpassen of schrappen (annuleren) uit het eigen informatiesysteem. Indien de MTD al wel gedeeld is met andere zorgverleners dan annuleert de toediener deze foutieve MTD en maakt een nieuwe MTD onder dezelfde MBH met de juiste informatie. De toediener stelt de gecorrigeerde MTD en nieuwe MTD (actief) beschikbaar.

===Opschorten van toediening ===
Er zijn gevallen waarbij de toediening niet is gelukt en in overleg met een voorschrijver of apotheker op een later moment alsnog toegediend kan worden. Als de medicatietoediening binnen de gemaakte afspraken over flexibele toedientijden valt, kan de toediener afwijken van de (richt)toedientijd.

Een voorbeeld voor het opschorten van toediening is:
*Medicatietoediening is niet gelukt, maar de bedoeling is om deze medicatietoediening op een later (of soms eerder) moment op de dag nog een keer te proberen. Bij deze medicatietoediening is sprake van het opschorten van de toediening én van een afwijking van de toedienlijst.

===Medicatietoediening door voorschrijver ===
Een voorschrijver kan net als een (professionele) toediener medicatie toedienen bij een patiënt en deze handeling vastleggen in een MTD.

===Meerdere toedienorganisaties ===
Meerdere toedienorganisaties kunnen betrokken zijn bij de medicatietoediening van één patiënt. Dit gaat bijvoorbeeld om zorgverlening waarbij de medicatietoedieningen in de avond of nacht door een andere organisatie geleverd wordt dan overdag. Wanneer meerdere toedienorganisaties de zorg leveren, kunnen deze zorgverleners elkaars MTD’s raadplegen om het proces van toedien van medicatie te volgen. De handelingen van de ene organisatie kan namelijk effect hebben op het proces van de andere organisatie (o.a. heeft de toediening plaatsgevonden of waren er afwijkingen ten opzichte van de toedienlijst).

===Feedback aan patiënt via medicatiesignalering===
De patiënt gebruikt bijvoorbeeld zijn mobiele app als medicatiesignaleringtoepassing. Daartoe heeft de apotheker of de patiënt zelf een toedienschema ingesteld op de gewenste innamemomenten (al dan niet met applicatie-intelligentie om uit de medicatieverstrekkingen/toedienafspraken toedienmomenten voor te stellen). Op de toedienmomenten ontvangt de patiënt een signaal dat hem eraan herinnert om de medicatie in te nemen. De patiënt registreert de toediening en geeft daarmee aan of hij het geneesmiddel heeft ingenomen of niet (bijv. omdat de patiënt het geneesmiddel vergeten heeft mee te nemen). Wanneer de app gekoppeld is aan bijvoorbeeld het PGO van de patiënt wordt dan de therapietrouw automatisch bijgehouden.
 
[[Bestand:Uc4.3.23.PNG|800px]]
 


==Use cases Gebruiken==

===Zelfzorgmiddel===
Een patiënt heeft bij de drogist Ibuprofen aangeschaft, en neemt dagelijks 1200 mg. De patiënt voert het middel op als gebruik, met gegevens als ingangsdatum en dosering, en eventueel de reden van gebruik. 
[[Bestand:Uc4.4.1.png|800px]] 

===Medicatie uit buitenland===
Een patiënt heeft op vakantie medicatie voorgeschreven gekregen en neemt deze in. De patiënt voert de medicatie op als gebruik, met gegevens als ingangsdatum en dosering, en eventueel de reden van gebruik. Indien bekend worden ook de naam van de voorschrijver vastgelegd. 
[[Bestand:Uc4.4.2.png|800px]] 

===Wijziging op initiatief patiënt===
Een patiënt heeft medicatie propranolol voorgeschreven gekregen. De patiënt slaapt er erg slecht door, en heeft zelf de medicatie geminderd. De patiënt legt gebruik vast met de gewijzigde dosering en de datum sinds wanneer deze verlaagde dosis wordt genomen. Daarbij geeft de patiënt als reden aan dat dit op eigen initiatief is. 
Bij bijvoorbeeld een dosisverlaging op eigen initiatief kan de patiënt langer doorgaan dan afgesproken omdat zij nog voorraad heeft. Dit kan de patiënt als aanvullend gebruik opgeven. 
Bij bijvoorbeeld een dosisverhoging op eigen initiatief kan de voorraad van de patiënt eerder op zijn. De patiënt komt dan mogelijk eerder dan verwacht terug bij de arts. 
[[Bestand:Uc4.4.3.png|800px]] 

===Stoppen medicatie op initiatief patiënt===
Sinds het gebruik van propranolol heeft een patiënt last van slapeloosheid. Hij besluit te stoppen zonder daarbij direct de voorschrijvend arts te informeren. De patiënt legt vast dat hij gestopt is, per wanneer en kiest als reden voor wijzigen/stoppen '(mogelijke) bijwerking'. In de toelichting vult hij aan dat de bijwerking slapeloosheid betreft. 
[[Bestand:Uc4.4.4.png|800px]] 

===Geen voorraad meer===
Een patiënt heeft 'zo nodig' medicatie gekregen ter bestrijding van huidklachten. De medicatie staat nog op actief in het medicatieprofiel maar is al op. De patiënt geeft aan dat de medicatie gestopt is, met als reden dat deze niet meer voorradig is, eventueel met de toevoeging dat de klachten verholpen zijn. 
[[Bestand:Uc4.4.5A.png|800px]] 
De patiënt kan ook een voorstel verstrekkingsverzoek doen om zijn voorraad aan te vullen. Het antwoord voorstel verstrekkingsverzoek komt in dit geval bij de patiënt terug (en indien geaccordeerd gaat er van de voorschrijver tevens een verstrekkingsverzoek naar de apotheker). 
[[Bestand:Uc4.4.5B.png|800px]] 

===Registreren van afwijkend medicatiegebruik door patiënt vanwege een bijwerking===
Sinds het gebruik van propranolol heeft een patiënt last van slapeloosheid. De patiënt legt de bijwerking vast in de toelichting bij het medicatiegebruik. Wanneer de patiënt de medicatie anders gebruikt dan afgesproken, bijvoorbeeld minder tabletten, dan kan hij de bijwerking als reden opgeven van deze wijziging. Wanneer de klachten verminderen of ophouden legt de patiënt dit vast in de toelichting van het medicatiegebruik. 
Het kan zijn dat de patiënt last heeft van bijwerkingen zonder precies te weten welk geneesmiddel daarvan de oorzaak is. Er is (nog) geen voorziening binnen medicatieproces om dat vast te leggen.

===Gebruik registreren op basis van verstrekking===

Dit is van toepassing in de transitie periode van de oude medicatieproces standaard 6.12 naar deze medicatieproces informatiestandaard.

Digitaal is alleen een verstrekking beschikbaar (volgens medicatieproces versie 6.12). Het informatiesysteem van de gebruiker biedt echter wel de mogelijkheid om al medicatiegebruik vast te leggen.
Het medicatiegebruik kan in dat geval vastgelegd worden met verwijzing naar het id van de versie 6.12 verstrekking. 
[[Bestand:Uc4.4.8.png|800px]] 

=Medicatieoverzicht en afleidingsregels=

Dit hoofdstuk toont een voorbeeld medicatieoverzicht en specificeert daarnaast afleidingsregels voor 'De laatst relevante bouwsteen', Verificatie per medicamenteuze behandeling etc.
==Inleiding==

De term 'actueel medicatieoverzicht' is vervangen door de term 'basisset medicatiegegevens':
het medicatieoverzicht in combinatie met aanvullende gegevens die (minimaal) nodig zijn om veilig en verantwoord medicatie te kunnen voorschrijven, wijzigen, stoppen of veilig ter hand te stellen in de Leidraad Overdracht van Medicatiegegevens in de keten (definitief concept 2017).

Deze pagina bevat een voorbeeld van een medicatieoverzicht. Dit voorbeeld is ontwikkeld in het programma Informatiestandaard Medicatieproces en dient als voorbeeld voor de manier waarop gegevens getoond kunnen worden in een applicatie. De in onderstaande plaatjes genummerde gegevens zijn daarbij normatief, deze zijn verplicht om te tonen. De andere (ongenummerde) gegevens in het voorbeeld zijn optioneel en worden mogelijk in de toekomst als normatief toegevoegd. De lay-out van het overzicht in een informatiesysteem kan verschillen per doelgroep en per device. Voor apothekers zijn bijvoorbeeld in eerste instantie alleen toedieningsafspraken zichtbaar waarbij vervolgens kan worden doorgeklikt naar de bijbehorende medicatieafspraak en het medicatiegebruik. Wanneer er alleen medicatiegebruik of een medicatieafspraak bekend is wordt deze uiteraard wel direct getoond. Uitgangspunt is dat op het overzicht alle medicatie van de patiënt getoond wordt, dus niet alleen de medicatie die in het eigen informatiesysteem is vastgelegd.

Het overzicht is generiek beschreven en daarmee voor alle leveranciers gelijk. Op deze pagina zijn de eisen van de eindgebruikers opgenomen en worden geen uitspraken gedaan over de technische realisatie of implementatie. De bestaande KNMP-specificatie “User requirements specification Medicatieoverzicht 2.0”, definitieve concept “Leidraad Overdracht van Medicatiegegevens in de keten” en de nieuwe inzichten uit het programma Medicatieproces zijn hierin verwerkt.

Uitgangspunten voor het overzicht zijn:
* Zorgverleners willen op een medicatieoverzicht onderscheid zien tussen de therapeutische bouwstenen:
** Medicatieafspraak
** Toedieningsafspraak
** Medicatiegebruik
* Logistieke bouwstenen (verstrekkingsverzoek, verstrekking) en de bouwsteen medicatietoediening zijn niet relevant voor het medicatieoverzicht.

[[Bestand:Medicatieoverzicht_1_v0.5.PNG|Medicatieoverzicht v0.5]]
[[Bestand:Medicatieoverzicht_2_v0.5.PNG|Medicatieoverzicht v0.5]]

==Functionele specificatie==
In de figuren hieronder zijn de onderdelen opgenomen met normatieve gegevens. De andere onderdelen zijn nog niet normatief.
De in de tabel genummerde elementen zijn normatief, overige elementen vooralsnog optioneel.

===Kop en Algemeen===
[[Bestand:Medicatieoverzicht_KopAlgemeen_v0.5.PNG]]

Filter: n.v.t.

Sorteren: n.v.t.

Datum medicatieoverzicht: dit is de datum dat de laatste wijziging in een medicatieafspraak, toedieningsafspraak of medicatiegebruik is vastgelegd binnen het informatiesysteem dat het medicatieoverzicht oplevert.

N.B. in de viewer worden alle datums getoond met de maand in letters, zodat geen verwarring kan ontstaan tussen dag-maand en maand-dag (Amerikaans formaat).
{| class="wikitable"
|-
! Nr !! Kop !! Dataset !! Toelichting
|-
| 1 || Naam || Patient – Naamgegevens (Initialen, Geslachtsnaam, GeslachtsnaamPartner), Geboortedatum, Geslacht ||
|-
| 2 || Telefoon || Patient – Contactgegevens – Telefoonnummers || Door patiënt als preferent opgegeven telefoonnummer
|-
| 3 || BSN || Patient – Patientidentificatienummer || Altijd BSN
|-
| 4 || Adres || Patient – Adresgegevens ||
|-
| 5 || Naam zorgaanbieder || Zorgaanbieder – Organisatienaam || Zorgaanbieder die het medicatieoverzicht heeft samengesteld
|-
| 6 || Zorgaanbieder Adres || Zorgaanbieder – Adres – Adresgegevens ||
|-
| 7 || Zorgaanbieder Telefoon || Zorgaanbieder – TelefoonMail – Contactgegevens – Telefoonnummers ||
|-
| 8 || Zorgaanbieder Email || Zorgaanbieder – TelefoonMail – Contactgegevens – Emailadressen ||
|-
| 9 || Datum medicatieoverzicht || Documentgegevens – Documentdatum ||
|-
| || Lengte || Lichaamslengte – LengteWaarde, LengteDatumTijd ||
|-
| || Gewicht || Lichaamsgewicht – GewichtWaarde, GewichtDatumTijd ||
|-
| || Gecontroleerd door zorgverlener || Documentgegevens – Verificatie zorgverlener ||
|-
| || Geverifieerd met patient/mantelzorger || Documentgegevens – Verificatie patient ||
|}
Elementen 5 tot en met 8 worden niet getoond als de patiënt de opsteller van het medicatieoverzicht is.

===Contra-indicaties en overgevoeligheden (CiO)===
[[Bestand:Medicatieoverzicht_ICA_v0.5.PNG]]

Actieve contra-indicaties en overgevoeligheden (intoleranties, allergieën/ bijwerkingen).

Filter: einddatum is niet gevuld, ligt in de toekomst of is minder dan een jaar geleden bij het samenstellen van het overzicht.

Sorteren: meest recente ingangsdatum bovenaan.

Dit onderdeel wordt op een later moment uitgewerkt en is nog niet normatief.

===Huidige medicatie===
[[Bestand:Medicatieoverzicht_HuidigeMedicatie_v0.5.PNG]]

Filter: alle huidige medicatie, dat wil zeggen alle medicatieafspraken en toedieningsafspraken die van toepassing zijn op het moment dat het overzicht wordt samengesteld en het daarbij behorende medicatiegebruik per bron. Ook de tijdelijk onderbroken medicatie wordt in deze categorie getoond.
Wanneer er alleen medicatiegebruik bekend is wordt deze getoond als deze niet ouder is dan 13 maanden. Wanneer medicatiegebruik is vastgelegd door zowel een zorgverlener als een patiënt wordt van beide het laatst geregistreerde medicatiegebruik getoond.

Sorteren: per medicamenteuze behandeling: medicatieafspraak, toedieningsafspraak, medicatiegebruik (vastgelegd door patiënt, zorgverlener). Medicamenteuze behandelingen worden gesorteerd op ingangsdatum MA/ TA/ MGB aflopend.

{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| '''Nr'''
! style="text-align:left;"| '''Kop'''
! style="text-align:left;" colspan="3"| '''Dataset'''
|-
|style="background-color: white;vertical-align:top;"|1
|style="background-color: white;vertical-align:top;"|Type
|style="background-color: white;vertical-align:top; text-align:center;"|Medicatieafspraak
|style="background-color: white;vertical-align:top; text-align:center;"|Toedieningsafspraak
|style="background-color: white;vertical-align:top; text-align:center;"|Medicatiegebruik
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|2
|style="background-color: white;vertical-align:top;" rowspan="2"|Geneesmiddel
|style="background-color: white;vertical-align:top; text-align:center;"|Afgesproken geneesmiddel-
|style="background-color: white;vertical-align:top; text-align:center;"|Geneesmiddel bij Toedieningsafspraak-
|style="background-color: white;vertical-align:top; text-align:center;"|Gebruiksproduct-
|-
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Product – ProductCode (als afwezig: ProductSpecificatie, ProductNaam)
|-
|style="background-color: white;vertical-align:top;"|3
|style="background-color: white;vertical-align:top;"|Ingangsdatum
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Ingangsdatum
|-
|style="background-color: white;vertical-align:top;"|4
|style="background-color: white;vertical-align:top;"|Stopdatum/Duur
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Einddatum(als afwezig: Duur)
|-
|style="background-color: white;vertical-align:top;"|5
|style="background-color: white;vertical-align:top;"|Dosering
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Gebruiksinstructie – Omschrijving
|-
|style="background-color: white;vertical-align:top;"|6
|style="background-color: white;vertical-align:top;"|Toedieningsweg
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Gebruiksinstructie – Toedieningsweg
|-
|style="background-color: white;vertical-align:top;"|7
|style="background-color: white;vertical-align:top;"|Reden
|style="background-color: white;vertical-align:top; text-align:center;"|Reden van voorschrijven & evt. Reden van staken/onderbreken
|style="background-color: white;vertical-align:top; text-align:center;"|Reden van staken/onderbreken
|style="background-color: white;vertical-align:top; text-align:center;"|Reden van staken/onderbreken
|-
|style="background-color: white;vertical-align:top;"|8
|style="background-color: white;vertical-align:top;"|Toelichting
|style="background-color: white;vertical-align:top; text-align:center;" colspan="2"|Toelichting & Aanvullende Informatie
|style="background-color: white;vertical-align:top; text-align:center;"|Toelichting
|-
|style="background-color: white;vertical-align:top;" rowspan="3"|9
|style="background-color: white;vertical-align:top;" rowspan="3"|Bron
|style="background-color: white;vertical-align:top; text-align:center;"|Voorschrijver-
|style="background-color: white;vertical-align:top; text-align:center;"|Verstrekker-
|style="background-color: white;vertical-align:top; text-align:center;"|Auteur-
|-
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Zorgverlener – Zorgverlenernaam, Specialisme
|-
|style="background-color: white;vertical-align:top; text-align:center;"|n.v.t
|style="background-color: white;vertical-align:top; text-align:center;"|n.v.t
|style="background-color: white;vertical-align:top; text-align:center;"|of "Patient"
|}

===Toekomstige medicatie===
[[Bestand:Medicatieoverzicht_ToekomstigeMedicatie_v0.5.PNG]]

Filter: alle medicatie die in de komende 3 maanden actueel wordt. Dit is inclusief voorgenomen medicatiegebruik.

Voor een beschrijving van de mapping geldt hetzelfde als bij de huidige medicatie, zie [[mp:V9.0_Voorbeeld_medicatieoverzicht#Huidige_medicatie|Huidige medicatie]].

===Recent beëindigde medicatie===
[[Bestand:Medicatieoverzicht_RecentBeeindigde_v0.5.PNG]]

Filter: alle medicatie die in de afgelopen 2 maanden geëindigd of gestopt is.

Voor een beschrijving van de mapping geldt hetzelfde als bij de huidige medicatie, zie [[mp:V9.0_Voorbeeld_medicatieoverzicht#Huidige_medicatie|Huidige medicatie]].

===Aanvullende labwaarden===
[[Bestand:Medicatieoverzicht_Labwaarden_v0.5.PNG]]

Meest recente labwaarden en afwijkende nierfunctiewaarden.

Dit onderdeel wordt op een later moment uitgewerkt en is nog niet normatief.

===Opmerkingen===
[[Bestand:Medicatieoverzicht_Opmerkingen_v0.5.PNG]]

Bijvoorbeeld relevante (beperkte) gezondheidsvaardigheden (competenties: geletterdheid, reken- en digitale vaardigheden) die impact kunnen hebben op medicatiegebruik/behandeling.

Dit onderdeel wordt op een later moment uitgewerkt en is nog niet normatief.

==Bouwsteen instantiaties==
Deze paragraaf beschrijft welke instantiaties van de bouwstenen horen bij het medicatieoverzicht. Dit gaat om ‘eigen’ én ‘andermans’ bouwstenen en dan alleen de laatste, relevante instantiaties hiervan.

===Eigen én andermans===
Zowel de eigen als een kopie van (bij de verzender bekende) bouwstenen van andere bronnen gaan mee in het medicatieoverzicht. Dit zodat het medicatieoverzicht zo compleet mogelijk is voor de ontvanger. Dit zorgt ervoor dat ontvangers er direct mee aan de slag kunnen en niet afhankelijk zijn van andere bronnen.
De technische representatie van andermans bouwsteen kan ánders zijn dan die van de echte bron. Het is belangrijk dat de ontvanger hiervan op de hoogte is. De originele OID van andermans bouwsteen moet gewoon meegegeven worden. De ontvanger kan er dan voor kiezen om de bouwsteen ook in zijn originele vorm bij de bron op te halen. 
De bouwstenen medicatieafspraak, toedieningsafspraak en medicatiegebruik zijn uitgebreid met een kenmerk dat aangeeft of:
* er sprake is van een ‘eigen’ bouwsteen of
* die van ‘iemand anders’ (een ''accent'' bouwsteen: MA’, TA’, MGB’)
Dit kenmerk is alleen van toepassing in de transactie voor het medicatieoverzicht, omdat dat de enige transactie is waar andermans bouwstenen opgeleverd mogen worden.

Het kenmerk 'bouwsteen van iemand anders' bevind zich op twee niveaus:
* Het template ID van een MA’, TA’, MGB’ verschilt van een MA, TA en MGB.
* Daarnaast wordt het element kopie indicator altijd meegestuurd met waarde '''true''' in MA’, TA’, MGB’.

Het is toegestaan om voor het medicatieoverzicht de medicatieafspraken, toedienafspraken en medicatiegebruik via een door het informatiesysteem gegenereerd MGB of MGB’ (Zorgaanbieder is auteur MGB) aan te bieden. Deze dient wel een referentie te hebben naar een MA, TA of MGB.

====Medicatieoverzicht en afleidingsregels====
Een overzicht van medicatie die de patiënt gebruikt (of zou moeten gebruiken) kan op twee manieren in een informatiesysteem worden samengesteld: 
1) tonen van een actueel medicatieoverzicht (of overzichten) verkregen uit andere bron (of bronnen) 
2) in samenhang tonen van losse medicatiebouwstenen verkregen uit het eigen informatiesysteem en uit andere bronnen. 
Dit overzicht van medicatie bestaat in beide gevallen uit de informatie zoals opgenomen in de bouwstenen medicatieafspraak, toedieningsafspraak en medicatiegebruik.

Ad 1) Wanneer in dit document gesproken wordt over een actueel medicatieoverzicht wordt daarmee een samenhangend overzicht bedoeld waarin actuele medicatieafspraken, toedieningsafspraken en medicatiegebruik is opgenomen. Dit actuele medicatieoverzicht wordt opgebouwd door de bron op basis van de op dat moment bij de bron bekende gegevens. Dit overzicht kan worden uitgewisseld met de transactiegroep Medicatieoverzicht (PULL of PUSH).

De gegevens en bouwstenen die bekend zijn bij de bron, maar afkomstig uit een andere bron, worden in de transactie opgeleverd met de 'accent' indicator zodat ze herkenbaar zijn als andermans bouwstenen (MA accent, TA accent, MGB accent). 

Ad 2) Het is ook mogelijk dat een informatiesysteem een overzicht samen stelt door het samenvoegen van eigen en andermans losse medicatiebouwstenen. Voor het opvragen van losse bouwstenen wordt de transactiegroep medicatiegegevens (PULL) gebruikt.

Met de transactiegroep medicatiegegevens (PUSH) kunnen losse bouwstenen ook direct aan een andere zorgverlener of de patiënt worden verstuurd (dus zonder opvragen). Dit gebeurt bijvoorbeeld bij ontslag of op verzoek van een medebehandelaar die de patiënt voor zich heeft (bijv. patiënt verschijnt bij huisarts of apotheker buiten de regio waarbij deze huisarts of apotheker bij de eigen huisarts van de patiënt de gegevens telefonisch opvraagt en digitaal ontvangt). 
Bij zowel medicatiegegevens PUSH als PULL mogen gegevens die uit andere bron zijn verkregen niet worden opgeleverd.
 

===Laatste relevante===
Alleen de laatste relevante bouwstenen (per medicamenteuze behandeling) zijn onderdeel van het medicatieoverzicht. Deze paragraaf beschrijft wat dan precies die laatst relevante bouwstenen zijn voor een medicatieoverzicht. Allereerst voor medicatie op voorschrift (paragraaf 5.3.2.1), dan voor ‘over the counter’ medicatie (paragraaf 5.3.2.2). De hierop volgende paragraaf 5.3.2.3 gaat nog in op de bijzondere situatie dat er behalve een huidige, ook een toekomstige medicatieafspraak binnen dezelfde medicamenteuze behandeling geldig is. Tenslotte vat de laatste paragraaf de te hanteren regels samen. 

====Medicatie op voorschrift====
=====Meest eenvoudige ‘happy flow’=====
In een medicamenteuze behandeling ontstaat er in de meest eenvoudige ‘happy flow’ een opeenvolging van:
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik''.
Normaal gesproken begint een medicamenteuze behandeling met een medicatieafspraak. Een toedieningsafspraak vult de medicatieafspraak concreet in. Medicatiegebruik zegt iets over het daadwerkelijk gebruik van de patiënt in deze medicamenteuze behandeling. Alle drie de bouwstenen zijn in zo’n geval relevant en horen bij de oplevering van een medicatieoverzicht, zoals aangegeven in groen hieronder.
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik.
Een toedieningsafspraak verwijst naar de medicatieafspraak die hij invult. Als er geen verwijzing beschikbaar is in de toedieningsafspraak dan moet de afspraakdatum (toedieningsafspraak) later zijn dan die van de medicatieafspraak om relevant te zijn voor oplevering. 
Medicatiegebruik kán verwijzen naar een medicatieafspraak óf toedieningsafspraak. Als er geen verwijzing beschikbaar is in het medicatiegebruik, dan moet de registratiedatum (medicatiegebruik) later zijn dan die van de medicatieafspraak om relevant te zijn voor oplevering.

=====Nieuwe medicatieafspraak in de medicamenteuze behandeling=====
Als je een nieuwe medicatieafspraak aanmaakt in een bestaande medicamenteuze behandeling zijn de op dát moment reeds bestaande medicatieafspraken, toedieningsafspraken en vastleggingen van medicatiegebruik niet meer relevant voor het medicatieoverzicht. Het idee is dat alle oudere bouwstenen dan de huidige medicatieafspraak per definitie ‘overruled’ zijn door deze nieuwe medicatieafspraak en dientengevolge niet meer relevant voor het medicatieoverzicht.
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik'' - stop-Medicatieafspraak – Medicatieafspraak – stop-Toedieningsafspraak

Wanneer er volgend op een dergelijke medicatieafspraak een toedieningsafspraak en eventueel ook medicatiegebruik aangemaakt en beschikbaar zijn, worden deze wél weer meegeleverd in het medicatieoverzicht.
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik'' – stop-Medicatieafspraak – Medicatieafspraak – stop-Toedieningsafspraak - Toedieningsafspraak
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik'' – stop-Medicatieafspraak - Medicatieafspraak - stop-Toedieningsafspraak – Toedieningsafspraak – Medicatiegebruik 

De nieuwe medicatieafspraak kan ook een stop-Medicatieafspraak zijn, als de patiënt in het geheel moet stoppen met deze medicatie. Deze stop-Medicatieafspraak blijft 2 maanden relevant voor het medicatieoverzicht. 
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – stop-Medicatieafspraak - stop-Toedieningsafspraak

=====Medicatiegebruik eerder dan toedieningsafspraak=====
Het kan gebeuren dat je medicatiegebruik hebt vastgelegd voordat de toedieningsafspraak aangemaakt is. Ook hier is het idee dat de nieuwere toedieningsafspraak de oudere vastlegging van toedieningsafspraak én medicatiegebruik ‘overrulet’. Het oudere medicatiegebruik is dan dus niet meer relevant voor het medicatieoverzicht.
* Medicatieafspraak – Medicatiegebruik
* Medicatieafspraak – ''Medicatiegebruik'' – Toedieningsafspraak

Natuurlijk kan er daarna weer een nieuwe vastlegging van medicatiegebruik plaatsvinden, die dan ook weer relevant is voor het medicatieoverzicht.
* Medicatieafspraak – ''Medicatiegebruik'' – Toedieningsafspraak - Medicatiegebruik

=====Nieuwe toedieningsafspraak=====
Soms maak je een nieuwe toedieningsafspraak onder een bestaande medicatieafspraak. Bijvoorbeeld omdat er een ander product verstrekt moet worden (ten gevolge van preferentiebeleid of voorraad). Ook dan geldt dat een dergelijke nieuwe toedieningsafspraak eventueel oudere toedieningsafspraken en medicatiegebruik ‘overrulet’.
* Medicatieafspraak – ''Toedieningsafspraak – Medicatiegebruik''- stop-Toedieningsafspraak - Toedieningsafspraak

Natuurlijk kan je daarna medicatiegebruik vastleggen, die is dan ook weer relevant voor het medicatieoverzicht.
* Medicatieafspraak – ''Toedieningsafspraak – Medicatiegebruik'' - stop-Toedieningsafspraak – Toedieningsafspraak - Medicatiegebruik

====Over the counter====
Soms gebruikt een patiënt medicatie waarvoor er geen voorschrift is. Dit geldt bijvoorbeeld voor pijnstillers als paracetamol of ibuprofen, die verkrijgbaar zijn zonder recept. We noemen dit “over the counter” medicatie.
Dergelijk gebruik van ‘over the counter’ medicatie kan vastgelegd worden met de bouwsteen medicatiegebruik. Ook dit is relevant voor het medicatieoverzicht.
* Medicatiegebruik

Een nieuwe vastlegging van medicatiegebruik door dezelfde type auteur (type auteur is patiënt of zorgverlener) ‘overrulet’ eventuele oudere vastleggingen van medicatiegebruik. Hieronder uitgewerkt, op volgorde van registratiedatum:
* ''Medicatiegebruik'' - Medicatiegebruik

Wanneer een voorschrijver beslist om deze medicamenteuze behandeling te formaliseren met een medicatieafspraak, gelden daarna de regels zoals hiervoor beschreven. Hieronder uitgewerkt, op volgorde van afspraakdatum (medicatie- of toedieningsafspraak)/registratiedatum (medicatiegebruik):
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak - Medicatiegebruik
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak – Toedieningsafspraak - Medicatiegebruik
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak – ''Medicatiegebruik'' - Toedieningsafspraak - Medicatiegebruik
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak - ''Medicatiegebruik'' - Medicatiegebruik

====Toekomstige medicatieafspraken en toedieningsafspraken====
Een medicamenteuze behandeling kan meer dan één actuele medicatieafspraak en toedieningsafspraak bevatten. Namelijk één voor de huidige situatie en één of meer voor de toekomstige situatie. Deze paragraaf beschrijft een voorbeeld met één huidige en één toekomstige. De toekomstige bouwstenen hebben in de voorbeelden voor de duidelijkheid een “T-“. Zowel huidige als toekomstige bouwstenen zijn relevant voor het medicatieoverzicht. De bouwstenen voor toedieningsafspraak en medicatiegebruik moeten wel adequate verwijzingen hebben naar ofwel de huidige ofwel de toekomstige afspraak. Hieronder drie voorbeelden, op volgorde van afspraakdatum/registratiedatum (indien deze gelijk zijn, dan gesorteerd op gebruiksperiode):
* Medicatieafspraak – T Medicatieafspraak
* Medicatieafspraak – Toedieningsafspraak – T Medicatieafspraak – T Toedieningsafspraak
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – T Medicatieafspraak – T Toedieningsafspraak – (eventueel T Medicatiegebruik)
Stel dat de toedieningsafspraak wijzigt omdat de verstrekker een andere sterkte levert (2x 500 mg tabletten ipv. 1x 1000 mg tabletten) en de patiënt nog voldoende voorraad heeft voor twee weken obv. de eerste toedieningsafspraak:
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – T Toedieningsafspraak

=====Nieuwe medicatieafspraak=====
Als je in deze situatie een nieuwe medicatieafspraak maakt, maak je ook altijd een (technische) stop-medicatieafspraak. Deze stop-medicatieafspraak kent twee verschijningsvormen: 
1) met verwijzing naar een specifieke medicatieafspraak die je stopt 
2) zonder verwijzing, en daarmee stop je de hele medicamenteuze behandeling

Ad 1) Stop-medicatieafspraak voor één actuele medicatieafspraak. Met deze stop-medicatieafspraak stop je één specifieke medicatieafspraak. Je maakt voor die medicatieafspraak ook weer een nieuwe.
Stel dat je alleen de huidige medicatieafspraak wilt wijzigen, dan geeft dit toegepast op de voorbeelden hierboven, op volgorde van afspraakdatum:
* ''Medicatieafspraak'' – T Medicatieafspraak - stop-Medicatieafspraak – Medicatieafspraak 
* ''Medicatieafspraak – Toedieningsafspraak'' – T Medicatieafspraak – T Toedieningsafspraak - stop-Medicatieafspraak – Medicatieafspraak
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik'' – T Medicatieafspraak – T Toedieningsafspraak – T Medicatiegebruik - stop-Medicatieafspraak – Medicatieafspraak

Stel dat je alleen de toekomstige medicatieafspraak wilt wijzigen, dan geeft dit toegepast op de voorbeelden hierboven, op volgorde van afspraakdatum:
* Medicatieafspraak – ''T Medicatieafspraak'' - stop- T Medicatieafspraak – T Medicatieafspraak
* Medicatieafspraak – Toedieningsafspraak – ''T Medicatieafspraak – T Toedieningsafspraak'' - stop- T Medicatieafspraak – T Medicatieafspraak
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – ''T Medicatieafspraak – T Toedieningsafspraak – T Medicatiegebruik'' - stop- T Medicatieafspraak – T Medicatieafspraak 

 Ad 2) Stop-medicatieafspraak voor de hele medicamenteuze behandeling.
Met deze stop-medicatieafspraak stop je alle bestaande (huidige en toekomstige) medicatieafspraken in de medicamenteuze behandeling. Als je nu – naast een huidige - ook weer een medicatieafspraak voor de toekomst wilt maken, moet je ook deze dus opnieuw maken. Hieronder uitgewerkt voor dezelfde drie voorbeelden als bovenstaand, op volgorde van afspraakdatum.
* ''Medicatieafspraak – T-Medicatieafspraak'' – stop-Medicatieafspraak (zonder referentie) - Medicatieafspraak 
* ''Medicatieafspraak – Toedieningsafspraak – T-Medicatieafspraak – T-Toedieningsafspraak'' - stop-Medicatieafspraak (zonder referentie) – Medicatieafspraak – T Medicatieafspraak
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – T-Medicatieafspraak – T-Toedieningsafspraak – T Medicatiegebruik'' - stop-Medicatieafspraak (zonder referentie) – stop-Toedieningsafspraak -Medicatieafspraak – stop- T Toedieningsafspraak - T Medicatieafspraak 

=====Nieuwe toedieningsafspraak=====
 Je kunt echter ook een nieuwe toedieningsafspraak maken voor alleen de huidige medicatieafspraak. Deze nieuwe toedieningsafspraak moet dan een verwijzing naar die huidige medicatieafspraak hebben. Hieronder uitgewerkt voor drie voorbeelden, op volgorde van afspraakdatum.
* Medicatieafspraak – T Medicatieafspraak – Toedieningsafspraak
* Medicatieafspraak – ''Toedieningsafspraak''– T-Medicatieafspraak – T Toedieningsafspraak - stop-Toedieningsafspraak – Toedieningsafspraak
* Medicatieafspraak – ''Toedieningsafspraak – Medicatiegebruik'' – T Medicatieafspraak – T-Toedieningsafspraak – T Medicatiegebruik – - stop-Toedieningsafspraak – Toedieningsafspraak

Een nieuwe toedieningsafspraak met een verwijzing naar de toekomstige medicatieafspraak ziet er als volgt uit.
* Medicatieafspraak – T Medicatieafspraak – Toedieningsafspraak – T-Toedieningsafspraak
* Medicatieafspraak –Toedieningsafspraak – T-Medicatieafspraak – ''T Toedieningsafspraak'' – stop-T Toedieningsafspraak - T Toedieningsafspraak
* Medicatieafspraak –Toedieningsafspraak – Medicatiegebruik – T Medicatieafspraak – ''T Toedieningsafspraak – T Medicatiegebruik'' - stop- T Toedieningsafspraak – T-Toedieningsafspraak

====Regels van het overrulen opgesomd====
Op basis van bovenstaande beschrijving/voorbeelden zijn de volgende algemene regels voor het overrulen af te leiden. Het gaat hier om de regels om te bepalen of een bouwsteen relevant is voor oplevering in het medicatieoverzicht.
Binnen een medicamenteuze behandeling:
* Een nieuwe medicatieafspraak overrulet alle oudere bouwstenen (medicatieafspraak, toedieningsafspraak, medicatiegebruik) behorende bij de medicatieafspraak/-afspraken die deze medicatieafspraak gestopt heeft.
* Een nieuwe toedieningsafspraak overrulet alle oudere bouwstenen van type toedieningsafspraak of medicatiegebruik die horen bij dezelfde medicatieafspraak als de nieuwe toedieningsafspraak.
* Een nieuwe vastlegging van medicatiegebruik overrulet in principe (zie uitzondering hieronder) oudere vastleggingen van medicatiegebruik die horen bij dezelfde medicatieafspraak als het nieuwe medicatiegebruik.
** Uitzondering op deze regel: medicatiegebruik met als auteur patiënt overrulet NIET een oudere vastlegging van medicatiegebruik met als auteur zorgverlener en vice versa. Beide zijn dan dus relevant voor het medicatieoverzicht.

Deze laatste uitzondering toegepast op een aantal situaties:
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik-ZVL – Medicatiegebruik-PAT
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik-PAT – Medicatiegebruik-ZVL
* Medicatieafspraak – Toedieningsafspraak – ''Medicatiegebruik-PAT'' – Medicatiegebruik-PAT
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik-ZVL – ''Medicatiegebruik-PAT'' – Medicatiegebruik-PAT
* Medicatieafspraak – Toedieningsafspraak – ''Medicatiegebruik-ZVL – Medicatiegebruik-PAT'' – Medicatiegebruik PAT – Medicatiegebruik-ZVL

==Verificatie per medicamenteuze behandeling==
Een zorgverlener legt verificatie per medicamenteuze behandeling vast met de bouwsteen medicatiegebruik:
* Auteur = Zorgverlener
* Eventuele informant: de patiënt, een zorgverlener of een andere persoon
* Eventueel kenmerk ‘volgens afspraak’: is het medicatiegebruik volgens de auteur conform medicatieafspraak of toedieningsafspraak?
* Eventuele link naar medicatieafspraak óf toedieningsafspraak:
** Medicatie- of toedieningsafspraak die de referentie is geweest voor het opgeven van dit gebruik.
** Wanneer er wordt aangegeven ‘volgens afspraak’ dan staat hier de medicatie- of toedieningsafspraak conform welke de patiënt gebruikt.
Een dergelijke vastlegging van medicatiegebruik betekent: “Volgens mij gebruikt de patiënt dit medicament als volgt:…..”. 
Bekend: het is nu niet voorzien in de informatiestandaard om aan te geven dat een medicatieafspraak of toedieningsafspraak klopt, los van of de patiënt het ook zo gebruikt.

==Proces van het medicatieoverzicht uitwisselen==
Naast de inhoud en de verificatie is ook het proces rondom het medicatieoverzicht van belang.

===Wie, wanneer, met welke informatie===
De betrouwbaarheid en de compleetheid van een medicatieoverzicht hangt af van:
* wie het heeft samengesteld,
* op welk moment en
* met welke basisinformatie.

Daarover kunnen we afspraken maken, bijvoorbeeld:
* een medicatieoverzicht pas uitwisselen/beschikbaar stellen zodra deze enige vorm van betrouwbaarheid heeft
** na een expliciete actie van een zorgverlener of
** automatisch als aan bepaalde voorwaarden is voldaan.
* medicatieoverzicht volledig automatisch uitwisselen/beschikbaar stellen zonder voorwaarden
* medicatieoverzicht volledig automatisch beschikbaar maken zonder dat een nieuwe gegevenssoort nodig is (dus bij aanmelding van één van de andere medicatie gegevenssoorten ben je automatisch ook bron voor een medicatieoverzicht).

====Besluit====
Bovenstaande vragen zijn nog niet beantwoord. Besloten is dat tijdens de Proof-Of-Concept alle partijen die een medicatieoverzicht kunnen opleveren dit ook doen.

===Verantwoordelijkheden opvrager en bron===
De opvrager krijgt medicatieoverzichten uit meerdere bronnen. Het verwerken hiervan is de verantwoordelijkheid van de ontvanger. De actualiteit van een medicatieoverzicht is hierbij van belang. 
'''Actie:''' de transactie medicatieoverzicht moet de meest recente datum bevatten van de verzameling van beschikbare afspraakdatums/registratiedatums van de opgeleverde instantiaties van bouwstenen. De samensteller (bron) van het medicatieoverzicht moet deze datum dus opleveren. Dit helpt de ontvanger om de actualiteit van het medicatieoverzicht beter in te schatten.

===Afspraken vervolg===
Met de uitkomsten van de Proof-Of-Concept vervolgen we de analyse om te komen tot een goed proces voor het medicatieoverzicht.

==Afleidingsregels==
Het is van belang dat iedere partij de arts, apotheker, verpleging en ook de patiënt uit de medicatiebouwstenen kan opmaken wat de bedoeling is (c.q. wat de actuele afspraken zijn). Die bedoeling mag niet per informatiesysteem verschillen. Daarom moeten informatiesystemen volgens dezelfde afleidingsregels de actuele situatie kunnen berekenen.

De actuele therapeutische situatie wordt berekend aan de hand van zowel medicatie- als toedieningsafspraken. Toedieningsafspraken hebben een relatie met de medicatieafspraak die zij concreet invullen. Toedieningsafspraken zijn daardoor te koppelen aan de medicatieafspraak die zij invullen. 
Het medicatiegebruik is uiteraard ook zinvol om te weten. Het geeft echter niet weer wat de bedoeling van de zorgverlener is, maar wat de patiënt heeft gebruikt. Onderstaande regels nemen daarom niet het ‘gebruik’ mee. Het gebruik is wel onderdeel van een medicatieprofiel maar wordt apart getoond onder de betreffende medicamenteuze behandeling.

===Effectieve periode===
De effectieve periode bestaat uit een ''effectieve ingangsdatum'' en een ''effectieve stopdatum.''
:''De effectieve periode beschrijft de periode waarin een medicatie- of toedieningsafspraak (uiteindelijk) geldt /van toepassing is.''
De effectieve periode is afhankelijk van aanpassingen (wijzigen / staken / onderbreken / hervatten) van medicatie en door de ‘concrete invulling’ van een medicatieafspraak door een toedieningsafspraak. De effectieve periode is niet beschreven in de dataset, omdat het een afgeleid gegeven is dat alleen wordt gebruikt om de actuele situatie te bepalen. De ''effectieve ingangsdatum'', ''effectieve stopdatum'' en ''effectieve periode'' zijn geen gegevens om aan de eindgebruiker te tonen. 
Medicatie voor onbepaalde duur heeft een ''effectieve stopdatum'' die in de toekomst ligt, maar op een (nog) niet af te leiden moment. Het is alleen bekend dat hij 'ergens' in de toekomst ligt.

===Actuele en huidige medicatie===
*''Actuele (medicatie– en toedienings)afspraken:'' de afspraken waarvan de effectieve stopdatum in de toekomst ligt.
*''Huidige (medicatie– en toedienings)afspraken:'' de afspraken waarvan het heden tussen de effectieve ingangsdatum en de effectieve stopdatum ligt.
*''Actuele medicatie:'' de verzameling van actuele (huidige en toekomstige) medicatie- en toedieningsafspraken en het actuele gebruik. Voorbehoud hierbij is dat nooit met zekerheid te zeggen is in hoeverre de patiënt zich aan de afspraken houdt en het daadwerkelijk gebruik meldt.

===Uitwerking===
'''Aanpak''' 
Aan de hand van een aantal situaties worden de afleidingsregels beschreven om te komen tot de effectieve therapeutische periode in een medicatieprofiel: 
:1) Medicatie starten
:2) Maken toedieningsafspraak
:3) Medicatie wijzigen
:4) Medicatie definitief stoppen
:5) Medicatie tijdelijk onderbreken en hervatten

Hieronder worden de afleidingsregels beschreven. Het nummer bij iedere afleidingsregel staat voor de volgorde waarin de regels moeten worden uitgevoerd.

'''1) Medicatie starten''' 
Medicatie wordt gestart door het maken van een nieuwe medicatieafspraak. De medicatieafspraak kent een:
*Afspraakdatum - de datum waarop de afspraak is gemaakt met de patiënt.
*Gebruiksperiode - de periode bestaat uit:
**ingangsdatum - de ingangsdatum van de medicatieafspraak kan in de toekomst liggen;
**gebruiksduur;
**stopdatum - tot wanneer geldt de medicatieafspraak.

1a: De effectieve periode van een ''nieuwe'' medicatieafspraak is gelijk aan diens gebruiksperiode

'''2) Maken toedieningsafspraak''' 
Een toedieningsafspraak vult een medicatieafspraak concreet in. In zekere zin, door de ogen van de patiënt gezien, zou je kunnen zeggen dat een toedieningsafspraak een medicatieafspraak vervangt. Dat is immers dichter bij wat hij zou moeten gebruiken.

Afleidingsregel 1 wordt uitgebreid:

1b: De effectieve periode van een nieuwe toedieningsafspraak is gelijk aan diens gebruiksperiode

Afleidingsregel 2 is van toepassing als een medicatieafspraak onderliggende toedieningsafspraken kent (zie afleidingsregel 2b voor nadere toelichting):

2a: De effectieve periode van een medicatieafspraak is gelijk aan de effectieve periode van de onderliggende toedieningsafspraak.

'''3) Medicatie wijzigen'''
:'''a) Door een medicatieafspraak'''
De voorschrijver wijzigt medicatie (c.q. de medicamenteuze behandeling) door het maken van een nieuwe medicatieafspraak (en het beëindigen van de bestaande) binnen een bestaande medicamenteuze behandeling. 
Doordat de ingangsdatum van een medicatieafspraak in de toekomst kan liggen kunnen er meerdere medicatieafspraken tegelijk actueel zijn. Bijvoorbeeld wanneer een medicatieafspraak geldt ‘voor onbepaalde duur’ (MA1) en er wordt afgesproken over twee weken de dosering te wijzigen (MA2) blijft de eerste medicatieafspraak (MA1) nog twee weken geldig, daarna gaat de tweede medicatieafspraak (MA2) in.
De voorgaande afleidingsregels veranderen hierdoor niet.

:'''b) Door een toedieningsafspraak'''
Een medicatieafspraak wordt concreet ingevuld door een toedieningsafspraak. Op deze toedieningsafspraak kan een wijziging plaatsvinden. Bijvoorbeeld wanneer deeltijden veranderen (wanneer GDS wordt geïnitieerd), of wanneer er van handelsproduct wordt gewijzigd (door bijvoorbeeld een preferentiebeleid). Er kunnen dus meerdere achtereenvolgende toedieningsafspraken onder één medicatieafspraak worden gemaakt. Daarom wordt regel 2 uitgebreid zodat effectieve periode van de medicatieafspraak wordt bepaald door de gehele reeks onderliggende toedieningsafspraken.

2b: Wanneer er meerdere toedieningsafspraken onder een medicatieafspraak gemaakt worden dan is de effectieve ingangsdatum van de medicatieafspraak gelijk aan de meest vroege ingangsdatum van de onderliggende toedieningsafspraken en de stopdatum van de laatste toedieningsafspraak.

Er kunnen parallelle toedieningsafspraken onder één medicatieafspraak zijn waarvan de afspraakdatum en ingangsdatum gelijk zijn. Beide zijn dan tegelijk geldig en daarmee wijzigt regel 2b niet.

In onderstaande figuur is een zeer eenvoudig voorbeeld opgenomen van een actueel profiel samengesteld uit de verschillende bouwstenen. De patiënt-, verificatie-, CiO- en labgegevens zijn in dit overzicht geheel buiten beschouwing gelaten. Er is verder een zeer beperkt aantal gegevens opgenomen om vooral de werking van de effectieve periode te tonen. Regels met een ‘-‘ zijn detailregels en kunnen desgewenst ‘ingeklapt’ worden in het medicatieprofiel. In de eerste regel is de effectieve periode getoond voor de onderliggende MA en TA's. Daaronder is ook gebruik zichtbaar, deze heeft geen invloed op de berekening van de effectieve therapeutische periode in de eerste regel.

{{anchor|figuur 9}}
[[Bestand:Voorbeeldeffectieveperioden.png|Figuur 9 Voorbeeld effectieve periode]]

'''4) Medicatie definitief stoppen''' 
Het stoppen van medicatie (c.q. medicamenteuze behandeling) gebeurt door het maken van een medicatieafspraak, waarin stoptype 'definitief' is aangegeven. De ingangsdatum van deze medicatieafspraak is de datum waarop de originele medicatieafspraak inging. De stopdatum is de datum waarop de medicatie gestopt wordt. De effectieve periode van de originele medicatieafspraak is daarmee vervangen door de effectieve periode van deze nieuwe stop-MA.

1c: Wanneer een medicatieafspraak gestopt wordt dan is de effectieve periode van de medicatieafspraak de effectieve periode van de stop-MA.

Een stop-toedieningsafspraak kan een stop-medicatieafspraak concreet invullen. Zo kan bijvoorbeeld worden uitgedrukt dat het stoppen ingaat met de volgende GDS uitgifte.

'''5) Medicatie tijdelijk onderbreken en hervatten''' 
Het onderbreken van medicatie gebeurt op dezelfde wijze als medicatie stoppen. Er wordt een stop-MA gemaakt (stoptype 'tijdelijk') met dezelfde ingangsdatum als de originele medicatieafspraak. De stopdatum van de stop-MA is het moment van tijdelijk onderbreken, het stoptype is 'tijdelijk'. Hervatten gebeurt door een medicatieafspraak te maken met de oude (of aangepaste) dosering waarbij de ingangsdatum de hervattingsdatum is. Een aansprekende reden (bijvoorbeeld: hervat eerder gemaakt beleid) kan e.e.a. verduidelijken. Als niet hervat wordt kan 'medicatie stoppen (stoptype 'definitief')' worden uitgevoerd om de medicamenteuze behandeling definitief te beëindigen waarmee het niet meer actuele medicatie is. Medicatie die onderbroken wordt blijft actueel zodat deze op het medicatieprofiel zichtbaar blijft.

1d: Wanneer medicatie tijdelijk wordt onderbroken wordt de effectieve periode daardoor niet beïnvloed. De effectieve periode wordt bepaald door de effectieve periode van de originele medicatieafspraak.

Deze afleidingsregels vormen de basis voor het bepalen van de actuele afspraken. Er zijn uitzonderingssituaties denkbaar die gerelateerd zijn aan het slechts deels beschikbaar hebben van medicatiegegevens. Deze zijn niet uitgewerkt.
In de open-source beschikbare medicatie-viewer zijn alle afleidingsregels opgenomen en geïmplementeerd.

==Gegevens die niet getoond hoeven te worden==
Diverse gegevens zijn belangrijk voor het correct kunnen verwerken van informatie, maar zijn voor de eindgebruiker niet relevant:
*Een applicatie hoeft niet de (technische) identificatie van een MBH te tonen (noch die van de bouwstenen zelf), maar wel de uitwerking daarvan: namelijk in samenhang getoonde bouwsteen instantiaties.
*De kopie-indicator bij de MA, TA en MGB bij het raadplegen van medicatieoverzicht. Of een bouwsteen een kopie betreft, is voor een gebruiker niet zo belangrijk en kan afgeleid worden door andere gegevens uit die bouwsteen (zoals auteur van de bouwsteen). Het is dus niet zo belangrijk dat een gebruiker kan zien dat dit 'als kopie' is opgeleverd en vermoedelijk alleen maar verwarrend. Voor leveranciers is dit gegeven echter wél belangrijk, bijvoorbeeld omdat zij soms met de gegevens willen rekenen en het dan veiliger is om het gegeven bij de échte bron op te halen. Het ligt daarom voor de hand om in je informatiesysteem wél bij te houden of je het gegeven van de échte bron hebt ontvangen.
*Een applicatie hoeft niet het stoptype (tijdelijk/definitief) van een stop-afspraak te tonen, maar wel de uitwerking daarvan: namelijk het verwerken van de betekenis, waardoor een gehele MBH als gestopte medicatie getoond wordt of als onderbroken medicatie (blijft inzichtelijk onder huidige medicatie) of als een wijziging in geval van een 'technische stop-afspraak'.

=Toedienlijst en afleidingsregels=

Dit hoofdstuk toont een mogelijke weergave van een toedienlijst en specificeert daarnaast afleidingsregels voor alle relevante bouwstenen en verificatie per medicamenteuze behandeling voor het opstellen van een toedienlijst.

==Inleiding ==

Deze paragraaf bevat een voorbeeld van een toedienlijst. De toedienlijst toont op elk moment van de dag de meeste recente medicatiegegevens zodat de medicatietoediening adequaat kan verlopen. Om te zorgen voor een veilige situatie waarbij een (professionele) toediener de juiste en actuele medicatiegegevens heeft om goed en veilig te kunnen toedienen, dient de toedieningssoftware in staat te zijn om de medicatiebouwstenen te kunnen verwerken en samenhang hierin te brengen met behulp van de spelregels die binnen deze informatiestandaard MP9 zijn bepaald.

Onder de term ‘toedienlijst’ wordt verstaan een digitale lijst van alle geneesmiddelen die zijn voorgeschreven door een voorschrijver en die aan een patiënt/cliënt toegediend moeten worden. Deze lijst wordt opgesteld op basis van de volgende medicatiebouwstenen: medicatieafspraak, wisselenddoseerschema, toedieningsafspraak, medicatieverstrekking en medicatietoediening.

Het (actief) beschikbaar stellen van medicatiegegevens aan (professionele) toedieners zorgt voor een totaal overzicht over alle toe te dienen medicatie. Dit betekent dat zowel het stoppen als het wijzigen van medicatie met of zonder medicatieverstrekking op elk moment beschikbaar is. Wijzigingen in medicatie en wisselende doseerschema’s, zoals van de trombosedienst, zijn direct beschikbaar voor toedieners.

In figuur 1 zijn de medicatiegegevens weergegeven die getoond kunnen worden op een toedienlijst. In tabel 1 wordt door middel van nummers aangegeven welke gegevens daarbij normatief zijn, deze medicatiegegevens zijn verplicht om te tonen. De andere gegevens in de figuur zijn optioneel en worden mogelijk in de toekomst als normatief toegevoegd. De lay-out van de toedienlijst in een informatiesysteem kan verschillen per doelgroep en per device, dit is afhankelijk van de gebruikerseisen.

De toedienlijst in dit voorbeeld is generiek beschreven. De algemene eisen van de eindgebruikers voor het opstellen van de toedienlijst zijn in dit hoofdstuk opgenomen en er worden geen uitspraken gedaan over de technische realisatie of implementatie.

De Veilige principes in de medicatieketen (2016) gaan over wat ‘in principe’ veilig is in de medicatieketen in de sector verpleging, verzorging en thuiszorg. De specificaties, die in de Veilige principes in de medicatieketen (2016), Richtlijn overdracht van medicatiegegevens in de keten herziening 2018/2019 en de nieuwe inzichten uit het programma Medicatieoverdracht zijn opgenomen, zijn in dit hoofdstuk verwerkt.

Uitgangspunten voor de toedienlijst zijn:
*Medicatiebouwstenen
**Medicatieafspraak (MA)
**Toedieningsafspraak (TA)
**Wisselenddoseerschema (WDS)
**Medicatietoediening (MTD)
**Medicatieverstrekking (MVE)
*Alle huidige medicatie, dat wil zeggen alle MA’s, TA’s en WDS’s die beschikbaar zijn en van toepassing zijn op het moment dat medicatie wordt toegediend, worden bepaald op basis van de Gebruiksperiode.
*De PrikPlakLocatie in de bouwsteen MTD wordt geraadpleegd op basis de toedieningsperiode (ToedieningsDatumTijd).
*(Professionele) toedieners kunnen op een toedienlijst een onderscheid maken tussen de verschillende medicatie die een patiënt toegediend krijgt, dit gebeurt op basis van het data-element “Distributievorm” in de bouwsteen TA en het data-element “zo nodig criterium” in de dosering (MA, TA of WDS). Het onderscheid kan er als volgt uit zien:
**GDS-medicatie;
**Niet GDS-medicatie;
**Niet GDS-medicatie zo nodig.
*De resterende bouwstenen (verstrekkingsverzoek, medicatiegebruik en medicatieverbruik) zijn niet relevant voor het opstellen van de toedienlijst.
 

{{anchor|figuur 1}}
[[Bestand:Toedienlijst_figuur_1a.PNG|Figuur 1: Voorbeeldweergave toedienlijst]]
[[Bestand:Toedienlijst_figuur_1b.PNG|Figuur 1: Voorbeeldweergave toedienlijst]]
[[Bestand:Toedienlijst_figuur_1c.PNG|Figuur 1: Voorbeeldweergave toedienlijst]]
 
''Figuur 1: Voorbeeldweergave toedienlijst''
 
 
{| class="wikitable"
|-
! Nr
! style="text-align:left;"|Kop
! style="text-align:left;" colspan="3"|Dataset
|-
| 1 || Type || Medicatieafspraak || Toedieningsafspraak || Wisselenddoseerschema
|-
| 2 || Geneesmiddel || Afgesproken geneesmiddel || Geneesmiddel bij toedieningsafspraak ||
|-
| 3 || Voorschrijver
|style="text-align:left;" colspan="3"|Medicatieafspraak – Voorschrijver – Zorgverlener
|-
| 4 || Verstrekker
|style="text-align:left;" colspan="3"|Toedieningsafspraak – Verstrekker – Zorgaanbieder
|-
| || Auteur
|style="text-align:left;" colspan="3"|Wisselenddoseerschema – Auteur – Zorgverlener (conditioneel)
|-
| 5 || Ingangsdatum || Medicatieafspraak - Gebruiksperiode || Toedieningsafspraak - Gebruiksperiode || Wisselenddoseerschema - Gebruiksperiode
|-
| 6 || Einddatum/duur || Medicatieafspraak - Gebruiksperiode || Toedieningsafspraak – Gebruiksperiode || Wisselenddoseerschema - Gebruiksperiode
|-
| 7 || Omschrijving
|style="text-align:left;" colspan="3"|Gebruiksinstructie – Omschrijving
|-
| || Toedieningsweg
|style="text-align:left;" colspan="3"|Gebruiksinstructie – Toedieningsweg

|-
| || Aanvullende instructie
|style="text-align:left;" colspan="3"|Gebruiksinstructie – Aanvullende instructie
|-
| || Keerdosis
|style="text-align:left;" colspan="3"|Gebruiksinstructie – Doseerinstructie – Dosering – Keerdosis
|-
| || Toedientijd
|style="text-align:left;" colspan="3"|Gebruiksinstructie – Doseerinstructie – Dosering – Toedieningsschema – Toedientijd
|-
| || Toedieningssnelheid
|style="text-align:left;" colspan="3"|Gebruiksinstructie – Doseerinstructie – Dosering – Toedieningssnelheid
|-
| || Toedieningsduur
|style="text-align:left;" colspan="3"|Gebruiksinstructie – Doseerinstructie – Dosering – Toedieningsduur
|-
| 8 || PrikPlakLocatie
|style="text-align:left;" colspan="3"|Medicatietoediening – PrikPlakLocatie
|-
| 9 || Toelichting
|style="text-align:left;" colspan="3"|Toelichting & Aanvullende Informatie
|}
''Tabel 1: Normatieve medicatiegegevens voor de toedienlijst''


==Functionele specificatie==

In de figuren hieronder zijn de onderdelen opgenomen met normatieve gegevens. De andere onderdelen zijn (nog) niet normatief. De in de tabel genummerde elementen zijn normatief, overige elementen zijn vooralsnog optioneel.

[[Bestand:Toedienlijst_Functionele_specificatie.png]]

===Kop en algemeen===

[[Bestand:Toedienlijst_Kop en algemeen.png]]

===Opmerkingen ===

In de opmerkingen kunnen bijvoorbeeld relevante (beperkte) gezondheidsvaardigheden (competenties: geletterdheid, reken- en digitale vaardigheden) vastgelegd worden die impact kunnen hebben op medicatietoediening. Dit onderdeel is bedoeld voor intern gebruik en wordt (nog) niet uitgewisseld.

'''NB.''' Dit onderdeel is nog niet normatief. Deze gegevens komen uit het interne informatiesysteem van de organisatie.

[[Bestand:Toedienlijst_Opmerkingen.png]]

===GDS-medicatie===

Geautomatiseerd geneesmiddeldistributiesysteem (GDS) wordt gedefinieerd als een verpakking waarin geneesmiddelen zijn verdeeld in eenheden per toedieningstijdstip en op naam van een individuele cliënt zijn gesteld ([https://www.knmp.nl/praktijkvoering/richtlijnen/knmp-richtlijnen-praktijkvoering/knmp-richtlijn-voor-geautomatiseerd-geneesmiddeldistributiesysteem-gds-september-2011| KNMP 2011]). Een GDS biedt een patiënt de mogelijkheid om zijn eigen medicatie langer zelf te beheren. Of medicatie in GDS wordt geplaatst wordt door een apotheker bepaald. In het data-element “Distributievorm” in de bijbehorende MVE en TA wordt aangegeven of er sprake is van GDS-medicatie.

Vanuit het zorgveld is de wens uitgesproken dat bij gewijzigde of gestopte medicatie een waarschuwingssignaal getoond wordt met de opmerking dat het geneesmiddel zich mogelijk in de GDS-verpakking bevindt en hier mogelijk een handeling op verricht moet worden. Nadere uitwerking van deze situatie is nodig.

===Niet GDS-medicatie ===

[[Bestand:Toedienlijst_Niet-GDS-medicatie.png]]

Niet GDS-medicatie zijn losse medicatie die om verschillende redenen niet in een geautomatiseerd geneesmiddeldistributiesysteem kunnen worden opgenomen. In het data-element “Distributievorm” in de bijbehorende TA wordt aangegeven of er geen sprake is van GDS-medicatie. Daarnaast is het criterium “ZoNodig” leeggelaten.

===Niet GDS-medicatie zo nodig ===

[[Bestand:Toedienlijst_Niet-GDS-medicatie_zo_nodig.png]]

Niet GDS-medicatie zo nodig zijn losse medicatie die in bijzondere gevallen toegediend mogen worden. De voorwaarde voor het toedienen van een zo nodig medicament kan zijn:

*een fysiologische meetwaarde (plasma glucose concentratie, lichaamstemperatuur, bloeddruk);
*een symptoom of andere omstandigheid (bij hoofdpijn, bij jeuk).

In het data-element “Distributievorm” in de bijbehorende TA wordt aangegeven of er geen sprake is van GDS-medicatie. Daarnaast is het criterium “ZoNodig” ingevuld.

==Bouwsteen instanties ==

Deze paragraaf beschrijft welke instanties van de bouwstenen horen bij de toedienlijst. Dit gaat alleen om ‘eigen’ bouwstenen ([[#Bouwsteen instantiaties|hoofdstuk 5.3.1]]) en dan alleen de laatste, relevante instanties hiervan ([[#Laatste relevante|paragraaf 6.3.2]]).

===Therapie en logistieke bouwstenen ===

De medicatiebouwstenen voor het samenstellen van een toedienlijst zijn zowel therapeutisch als logistiek van aard. Bouwstenen kunnen op basis van afleidingregels overruled worden. Hierbij zijn de afleidregels die eerder in [[#Medicatieoverzicht_en_afleidingsregels|hoofdstuk 5]] benoemd zijn van toepassing (zie [[#Medicatieoverzicht en afleidingsregels|hoofdstuk 5]]). Alleen voor WDS als nieuwe bouwsteen zijn de regels nog niet opgesteld. Deze afleidingsregels zullen in deze paragraaf opgenomen worden. Voor MTD zijn de afleidingsregels niet van toepassing, dit gaat namelijk over een feitelijke gebeurtenis op een bepaald moment en niet over een periode waarbij een bepaalde afspraak actueel is zoals bij de MA, TA en MGB.

Bij het opstellen van een toedienlijst moet er ook rekening gehouden worden met de logistieke bouwsteen MVE om de distributievorm te kunnen bepalen.

====Toedienlijst en afleidingsregels ====

Een toedienlijst kan o.a. in het informatiesysteem van de toediener, door middel van losse medicatiebouwstenen worden samengesteld. De medicatiebouwstenen kunnen worden verkregen uit het eigen informatiesysteem en uit andere bronnen. Voor het raadplegen en beschikbaarstellen van losse bouwstenen wordt de transactie Medicatiegegevens (raadplegen/ beschikbaarstellen) gebruikt.

Met de transactiegroep Medicatiegegevens (sturen/ ontvangen) kunnen losse bouwstenen direct aan een andere zorgverlener of de patiënt worden verstuurd (dus zonder eerst te raadplegen). Dit gebeurt bijvoorbeeld bij ontslag of op verzoek van een medebehandelaar (bijv. een patiënt verschijnt bij een huisarts of apotheker buiten de regio waarbij deze huisarts of apotheker bij de eigen huisarts van de patiënt de gegevens telefonisch opvraagt en digitaal ontvangt).

Bij zowel Medicatiegegevens sturen/ ontvangen als raadplegen/ beschikbaarstellen mogen gegevens die uit andere bron zijn verkregen niet worden opgeleverd.

===Laatste relevante ===

Alleen de laatste relevante bouwstenen (per medicamenteuze behandeling) zijn onderdeel van de toedienlijst. Deze paragraaf beschrijft wat precies die laatst relevante bouwstenen zijn voor een toedienlijst van medicatie op voorschrift. De hierop volgende paragraaf 6.3.2.1 gaat in op de bijzondere situatie waarbij een WDS van toepassing is. Een WDS kan wat betreft afleidingsregels op dezelfde manier behandeld worden als de MA. Bij het opstellen van toedienlijst is bij aanwezigheid van een WDS, dit WDS leidend voor de gebruiksinstructie. Alle andere situaties zonder WDS, die in [[#Laatste relevante|paragraaf 5.3.2]] beschreven worden, zijn ook van toepassing.

Query om te komen tot de juiste, relevante en toekomstige bouwstenen:

{| class="wikitable"
|-
! Nr
! style="text-align:left;"|Bouwsteen
! style="text-align:left;"|Query
! style="text-align:left;"|Wat is de specifieke invulling?
|-
| 1 || MA, TA, WDS || Gebruiksperiode || Alles wat vandaag toegediend moet worden en daarmee van toepassing is: Dag = T, BeginDatum = T: 00:00:00 uur, EindDatum = T: 23:59:59 uur
|-
| 2 || MTD || Toedieningsperiode || Afhankelijk hoe ver in het verleden de prik- en plaklocaties medisch of voor het toedienen noodzakelijk zijn. Bijvoorbeeld als een week voldoende is (er kan ook gekozen worden voor een andere periode): Dag = T, BeginDatum = T-7 dag
|-
| 3 || MVE || Verstrekkingsperiode || Ruim opvragen (+/- één maand)
|}

Als alle bouwstenen verzameld zijn, kunnen de volgende medicatiegegevens afhankelijk van de situatie uit de volgende bouwstenen gebruikt worden:

{| class="wikitable"
|-
! style="text-align:left;"|Bouwsteen
! style="text-align:left;"|Situatie: alleen MA*
! style="text-align:left;"|Situatie: MA + TA
! style="text-align:left;"|Situatie: MA + TA + WDS
|-
| MA || Leidend** voor het opstellen van de toedienlijst (nummer: 2, 5, 6, 7, 9, 10) || Gegevens van de voorschrijver || Gegevens van de voorschrijver
|-
| TA || - || Leidend** voor het opstellen van de toedienlijst (nummer 2, 5, 6, 7, 9, 10) || Gegevens van de verstrekker en geneesmiddel
|-
| WDS || - || - || Leidend** voor het opstellen van de toedienlijst (nummer 5, 6, 7, 10)
|}

* Situatie waarbij een apotheker de MA nog niet verwerkt heeft.
** Met leidend worden de data-elementen die in de functionele eisen zijn opgenomen. De nummers van deze elementen zijn toegevoegd.

====Medicatie op voorschrift met een wisselend doseerschema ====

======Meest eenvoudige ‘happy flow’======

In een medicamenteuze behandeling ontstaat er in de meest eenvoudige ‘happy flow’ een opeenvolging van:

*Medicatieafspraak – Wisselenddoseerschema – Toedieningsafspraak

Normaal gesproken begint een medicamenteuze behandeling met een medicatieafspraak. Een toedieningsafspraak vult de medicatieafspraak concreet in. Daarnaast wordt er met een WDS vastgesteld of er sprake is van een wisselenddoseerschema. In zowel de MA als in de TA wordt “Gebruik volgens schema trombosedienst” bij de dosering vastgelegd. In het WDS wordt invulling gegeven aan de dosering; doseerschema wordt vastgelegd. De drie bouwstenen zijn relevant en horen bij het samenstellen van een toedienlijst, zoals aangegeven in groen hieronder. 

*Medicatieafspraak – Wisselenddoseerschema – Toedieningsafspraak 

Een toedieningsafspraak verwijst in principe naar de medicatieafspraak die hij invult. Ook een wisselend doseerschema verwijst naar de medicatieafspraak die het invult. Een WDS is altijd gerelateerd aan een medicatieafspraak.

======Nieuwe Wisselenddoseerschema ======


*Medicatieafspraak – Wisselenddoseerschema – Toedieningsafspraak – Wisselenddoseerschema

De gebruiksperiode van wisselenddoseerschema is afgelopen en er wordt een nieuw doseerschema aangemaakt. Voor een wisselenddoseerschema waarin al direct een stopdatum is afgesproken, is geen aanvullende stop-WDS nodig.

======Wijziging Wisselenddoseerschema ======


*Medicatieafspraak – Wisselenddoseerschema – Toedieningsafspraak – stop-Wisselenddoseerschema – Wisselenddoseerschema

Het wisselenddoseerschema is gewijzigd.

======Stoppen van medicatie ======

*Medicatieafspraak – Wisselenddoseerschema – Toedieningsafspraak – stop-Medicatieafspraak

Het stoppen van medicatie met een wisselenddoseerschema wordt met behulp van de MA gestopt.

======Wijzigen van handelsproduct ======


*Medicatieafspraak – Wisselenddoseerschema – Toedieningsafspraak – stop-Toedieningsafspraak – Toedieningsafspraak

Het handelsproduct wordt gewijzigd, dit heeft geen invloed op het wisselenddoseerschema.

======Regels van het overrulen opgesomd ======

Op basis van bovenstaande beschrijvingen/voorbeelden zijn de volgende algemene regels voor het overrulen af te leiden. Het gaat hier om de regels om te bepalen of een bouwsteen relevant is voor oplevering in de toedienlijst. Binnen een medicamenteuze behandeling: 
*Een nieuwe medicatieafspraak overrulet alle oudere therapie bouwstenen (medicatieafspraak, toedieningsafspraak, wisselenddoseerschema) behorende bij de medicatieafspraak/-afspraken die deze medicatieafspraak gestopt heeft.
*Een nieuwe toedieningsafspraak overrulet de oudere toedieningsafspraak die hoort bij dezelfde medicatieafspraak als de nieuwe toedieningsafspraak.
*Een nieuw wisselenddoseerschema overrulet alle oudere wisselenddoseerschema’s die horen bij dezelfde medicatieafspraak.


=Systemen en transacties=
Dit hoofdstuk bevat een opsomming van alle systeemrollen en transacties. In de verschillende proceshoofdstukken wordt hiernaar verwezen.

Onderstaande figuur ([[#figuur 10|Figuur 10]]) bevat een overzicht van alle informatiesystemen met hun bijbehorende systeemrollen. De systeemrollen zijn beschreven in de daaronder opgenomen [[#tabel 3|Tabel 3]]. De systeemrollen die betrekking hebben op raadplegen/beschikbaarstellen van medicatiegegevens en medicatieoverzicht zijn voor alle informatiesystemen van belang al naar gelang het proces waarin zij gebruikt worden. Het elektronisch voorschrijfsysteem (EVS) heeft daarnaast de systeemrollen voor het ontvangen van een voorstel verstrekkingsverzoek, het versturen van een antwoord voorstel verstrekkingsverzoek en het ontvangen van een voorstel medicatieafspraak en in de ambulante situatie voor het versturen van een voorschrift en het ontvangen van een vervulling van het voorschrift. Een XIS en PGO hebben naast de generieke systeemrollen ook de systeemrollen voor het versturen van een voorstel medicatieafspraak en voorstel verstrekkingsverzoek en het sturen van gebruik en ontvangen antwoord voorstel verstrekkingsverzoek. Een apotheekinformatiesysteem heeft naast de basis systeemrollen ook de rollen voor sturen van voorstel medicatieafspraak, voorstel verstrekkingsverzoek en afhandeling voorschrift en het ontvangen van een voorschrift en antwoord voorstel verstrekkingsverzoek. In [[#Medicatieproces|hoofdstuk 2]] zijn de belangrijkste systeemrollen per proces benoemd.

{{anchor|figuur 10}}
[[Bestand:Systemen.png|Figuur 10 Overzicht systemen en systeemrollen]]

{{anchor|tabel 3}}
{| class="wikitable" "cellpadding="10"
!style="text-align:left;"|Naam systeemrol
!style="text-align:left;"|Afk.
!style="text-align:left;"|Omschrijving
|-
| style="background-color: white;"| MedicatieGegevensBeschikbaarstellend
| style="background-color: white;"| MP-MGB
| style="background-color: white;"| Beschikbaarstellen medicatiegegevens aan medebehandelaars/patiënt
|-
| style="background-color: white;"| MedicatieGegevensRaadplegend
| style="background-color: white;"| MP-MGR
| style="background-color: white;"| Raadplegen medicatiegegevens bij medebehandelaars/patiënt
|-
| style="background-color: white;"| MedicatieGegevensSturend
| style="background-color: white;"| MP-MGS
| style="background-color: white;"| Sturen medicatiegegevens aan medebehandelaar/patiënt
|-
| style="background-color: white;"| MedicatieGegevensOntvangend
| style="background-color: white;"| MP-MGO
| style="background-color: white;"| Ontvangen medicatiegegevens van medebehandelaar/patiënt
|-
| style="background-color: white;"| MedicatieOverzichtBeschikbaarstellend
| style="background-color: white;"| MP-MOB
| style="background-color: white;"| Beschikbaarstellen medicatieoverzicht aan medebehandelaars/patiënt
|-
| style="background-color: white;"| MedicatieOverzichtRaadplegend
| style="background-color: white;"| MP-MOR
| style="background-color: white;"| Raadplegen medicatieoverzicht bij medebehandelaars/patiënt
|-
| style="background-color: white;"| MedicatieOverzichtSturend
| style="background-color: white;"| MP-MOS
| style="background-color: white;"| Sturen medicatieoverzicht aan medebehandelaar/patiënt
|-
| style="background-color: white;"| MedicatieOverzichtOntvangend
| style="background-color: white;"| MP-MOO
| style="background-color: white;"| Ontvangen medicatieoverzicht van medebehandelaar/patiënt
|-
| style="background-color: white;"| VoorschriftSturend
| style="background-color: white;"| MP-VOS
| style="background-color: white;"| Sturen verzoek tot medicatieverstrekking van medicatie of verwerking van wijziging in medicatieafspraak
|-
| style="background-color: white;"| VoorschriftOntvangend
| style="background-color: white;"| MP-VOO
| style="background-color: white;"| Ontvangen verzoek tot medicatieverstrekking van medicatie of verwerking wijziging in medicatieafspraak
|-
| style="background-color: white;"| VoorschriftAfhandelingSturend
| style="background-color: white;"| MP-VAS
| style="background-color: white;"| Sturen afhandeling van de medicatieafspraak en evt. verstrekkingverzoek in toedieningsafspraak en/of medicatieverstrekking
|-
| style="background-color: white;"| VoorschriftAfhandelingOntvangend
| style="background-color: white;"| MP-VAO
| style="background-color: white;"| Ontvangen afhandeling van de medicatieafspraak en evt. verstrekkingverzoek in toedieningsafspraak en/of medicatieverstrekking
|-
| style="background-color: white;"| VoorstelVerstrekkingsverzoekSturend
| style="background-color: white;"| MP-VVS
| style="background-color: white;"| Informeren voorschrijver over voorstel tot nieuw verstrekkingsverzoek, ontvangen antwoord op voorstel verstrekkingsverzoek
|-
| style="background-color: white;"| VoorstelVerstrekkingsverzoekOntvangend
| style="background-color: white;"| MP-VVO
| style="background-color: white;"| Ontvangen voorstel tot nieuw verstrekkingsverzoek, sturen antwoord op voorstel verstrekkingsverzoek
|-
| style="background-color: white;"| VoorstelMedicatieafspraakSturend
| style="background-color: white;"| MP-VMS
| style="background-color: white;"| Informeren voorschrijver over voorstel tot nieuwe of gewijzigde medicatieafspraak, ontvangen antwoord op voorstel medicatieafspraak
|-
| style="background-color: white;"| VoorstelMedicatieafspraakOntvangend
| style="background-color: white;"| MP-VMO
| style="background-color: white;"| Ontvangen voorstel tot nieuwe of gewijzigde medicatieafspraak, sturen antwoord op voorstel medicatieafspraak
|}Tabel 3 Overzicht systeemrollen
In Tabel 4 is een overzicht opgenomen van alle transactiegroepen, transacties, bijbehorende systeemrollen en de bouwstenen die met deze transactiegroep worden uitgewisseld. De namen van de transactiegroepen en transacties linken naar de Art-decor publicatie waarin per scenario is uitgewerkt welke gegevenselementen daarin voorkomen.

{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| '''Transactiegroep'''
! style="text-align:left;"| '''Transactie'''
! style="text-align:left;"| '''Systeemrol'''
! style="text-align:left;"| '''Bouwstenen'''
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.131-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.299_20220207000000 Medicatiegegevens (Raadplegen/Beschikbaarstellen)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.301-2022-02-07T000000.html Beschikbaarstellen medicatiegegevens]
|style="background-color: white;vertical-align:top;"|MP-MGB
|style="background-color: white;vertical-align:top;" rowspan="2"|Eén of meer: MA, VV, TA, MVE, MTD, MGB, WDS
|-
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.300-2022-02-07T000000.html Raadplegen medicatiegegevens]
|style="background-color: white;vertical-align:top;"|MP-MGR
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.131-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.302_20220207000000 Medicatiegegevens (Sturen/Ontvangen)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.303-2022-02-07T000000.html Sturen medicatiegegevens]
|style="background-color: white;vertical-align:top;"|MP-MGS
|style="background-color: white;vertical-align:top;" rowspan="2"|Eén of meer: MA, VV, TA, MVE, MTD, MGB, WDS
|-
|style="background-color: white;vertical-align:top;"|Ontvangen medicatiegegevens
|style="background-color: white;vertical-align:top;"|MP-MGO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.132-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.315_20220207000000 Medicatieoverzicht (Raadplegen/Beschikbaarstellen)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.317-2022-02-07T000000.html Beschikbaarstellen medicatieoverzicht]
|style="background-color: white;vertical-align:top;"|MP-MOB
|style="background-color: white;vertical-align:top;" rowspan="4"|MA, TA, MGB
|-
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.316-2022-02-07T000000.html Raadplegen medicatieoverzicht]
|style="background-color: white;vertical-align:top;"|MP-MOR
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.132-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.318_20220207000000 Medicatieoverzicht (Sturen/Ontvangen)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.319-2022-02-07T000000.html Sturen medicatieoverzicht]
|style="background-color: white;vertical-align:top;"|MP-MOS
|-
|style="background-color: white;vertical-align:top;"|Ontvangen medicatieoverzicht
|style="background-color: white;vertical-align:top;"|MP-MOO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.133-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.321_20220207000000 MedicatieVoorschrift (Sturen/Ontvangen)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.322-2022-02-07T000000.html Sturen medicatievoorschrift]
|style="background-color: white;vertical-align:top;"|MP-VOS
|style="background-color: white;vertical-align:top;" rowspan="2"|MA met of zonder VV, lengte, gewicht, nierfunctiewaarde
|-
|style="background-color: white;vertical-align:top;"|Ontvangen medicatievoorschrift
|style="background-color: white;vertical-align:top;"|MP-VOO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.135-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.333_20220207000000 MedicatieVoorschrift Afhandeling (Sturen/Ontvangen)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.334-2022-02-07T000000.html Sturen afhandeling medicatievoorschrift]
|style="background-color: white;vertical-align:top;"|MP-VAS
|style="background-color: white;vertical-align:top;" rowspan="2"|TA met of zonder MVE
|-
|style="background-color: white;vertical-align:top;"|Ontvangen afhandeling medicatievoorschrift
|style="background-color: white;vertical-align:top;"|MP-VAO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.134-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.327_20220207000000 Voorstel verstrekkingsverzoek (Sturen/Ontvangen)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.328-2022-02-07T000000.html Sturen voorstel verstrekkingsverzoek]
|style="background-color: white;vertical-align:top;"|MP-VVS
|style="background-color: white;vertical-align:top;" rowspan="2"|VVV
|-
|style="background-color: white;vertical-align:top;"|Ontvangen voorstel verstrekkingsverzoek
|style="background-color: white;vertical-align:top;"|MP-VVO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.134-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.330_20220207000000 Antwoord voorstel verstrekkingsverzoek (Ontvangen/Sturen)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.331-2022-02-07T000000.html Sturen antwoord voorstel verstrekkingsverzoek]
|style="background-color: white;vertical-align:top;"|MP-VVO
|style="background-color: white;vertical-align:top;" rowspan="2"|AVVV
|-
|style="background-color: white;vertical-align:top;"|Ontvangen antwoord voorstel
|style="background-color: white;vertical-align:top;"|MP-VVS
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.134-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.324_20220207000000 Voorstel medicatieafspraak (Sturen/Ontvangen)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.325-2022-02-07T000000.html Sturen voorstel medicatieafspraak]
|style="background-color: white;vertical-align:top;"|MP-VMS
|style="background-color: white;vertical-align:top;" rowspan="2"|VMA met of zonder lengte, gewicht
|-
|style="background-color: white;vertical-align:top;"|Ontvangen voorstel medicatieafspraak
|style="background-color: white;vertical-align:top;"|MP-VMO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.134-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.372_20220302000000 Antwoord voorstel medicatieafspraak (Ontvangen/Sturen)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.373-2022-03-02T000000.html Sturen antwoord voorstel medicatieafspraak]
|style="background-color: white;vertical-align:top;"|MP-VMO
|style="background-color: white;vertical-align:top;" rowspan="2"|AVMA
|-
|style="background-color: white;vertical-align:top;"|Ontvangen antwoord voorstel medicatieafspraak
|style="background-color: white;vertical-align:top;"|MP-VMS
|}Tabel 4 Overzicht transactiegroepen

In [[#Medicatieproces|hoofdstuk 2]] zijn per proces alleen de relevante transacties per processtap aangegeven. Daarin zijn de transactiegroepen niet opgenomen. Bovenstaande tabel bevat alle transactiegroepen en transacties.

=Functionaliteit=
Dit hoofdstuk beschrijft aanwijzingen voor de functionaliteit van een informatiesysteem.

==Filteren van medicatie uit 2e/3e lijn (alle informatiesystemen)==
Een instelling stelt alle eigen medicatiegegevens (alle bouwstenen) beschikbaar. Deze gegevens zijn voor de ontvangende zorgverleners mogelijk niet allemaal relevant. De ontvangende informatiesystemen kunnen een filter opnemen afhankelijk van de behoefte van de betreffende zorgverlener/patiënt. Onderstaande lijst (Tabel 5) bevat typen medicatie waarvan benoemd is dat medicatietoediening tijdens de opname relevant is voor zorgverleners buiten de instelling.

{{anchor|tabel 5}}
{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| ATC-groepscode
! style="text-align:left;"| Naam
|-
| style="background-color: white;vertical-align:top;"|L01
| style="background-color: white;vertical-align:top;"|Cytostatica
|-
| style="background-color: white;vertical-align:top;"| L03AX03
| style="background-color: white;vertical-align:top;"|BCG-vaccin urologie
|-
| style="background-color: white;vertical-align:top;"|L04AA23; L04AA25; L04AA26; L04AA33; L04AA34; L04AB; L04AC
| style="background-color: white;vertical-align:top;"|Immunosuppresiva
|-
| style="background-color: white;vertical-align:top;"|B03AC; B03XA; B06AC
| style="background-color: white;vertical-align:top;"| IJzer, epo, middelen tegen angioedeem
|-
| style="background-color: white;vertical-align:top;"|G03GA; G03GB02
| style="background-color: white;vertical-align:top;"|Gonadotropines (HCG etc), clomifeen
|-
| style="background-color: white;vertical-align:top;"|H01CA; H01CC; L02AE04
| style="background-color: white;vertical-align:top;"|Gonadoreline, hypothalamus hormonen, triptoreline
|-
| style="background-color: white;vertical-align:top;"|J06; J07
| style="background-color: white;vertical-align:top;"|Immunoglobulines, vaccins
|-
| style="background-color: white;vertical-align:top;"|M03AX01
| style="background-color: white;vertical-align:top;"|Botox
|-
| style="background-color: white;vertical-align:top;"|R03DX05
| style="background-color: white;vertical-align:top;"|Omalizumab
|-
| style="background-color: white;vertical-align:top;"|S01LA04; S01LA05; S01LA
| style="background-color: white;vertical-align:top;"|Oogheelkundige anti neovasculaire stoffen
|}Tabel 5 Typen klinische medicatie relevant voor extramurale zorgverleners

==Beschikbaarstellen medicatiegegevens (alle informatiesystemen)==
Alle eigen medicatiegegevens mogen beschikbaargesteld worden wanneer de patiënt daarvoor toestemming heeft gegeven (conform vigerende wet- en regelgeving). Gegevens ontvangen van anderen (zorgverleners/patiënt) die men in het eigen informatiesysteem heeft overgenomen en aangemerkt als kopie worden niet beschikbaargesteld. De enige uitzondering is de transactie Medicatieoverzicht PUSH en PULL, daar worden bouwstenen van anderen beschikbaar gesteld mits zij voorzien zijn van de originele identificatie (zie ook [[#paragraaf5.1|paragraaf 5.1]]).

==Aanschrijfdatum of verstrekkingsdatum (apotheekinformatiesysteem)==
In de medicatieverstrekking kan zowel de aanschrijfdatum als de daadwerkelijke datum van uitgifte worden vastgelegd. Wanneer een verstrekkingsverzoek direct verwerkt wordt en de patiënt komt het nog dezelfde dag ophalen zijn beide datums gelijk. Wanneer de patiënt de medicatie één of meerdere dagen later komt ophalen dan moeten deze datums verschillend worden ingevuld. De verstrekkingsdatum is de datum dat de daadwerkelijke medicatie-uitgifte heeft plaats gevonden. De aanschrijfdatum is het tijdstip waarop een apotheker een voorgenomen uitgifte vastlegt. Wanneer er meerdere verstrekkingen worden gedaan onder hetzelfde verstrekkingsverzoek (bijv. bij knippen recept) dan heeft elke verstrekking een eigen aanschrijfdatum.
Wanneer er gewerkt wordt met een uitgifte-automaat is de verstrekkingsdatum het tijdstip waarop de patient de medicatie uit de automaat haalt. Wanneer dit tijdstip niet beschikbaar is in het AIS mag tot die tijd ook het tijdstip worden gebruikt waarop de medicatie in de uitgifte-automaat wordt gelegd. Zie ook [[#Aanschrijven, verstrekken en niet afhalen| paragraaf 4.2.5 Aanschrijven, verstrekken en niet afhalen]].

==Bijwerken na systeemstoring==
Na systeemuitval moet het informatiesysteem van de voorschrijver controleren of er wijzigingen zijn doorgevoerd in medicatieafspraken. Zie voor use cases en onderbouwing [[#Staken van medicatie door derden|paragraaf 4.1.26]] en [[#Twee PRK's onder één medicamenteuze behandeling|paragraaf 4.1.27]].

==Constructie voor interval eenmaal per 36 uur==
Wanneer de doseerinstructie luidt 1 tablet per 36uur kan dit normaliter in één medicatieafspraak worden weergegeven (keerdosis: 1 tablet, interval: 36uur). Maar wanneer een informatiesysteem niet verder gaat dan een interval van bijvoorbeeld 24 uur dan is er een andere oplossing nodig. 

''Variant 1:''
Gebruik maken van een Zo nodig instructie waarbij het criterium is: ‘er is 36 uur verstreken sinds de laatste medicatietoediening’. Maar dit levert een bepaalde mate van vrijblijvendheid die mogelijk niet gewenst is.

''Variant 2:''
Er kan ook een repeterend schema worden gemaakt waarbij gewisseld wordt tussen ochtend en avond en een dag niet:
Herhaalperiode: 3 dagen
Doseerinstructie
Volgnummer: 1
Doseerduur: 1 dag
Dosering
Keerdosis: 1 stuks
Toedientijd: 9uur (bijvoorbeeld, kan ook een dagdeel zijn)
Volgnummer: 2
Doseerduur: 1 dag
Dosering
Keerdosis: 1 stuks
Toedientijd: 21uur (bijvoorbeeld, kan ook een dagdeel zijn)

Wanneer het in het informatiesysteem niet mogelijk is om een interval van 36uur te kiezen wordt variant 2 toegepast.

==EVS/HIS verwerken Afhandeling voorschrift==
Het voorschrijvende informatiesysteem wordt door de apotheker geïnformeerd over alle verstrekkingen en wijzigingen in toedieningsafspraken middels de transactie Afhandeling voorschrift. Deze afhandeling moet automatisch verwerkt worden in het voorschrijvende informatiesysteem. De voorschrijver beoordeelt alleen de toedieningsafspraken en hoeft niet alle verstrekkingen te beoordelen.

==Voorbeelden doseringen==
Zie [[mp:V9.2.0.0 Voorbeelden doseringen|Voorbeelden doseringen 9.2.0 (zowel functioneel als technische uitwerking in HL7v3 CDA én in FHIR)]]

==Medicatiegebruik: gebruikindicator, volgens afspraak indicator, stoptype, gebruiksperiode en doseerinstructie==
{| class="wikitable"
|-
|style="text-align:center;" |Situatie || 1. Medicatie is/wordt in gebruiksperiode gebruikt volgens afspraak|| 2. Medicatie is/wordt in gebruiksperiode gebruikt maar niet volgens afspraak || 3. In tegenstelling tot de afspraak is/wordt in gebruiksperiode de medicatie niet gebruikt || 4. Medicatie is/wordt in de gebruiksperiode niet gebruikt en dat is ook volgens afspraak || 5. Medicatie is/wordt in de gebruiksperiode gebruikt maar onbekend of dit volgens afspraak is of er is geen afspraak (zelfzorgmedicatie)
|-
! Gebruikindicator ''(wordt dit product gebruikt)'' !! Ja !! Ja !! Nee !! Nee !! Ja
|-
! Volgens afspraak indicator!! Ja !! Nee !! Nee !! Ja !! -
|-
! Stoptype!! Nvt !! Nvt!! Definitief of Tijdelijk !! Definitief of Tijdelijk !! Nvt
|-
| || || || Stoptype afhankelijk of er gestaakt of onderbroken wordt || Stoptype conform de stop-afspraak ||
|-
! Gebruiksperiode!! Conform MA of TA !! Max. 2 van de 3 !! Max. 2 van de 3 !! Max. 2 van de 3 !! Max. 2 van de 3
|-
|style="text-align:right;" | ingangsdatum || Het tijdstip waarop het gebruik is gestart. || Het tijdstip waarop het afwijkende gebruik is/wordt gestart. || Het tijdstip vanaf wanneer gestaakt of onderbroken wordt.|| Het tijdstip vanaf wanneer gestaakt of onderbroken wordt. || Het tijdstip waarop het gebruik is gestart.
|-
|style="text-align:right;" | gebruiksduur || De beoogde gebruiksduur. || De beoogde duur van het afwijkende gebruik. || De (beoogde) duur van het onderbreken. (nvt. voor staken)|| De (beoogde) duur van het onderbreken. (nvt. voor staken)|| De beoogde gebruiksduur.
|-
|style="text-align:right;" | stopdatum || Het tijdstip waarop de gebruiksperiode eindigt (of geëindigd is of zal eindigen). || Het tijdstip waarop het afwijkende gebruik eindigt (of geëindigd is of zal eindigen). || Het tijdstip waarop het onderbreken eindigt en gebruik is/wordt herstart (of beoogd wordt te herstarten). (nvt. voor staken)|| Het tijdstip waarop het onderbreken eindigt en gebruik is/wordt herstart (of beoogd wordt te herstarten). (nvt. voor staken) || Het tijdstip waarop de gebruiksperiode eindigt (of geëindigd is of zal eindigen).
|-
! Doseerinstructie!! Conform MA of TA !! Verplicht!! Nvt !! Nvt !! Verplicht
|-
| || Medicatie is/wordt in gebruiksperiode gebruikt volgens afspraak || Medicatie is/wordt in gebruiksperiode niet gebruikt volgens afspraak, daadwerkelijk gebruikte dosering moet doorgegeven worden. || De medicatie is/wordt niet gebruikt, er is geen dosering. || De medicatie is/wordt niet gebruikt, er is geen dosering.|| Dosering die patiënt met zichzelf heeft afgesproken.
|}
'''VOORBEELDEN:''' 
'''Situatie 1: Medicatie is/wordt in gebruiksperiode gebruikt volgens afspraak''' 
Patiënt heeft Ferrofumaraat voorgeschreven gekregen tegen bloedarmoede. Dosering is 3x daags 1 tablet een half uur voor het eten innemen, met als startdatum 4 juni 2018 en zonder stopdatum. 
Op 10 juni registreert de patiënt het medicatiegebruik over de afgelopen periode (van 4 t/m 10 juni). 
{| class="wikitable"
|-
! Situatie 1 !!
|-
| Geneesmiddel || FERROFUMARAAT 100 MG TABLET
|-
| Gebruiksindicator || Ja
|-
| Volgens afspraak indicator || Ja
|-
| Stoptype || nvt
|-
| Ingangsdatum || 4 juni 2018
|-
| Stopdatum || 10 juni 2018
|-
| Doseerinstructie || ''Overeenkomstig de afspraak''
|}

'''Situatie 1: Medicatie is/wordt in gebruiksperiode gebruikt volgens afspraak''' 
Patiënt heeft Ferrofumaraat voorgeschreven gekregen tegen bloedarmoede. Dosering is 3x daags 1 tablet een half uur voor het eten innemen, met als startdatum 4 juni 2018 en zonder stopdatum. 
Op 10 juni registreert de patiënt het medicatiegebruik en het voornemen om deze medicatie te blijven gebruiken volgens de afspraak. 
{| class="wikitable"
|-
! Situatie 1 !!
|-
| Geneesmiddel || FERROFUMARAAT 100 MG TABLET
|-
| Gebruiksindicator || Ja
|-
| Volgens afspraak indicator || Ja
|-
| Stoptype || nvt
|-
| Ingangsdatum || 4 juni 2018
|-
| Stopdatum || -
|-
| Doseerinstructie || ''Overeenkomstig de afspraak''
|}

'''Situatie 2: Medicatie is/wordt in gebruiksperiode gebruikt maar niet volgens afspraak''' 
Patiënt heeft Ferrofumaraat voorgeschreven gekregen tegen bloedarmoede. Dosering is 3x daags 1 tablet een half uur voor het eten innemen, met als startdatum 4 juni 2018 en zonder stopdatum. 
De patiënt is overdag veel op pad en vergeet een werkweek lang om telkens de medicijnen voor de lunch in te nemen. Wel worden de tabletten 's ochtends en 's avonds voor het eten ingenomen 
{| class="wikitable"
|-
! Situatie 2 !!
|-
| Geneesmiddel || FERROFUMARAAT 100 MG TABLET
|-
| Gebruiksindicator || Ja
|-
| Volgens afspraak indicator || Nee
|-
| Stoptype || nvt
|-
| Ingangsdatum || 11 juni
|-
| Stopdatum || 15 juni
|-
| Doseerinstructie || 2x daags 1 tablet
|}
'''Situatie 3: In tegenstelling tot de afspraak is/wordt in gebruiksperiode de medicatie niet gebruikt''' 
Patiënt heeft Ferrofumaraat voorgeschreven gekregen tegen bloedarmoede. Dosering is 3x daags 1 tablet een half uur voor het eten innemen, met als startdatum 4 juni 2018 en zonder stopdatum. 
De patiënt gaat een lang weekend op vakantie en komt er te laat achter dat de medicatie niet ingepakt is. De komende paar dagen zal de patiënt de tabletten niet nemen en ze wil dit registreren. 
{| class="wikitable"
|-
! Situatie 3 !!
|-
| Geneesmiddel || FERROFUMARAAT 100 MG TABLET
|-
| Gebruiksindicator || Nee
|-
| Volgens afspraak indicator || Nee
|-
| Stoptype || Tijdelijk
|-
| Ingangsdatum || 20 juli
|-
| Stopdatum || 23 juli
|-
| Doseerinstructie || nvt
|}
'''Situatie 4: Medicatie is/wordt in de gebruiksperiode niet gebruikt en dat is ook volgens afspraak''' 
Patiënt heeft Ferrofumaraat voorgeschreven gekregen tegen bloedarmoede. Dosering is 3x daags 1 tablet een half uur voor het eten innemen, met als startdatum 4 juni 2018. 
Op 12 augustus blijkt na controle dat er geen sprake meer is van bloedarmoede en de arts stopt de medicatie. De patiënt wil registreren dat ze gestopt is met de medicatie en registreert dit zelf op 15 augustus. 
{| class="wikitable"
|-
! Situatie 4 !!
|-
| Geneesmiddel || FERROFUMARAAT 100 MG TABLET
|-
| Gebruiksindicator || Nee
|-
| Volgens afspraak indicator || Ja
|-
| Stoptype || Definitief
|-
| Ingangsdatum || 12 augustus 2018
|-
| Stopdatum || -
|-
| Doseerinstructie || nvt
|}
'''Situatie 5: Medicatie is/wordt in de gebruiksperiode gebruikt maar onbekend of dit volgens afspraak is of er is geen afspraak (zelfzorgmedicatie)''' 
Patiënt heeft de griep en hij neemt tegen de koorts en pijn paracetamol 500 mg van de plaatselijke drogist. Hij neemt inmiddels al vier dagen 4 tot 6 tabletten per dag en denkt dit nog drie dagen te zullen doen. Hij registreert dit op 12 augustus als medicatiegebruik. 
{| class="wikitable"
|-
! Situatie 5 !!
|-
| Geneesmiddel || Paracetamol 500 mg
|-
| Gebruiksindicator || Ja
|-
| Volgens afspraak indicator || -
|-
| Stoptype || nvt
|-
| Ingangsdatum || 9 augustus 2018
|-
| Duur || 7 dagen
|-
| Doseerinstructie || 4 tot 6 tabletten per dag
|}

==Implementatie geneesmiddel distributiesysteem (GDS)-velden==

===Achtergrond===
Steeds meer patiënten ontvangen hun medicatie via een geneesmiddel distributiesysteem (GDS), waarbij de apotheker overzicht en ordening voor de patiënt aanbrengt in diens geneesmiddelen door deze gereed te maken in afzonderlijke compartimenteenheden. Deze aflevervorm heeft met name een vlucht genomen toen de Geneesmiddelenwet in 2007 bepaalde dat in zorginstellingen zonder apotheek de medicatie voor de patiënten op naam gesteld dient te zijn.

Voor zorgverleners is het van belang om te weten of een patiënt een gebruikmaakt van GDS. In 2018 is geanalyseerd (onder regie van Z-Index, met zorgverleners) wat de knelpunten en wensen zijn rondom het vastleggen dat een patiënt gebruikmaakt van GDS. Daaruit is globaal naar voren gekomen dat het wenselijk is om zowel op medicatieniveau als op patiëntniveau te kunnen zien of een patiënt gebruik maakt van GDS. Voor de details zie volgende paragraaf.

Onderstaande aanwijzingen geven een handreiking hoe het Medicatieproces deze wensen kan ondersteunen.

===Wensen zorgverleners===
In 2018 is met de gebruikersraden van Z-Index geïnventariseerd wat de wensen rondom het vastleggen en uitwisselen van GDS is. Hieronder het overzicht van deze wensen. 

'''Wie'''
*Alle zorgpartijen (van voorschrijver t/m toediener)
'''Wat'''
*Vastleggen/uitwisselen dat iemand gebruik maakt van GDS
*Vastleggen waaróm iemand GDS patiënt is
*Vastleggen/uitwisselen bij medicatie dat dit in de GDS moet
*Vastleggen/uitwisselen wat de duur van een rol is
*Uitwisselen of wijziging per direct is of bij volgende rolwissel
'''Waarom'''
*Bepaalt welke apotheek aflevert
*Apotheek moet weten of wijziging voor lopende rol geldt of niet
*Van belang voor stoppen van eerdere medicatie bij starten van GDS
*Evaluatie van GDS-patiënten voor zorgverzekeraar
*Overige logistieke processen richting thuiszorg/mantelzorg
'''Wanneer'''
*Bij starten van medicatie, in apotheek al voor aanschrijven recept
*Bij overdracht 1e/2e lijn
*Bij wijzigen (incl. stoppen) van medicatie
*Bij wijzigen CiO-gegevens
'''Waar'''
*Bij het werken in het dossier van de patiënt dient inzichtelijk te zijn dat dit kenmerk bij betreffende patiënt van toepassing is. Per soort zorgverlener kan dit een verschillende plaats zijn (patiëntendossier, medicatiedossier). De wens van openbaar apothekers is dat ze dit kenmerk altijd bij de patiënt inzichtelijk hebben.
*Op medicatieoverzicht

===Data-elementen Medicatieproces===
De bouwstenen voor het Medicatieproces kennen de volgende velden die een rol spelen bij het vastleggen van GDS. 

{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| '''Bouwsteen'''
! style="text-align:left;"| '''Data-element nr'''
! style="text-align:left;"| '''Omschrijving'''
! style="text-align:left;"| '''Soort inhoud'''
|-
|style="background-color: white;vertical-align:top;"| Medicatieafspraak
|style="background-color: white;vertical-align:top;"|23283
|style="background-color: white;vertical-align:top;"|Aanvullende informatie
|style="background-color: white;vertical-align:top;"|Aanvullende informatie bevat een lijst van bijzonderheden over de gemaakte afspraak die van belang zijn voor de medicatiebewaking en invulling door de apotheker.
Bijvoorbeeld: ‘wijziging in GDS per direct’.
|-
|style="background-color: white;vertical-align:top;"| Verstrekkingsverzoek
|style="background-color: white;vertical-align:top;"|22759
|style="background-color: white;vertical-align:top;"|Aanvullende wensen
|style="background-color: white;vertical-align:top;"|Logistieke aanwijzingen van belang voor de invulling van het verstrekkingsverzoek door de apotheker. Bijvoorbeeld: ‘niet opnemen in GDS’
|-
|style="background-color: white;vertical-align:top;" rowspan="4"| Verstrekking
|style="background-color: white;vertical-align:top;"|20927
|style="background-color: white;vertical-align:top;"|Distributievorm
|style="background-color: white;vertical-align:top;"|Distributievorm.
Bijvoorbeeld: GDS
|-
|style="background-color: white;vertical-align:top;"|20924
|style="background-color: white;vertical-align:top;"|Verbruiksduur
|style="background-color: white;vertical-align:top;"|Voorraad voor deze duur
|-
|style="background-color: white;vertical-align:top;"|22500
|style="background-color: white;vertical-align:top;"|Aanschrijfdatum
|style="background-color: white;vertical-align:top;"|De aanschrijfdatum is het tijdstip waarop een apotheker een voorgenomen uitgifte vastlegt
|-
|style="background-color: white;vertical-align:top;"|20272
|style="background-color: white;vertical-align:top;"|Datum
|style="background-color: white;vertical-align:top;"|Het tijdstip van uitgifte. De datumtijd waarop het geneesmiddel ter hand gesteld wordt
|}

===Toepassing data-elementen ter ondersteuning gewenste functionaliteit voor GDS-patiënten===
====Vastleggen dát iemand gebruik maakt van GDS====
Bij het werken in het dossier van de patiënt is het van belang om te zien dat iemand gebruik maakt van GDS. Dat geldt zowel voor de apotheek die de GDS levert, als andere zorgverleners van de patiënt. Daarom is het van belang dat dit gegeven kan worden gecommuniceerd naar en getoond aan andere zorgverleners. 
Zolang er nog geen patiëntkenmerk is waarmee GDS vastgelegd kan worden, kan ervoor gekozen worden dit gegeven af te leiden uit de GDS-gegevens die bij de medicatie zijn vastgelegd.
Een mogelijk handvat hiervoor is het feit dat medicatie in de distributiemodule is opgenomen tezamen met het veld Distributievorm in de verstrekking.
*Stap 1: indien medicatie in de distributiemodule is opgenomen: vul het veld Distributievorm in de verstrekking met ‘GDS’.
*Stap 2: op basis van het veld Distributievorm afleiden dat een patiënt gebruikmaakt van GDS. Het feit dat een patiënt enige verstrekking heeft waarbij het veld Distributievorm met ‘GDS’ is gevuld, geeft aan dat de patiënt gebruik maakt van GDS. Deze verstrekking kan een eigen verstrekking zijn, of een verstrekking ontvangen van een andere apotheek (voor zover deze gegevens worden binnengehaald en zodanig worden vastgelegd dat de inhoud van het veld Distributievorm herbruikbaar is). Het gegeven dat een patiënt gebruikmaakt van GDS, kan vervolgens getoond worden bij het werken in het medicatiedossier c.q. het patiëntendossier. In overleg met eindgebruikers dient nader bepaald te worden waar en hoe dit getoond wordt.

====Vastleggen waaróm iemand gebruik maakt van GDS====
Gebruikers hebben aangegeven dat het wenselijk is om te kunnen vastleggen waarom iemand gebruik maakt van GDS. Op dit moment zijn hier geen structurele velden voor beschikbaar.

====Bij medicatie vastleggen dat dit in de GDS moet====
Voorschrijvers willen kunnen aangeven of een middel al dan niet via GDS verstrekt dient te worden. Dit kan als volgt:
*Verstrekkingsverzoek, veld Aanvullende wensen. De codelijst voor dit veld bevat het item ‘niet in GDS’. Deze codelijst is thesaurus 2051 van bestand 902 in de G-Standaard.

====Vastleggen/uitwisselen wat de duur van een medicatierol is====
De duur van de medicatierol kan worden bepaald op basis van de ‘verbruiksduur’ van de verstrekking: de ‘verbruiksduur’ geeft aan wat de loopduur van een medicatierol is.

====Vastleggen/uitwisselen of een wijziging in de medicatie per direct moet of niet====
Het is wenselijk dat een voorschrijver kan aangeven of wijzigingen in de medicatie per direct doorgevoerd moeten worden of dat deze kunnen wachten tot de volgende rolwissel. De handvatten hiervoor zijn als volgt:
*Medicatieafspraak, veld Aanvullende informatie. De codelijst voor dit veld bevat twee items die betrekking hebben op wijzigingen in de GDS, namelijk ‘Wijziging in GDS per direct’ en ‘Wijziging in GDS per rolwissel’. Deze codelijst is thesaurus 2050 van bestand 902 in de G-Standaard.
*Daarbij is het van belang dat de voorschrijver inzicht heeft in de duur van de rol en hoe lang het nog duurt voordat de huidige medicatierol op is. Dit is te herleiden uit:
**De verstrekking, veld Verbruiksduur, zie hierboven. Hiervoor dient het voorschrijfsysteem wel de beschikking te hebben over de verstrekkingsgegevens van eerdere verstrekkingen.
**Verstrekking, veld Aanschrijfdatum of Datum (of als niet dit veld gevuld is maar het veld Aanschrijfdatum, dan het veld Aanschrijfdatum; als beide zijn gevuld heeft Datum de voorkeur). Op basis van deze datum en de verbruiksduur, kan berekend worden per welke datum de huidige medicatierol is verbruikt.

=Beschouwingen=
==Ongeadresseerd voorschrijven (ambulant)==
In deze paragraaf wordt de term “prescriptie” gebruikt om het bericht waarmee een patiënt een geneesmiddel bij een verstrekker mag afhalen aan te duiden. Een prescriptie bevat een medicatieafspraak en een verstrekkingsverzoek.

In Nederland is het tot op heden gebruikelijk om prescripties digitaal te versturen naar een ontvangende apotheek in plaats van het ophalen van prescripties. Daarvoor is nodig, dat de apotheek al van te voren bekend is. 

Deze paragraaf is een beschouwing of er meer flexibiliteit in de logistieke afhandeling van prescripties te bereiken is, zonder de huidige voordelen teniet te doen. Deze paragraaf kan beschouwd worden als een lange termijn visie waar wij naar toe willen werken.

===Uitgangspunten===
In de afweging hoe wij flexibiliteit in de afhandeling kunnen bewerkstelligen zijn uitgangspunten geformuleerd. Deze zijn:
*De patiënt heeft de keuzevrijheid van afhandeling.
*De huidige verwerking van verzenden van prescripties blijft mogelijk.
*Het informatiesysteem moet zoveel mogelijk dezelfde functionaliteit hergebruiken.
*Een prescriptie mag maar éénmaal verstrekt worden.

Omdat de hieronder beschreven methodiek gebruik maakt van de bestaande methode van verzenden van prescripties, gelden dezelfde juridische regels over de geldigheid van de prescripties. Alle discussies over elektronische handtekeningen gelden evenzeer voor de huidige methode van communicatie van prescripties.

===Uitwerking===
Een patiënt kan kiezen uit 3 keuzemogelijkheden:
#Een prescriptie wordt altijd naar een vaste apotheker verzonden.
#De patiënt geeft per keer op waar de prescriptie naar toe verzonden wordt.
#De patiënt geeft niets op en komt bij een apotheek die een prescriptie opvraagt en afhandelt.

Voor opties 1 en 2 is een patiënt portaal nodig, waarin de patiënt zijn voorkeur aangeeft. Bij optie 2 mag een patiënt een voorkeurapotheek definiëren, die boven aan in het selectiescherm zal staan als de patiënt gevraagd wordt, waarheen de prescriptie gestuurd moet worden. Als een patiënt niets opgeeft kan optie 3 de enige werkwijze zijn.

De methodiek maakt deels gebruik van een concept dat “publish en subscribe” heet.

Het is van belang, dat de apotheker aan zijn vaste klanten uitlegt hoe het principe werkt.

===Werkproces===
Een arts besluit een prescriptie te doen aan een patiënt. Dit kan bij een consult of zelfs bij aanvraag van herhaalreceptuur zijn. De arts registreert de prescriptie in zijn voorschrijfsysteem ( EVS). De arts hoeft zich niet te bekommeren om de apotheek, dat doet de patiënt immers via het portaal.

Na akkoord van de prescriptie wordt een centrale prescriptie-index bijgewerkt. Dit gebeurt automatisch door het EVS, die een aanmelding stuurt naar deze prescriptie register. In deze beschouwing wordt de prescriptie-index als een apart register beschouwd met de gegevenssoort “voorschriften”. Later kan altijd nog geëvalueerd worden of dit niet samengevoegd kan worden. In eerste instantie wordt ook gedacht aan een atomaire registratie in het register. Later kan overwogen worden of een categorale registratie niet toereikend is.

Het is belangrijk om te begrijpen, dat er op dit moment alleen nog maar gemeld wordt, dat een prescriptie klaar staat. De prescriptie is immers nog altijd bij het EVS in een database vorm met status “staat klaar”. Er is dus nog geen prescriptie bericht.

Het registersysteem weet uit de voorkeurinstelling van de patiënt wat er met de aanmelding moet gebeuren:
#Bij de keuze vaste apotheker van de patient wordt een signaal naar de ingevulde abonneehouder van de patiënt gestuurd met de melding, dat een prescriptie opgehaald kan worden.
#Bij deze keuze stuurt het registersysteem een signaal (bijv. SMS) naar de patiënt. Vervolgens wacht het registersysteem totdat de patiënt via een app op de smartphone of via het patiëntportaal ingeeft naar welke apotheek het signaal verzonden moet worden.
#Bij deze optie doet het registersysteem niets. De patiënt heeft geen vaste abonneehouder.

===Verwerking in de apotheek===
Een ontvangende apotheek herkent aan het doorgestuurde signaal (gegevenssoort), dat dit om een openstaande prescriptie gaat. In het signaal is ook bekend wie de patiënt is en wie de bron is van de prescriptie.

Bij een patiënt die voor optie 3 gekozen heeft, begint het proces pas hierna. De patiënt identificeert zich en meldt aan de apotheker, dat een prescriptie bij een bepaalde instelling klaar staat. De apotheker zoekt eventueel in het prescriptieregister om welk EVS het gaat.

Het apotheek informatiesysteem vraagt dan aan het EVS bronsysteem om de verzending van de prescriptie van de betreffende patiënt. Aangezien dit ook een verzoek is zonder medische inhoud, zou dit zelfs met een laag vertrouwensniveau verzocht kunnen worden.

===Verzending door het EVS===
Als een EVS een verzoek ontvangt voor “verzending van openstaande prescriptie” dan controleert het EVS of de prescriptie inderdaad nog open staat. Hiermee wordt voorkomen, dat een prescriptie meerdere keren wordt opgevraagd. Het adres van de apotheek wordt ingevuld en het voorbereide prescriptie bericht wordt dan eindelijk aangemaakt. Het prescriptie bericht wordt verzonden naar de betreffende apotheek.

Als de prescriptie al eerder opgevraagd is geweest, dan wordt een foutmelding naar de opvragende apotheek verzonden met de mededeling dat de prescriptie niet meer opvraagbaar is.

'''Het verzenden van een prescriptie is feitelijk het standaard proces, dat nu al gebruikelijk is bij het pushen van prescripties.''' Dit heeft het voordeel dat de ontvangende apotheek alleen één manier hoeft te onderhouden voor het verwerken van ontvangende prescripties. Hier wordt nogmaals opgemerkt, dat dezelfde juridische regels van toepassing blijven.

Na de verzending wordt door het EVS tevens een bericht naar het prescriptie register verzonden om de registratie van de openstaande prescriptie te verwijderen. Hiermee wordt dan duidelijk gemaakt, dat de betreffende prescriptie niet meer op te vragen is.

{{anchor|figuur 11}}
[[Bestand:Interactiediagramvoorschrijven.png|Figuur 11 Interactiediagram Ongeadresseerd voorschrijven]]

=Bijlage referenties=

==Algemene referenties==
{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| Auteur(s)
! style="text-align:left;"| Titel
! style="text-align:left;"| Versie
! style="text-align:left;"| Datum (raadplegen)
! style="text-align:left;"| Bron
! style="text-align:left;"| Organisatie
|-
| style="background-color: white;vertical-align:top;"| NHG, KNMP, Z-index
| style="background-color: white;vertical-align:top;"| Bouwstenen van het medicatieproces
| style="background-color: white;vertical-align:top;"| 2014
| style="background-color: white;vertical-align:top;"| Augustus 2015
| style="background-color: white;vertical-align:top;"| https://www.nhg.org/bouwstenen
| style="background-color: white;vertical-align:top;"| NHG, KNMP, Z-index
|-
| style="background-color: white;vertical-align:top;"| ActiZ, KNMP, NVZA e.a.
| style="background-color: white;vertical-align:top;"| Veilige principes in de medicatieketen
| style="background-color: white;vertical-align:top;"| 2014
| style="background-color: white;vertical-align:top;"| Augustus 2015
| style="background-color: white;vertical-align:top;"| http://www.knmp.nl/patiëntenzorg/samenwerking/brochure-veilige-principes-in-de-medicatieketen
| style="background-color: white;vertical-align:top;"| ActiZ, KNMP, NVZA e.a.
|-
| style="background-color: white;vertical-align:top;"| Diversen
| style="background-color: white;vertical-align:top;"| Richtlijn Overdracht van medicatiegegevens in de keten
| style="background-color: white;vertical-align:top;"| 25-4-2008
| style="background-color: white;vertical-align:top;"| Augustus 2015
| style="background-color: white;vertical-align:top;"| Website KNMP
| style="background-color: white;vertical-align:top;"| Diversen
|-
| style="background-color: white;vertical-align:top;"| Paul Geels
| style="background-color: white;vertical-align:top;"| Beoordeling Eigen beheer van Medicatie (BEM) in verzorgingshuizen, Instituut voor Verantwoord Medicijngebruik
| style="background-color: white;vertical-align:top;"| Februari 2009
| style="background-color: white;vertical-align:top;"|
| style="background-color: white;vertical-align:top;"| http://www.instellingsapotheek.nl/downloads/rapporten/beoordeling_eigen_beheer_van_medicatie_in_verzorgingshuizen.pdf
| style="background-color: white;vertical-align:top;"| Instituut voor Verantwoord Medicijngebruik
|-
| style="background-color: white;vertical-align:top;"| ActiZ
| style="background-color: white;vertical-align:top;"| Veiligheid in de medicatieketen
| style="background-color: white;vertical-align:top;"| Maart 2012
| style="background-color: white;vertical-align:top;"|
| style="background-color: white;vertical-align:top;"| https://www.knmp.nl/downloads/brochure-veiligheid-in-de-medicatieketen.pdf
| style="background-color: white;vertical-align:top;"| ActiZ, Diversen
|-
| style="background-color: white;vertical-align:top;"| KNMG
| style="background-color: white;vertical-align:top;"| Richtlijn electronisch voorschrijven
| style="background-color: white;vertical-align:top;"| September 2013
| style="background-color: white;vertical-align:top;"|
| style="background-color: white;vertical-align:top;"| Website KNMG
| style="background-color: white;vertical-align:top;"| KNMG
|}

==Kwalificatiescripts==
Kwalificatiescripts zijn gepubliceerd op [[mp:Vcurrent Kwalificatie|de wiki pagina "Kwalificatie".]]

=Bijlage: Documenthistorie=

{{anchor|tabel 6}}
{| class="wikitable" "cellpadding="10"
!style="text-align:left;"|Versie
!style="text-align:left;"|Datum
!style="text-align:left;"|Omschrijving
|-
| style="background-color: white;"| 0.95
| style="background-color: white;"| 15 juli 2016
| style="background-color: white;"| Versie t.b.v. pilot
|-
| style="background-color: white;"| 0.96
| style="background-color: white;"| 1 december 2016
| style="background-color: white;"| Paragraaf 2.4 Proces: toedienen aangepast en als gevolg daarvan ook H6: toegevoegd Sturen/ontvangen toediengegevens.
|-
| style="background-color: white;vertical-align:top;"| 0.97
| style="background-color: white;vertical-align:top;"| 22 december 2016
| style="background-color: white;"| Paragraaf 2.4, 4.3.1 opmerkingen review verwerkt. Paragraaf 4.2.11 aanscherping in tekst.
|-
| style="background-color: white;vertical-align:top;"| 9.0.2
| style="background-color: white;vertical-align:top;"| 18 juni 2017
| style="background-color: white;"| Omzetting document naar wiki.
|-
| style="background-color: white;vertical-align:top;"| 9.0.4
| style="background-color: white;vertical-align:top;"| september 2017
| style="background-color: white;vertical-align:top;"|
*Verwerkt [[mp:V9.0_Ontwerpbeslissingen|Ontwerpbeslissingen]] in functioneel ontwerp. Daarmee zijn de ontwerpbeslissingen vervallen. Het huidige FO is vanaf nu leidend. 
*Par. 1.3.1. Definities bouwstenen aangepast en afkorting voor medicatieverstrekking gewijzigd van VS naar MVE. 
*Par. 1.3.3. Medicamenteuze behandeling nu op basis van PRK, stuk herschreven en ontstaan mbh en omgang met parallelle MA toegevoegd. 
*Par. 1.3.4. Nieuw datamodelplaaje, diverse relatie toegevoegd en aangepast op basis van ontwerpbeslissingen. 
*Par. 1.5 Begrippenlijst verwijderd. 
*H.2 Plaatje medicatieproces aangepast: mo toegevoegd bij actief beschikbaarstellen door gebruiker; lijnen in swimlane van toediener/gebruiker aangepast. 
*H4.1 Nieuwe use cases toegevoegd: Niet verstrekken voor, Verschillende PRKs onder dezelfde medicamenteuze behandeling, Staken van medicatie door derden, Achteraf vastleggen medicatieafspraak, Parallelle medicatieafspraken. 
*H4.2 Nieuwe use case: Stop-toedieningsafspraak; gewijzigde use case: Aanschrijfdatum, verstrekken en niet afhalen. 
*H5: Onderscheiden van medicatieprofiel en medicatieoverzicht beschreven; afleidingsregels aangepast op basis van de nieuwe ontwerpbeslissingen. 
*Waar logisch verwijzingen vanuit Art-decor naar FO H7 aangebracht. 
*Diverse grammaticale en kleine tekstuele wijzigingen. 
|-
| style="background-color: white;vertical-align:top;"| 9.0.5
| style="background-color: white;vertical-align:top;"| januari 2018
| style="background-color: white;vertical-align:top;"|
*Terminologie: Stop-MA gewijzigd naar staken-MA conform eerdere projectafspraken. 
*Par. 1.3.4 Aanvulling dat MA ook mag verwijzen naar bouwsteen onder andere medicamenteuze behandeling. 
*Par. 4.1.22 Ontslag aangepast omdat bij ontslag eerder gestaakte ambulante medicatie opnieuw gestart kan worden. 
*Par. 4.1.26 Staken van medicatie door derden aangepast. 
*Par. 4.1.27 Twee PRK's onder één medicamenteuze behandeling. 
*Par. 2.2.5.3 Staken medicatieafspraak aangepast ter verduidelijking van impact op reeds ingevoerde toekomstige medicatieafspraken. 
*Voetnoot 3 Voorlopige en definitieve medicatieopdracht verduidelijkt en use case medicatieopdracht (par. 4.1.31) toegevoegd. 
*Par. 4.1.30 Use case Eenmalig gebruik toegevoegd. 
*Paragraaf 2.2.4, 2.2.5.2, 2.2.5.4, 4.1.16, 4.1.22 aangepast voor substitutie. Bij substitutie wordt een medicamenteuze behandeling niet tijdelijk onderbroken maar daadwerkelijk gestaakt. Het substituut wordt onder een nieuwe medicamenteuze behandeling gestart. 
*Paragraaf 4.1.33 Ontbreken digitale medicatieafspraak bij opname toegevoegd. 
*H5 Medicatieoverzicht aangepast met verwijzing naar nieuwe inhoudelijke pagina met functionele uitwerking. 
*Paragraaf 7.10 Medicatiegebruik: gebruikindicator, volgens afspraak indicator en stoptype toegevoegd. 
*H6 Bouwstenen van medicatieoverzicht gewijzigd naar MA, TA en MGB. 
*Figuur 2 Kleuren in datamodel conform figuur 1. 
*Diverse afkortingen verklaard. 
|-
| style="background-color: white;vertical-align:top;"| 9.0.6
| style="background-color: white;vertical-align:top;"| mei 2018
| style="background-color: white;vertical-align:top;"|
*Aanvulling op voorstel verstrekkingsverzoek en toevoeging van antwoord-voorstel verstrekkingsverzoek 
*Hoofdstuk 6 tabel 4 toevoeging van linkjes naar ART-DECOR transacties 
*Verwijderd: hoofdstuk over LSP 
*Par. 7.10 tabel uitgebreid met gebruiksperiode en doseerinstructie 
*Aanscherpingen in diverse teksten 
*Toevoeging van kenmerk 'bouwsteen van iemand anders' voor MA, TA, MGB in medicatieoverzicht 
|-
| style="background-color: white;vertical-align:top;"| 9.0.7
| style="background-color: white;vertical-align:top;"| december 2018
| style="background-color: white;vertical-align:top;"|
*Par 1.3.3. MBH op HPK niveau in geval van 'niet geneesmiddelen' zonder een PRK niveau 
*Par 1.3.3. MBH voor geneesmiddelen zonder PRK (magistralen, infusen etc) 
*Par 2.2.5.5. Wijzigen medicatie: Technisch stop-MA: afspraak datum voor stop-MA en nieuwe MA moeten hetzelfde zijn. Wijziging op MA die reeds gestopt is toegelicht (geen extra staken-MA nodig) 
*Par 2.2.6. Toegevoegd: VV onder MA van iemand anders 
*Par 4.2.15. Uitleg GDS leverancier levert ander HPK 
*Par 7.10: Medicatiegebruik gebruikindicator, volgens afspraak indicator, stoptype, gebruiksperiode en doseerinstructie: tabel aangepast en voorbeelden toegevoegd 
*Par 4.1.34: Eigen artikelen uitleg toegevoegd 
*Hoofdstuk 5: voorbeeld medicatieoverzicht ingevoegd in deze wiki pagina ipv een losse wiki pagina (om zoeken binnen het FO te vereenvoudigen).
*Diverse tekstuele aanscherpingen/verbeteringen
|-
| style="background-color: white;vertical-align:top;"| 9.0.7
| style="background-color: white;vertical-align:top;"| juli 2019
| style="background-color: white;vertical-align:top;"|
Voorbeelden voor specifieke infrastructuren verwijderd.
|-
| style="background-color: white;vertical-align:top;"| 9.1.0
| style="background-color: white;vertical-align:top;"| 29 januari 2020
| style="background-color: white;vertical-align:top;"|
*Tekstuele aanpassingen staken/stoppen 
*Par 7.11 toegevoegd: Implementatie geneesmiddel distributiesysteem (GDS)-velden
*[https://bits.nictiz.nl/browse/MP-85 BITS MP-85], [https://bits.nictiz.nl/browse/MP-93 BITS MP-93], [https://bits.nictiz.nl/browse/MP-122 BITS MP-122] Use cases toegevoegd (Gebruik registreren op basis van verstrekking, Verstrekkingsverzoek met aantal herhalingen, Voorschrijven van niet geneesmiddelen)
*Hoofdstuk 4: plaatjes bij use cases toegevoegd
*Nierfunctiewaarde in het voorschrift
*[https://bits.nictiz.nl/browse/MP-48 BITS MP-48] Medicatieoverzicht: Par 5.7 toegevoegd 'Velden die niet getoond hoeven te worden'
*Diverse tekstuele aanscherpingen/verbeteringen [https://bits.nictiz.nl/browse/MP-131 o.a. BITS MP-131]
*Paragraaf 'Ongeadresseerd voorschrijven' verplaatst naar hoofdstuk 'Beschouwingen'
*[https://bits.nictiz.nl/browse/MP-151 BITS MP-151] Proces van aanmaken concept-TA verwijderd
*[https://bits.nictiz.nl/browse/MP-128 BITS MP-128] Par 4.1.8: Toelichting 'Medische noodzaak'
*[https://bits.nictiz.nl/browse/MP-129 BITS MP-129] Par 4.1.35: Use case toegevoegd
|-
| style="background-color: white;vertical-align:top;"| 9 2.0.0 bèta
| style="background-color: white;vertical-align:top;"| 01 oktober 2021
| style="background-color: white;vertical-align:top;"| voor alle wijzigingen zie: *[https://informatiestandaarden.nictiz.nl/wiki/mp:V9_2.0.beta_releasenotes Releasenotes]
|}

=Bijlage: Figuren en tabellen=
[[#figuur 1|Figuur 1 Bouwstenen - overzicht]] 
[[#figuur 2|Figuur 2 Bouwstenen - samenhang]] 
[[#figuur 3|Figuur 3 Activiteitendiagram - Medicatieproces algemeen]] 
[[#figuur 4|Figuur 4 Processtappen en transacties - medicatieverificatie]] 
[[#figuur 5|Figuur 5 Processtappen en transacties - voorschrijven]] 
[[#figuur 6|Figuur 6 Processtappen en transacties - ter hand stellen]] 
[[#figuur 7|Figuur 7 Processtappen en transacties - toedienen]] 
[[#figuur 8|Figuur 8 Processtappen en transacties - gebruiken]] 
[[#figuur 9|Figuur 9 Voorbeeld effectieve periode]] 
[[#figuur 10|Figuur 10 Overzicht systemen en systeemrollen]] 
[[#figuur 11|Figuur 11 Interactiediagram Ongeadresseerd voorschrijven]] 

[[#tabel 1|Tabel 1 Bouwstenen – beschrijving]] 
[[#tabel 2|Tabel 2 Informeren versus (Actief) beschikbaarstellen]] 
[[#tabel 3|Tabel 3 Overzicht systeemrollen]] 
[[#tabel 4|Tabel 4 Overzicht transactiegroepen]] 
[[#tabel 5|Tabel 5 Typen klinische medicatie relevant voor extramurale zorgverleners]]

mp:V2.0.0 Ontwerp medicatieproces 9

2022-04-04T14:47:14Z

Petra van Deursen: /* Onderbreken voor een ingreep */

{{IssueBox|'''LET OP: Dit is een ontwikkel versie. Voor een overzicht van relevante en gepubliceerde wiki-pagina's voor Medicatieproces zie [[Landingspagina_Medicatieproces]].'''}}

__NUMBEREDHEADINGS__
{{DISPLAYTITLE: Functioneel Ontwerp Medicatieproces 9 versie 2.0.0 ONTWIKKELVERSIE definitieve publicatie}}
[[Bestand:NL.jpg|50px]] [[mp:V2.0.0_Ontwerp_medicatieproces_9|Dit is de NL versie]] 
[[Bestand:ENG.jpg|50px]] [[mp:V2.0.0_Ontwerp_medicatieproces_9_ENG|Click here for the ENG version]] 
Voor een overzicht van relevante wiki-pagina's voor Medicatieproces zie [[Landingspagina_Medicatieproces]]

=Inleiding=

Dit document is het functioneel ontwerp van de informatiestandaard Medicatieproces. Het beschrijft de algemene werking en specifieke praktijksituaties. Daarbij is voor een concrete situatie het vastleggen en uitwisselen van informatie beschreven aan de hand van actoren (mensen, informatiesystemen) en transacties (welke informatie wordt wanneer uitgewisseld).

Doelgroep voor dit document zijn:
* zorgverleners;
* informatieanalisten en -architecten;
* softwareleveranciers.

==Scope en visie==

Dit document is tot stand gekomen binnen het programma Medicatieproces. Het programma Medicatieproces beoogt allereerst om bestaande knelpunten in het medicatieproces op te lossen, rekening houdend met de huidige wetgeving en de haalbaarheid van concrete resultaten binnen afzienbare termijn.

Een van de belangrijkste knelpunten betreft het onvoldoende zicht hebben op de medicatie die de patiënt gebruikt. Dit heeft onder andere te maken met het vermengen van therapeutische en logistieke informatie wat leidt tot een onoverzichtelijke medicatiehistorie. Het onderscheid tussen therapie en logistiek is als volgt gemaakt:
* '''Therapie''' omvat de ‘medisch-inhoudelijke’ aspecten. Het omvat onder andere de medicamenteuze (behandelings-)afspraken, de begeleiding en de uitvoering ervan. Ook de therapeutische intentie, het (werkelijk) gebruik, zelfmedicatie en farmacotherapie zijn termen die passen onder de paraplu van ‘therapie’, zoals in dit document is bedoeld.
* '''Logistiek''' omvat de aspecten rondom de fysieke goederenstroom van geneesmiddelen, inclusief aanvragen, planning en afleveringen. Ook de medicatievoorraad en het verbruik ervan vallen onder dit begrip.

Het programma heeft rekening gehouden met huidige wetgeving en haalbaarheid binnen een afzienbare termijn. De visie gaat wel verder dan de scope van het programma Medicatieproces en legt het fundament voor een situatie waarin het verstrekkingsverzoek verdwijnt. Het uiteindelijke doel is dat voorschrijvers zich uitsluitend bezig houden met therapeutische aspect (welk geneesmiddel, welke sterkte, welke dosering, wanneer starten, etc.). Daardoor is het maken van een verstrekkingsverzoek niet meer nodig. In plaats daarvan maakt de voorschrijver medicatieafspraken met de patiënt. Op basis van deze medicatieafspraken verzorgt de apotheker het logistieke proces en daarmee kan het verstrekkingsverzoek verdwijnen.
Dit is echter (nog) niet mogelijk vanwege wetgeving. Het programma Medicatieproces zet wel de eerste noodzakelijke stap in die richting.

==Leeswijzer==

De volgende paragraaf bevat een introductie van de belangrijkste bouwstenen en termen die in dit document gebruikt worden.
In [[#Medicatieproces|hoofdstuk 2]] zijn de verschillende processen (voorschrijven, ter hand stellen, toedienen, gebruiken) uitgewerkt. Het doel van de beschrijving is helder te maken hoe het zorgproces in de gewenste situatie loopt, welke processtappen nodig zijn, welke actoren daaraan deelnemen, welke informatie daarbij van toepassing is en welke uitwisselingsmomenten er zijn.
De processen zijn volgens een vaste indeling beschreven:

* Huidige situatie Deze paragraaf beschrijft de relevante verschillen van de huidige situatie ten opzichte van de gewenste situatie (“soll”, volgens deze informatiestandaard). Hier vindt u dus knelpunten terug.
* Procesbeschrijving met de paragrafen:
** ''Preconditie'' De voorwaarden waaraan voldaan moet zijn vóór het starten van het proces.
** ''Trigger Event'' De gebeurtenis die het proces start.
** ''Een of meerdere processtappen'' Beschrijving van een onderdeel van het proces.
** ''Postconditie'' De voorwaarden waaraan voldaan is nadat de processtappen van het proces zijn uitgevoerd.
* Use cases Opsomming van de use cases die horen bij dit deelproces. De uitwerking van de use cases is opgenomen in [[#Beschrijving use cases|Hoofdstuk 4]].
* Informatiesystemen en transactiesgroepen Deze paragraaf beschrijft de betrokken informatiesystemen, systeemrollen, transacties en transactiegroepen in relatie tot de processtappen. Alle informatie rond informatiesystemen en transactiegroepen is ook opgenomen in [[#Systemen en transacties|Hoofdstuk 7]].

In [[#Domeinspecifieke invulling medicatieproces|hoofdstuk 3]] zijn enkele domeinspecifieke invullingen van het medicatieproces beschreven bijvoorbeeld die bij de dienstwaarneming in de ambulante situatie. In [[#Beschrijving use cases|Hoofdstuk 4]] zijn verschillende use cases in meer detail beschreven. De praktijk situaties zijn in een groot aantal gevallen ontleent aan de huisartsenpraktijk maar zijn illustratief voor vergelijkbare situaties in een andere setting. De use cases zijn onderverdeeld naar deelproces, zoals aangegeven in Hoofdstuk 2. 
[[#Medicatieoverzicht en afleidingsregels|Hoofdstuk 5]] beschrijft hoe een medicatieprofiel kan worden opgebouwd uit de verschillende bouwstenen. In [[#Systemen en transacties|Hoofdstuk 7]] is een overzicht opgenomen van alle informatiesystemen, systeemrollen, transacties en transactiegroepen. Aanwijzingen voor de functionaliteit van verschillende informatiesystemen zijn uitgewerkt in [[#Functionaliteit|Hoofdstuk 8]].

==Introductie van relevante termen==
===Therapeutische en logistieke bouwstenen===
De use cases bevatten een beschrijving van het proces en de gegevenselementen die daarin een rol spelen. Daarbij wordt gebruik gemaakt van groepen van bij elkaar horende gegevenselementen: zorginformatiebouwstenen (zib), de zorginformatiebouwstenen zijn in sommige gevallen aangevuld met elementen die nodig zijn voor de context en/ of het werkproces. In de dataset is uitgewerkt uit welke gegevenselementen deze bouwstenen bestaan. De dataset bevat de complete set van definities van de gegevenselementen in de bouwstenen. De bouwstenen met hun gegevenselementen worden gebruikt in verschillende scenario’s waarmee zorgtoepassingen kunnen worden ingericht/gemodelleerd of waarmee koppelvlakken voor gegevensuitwisseling worden gedefinieerd.

Onderstaande figuur geeft de bouwstenen weer. Zij zijn gerangschikt naar (deel)proces en naar therapie versus logistiek.

{{anchor|figuur 1}}
[[Bestand:Figuur 1 Bouwstenen - overzicht.png|Figuur 1 Bouwstenen - overzicht]]

Onderstaande tabel geeft een beschrijving van deze bouwstenen. Ook de vier aanvullende concepten ‘voorstel medicatieafspraak’ (therapeutisch), 'antwoord voorstel medicatieafspraak' (therapeutisch), 'voorstel verstrekkingsverzoek’ (logistiek) en ‘antwoord voorstel verstrekkingsverzoek’ (logistiek) zijn beschreven.

{{anchor|tabel 1}}
{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| Bouwsteen
! style="text-align:left;"| Afk.
! style="text-align:left;"| Beschrijving
|-
| style="background-color: white;vertical-align:top;"| medicatieafspraak
|style="background-color: white;vertical-align:top;"| MA
| style="background-color: white;vertical-align:top;"| Een medicatieafspraak is het voorstel van een voorschrijver tot gebruik van medicatie waarmee de patiënt akkoord is. Ook de afspraak om het medicatiegebruik te stoppen is een medicatieafspraak<ref>In dit document wordt alleen medicatieafspraak gebruikt waarmee dus ook het klinische equivalent voorlopige medicatie-opdracht wordt aangeduid</ref>.
|-
| style="background-color: white;vertical-align:top;"| wisselend doseerschema
| style="background-color: white;vertical-align:top;"| WDS
| style="background-color: white;vertical-align:top;"| Een wisselend doseerschema is het doseerschema van een (externe) voorschrijver, waarbij het onderdeel gebruiksinstructie van een medicatieafspraak concreet wordt ingevuld. Het doseerschema kan tussentijds aangepast worden zonder dat de medicatieafspraak gewijzigd hoeft te worden.
|-
| style="background-color: white;vertical-align:top;"| verstrekkingsverzoek
| style="background-color: white;vertical-align:top;"| VV
| style="background-color: white;vertical-align:top;"| Een verstrekkingsverzoek is het verzoek van een voorschrijver aan de apotheker om medicatieverstrekking(en) te doen aan de patiënt, ter ondersteuning van de geldende medicatieafspraken<ref>De bouwsteen verstrekkingsverzoek is in de klinische situatie niet van toepassing. Verstrekken van medicatie wordt in de klinische situatie op verschillende manieren ingevuld. Het aanvullen van bijvoorbeeld een afdelingsdepot wordt hier niet als medicatieverstrekking gezien maar als verlengde voorraad van de apotheker. Er is pas sprake van een medicatieverstrekking als de koppeling tussen het geneesmiddel en de patiënt gelegd is. In de klinische situatie wordt daarna vaak gelijk toegediend.
</ref>.
|-
| style="background-color: white;vertical-align:top;"| toedieningsafspraak
| style="background-color: white;vertical-align:top;"| TA
| style="background-color: white;vertical-align:top;"| Een toedieningsafspraak is de gebruiks- (of toedienings-)instructie van de apotheker aan de patiënt (of zijn vertegenwoordiger of toediener), waarbij een medicatieafspraak concreet wordt ingevuld<ref name="MO">Een voorlopige medicatieopdracht, zoals die in ziekenhuizen wordt gebruikt, is zowel het verzoek van de arts aan de toediener om medicatie toe te dienen aan de patiënt als een verstrekkingsverzoek aan de apotheker om ervoor te zorgen dat de medicatie beschikbaar is voor de toediener. Dit laatste komt overeen met de medicatieafspraak en verstrekkingsverzoek uit de eerste lijn. De apotheker in het ziekenhuis voert in de regel bovendien een validatie van het toedieningsverzoek uit (zo ontstaat de definitieve medicatieopdracht en dit wordt hier de toedieningsafspraak genoemd). Met voorlopige medicatieopdracht wordt dus niet bedoeld een voorstel van bijvoorbeeld de verpleegkundige op basis van protocol welke nog niet geaccordeerd is door een arts.</ref>.
|-
| style="background-color: white;vertical-align:top;"| medicatieverstrekking
| style="background-color: white;vertical-align:top;"| MVE
| style="background-color: white;vertical-align:top;"| Een medicatieverstrekking is de ter handstelling van een hoeveelheid van een geneesmiddel aan de patiënt, zijn toediener of zijn vertegenwoordiger.
|-
| style="background-color: white;vertical-align:top;"| medicatietoediening
| style="background-color: white;vertical-align:top;"| MTD
| style="background-color: white;vertical-align:top;"| Medicatietoediening is de registratie van de afzonderlijke toedieningen van het geneesmiddel aan de patiënt door de toediener (zoals een verpleegkundige of patiënt zelf), in relatie tot de gemaakte afspraken.
|-
| style="background-color: white;vertical-align:top;"| medicatiegebruik
| style="background-color: white;vertical-align:top;"| MGB
| style="background-color: white;vertical-align:top;"| Medicatiegebruik is een uitspraak over historisch, huidig of voorgenomen gebruik van een geneesmiddel<ref>Gebruik kan voorafgegaan zijn door een medicatietoediening. Registratie van gebruik na bijvoorbeeld medicatietoediening van rabiës vaccinatie of infuus ligt niet voor de hand.</ref>.
|-
| style="background-color: white;vertical-align:top;"| medicatieverbruik
| style="background-color: white;vertical-align:top;"| MVB
| style="background-color: white;vertical-align:top;"| Het verbruik is de logistieke invalshoek van het gebruik. Het beschrijft tot wanneer een patiënt heeft gedaan of nog kan doen met een (deel)voorraad geneesmiddelen<ref>Van eenmalig tot een bepaalde periode. De bouwsteen Medicatieverbruik is niet verder uitgewerkt in deze informatiestandaard.</ref>.
|-
| style="background-color: white;vertical-align:top;"| voorstel medicatieafspraak
| style="background-color: white;vertical-align:top;"| VMA
| style="background-color: white;vertical-align:top;"| Het voorstel medicatieafspraak is een advies of verzoek van de apotheker of de patiënt aan de voorschrijver over de afgesproken medicatie. Het adviesverzoek kan bijvoorbeeld inhouden medicatie te evalueren, te stoppen, te starten of te wijzigen.
|-
| style="background-color: white;vertical-align:top;"| antwoord voorstel medicatieafspraak
| style="background-color: white;vertical-align:top;"| AVMA
| style="background-color: white;vertical-align:top;"| Het antwoord voorstel medicatieafspraak is een antwoord van de voorschrijver op de voorstel medicatieafspraak. Hierin geeft de voorschrijver aan akkoord te gaan (waarna een (aangepaste) medicatieafspraak zal volgen) of niet (en de reden daarvoor).
|-
| style="background-color: white;vertical-align:top;"| voorstel verstrekkingsverzoek
| style="background-color: white;vertical-align:top;"| VVV
| style="background-color: white;vertical-align:top;"| Het voorstel verstrekkingsverzoek is een voorstel van de apotheker aan de voorschrijver om (een) medicatieverstrekking(en) te fiatteren ten behoeve van geldende medicatieafspr(a)ak(en). Dit is vergelijkbaar met de huidige situatie van het aanbieden van het autorisatieformulier of verzamelrecept of het ter ondertekening aanbieden van een herhaalrecept. Ook de patiënt kan een voorstel verstrekkingsverzoek indienen bij de voorschrijver.
|-
| style="background-color: white;vertical-align:top;"| antwoord voorstel verstrekkingsverzoek
| style="background-color: white;vertical-align:top;"| AVVV
| style="background-color: white;vertical-align:top;"| Het antwoord voorstel verstrekkingsverzoek is een antwoord van de voorschrijver op het voorstel verstrekkingsverzoek. Hierin geeft de voorschrijver aan akkoord te gaan (waarna een verstrekkingsverzoek zal volgen) of niet (en de reden daarvoor).
|}Tabel 1 Bouwstenen – beschrijving

===Medicatieoverzicht===
Zie [[#Medicatieoverzicht en afleidingsregels|hoofdstuk 5]] voor meer informatie over deze overzichten, welke bouwstenen daarbij van toepassing zijn en hoe een medicatieprofiel/actueel overzicht kan worden samengesteld.

===Medicamenteuze behandeling===
De verschillende medicatiebouwstenen representeren stappen in het medicatieproces, van het voorschrijven van een geneesmiddel (medicatieafspraak en/of verstrekkingsverzoek), gevolgd door het ter hand stellen (toedieningsafspraak en/of medicatieverstrekking) tot en met het toedienen en gebruik. Het model is zo ingericht dat therapeutische bouwstenen en logistieke bouwstenen van elkaar gescheiden zijn. 
'''Scope''' 
Om de onderlinge samenhang tussen de medicatiebouwstenen te kunnen benoemen, is het begrip ‘medicamenteuze behandeling’ geïntroduceerd. 
:''Medicamenteuze behandeling is in de informatiestandaard een '''technisch begrip'''. Het heeft als doel om: 
:#'' de verzameling van samenhangende medicatiebouwstenen eenduidig te identificeren, en'' 
:#'' regels op toe te passen waarmee de actuele situatie eenduidig wordt bepaald.''
 
De functionele toepassing van het begrip medicamenteuze behandeling is als volgt:
*Het starten van medicatie (c.q. medicamenteuze behandeling) wordt gedaan door het maken van een eerste medicatieafspraak binnen een nieuwe medicamenteuze behandeling.
*Het stoppen van medicatie (c.q. medicamenteuze behandeling) gebeurt door een nieuwe medicatieafspraak te maken binnen dezelfde medicamenteuze behandeling (een stop-medicatieafspraak).
*Het wijzigen van de medicatie (c.q. medicamenteuze behandeling) gebeurt door:
#de bestaande medicatieafspraak te stoppen en
#een nieuwe medicatieafspraak met de wijziging te maken binnen dezelfde medicamenteuze behandeling. De ingangsdatum van deze nieuwe medicatieafspraak kan ook in de toekomst liggen.

Het voorschrijven van een nieuw geneesmiddel resulteert altijd in een nieuwe medicatieafspraak. Een medicatieafspraak hoort altijd bij één medicamenteuze behandeling. Vooralsnog bepaalt het PRK-niveau (Prescriptie Kode uit de G-standaard) van het geneesmiddel of de medicatieafspraak bij een nieuwe of bestaande medicamenteuze behandeling hoort. In de toekomst wordt dit mogelijk verruimd naar SNK-niveau (Stam Naam Kode uit de G-standaard) zodat sterktewijzigingen en geneesmiddelen uit dezelfde groep niet meer leiden tot een nieuwe medicamenteuze behandeling. Een nadere beschrijving is te vinden in [[#Processtap: Maken medicatieafspraak| paragraaf 2.2.5 Processtap: Maken Medicatieafspraak]]. 
Uitzonderingen: 
*Middelen zonder PRK (een niet geneesmiddel zoals krukken of verbandmiddelen). In dit geval bepaalt het HPK niveau (Handels Product Kode uit de G-standaard) of deze tot een nieuwe medicamenteuze behandeling leidt.
*Medicatie zonder PRK (magistralen bestaan veelal uit meerdere stoffen die niet onder eenzelfde PRK vallen, deze stoffen worden afzonderlijk als ingrediënten opgenomen in de medicatieafspraak). Elk magistraal of aanpassing daarop valt onder een nieuwe medicamenteuze behandeling.
*Eigen artikelen zonder PRK (artikelen die in het interne informatiesysteem onder de 90 miljoen nummers opgeslagen staan, zoals bijvoorbeeld halve tabletten, veel gebruikte magistralen). Elk artikel of aanpassing daarop valt onder een nieuwe medicamenteuze behandeling.
*Infusen (wordt nog uitgezocht)

 
'''Voorbeelden''' 
Een vijftal voorbeelden lichten de reikwijdte van een medicamenteuze behandeling toe: 
*Diazepam 5 mg 4x daags 1 tablet wordt gewijzigd naar diazepam 5 mg 3x daags 1 tablet. Het PRK van beide middelen is gelijk, ze vallen beide onder dezelfde medicamenteuze behandeling.
*Paroxetine tablet 10 mg 1 maal per dag 1 tablet wordt gewijzigd naar paroxetine tablet 20 mg 1 maal per dag 1 tablet. Het betreft hierbij een wijziging van een medicatieafspraak met twee verschillende geneesmiddelen op PRK-niveau. Bij deze wijziging dient dus de eerste medicamenteuze behandeling te worden beëindigd en een nieuwe medicamenteuze behandeling te worden gestart.
*Uit voorzorg is een maagbeschermer afgesproken bij een behandeling met prednison: prednison en maagbeschermer zijn hier twee verschillende geneesmiddelen, die parallel aan elkaar lopen en apart van elkaar gewijzigd en gestopt kunnen worden. Daarmee vallen zij niet onder dezelfde medicamenteuze behandeling.
*Het wisselen van bètablokker naar een ACE-remmer betekent een andere PRK en wordt dan ook ingevuld met het stoppen van de medicamenteuze behandeling van de bètablokker én het starten van een nieuwe medicamenteuze behandeling voor de ACE-remmer.
*Wanneer er geen PRK is en de samenstelling van de geneesmiddelen in de medicatieafspraak verandert (elke wijziging in de ingrediënten), wordt de bestaande medicamenteuze behandeling beëindigd en wordt een nieuwe medicamenteuze behandeling gestart. Dit geldt bijvoorbeeld voor magistralen, infusen en eigen artikelen.

 
'''Ontstaan medicamenteuze behandeling''' 
In onderstaande figuur is het ontstaan van de medicamenteuze behandeling (MBH) schematisch weergegeven. Bij het ontstaan van een nieuwe bouwsteen (MA, TA, VV, MVE, MTD of MGB) wordt eerst gecontroleerd of het nieuwe medicatie betreft of dat er al een bouwsteen met hetzelfde product bestaat en actueel is. Hiervoor worden zowel de eigen als andermans bouwstenen beschouwd. In de meeste informatiesystemen zal de gebruiker van het informatiesysteem aangeven een wijziging te willen uitvoeren op één van de bestaande medicatiebouwstenen of nieuwe medicatie op te willen voeren. In dat geval is het eenvoudig om te ontdekken of er al een medicamenteuze behandeling is waar de bouwsteen bij hoort.
*Wanneer er geen bestaande bouwsteen voor deze medicatie is dan wordt een nieuwe bouwsteen gemaakt met een nieuwe medicamenteuze behandeling.
*Wanneer er een bouwsteen bestaat met een medicamenteuze behandeling dan wordt de gebruiker van het informatiesysteem gevraagd of de nieuwe bouwsteen en de bestaande bouwsteen bij dezelfde behandeling horen. Wanneer dit het geval is dan wordt dezelfde medicamenteuze behandeling gebruikt. Wanneer de bouwstenen niet bij dezelfde behandeling horen dan wordt een nieuwe medicamenteuze behandeling gemaakt.
{{anchor|figuur 2}}
[[Bestand:Ontstaan_MBH.png|500px|Figuur 2 Ontstaan medicamenteuze behandeling]]

 
'''Parallelle medicatieafspraken''' 
Binnen een medicamenteuze behandeling kunnen meerdere medicatieafspraken gelijktijdig actueel zijn. Dit zijn alle medicatieafspraken die op dit moment geldig zijn (“huidig”) of in de toekomst geldig worden. Binnen een medicamenteuze behandeling is in principe op enig moment één medicatieafspraak geldig. Maar er is een aantal situaties waarin parallelle medicatieafspraken denkbaar zijn:
#Zelfde geneesmiddel, andere sterkte waarbij eigenlijk in één afspraak de totale sterkte voorgeschreven wordt.
#Aan elkaar gerelateerde (andere) geneesmiddelen die samen gegeven worden en je ook als één geheel wilt beschouwen bij evaluatie van de therapie.
#Technische omissies in informatiesystemen bij bijvoorbeeld complexe doseerschema’s of combinatie-infusen.
'''Situatie 1''' kan worden opgelost door op een hoger niveau (SNK) voor te schrijven. G-standaard/Zindex werkt hieraan, maar dit is nog niet mogelijk. Tot die tijd wordt gekozen voor het combineren van 1 of meer producten in dezelfde medicatieafspraak door de producten als ingrediënt op te nemen. Dit is vergelijkbaar met magistrale producten. De gebruiksinstructie voor al deze producten moet dan wel identiek zijn.<ref>In de praktijk worden vaak meerdere medicatieafspraken (met verschillende PRK's) gecombineerd tot één product in plaats van één medicatieafspraak met daaronder de samenstelling.</ref> 
'''Situatie 2''' wordt in informatiesystemen op verschillende wijze opgelost, met eigen groeperingsmechanismen. Het betreft hier het relateren van verschillende medicamenteuze behandelingen. De informatiestandaard laat dit vrij en heeft hiervoor dus geen universeel groeperingsmechanisme. 
'''Situatie 3''' is de enige situatie waarin parallelle medicatieafspraken onder één medicamenteuze behandeling toegestaan zijn. Complexe op- en afbouwschema’s en combinatie infusen kunnen in één medicatieafspraak worden opgenomen maar niet alle informatiesystemen ondersteunen dit. Voor die informatiesystemen is het toegestaan om parallelle medicatieafspraken in één medicamenteuze behandeling te maken.

===Samenhang tussen de bouwstenen en medicamenteuze behandeling===
In onderstaande figuur is de samenhang tussen de bouwstenen en de medicamenteuze behandeling schematisch weergegeven. Hier volgt een beschrijving van de relaties tussen de bouwstenen onderling en met medicamenteuze behandeling:
*De bouwstenen horen bij één medicamenteuze behandeling. Een medicamenteuze behandeling heeft tenminste één medicatieafspraak en kan 0 of meer van de bouwstenen verstrekkingsverzoeken, wisselend doseerschema's, toedieningsafspraken, medicatieverstrekkingen, gebruik en medicatietoediening hebben. Tenzij bijvoorbeeld zelfmedicatie met gebruik is vastgelegd of er een papieren recept is aangeleverd, dan kan een medicamenteuze behandeling bestaan zonder medicatieafspraak, maar met medicatiegebruik, medicatietoediening of een toedieningsafspraak. Een MBH blijft altijd bestaan, het kan alleen zijn dat hij niet meer effectief is, omdat er geen actuele bouwstenen meer onder hangen. Een voorstel medicatieafspraak, antwoord voorstel medicatieafspraak, voorstel verstrekkingsverzoek en antwoord voorstel verstrekkingsverzoek vallen nog buiten de medicamenteuze behandeling omdat het gaat om een concept/voorstel dat al dan niet leidt tot een definitieve medicatieafspraak of verstrekkingsverzoek met een relatie naar een medicamenteuze behandeling. Een voorstel medicatieafspraak kan leiden tot nul (wanneer het advies niet opgevolgd wordt), één of meerdere medicatieafspraken en een voorstel verstrekkingsverzoek kan leiden tot nul (wanneer het voorstel niet gehonoreerd wordt), één of meerdere verstrekkingsverzoeken.
*Een MBH kan ook alleen een stop-MA hebben naast bijvoorbeeld een gebruiksbouwsteen. Bijvoorbeeld in het geval dat de zorgverlener de patiënt verzoekt om het gebruik van een vrij verkrijgbaar geneesmiddel (ook wel zelfzorgmedicatie of Over-The-Counter (OTC) medicatie genoemd) te stoppen. Dan legt de zorgverlener het gebruik van de zelfzorgmedicatie vast in een gebruiksbouwsteen en stopt het gebruik door het maken van een stop-afspraak (stop-MA die onder dezelfde MBH hangt).
*Een MA kan verwijzen naar de vorige MA of een TA of MGB waarop deze gebaseerd is. Dit mag ook een MA, TA of MGB onder een andere medicamenteuze behandeling zijn. Het kan zijn dat er geen digitale MA beschikbaar is (bijvoorbeeld [[#Papieren recept|Papieren recept (paragraaf 4.1.17)]]), deze MA moet dan worden aangemaakt. Die MA mag verwijzen naar de TA of MGB. Een apotheker is nooit de bron van een MA; hij kan wel een kopie hebben.
*Binnen een medicamenteuze behandeling is in principe op enig moment één medicatieafspraak geldig. Alleen vanwege technische omissies in informatiesystemen bij bijvoorbeeld complexe doseerschema’s of combinatie-infusen, zijn parallelle medicatieafspraken toegestaan (zie ook vorige paragraaf).
*Een medicatieafspraak wordt ondersteund door nul (wanneer er nog voldoende voorraad is of wanneer er geen medicatieverstrekking nodig is), één of meerdere (wanneer er bijvoorbeeld sprake is van doorlopende medicatie) verstrekkingsverzoeken.
*Een verstrekkingsverzoek is gebaseerd op de actuele medicatieafspraken en eventueel reeds bestaande bijbehorende toedieningsafspraken in een behandeling. Dit kunnen er meerdere zijn.
*Een verstrekkingsverzoek verwijst naar één of meerdere MA’s (bij bijvoorbeeld een tussentijdse doseringsverhoging kan er een Verstrekkingsverzoek gedaan worden die zowel de voorraad voor de bestaande MA aanvult als de voorraad voor de toekomstige MA start).
*Een verstrekkingsverzoek kan resulteren in nul (bijvoorbeeld wanneer de patiënt de medicatie niet afhaalt) tot meerdere medicatieverstrekkingen.
*Een medicatieafspraak kan leiden tot nul, één of meerdere wisselend doseerschema’s.
*Er kunnen meerdere (evt. parallelle) toedieningsafspraken gebaseerd zijn op dezelfde medicatieafspraak (bijvoorbeeld wanneer een apotheker wisselt van handelsproduct of wanneer het geneesmiddel geleverd wordt in twee of meer geneesmiddelen met andere sterkte waarbij de totale sterkte gelijk blijft). Wanneer er een papieren recept wordt aangeleverd en de medicatieafspraak en het verstrekkingsverzoek niet digitaal beschikbaar zijn, is er een toedieningsafspraak zonder medicatieafspraak.
*Een medicatieafspraak hoeft niet altijd te leiden tot een toedieningsafspraak. Bijvoorbeeld wanneer er geen verstrekkingsverzoek nodig is bij een MA met korte gebruiksperiode, waarbij de patiënt nog voldoende voorraad heeft.
*Een toedieningsafspraak wordt ondersteund door nul (wanneer er voldoende voorraad is), één of meerdere medicatieverstrekkingen.
*Een medicatieverstrekking is gebaseerd op een medicatieafspraak (en een toedieningsafspraak) en in de ambulante situatie op een verstrekkingsverzoek. De uitzondering hierop is de verkoop ten behoeve van zelfzorgmedicatie: deze heeft geen medicatieafspraak en geen verstrekkingsverzoek. Zelfzorgmedicatie verstrekt door de apotheker kan wel door die apotheker worden vastgelegd als toedieningsafspraak met medicatieverstrekking of door een willekeurige zorgverlener of de patiënt zelf als gebruik.
*Een medicatieverstrekking kan meerdere toedieningsafspraken ondersteunen.
*Een medicatie- of toedieningsafspraak kan opgevolgd worden door een nieuwe medicatie- of toedieningsafspraak. Dit kan het geval zijn bij een wijziging van de bestaande medicatie (wijziging MA en/of TA) of bij het stoppen van het medicatiegebruik (stoppen MA/TA).

{{anchor|figuur 2}}
[[Image: Datamodel_MP92.PNG|800px|Figuur 2 - Datamodel Medicatieproces]]

===Informeren en (actief) beschikbaar stellen===
[[#Medicatieproces|Hoofdstuk 2]] beschrijft het medicatieproces. Daarbij zijn processtappen opgenomen met de tekst 'Informeren' of '(Actief) beschikbaar stellen'. Onderstaande tabel bevat een nadere omschrijving van de betekenis hiervan. In [[#Medicatieproces|hoofdstuk 2]] is verder uitgewerkt in welke situatie er sprake is van actief versturen danwel beschikbaar stellen.

{{anchor|tabel 2}}
{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| Term
! style="text-align:left;"| Toelichting
|-
| style="background-color: white;vertical-align:top;"| Informeren
| style="background-color: white;vertical-align:top;"| Informeren betekent het geadresseerd sturen van een opdracht of verzoek aan een andere actor. Het gaat hier om een zogenaamde 'push' van informatie: de actor stuurt de informatie gericht naar de ander. Dit kan bijvoorbeeld met
*een elektronisch bericht via een digitaal netwerk,
*papier (bijvoorbeeld door een recept bestemd voor een apotheker mee te geven met de patiënt),
*een fax,
*een combinatie van bovengenoemde opties.
|-
| style="background-color: white;vertical-align:top;"| (Actief) beschikbaar stellen
| style="background-color: white;vertical-align:top;"| De zorgverlener stelt de informatie (actief) beschikbaar voor een andere actor. Het gaat in deze processtap om:
*actief versturen ofwel informeren (‘push’) zoals hierboven beschreven of
*geautomatiseerd beschikbaar stellen aan zorgverleners en/of de patiënt wanneer deze daarom vragen op basis van vooraf verleende toestemming of
*een combinatie van beide voorgaande bullets.
Gegevens worden altijd beschikbaar gesteld en daarnaast heeft de zorgverlener de keus om medebehandelaars en/of de patiënt op enig moment in het proces ook geadresseerd te informeren. Gegevens kunnen in overleg met de patiënt naar een door de patiënt gewenste zorgverlener worden verstuurd (informeren).
|} Tabel 2 Informeren versus (Actief) beschikbaarstellen

Het technisch mechanisme (‘pull’, ‘publish and subscribe’, ‘push’, etc.) waarmee gegevens (actief) beschikbaar worden gesteld is infrastructuur afhankelijk en daarom niet in dit document uitgewerkt.

Artsenfederatie KNMG beschrijft in zijn publicatie “Van wet naar praktijk: implementatie van de WGBO Deel 4. Toegang tot patiëntengegevens” wanneer er sprake is van veronderstelde toestemming en expliciete toestemming. Op de uitwisseling beschreven in deze informatiestandaard zijn de vigerende wettelijke kaders en richtlijnen rond toestemming en opt-in van toepassing en derhalve niet expliciet beschreven.

==Legenda/Uitleg==
Een handleiding bij deze Nictiz wiki documentatie is te vinden op: 
http://informatiestandaarden.nictiz.nl/wiki/Handleiding_Wiki_documentatie 
Daarin is ook een legenda opgenomen bij de verschillende diagrammen die in dit document voorkomen.

=Medicatieproces=
Dit hoofdstuk beschrijft het medicatieproces in relatie tot de bouwstenen voor zowel de 1e, 2e als 3e lijnszorg. In de kern is het proces in al deze lijnen hetzelfde. Het belangrijkste verschil is welke apotheek de medicatie levert: de openbare apotheek (incl. poliklinische apotheek) of de ziekenhuisapotheek. 
Daarnaast is het verschil dat in de ambulante setting een verstrekkingsverzoek nodig is om medicijnen geleverd te krijgen. In de klinische setting is dit niet nodig: de (ziekenhuis)apotheker zorgt dat de medicijnen er zijn zolang de medicatieafspraak loopt.

Het medicatieproces is een cyclisch proces dat bestaat uit voorschrijven, ter hand stellen, toedienen en gebruiken. Het proces start op het moment dat de patiënt/cliënt bij de zorgaanbieder (huisarts, ziekenhuis of andere instelling) komt voor een behandeling met een geneesmiddel en eindigt wanneer de medicatie niet meer gebruikt hoeft te worden. Het proces is weergegeven in onderstaande figuur. De gele balk betreft het proces van medicatieverificatie, groen voorschrijven, paars ter hand stellen, oranje toedienen en gebruiken. De blauwe balk geeft het ontvangen of opvragen van beschikbaar gestelde gegevens aan, dit kan in elk van de deelprocessen plaats vinden. Een verdere uitwerking hiervan is in het vervolg van dit hoofdstuk bij het betreffende deelproces beschreven. 
In de volgende paragrafen zijn de processen medicatieverificatie, voorschrijven, ter hand stellen, toedienen en gebruiken beschreven.

{{anchor|figuur 3}}
[[Bestand:ActiviteitendiagramMP.png|1600px|Figuur 3 Activiteitendiagram - Medicatieproces algemeen]] 

==Proces: medicatieverificatie==
Voorafgaande aan het proces van voorschrijven wordt het werkelijke medicatiegebruik van de patiënt vastgesteld. Dit gebeurt<ref>De patiënt kan ook zijn eigen medicatie verifiëren. Hij legt dan gebruik vast, zie [[#Vastleggen medicatiegebruik door de patiënt|paragraaf 2.5.4.1]].</ref>:
*in de huisartsenpraktijk door de huisarts tijdens het consult,
*op de huisartsenpost, SEH (Spoedeisende Hulp), crisisdienst GGZ (Geestelijke gezondheidszorg) door bijvoorbeeld de triagist of de behandelaar zelf, zo snel mogelijk, bij aankomst of opname,
*bij klinische of dagopname in een ziekenhuis of andere instellingen door bijvoorbeeld de verpleging, apothekersassistent of poliklinische/ziekenhuisapotheker,
*bij poliklinisch consult door bijvoorbeeld de verpleging, doktersassistent of behandelaar zelf.

===Huidige situatie===
*In de huidige situatie wordt aan de patiënt of de familie/mantelzorgers gevraagd welke medicatie zij gebruiken. Soms is de patiënt niet in staat om hier antwoord op te geven. Familie/mantelzorgers (indien bekend) kunnen hier vaak ook geen antwoord op geven. De arts neemt dan contact op met huisarts of apotheek om de medicatie te achterhalen. Buiten kantooruren en in het weekend lukt dit slecht.

===Preconditie===
De patiënt komt op (poliklinisch) consult of wordt (in de toekomst) opgenomen.

===Trigger event===
*Ambulante setting: consult van en/of voorschrijven aan ambulante patiënten en patiënten die in een andere zorginstelling<ref>Het gaat om patiënten uit een verpleeghuis of GGZ-instelling die naar de polikliniek van een ziekenhuis gaan.</ref> verblijven. Medicatieverificatie gebeurt dan vaak tijdens het evalueren van de behandeling (zie [[#Processtap: Evalueren (medicamenteuze) behandeling|paragraaf 2.2.4]]).
*Klinische setting: voorbereiding bij opname van patiënt.

===Proces===
De zorgverlener verzamelt de medicatiegegevens uit verschillende bronnen. Bronnen kunnen zijn:
*verhaal van patiënt,
*afleveroverzichten van apotheken,
*digitaal beschikbare medicatiegegevens van zorgverleners of PGO (Persoonlijke GezondheidsOmgeving),
*meegenomen medicatie,
*indien nodig telefonische informatie van eigen apotheker of huisarts.

De zorgverlener voert de medicatieverificatie uit met de patiënt en legt daarbij de geverifieerde medicatie als medicatiegebruik (MGB, incl. zelfzorgmedicatie) vast. Er ontstaat een geactualiseerd medicatieprofiel; zie ook [[#paragraaf5.1|paragraaf 5.1]].

In de praktijk zal alleen wanneer dit klinisch relevant is de medicatieverificatie leiden tot het vastleggen van gebruik en het actualiseren van het medicatieprofiel. Hierbij kan vooral gedacht worden aan opname en ontslag. 
De vastgelegde gegevens rond medicatiegebruik worden ter beschikking gesteld voor medebehandelaars en patiënt zodat deze de gegevens kunnen opvragen.

===Postconditie===
Het medicatiegebruik van de patiënt is vastgelegd. Medicatiegegevens (gebruik) zijn beschikbaar gesteld.

===Informatiesystemen en transactiegroepen===
[[#Systemen en transacties|Hoofdstuk 7]] geeft een overzicht van alle informatiesystemen, systeemrollen, transacties, etc. De belangrijkste voor het proces van medicatieverificatie zijn in onderstaand overzicht opgenomen.

{{anchor|figuur 4}}
[[Bestand:Medicatieverificatie.png|Figuur 4 Processtappen en transacties - medicatieverificatie]]

==Proces: voorschrijven==
Deze paragraaf beschrijft het proces van voorschrijven. Het gaat hierbij om alle voorschrijvers; denk bijvoorbeeld aan: huisarts, specialist, andere arts of specialistisch verpleegkundige met een voorschrijfbevoegdheid. Het proces van voorschrijven bestaat uit het evalueren van de eventueel reeds bestaande medicamenteuze behandeling. Zo nodig wordt er een medicatieafspraak gemaakt en, alleen in de ambulante situatie, eventueel een verstrekkingsverzoek. Ten slotte worden de vastgelegde gegevens (actief) beschikbaar gesteld. Voor een plaat van dit proces zie [[#Bijlage: Diagram Medicatieproces algemeen|hoofdstuk 13]].

===Huidige situatie===
Afwijkingen in de huidige situatie (ten opzicht van de gewenste) betreffen:
*Het logistieke proces bepaalt vaak de registratie (en zeker de communicatie). Het wijzigen en stoppen van medicatie wordt onvoldoende vastgelegd en/of gecommuniceerd. Dit leidt onder andere tot onnauwkeurige medicatiebewaking, onjuist gebruik en onjuiste medicatieprofielen. In plaats van het logistieke proces zou het farmacotherapeutisch beleid bepalend moeten zijn.
*Doordat de therapeutische intentie niet gecommuniceerd wordt naar de apotheker, is uit de beschikbare gegevens niet af te leiden of een aanvraag voor een herhaalrecept binnen die therapeutische intentie valt. Hierdoor kan onterecht een geneesmiddel hervat of gecontinueerd worden.
*Wanneer een wijziging niet wordt gecommuniceerd kan een aanvraag voor een herhaalrecept (via de apotheker) gebaseerd zijn op een verouderde gebruiksinstructie. Dit kan gemakkelijk leiden tot fouten.
*Vanuit de poliklinische setting wordt een medicatieafspraak en/of een verstrekkingsverzoek nu meestal niet (elektronisch) verstuurd naar de apotheker.

===Preconditie===
Er is een bepaalde reden waarom een voorschrijver een medicamenteuze behandeling wil starten of evalueren/herzien.

===Trigger event===
De trigger voor het proces is het starten van een nieuwe medicamenteuze behandeling of evalueren van een lopende behandeling of het ontvangen van een voorstel verstrekkingsverzoek of voorstel medicatieafspraak of het ontvangen van een afhandeling voorschrift van een apotheker of opname in of ontslag van een patiënt uit een instelling.

===Processtap: Evalueren (medicamenteuze) behandeling===
Om de behandeling te kunnen evalueren is er behoefte aan een actueel overzicht van medicatiegegevens. Het dossier van de zorgverlener wordt zo mogelijk en indien nodig aangevuld met gegevens uit externe bronnen en eventueel wordt aan de patiënt gevraagd welke geneesmiddelen hij gebruikt. Dit gebruik kan door de zorgverlener worden vastgelegd. Desgewenst vindt er eerst uitgebreidere medicatieverificatie plaats (zie [[#Proces: medicatieverificatie|paragraaf 2.1]]).

De behandelend arts<ref>Hiertoe behoren alle zorgverleners die bevoegd zijn tot voorschrijven: naast artsen zijn dat bijvoorbeeld ook verpleegkundig specialisten en physician assistants.</ref> evalueert de (medicamenteuze) behandeling en besluit tot:
*het starten van een nieuwe medicamenteuze behandeling door het maken van een eerste medicatieafspraak en/of
*het continueren, stoppen (definitief of tijdelijk) of wijzigen van een bestaande medicatieafspraak (1 of meerdere)<ref>Bij substitutie is er sprake van het staken van de bestaande medicatieafspraak en het maken van een nieuwe medicatieafspraak onder een nieuwe medicamenteuze behandeling.</ref> en/of
*het corrigeren/annuleren van een bestaande medicatieafspraak en/of
*accorderen voorstel verstrekkingsverzoek (en antwoorden via het antwoord voorstel verstrekkingsverzoek) of voorstel medicatieafspraak.
In de volgende paragraaf worden deze situaties nader toegelicht. Zie ook [[#Medicamenteuze behandeling|paragraaf 1.3.3]] voor meer informatie over het begrip medicamenteuze behandeling. 

===Processtap: Maken medicatieafspraak===
Bij het maken van een medicatieafspraak geldt het uitgangspunt: elke wijziging wordt vastgelegd in een nieuwe medicatieafspraak.
Een wijziging wordt technisch ingevuld door het beëindigen van de bestaande medicatieafspra(a)k(en) door de stopdatum (einddatum van de gebruiksperiode) in te vullen én het maken van een nieuwe medicatieafspraak met de wijzigingen <ref>Informatiesystemen houden een audittrail bij. Bij een wijziging wordt de bestaande MA gestopt (nieuw record) en vervolgens wordt een nieuwe MA met daarin de wijziging aangemaakt (nieuw record). Door gebruik te maken van de records in de audittrail zijn er voor het stoppen van een MA in de meeste informatiesystemen geen grote aanpassingen nodig.</ref>. 
Medicatieafspraken kunnen ook gemaakt worden om te starten in de toekomst. Ze krijgen dan een gebruiksperiode met een toekomstige ingangsdatum die dus later is dan de datum van de afspraak. Een eventuele voorgaande medicatieafspraak heeft dan een stopdatum pas net voor de ingangsdatum/tijd van de toekomstige.
In de gebruiksperiode kan ook enkel een ingangsdatum aangegeven worden (zonder duur of stopdatum), dit is het geval bij doorlopende medicatie. Om verwarring te voorkomen tussen 'tot' en 'tot en met' is het meegeven van de tijd altijd verplicht bij de stopdatum. 'Tot en met' datum (bij een gehele dag) is tijdstip 23:59:59 van toepassing.

Voordat de medicatieafspraak (actief) beschikbaar wordt gesteld, vindt medicatiebewaking plaatst conform de geldende richtlijnen. Dit is onderdeel van deze processtap.

In de volgende paragrafen zijn de verschillende situaties beschreven waarin een medicatieafspraak wordt gemaakt: eerste medicatieafspraak, continueren medicatie, stoppen medicatie, tijdelijk onderbreken medicatie, wijzigen medicatie of het corrigeren/annuleren van een medicatieafspraak. Informatie over de Medicamenteuze behandeling wordt bekend verondersteld (zie [[#Medicamenteuze behandeling|paragraaf 1.3.3]]).

====''Nieuwe medicatieafspraak''====
Een nieuwe medicatieafspraak wordt gemaakt bij de start van een medicamenteuze behandeling of een wijziging daarvan. Wanneer er een nieuwe medicamenteuze behandeling gestart wordt dient de voorschrijver te overwegen of een bestaande medicamenteuze behandeling gestopt moet worden.
De beschrijving in [[#Medicamenteuze behandeling|paragraaf 1.3.3]] gaat uit van het meest gangbare proces van voorschrijven tot toedienen of gebruiken. In de overgangssituatie of bij het ontbreken van digitale gegevens kan het ook gebeuren dat een medicamenteuze behandeling systeemtechnisch gezien begint met bijvoorbeeld een toedieningsafspraak. Dit treedt bijvoorbeeld op wanneer de apotheker de medicatieafspraak met bijbehorende medicamenteuze behandeling niet digitaal heeft ontvangen. De apotheker start dan een nieuwe medicamenteuze behandeling bij het maken van de toedieningsafspraak. Dit kan met elke andere bouwsteen ook het geval zijn. Zo kan ook de patiënt bijvoorbeeld een medicamenteuze behandeling starten door het vastleggen van medicatiegebruik zonder daarbij de oorspronkelijke medicamenteuze behandeling te hebben.

====''Continueren medicatie''====
In een aantal gevallen blijft de therapeutische intentie van de voorschrijver gelijk en hoeft de medicatieafspraak niet aangepast te worden. Dit gebeurt bijvoorbeeld
*in de ambulante situatie wanneer er alleen een nieuw verstrekkingsverzoek gewenst is ingeval van een herhaling, of
*bij opname in een instelling waarbij de thuismedicatie wordt doorgebruikt, al dan niet gecombineerd met ‘Medicatie in Eigen Beheer’
In deze beide gevallen wordt de bestaande medicatieafspraak niet aangepast. 
Wanneer, bijvoorbeeld bij een opname of ontslag, sprake is van een wijziging in PRK wordt in alle gevallen de bestaande medicamenteuze behandeling beëindigd door het maken van een stop-MA (zie [[#Stoppen medicatie|Stoppen medicatie (paragraaf 2.2.5.3)]]) en een nieuwe medicamenteuze behandeling gestart (zie [[#Nieuwe medicatieafspraak|Nieuwe medicatieafspraak (paragraaf 2.2.5.1.)]]).

====''Stoppen medicatie''====
Medicatie wordt gestopt door het maken van een nieuwe medicatieafspraak (stop-MA) binnen dezelfde medicamenteuze behandeling. De reden van het stoppen wordt in deze medicatieafspraak vastgelegd. De medicatie kan per direct of in de toekomst gestopt worden. 
De nieuwe stop-medicatieafspraak is een kopie van de bestaande medicatieafspraak met:
*in de gebruiksperiode als stopdatum de datum waarop de medicatieafspraak eindigt (kan ook in de toekomst liggen),
*een stopdatum die ook moet terugkomen in de tekstuele omschrijving van de gebruiksinstructie,
*een eigen auteur,
*een eigen afspraakdatum,
*stoptype 'definitief',
*verwijzing naar de specifieke medicatieafspraak die gewijzigd wordt (toekomstige medicatieafspraken blijven bestaan). Het is niet mogelijk om een stop-MA aan te maken zonder verwijzing naar de MA die gestopt moet worden, behalve als er geen MA beschikbaar is in de MBH om naar te verwijzen. Wanneer er alleen TA('s) en/of MGB('s) beschikbaar zijn in de MBH moet de voorschrijver deze kunnen stoppen met een stop-MA zonder relatie naar MA.
Voor een medicatieafspraak waarin al direct een stopdatum is afgesproken, bijvoorbeeld in geval van een kuur, is geen aanvullende stop-MA nodig. Wanneer een medicatieafspraak met een stopdatum die nog in de toekomst ligt wordt verlengd, is dat een gewone wijziging (zie [[#Wijzigen medicatie|Wijzigen medicatie (paragraaf 2.2.5.5)]]). Een stop-MA heeft ook het stoptype 'definitief' als het een stop-MA is als gevolg van een wijziging. Bij een wijziging wordt de stop-MA opgevolgd door een nieuwe medicatieafspraak. Voor de eindgebruikers is de stop-MA als gevolg van een wijziging minder relevant. Een stop-MA als gevolg van een wijziging wordt ook wel een technische stop-MA genoemd. De user-interface dient hierbij adequaat te ondersteunen. Een voorschrijver zal hier minder behoefte aan hebben dan een apotheker die zijn logistieke proces mogelijk moet aanpassen vanwege de wijziging.

====''Tijdelijk onderbreken en hervatten van medicatie''====
Tijdelijk onderbreken is het stoppen van het medicatiegebruik gedurende een bepaalde, vooraf bekende of onbekende, periode. Tijdelijk onderbreken kan per direct of in de toekomst plaatsvinden. In de periode van onderbreken blijft de medicatie relevant voor medicatiebewaking in verband met het mogelijk hervatten in de toekomst. Tijdelijke substitutie met een ander middel is dus geen onderbreking maar daadwerkelijk stoppen van het eerste middel en het starten van een nieuwe medicamenteuze behandeling met het substituut. Tijdelijk onderbreken bestaat uit twee medicatieafspraken<ref>Dit betekent niet dat eindgebruikers ook daadwerkelijk twee afspraken moeten maken. Een gebruikersvriendelijke presentatie door het informatiesysteem is gewenst. </ref>: als start van de onderbreking wordt een medicatieafspraak (stop-MA) vastgelegd overeenkomstig de stop-MA (zie vorige paragraaf), maar met stoptype 'tijdelijk' en voor het hervatten van de medicatie wordt een nieuwe medicatieafspraak (met eventueel reden van hervatting) vastgelegd. Al deze medicatieafspraken vallen onder dezelfde medicamenteuze behandeling. De reden van de onderbreking wordt in de stop-MA vastgelegd. De stop-MA verwijst naar de originele medicatieafspraak om deze tijdelijk te onderbreken. Het stoptype voor het tijdelijk onderbreken van medicatie is 'tijdelijk'.

====''Wijzigen medicatie''====
Het wijzigen van een medicatieafspraak kan onder andere betrekking hebben op:
:a) de dosering,
:b) de sterkte van het geneesmiddel,
:c) toedieningswijze,
:d) de duur (bijvoorbeeld een verlenging van de therapie);
:e) de verantwoordelijk voorschrijver.
Bij een overstap naar een geheel ander geneesmiddel is er in principe sprake van het overstappen op een andere medicamenteuze behandeling (zie ook [[#Medicamenteuze behandeling|paragraaf 1.3.3]]). In dat geval stopt de arts de bestaande behandeling (zie [[#Stoppen medicatie|paragraaf 2.2.5.13]]) en start een nieuwe (zie [[#Nieuwe medicatieafspraak|paragraaf 2.2.5.1]]). 
Wijzigingen worden, bij gelijkblijvende PRK, vastgelegd onder dezelfde medicamenteuze behandeling. Bij een wijziging wordt er een technische stop-MA gemaakt (zie [[#Stoppen medicatie|paragraaf 2.2.5.3]]) en een nieuwe medicatieafspraak met de wijziging. De afspraak datum van de technisch stop-MA en de nieuwe medicatieafspraak moeten altijd hetzelfde zijn. In de nieuwe medicatieafspraak wordt de reden van de wijziging opgenomen en (zo mogelijk) een verwijzing naar de oorspronkelijke medicatieafspraak. Wijzigingen kunnen per direct of in de toekomst ingaan. Een technische stop-MA en bijbehorende nieuwe medicatieafspraak worden gelijktijdig ter beschikking gesteld.
Ingeval van het verlengen van een medicatieafspraak waarvan de duur al is verlopen of de ingevulde stopdatum al voorbij is, dan wordt dit niet gezien als een wijziging (een stop-MA op de reeds automatisch gestopte medicatieafspraak is overbodig). In dit geval kan er onder de betreffende medicamenteuze behandeling een nieuwe MA worden gemaakt.

====''Corrigeren / annuleren medicatieafspraak''<ref>Het corrigeren/annuleren van toedieningsafspraken vindt op gelijke wijze plaats.
XIS is een generieke term voor een willekeurig (zorg)informatiesysteem. PGO=Persoonlijke GezondheidsOmgeving.</ref>====
Dit betreft het corrigeren of annuleren van een medicatieafspraak omdat een voorschrijver een fout maakte. Dit kan ontdekt zijn door de voorschrijver zelf of door een medebehandelaar. 
Bijvoorbeeld een arts die een typefout maakt in de dosering van een medicatieafspraak: 2 maal daags 10 inhalaties in plaats van 2 maal daags 1 inhalatie. Indien de medicatieafspraak nog niet gedeeld is met andere zorgverleners, dan kan de voorschrijver die medicatieafspraak zelf aanpassen of schrappen (annuleren) uit het eigen informatiesysteem. Indien de afspraak al wel gedeeld is met andere zorgverleners dan stopt hij deze foutieve medicatieafspraak met een stop-MA en als reden 'foutieve registratie' en maakt een nieuwe medicatieafspraak onder dezelfde medicamenteuze behandeling met de juiste informatie. De arts informeert de apotheker en eventuele medebehandelaren actief hierover en stelt de stop-MA en nieuwe medicatieafspraak beschikbaar (zie [[#Processtap: (Actief) beschikbaarstellen|paragraaf 2.2.10]]).

====''Stoppen toekomstige medicatieafspraak''====
Dit betreft alleen medicatieafspraken waarvan de startdatum in de toekomst ligt. Een voorschrijver kan deze toekomstige MA om wat voor reden dan ook willen beëindigen. Hiervoor wordt geen stop-MA aangemaakt maar annuleert de voorschrijver de toekomstige MA. Dit doet de voorschrijver door gebruik te maken van de geannuleerd indicator. Hier kan de voorschrijver alleen gebruik van maken als de startdatum van de MA in toekomst ligt. Als deze voorschrijver de toekomstige MA wil beëindigen dan verandert hij/zij de status van de originele MA naar ‘geannuleerd’. Hier wordt dan dus geen gebruik meer gemaakt van de stop-MA.

In het scenario waarbij niet de originele voorschrijver van de MA maar een andere voorschrijver de toekomstige MA wil beëindigen werkt het proces op de volgende manier. Deze voorschrijver maakt een nieuwe MA aan met daarin geannuleerd indicator geactiveerd. Deze ‘geannuleerd-MA’ stuurt de voorschrijver op naar de originele voorschrijver van de MA. De originele voorschrijver van de MA wijzigt dan ook in de originele MA de status naar geannuleerd.

===Processtap: Maken wisselend doseerschema===
Als een voorschrijver medicatie met een wisselend doseerschema voorschrijft, kan de dosering van deze medicatie tussentijds aangepast worden door een (andere) voorschrijver, zonder dat de medicatieafspraak iedere keer gewijzigd moet worden. Dit is het geval bij antistollingsmedicatie. Bij deze medicatie bepaalt de voorschrijver de therapeutische INR-range (International Normalized Ratio, maat voor de stollingstijd van het bloed) waarbinnen de behandeling plaats dient te vinden.
De invulling van de wisselende doseerschema’s wordt gedaan door de trombosedienst. Het doseerschema wordt in de medicatiebouwsteen wisselend doseerschema (WDS) ingevuld door een voorschrijver, vaak de trombosearts. De voorschrijvend arts, die de medicatieafspraak heeft gemaakt, blijft verantwoordelijk voor de verstrekkingsverzoeken, de trombosearts stelt het specifieke doseerschema op binnen de afgesproken INR-range en op basis van de gemeten INR-waarde. 

====Opstarten wisselend doseerschema ====
De voorschrijver schrijft antistollingsmedicatie voor en geeft in de medicatieafspraak aan:
* Welk geneesmiddel (PRK) de patiënt voorgeschreven krijgt. In het wisselend doseerschema is altijd hetzelfde geneesmiddel opgenomen als in de medicatieafspraak.
* Dat de medicatie wordt gebruikt volgens schema trombosedienst. Dit wordt geregistreerd onder ‘aanvullende instructie’, er wordt in de medicatieafspraak dus geen doseerschema opgenomen;
* Binnen welke INR-range de behandeling plaats dient te vinden (in ‘toelichting’)
Om de periode tot de trombosezorg betrokken is te overbruggen, maakt de voorschrijver een eerste wisselend doseerschema aan voor de eerste periode (vaak tussen de 4 en 7 dagen). Na aanmelding bij de trombosedienst, wordt meestal een controledatum afgesproken waarbij de INR-waarde gemeten wordt. Op basis van de INR-waarde en/ of de professionele inschatting van de trombosearts stelt de trombosedienst een doseerschema op dat het schema van de voorschrijver wijzigt of opvolgt. Vanaf dit moment neemt de trombosedienst het opstellen van de doseerschema’s over van de oorspronkelijke voorschrijver.

''INR-waarde bij het WDS'' 
Het wisselend doseerschema is vaak gebaseerd op een INR-waarde. Voor andere betrokkenen in de keten is het belangrijk om te kunnen achterhalen op welke waarde een bepaald wisselend doseerschema gebaseerd is. Daarom kan bij het beschikbaarstellen (of gericht sturen) van een wisselend doseerschema ook de bijbehorende INR-waarde beschikbaar gesteld worden. De INR-waarde wordt opgenomen in vrije tekst onder ‘toelichting’ in het wisselend doseerschema.

====Wijzigen wisselend doseerschema ====
Wanneer het wisselend doseerschema gebruikt wordt tot de stopdatum van het schema, kan het doseerschema opgevolgd worden door een nieuw schema. In het wisselend doseerschema staat een relatie naar de medicatieafspraak en naar het vorige wisselend doseerschema.
Het is ook mogelijk om een doseerschema tussentijds aan te passen. In dat geval sluit het informatiesysteem het huidige wisselend doseerschema af met een technische stop-WDS (niet zichtbaar voor de gebruiker). Het nieuwe wisselend doseerschema volgt daarop en heeft een reden van wijzigen en een relatie naar de medicatieafspraak en het vorige wisselend doseerschema.
Alle wijzigingen die gaan over het doseerschema, kunnen in het wisselend doseerschema opgenomen worden. Wijzigingen die gaan over het verdere behandelbeleid (bijv. het geneesmiddel, de toedieningsweg of de INR-range) worden opgenomen in de medicatieafspraak.

====Stoppen wisselend doseerschema ====
Antistollingsmedicatie kan om verschillende redenen (tijdelijk) gestopt worden. Bijvoorbeeld in geval van een ingreep, of omdat er tijdelijk sprake is van co-medicatie. Er zijn twee situaties te onderscheiden, afhankelijk van de situatie en de inschatting van de trombosearts kan voor een van beide werkwijzen gekozen worden.
# ''(tijdelijk) aanpassen van beleid:'' De trombosearts kan kiezen om de dosering voor de antistollingsmedicatie tijdelijk aan te passen naar 0. Bijvoorbeeld in aanloop naar een geplande ingreep. De medicatieafspraak (en daarmee de behandeling met antistollingsmedicatie) en de toedieningsafspraak lopen in dit geval door, maar in het wisselend doseerschema wordt de dosering tijdelijk aangepast naar 0. Op het medicatieoverzicht zal de medicatieafspraak van de antistollingsmedicatie te zien zijn onder ‘actuele medicatie’. Bij een dergelijke aanpassing in het wisselend doseerschema is het wenselijk om de reden voor deze wijziging mee te sturen.
# ''staken of stoppen antistollingsmedicatie:'' De trombosearts (of een andere voorschrijver) kan er ook voor kiezen om de behandeling met antistollingsmedicatie (tijdelijk) te stoppen. Dit betekent dat er geen dosering meer plaats mag vinden. In dat geval maakt de trombosearts een stop-MA aan (of stuurt deze een voorstel-MA aan de voorschrijver). Met het stoppen van de medicatieafspraak wordt ook het onderliggende WDS en de bijbehorende TA gestopt. Op het medicatieoverzicht zal de medicatieafspraak van de antistollingsmedicatie te zien zijn onder ‘recent gestopte medicatie’.
Als de MA na een bepaalde periode weer opgestart of gewijzigd moet worden, doet de oorspronkelijke voorschrijver van de antistollingsmedicatie dit door een nieuwe MA aan te maken. In veel gevallen is de trombosedienst ook (tijdelijk) niet meer betrokken bij de patiënt, mocht dit wel het geval zijn dan kan de trombosearts een voorstel-MA sturen naar de oorspronkelijke voorschrijver en kan deze dit voorstel overnemen in een MA.

===Processtap: Maken verstrekkingsverzoek===
Een verstrekkingsverzoek (naast een medicatieafspraak) is alleen van toepassing in de ambulante situatie. Er kan een verstrekkingsverzoek worden gedaan als de voorraad medicatie van de patiënt moet worden aangevuld. Dit hoeft niet tegelijk met een medicatieafspraak plaats te vinden. Bij de start van een medicamenteuze behandeling waarbij de patiënt nog voldoende voorraad thuis heeft van een vorige keer is een verstrekkingsverzoek niet nodig. Ook wanneer de dosering verlaagd wordt, kan de patiënt nog genoeg op voorraad hebben. Bij een geneesmiddel dat lang loopt (bijvoorbeeld een bloeddrukverlager waarbij er een doorlopende medicatieafspraak is gemaakt, dus een gebruiksperiode met enkel een ingangsdatum), kunnen er in de loop van de tijd meerdere verstrekkingsverzoeken worden gedaan onder deze bestaande medicatieafspraak. Het is ook mogelijk dat een andere voorschrijver dan degene die de medicatieafspraak heeft gemaakt, een verstrekkingsverzoek onder deze medicatieafspraak doet. 
In het verstrekkingsverzoek kunnen logistieke en urgentie aanwijzingen worden meegegeven, zoals afleverlocatie, niet opnemen in GDS (Geneesmiddel Distributie Systeem), etc.

Bij een verstrekkingsverzoek kan de te verstrekken hoeveelheid opgegeven worden óf de verbruiksperiode. Bij een verbruiksperiode moet de hoeveelheid wel eenduidig afleidbaar zijn uit de doseerinstructie van de medicatieafspraak. Let op: een verbruiksperiode einddatum heeft een andere betekenis dan de gebruiksperiode stopdatum uit de medicatieafspraak en kunnen ongelijk zijn.
* verbruiksperiode einddatum: datum tot wanneer de apotheker toestemming heeft om verstrekkingen te doen (en daarmee voldoende voorraad aan de patiënt mee te geven voor gebruik tot aan die datum).
* gebruiksperiode stopdatum: datum waarop de patiënt moet stoppen met de medicatie (deze kan gelijk zijn aan de verbruiksperiode einddatum of verder in de toekomst liggen).

===Processtap: Nierfunctiewaarde meesturen met het voorschrift ===

Voor sommige geneesmiddelen is het functioneren van de nieren van belang. De nierfunctiewaarde bepaalt dan de keuze van het geneesmiddel en/of de geneesmiddeldosering. Wettelijk is vastgelegd dat indien een beroepsbeoefenaar bij een patiënt nader onderzoek heeft laten uitvoeren naar de nierfunctie, hij afwijkende nierfunctiewaarden deelt met de daartoe door patiënt aangewezen apotheker (artikel 6.10, regeling geneesmiddelenwet).

De nierfunctiewaarde wordt altijd met het voorschrift meegestuurd (m.b.v. de bouwsteen laboratoriumuitslag) voor geneesmiddelen waarvoor dit van belang is (kenmerk in de G-standaard), zodat de apotheker goede medicatiebewaking kan uitvoeren. De nierfunctiewaarde mag niet ouder zijn dan 13 maanden, omdat bij een stabiele chronische verminderde nierfunctie de nierfunctie 1x per jaar gecontroleerd moet worden. Hier is 1 maand aan toegevoegd, zodat er voor de praktijk enige speling is.

Als op het moment van het sturen van een medicatieafspraak en/of verstrekkingsverzoek geen nierfunctie bekend is, betreft dat het voorschrijfbeleid van dat moment.
Het los sturen van de laboratoriumuitslag nierfunctiewaarde zonder medicatieafspraak en/of verstrekkingsverzoek valt buiten scope van deze informatiestandaard.

===Processtap: Lengte en gewicht meesturen in het voorschrift ===

De voorschrijver kan bij het versturen van het medicatievoorschrift ook de lichaamslengte en het lichaamsgewicht van de patiënt meesturen. Het gaat om de lengte en het gewicht dat de voorschrijver heeft aangehouden voor het bepalen van de medicatieafspraak. Deze kan dus afwijken (nauwkeuriger zijn) van de lengte of het gewicht dat algemeen is vastgelegd over de patiënt. Dit kan bijvoorbeeld gedaan worden bij het voorschrijven aan kinderen, of het voorschrijven van medicatie waarbij gewicht (bepaalde stollingsmedicatie) of lichaamsoppervlak (bijv. bij sommige oncolytica) van belang zijn.

Lichaamslengte en lichaamsgewicht zijn losse bouwstenen en kunnen alleen worden meegestuurd bij het versturen van het medicatievoorschrift en bij het versturen van een voorstel medicatieafspraak. Deze informatie is verder niet opvraagbaar.

===Processtap: (Actief) beschikbaarstellen===
In deze stap vindt informatie-uitwisseling plaats. De informatie kan met verschillende intenties gestuurd of beschikbaar gesteld worden:
:A. Als opdracht aan de apotheker om medicatie ter hand te stellen. De voorschrijver verstuurt de medicatieafspraak aan de apotheker. In de ambulante situatie wordt daarbij ook het verstrekkingsverzoek naar de apotheker van keuze van de patiënt gestuurd. Wanneer de apotheker niet bekend is kan deze processtap ook worden vervuld met een papieren recept en/of het (reactief) beschikbaarstellen van de gegevens (zie C). Wanneer de apotheker de opdracht heeft ingevuld dan ontvangt de voorschrijver daarvan bericht (zie [[#Processtap:_.28Actief.29_beschikbaarstellen_2|paragraaf 2.3.8]]).
:B. Als opdracht aan de apotheker om een wijziging in medicatie (incl. stop-MA met stoptype definitief of tijdelijk) door te voeren dat impact heeft of kan hebben op een lopende ter hand stelling van deze apotheker. Een lopende ter hand stelling houdt in dat er een opdracht (als bij A) is aangenomen die nog niet volledig is ingevuld. Er vinden bijvoorbeeld nog uitgiftes plaats of er is sprake van meerdere uitgiftes op basis van een verstrekkingsverzoek waarvan nog niet alle uitgiftes hebben plaatsgevonden. Dit komt bijvoorbeeld bij GDS voor.
:C. Het beschikbaarstellen van de medicatiegegevens (MA, WDS, VV (aan patiënt), MGB) zodat medebehandelaren en/of patiënt deze later kunnen opvragen eventueel in combinatie met ongeadresseerd voorschrijven (zie [[#Ongeadresseerd voorschrijven (ambulant)|paragraaf 9.1]]).
:D. Het geadresseerd sturen (informeren) van medicatiegegevens (één of meerdere bouwstenen) aan een andere zorgverlener op verzoek van de patiënt die bij deze zorgverlener aanwezig is of bij ontslag.

Bij gecorrigeerde gegevens schat de voorschrijver in wie hij actief op de hoogte moet stellen van deze correctie bijvoorbeeld door het sturen van de nieuwe afspraak (optie A of B hierboven) of door middel van telefonisch overleg. 
In de ambulante setting (huisarts/polikliniek) worden gegevens meestal direct gestuurd of beschikbaar gesteld, in de klinische setting meestal bij ontslag of tussentijds verlof uit de instelling. 
In dit hoofdstuk wordt uitgegaan van geadresseerd voorschrijven; in [[#Ongeadresseerd voorschrijven (ambulant)|paragraaf 7.5]] is het ongeadresseerd voorschrijven uitgewerkt. 
Zie ook [[#Informeren en (actief) beschikbaar stellen|paragraaf 1.3.5]] voor een nadere toelichting op informeren (situatie A, B, D) en beschikbaar stellen (situatie C).

===Postconditie===
*Er kan een nieuwe medicatieafspraak gemaakt zijn (starten, wijzigen of stoppen van medicatie)
*Er kan een verstrekkingsverzoek gedaan zijn (alleen ambulant)
*Er kan een opdracht gestuurd zijn naar de apotheker om een ter hand stelling uit te voeren
*Er kan een opdracht gestuurd zijn naar de apotheker om een ter hand stelling aan te passen
*Medebehandelaars en de patiënt zijn geïnformeerd of kunnen zich informeren over de nieuwe medicatiegegevens: medicatieafspraak, verstrekkingsverzoek, gebruik.

===Informatiesystemen en transactiegroepen===
Zowel de ''voorschrijver'' als de ''apotheker'' als andere ''medebehandelaars'' en ''gebruikers'' maken ieder gebruik van een informatiesysteem, respectievelijk een elektronisch voorschrijfsysteem (EVS), een apothekersinformatiesysteem (AIS, incl. ZAIS), een XIS en een PGO<ref>XIS is een generieke term voor een willekeurig (zorg)informatiesysteem. PGO=Persoonlijke GezondheidsOmgeving.</ref>. Deze informatiesystemen kennen ieder verschillende systeemrollen, die het uitwisselen van gegevens tussen deze informatiesystemen in het kader van het voorschrijfproces mogelijk maken. 
[[#Systemen en transacties|Hoofdstuk 7]] geeft een overzicht van alle informatiesystemen, systeemrollen, transacties, etc. De belangrijkste voor het proces van voorschrijven zijn in onderstaand overzicht opgenomen.

{{anchor|figuur 5}}
[[Bestand:Uc Voorschrijven.png|Figuur 5 Processtappen en transacties - voorschrijven]]

===Use cases===
De volgende specifieke use cases van voorschrijven zijn uitgewerkt:
*[[#Kortdurende_medicatie|Kortdurende medicatie (paragraaf 4.1.1)]]
*[[#Doorlopende medicatie|Doorlopende medicatie (paragraaf 4.1.2)]]
*[[#Harde stopdatum gebruiksperiode| Harde stopdatum gebruiksperiode (paragraaf 4.1.3)]]
*[[#Zo nodig medicatie|Zo nodig medicatie (paragraaf 4.1.4)]]
*[[#Kuur zo nodig startend in de toekomst|Kuur zo nodig startend in de toekomst (paragraaf 4.1.5)]]
*[[#Twee doseringen van hetzelfde geneesmiddel tegelijkertijd|Twee doseringen van hetzelfde geneesmiddel tegelijkertijd (paragraaf 4.1.6)]]
*[[#Hetzelfde geneesmiddel met verschillende sterkte tegelijkertijd|Hetzelfde geneesmiddel met verschillende sterkte tegelijkertijd (paragraaf 4.1.7)]]
*[[#Toelichting in medicatieafspraak bij bewust gekozen bijzonderheid|Toelichting in medicatieafspraak bij bewust gekozen bijzonderheid (paragraaf 4.1.8)]]
*[[#Nieuwe medicatieafspraak, geen verstrekkingsverzoek|Nieuwe medicatieafspraak, geen verstrekkingsverzoek (paragraaf 4.1.9)]]
*[[#Nieuw verstrekkingsverzoek onder bestaande medicatieafspraak|Nieuw verstrekkingsverzoek onder bestaande medicatieafspraak (paragraaf 4.1.10)]]
*[[#Wijziging in dosering (voldoende voorraad)|Wijziging in dosering (voldoende voorraad) (paragraaf 4.1.11)]]
*[[#Recept niet meer nodig na eerste verstrekkingsverzoek|Recept niet meer nodig na eerste verstrekkingsverzoek (paragraaf 4.1.12)]]
*[[#Stoppen medicatie|Stoppen medicatie (paragraaf 4.1.13)]]
*[[#Onderbreken / hervatten medicatie|Onderbreken / hervatten medicatie (paragraaf 4.1.14)]]
*[[#Onderbreken voor een ingreep|Onderbreken voor een ingreep (paragraaf 4.1.15)]]
*[[#Substitutie|Substitutie (paragraaf 4.1.16)]]
*[[#Papieren recept|Papieren recept (paragraaf 4.1.17)]]
*[[#Uitvoeren medicatieverificatie en evaluatie bij buitenlandse of zelfzorgmedicatie|Uitvoeren medicatieverificatie en evaluatie bij buitenlandse of zelfzorgmedicatie (paragraaf 4.1.18)]]
*[[#Dagbehandeling|Dagbehandeling (paragraaf 4.1.19)]]
*[[#Starten met medicatie voor opname|Starten met medicatie voor opname (paragraaf 4.1.20)]]
*[[#Spoedopname|Spoedopname (paragraaf 4.1.21)]]
*[[#Ontslag|Ontslag (paragraaf 4.1.22)]]
*[[#Tussentijds ontslag|Tussentijds ontslag (paragraaf 4.1.23)]]
*[[#Ontslag naar andere instelling|Ontslag naar andere instelling (paragraaf 4.1.24)]]
*[[#Niet verstrekken voor|Niet verstrekken voor (paragraaf 4.1.25)]]
*[[#Stoppen van medicatie door derden|Stoppen van medicatie door derden (paragraaf 4.1.26)]]
*[[#Verschillende PRKs onder dezelfde medicamenteuze behandeling|Verschillende PRKs onder dezelfde medicamenteuze behandeling (paragraaf 4.1.27)]]
*[[#Achteraf vastleggen medicatieafspraak|Achteraf vastleggen medicatieafspraak (paragraaf 4.1.28)]]
*[[#Eenmalig gebruik|Eenmalig gebruik (paragraaf 4.1.30)]]
*[[#Voorlopige en definitieve medicatieopdracht|Voorlopige en definitieve medicatieopdracht (paragraaf 4.1.31)]]
*[[#Onterecht openstaande medicatie of 'weeskinderen'|Onterecht openstaande medicatie of 'weeskinderen' (paragraaf 4.1.32)]]
*[[#Ontbreken digitale medicatieafspraak bij opname|Ontbreken digitale medicatieafspraak bij opname (paragraaf 4.1.33)]]
*[[#Eigen artikelen (90 miljoen nummers)|Eigen artikelen (90 miljoen nummers) (paragraaf 4.1.34)]]
*[[#Dosering met minimum interval|Dosering met minimum interval (paragraaf 4.1.35)]]
*[[#Verstrekkingsverzoek met aantal herhalingen|Verstrekkingsverzoek met aantal herhalingen (paragraaf 4.1.36)]]
*[[#Voorschrijven van niet geneesmiddelen (verbandmiddelen, krukken of andere hulpmiddelen)|Voorschrijven van niet geneesmiddelen (verbandmiddelen, krukken of andere hulpmiddelen) (paragraaf 4.1.37)]]
*[[#Nierfunctiewaarde sturen met het voorschrift|Nierfunctiewaarde sturen met het voorschrift (paragraaf 4.1.38)]]
*[[#Annuleren eerder verstuurd voorschrift|Annuleren eerder verstuurd voorschrift (paragraaf 4.1.39)]]
*[[#Wijzigen van andermans medicatieafspraak|Wijzigen van andermans medicatieafspraak (paragraaf 4.1.40)]]
*[[#Opstarten van een wisselend doseerschema|Opstarten van een wisselend doseerschema (paragraaf 4.1.41)]]
*[[#Tussentijds wijzigen wisselend doseerschema|Tussentijds wijzigen wisselend doseerschema (paragraaf 4.1.42)]]
*[[#Stoppen medicatie met een wisselend doseerschema|Stoppen medicatie met een wisselend doseerschema (paragraaf 4.1.43)]]

==Proces: ter hand stellen==
Deze paragraaf beschrijft het proces van het ter hand stellen, inclusief herhaling en GDS. Het proces omvat het geheel van handelingen die de apotheker uitvoert opdat de patiënt niet alleen een farmaceutisch product ontvangt, maar ook de daarbij behorende farmaceutische zorg, zodat hij het product veilig en effectief kan gebruiken. Het proces van ter hand stellen start met het uitvoeren van farmaceutische zorg. Vervolgens wordt er zo nodig een toedieningsafspraak gemaakt en vindt er (indien nodig) een verstrekking plaats. Er hoeft niet altijd een medicatieverstrekking (d.w.z uitgifte van een geneesmiddel) plaats te vinden. Dit is het geval bij sommige wijzigingen in de medicatieafspraak (bijv. dosisverlaging waarbij de patiënt nog genoeg voorraad heeft), het stoppen van de medicatie of, in de ambulante situatie, het niet afhalen van de medicatie. Wanneer de medicatieafspraak en/of het verstrekkingsverzoek niet voldoen (zie [[#Processtap: Informeren schrijver|paragraaf 2.3.5]]) wordt de voorschrijver daarover ingelicht. Ten slotte worden de vastgelegde gegevens (actief) beschikbaar gesteld. Voor een plaat van dit proces zie [[#Bijlage: Diagram Medicatieproces algemeen|hoofdstuk 13]].

Medicatiebeoordeling is het proces waarbij arts en apotheker de complete medicatie van de patiënt beschouwen tegen de achtergrond van zijn aandoening, de geldende richtlijnen voor behandeling, het welbevinden van de patiënt, etc. Medicatiebeoordeling wordt in dit document gezien als een combinatie van evalueren medicamenteuze behandeling (zoals in de vorige paragrafen beschreven) en het verlenen van farmaceutische zorg. Afhankelijk van de bevindingen worden de eerder beschreven processen van medicatieverificatie en voorschrijven doorlopen en opgevolgd door ter hand stellen.

Veel apothekers werken voor GDS samen met een andere organisatie die een deel van de logistiek van de apotheker overneemt. Daarbij is ook informatie-uitwisseling met die partij nodig. Daarnaast is niet alle medicatie 'rolgeschikt'. Dit zorgt voor extra logistieke complexiteit bij de apotheker.
De interne logistieke activiteiten en communicatie tussen de apotheker en zijn 'onderaannemer(s)' zijn buiten scope van deze informatiestandaard. Wel is geconstateerd dat met het aanbieden van de huidige bouwstenen en onderliggende dataelementen dit logistieke proces voldoende ondersteund kan worden.

===Huidige situatie===
Afwijkingen in de huidige situatie (ten opzicht van de gewenste situatie) betreffen:
*In de huidige situatie, bij GDS, ontvangen de voorschrijvend arts en andere medebehandelaars een grote hoeveelheid afleverberichten. Dit is voor deze zorgverleners moeilijk te overzien.
*In de huidige situatie is er, bij geneesmiddel distributiesystemen, communicatie tussen apothekers en huisartsen via zogenaamde autorisatielijsten. Hierbij stuurt de apotheker een overzicht van alle medicatie van de patiënt naar de huisarts om deze in zijn geheel te autoriseren. Dit is lastig voor een huisarts omdat hij dan alle medicatieafspraken opnieuw moet verifiëren. Dit zou eigenlijk ook niet nodig moeten zijn, omdat de meeste medicatieafspraken/verstrekkingsverzoeken al geautoriseerd zijn. Het is dan ook veel efficiënter voor de huisarts om alleen die medicatieafspraken/verstrekkingsverzoeken te autoriseren die ook daadwerkelijk nog geautoriseerd moeten worden. Bijvoorbeeld een nieuw verstrekkingsverzoek op basis van een bestaande medicatieafspraak.
*Een dienstapotheek informeert de vaste huisarts en vaste apotheker in de huidige situatie vaak niet over uitgevoerde terhandstellingen.
*In de huidige situatie wordt een voorstel medicatieafspraak meestal per telefoon met de voorschrijver afgestemd en/of de apotheker en voorschrijver hebben een afspraak gemaakt over de afhandeling van een medicatiebewakingssignaal.
*De bedoeling van het retourbericht is niet altijd duidelijk: in het retour-/afleverbericht is geen onderscheid te maken tussen weergave van de fysieke aflevering en het doorgeven van informatie over een aanpassing in de medicatie.
*In de huidige situatie registreren (en communiceren) apothekers soms al medicatieverstrekkingen bij het gereed maken van de medicatie voor de patiënt in plaats van bij de daadwerkelijke uitgifte aan de patiënt. Dit betekent dat er soms ten onrechte medicatieverstrekkingen zijn geregistreerd voor niet afgehaalde medicatie.

===Preconditie===
Er is een medicatieafspraak en in de ambulante situatie eventueel een bijbehorend verstrekkingsverzoek.

===Trigger event===
De apotheker start het proces van ter hand stellen op basis van één van de volgende gebeurtenissen:
*Ontvangen van een opdracht om op basis van een nieuwe medicatieafspraak een medicatieverstrekking te doen. In de ambulante situatie gaat deze opdracht altijd gepaard met een verstrekkingsverzoek.
*Ontvangen van een opdracht om een nieuwe medicatieafspraak te verwerken in een lopende ter hand stelling.
*Ontvangen van een trigger (via bijvoorbeeld patiënt of herhaalmodule van het apotheekinformatiesysteem) voor een herhaalde terhandstelling onder een bestaande of nieuw voor te stellen verstrekkingsverzoek.

===Processtap: Uitvoeren farmaceutische zorg===
Het uitvoeren van de farmaceutische zorg gebeurt door de openbare, poliklinische of ziekenhuisapotheek, afhankelijk vanuit welke zorgaanbieder de medicatieafspraak afkomstig is:
*medicatieafspraken evt. met verstrekkingsverzoek van de huisarts of specialist door de openbare of poliklinische apotheek,
*medicatieafspraken van specialisten en andere voorschrijvers in ziekenhuizen/instellingen door de ziekenhuisapotheek of de openbare apotheek die levert aan de betreffende instelling.
Medicatiebewaking is ook een onderdeel van de farmaceutische zorg.

De apotheker besluit op basis van de ontvangen medicatieafspraak of wijziging in de situatie van de patiënt hoe hij deze kan invullen door:
*het maken van een of meerdere nieuwe toedieningsafspraken,
*het continueren, definitief stoppen, tijdelijk onderbreken of wijzigen van een bestaande toedieningsafspraak,
*het afwijzen van de medicatieafspraak,
*het voorstellen van een nieuwe medicatieafspraak,
*het voorstellen van een nieuw verstrekkingsverzoek.
De laatste drie situaties zijn in de volgende paragraaf toegelicht. De eerste twee situaties zijn toegelicht in [[#Processtap: Maken toedieningsafspraak|paragraaf 2.3.6.]] 

===Processtap: Informeren voorschrijver===
Er is een aantal situaties waarin de apotheker de voorschrijver informeert waaronder:
*omdat er mogelijk een nieuwe of gewijzigde medicatieafspraak nodig is
*omdat er een nieuw verstrekkingsverzoek nodig is.
Voor meer informatie over Informeren zie [[#Informeren en (actief) beschikbaar stellen|paragraaf 1.3.5.]]

Een nieuwe of gewijzigde medicatieafspraak is nodig:
*wanneer op basis van de ontvangen medicatieafspraak geen toedieningsafspraak kan worden gemaakt omdat de apotheker een fout in de medicatieafspraak vermoedt, of
*na een medicatiebewakingssignaal als onderdeel van de farmaceutische zorg. Daaruit blijkt bijvoorbeeld dat de dosering moet worden verlaagd of verhoogd, dat het raadzaam is een ander middel te kiezen, dat een middel tijdelijk gestopt dient te worden, dat een ander middel moet worden toegevoegd, et cetera, of
*op basis van het medicatiegebruik zoals verwoord door de patiënt tijdens het uitvoeren van de farmaceutische zorg, of
*wanneer de tijdelijk onderbroken medicamenteuze behandeling mogelijk kan worden hervat.
Er wordt in deze situaties dus nog geen toedieningsafspraak gemaakt of gewijzigd. 
In deze situaties belt in eerste instantie de apotheker de voorschrijver, informeert deze over de vermoede fout en stelt een alternatief voor. De apotheker kan ook een digitaal voorstel medicatieafspraak sturen naar de voorschrijver. Hij adviseert daarin een concrete medicatieafspraak, met de aanleiding en de argumenten voor dat advies. Vervolgens kan de voorschrijver de voorstel medicatieafspraak accorderen tot een definitieve medicatieafspraak (zie ook [[#Processtap: Evalueren (medicamenteuze) behandeling|paragraaf 2.2.4]]).

Er is een nieuw verstrekkingsverzoek nodig wanneer de medicatie op of bijna op is voor de patiënt en de behandeling mogelijk moet worden voortgezet (herhaling aanvragen). De patiënt vraagt herhaling van medicatie aan bij apotheker of de patiënt heeft zich in het verleden aangemeld voor proactief herhalen en de herhaalmodule van het AIS genereert een signaal wanneer een patiënt nieuwe medicatie nodig heeft<ref>De patiënt kan ook een herhaling rechtstreeks bij de voorschrijver aanvragen: zie [[#Processtap: Informeren voorschrijver|paragraaf 2.5.6]].</ref>. 
Wanneer het bestaande verstrekkingsverzoek niet voldoet kan de apotheker dit verzoek telefonisch doorgeven of een digitaal voorstel verstrekkingsverzoek naar de voorschrijver sturen. Het voorstel verstrekkingsverzoek kan aanwijzingen bevatten voor de voorschrijver zoals urgentie. De voorschrijver ontvangt het voorstel en kan deze accorderen tot een definitief verstrekkingsverzoek. De voorschrijver informeert de verzoeker via een antwoord voorstel verstrekkingsverzoek. (zie ook [[#Processtap: Evalueren (medicamenteuze) behandeling|paragraaf 2.2.4]] en volgende).

===Processtap: Maken toedieningsafspraak===
Indien de medicatieafspraak en eventueel het bijbehorende verstrekkingsverzoek verwerkt kunnen worden dan wordt er een toedieningsafspraak gemaakt. Met het maken van een toedieningsafspraak vult de apotheker een medicatieafspraak concreet in. De toedieningsafspraak wordt gecommuniceerd met de patiënt of diens toediener. De toedieningsafspraak hoort bij dezelfde medicamenteuze behandeling als de medicatieafspraak die hij vervult. Een toedieningsafspraak kan net als de bijbehorende medicatieafspraak ook in de toekomst starten. De dosering in de toedieningsafspraak kan afwijken van die in de medicatieafspraak omdat bijvoorbeeld een bepaalde sterkte niet op voorraad is. Daarmee kan er dus ook een andere 'PRK' onder de medicamenteuze behandeling vallen wanneer bijvoorbeeld gewijzigd wordt van 1x 20 mg naar 2x 10 mg tabletten. 
Voordat de toedieningsafspraak (actief) beschikbaar wordt gesteld, vindt medicatiebewaking plaatst conform de geldende richtlijnen van ter hand stellen. Dit is onderdeel van deze processtap.

Op basis van de toedieningsafspraken kan voor o.a. de thuiszorg of de verpleging in een instelling een toedienlijst<ref>In dit document wordt met toedienlijst zowel de digitale als papieren variant bedoeld, tenzij anders aangeduid. Synoniem zijn deellijst, aftekenlijst.</ref> worden samengesteld.

Bij het maken van een toedieningsafspraak geldt hetzelfde uitgangspunt als bij de medicatieafspraak: elke wijziging wordt vastgelegd in een nieuwe toedieningsafspraak.

In de volgende paragrafen zijn de verschillende situaties beschreven waarin een toedieningsafspraak wordt gemaakt: nieuwe toedieningsafspraak of continueren, definitief stoppen, tijdelijk onderbreken of wijzigen van een bestaande toedieningsafspraak.

====''Nieuwe toedieningsafspraak''====
Bij een nieuwe medicatieafspraak wordt altijd een nieuwe toedieningsafspraak gemaakt. Een nieuwe toedieningsafspraak wordt ook gemaakt bij nieuw preferentiebeleid of een wijziging in assortiment die leidt tot de keus voor een ander geneesmiddel. 
Bij het maken van een nieuwe toedieningsafspraak houdt de apotheker onder andere rekening met:
*preferentiebeleid,
*levering in GDS-verpakking,
*beschikbaar assortiment van de instelling (‘ziekenhuisformularium’) of de apotheek zelf.

''Toedieningsafspraak bij antistollingsmedicatie'' 
Bij medicatie met een wisselend doseerschema is ook een toedieningsafspraak en/ of medicatieverstrekking nodig. Hiervoor wordt het reguliere proces gevolgd. Alleen wordt in de toedieningsafspraak, net als in de medicatieafspraak geen doseerschema opgenomen maar de aanvullende instructie: 'gebruik volgens schema trombosedienst'. Zie [[#Processtap:_Maken_wisselend_doseerschema|paragraaf 2.2.6]] voor meer informatie over het wisselend doseerschema.

====''Continueren toedieningsafspraak''====
Wanneer de bestaande medicatieafspraak en toedieningsafspraak voldoende zijn om een medicatieverstrekking te doen dan wordt de toedieningsafspraak niet aangepast.

====''Stoppen toedieningsafspraak''====
Een medicatieafspraak waarin afgesproken is om de medicatie definitief te stoppen leidt tot een stop-toedieningsafspraak onder dezelfde medicamenteuze behandeling met als stoptype 'definitief' (dit geldt ook voor de stop-MA als gevolg van een wijziging). Daarmee wordt een nieuwe medicatieverstrekking van de medicatie voorkomen. 
In de ambulante situatie kan de voorschrijver in de medicatieafspraak aangeven dat de medicatie gestopt wordt met ingang van de volgende rol (GDS). Dit kan betekenen dat de ingangsdatum van de stop-toedieningsafspraak later is dan in de oorspronkelijke stop-medicatieafspraak is aangegeven.

====''Tijdelijk onderbreken toedieningsafspraak''====
Een tijdelijk onderbreken medicatieafspraak leidt tot een stop-toedieningsafspraak (stoptype: tijdelijk). Bij hervatting wordt er een nieuwe toedieningsafspraak gemaakt. Beide toedieningsafspraken horen bij dezelfde medicamenteuze behandeling als de medicatieafspraak.

====''Wijzigen toedieningsafspraak''====
Een gewijzigde medicatieafspraak (bestaande uit een technische stop-MA en een nieuwe medicatieafspraak) leidt tot een nieuwe toedieningsafspraak onder dezelfde medicamenteuze behandeling. Net als bij de medicatieafspraak betekent een wijziging in een toedieningsafspraak het stoppen van de bestaande toedieningsafspraak (een technische stop-TA) en het maken van een nieuwe toedieningsafspraak.

===Processtap: Verstrekken===
Na het maken van de toedieningsafspraak maakt de apotheker het product gereed en levert deze af voor:
*de patiënt in de thuissituatie,
*de patiënt die is opgenomen in een ziekenhuis, verpleeghuis of andere instelling.
De apotheker registreert de medicatieverstrekking<ref>In de klinische situatie wordt eventueel vanuit de afdelingsvoorraad gehaald waarna direct toediening plaatsvindt en de toediening wordt vastgelegd.</ref>.

Levering aan patiënten:
*in de ambulante situatie gebeurt alleen op basis van een verstrekkingsverzoek of een herhaling van dat verzoek,
*in de klinische situatie gebeurt op basis van de medicatieafspraak zonder dat een verstrekkingsverzoek nodig is.

===Processtap: (Actief) beschikbaarstellen===
In deze stap vindt informatie-uitwisseling plaats. De informatie kan met verschillende intenties gestuurd of beschikbaar gesteld worden:
*Als verzoek aan de voorschrijver om een nieuwe medicatieafspraak (VMA) of verstrekkingsverzoek (VVV) te maken.
*Het informeren van de voorschrijver over de afhandeling van het voorschrift (toedieningsafspraak en/of medicatieverstrekking).
*Het beschikbaarstellen van de medicatiegegevens (toedieningsafspraak en medicatieverstrekking) zodat medebehandelaren en/of patiënt deze later kunnen opvragen.

===Postconditie===
*Er kan toedieningsafspraak zijn gemaakt.
*Er kan een medicatieverstrekking zijn gedaan en de patiënt heeft zo nodig uitleg gekregen hoe hij het geneesmiddel moet gebruiken.
*Medebehandelaars zijn op de hoogte gesteld of kunnen zich op de hoogte stellen. De voorschrijver is op de hoogte gesteld.
*De voorschrijvend arts is zo nodig verzocht om een nieuwe/gewijzigde medicatieafspraak of verstrekkingsverzoek.

===Informatiesystemen en transactiegroepen===
Zowel de ''voorschrijver'' als de ''apotheker'' als andere ''medebehandelaars'' en ''gebruikers'' maken ieder gebruik van een informatiesysteem, respectievelijk een elektronisch voorschrijfsysteem (EVS), een apothekersinformatiesysteem (AIS, incl. ZAIS), een XIS en een PGO<ref>XIS is een generieke term voor een willekeurig (zorg)informatiesysteem. PGO=Persoonlijke GezondheidsOmgeving.</ref>. Deze informatiesystemen kennen ieder verschillende systeemrollen, die het uitwisselen van gegevens tussen deze informatiesystemen in het kader van het ter handstellingsproces mogelijk maken. 
[[#Systemen en transacties|Hoofdstuk 7]] geeft een overzicht van alle informatiesystemen, systeemrollen, transacties, etc. De belangrijkste voor het proces van ter hand stellen zijn in onderstaand overzicht opgenomen.

{{anchor|figuur 6}}
[[Bestand:Uc Ter handstellen.png|Figuur 6 Processtappen en transacties - ter hand stellen]]

===Use cases===
De volgende specifieke use cases van ter hand stellen zijn uitgewerkt:
*[[#Nieuwe medicatieafspraak, medicatieverstrekking zelfde product|Nieuwe medicatieafspraak, medicatieverstrekking zelfde product (paragraaf 4.2.1)]]
*[[#Nieuwe medicatieafspraak, nadere specificering product|Nieuwe medicatieafspraak, nadere specificering product (paragraaf 4.2.2)]]
*[[#Bestaande toedieningsafspraak voldoet|Bestaande toedieningsafspraak voldoet (paragraaf 4.2.3)]]
*[[#Medicatieafspraak gewenst (Informeren voorschrijver)|Medicatieafspraak gewenst (Informeren voorschrijver) (paragraaf 4.2.4)]]
*[[#Aanschrijven en verstrekken|Aanschrijven en verstrekken (paragraaf 4.2.5)]]
*[[#Patiënt vraagt herhaalrecept via arts (reactief herhalen)|Patiënt vraagt herhaalrecept via arts (reactief herhalen) (paragraaf 4.2.6)]]
*[[#Patiënt vraagt herhaalrecept via apotheker (Informeren voorschrijver)|Patiënt vraagt herhaalrecept via apotheker (Informeren voorschrijver) (paragraaf 4.2.7)]]
*[[#Proactief herhaalrecept door apotheker (Informeren voorschrijver)|Proactief herhaalrecept door apotheker (Informeren voorschrijver) (paragraaf 4.2.8)]]
*[[#Verstrekken op basis van bestaand verstrekkingsverzoek|Verstrekken op basis van bestaand verstrekkingsverzoek (paragraaf 4.2.9)]]
*[[#Knippen van recept|Knippen van recept (paragraaf 4.2.10)]]
*[[#Het opstarten en continueren van GDS|Het opstarten en continueren van GDS (paragraaf 4.2.11)]]
*[[#De apotheker wijzigt van handelsproduct|De apotheker wijzigt van handelsproduct (paragraaf 4.2.12)]]
*[[#Medicatie toevoegen aan GDS|Medicatie toevoegen aan GDS (paragraaf 4.2.13)]]
*[[#Medicatie in GDS stoppen|Medicatie in GDS stoppen (paragraaf 4.2.14)]]
*[[#GDS leverancier levert ander handelsproduct|GDS leverancier levert ander handelsproduct (paragraaf 4.2.15)]]
*[[#Parallelle toedieningsafspraken bij GDS- en niet-GDS-verstrekking|Parallelle toedieningsafspraken bij GDS- en niet-GDS-verstrekking (paragraaf 4.2.16)]]
*[[#Afhandelen stop medicatieafspraak|Afhandelen stop medicatieafspraak (paragraaf 4.2.17)]]
*[[#Verstrekken onder andermans toedieningsafspraak|Verstrekken onder andermans toedieningsafspraak (paragraaf 4.2.18)]]
*[[#Wijzigen van andermans toedieningsafspraak|Wijzigen van andermans toedieningsafspraak (paragraaf 4.2.19)]]
*[[#Verstrekkingsverzoek met aantal herhalingen|Verstrekkingsverzoek met aantal herhalingen (paragraaf 4.1.36)]]

==Proces: toedienen==

Deze paragraaf beschrijft het proces van toedienen. Dit proces bestaat uit het samenstellen van de toedienlijst voor (professionele) toedieners en de toediening die wordt gedaan door een (professionele) toediener, de patiënt zelf of een mantelzorger. Professionele toedieners zijn artsen, verpleegkundigen en verzorgenden.

In [[#Huidige_situatie_.28b.C3.A8ta-versie.29|paragraaf 2.4.1]] wordt de huidige situatie omschreven en in de paragrafen die volgen zal de nieuwe situatie met aanpassingen omschreven worden.

===Huidige situatie===

In de huidige situatie controleert de (professionele) toediener samen met de patiënt de toe te dienen medicatie aan de hand van de aanwezige informatie: papieren en/of digitale toedienlijst(en), een doseerschema van bijvoorbeeld antistollingsmedicatie en etiketinformatie, en dient toe. Bij onduidelijkheden neemt de toediener contact op met voorschrijver of apotheker. Mogelijke onduidelijkheden nemen toe naarmate er meer voorschrijvers, verstrekkers en toedieners betrokken zijn in het toedienproces.

In de huidige situatie is er een aantal knelpunten in de overdracht van medicatiegegevens voor de toediener:
*ontbreken van of geen tijdige overdracht van medicatiegegevens tussen intramurale zorginstelling en thuiszorg enerzijds en ziekenhuis anderzijds;
*het niet of niet tijdig doorkrijgen van wijzigingen en ontbrekende stops;
*het niet op een veilige manier beschikbaar hebben van actuele gegevens op de toedienlijst bij verstrekkingen door meerdere apothekers en tijdens ANW-uren (avond, nacht, weekend);
*naast de toedienlijst een apart doseerschema van (snel) wisselende doseringen, zoals antistollingsmedicatie.
*gerelateerde problemen aan apart doseerschema, zoals het kwijtraken van het doseerschema, mondeling doorgeven van wijzigingen van het doseerschema;
*ontbreken van zo nodig medicatie en bijspuitschema’s (bijvoorbeeld bij insuline) op de toedienlijst (in de toekomst zal dit opgepakt worden);
*ontbreken van inzicht in alle betrokken zorgverleners en zorgaanbieders.

In de huidige situatie zorgt de apotheker voor de toedienlijst voor de (professionele) toediener of de patiënt. Op de toedienlijst staan toedientijden en de toediener en apotheker stemmen deze toedientijden af op de logistieke ronde van de thuiszorgorganisatie en de farmaceutische mogelijkheden.
Aan de hand van de papieren of digitale toedienlijst registreren (professionele) toedieners de medicatietoediening. Een papieren toedienlijst ligt achter de voordeur van de patiënt (inclusief toedieningsregistratie). Elke betrokken professionele toediener (ongeacht van welke organisatie) heeft in principe achter de voordeur toegang tot deze toedienlijst en registratie van voorgangers. De vastgelegde medicatietoedieningen in digitale vorm worden in de huidige situatie alleen bij uitzonderlijke situaties (soms in geval van opname of bijzonderheden) met andere zorgverleners uitgewisseld. Met de overstap van elektronische toedienregistratie is de toedienlijst (met geregistreerde toedienmomenten) niet meer fysiek aanwezig bij de patiënt, maar is deze vastgelegd in de E-TDR/E-TRS (elektronische toedienregistratie/elektronisch toedienregistratiesysteem) oplossing ([[#Systemen_en_transactiegroepen_.28b.C3.A8ta-versie.29|zie paragraaf 2.4.8]]). Betrokken professionele toedieners van verschillende organisatie (met al dan niet verschillende E-TRS applicaties) kunnen niet of moeizaam elkaars geregistreerde toedienmomenten inzien omdat deze in verschillende applicaties c.q. databases vastgelegd worden.

===Preconditie===

De patiënt dient zichzelf medicatie toe of de patiënt krijgt hulp bij de medicatietoediening door een (professionele) toediener en heeft hiervoor een toedienlijst nodig.

===Trigger event===

Het moment dat de geneesmiddelen zouden moeten worden toegediend.

===Processtap: Toedienlijst===

De (professionele) toediener of patiënt ontvangt of vraagt de (actief) beschikbaar gestelde medicatiegegevens op die nodig zijn voor het geautomatiseerd genereren van de toedienlijst. Voor de toedienlijst zijn hiervoor de bouwstenen medicatieafspraak (MA), wisselend doseerschema (WDS), toedieningsafspraak (TA), medicatieverstrekking (MVE) en medicatietoediening (MTD) nodig. Om een complete toedienlijst te kunnen genereren zijn de (richt)toedientijden en doseerinstructies noodzakelijk. Deze gegevens kunnen door de apotheker in de TA vastgelegd worden of door de voorschrijver in de MA of WDS. Apothekers en voorschrijvers in de ambulante setting leggen niet standaard de (richt)toedientijden vast en zullen dan ook een trigger moeten ontvangen dat het hier gaat om een ‘toedienpatiënt’, een patiënt die hulp krijgt bij de medicatietoediening of zelf een toedienlijst nodig heeft. Voor sommige medicatie is het noodzakelijk om te weten wat de prik- en plakplekken (toedienlocatie) zijn, dit wordt vastgelegd in de MTD. In de klinische setting is voor alle patiënten een toedienlijst aanwezig en worden de (richt)toedientijden standaard vastgelegd.

De meeste (richt)toedientijden zullen bepaald worden op basis van de toedientijden van andere voorgeschreven medicatie en de logistieke rondes van de toediener. Dit is vooral het geval bij MA’s en TA’s waarbij de (richt)toedientijd standaard flexibel is. Over de (richt)toedientijden zullen nog verdere afspraken in het zorgveld gemaakt moeten worden (o.a. hoeveel de patiënt of toediener mag afwijken van de (richt)toedientijd). Als een toediening van medicatie een specifieke tijd vereist, bijvoorbeeld door een wisselwerking tussen medicaties, wordt dit gecommuniceerd door de (richt)toedientijd als niet flexibel aan te geven in de TA en/of MA.

Op de toedienlijst wordt op basis van de distributievorm een onderscheid gemaakt tussen GDS-medicatie en niet-GDS-medicatie. Deze gegevens worden in de bouwsteen MVE en TA vastgelegd. Vervolgens stelt de toediener (toedieningssoftware) op basis van de MA, het WDS, de TA en de MTD de toedienlijst samen, met een uitsplitsing naar toedieningen per toedienmoment. Voorschrijvers, apothekers en toedieners (PrikPlakLocatie) zijn verantwoordelijk voor het aanleveren van de medicatiegegevens die noodzakelijk zijn voor het samenstellen van een toedienlijst.

===Processtap: Medicatietoediening===

De (professionele) toediener heeft de medicatiegegevens (MA, WDS, TA, MVE en MTD), die nodig zijn voor de medicatietoediening, ontvangen. Deze gegevens worden in de hierboven beschreven toedienlijst voor de toedienpatiënten weergegeven. De (professionele) toediener controleert samen met de patiënt de aanwezige medicatie en de toediengegevens. Indien afgesproken en nodig maakt de toediener het geneesmiddel voor medicatietoediening gereed. De medicatie wordt toegediend en de toediener legt de medicatietoediening in het informatiesysteem of op de toedienlijst vast. Afwijkingen in de medicatietoediening (niet toedienen, gewijzigde dosering, weigering van de patiënt, slikproblemen, bijwerkingen, etc.) worden daarbij vastgelegd.

===Processtap: (Actief) beschikbaarstellen===

In deze stap vindt informatie-uitwisseling plaats. De informatie kan met verschillende intenties gestuurd of beschikbaar gesteld worden:
*De vastgelegde MTD’s en afwijkingen kunnen ter kennisgeving worden gestuurd naar een medebehandelaar;
*Het beschikbaarstellen van de MTD zodat medebehandelaars en/of patiënt deze later kunnen opvragen. Dit kan bijvoorbeeld van belang zijn bij de verplaatsing van een patiënt naar een andere afdeling of instelling. Daarnaast kan een zorgverlener controleren welke medicatie bij een patiënt toegediend is.

===Postconditie ===

De patiënt heeft geneesmiddelen zelf toegediend of toegediend gekregen. De MTD’s kunnen zijn vastgelegd in een informatiesysteem en worden (actief) beschikbaar gesteld voor medebehandelaars en/of patiënt.

===Systemen en transactiegroepen===

Zowel de voorschrijver en apotheker als de toedieners en patiënten (optioneel) maken ieder gebruik van een informatiesysteem, respectievelijk een elektronisch voorschrijfsysteem (EVS), een elektronisch cliëntendossier (ECD), een apothekersinformatiesysteem (AIS), ziekenhuisapotheekinformatiesysteem (ZAIS), een toedieningsregistratiesysteem (TRS), trombosedienstinformatiesysteem (TrIS) en een persoonlijke gezondheidsomgeving (PGO). Deze informatiesystemen kennen ieder verschillende systeemrollen, die het uitwisselen van gegevens tussen deze informatiesystemen in het kader van het proces toedienen mogelijk maken. Deze informatiesystemen kunnen een systeemrol spelen bij het opstellen van een toedienlijst en bij het vastleggen, versturen en opleveren van een MTD.
[[#Systemen_en_transacties|Hoofdstuk 7]] geeft een voorbeeld van het opstellen van een toedienlijst. De belangrijkste processtappen voor het proces van toedienen zijn in het onderstaande overzicht opgenomen.

{{anchor|figuur 7}}
[[Bestand:Toedienen.png|Figuur 7 Processtappen en transacties - toedienen|800px]]

===Use cases ===

De volgende specifieke use cases van het proces toediening zijn uitgewerkt:

*[[#Toedienlijst opstarten|4.3.1 Toedienlijst opstarten]]
*[[#Exacte toedientijden nodig|4.3.2 Exacte toedientijden nodig]]
*[[#Ontbreken (richt)toedientijden|4.3.3 Ontbreken (richt)toedientijden]]
*[[#Niet-GDS-medicatie zo nodig|4.3.4 Niet-GDS-medicatie zo nodig]]
*[[#Meerdere apotheken leveren medicatie|4.3.5 Meerdere apotheken leveren medicatie]]
*[[#Wijziging in GDS vanaf volgende levering of per direct|4.3.6 Wijziging in GDS vanaf volgende levering of per direct]]
*[[#Verhogen dosering GDS in nieuwe MBH|4.3.7 Verhogen dosering GDS in nieuwe MBH ]]
*[[#Verlagen dosering GDS in nieuwe MBH|4.3.8 Verlagen dosering GDS in nieuwe MBH]]
*[[#Wijziging verwerkt door de apotheker|4.3.9 Wijziging verwerkt door de apotheker ]]
*[[#Wijziging niet verwerkt door de apotheker|4.3.10 Wijziging niet verwerkt door de apotheker]]
*[[#Aanvullende informatie|4.3.11 Aanvullende informatie]]
*[[#Medicatietoediening afwijkend ten opzichte van toedienlijst|4.3.12 Medicatietoediening afwijkend ten opzichte van toedienlijst]]
*[[#Medicatietoediening zonder medicatieafspraak en toedieningsafspraak|4.3.13 Medicatietoediening zonder medicatieafspraak en toedieningsafspraak]]
*[[#Medicatietoediening van zelfzorgmedicatie|4.3.14 Medicatietoediening van zelfzorgmedicatie]]
*[[#Corrigeren/annuleren van toediening|4.3.15 Corrigeren/annuleren van toediening]]
*[[#Opschorten van toediening|4.3.16 Opschorten van toediening ]]
*[[#Medicatietoediening door voorschrijver|4.3.17 Medicatietoediening door voorschrijver ]]
*[[#Meerdere toedienorganisaties|4.3.18 Meerdere toedienorganisaties ]]
*[[#Feedback aan patiënt via medicatiesignalering|4.3.19 Feedback aan patiënt via medicatiesignalering]]

==Proces: gebruiken==
Deze paragraaf beschrijft het proces van gebruiken van de medicatie inclusief de registratie van het gebruik door de patiënt of een zorgverlener. De door de patiënt of zorgverlener vastgelegde informatie kan onder andere worden gebruikt bij medicatieverificatie door de zorgverlener. Tijdens medicatieverificatie wordt het gebruik vastgelegd door de zorgverlener. Voor een plaat van dit proces zie [[#Bijlage: Diagram Medicatieproces algemeen|hoofdstuk 13]].

===Huidige situatie===
*Er is op dit moment een beperkt aantal informatiesystemen beschikbaar waarin de patiënt zelf het gebruik van medicatie kan vastleggen. Ook de uitwisseling naar zorgverleners is sterk afhankelijk van het gebruikte informatiesysteem en beperkt zich veelal tot één specifieke zorgaanbieder via bijvoorbeeld één specifiek zorgaanbiedersplatform/app.
*De huidige medicatieprofielen zijn vaak onvolledig en niet actueel.

===Preconditie===
De patiënt heeft medicatie voorgeschreven gekregen.

===Trigger event===
De patiënt heeft de medicatie gebruikt of gebruikt deze niet (meer).

===Processtap: Gebruiken===
De patiënt gebruikt de voorgeschreven medicatie of zelfzorgmedicatie. Het medicatiegebruik kan worden vastgelegd door
*de patiënt zelf of zijn mantelzorger,
*een thuiszorg- of instellingsverpleegkundige en/of
*een andere zorgverlener.
Dit laatste vindt vaak plaats bij medicatieverificatie (zie [[#Proces: medicatieverificatie|paragraaf 2.1]]). Er zijn allerlei informatiesystemen beschikbaar om het gebruik vast te leggen: PGO, XIS, EPD/ECD, app, etc.

Als medicatiegebruik kunnen worden vastgelegd:
*zelfzorg en andere eigen medicatie,
*het aangeven van afwijkingen ten opzichte van de gemaakte afspraken,
*bevestiging van gebruik (bevorderen therapietrouw),
*geverifieerde medicatie (zie [[#Proces: medicatieverificatie|paragraaf 2.1]]),
*wijzigingen als gevolg van bijvoorbeeld bijwerkingen (door de patiënt zelf; een zorgverlener zal dit op een andere wijze registreren).

Patiënten die medicatie krijgen toegediend door een verpleegkundige nemen afhankelijk van de BEM score (Beoordeling Eigen beheer Medicatie) soms zelf later de medicatie in; de gegevens van de medicatietoediening kunnen dan afwijken van het medicatiegebruik. 
Gedurende het gebruik wordt farmaceutische zorg uitgevoerd door de apotheker (zie [[#Processtap: Uitvoeren farmaceutische zorg|paragraaf 2.3.4]] bijv. in geval van nieuwe laboratoriumwaarden). Ook kan er een vervolgcontact plaatsvinden waarin de medicamenteuze behandeling wordt geëvalueerd (zie [[#Processtap: Evalueren (medicamenteuze) behandeling|paragraaf 2.2.4]]).

====''Vastleggen medicatiegebruik door de patiënt''====
De patiënt maakt gebruik van een medicatieprofiel en geeft per medicijn, waarvoor dit relevant is, het daadwerkelijk gebruik aan. Daarbij kan de patiënt aangeven of hij het product wel of niet gebruikt en of dit 'gebruik volgens afspraak' is (waarbij de medicatieafspraak en/of toedieningsafspraak getoond is) en afwijkingen daarvan. Bij afwijkingen kan ingevoerd worden welke afwijking het betreft, dus volgens het werkelijk door de patiënt gevolgde schema, maar ook in algemenere termen (bijvoorbeeld ik neem de medicatie: 'af en toe', 'gemiddeld [x] keer per [dag/week]', '1x per dag in plaats van 2x', 'niet meer sinds 22-1-2015' of 'niet meer sinds ongeveer een maand'). Bij afwijking van de afspraken geeft de patiënt ook de reden van wijzigen of stoppen aan. 
Daarnaast kan de patiënt zijn eigen medicatie toevoegen aan het overzicht en eventuele bijwerkingen als reden voor wijzigingen opgeven.

Informatie over gebruik zal niet altijd aanwezig zijn. Daarnaast is er geen zekerheid over de betrouwbaarheid van de informatie. Soms zijn er afspraken tussen zorgverlener en patiënt over het bijhouden van medicatiegebruik, soms ligt het initiatief geheel bij de patiënt zelf.

====''Vastleggen medicatiegebruik door zorgverlener''====
Tijdens het proces van medicatieverificatie ([[#Proces: medicatieverificatie|paragraaf 2.1]]) of Evalueren van de medicamenteuze behandeling ([[#Processtap: Evalueren (medicamenteuze) behandeling|2.2.4]]) geeft de patiënt (of zijn mantelzorger) bijvoorbeeld aan dat hij medicatie niet of anders gebruikt dan afgesproken. Of dat hij ook nog andere medicatie gebruikt (zelfzorgmiddelen of buitenlandse medicatie). De zorgverlener kan deze gegevens vastleggen als medicatiegebruik. De gegevens over gebruik worden naast de primaire medicatiegegevens vastgelegd, de patiënt wordt daarbij als bron van de informatie vastgelegd, de zorgverlener als auteur. 
In plaats van of naast het vastleggen van het gebruik kan een voorschrijver er ook voor kiezen om een nieuwe of gewijzigde medicatieafspraak te maken met de patiënt (conform proces beschreven in [[#Processtap: Maken medicatieafspraak|paragraaf 2.2.5]]). Dit gebeurt wanneer de voorschrijver reden ziet om de afspraak bij te stellen naar aanleiding van het gebruik door de patiënt. Wanneer de voorschrijver geen reden ziet de afspraak bij te stellen kan hij er voor kiezen alleen het gebruik vast te leggen, met eventueel de opmerking dat hij de patiënt heeft verzocht zich te houden aan de eerder gemaakte afspraken.

Bij afwijkend gebruik zal een apotheker mogelijk een voorstel medicatieafspraak opstellen ten behoeve van de voorschrijver (zie [[#Processtap: Informeren voorschrijver|paragraaf 2.3.5]]) en/of de patiënt aanraden de voorschrijver te informeren over het afwijkende gebruik.

De verslaglegging rondom de evaluatie van gebruik (werking en bijwerking) zal de arts in de anamnese vastleggen of gebruiken als reden om een medicatieafspraak te wijzigen of te stoppen.

===Processtap: (Actief) beschikbaarstellen===
De vastgelegde medicatiegegevens (gebruik) kunnen ter kennisgeving worden verstuurd naar een medebehandelaar of beschikbaar worden gesteld zodat zij later opgevraagd kunnen worden.

===Processtap: Informeren voorschrijver===
De patiënt kan de voorschrijver ook zelf informeren wanneer er een nieuwe of gewijzigde medicatieafspraak of een nieuw verstrekkingsverzoek nodig is. Het proces is analoog aan het proces van Informeren voorschrijver door de apotheker ([[#Processtap: Informeren voorschrijver|paragraaf 2.3.5]]).

===Postconditie===
De lijst met medicatie is door de patiënt bijgewerkt en het daadwerkelijk gebruik is toegevoegd. De patiënt heeft zo nodig de voorschrijver verzocht om een nieuwe of gewijzigde medicatieafspraak of verstrekkingsverzoek.

===Informatiesystemen en transactiegroepen===
Zowel de ''voorschrijver'' als de ''apotheker'' als andere ''medebehandelaars'' en ''gebruikers'' maken ieder gebruik van een informatiesysteem, respectievelijk een elektronisch voorschrijfsysteem (EVS), een apothekersinformatiesysteem (AIS, incl. ZAIS), een XIS en een PGO<ref>XIS is een generieke term voor een willekeurig (zorg)informatiesysteem. PGO=Persoonlijke GezondheidsOmgeving.</ref>. Deze informatiesystemen kennen ieder verschillende systeemrollen, die het uitwisselen van gegevens tussen deze informatiesystemen in het kader van het gebruiksproces mogelijk maken.
[[#Systemen en transacties|Hoofdstuk 7]] geeft een overzicht van alle informatiesystemen, systeemrollen, transacties, etc. De belangrijkste voor het proces van gebruiken zijn in onderstaand overzicht opgenomen.

{{anchor|figuur 8}}
[[Bestand:Gebruiken.png|Figuur 8 Processtappen en transacties - gebruiken]]

===Use cases===
De use cases voor Gebruiken zijn beschreven vanuit registratie door de patiënt. De voorschrijver kan het medicatiegebruik op dezelfde wijze vastleggen maar zal de verslaglegging rondom de evaluatie van gebruik (werking en bijwerking) eerder in de anamnese vastleggen of gebruiken als reden om een medicatieafspraak te wijzigen of te stoppen.

De volgende specifieke use cases van gebruik zijn uitgewerkt:
*[[#Zelfzorgmiddel|Zelfzorgmiddel (paragraaf 4.4.1)]]
*[[#Medicatie uit buitenland|Medicatie uit buitenland (paragraaf 4.4.2)]]
*[[#Wijziging op initiatief patiënt|Wijziging op initiatief patiënt (paragraaf 4.4.3)]]
*[[#Stoppen medicatie op initiatief patiënt|Stoppen medicatie op initiatief patiënt (paragraaf 4.4.4)]]
*[[#Geen voorraad meer|Geen voorraad meer (paragraaf 4.4.5)]]
*[[#Registreren van afwijkend medicatiegebruik door patiënt vanwege een bijwerking|Registreren van afwijkend medicatiegebruik door patiënt vanwege een bijwerking (paragraaf 4.4.6)]]
*[[#Gebruik registreren op basis van verstrekking|Gebruik registreren op basis van verstrekking (paragraaf 4.4.7)]]

=Domeinspecifieke invulling medicatieproces=

==Dienstwaarneming door HAP==
De huisartsenpost (HAP) werkt in opdracht van de vaste huisarts. De huisartsenpost kan (onder andere) medicatieafspraken starten, wijzigen en stoppen conform het proces beschreven in [[#Proces: medicatieverificatie|paragraaf 2.1]]. De HAP zal zo nodig ook de bijbehorende verstrekkingsverzoeken doen. 
De HAP informeert de vaste huisarts over de waarneming. Bestaande afspraak is dat de HAP zelf geen bron is van informatie voor andere medebehandelaars van deze patiënt. Dit betekent dat de HAP de processtap ‘(Actief) beschikbaar stellen’ niet zal vervullen. In plaats daarvan stelt de vaste huisarts de betreffende informatie beschikbaar voor de medebehandelaars. Uitzondering hierop is het eventueel ongeadresseerd voorschrijven door een HAP, zie hiervoor [[#Ongeadresseerd voorschrijven (ambulant)|paragraaf 7.5]]. 
Dienstwaarneming volgt daarmee in principe het generieke proces van voorschrijven. Het verschil is dat een waarnemend arts sommige stappen uitvoert in opdracht van de vaste huisarts ('gedelegeerd').

==GGZ==
In de GGZ komen maar weinig geplande opnames voor (eigenlijk alleen bij afdelingen als eetstoornissen, klinisch herstel, e.d.). De meeste opnames betreffen opnames t.g.v. acute crisissituaties en zijn daarmee vergelijkbaar met opnames via de SEH in ziekenhuizen (zie ook [[#Starten met medicatie voor opname|paragraaf 4.1.20]]).

===Huidige situatie===
In de huidige situatie wordt aan de patiënt of de familie/mantelzorgers gevraagd welke medicatie zij gebruiken. In de meeste gevallen is de patiënt niet in staat om hier antwoord op te geven (dat is namelijk ook de reden voor opname). Familie/mantelzorgers (indien bekend) kunnen hier ook niet altijd antwoord op geven. De opnemend arts/psychiaters nemen contact op met huisarts of apotheek om de medicatie te achterhalen. Buiten kantooruren en in het weekend lukt dit slecht. En wanneer er gegevens binnen komen worden deze maar deels overgetypt in het informatiesysteem van de zorgverleners.

===Proces===
In de nieuwe situatie kunnen de beschikbaargestelde medicatiegegevens worden opgevraagd. Op basis daarvan wordt gestart met medicatieverificatie en het evalueren van de medicamenteuze behandeling (zodra mogelijk) en het toedienen van medicatie (conform [[#Medicatieproces|hoofdstuk 2]]). De medicatieverstrekking wordt poliklinisch door de openbare apothekers gedaan en klinisch vaak door een gecontracteerde ziekenhuisapotheek. 
Bij ontslag uit een GGZ-instelling wordt, net als in de ziekenhuizen, de medicamenteuze behandeling geëvalueerd ([[#Processtap: Evalueren (medicamenteuze) behandeling|paragraaf 2.2.4]]). Daarin wordt de klinische medicatie gestopt en wordt zo nodig nieuwe medicatie voorgeschreven of eerder tijdelijk onderbroken ambulante medicatie definitief gestopt of hervat. De arts/psychiater richt zich vooral op de psychiatrische medicatie, somatische medicatie blijft meestal ongemoeid. 
Het vastleggen van medicatiegebruik door de psychiatrische patiënt kan ervaren worden als ongewenste controle in plaats van dat dit het gebruik stimuleert. 
De medicatiegegevens worden beschikbaargesteld.

==VVT==
Het medicatieproces in een VVT-instelling (Verpleeg-, Verzorgingshuizen en Thuiszorg) verloopt analoog aan die van de klinische situatie echter in de VVT-instelling is een specialist ouderengeneeskunde als voorschrijver verantwoordelijk voor de medicatie van de opgenomen cliënten en wordt de levering van medicatie door één of meerdere openbare apothekers gedaan, zo nodig in de vorm van GDS.
In de VVT-instelling en in de thuiszorg wordt met een toedienlijst gewerkt. Deze wordt samengesteld op basis van de toedieningsafspraken. De toedienlijst wordt gebruikt om controle te doen op de medicatie voorafgaand aan de medicatietoediening en om de daadwerkelijke medicatietoediening op af te tekenen. Het communiceren van de toedienlijst tussen apotheker, voorschrijver en verpleegkundige wordt in een later stadium in deze informatiestandaard uitgewerkt.

==Opname en ontslag==
Een bijzondere situatie bij medicatieoverdracht ontstaat wanneer een patiënt wordt opgenomen in een instelling en vanuit een ambulante situatie in een klinische situatie terecht komt.
Omdat op het moment van opname in de instelling en bij ontslag uit de instelling veel wijzigingen in medicatie- en toedieningsafspraken kunnen plaatsvinden, wordt dit onderwerp hier apart genoemd. In handleidingen voor zorgverleners en leveranciers worden de werking van proces en systeem in de verschillende voorkomende situaties gedetailleerd beschreven.

===Voorafgaand aan opname===
Voordat de patiënt wordt opgenomen, kan al sprake zijn van een aanpassing in de medicatie. De medisch specialist kan met de patiënt afspreken dat deze een aantal dagen voor opname start met nieuwe medicatie of stopt met lopende medicatie.
De medisch specialist maakt in zo’n geval een medicatieafspraak of een stop-MA, waarbij hij in de toelichting aangeeft hoeveel dagen voor opname de patiënt met de medicatie moet starten of stoppen. Op het moment dat deze afspraak wordt gemaakt, is de opnamedatum vaak nog niet bekend. De medisch specialist geeft daarom bij het maken van de medicatieafspraak of stop-MA aan dat deze afhankelijk is van een opname, waardoor de gebruiksperiode onzeker is. Technisch wordt dit ingevuld door de gevulde toelichting op te nemen in element ‘Criterium’ bij de gebruiksperiode in de medicatieafspraak. Wanneer dit element bij een medicatieafspraak is gevuld, moet voor alle zorgverleners in de keten duidelijk zijn dat de gebruiksperiode onzeker is.

===Tijdens opname en bij ontslag===
Wanneer een patiënt wordt opgenomen in een instelling, kunnen voor de medicatie die de patiënt in de ambulante situatie gebruikt de volgende situaties van toepassing zijn:
* Ongewijzigd doorgebruiken,
* Wijziging dosering,
* Generieke substitutie (werkzame stof blijft gelijk),
* Farmacotherapeutische substitutie (werkzame stof wijzigt, maar middel is geregistreerd voor dezelfde indicatie),
* (Tijdelijke) stop.

Hieronder volgt per situatie een toelichting op de gevolgen voor de registratie van de medicatie van de patiënt.

====Ongewijzigd doorgebruiken====
De patiënt blijft de medicatie uit de ambulante situatie ongewijzigd doorgebruiken tijdens opname.

De medicatieafspraak en toedieningsafspraak uit de ambulante situatie blijven doorlopen tijdens opname en na ontslag.

====Wijziging dosering====
De patiënt gebruikt tijdens opname hetzelfde geneesmiddel als in de ambulante situatie, echter met een andere dosering.

De medicatieafspraak uit de ambulante situatie wordt gestopt bij opname. Tijdens opname wordt een nieuwe medicatieafspraak gemaakt met de aangepaste dosering. Bij ontslag bepaalt de voorschrijver welke dosering gaat gelden voor de ambulante situatie. Afhankelijk hiervan wordt de medicatieafspraak uit de ambulante situatie voortgezet of wordt een nieuwe medicatieafspraak gemaakt voor de ambulante situatie.
Ook de toedieningsafspraak uit de ambulante situatie wordt gestopt bij opname. Tijdens opname wordt een nieuwe toedieningsafspraak gemaakt op basis van de nieuwe medicatieafspraak. Bij ontslag wordt de toedieningsafspraak uit de ambulante situatie voortgezet of wordt een nieuwe toedieningsafspraak gemaakt voor de ambulante situatie.

====Generieke substitutie====
De patiënt gebruikt tijdens opname een ander geneesmiddel dan in de ambulante situatie, echter met dezelfde werkzame stof en in dezelfde hoeveelheid en farmaceutische vorm.

De medicatieafspraak uit de ambulante situatie blijft doorlopen tijdens opname en na ontslag. De toedieningsafspraak uit de ambulante situatie wordt bij opname gestopt en na ontslag weer voortgezet. Tijdens opname wordt een nieuwe toedieningsafspraak gemaakt die bij ontslag wordt gestopt.

====Farmacotherapeutische substitutie====
De patiënt gebruikt tijdens opname een ander geneesmiddel dan in de ambulante situatie, dit middel is echter geregistreerd voor dezelfde indicatie (bijvoorbeeld omeprazol/pantoprazol).

De medicatieafspraak uit de ambulante situatie wordt gestopt bij opname en na ontslag weer voortgezet. Tijdens opname wordt een nieuwe medicatieafspraak gemaakt die bij ontslag wordt gestopt.
Ook de toedieningsafspraak uit de ambulante situatie wordt gestopt bij opname en na ontslag weer voortgezet. Tijdens opname wordt een nieuwe toedieningsafspraak gemaakt die bij ontslag wordt gestopt.

====(Tijdelijke) stop====
De patiënt stopt tijdens opname (tijdelijk) met de ambulante medicatie.

De medicatieafspraak uit de ambulante situatie wordt (tijdelijk) gestopt bij opname. Indien het gaat om een tijdelijke stop, wordt de medicatieafspraak na ontslag weer voortgezet. Bij een definitieve stop volgt er geen medicatieafspraak meer voor de ambulante situatie.
Ook de toedieningsafspraak uit de ambulante situatie wordt (tijdelijk) gestopt. Indien het gaat om een tijdelijke stop, wordt de toedieningsafspraak na ontslag weer voortgezet. Bij een definitieve stop volgt er geen toedieningsafspraak meer voor de ambulante situatie.

=Beschrijving use cases=
Dit hoofdstuk bevat een beschrijving van verschillende use cases. Er zijn concrete praktijksituaties beschreven voor de verschillende deelprocessen. De praktijksituaties zijn in een groot aantal gevallen ontleend aan de huisartsenpraktijk maar zijn illustratief voor vergelijkbare situaties in een andere setting. Dit hoofdstuk veronderstelt voorkennis zoals beschreven in [[#Medicatieproces|hoofdstuk 2]].

==Use cases Voorschrijven==

===Kortdurende medicatie===
Een 35-jarige vrouwelijke patiënt met urineweginfectie in de voorgeschiedenis, brengt haar urine naar de assistente aan de balie en vertelt dezelfde klachten als de vorige keren te hebben. De assistente vraagt nog naar andere klachten zoals koorts en pijn in de flank en kijkt de urine na. Er zijn geen andere klachten en uit de urine blijkt een urineweginfectie. Zij vertelt de patiënt dat de huisarts een kuur zal voorschrijven en dat ze die later bij de apotheker op kan halen. De huisarts kijkt naar de vorige kuren en een eventuele kweek en legt een medicatieafspraak vast. Op ''27 januari'' is afgesproken:
:''Nitrofurantoïne capsule mga 100 mg, 2 maal daags 1 capsule, vanaf heden<ref>Zie ook [[#Harde einddatum gebruiksperiode|paragraaf 4.1.3]].</ref> gedurende 5 dagen.''
Hij legt deze medicatieafspraak vast in zijn informatiesysteem. Vervolgens maakt de huisarts direct ook een verstrekkingsverzoek voor de apotheker naar keuze van de patiënt:
:''Nitrofurantoïne capsule mga 100 mg; 10 stuks.''
De huisarts legt ook dit verstrekkingsverzoek vast in zijn informatiesysteem. 
De huisarts overlegt met de patiënt bij welke apotheker zij de medicatie wil afhalen. De huisarts kan deze apotheker vervolgens informeren over het verstrekkingsverzoek én de medicatieafspraak. 
Het informatiesysteem van de huisarts maakt de informatie (verstrekkingsverzoek en medicatieafspraak) beschikbaar voor de medebehandelaars van deze patiënt. 
 
[[Bestand:Uc4.1.1.PNG|800px]]

===Doorlopende medicatie===
Het proces bij doorlopende medicatie is hetzelfde als bij kortdurende medicatie (zie [[#Kortdurende medicatie|paragraaf 4.1.1]]). Het verschil is dat bij doorlopende medicatie de medicatieafspraak voor onbepaalde tijd wordt gemaakt.

Bijvoorbeeld: de voorschrijver spreekt met een patiënt met hypertensie af een diureticum doorlopend te gebruiken. Op ''30 maart 2013'' is afgesproken:
:''Hydrochloorthiazide tablet 12,5 mg; eenmaal daags een tablet; vanaf heden voor onbepaalde duur.''
De voorschrijver kiest bijvoorbeeld in het verstrekkingsverzoek voor initieel een te verstrekken hoeveelheid van 100 stuks. 
 
[[Bestand:Uc4.1.2.PNG|800px]]

===Harde stopdatum gebruiksperiode===
In de gebruiksperiode van een medicatieafspraak kan een ingangsdatum, stopdatum en/of duur worden meegegeven. Wanneer er een harde stopdatum gewenst is, dient dit ook expliciet in de Toelichting te worden aangegeven. Het enkel opnemen van een stopdatum is niet voldoende omdat dit niet genoeg duidelijkheid geeft over de intentie van de voorschrijver. 
 
[[Bestand:Uc4.1.3.PNG|800px]]

===Zo nodig medicatie===
Een 31 jarige vrouwelijke patiënt heeft in een jaar een paar keer hoofdpijnaanvallen gehad, waarbij nu de diagnose migraine wordt gesteld. De huisarts schrijft voor:
:''Rizatriptan 10 mg tabletten zo nodig 1c1t onder de tong. Eerste tablet bij eerstvolgende duidelijke migraine aanval.''
De huisarts legt de medicatieafspraak vast en doet een verstrekkingsverzoek:
:''6 Tabletten rizatriptan s.l. 10 mg.'' 
 
[[Bestand:Uc4.1.4.png|800px]]

===Kuur zo nodig startend in de toekomst===
Een zestigjarige patiënt met een status na een trombosebeen heeft soms om het jaar, soms driemaal per jaar een erysipelas (ernstige infectie aan het been waarvoor als de medicatie niet snel begint opname nodig kan zijn). Op verzoek van de patiënt schrijft de huisarts een antibioticumkuur voor waar hij meteen mee kan beginnen bij een recidief erysipelas. De volgende medicatieafspraak wordt gemaakt:
:''Flucloxacilline 500 mg capsules, 4d1 capsule, gedurende 10 dagen. In de medicatieafspraak wordt aangegeven (zo nodig): start zo nodig bij recidief.''
De huisarts doet meteen een verstrekkingsverzoek:
:''Flucloxacilline 500 mg capsules 40stuks.'' 
 
[[Bestand:Uc4.1.5.PNG|800px]]

===Twee doseringen van hetzelfde geneesmiddel tegelijkertijd===
Een 79 jarige man met uitgezaaide prostaatkanker heeft meer pijn en zijn medicatie wordt gewijzigd. De specialist schrijft (op 9 oktober) oxycodon 10 mg tabletten voor 4d1t en zo nodig bij pijn ’s nachts 1d1t. De specialist legt dit in één medicatieafspraak met twee doseerinstructies vast en doet een verstrekkingsverzoek voor 60 tabletten oxycodon 10 mg. 
 
[[Bestand:Uc4.1.6.PNG|800px]]

===Hetzelfde geneesmiddel met verschillende sterkte tegelijkertijd===
Dezelfde 79 jarige patiënt (zie [[#Twee doseringen van hetzelfde geneesmiddel tegelijkertijd|paragraaf 4.1.6]]) krijgt toch weer meer pijn. De specialist stopt op 16 oktober de oxycodon 10 mg tabletten en schrijft oxycodon 20 mg retard tabletten voor 3d2t en oxycodon 20 mg tabletten (normale afgifte) zo nodig bij pijn ’s nachts 1d1t. De specialist legt dit in twee medicatieafspraken (bij vooralsnog twee separate medicamenteuze behandelingen) vast en doet voor beide medicatieafspraken een verstrekkingsverzoek, respectievelijk 45 retardtabletten oxycodon 20 mg en 30 tabletten oxycodon 20 mg (normale afgifte). 
 
[[Bestand:Uc4.1.7.PNG|800px]]

===Toelichting in medicatieafspraak bij bewust gekozen bijzonderheid===
Bij het kiezen van een geneesmiddel kan er worden afgeweken van wat er verwacht wordt of van wat de standaard is. Bijvoorbeeld wanneer het ziekenhuis een ander formularium hanteert dan de openbare apotheek. Uit efficiencyoverwegingen is in het ziekenhuis bijvoorbeeld gekozen voor één maagzuurremmer: pantoprazol. 
Bij opname wordt een patiënt met omeprazol omgezet naar pantoprazol voor de duur van het verblijf. Bij ontslag gaat de patiënt weer terug naar omeprazol. 
Het is duidelijk dat hier nog wel eens wat mis kan gaan en dat de patiënt zowel omeprazol als pantoprazol slikt als er niet ingegrepen wordt. In de medicatieafspraak van het ziekenhuis voor pantoprazol kan een opmerking worden gemaakt (in de toelichting) over de afwijking zodat duidelijk is dat pantoprazol de vervanger is van omeprazol of juist naast omeprazol moet worden gebruikt. 
Zie ook voorbeeld [[mp:V9_2.0.0_Ontwerp_medicatieproces#Substitutie|substitutie]]. 
 
Ander voorbeeld zijn de halve sterktes. Het ziekenhuis heeft soms de beschikking over tabletten met de halve sterkte van het normale handelspreparaat (eigen productie). Waar de patiënt het ziekenhuis ingaat met chlortalidon 25 mg, een maal daags een halve tablet krijgt hij intramuraal chlortalidon 12,5 mg, eenmaal daags één tablet. Dan hoeft de verpleging in dit geval geen tabletten te breken. Hier bestaat het risico dat de patiënt bij thuiskomst weer de 25 mg gaat gebruiken, maar dan een hele tablet per keer. In de medicatieafspraak (Aanvullende informatie) van de laatste chlortalidon 25 mg kan worden aangegeven of dit een bewuste verhoging is geweest. 
 
Indien een voorgeschreven middel heel specifiek een bepaald handelsproduct dient te zijn (HPK), dan kan dit worden aangegeven met (Aanvullende informatie) 'Medische noodzaak'.

===Nieuwe medicatieafspraak, geen verstrekkingsverzoek===
Een 50-jarige man komt bij de huisarts met rugklachten. De klachten bestaan al 3 weken en hij gebruikt al paracetamol. De huisarts spreekt met de patiënt af aanvullend diclofenac te gebruiken:

Op ''30 januari'' is afgesproken:
:''Diclofenac tablet 50 mg, 3 maal daags 1 tablet, vanaf heden gedurende 3 weken.''
Hij legt deze medicatieafspraak vast in zijn informatiesysteem. De patiënt geeft aan voldoende voorraad thuis te hebben: zijn vrouw heeft nog een ruime voorraad diclofenac over vanwege een ander probleem een jaar geleden.

Er is dus geen verstrekkingsverzoek nodig en de apotheker stelt dus ook geen medicatie ter hand. 
De huisarts stelt de nieuwe medicatieafspraak beschikbaar voor eventuele medebehandelaars van deze patiënt. De vaste apotheker kan zich informeren over deze nieuwe medicatieafspraak. 
 
[[Bestand:Uc4.1.9a.PNG|800px]]

Een ander voorbeeld:
Dhr Simons krijgt wekelijks zijn medicatie verstrekt door de apotheek. In het verleden waren er namelijk veel verzoeken om extra medicatie, wat leidde tot duidelijke afspraken over het afgiftebeleid.

Het gaat om:
:''Medicatieafspraak: Diazepam 5 mg 4 maal daags 1 tablet vanaf 1-1-2012 tot voor onbepaalde duur''
:''Verstrekkingsverzoek: 28 stuks iter 10; toelichting: wekelijkse medicatieverstrekkingen''
Het verstrekkingsverzoek wordt ongeveer iedere 11 weken herhaald.

Het laatste verstrekkingsverzoek was op 3-3-2016:
:''een week (28 tabletten) met iter 10x ''
zodat de apotheek er 11 weken mee vooruit kan. 
 
[[Bestand:Uc4.1.9b.PNG|800px]]

De laatste jaren is het rustig. Hij vraagt niet meer om extra medicatie. Bij het laatste gesprek vertelde hij dat hij toe kan met 3 x daags diazepam. Dit wordt in een medicatieafspraak vastgelegd:
:''1-4-2016 Diazepam 5 mg 3x daags 1 tablet vanaf 1-4-2016 tot voor onbepaalde duur.''
De vorige medicatieafspraak wordt beëindigd per 31-3-2016 (zie stoppen van medicatie in [[#Processtap: Maken medicatieafspraak|paragraaf 2.2.5]]).

In de huidige situatie belde de huisarts de apotheek om te zorgen dat er bij de volgende medicatieverstrekkingen 21 tabletten diazepam worden meegegeven i.p.v. 28. Er was toen geen nieuwe verstrekkingsverzoek nodig.

In de nieuwe situatie stuurt de huisarts de nieuwe medicatieafspraak naar de apotheek. Op basis van de nieuwe medicatieafspraak verstrekt de apotheek 21 tabletten per week, het vorige verstrekkingsverzoek volstaat nog. 
 
[[Bestand:Uc4.1.9c.png|800px]]

===Nieuw verstrekkingsverzoek onder bestaande medicatieafspraak===
Een voorschrijver kan ook een nieuw verstrekkingsverzoek doen onder een bestaande medicatieafspraak. Deze medicatieafspraak kan gemaakt zijn door een andere voorschrijver bijvoorbeeld een psychiater of in geval van waarneming de vaste huisarts. Het betreft hier herhaalmedicatie. Deze use case is beschreven in [[#Patiënt vraag herhaalrecept via arts (reactief herhalen)|paragraaf 4.2.6]]. 
 
[[Bestand:Uc4.1.10.png|800px]]

===Wijziging in dosering (voldoende voorraad)===
Patiënt (37 jaar, astma) is op 13 augustus 2013 bij de longarts voor controle van zijn astma. De longarts heeft vastgesteld dat de astma onvoldoende gereguleerd is. 
De patiënt gebruikt op dit moment Beclometason volgens een eerder gemaakte en geregistreerde medicatieafspraak: op 10 juni 2010 is afgesproken
:''Beclometason aerosol 100 microg/dosis inh; 2 maal daags 1 inhalatie; vanaf 10 juni 2010 voor onbepaalde duur.''
De longarts spreekt op 13 augustus 2013 met de patiënt een verhoging van de dosering af:
:''Beclometason aerosol 100 microg/dosis inh; 2 maal daags 2 inhalaties; van 13 augustus 2013 tot voor onbepaalde duur; reden van aanpassing: onvoldoende werking.''
De voorgaande medicatieafspraak van 10 juni 2010 geldt niet meer: deze wordt beëindigd (zie wijzigen van medicatie in [[#Processtap: Maken medicatieafspraak|paragraaf 2.2.5]]) . De patiënt heeft nog voldoende voorraad, er is dus geen verstrekkingsverzoek nodig. 
 
[[Bestand:Uc4.1.11.PNG|800px]] 
In het geval de patiënt geen voorraad meer zou hebben dan wordt er ook een nieuw verstrekkingsverzoek gemaakt. 
Het informatiesysteem van de longarts maakt de nieuwe medicatieafspraak beschikbaar voor de medebehandelaars van deze patiënt. Deze wijziging komt binnen bij de apotheker (medebehandelaar). De apotheker verwerkt de wijziging. De apotheker kan er ook voor kiezen om wijzigingen automatisch te accepteren.

===Recept niet meer nodig na eerste verstrekkingsverzoek===
Een 16 jarige vrouw heeft een vriend en wil niet zwanger worden. Na uitleg kiest zij voor de pil. De huisarts schrijft ethinylestradiol/levonorgestrel tablet 20/100ug voor, 1d1t gedurende 21 dagen, vervolgens 7 dg geen pil nemen, dan weer 21 dagen wel. Start op de 1e dag van de volgende menstruatie. De huisarts legt de medicatieafspraak vast en doet een verstrekkingsverzoek voor 63 tabletten microgynon 20 tablet omhuld. Hij legt haar uit dat indien zij geen klachten heeft, zij de pil verder via de apotheek kan krijgen. 
Drie maanden later doet de vrouw een voorstel tot herhaalverstrekking aan de apotheek. De apotheek verstrekt het middel en communiceert de medicatieverstrekking aan de huisarts. 
[[Bestand:Uc4.1.12.png|800px]] 

===Stoppen medicatie===
Patiënt (37 jaar, astma) is op 13 augustus 2013 bij de longarts voor controle van zijn astma. De patiënt heeft last van een bijwerking.
De patiënt gebruikt op dit moment Beclometason volgens een eerder gemaakte en geregistreerde medicatieafspraak. Op ''10 juni 2010'' is afgesproken:
:''Beclometason aerosol 100 microg/dosis inh; 2 maal daags 1 inhalatie; vanaf 10 juni 2010 voor onbepaalde duur.''
De longarts spreekt op 13 augustus 2013 met de patiënt af om de medicatie te stoppen (medicamenteuze behandeling wordt gestopt). Medicatieverificatie is ook hier van toepassing. Verder kan ook medicatiebewaking hierbij relevant zijn, bijvoorbeeld wanneer maagbeschermers geslikt worden vanwege gebruik van de te stoppen medicatie (het informatiesysteem zal dit niet altijd automatisch signaleren). 
De longarts legt vast:
:''Beclometason aerosol 100 microg/dosis inh; stoptype 'definitief'; vanaf 13 augustus 2013. Vanwege een bijwerking.''
Deze wijziging komt binnen bij de apotheker (medebehandelaar). De apotheker verwerkt de wijziging. De apotheker kan er ook voor kiezen om wijzigingen automatisch te accepteren.
De longarts besluit ook om een medebehandelaar (bijv. de huisarts) hierover actief te informeren (onderdeel van de processtap (Actief) Beschikbaarstellen). 
Het informatiesysteem van de longarts maakt deze informatie (afspraak om te stoppen) beschikbaar voor alle medebehandelaars van deze patiënt. 
[[Bestand:Uc4.1.13.png|800px]] 

===Onderbreken / hervatten medicatie===
De patiënt wordt behandeld met Simvastatine (cholesterolverlager): 40 mg 1D1T voor onbepaalde duur.
Vanwege een keelontsteking in combinatie met een allergie voor het eerste keuze antibioticum wordt gedurende 1 week Claritromycine 250 mg 2D1T (antibioticum) voorgeschreven. Gedurende die week wordt de simvastatine onderbroken vanwege een interactie. 
De huisarts legt vast:
:''Simvastatine 40 mg; tijdelijk onderbreken; gedurende 1 week; reden: interactie''
:''Claritromycine 250 mg; 2D1T; gedurende 1 week (en een bijbehorend verstrekkingsverzoek)''
De apotheker wordt over het tijdelijk onderbreken van de simvastatine door de huisarts actief geïnformeerd. Er wordt ook een nieuwe medicatieafspraak gemaakt waarmee de simvastatine na een week wordt hervat. Ook ontvangt de apotheker de medicatieafspraak en het bijbehorende verstrekkingsverzoek voor de claritromycine. Zie ook Tijdelijk onderbreken en hervatten van medicatie in [[#Processtap: Maken medicatieafspraak|paragraaf 2.2.5]]. 
[[Bestand:Uc4.1.14.png|800px]] 

===Onderbreken voor een ingreep===
Een 62 jarige man gebruikt acetylsalicylzuur 100 mg 1d1t wegens coronairlijden. Hij moet een darmpoliep laten verwijderen. De huisarts bespreekt met hem dat hij de acetylsalicylzuur drie dagen voor de ingreep moet stoppen en de dag na de ingreep moet hervatten. De huisarts legt het tijdelijk onderbreken in een stop-medicatieafspraak vast met als stopdatum 3 dagen voor de ingreep; stoptype 'tijdelijk'; reden onderbreken ‘ingreep’. In de (tweede) medicatieafspraak voor het hervatten wordt als ingangsdatum 1 dag na de ingreep opgenomen. De huisarts informeert actief de apotheker en de maag-darm-leverarts over de medicatieafspraken. 
Wanneer de datum van de ingreep niet bekend of onzeker is wordt in de toelichting aangegeven dat er 3 dagen voor de ingreep moet worden gestopt en na 1 dag wordt hervat. De duur van de onderbreking is dan 4 dagen. Zie ook Tijdelijk onderbreken en hervatten van medicatie in [[#Processtap: Maken medicatieafspraak|paragraaf 2.2.5]] en Voorafgaand aan opname in [[#Voorafgaand aan opname|paragraaf 3.4.1]]. 
[[Bestand:Uc4.1.15.png|800px]] 

===Papieren recept===
De arts geeft een papieren recept mee aan de patiënt<ref>Eenzelfde situatie doet zich voor wanneer de apotheker een fax ontvangt.</ref>. Een papieren recept bevat een medicatieafspraak en een verstrekkingsverzoek. De patiënt kan met dit recept bij een willekeurige apotheker de medicatie afhalen. De huisarts informeert de verstrekkende apotheker in dit geval niet zelf. Het proces is echter eigenlijk toch hetzelfde: de activiteit '(Actief) beschikbaar stellen' wordt nu alleen 'vervuld' door het papieren recept in handen van de patiënt. De verstrekkende apotheker zal deze papieren medicatieafspraak en verstrekkingsverzoek overnemen in het eigen informatiesysteem en deze invullen met een toedieningsafspraak. Ook kan de apotheker mogelijk de beschikbaar gestelde medicatieafspraak en verstrekkingsverzoek digitaal opvragen en zo verwerken in het eigen informatiesysteem. 
Het informatiesysteem van de huisarts stelt de nieuwe medicatieafspraak en het verstrekkingsverzoek beschikbaar voor medebehandelaars. 
Wanneer het informatiesysteem van de huisarts deze niet beschikbaar heeft gesteld kan er dus sprake zijn van een toedieningsafspraak zonder digitaal beschikbare medicatieafspraak en verstrekkingsverzoek. De apotheker stelt de ‘van papier’ verkregen medicatieafspraak en verstrekkingsverzoek niet beschikbaar omdat hij daar zelf geen eigenaar van is. Daarnaast zou dit er toe kunnen leiden dat er anders, mogelijk pas in de toekomst, onterecht dubbele medicatieafspraken en verstrekkingsverzoeken kunnen voorkomen. 
[[Bestand:Uc4.1.17.png|800px]] 

===Uitvoeren medicatieverificatie en evaluatie bij buitenlandse of zelfzorgmedicatie===
Wanneer medicatie niet in het informatiesysteem gevonden kan worden (bijvoorbeeld buitenlands medicatie en zelfzorgmedicatie) dan wordt deze medicatie vastgelegd als medicatiegebruik (zie [[#Proces: gebruiken|paragraaf 2.5]]).

===Dagbehandeling===
Een dagopname is te vergelijken met een poliklinisch consult of een spoedopname waarbij de medicatie door de ziekenhuisapotheker wordt geleverd. Bij dagopname vindt niet altijd uitgebreide medicatieverificatie plaats. Bij dagopname wordt vastgelegd welke medicatie wordt voorgeschreven (gebeurt vaak op basis van protocollen waarbij achteraf verificatie plaatsvindt) en toegediend. 
Bij bijvoorbeeld cytostatica kuren is er wel een medicatieafspraak maar is niet altijd van te voren duidelijk wanneer de medicatieverstrekking/toediening plaatsvindt. Reden: vaak worden kuren uitgesteld en dan wordt pas later verstrekt en toegediend.

===Starten met medicatie voor opname===
Bij een cataractoperatie wordt 3 dagen voor de behandeling gestart met Nevanac. Deze worden gebruikt tot 3 weken na de operatie (een totale gebruiksduur van 24 dagen). Er wordt door de specialist een medicatieafspraak gemaakt voor Nevanac, 1 druppel ’s morgens, gedurende 24 dagen. Wanneer de datum van de operatie niet bekend of onzeker is kan in de toelichting worden aangegeven dat er 3 dagen voor de operatie moet worden gestart. Zie ook Voorafgaand aan opname in [[#Processtap: Voorafgaand aan opname|paragraaf 3.4.1]]. 
[[Bestand:Uc4.1.20.png|800px]] 

===Spoedopname===
Bij een spoedopname vindt vooraf geen uitgebreide medicatieverificatie plaats zoals dat bij een klinische opname wel gebeurt. Ook het afspreken van medicatie met de patiënt is vaak niet mogelijk. De patiënt krijgt zo snel mogelijk de medicatie toegediend waarbij verificatie vaak achteraf plaatsvindt.

===Tussentijds ontslag===
Wanneer een patiënt tussentijds uit het ziekenhuis/de instelling naar huis gaat, bijvoorbeeld met weekendverlof, loopt de klinische medicatie door. Om de vaste huisarts op de hoogte te houden wordt het medicatieoverzicht meegegeven met de patiënt en worden de medicatiegegevens beschikbaar gesteld.

===Ontslag naar andere instelling===
Bij ontslag naar een andere instelling wordt de medicamenteuze behandeling geëvalueerd (zie [[#Processtap: Evalueren (medicamenteuze) behandeling|hoofdstuk 2.2.4]] en [[#Processtap: Maken medicatieafspraak|2.2.5]]). De medicatiegegevens worden (actief) beschikbaar gesteld. De nieuwe behandelend arts evalueert de medicamenteuze behandeling en bepaalt de instellingsmedicatie.

===Niet verstrekken voor===
De voorschrijvend arts doet op 14 april 2017 een verstrekkingsverzoek, maar wil in datzelfde verstrekkingsverzoek aangeven dat er pas verstrekt mag worden op of vanaf een latere datum, bijvoorbeeld 23 april 2017. In het verstrekkingsverzoek kan dit niet gestructureerd worden vastgelegd maar wordt dit opgenomen in de toelichting (vrije tekst). 
[[Bestand:Uc4.1.25.png|800px]] 

===Stoppen van medicatie door derden===
Medicatie kan door de voorschrijver zelf gestopt worden (zie [[#Stoppen medicatie|Paragraaf 2.2.5.3]]) maar ook door een andere voorschrijver. Bijvoorbeeld de specialist kan medicatieafspraken gemaakt door een huisarts stoppen die volgens het informatiesysteem weliswaar actueel zijn, maar - na bijvoorbeeld medicatieverificatie - dat toch niet blijken te zijn. Wanneer een zorgverlener medicatie stopt maakt hij een nieuwe stop-MA. De zorgverlener kan de medicatieafspraak van een ander niet aanpassen, alleen een stop-MA maken. Hij informeert daarom de zorgverlener van de originele medicatieafspraak actief over deze wijziging (zie [[#Informeren en (actief) beschikbaar stellen|Paragraaf 1.3.5]]). De zorgverlener van de originele medicatieafspraak past de stopdatum aan in de bestaande medicatieafspraak. Dit kan desgewenst ook geautomatiseerd worden door het informatiesysteem. Hiermee wordt voorkomen dat na verloop van tijd de tweede zorgverlener geen gegevens meer hoeft op te leveren omdat de oplevertermijn is verstreken (ook geen stop-MA) terwijl de zorgverlener van de originele medicatieafspraak deze onterecht (zonder stopdatum) wel blijft opleveren. 
[[Bestand:Uc4.1.26.png|800px]] 

===Twee PRK's onder één medicamenteuze behandeling===
Het is een apotheek, binnen bepaalde kaders, toegestaan om een andere PRK te kiezen voor de toedieningsafspraak dan is aangegeven in de medicatieafspraak gemaakt door een voorschrijver. Wanneer vervolgens alleen de toedieningsafspraak kan worden gecommuniceerd vanwege bijvoorbeeld een storing in het informatiesysteem bij de voorschrijver dan heeft een volgende voorschrijver alleen deze toedieningsafspraak met nieuwe PRK. De volgende voorschrijver gaat er dan waarschijnlijk vanuit dat deze PRK ook de PRK van de medicatieafspraak is. Een wijziging in de medicatieafspraak zal dan ook een stop-MA (zonder verwijzing naar originele MA) en een nieuwe medicatieafspraak op basis van deze PRK tot gevolg hebben. Dit betekent dat er twee medicatieafspraken met verschillende PRK's voorkomen onder dezelfde medicamenteuze behandeling. Deze twee medicatieafspraken blijven bestaan. (Het informatiesysteem van) de voorschrijver moet na uitval controleren of er wijzigingen zijn geweest en deze zo nodig doorvoeren (zie ook [[#Stoppen van medicatie door derden|paragraaf 4.1.26]]). 
[[Bestand:Uc4.1.27.png|800px]] 

===Achteraf vastleggen medicatieafspraak===
In bijvoorbeeld spoedsituaties kan het voorkomen dat de medicatieafspraak pas wordt vastgelegd na het verstrekken of toedienen van de medicatie. Dit kan leiden tot conflicterende medicatieafspraken. Op basis hiervan moeten één of meerdere medicatieafspraken gestopt worden zodat er geen parallelle medicatieafspraken voorkomen. De enige uitzondering voor parallelle medicatieafspraken is beschreven in [[#Medicamenteuze behandeling|Paragraaf 1.3.3]].

===Eenmalig gebruik===
Bij medicatie die eenmalig moet worden gebruikt wordt in de gebruiksperiode alleen een stopdatum opgenomen.
Denk aan vaccinaties (bijv. tetanusprik) of de situatie waarin gezegd wordt neem dit eenmalig 3 weken voordat je op vakantie gaat. 
[[Bestand:Uc4.1.30.png|800px]] 

===Voorlopige en definitieve medicatieopdracht===
In de kliniek schrijft de voorschrijver medicatie voor. Dit wordt vastgelegd in een voorlopige medicatieopdracht oftewel, in termen van deze informatiestandaard, de medicatieafspraak. De ziekenhuisapotheker verifieert deze opdracht en legt dit vast als definitieve medicatieopdracht oftewel, in termen van deze informatiestandaard, de toedieningsafspraak.
Zie ook <ref name="MO"/>.

===Onterecht openstaande medicatie of 'weeskinderen'===
In de overgangssituatie en in een situatie waarin niet elk XIS is aangesloten kunnen er medicatieafspraken zijn bij dezelfde behandeling die door verschillende informatiesystemen zijn vastgelegd onder verschillende medicamenteuze behandelingen. Deze medicatieafspraken wil je eigenlijk samenvoegen onder één medicamenteuze behandeling. Dit probleem dient in ieder geval opgelost te worden voor medicatie met een open stopdatum. Die medicatie kan namelijk onder een andere medicamenteuze behandeling zijn gestopt en daardoor open blijven staan en dus blijvend opgeleverd worden. Het betreft hier een ‘weeskind’ (dat wil zeggen: een bouwsteen die is vastgelegd, maar waarbij de zorgverlener op een gegeven moment geen actieve rol meer heeft en zijn informatiesysteem de bouwsteen dus blijft opleveren ook als deze elders al gestopt is). Voor medicatie met stopdatum, sterft dit probleem vanzelf uit en wordt geen koppelingsactie ondernomen.
Wanneer bij medicatieverificatie of -beoordeling wordt geconstateerd dat medicatie onterecht nog open staat wordt er een stop-MA gemaakt onder dezelfde medicamenteuze behandeling. De originele voorschrijver wordt actief geïnformeerd over deze stop-MA en voorziet de medicatieafspraak in zijn eigen informatiesysteem van een stopdatum. Het zetten van de stopdatum kan, afhankelijk van de leverancier en wensen van de klant, automatisch of met tussenkomst van de voorschrijver gebeuren.
Zie ook [[#Staken van medicatie door derden|paragraaf 4.1.26]] en [[#Wijzigen van andermans medicatieafspraak|paragraaf 4.1.40]]. 
[[Bestand:Uc4.1.32.png|800px]] 

===Ontbreken digitale medicatieafspraak bij opname===
Wanneer bij medicatieverificatie geen digitale medicatieafspraak beschikbaar is wordt een nieuwe medicamenteuze behandeling gestart met het vastleggen van medicatiegebruik. Wanneer dit gebruik gestopt moet worden, wordt vervolgens een stop-medicatieafspraak gemaakt onder deze zelfde medicamenteuze behandeling die verwijst naar het vastgelegde medicatiegebruik. 
[[Bestand:Uc4.1.33.png|800px]] 

Zo mogelijk worden oorspronkelijke voorschrijver (bijv. huisarts) en apotheek actief geïnformeerd over het stoppen van deze medicatie.

===Eigen artikelen (90 miljoen nummers)===
Het is mogelijk om een 90 miljoen nummer uit te wisselen. Voorwaarde is dat binnen een organisatie een eenmaal aangemaakt 90 miljoen nummer nooit aangepast mag worden. Bij de uitwisseling zorgt de root oid (unieke technische identificatie van de organisatie) in combinatie met het 90 miljoen nummer ervoor dat deze uniek is ten opzichte van alle 90 miljoen nummers vanuit andere organisaties. 
De stoffen waaruit dit artikel bestaat worden als ingrediënten in de medicatieafspraak meegegeven (minimaal één ingrediënt) zoals dit ook het geval is bij magistralen.

===Dosering met minimum interval===
Medicatie kan voorgeschreven worden met een vast interval (bijvoorbeeld: elke 6 uur 2 tabletten). Het voorschrijven van medicatie met een minimum interval dient gedeeltelijk in vrije tekst te gebeuren. 
Bijvoorbeeld zo nodig maximaal 3x per dag, minimaal 6 uur tussen de innamemomenten: 
Hierbij wordt ''zo nodig'' en ''maximaal 3x per dag'' op de standaard manier vastgelegd. Het onderdeel ''"minimaal 6 uur tussen de innamemomenten"'' wordt in vrije tekst als ''Aanvullende instructie'' vastgelegd. 
 
[[Bestand:Uc4.1.35.png|800px]]

===Verstrekkingsverzoek met aantal herhalingen===
De voorschrijver maakt een verstrekkingsverzoek bij een medicatieafspraak waarin zij het aantal herhalingen invult.
Hiermee geeft de voorschrijver bij de verstrekker aan dat deze additionele verstrekkingen mag doen.

Het aantal herhalingen in combinatie met de te verstrekken hoeveelheid resulteert in: (Aantal herhalingen + 1) x te verstrekken hoeveelheid.
In geval van "Aantal herhalingen = 3" en "Te verstrekken hoeveelheid = 30 stuks", mag de verstrekker 4 maal 30 stuks verstrekken (in totaal 120 stuks).

Het aantal herhalingen in combinatie met de verbruiksperiode duur resulteert in: (Aantal herhalingen + 1) x verbruiksperiode duur.
De te verstrekken hoeveelheid is hierbij afhankelijk van de dosering.
In geval van "Dosering = 3x per dag 2 stuks", "Aantal herhalingen = 3" en "Verbruiksperiode duur = 30 dagen", mag de verstrekker 4 maal (6 stuks per dag x 30 dagen=) 180 stuks verstrekken (in totaal 720 stuks). 
 
[[Bestand:Uc4.1.36.png|800px]]

===Voorschrijven van niet geneesmiddelen (verbandmiddelen, krukken of andere hulpmiddelen)===
Niet geneesmiddelen kunnen vanuit de G-standaard voorgeschreven worden op HPK niveau.
Dit kan bijvoorbeeld een inhalator (Aerochamber, HPK 1915185) als hulpmiddel voor voorgeschreven aerosolen zijn.
Niet geneesmiddelen zijn niet van toepassing voor het medicatieoverzicht of medicatiebewaking.

===Nierfunctiewaarde sturen met het voorschrift ===

'''A) Nierfunctiewaarde met een nieuw voorschrift:''' 
Ter preventie van een beroerte krijgt een patiënt (man, 65 jaar) voor het eerst Dabigatran voorgeschreven.
De patiënt heeft een verminderde nierfunctie en de voorschrijver heeft een recente nierfunctiewaarde beschikbaar.
Op basis van deze nierfunctiewaarde wijkt de voorschrijver af van de standaard dosering en maakt een medicatieafspraak aan met een lagere dosering van Dabigatran 2x daags 1 capsule van 110 mg vanaf 15 januari 2020.
De voorschrijver maakt ook een verstrekkingsverzoek en stuurt het voorschrift (medicatieafspraak, verstrekkingsverzoek) met de laboratoriumuitslag nierfunctiewaarde aan de apotheker. 
[[Bestand:Uc4.1.38A.PNG|800px]]

'''B) Nierfunctiewaarde reden voor een wijziging:''' 
Een man van 70 jaar heeft enkele dagen geleden 3x daags 1 tablet metformine 500 mg voorgeschreven gekregen (medicatieafspraak met verstrekkingsverzoek). De arts heeft tegelijkertijd een bloed onderzoek in gang gezet om de nierfunctiewaarde te bepalen van de patiënt. De waarde was nog niet bekend op het moment van voorschrijven. 
[[Bestand:Uc4.1.38B1.PNG|800px]]

Uit het onderzoek blijkt dat de nierfunctie verminderd is en reden geeft tot aanpassing van de medicatieafspraak.
De voorschrijver past de dosering op 17 januari 2020 aan naar 2x daags 1 tablet metformine 500 mg en bespreekt dit met de patiënt.
Het nieuwe voorschrift (de 'technische' stop-medicatieafspraak, nieuwe medicatieafspraak) wordt met de laboratoriumuitslag nierfunctiewaarde door de voorschrijver aan de apotheek gestuurd.
Omdat de patiënt de medicatie al had opgehaald en daardoor voldoende voorraad heeft, wordt er geen nieuw verstrekkingsverzoek meegestuurd. 
[[Bestand:Uc4.1.38B2.PNG|800px]]

'''C) Nierfunctiewaarde van toepassing vanwege geneesmiddel:''' 
Patiënte krijgt vanwege een blaasontsteking Nitrofurantoine 100 mg, 2x daags 1 capsule voorgeschreven als kuur van 5 dagen en moet meteen starten op 6 januari 2020. Bij dit geneesmiddel moet de nierfunctie waarde (indien bekend en niet ouder dan 13 maanden) meegestuurd worden. De voorschrijver heeft voor deze patiënte een nierfunctie waarde beschikbaar, welke echter geen aanleiding geeft tot een aangepaste dosering.
De voorschrijver stuurt het voorschrift (medicatieafspraak, verstrekkingsverzoek) met de laboratoriumuitslag nierfunctiewaardenaar de apotheker. 
[[Bestand:Uc4.1.38C.PNG|800px]]

===Annuleren eerder verstuurd voorschrift ===
Patiënt komt 's ochtends bij huisarts in verband met maagklachten. De huisarts schrijft pantoprazol voor en stuurt het voorschrift (MA + VV1) naar de voorkeursapotheek zoals bij de huisarts bekend is. Patiënt belt ’s middags op dat hij de medicatie nog niet heeft opgehaald en dat hij dit graag bij een andere apotheek wil doen i.v.m. een recente verhuizing, maar dat hij dit ’s ochtends is vergeten aan te geven. De huisarts stuurt de apotheek waar het eerdere voorschrift naartoe is gestuurd opnieuw het voorschrift, maar waarbij het VV de geannuleerd indicator bevat (MA + VV1”geannuleerd”), zodat de apotheker weet dat hij op dit voorschrift niet moet verstrekken.
Daarna stuurt de voorschrijver een nieuw voorschrift (MA + VV2) naar de nieuwe apotheek van de patiënt. De patiënt kan de medicatie daar ophalen. 
In medicatiebouwstenen ziet dit er als volgt uit: 
[[Bestand:Uc4.1.39A.png|800px]] 
De transacties zien er zo uit: 
[[Bestand:Uc4.1.39B.png|600px]] 

===Wijzigen van andermans medicatieafspraak ===
Een patiënt slikt een keer per dag 40 mg Lisinopril in verband met hypertensie. Deze medicatieafspraak is eerder door de huisarts met de patiënt gemaakt. De patiënt komt binnen op de spoedeisende hulp in verband met een val door duizeligheid. De specialist constateert hypotensie en besluit om de dosering van de Lisinopril te verlagen naar een keer per dag 20 mg. Hierop stopt de specialist de huidige MA, en start de nieuwe MA met een lagere dosering. Hiermee wijzigt hij de medicatieafspraak met de patiënt. De specialist informeert de oorspronkelijke voorschrijver(de huisarts) hierover met een stop-MA en de nieuwe MA.
De zorgverlener van de originele medicatieafspraak past de stopdatum aan in de bestaande medicatieafspraak. Dit kan desgewenst ook geautomatiseerd worden door het informatiesysteem. Hiermee wordt voorkomen dat na verloop van tijd de tweede zorgverlener geen gegevens meer hoeft op te leveren omdat de oplevertermijn is verstreken (ook geen stop-MA) terwijl de zorgverlener van de originele medicatieafspraak deze onterecht (zonder stopdatum) wel blijft opleveren.
 
[[Bestand:Uc4.1.40.PNG|800px]]
 
===Opstarten van een wisselend doseerschema ===
De voorschrijver schrijft bij een patiënt antistollingsmedicatie voor en geeft in de MA aan dat de medicatie gebruikt wordt volgens het schema van de trombosedienst. De voorschrijver stuurt een VV naar de apotheker en de patiënt wordt aangemeld bij de trombosedienst. Om de periode tot de trombosezorg betrokken is te overbruggen, maakt de voorschrijver een wisselend doseerschema aan voor de eerste periode. Na de aanmelding stelt de trombosedienst een doseerschema op dat het schema van de voorschrijver overschrijft of opvolgt. Vanaf dit moment neemt de trombosedienst de doseerschema’s over van de oorspronkelijke voorschrijver.

[[Bestand:Opstarten wisselend doseerschema.png|800px]]

===Tussentijds wijzigen wisselend doseerschema ===
Het kan nodig zijn om het doseerschema uit een WDS te herzien voor de stopdatum uit het schema. Bijvoorbeeld wanneer de patiënt onverwacht een kleine ingreep moet ondergaan. In dit geval stopt de voorschrijver het lopende WDS met een technische stop (niet zichtbaar voor de gebruiker) en maakt de voorschrijver een nieuw WDS aan met enkele 0-doseringen de dagen voorafgaand aan de ingreep. De MA loopt in de tussentijd gewoon door.
[[Bestand:Uc_Tussentijds_wijzigen_WDS.png|800px]]

===Stoppen medicatie met een wisselend doseerschema ===
Wanneer de patiënt (tijdelijk) helemaal moet stoppen met het gebruik van antistollingsmedicatie, wordt dit vastgelegd op het niveau van de MA. De trombosearts maakt dan een stop-MA aan. Daarmee wordt ook het onderliggende WDS en de bijbehorende TA gestopt. De originele voorschrijver verwerkt de stopdatum ook in zijn MA.
Als de antistollingsmedicatie na een aantal maanden weer opgestart moet worden, doet de oorspronkelijke voorschrijver van de antistollingsmedicatie dit door het proces van het opstarten van een WDS te volgen. Dus door een nieuwe MA te maken en een eerste WDS (zie de use case [[#Opstarten van een wisselend doseerschema|opstarten van een wisselend doseerschema]]).
[[Bestand:Uc_Stoppen_WDS.png|800px]]

==Use cases Ter hand stellen==

===Nieuwe medicatieafspraak, medicatieverstrekking zelfde product===
De patiënt is op 27 januari 2013 bij de apotheker om medicatie af te halen. De apotheker opent het dossier van de patiënt en verifieert het medicatiedossier. Het betreft een nieuwe medicatieafspraak voor deze patiënt. De relevante informatie van de voorschrijvende arts is weergegeven op het scherm van de apotheker: 
Medicatieafspraak: ''Nitrofurantoïne capsule mga 100 mg, 2 maal daags 1 capsule, vanaf heden gedurende 5 dagen.'' 
Verstrekkingsverzoek: ''Nitrofurantoïne capsule mga 100 mg; 10 stuks.''

De apotheker kiest een product op basis van de medicatieafspraak en andere factoren (zoals bijvoorbeeld de voorraad van de apotheker, preferentiebeleid zorgverzekeraar): 
''FURABID CAPSULE MGA 100 MG'' 
De apotheker voert medicatiebewaking uit met behulp van het informatiesysteem, er zijn geen signalen. 
De apotheker voert farmaceutische zorg (therapietrouw, voorlichting, etcetera) uit en spreekt met de patiënt af hoe zij de medicatie zal gebruiken. Deze toedieningsafspraak op 27 januari 2013 luidt: 
''FURABID CAPSULE MGA 100 MG; 2 maal daags 1 capsule; vanaf heden gedurende 5 dagen.''
De apotheker verstrekt de medicatie aan de patiënt: 
''op 27 januari 2013, FURABID CAPSULE MGA 100 MG; 10 stuks.''
De apotheker informeert de voorschrijvende arts actief over de toedieningsafspraak en de medicatieverstrekking. 
Het informatiesysteem van de apotheker maakt de nieuwe toedieningsafspraak en medicatieverstrekking beschikbaar voor de medebehandelaars van deze patiënt. 
 
[[Bestand:Uc4.2.1.PNG|800px]]

===Nieuwe medicatieafspraak, nadere specificering product===
Het verschil bij het specificeren van het product is dat de afspraak over toediening en ook de medicatieverstrekking afwijkt van de afspraak die de patiënt met de voorschrijvende arts heeft gemaakt. Verder is het proces hetzelfde als beschreven in de voorgaande paragraaf.

'''Voorbeeld''' 
Medicatieafspraak: ''Nitrofurantoïne capsule mga 100 mg, 2 maal daags 1 capsule, vanaf heden gedurende 5 dagen.'' 

De apotheker specificeert een ander product:
:''Nitrofurantoïne MC Actavis capsule 50 mg.''
De apotheker spreekt met de patiënt af hoe zij de medicatie zal gebruiken. Deze toedieningsafspraak op 27 januari 2013 luidt:
:''Nitrofurantoïne MC Actavis capsule 50 mg; 4 maal daags 1 capsule; vanaf heden gedurende 5 dagen.''
De apotheker verstrekt de medicatie aan de patiënt:
:''op 27 januari 2013, Nitrofurantoïne MC Actavis capsule 50 mg; 20 stuks.'' 
 
[[Bestand:Uc4.2.2.PNG|800px]]

===Bestaande toedieningsafspraak voldoet===
Het proces van het doen van een nieuwe medicatieverstrekking op basis van een bestaande medicatieafspraak, evt. bestaand verstrekkingsverzoek én toedieningsafspraak komt voor bij herhalen en is beschreven in paragraaf [[#Knippen van recept|4.2.10]], situatie 2.

===Medicatieafspraak gewenst (Informeren voorschrijver)===
'''Voorbeeld 1 - dosering aanpassen:''' 
De apotheker voert bij een patiënt van 70 jaar met creatinineklaring 45 ml/min een toedieningsafspraak in voor gabapentine tablet 600 mg 3x per dag 1 tablet. In de apotheek is de nierfunctie vastgelegd in het patiëntendossier, en op basis daarvan verschijnt er een signaal dat de maximale dosering 900 mg per dag is. De apotheker stuurt een voorstel medicatieafspraak met een aangepaste dosering van 300 mg 3x per dag en de reden voor dit voorstel (maximale dosering overschreden) naar de voorschrijver. De voorschrijver ontvangt het voorstel medicatieafspraak in zijn EVS. Hierop verstuurt de voorschrijver een aangepaste medicatieafspraak en optioneel een antwoord voorstel medicatieafspraak terug naar de apotheker. 
[[Bestand:Uc4.2.4.1.png|800px]] 

'''Voorbeeld 2 – geneesmiddel tijdelijk stoppen:''' 
De apotheker voert bij een patiënt van 50 jaar met een kuur fluconazol oraal in de actuele medicatie, een toedieningsafspraak in voor simvastatine. Er verschijnt een melding met het advies om te overwegen simvastatine tijdelijk te stoppen. De apotheker kan een voorstel medicatieafspraak voor het stoppen van simvastatine maken (stoptype 'tijdelijk'). Voor verdere stappen zie voorbeeld 1. 
[[Bestand:Uc4.2.4.2.png|800px]] 

'''Voorbeeld 3 – geneesmiddel toevoegen:''' 
De apotheker voert bij een vrouw van 55 jaar een toedieningsafspraak in voor prednison 10 mg per dag gedurende 3 maanden. De patiënt gebruikt geen osteoporoseprofylaxe. Er verschijnt een melding met het advies om een bisfosfonaat toe te voegen en na te gaan of de patiënt calcium en vitamine D gebruikt. Wanneer de patiënt deze middelen niet gebruikt kan de apotheker een voorstel medicatieafspraak voor deze middelen maken. Voor verdere stappen zie voorbeeld 1. 
[[Bestand:Uc4.2.4.3.png|800px]] 

LET OP: het zal van de situatie afhangen of het zinvol is geautomatiseerd een voorstel voor aanpassing/toevoeging van een MA te doen. Als het advies complex is, kan het nog steeds zinvol zijn om te bellen en te overleggen, i.p.v. een digitaal voorstel te sturen. 
De voorstel medicatieafspraak kan de voorschrijver helpen deze wijziging in de registratie door te voeren. Dit laatste is van belang wanneer medicatieafspraken worden geraadpleegd zoals in de dienstwaarneming huisartsen.

===Aanschrijven en verstrekken===
Wanneer een medicatieafspraak met verstrekkingsverzoek bij de apotheek binnen komt wordt deze verwerkt in het apotheek informatiesysteem tot een voorgenomen uitgifte. Dit wordt het moment van aanschrijven genoemd, welke als aanschrijfdatum in de medicatieverstrekking wordt vastgelegd. De verstrekkingsdatum wordt gevuld bij afhalen of overhandigen. De apotheker informeert de voorschrijver over de afhandeling van het voorschrift (toedieningsafspraak en/of medicatieverstrekking).

Het is mogelijk om meerdere verstrekkingen onder dezelfde TA aan te maken:
*Er komt een verstrekkingsverzoek binnen met een medicatieafspraak met een gebruiksperiode van een jaar.
*Er vindt een eerste verstrekking plaats met een nieuwe TA en een medicatieverstrekking welke voldoende is voor bijvoorbeeld een periode van 4 maanden.
 
[[Bestand:Uc4.2.5a.PNG|800px]]
 
*De tweede verstrekking wordt op basis van de bestaande medicatieafspraak, verstrekkingsverzoek en toedieningsafspraak uitgevoerd (er is geen nieuw voorschrift of een nieuwe toedieningsafspraak nodig). De nieuwe tweede medicatieverstrekking (met nieuwe aanschrijfdatum en de reeds bestaande bijbehorende toedieningsafspraak) wordt verstuurd naar de voorschrijver wanneer de verstrekkingsdatum geregistreerd is.
 
[[Bestand:Uc4.2.5b.PNG|800px]]

===Patiënt vraagt herhaalrecept via arts (reactief herhalen)===
Een arts heeft eerder hypertensie geconstateerd bij een patiënt (57 jaar) en heeft de patiënt hiervoor medicatie voorgeschreven. De patiënt gebruikt deze medicatie en de medicatie raakt op. De patiënt doet een verzoek om de medicatie te herhalen via bijvoorbeeld de herhaallijn, telefonisch, per e-mail aan de praktijk, balie/doosjes, website, app of portaal van de arts. De arts geeft toestemming voor herhaling. Dit leidt tot een nieuw verstrekkingsverzoek. 
Bijvoorbeeld:
:De huisarts doet, in het kader van de medicatieafspraak van 30 maart 2010:
:''Nifedipine mga 30 mg; 1 maal daags 1 tablet vanaf 30 maart 2010 tot voor onbepaalde duur''
:op 13 april 2013 een verstrekkingsverzoek aan een apotheker naar keuze van de patiënt:
:''Nifedipine tablet mga 30 mg; ‘voor drie maanden’.''
In overleg met de patiënt kan de voorschrijver het verstrekkingsverzoek met de bijbehorende medicatieafspraken als opdracht versturen naar de apotheker naar keuze van de patiënt. Daarnaast stelt de voorschrijver het nieuwe verstrekkingsverzoek beschikbaar aan medebehandelaars en patiënt. De bestaande medicatieafspraken waren reeds eerder beschikbaar gesteld. 
[[Bestand:Uc4.2.6.png|800px]] 
De apotheker ontvangt het verstrekkingsverzoek tezamen met de medicatieafspraak en handelt het af conform het proces van ter hand stellen en start met de processtap farmaceutische zorg. 
Wanneer de patiënt op basis van een toedieningsafspraak of op basis van zijn gebruik om een herhaalrecept vraagt, waarbij de medicatieafspraak niet digitaal beschikbaar is, maakt de arts een nieuwe medicatieafspraak die gebaseerd is op deze toedieningsafspraak of gebruik van de patiënt. Er vindt dan geen verwijzing plaats naar de bestaande medicatieafspraak.

===Patiënt vraagt herhaalrecept via apotheker (Informeren voorschrijver)===
De patiënt vraagt herhaling van medicatie aan bij apotheker, bijvoorbeeld via herhaallijn, telefonisch, e-mail, balie/doosjes, website, app of portaal van de apotheker. 
De apotheker stuurt een voorstel verstrekkingsverzoek ter autorisatie aan de voorschrijver. De arts beoordeelt het voorstel verstrekkingsverzoek en accordeert deze. Hij informeert de apotheker via het antwoord voorstel verstrekkingsverzoek en stuurt een nieuw verstrekkingsverzoek samen met de actuele afspraken naar de apotheker. De apotheker vervolgt het proces van ter hand stellen en start met de processtap farmaceutische zorg. 
[[Bestand:Uc4.2.7.png|800px]] 
Als de voorschrijver geen verstrekkingsverzoek afgeeft informeert hij de apotheker via het antwoord voorstel verstrekkingsverzoek hierover.

===Proactief herhaalrecept door apotheker (Informeren voorschrijver)===
De patiënt heeft zich in het verleden aangemeld voor proactief herhalen en de apotheker heeft dit geregistreerd in het eigen apotheek informatiesysteem (AIS). De herhaalmodule van dit informatiesysteem zal een signaal genereren wanneer een patiënt nieuwe medicatie nodig heeft. Als er een nieuw verstrekkingsverzoek nodig is komt dit overeen met het proces beschreven in de vorige paragraaf, alleen de trigger is niet de patiënt maar de apotheker (of zijn informatiesysteem) zelf. Proactief herhalen wordt ook gebruikt voor GDS, zie [[#Het opstarten en continueren van GDS|paragraaf 4.2.11]]. 
[[Bestand:Uc4.2.8.png|800px]] 

===Verstrekken op basis van bestaand verstrekkingsverzoek===
De patiënt levert een herhaalrecept in bij de apotheker. Het betreft in dit geval een verzoek tot medicatieverstrekking op basis van een bestaand, nog geldig, verstrekkingsverzoek. Zie hiervoor [[#Knippen van recept|paragraaf 4.2.10 situatie (3)]].

===Knippen van recept===
Een patiënt gebruikt al jaren dezelfde medicatie. De medicatieafspraak kan voor onbepaalde duur worden gemaakt. Ook de toedieningsafspraak volstaat voor onbepaalde duur. De patiënt komt dan in aanmerking voor een jaarrecept. Wanneer de patiënt een jaarrecept krijgt dan moet er geknipt worden door de apotheker. De geknipte recepten zijn feitelijk geen 'herhaalrecept' maar we noemen het in de wandelgangen wel zo. 
Er zijn drie situaties: 
1) Patiënt komt terug bij behandelend arts en de klachten zijn nog niet over. De voorschrijver schrijft hetzelfde voor (bij een verlopen medicatieafspraak wordt een nieuwe medicatieafspraak met nieuw verstrekkingsverzoek gemaakt en bij een nog lopende medicatieafspraak wordt alleen een nieuw verstrekkingsverzoek gemaakt). 
[[Bestand:Uc4.2.10A.png|800px]] 

2) Voorschrijver en patiënt spreken initieel af: 90 stuks met 3x herhalen. De patiënt krijgt initieel 90 stuks verstrekt. De volgende keer dat de patiënt bij de apotheker komt wordt er een medicatieverstrekking gedaan onder de bestaande afspraken. 
[[Bestand:Uc4.2.10B.png|800px]] 
3) Voorschrijver en patiënt spreken initieel af: 360 stuks gedurende een jaar. De apotheker knipt dit in 4 deelverstrekkingen. De patiënt krijgt dan initieel 90 stuks verstrekt en kan zonder nieuw verstrekkingsverzoek daarna nog 3x bij de apotheker een medicatieverstrekking afhalen van 90 stuks. 
[[Bestand:Uc4.2.10C.png|800px]] 
Deze laatste situatie beschrijft feitelijk de situatie van het knippen van een jaarrecept door de apotheker.

===Het opstarten en continueren van GDS===
Het voorbeeld hierna toont het proces rondom één geneesmiddel dat door de patiënt voor onbepaalde duur wordt gebruikt. In het informatiesysteem van de voorschrijver en de apotheker staan (onder andere) de volgende gegevens over een patiënt:
*De medicatieafspraak op 2 januari 2013 luidt: Metoprolol tablet mga 100 mg (succinaat); een maal daags een tablet; van 2 januari 2013 voor onbepaalde duur.
*De toedieningsafspraak op 2 januari 2013 luidt: Metoprolol PCH retard 100 tablet mga 95 mg; een maal daags een tablet; van 2 januari 2013 voor onbepaalde duur.
Deze bejaarde patiënt heeft zoveel medicatie dat hij geen overzicht meer heeft: een potentieel gevaar. Op 6 februari spreken de apotheker en de voorschrijver af dat de medicatieverstrekking van geneesmiddelen aan deze patiënt gebeurt via GDS.

De GDS wordt opgestart: de apotheker stuurt een voorstel verstrekkingsverzoek (qua gebeurtenis vergelijkbaar met het huidige verzamelrecept of autorisatieformulier).

Het voorstel verstrekkingsverzoek van 6 februari luidt:
*Verstrekkingsverzoek ten behoeve van de medicatieafspraak van 2 januari 2013: Metoprolol tablet mga 100 mg (succinaat), en een verbruiksperiode voor voldoende voorraad tot en met 1 mei 2013.
De apotheker stuurt het voorstel naar de voorschrijver. De voorschrijver fiatteert het voorstel op 6 februari en stuurt het als verstrekkingsverzoek ongewijzigd naar de apotheker. In zowel het informatiesysteem van de voorschrijver als de apotheker wordt bij de patiënt het kenmerk GDS aangezet.

De apotheker kiest met de patiënt een deeltijd voor het middel. Deze toedieningsafspraak luidt als volgt:
*Op 7 februari is afgesproken: Metoprolol PCH retard 100 tabl mga 95 mg; 1 tablet ‘s morgens; vanaf 11 februari (week 6) voor onbepaalde duur.
De apotheker verstrekt iedere tweede week een baxterrol medicatie met (onder andere) de Metoprolol:
*Verstrekking 1: De apotheker verstrekt op vrijdag 8 februari 2013: 14 tabletten; gepland voor week 6 en 7 (een verbruiksduur van 2 weken).
*Verstrekking 2: De apotheker verstrekt op vrijdag 22 februari: 14 tabletten; gepland voor week 8 en 9.
*Verstrekking 3, 4, 5, enzovoorts...
Bij elke medicatieverstrekking wordt aangegeven dat deze via GDS geleverd is. 
Na drie maanden volgt opnieuw een voorstel verstrekkingsverzoek van de apotheek aan de voorschrijver, enzovoorts. 
[[Bestand:Uc4.2.11.png|800px]] 

'''Beschouwing''' 
*Het toepassen van een voorstel verstrekkingsverzoek in plaats van een autorisatieformulier maakt de betekenis ervan eenduidig.
*Doordat in de huidige situatie toedieningsafspraken en medicatieverstrekkingen als één aflevering wordt geregistreerd, is het moeilijk om in de grote hoeveelheid berichten zinvolle informatie te vinden. Het scheiden van het afleverbericht in twee bouwstenen maakt het overzicht eenvoudiger te overzien: er zijn géén nieuwe medicatieafspraken en er is één nieuwe toedieningsafspraak gemaakt. De resterende logistieke gegevens bevatten geen verrassingen. De medicatieverstrekkingen hoeven in dit scenario niet onder de aandacht van de huisarts te komen.
*Deze wijze van registreren en uitwisselen voorkomt dubbele registratie, en fouten ten gevolge daarvan.
*De toedieningsafspraken vormen de basis voor toedienlijst en aftekenlijsten van verpleeg- en verzorgingshuizen. Het aftekenen ervan komt overeen met de toediening(en).

===De apotheker wijzigt van handelsproduct===
Dit scenario bouwt voort op het vorige scenario: na een half jaar wordt een ander handelsproduct afgesproken met de patiënt (toedieningsafspraak), omdat het andere product niet leverbaar is. Er wordt geen nieuwe medicatieafspraak gemaakt, op dat niveau vindt geen wijziging plaats. De toedieningsafspraak wordt gewijzigd:
*Op 1 juli is afgesproken: Metoprolol Sandoz ret 100 tabl mga 95 mg; 1 tablet ‘s morgens; vanaf 3 juli voor onbepaalde duur. Reden: niet leverbaar.
De toedieningsafspraak is een wijziging van de toedieningsafspraak van 7 februari (welke stopt op 2 juli (23.59u)) en is een concrete invulling van de medicatieafspraak van 2 januari. De apotheker informeert de huisarts over deze gegevens.
[[Bestand:Uc4.2.12.PNG|800px]] 

'''Beschouwing''' 
Deze wijziging in de concrete invulling van de medicatieafspraak door middel van een toedieningsafspraak, verandert niets aan de geldigheid van de medicatieafspraak. Dit komt het overzicht ten goede. Aanvullend kan, doordat de apotheker de reden van aanpassing vastlegt en uitwisselt, de voorschrijver beter inschatten of de informatie relevant is.

===Medicatie toevoegen aan GDS===
Wanneer nieuwe medicatie wordt toegevoegd aan bestaande GDS kan de voorschrijver kiezen voor directe toevoeging aan de rol (Wijziging in GDS per direct) of met ingang van de volgende rol (Wijziging in GDS per rolwissel). Dit geeft de voorschrijver aan in de medicatieafspraak (Aanvullende informatie).
Wanneer gekozen wordt voor ‘Wijziging in GDS per direct’ zal de apotheker de medicatie eerst los, naast de bestaande GDS leveren. Dit betekent dat er een toedieningsafspraak door de apotheker wordt gemaakt voor de overbruggingsperiode. Met ingang van de nieuwe rol wordt de nieuwe medicatie toegevoegd aan de rol. Met ingang van de ingangsdatum van de nieuwe rol kan er een toedieningsafspraak worden gemaakt door de apotheker met specifieke toedientijden. Wanneer de 'overbruggings-toedieningsafspraak' al de juiste toedientijden bevat wordt er geen nieuwe toedieningsafspraak gemaakt bij opname in de rol. 
[[Bestand:Uc4.2.13.png|800px]] 
Wanneer gekozen wordt voor 'Wijziging in GDS per rolwissel' zal de apotheker de medicatie opnemen in de eerstvolgende rol die wordt uitgegeven aan de patiënt. Er hoeft geen toedieningsafspraak gemaakt te worden voor de overbruggingsperiode.

===Medicatie in GDS stoppen===
Wanneer medicatie wordt gestopt wordt er een stop-medicatieafspraak gemaakt door de voorschrijver. De apotheker wordt conform het proces geïnformeerd over deze stop-medicatieafspraak en kan de levering daarop aanpassen. De apotheker zal een stop-toedieningsafspraak maken. Zie hiervoor paragraaf [[#Stoppen medicatie|2.2.5.3]] en [[#Stoppen toedieningsafspraak|2.3.6.3]].

===GDS leverancier levert ander handelsproduct===
Het kan zijn dat een GDS leverancier een ander handelsproduct levert dan door de apotheek in de TA is opgenomen.
Hier is dus sprake van een wijziging in de HPK welke zorgt voor een gewijzigde TA.
Eventueel is dit pas achteraf, na terugkoppeling van de GDS leverancier van de definitieve invulling. 
[[Bestand:Uc4.2.15.png|800px]] 
 
===Parallelle toedieningsafspraken bij GDS- en niet-GDS-verstrekking===
Een patiënt slikt twee tot drie keer per dag 20 mg pantoprazol in verband met maagklachten. De eerste twee tabletten zijn vaste dosering en worden geleverd in GDS. De derde tablet neemt hij zo nodig en is los verpakt. Op een bepaald moment is de pantoprazol 20 mg van Sandoz niet leverbaar voor losse verstrekkingen. Daarop besluit de apotheker om Apotex te verstrekken. Hiervoor stopt hij de bestaande TA en splitst deze (onder de bestaande MA) op in twee TA’s, beide met dezelfde startdatum/tijd. De eerste TA heeft betrekking op de vaste dosering in GDS, de tweede gaat over de zo nodig tablet. 
''NB. Er is op dit moment nog geen relatie tussen de verstrekking en een specifieke TA. Daarom is nu niet te zien bij welke TA een verstrekking hoort zonder de inhoud te checken. Er wordt gekeken of dit in de toekomst anders moet.'' 
 
[[Bestand:Uc4.2.16.png|800px]] 

===Afhandelen stoppen medicatieafspraak===
Wanneer er door de voorschrijver afgesproken wordt medicatie te stoppen wordt een stop-MA gemaakt. Deze stop-MA wordt bij de apotheker ingevuld door het stoppen van de toedieningsafspraak.

===Verstrekken onder andermans toedieningsafspraak===
Een patiënt slikt twee keer per dag 20 mg pantoprazol in verband met maagklachten. Tijdens een vakantie komt de patiënt erachter dat hij zijn medicatie vergeten is. Hij gaat naar een HAP bij hem in de buurt en vraagt om extra tabletten voor tijdens zijn vakantie. De dienstdoende arts stuurt een VV aan de dienstapotheek onder de bestaande MA. 
De apotheker van de dienstapotheek ziet het medicatievoorschrift en maakt een MVE aan onder de reeds bestaande TA voor de 10 tabletten die de patiënt nodig heeft en informeert de dienstdoende arts over deze verstrekking. Daarbij stuurt de apotheker een kopie van de oorspronkelijke TA mee. 
''NB. De oorspronkelijke voorschrijver en verstrekker worden niet automatisch geïnformeerd, maar de gegevens zijn voor hen wel beschikbaar.'' 
 
[[Bestand:Uc4.2.18A.png|800px]] 
 
===Wijzigen van andermans toedieningsafspraak===
Een patiënt slikt twee keer per dag 20 mg pantoprazol in verband met maagklachten. Tijdens een vakantie komt de patiënt erachter dat hij zijn medicatie vergeten is. Hij gaat naar een HAP bij hem in de buurt en vraagt om extra tabletten voor tijdens zijn vakantie. De dienstdoende arts stuurt een VV aan de dienstapotheek onder de bestaande MA. 
De apotheker van de dienstapotheek constateert dat zij geen voorraad pantoprazol van Sandoz hebben, maar van Apotex. Hierop stopt ze de huidige TA, start ze de nieuwe TA voor de Apotex en maakt ze de MVE voor de 10 tabletten Apotex aan. De dienstapotheker informeert de oorspronkelijke apotheker hierover en de oorspronkelijke apotheker verwerkt de stop-TA.
 
[[Bestand:Uc4.2.18B.png|800px]] 
 

==Use cases Toedienen==

===Toedienlijst opstarten===
Wanneer gestart wordt met het gebruik van een toedienlijst, bijvoorbeeld wanneer de patiënt in zorg komt bij een (professionele) toediener, start met GDS-medicatie of niet-GDS-medicatie, vindt een intake plaats met de patiënt en voorschrijver, apotheker of toediener (proces verschilt per zorginstelling). Vervolgens vindt er overleg plaats tussen voorschrijver, apotheker, toediener en/of patiënt waarbij afgestemd wordt welke medicatie op de toedienlijst komt en welke (richt)toedientijden geschikt zijn. De apotheker registreert de (richt)toedientijden in de TA en stelt de benodigde medicatiegegevens voor de toedienlijst (actief) beschikbaar aan toediener en/of patiënt.

===Exacte toedientijden nodig ===
Wanneer er exacte toedientijden nodig zijn, bijvoorbeeld in geval van een wisselwerking tussen medicatie kan de voorschrijver of apotheker aangeven dat een exacte toedientijd nodig is en dat de toedientijd geen richttijd is. De voorschrijver of apotheker kan dit vastleggen door aan te geven dat de toedientijd niet flexibel is. Standaard wordt uitgegaan van flexibele (richt)toedientijden. Een exacte toedientijd moet vermeld worden op de toedienlijst, zodat de toediener weet dat van deze toedientijd niet afgeweken mag worden.

===Ontbreken (richt)toedientijden ===
Wanneer (richt)toedientijden ontbreken in zowel MA als TA zoeken toedieners contact met de voorschrijver of apotheker om de (richt)toedientijd te achterhalen. Dit wordt niet digitaal ondersteund in deze informatiestandaard.

===Niet-GDS-medicatie zo nodig ===
Niet-GDS-medicatie zo nodig staat op de toedienlijst, maar niet per toedienmoment en/of tijd, omdat dit van te voren niet bekend is. Wanneer het relevant is (bijv. bij interactie met andere medicatie) kunnen er wel (richt)toedientijden meegegeven worden.

Zie de volgende use cases voor praktische voorbeelden: [[mp:V9_2.0.0_Ontwerp_medicatieproces#Zo nodig medicatie|4.1.4 Zo nodig medicatie]], [[mp:V9_2.0.0_Ontwerp_medicatieproces#Kuur zo nodig startend in de toekomst|4.1.5 Kuur zo nodig startend in de toekomst]], [[mp:V9_2.0.0_Ontwerp_medicatieproces#Twee doseringen van hetzelfde geneesmiddel tegelijkertijd|4.1.6 Twee doseringen van hetzelfde geneesmiddel tegelijkertijd]],
[[mp:V9_2.0.0_Ontwerp_medicatieproces#Hetzelfde geneesmiddel met verschillende sterkte tegelijkertijd|4.1.7 Hetzelfde geneesmiddel met verschillende sterkte tegelijkertijd]].

===Meerdere apotheken leveren medicatie ===
Meerdere apothekers kunnen betrokken zijn bij medicatieverstrekkingen voor één patiënt. Dit gaat bijvoorbeeld om verstrekkingen door een poliklinische apotheker, naast de verstrekkingen door een openbare apotheker of verstrekkingen van add-on medicatie door een ziekenhuisapotheker, naast verstrekkingen door een openbare apotheker. Wanneer meerdere apothekers medicatie leveren, is iedere apotheker zelf verantwoordelijk voor de medicatiegegevens die nodig zijn voor de toedienlijst. Dit omvat dus ook de (richt)toedientijden in de TA. De verantwoordelijkheid om te bepalen of een toevoeging/wijziging past bij het totaal van (bekende) medicatiegegevens ligt bij de voorschrijver of apotheker van de laatst toegevoegde/gewijzigde medicatie. Dit gaat dan om zowel medicatiebewaking als om (richt)toedientijden. De medicatiegegevens worden (actief) beschikbaar gesteld, zodat alle medicatiegegevens vanuit de verschillende apothekers op één toedienlijst kunnen komen.

===Wijziging in GDS-medicatie vanaf volgende levering of per direct ===
Indien GDS-medicatie gewijzigd wordt, is het situatieafhankelijk of deze wijziging per direct of pas vanaf de eerstvolgende levering kan ingaan. De voorschrijver kan dit aangeven in de MA. Indien het gaat om een directe wijziging, moet dit direct zichtbaar zijn op de toedienlijst, zodat de (professionele) toediener de juiste (hoeveelheid) medicatie toedient. Bij een wijziging die pas bij de eerstvolgende levering ingaat, moet dit niet direct op de toedienlijst worden aangepast, omdat de oude afspraken op dat moment nog geldig zijn. De toedienlijst moet pas worden aangepast op het moment dat de wijziging ook daadwerkelijk ingaat.

Zie ook use case [[mp:V9_2.0.0_Ontwerp_medicatieproces#Medicatie toevoegen aan GDS|4.2.13 Medicatie toevoegen aan GDS]].

===Verhogen dosering GDS-medicatie in nieuwe MBH ===
Patiënt krijgt iedere dag 1 tablet propranolol 40 mg toegediend. Wegens onvoldoende effect besluit de voorschrijver de dosis te verhogen naar 80 mg 1x daags. Er wordt voor deze MA een nieuwe MBH aangemaakt, want het voorschrijven op prescriptieniveau wijzigt. Echter, de patiënt heeft nog voor enkele dagen voorraad van de 40 mg tabletten in haar GDS-rol zitten. Daarom besluit de apotheker om tot de rolwissel over 5 dagen de GDS-medicatie aan te vullen met het toedienen van 1 tablet propranolol 40 mg buiten de GDS, naast de tablet uit de GDS. De apotheker maakt twee TA’s aan, namelijk één voor de oude GDS-medicatie en één voor de overbrugging een niet-GDS bij de medicatieverstrekking. Bij de nieuwe rol GDS (rolwissel) worden de 80 mg tabletten in haar GDS opgenomen.

[[Bestand:Usecase verhogen dosering losse levering nieuwe MBH.png|800px]]

===Verlagen dosering GDS in nieuwe MBH ===
Patiënt krijgt iedere dag 1 tablet propranolol 80 mg toegediend. Wegens een te sterk effect besluit de voorschrijver de dosis zo snel mogelijk te verlagen naar 40 mg 1x daags. Er wordt voor deze MA een nieuwe MBH aangemaakt. Patiënt heeft nog voor enkele dagen voorraad van de 80 mg tabletten in haar GDS-rol zitten. Omdat de toediener tabletten niet mag halveren besluit de verstrekker dat de overgebleven GDS-zakjes dezelfde dag nog worden opgehaald en worden vervangen door een nieuwe GDS-rol met de 40 mg tabletten.

[[Bestand:Verlagen dosering GDS in nieuwe MBH.png|800px]]

===Wijziging verwerkt door de apotheker ===
Wijziging door de voorschrijver, zoals het starten van nieuwe medicatie, het wijzigen van de dosering, het (tijdelijk) stoppen van medicatie, legt de voorschrijver vast in de MA en/of het VV. De apotheker verwerkt deze in de TA en/of MVE. Dit vindt plaats tijdens openingstijden van de openbare apotheker, maar ook wanneer er een wijziging plaatsvindt buiten de openingstijden en er een medicatieverstrekking nodig is. De dienstapotheker verstrekt in dit geval de medicatie en er zijn dan meerdere apotheken die medicatie leveren (zie ook paragraaf 2.5.9.4). De medicatiegegevens van de apotheker(s) en de voorschrijver(s) worden door de voorschrijver en dienstapotheker (actief) beschikbaar gesteld aan de toediener voor de toedienlijst.

===Wijziging niet verwerkt door de apotheker ===
Wanneer een wijziging in de medicatie van een patiënt plaatsvindt door toedoen van de voorschrijver buiten de openingstijden van de openbare apotheker en er geen medicatieverstrekking nodig is, is er geen tussenkomst van een apotheker. In dit geval is de MA leidend en stelt de voorschrijver deze(actief) beschikbaar. De toediener ziet op de toedienlijst de gewijzigde of gestopte MA en deze overrulet alle medicatiebouwstenen binnen dezelfde medicamenteuze behandeling. Deze situatie is ook van toepassing als de apotheker de wijziging van de voorschrijver nog niet heeft verwerkt. De apotheker zorgt zo snel mogelijk alsnog voor aanpassing van de TA.

===Aanvullende informatie ===
Aanvullende informatie is een aanvullende uitleg over het gebruik voor de (professionele) toediener en/of patiënt. Een voorbeeld hiervan is dat bij het stoppen van een fentanylpleister er een extra instructie is dat de pleister verwijderd moet worden. Een ander voorbeeld is dat bij dosering van een halve tablet een instructie is bijgevoegd wat er met de andere halve tablet moet gebeuren. Deze gegevens kunnen vastgelegd worden in vrije tekst in de toelichting van de MA, TA en/of WDS.

Zie use case [[mp:V9_2.0.0_Ontwerp_medicatieproces#Toelichting in medicatieafspraak bij bewust gekozen bijzonderheid|4.1.8 Toelichting in medicatieafspraak bij bewust gekozen bijzonderheid]] van de informatiestandaard MP9 voor meer informatie.

===Medicatietoediening afwijkend ten opzichte van toedienlijst===
Er kan een afwijking zijn geweest in de toediening ten opzichte van wat door de voorschrijver en apotheker is vastgelegd in de MA of TA. Dit kan een afwijking betreffen in tijdstip, hoeveelheid, toedieningsweg, toedieningssnelheid, product of het in het geheel niet toedienen. Een (professionele) toediener kan in overleg met de voorschrijver van de regels afwijken als deze goede argumenten heeft en veilige zorg en veilig werken wordt gerealiseerd. De reden van de afwijking wordt in de MTD vastgelegd.

===Medicatietoediening zonder medicatieafspraak en toedieningsafspraak ===
Bij een spoedsituatie kan er mogelijk (nog) geen MA en TA beschikbaar zijn, maar moet de (professionele) toediener op basis van een mondelinge/telefonische MA medicatie toedienen. Deze medicatie staat dan niet op de toedienlijst. De (professionele) toediener legt een dergelijke MTD vast in het informatiesysteem van de toediener (o.a. ECD, TDR). Dit is de eerste bouwsteen in een nieuwe medicamenteuze behandeling (MBH) en dus start de toediener hier een MBH.

===Medicatietoediening van zelfzorgmedicatie ===
Volgens de veilige principes in de medicatieketen heeft de toediener geen taak in het toedienen van zelfzorgmedicatie, behalve als deze uiteindelijk wordt voorgeschreven door een voorschrijver (MA wordt aangemaakt). Dan komt de zelfzorgmedicatie als GDS- of als niet-GDS-medicatie (zo nodig) op de toedienlijst.

===Corrigeren/annuleren van toediening ===
Dit betreft het corrigeren of annuleren van een MTD omdat een toediener een fout in de registratie maakte en er geen medicatietoediening heeft plaatsgevonden. Indien de MTD nog niet gedeeld is met andere zorgverleners, dan kan de toediener die MTD zelf aanpassen of schrappen (annuleren) uit het eigen informatiesysteem. Indien de MTD al wel gedeeld is met andere zorgverleners dan annuleert de toediener deze foutieve MTD en maakt een nieuwe MTD onder dezelfde MBH met de juiste informatie. De toediener stelt de gecorrigeerde MTD en nieuwe MTD (actief) beschikbaar.

===Opschorten van toediening ===
Er zijn gevallen waarbij de toediening niet is gelukt en in overleg met een voorschrijver of apotheker op een later moment alsnog toegediend kan worden. Als de medicatietoediening binnen de gemaakte afspraken over flexibele toedientijden valt, kan de toediener afwijken van de (richt)toedientijd.

Een voorbeeld voor het opschorten van toediening is:
*Medicatietoediening is niet gelukt, maar de bedoeling is om deze medicatietoediening op een later (of soms eerder) moment op de dag nog een keer te proberen. Bij deze medicatietoediening is sprake van het opschorten van de toediening én van een afwijking van de toedienlijst.

===Medicatietoediening door voorschrijver ===
Een voorschrijver kan net als een (professionele) toediener medicatie toedienen bij een patiënt en deze handeling vastleggen in een MTD.

===Meerdere toedienorganisaties ===
Meerdere toedienorganisaties kunnen betrokken zijn bij de medicatietoediening van één patiënt. Dit gaat bijvoorbeeld om zorgverlening waarbij de medicatietoedieningen in de avond of nacht door een andere organisatie geleverd wordt dan overdag. Wanneer meerdere toedienorganisaties de zorg leveren, kunnen deze zorgverleners elkaars MTD’s raadplegen om het proces van toedien van medicatie te volgen. De handelingen van de ene organisatie kan namelijk effect hebben op het proces van de andere organisatie (o.a. heeft de toediening plaatsgevonden of waren er afwijkingen ten opzichte van de toedienlijst).

===Feedback aan patiënt via medicatiesignalering===
De patiënt gebruikt bijvoorbeeld zijn mobiele app als medicatiesignaleringtoepassing. Daartoe heeft de apotheker of de patiënt zelf een toedienschema ingesteld op de gewenste innamemomenten (al dan niet met applicatie-intelligentie om uit de medicatieverstrekkingen/toedienafspraken toedienmomenten voor te stellen). Op de toedienmomenten ontvangt de patiënt een signaal dat hem eraan herinnert om de medicatie in te nemen. De patiënt registreert de toediening en geeft daarmee aan of hij het geneesmiddel heeft ingenomen of niet (bijv. omdat de patiënt het geneesmiddel vergeten heeft mee te nemen). Wanneer de app gekoppeld is aan bijvoorbeeld het PGO van de patiënt wordt dan de therapietrouw automatisch bijgehouden.
 
[[Bestand:Uc4.3.23.PNG|800px]]
 


==Use cases Gebruiken==

===Zelfzorgmiddel===
Een patiënt heeft bij de drogist Ibuprofen aangeschaft, en neemt dagelijks 1200 mg. De patiënt voert het middel op als gebruik, met gegevens als ingangsdatum en dosering, en eventueel de reden van gebruik. 
[[Bestand:Uc4.4.1.png|800px]] 

===Medicatie uit buitenland===
Een patiënt heeft op vakantie medicatie voorgeschreven gekregen en neemt deze in. De patiënt voert de medicatie op als gebruik, met gegevens als ingangsdatum en dosering, en eventueel de reden van gebruik. Indien bekend worden ook de naam van de voorschrijver vastgelegd. 
[[Bestand:Uc4.4.2.png|800px]] 

===Wijziging op initiatief patiënt===
Een patiënt heeft medicatie propranolol voorgeschreven gekregen. De patiënt slaapt er erg slecht door, en heeft zelf de medicatie geminderd. De patiënt legt gebruik vast met de gewijzigde dosering en de datum sinds wanneer deze verlaagde dosis wordt genomen. Daarbij geeft de patiënt als reden aan dat dit op eigen initiatief is. 
Bij bijvoorbeeld een dosisverlaging op eigen initiatief kan de patiënt langer doorgaan dan afgesproken omdat zij nog voorraad heeft. Dit kan de patiënt als aanvullend gebruik opgeven. 
Bij bijvoorbeeld een dosisverhoging op eigen initiatief kan de voorraad van de patiënt eerder op zijn. De patiënt komt dan mogelijk eerder dan verwacht terug bij de arts. 
[[Bestand:Uc4.4.3.png|800px]] 

===Stoppen medicatie op initiatief patiënt===
Sinds het gebruik van propranolol heeft een patiënt last van slapeloosheid. Hij besluit te stoppen zonder daarbij direct de voorschrijvend arts te informeren. De patiënt legt vast dat hij gestopt is, per wanneer en kiest als reden voor wijzigen/stoppen '(mogelijke) bijwerking'. In de toelichting vult hij aan dat de bijwerking slapeloosheid betreft. 
[[Bestand:Uc4.4.4.png|800px]] 

===Geen voorraad meer===
Een patiënt heeft 'zo nodig' medicatie gekregen ter bestrijding van huidklachten. De medicatie staat nog op actief in het medicatieprofiel maar is al op. De patiënt geeft aan dat de medicatie gestopt is, met als reden dat deze niet meer voorradig is, eventueel met de toevoeging dat de klachten verholpen zijn. 
[[Bestand:Uc4.4.5A.png|800px]] 
De patiënt kan ook een voorstel verstrekkingsverzoek doen om zijn voorraad aan te vullen. Het antwoord voorstel verstrekkingsverzoek komt in dit geval bij de patiënt terug (en indien geaccordeerd gaat er van de voorschrijver tevens een verstrekkingsverzoek naar de apotheker). 
[[Bestand:Uc4.4.5B.png|800px]] 

===Registreren van afwijkend medicatiegebruik door patiënt vanwege een bijwerking===
Sinds het gebruik van propranolol heeft een patiënt last van slapeloosheid. De patiënt legt de bijwerking vast in de toelichting bij het medicatiegebruik. Wanneer de patiënt de medicatie anders gebruikt dan afgesproken, bijvoorbeeld minder tabletten, dan kan hij de bijwerking als reden opgeven van deze wijziging. Wanneer de klachten verminderen of ophouden legt de patiënt dit vast in de toelichting van het medicatiegebruik. 
Het kan zijn dat de patiënt last heeft van bijwerkingen zonder precies te weten welk geneesmiddel daarvan de oorzaak is. Er is (nog) geen voorziening binnen medicatieproces om dat vast te leggen.

===Gebruik registreren op basis van verstrekking===

Dit is van toepassing in de transitie periode van de oude medicatieproces standaard 6.12 naar deze medicatieproces informatiestandaard.

Digitaal is alleen een verstrekking beschikbaar (volgens medicatieproces versie 6.12). Het informatiesysteem van de gebruiker biedt echter wel de mogelijkheid om al medicatiegebruik vast te leggen.
Het medicatiegebruik kan in dat geval vastgelegd worden met verwijzing naar het id van de versie 6.12 verstrekking. 
[[Bestand:Uc4.4.8.png|800px]] 

=Medicatieoverzicht en afleidingsregels=

Dit hoofdstuk toont een voorbeeld medicatieoverzicht en specificeert daarnaast afleidingsregels voor 'De laatst relevante bouwsteen', Verificatie per medicamenteuze behandeling etc.
==Inleiding==

De term 'actueel medicatieoverzicht' is vervangen door de term 'basisset medicatiegegevens':
het medicatieoverzicht in combinatie met aanvullende gegevens die (minimaal) nodig zijn om veilig en verantwoord medicatie te kunnen voorschrijven, wijzigen, stoppen of veilig ter hand te stellen in de Leidraad Overdracht van Medicatiegegevens in de keten (definitief concept 2017).

Deze pagina bevat een voorbeeld van een medicatieoverzicht. Dit voorbeeld is ontwikkeld in het programma Informatiestandaard Medicatieproces en dient als voorbeeld voor de manier waarop gegevens getoond kunnen worden in een applicatie. De in onderstaande plaatjes genummerde gegevens zijn daarbij normatief, deze zijn verplicht om te tonen. De andere (ongenummerde) gegevens in het voorbeeld zijn optioneel en worden mogelijk in de toekomst als normatief toegevoegd. De lay-out van het overzicht in een informatiesysteem kan verschillen per doelgroep en per device. Voor apothekers zijn bijvoorbeeld in eerste instantie alleen toedieningsafspraken zichtbaar waarbij vervolgens kan worden doorgeklikt naar de bijbehorende medicatieafspraak en het medicatiegebruik. Wanneer er alleen medicatiegebruik of een medicatieafspraak bekend is wordt deze uiteraard wel direct getoond. Uitgangspunt is dat op het overzicht alle medicatie van de patiënt getoond wordt, dus niet alleen de medicatie die in het eigen informatiesysteem is vastgelegd.

Het overzicht is generiek beschreven en daarmee voor alle leveranciers gelijk. Op deze pagina zijn de eisen van de eindgebruikers opgenomen en worden geen uitspraken gedaan over de technische realisatie of implementatie. De bestaande KNMP-specificatie “User requirements specification Medicatieoverzicht 2.0”, definitieve concept “Leidraad Overdracht van Medicatiegegevens in de keten” en de nieuwe inzichten uit het programma Medicatieproces zijn hierin verwerkt.

Uitgangspunten voor het overzicht zijn:
* Zorgverleners willen op een medicatieoverzicht onderscheid zien tussen de therapeutische bouwstenen:
** Medicatieafspraak
** Toedieningsafspraak
** Medicatiegebruik
* Logistieke bouwstenen (verstrekkingsverzoek, verstrekking) en de bouwsteen medicatietoediening zijn niet relevant voor het medicatieoverzicht.

[[Bestand:Medicatieoverzicht_1_v0.5.PNG|Medicatieoverzicht v0.5]]
[[Bestand:Medicatieoverzicht_2_v0.5.PNG|Medicatieoverzicht v0.5]]

==Functionele specificatie==
In de figuren hieronder zijn de onderdelen opgenomen met normatieve gegevens. De andere onderdelen zijn nog niet normatief.
De in de tabel genummerde elementen zijn normatief, overige elementen vooralsnog optioneel.

===Kop en Algemeen===
[[Bestand:Medicatieoverzicht_KopAlgemeen_v0.5.PNG]]

Filter: n.v.t.

Sorteren: n.v.t.

Datum medicatieoverzicht: dit is de datum dat de laatste wijziging in een medicatieafspraak, toedieningsafspraak of medicatiegebruik is vastgelegd binnen het informatiesysteem dat het medicatieoverzicht oplevert.

N.B. in de viewer worden alle datums getoond met de maand in letters, zodat geen verwarring kan ontstaan tussen dag-maand en maand-dag (Amerikaans formaat).
{| class="wikitable"
|-
! Nr !! Kop !! Dataset !! Toelichting
|-
| 1 || Naam || Patient – Naamgegevens (Initialen, Geslachtsnaam, GeslachtsnaamPartner), Geboortedatum, Geslacht ||
|-
| 2 || Telefoon || Patient – Contactgegevens – Telefoonnummers || Door patiënt als preferent opgegeven telefoonnummer
|-
| 3 || BSN || Patient – Patientidentificatienummer || Altijd BSN
|-
| 4 || Adres || Patient – Adresgegevens ||
|-
| 5 || Naam zorgaanbieder || Zorgaanbieder – Organisatienaam || Zorgaanbieder die het medicatieoverzicht heeft samengesteld
|-
| 6 || Zorgaanbieder Adres || Zorgaanbieder – Adres – Adresgegevens ||
|-
| 7 || Zorgaanbieder Telefoon || Zorgaanbieder – TelefoonMail – Contactgegevens – Telefoonnummers ||
|-
| 8 || Zorgaanbieder Email || Zorgaanbieder – TelefoonMail – Contactgegevens – Emailadressen ||
|-
| 9 || Datum medicatieoverzicht || Documentgegevens – Documentdatum ||
|-
| || Lengte || Lichaamslengte – LengteWaarde, LengteDatumTijd ||
|-
| || Gewicht || Lichaamsgewicht – GewichtWaarde, GewichtDatumTijd ||
|-
| || Gecontroleerd door zorgverlener || Documentgegevens – Verificatie zorgverlener ||
|-
| || Geverifieerd met patient/mantelzorger || Documentgegevens – Verificatie patient ||
|}
Elementen 5 tot en met 8 worden niet getoond als de patiënt de opsteller van het medicatieoverzicht is.

===Contra-indicaties en overgevoeligheden (CiO)===
[[Bestand:Medicatieoverzicht_ICA_v0.5.PNG]]

Actieve contra-indicaties en overgevoeligheden (intoleranties, allergieën/ bijwerkingen).

Filter: einddatum is niet gevuld, ligt in de toekomst of is minder dan een jaar geleden bij het samenstellen van het overzicht.

Sorteren: meest recente ingangsdatum bovenaan.

Dit onderdeel wordt op een later moment uitgewerkt en is nog niet normatief.

===Huidige medicatie===
[[Bestand:Medicatieoverzicht_HuidigeMedicatie_v0.5.PNG]]

Filter: alle huidige medicatie, dat wil zeggen alle medicatieafspraken en toedieningsafspraken die van toepassing zijn op het moment dat het overzicht wordt samengesteld en het daarbij behorende medicatiegebruik per bron. Ook de tijdelijk onderbroken medicatie wordt in deze categorie getoond.
Wanneer er alleen medicatiegebruik bekend is wordt deze getoond als deze niet ouder is dan 13 maanden. Wanneer medicatiegebruik is vastgelegd door zowel een zorgverlener als een patiënt wordt van beide het laatst geregistreerde medicatiegebruik getoond.

Sorteren: per medicamenteuze behandeling: medicatieafspraak, toedieningsafspraak, medicatiegebruik (vastgelegd door patiënt, zorgverlener). Medicamenteuze behandelingen worden gesorteerd op ingangsdatum MA/ TA/ MGB aflopend.

{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| '''Nr'''
! style="text-align:left;"| '''Kop'''
! style="text-align:left;" colspan="3"| '''Dataset'''
|-
|style="background-color: white;vertical-align:top;"|1
|style="background-color: white;vertical-align:top;"|Type
|style="background-color: white;vertical-align:top; text-align:center;"|Medicatieafspraak
|style="background-color: white;vertical-align:top; text-align:center;"|Toedieningsafspraak
|style="background-color: white;vertical-align:top; text-align:center;"|Medicatiegebruik
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|2
|style="background-color: white;vertical-align:top;" rowspan="2"|Geneesmiddel
|style="background-color: white;vertical-align:top; text-align:center;"|Afgesproken geneesmiddel-
|style="background-color: white;vertical-align:top; text-align:center;"|Geneesmiddel bij Toedieningsafspraak-
|style="background-color: white;vertical-align:top; text-align:center;"|Gebruiksproduct-
|-
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Product – ProductCode (als afwezig: ProductSpecificatie, ProductNaam)
|-
|style="background-color: white;vertical-align:top;"|3
|style="background-color: white;vertical-align:top;"|Ingangsdatum
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Ingangsdatum
|-
|style="background-color: white;vertical-align:top;"|4
|style="background-color: white;vertical-align:top;"|Stopdatum/Duur
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Einddatum(als afwezig: Duur)
|-
|style="background-color: white;vertical-align:top;"|5
|style="background-color: white;vertical-align:top;"|Dosering
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Gebruiksinstructie – Omschrijving
|-
|style="background-color: white;vertical-align:top;"|6
|style="background-color: white;vertical-align:top;"|Toedieningsweg
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Gebruiksinstructie – Toedieningsweg
|-
|style="background-color: white;vertical-align:top;"|7
|style="background-color: white;vertical-align:top;"|Reden
|style="background-color: white;vertical-align:top; text-align:center;"|Reden van voorschrijven & evt. Reden van staken/onderbreken
|style="background-color: white;vertical-align:top; text-align:center;"|Reden van staken/onderbreken
|style="background-color: white;vertical-align:top; text-align:center;"|Reden van staken/onderbreken
|-
|style="background-color: white;vertical-align:top;"|8
|style="background-color: white;vertical-align:top;"|Toelichting
|style="background-color: white;vertical-align:top; text-align:center;" colspan="2"|Toelichting & Aanvullende Informatie
|style="background-color: white;vertical-align:top; text-align:center;"|Toelichting
|-
|style="background-color: white;vertical-align:top;" rowspan="3"|9
|style="background-color: white;vertical-align:top;" rowspan="3"|Bron
|style="background-color: white;vertical-align:top; text-align:center;"|Voorschrijver-
|style="background-color: white;vertical-align:top; text-align:center;"|Verstrekker-
|style="background-color: white;vertical-align:top; text-align:center;"|Auteur-
|-
|style="background-color: white;vertical-align:top; text-align:center;" colspan="3"|Zorgverlener – Zorgverlenernaam, Specialisme
|-
|style="background-color: white;vertical-align:top; text-align:center;"|n.v.t
|style="background-color: white;vertical-align:top; text-align:center;"|n.v.t
|style="background-color: white;vertical-align:top; text-align:center;"|of "Patient"
|}

===Toekomstige medicatie===
[[Bestand:Medicatieoverzicht_ToekomstigeMedicatie_v0.5.PNG]]

Filter: alle medicatie die in de komende 3 maanden actueel wordt. Dit is inclusief voorgenomen medicatiegebruik.

Voor een beschrijving van de mapping geldt hetzelfde als bij de huidige medicatie, zie [[mp:V9.0_Voorbeeld_medicatieoverzicht#Huidige_medicatie|Huidige medicatie]].

===Recent beëindigde medicatie===
[[Bestand:Medicatieoverzicht_RecentBeeindigde_v0.5.PNG]]

Filter: alle medicatie die in de afgelopen 2 maanden geëindigd of gestopt is.

Voor een beschrijving van de mapping geldt hetzelfde als bij de huidige medicatie, zie [[mp:V9.0_Voorbeeld_medicatieoverzicht#Huidige_medicatie|Huidige medicatie]].

===Aanvullende labwaarden===
[[Bestand:Medicatieoverzicht_Labwaarden_v0.5.PNG]]

Meest recente labwaarden en afwijkende nierfunctiewaarden.

Dit onderdeel wordt op een later moment uitgewerkt en is nog niet normatief.

===Opmerkingen===
[[Bestand:Medicatieoverzicht_Opmerkingen_v0.5.PNG]]

Bijvoorbeeld relevante (beperkte) gezondheidsvaardigheden (competenties: geletterdheid, reken- en digitale vaardigheden) die impact kunnen hebben op medicatiegebruik/behandeling.

Dit onderdeel wordt op een later moment uitgewerkt en is nog niet normatief.

==Bouwsteen instantiaties==
Deze paragraaf beschrijft welke instantiaties van de bouwstenen horen bij het medicatieoverzicht. Dit gaat om ‘eigen’ én ‘andermans’ bouwstenen en dan alleen de laatste, relevante instantiaties hiervan.

===Eigen én andermans===
Zowel de eigen als een kopie van (bij de verzender bekende) bouwstenen van andere bronnen gaan mee in het medicatieoverzicht. Dit zodat het medicatieoverzicht zo compleet mogelijk is voor de ontvanger. Dit zorgt ervoor dat ontvangers er direct mee aan de slag kunnen en niet afhankelijk zijn van andere bronnen.
De technische representatie van andermans bouwsteen kan ánders zijn dan die van de echte bron. Het is belangrijk dat de ontvanger hiervan op de hoogte is. De originele OID van andermans bouwsteen moet gewoon meegegeven worden. De ontvanger kan er dan voor kiezen om de bouwsteen ook in zijn originele vorm bij de bron op te halen. 
De bouwstenen medicatieafspraak, toedieningsafspraak en medicatiegebruik zijn uitgebreid met een kenmerk dat aangeeft of:
* er sprake is van een ‘eigen’ bouwsteen of
* die van ‘iemand anders’ (een ''accent'' bouwsteen: MA’, TA’, MGB’)
Dit kenmerk is alleen van toepassing in de transactie voor het medicatieoverzicht, omdat dat de enige transactie is waar andermans bouwstenen opgeleverd mogen worden.

Het kenmerk 'bouwsteen van iemand anders' bevind zich op twee niveaus:
* Het template ID van een MA’, TA’, MGB’ verschilt van een MA, TA en MGB.
* Daarnaast wordt het element kopie indicator altijd meegestuurd met waarde '''true''' in MA’, TA’, MGB’.

Het is toegestaan om voor het medicatieoverzicht de medicatieafspraken, toedienafspraken en medicatiegebruik via een door het informatiesysteem gegenereerd MGB of MGB’ (Zorgaanbieder is auteur MGB) aan te bieden. Deze dient wel een referentie te hebben naar een MA, TA of MGB.

====Medicatieoverzicht en afleidingsregels====
Een overzicht van medicatie die de patiënt gebruikt (of zou moeten gebruiken) kan op twee manieren in een informatiesysteem worden samengesteld: 
1) tonen van een actueel medicatieoverzicht (of overzichten) verkregen uit andere bron (of bronnen) 
2) in samenhang tonen van losse medicatiebouwstenen verkregen uit het eigen informatiesysteem en uit andere bronnen. 
Dit overzicht van medicatie bestaat in beide gevallen uit de informatie zoals opgenomen in de bouwstenen medicatieafspraak, toedieningsafspraak en medicatiegebruik.

Ad 1) Wanneer in dit document gesproken wordt over een actueel medicatieoverzicht wordt daarmee een samenhangend overzicht bedoeld waarin actuele medicatieafspraken, toedieningsafspraken en medicatiegebruik is opgenomen. Dit actuele medicatieoverzicht wordt opgebouwd door de bron op basis van de op dat moment bij de bron bekende gegevens. Dit overzicht kan worden uitgewisseld met de transactiegroep Medicatieoverzicht (PULL of PUSH).

De gegevens en bouwstenen die bekend zijn bij de bron, maar afkomstig uit een andere bron, worden in de transactie opgeleverd met de 'accent' indicator zodat ze herkenbaar zijn als andermans bouwstenen (MA accent, TA accent, MGB accent). 

Ad 2) Het is ook mogelijk dat een informatiesysteem een overzicht samen stelt door het samenvoegen van eigen en andermans losse medicatiebouwstenen. Voor het opvragen van losse bouwstenen wordt de transactiegroep medicatiegegevens (PULL) gebruikt.

Met de transactiegroep medicatiegegevens (PUSH) kunnen losse bouwstenen ook direct aan een andere zorgverlener of de patiënt worden verstuurd (dus zonder opvragen). Dit gebeurt bijvoorbeeld bij ontslag of op verzoek van een medebehandelaar die de patiënt voor zich heeft (bijv. patiënt verschijnt bij huisarts of apotheker buiten de regio waarbij deze huisarts of apotheker bij de eigen huisarts van de patiënt de gegevens telefonisch opvraagt en digitaal ontvangt). 
Bij zowel medicatiegegevens PUSH als PULL mogen gegevens die uit andere bron zijn verkregen niet worden opgeleverd.
 

===Laatste relevante===
Alleen de laatste relevante bouwstenen (per medicamenteuze behandeling) zijn onderdeel van het medicatieoverzicht. Deze paragraaf beschrijft wat dan precies die laatst relevante bouwstenen zijn voor een medicatieoverzicht. Allereerst voor medicatie op voorschrift (paragraaf 5.3.2.1), dan voor ‘over the counter’ medicatie (paragraaf 5.3.2.2). De hierop volgende paragraaf 5.3.2.3 gaat nog in op de bijzondere situatie dat er behalve een huidige, ook een toekomstige medicatieafspraak binnen dezelfde medicamenteuze behandeling geldig is. Tenslotte vat de laatste paragraaf de te hanteren regels samen. 

====Medicatie op voorschrift====
=====Meest eenvoudige ‘happy flow’=====
In een medicamenteuze behandeling ontstaat er in de meest eenvoudige ‘happy flow’ een opeenvolging van:
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik''.
Normaal gesproken begint een medicamenteuze behandeling met een medicatieafspraak. Een toedieningsafspraak vult de medicatieafspraak concreet in. Medicatiegebruik zegt iets over het daadwerkelijk gebruik van de patiënt in deze medicamenteuze behandeling. Alle drie de bouwstenen zijn in zo’n geval relevant en horen bij de oplevering van een medicatieoverzicht, zoals aangegeven in groen hieronder.
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik.
Een toedieningsafspraak verwijst naar de medicatieafspraak die hij invult. Als er geen verwijzing beschikbaar is in de toedieningsafspraak dan moet de afspraakdatum (toedieningsafspraak) later zijn dan die van de medicatieafspraak om relevant te zijn voor oplevering. 
Medicatiegebruik kán verwijzen naar een medicatieafspraak óf toedieningsafspraak. Als er geen verwijzing beschikbaar is in het medicatiegebruik, dan moet de registratiedatum (medicatiegebruik) later zijn dan die van de medicatieafspraak om relevant te zijn voor oplevering.

=====Nieuwe medicatieafspraak in de medicamenteuze behandeling=====
Als je een nieuwe medicatieafspraak aanmaakt in een bestaande medicamenteuze behandeling zijn de op dát moment reeds bestaande medicatieafspraken, toedieningsafspraken en vastleggingen van medicatiegebruik niet meer relevant voor het medicatieoverzicht. Het idee is dat alle oudere bouwstenen dan de huidige medicatieafspraak per definitie ‘overruled’ zijn door deze nieuwe medicatieafspraak en dientengevolge niet meer relevant voor het medicatieoverzicht.
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik'' - stop-Medicatieafspraak – Medicatieafspraak – stop-Toedieningsafspraak

Wanneer er volgend op een dergelijke medicatieafspraak een toedieningsafspraak en eventueel ook medicatiegebruik aangemaakt en beschikbaar zijn, worden deze wél weer meegeleverd in het medicatieoverzicht.
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik'' – stop-Medicatieafspraak – Medicatieafspraak – stop-Toedieningsafspraak - Toedieningsafspraak
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik'' – stop-Medicatieafspraak - Medicatieafspraak - stop-Toedieningsafspraak – Toedieningsafspraak – Medicatiegebruik 

De nieuwe medicatieafspraak kan ook een stop-Medicatieafspraak zijn, als de patiënt in het geheel moet stoppen met deze medicatie. Deze stop-Medicatieafspraak blijft 2 maanden relevant voor het medicatieoverzicht. 
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – stop-Medicatieafspraak - stop-Toedieningsafspraak

=====Medicatiegebruik eerder dan toedieningsafspraak=====
Het kan gebeuren dat je medicatiegebruik hebt vastgelegd voordat de toedieningsafspraak aangemaakt is. Ook hier is het idee dat de nieuwere toedieningsafspraak de oudere vastlegging van toedieningsafspraak én medicatiegebruik ‘overrulet’. Het oudere medicatiegebruik is dan dus niet meer relevant voor het medicatieoverzicht.
* Medicatieafspraak – Medicatiegebruik
* Medicatieafspraak – ''Medicatiegebruik'' – Toedieningsafspraak

Natuurlijk kan er daarna weer een nieuwe vastlegging van medicatiegebruik plaatsvinden, die dan ook weer relevant is voor het medicatieoverzicht.
* Medicatieafspraak – ''Medicatiegebruik'' – Toedieningsafspraak - Medicatiegebruik

=====Nieuwe toedieningsafspraak=====
Soms maak je een nieuwe toedieningsafspraak onder een bestaande medicatieafspraak. Bijvoorbeeld omdat er een ander product verstrekt moet worden (ten gevolge van preferentiebeleid of voorraad). Ook dan geldt dat een dergelijke nieuwe toedieningsafspraak eventueel oudere toedieningsafspraken en medicatiegebruik ‘overrulet’.
* Medicatieafspraak – ''Toedieningsafspraak – Medicatiegebruik''- stop-Toedieningsafspraak - Toedieningsafspraak

Natuurlijk kan je daarna medicatiegebruik vastleggen, die is dan ook weer relevant voor het medicatieoverzicht.
* Medicatieafspraak – ''Toedieningsafspraak – Medicatiegebruik'' - stop-Toedieningsafspraak – Toedieningsafspraak - Medicatiegebruik

====Over the counter====
Soms gebruikt een patiënt medicatie waarvoor er geen voorschrift is. Dit geldt bijvoorbeeld voor pijnstillers als paracetamol of ibuprofen, die verkrijgbaar zijn zonder recept. We noemen dit “over the counter” medicatie.
Dergelijk gebruik van ‘over the counter’ medicatie kan vastgelegd worden met de bouwsteen medicatiegebruik. Ook dit is relevant voor het medicatieoverzicht.
* Medicatiegebruik

Een nieuwe vastlegging van medicatiegebruik door dezelfde type auteur (type auteur is patiënt of zorgverlener) ‘overrulet’ eventuele oudere vastleggingen van medicatiegebruik. Hieronder uitgewerkt, op volgorde van registratiedatum:
* ''Medicatiegebruik'' - Medicatiegebruik

Wanneer een voorschrijver beslist om deze medicamenteuze behandeling te formaliseren met een medicatieafspraak, gelden daarna de regels zoals hiervoor beschreven. Hieronder uitgewerkt, op volgorde van afspraakdatum (medicatie- of toedieningsafspraak)/registratiedatum (medicatiegebruik):
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak - Medicatiegebruik
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak – Toedieningsafspraak - Medicatiegebruik
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak – ''Medicatiegebruik'' - Toedieningsafspraak - Medicatiegebruik
* ''Medicatiegebruik – Medicatiegebruik'' – Medicatieafspraak - ''Medicatiegebruik'' - Medicatiegebruik

====Toekomstige medicatieafspraken en toedieningsafspraken====
Een medicamenteuze behandeling kan meer dan één actuele medicatieafspraak en toedieningsafspraak bevatten. Namelijk één voor de huidige situatie en één of meer voor de toekomstige situatie. Deze paragraaf beschrijft een voorbeeld met één huidige en één toekomstige. De toekomstige bouwstenen hebben in de voorbeelden voor de duidelijkheid een “T-“. Zowel huidige als toekomstige bouwstenen zijn relevant voor het medicatieoverzicht. De bouwstenen voor toedieningsafspraak en medicatiegebruik moeten wel adequate verwijzingen hebben naar ofwel de huidige ofwel de toekomstige afspraak. Hieronder drie voorbeelden, op volgorde van afspraakdatum/registratiedatum (indien deze gelijk zijn, dan gesorteerd op gebruiksperiode):
* Medicatieafspraak – T Medicatieafspraak
* Medicatieafspraak – Toedieningsafspraak – T Medicatieafspraak – T Toedieningsafspraak
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – T Medicatieafspraak – T Toedieningsafspraak – (eventueel T Medicatiegebruik)
Stel dat de toedieningsafspraak wijzigt omdat de verstrekker een andere sterkte levert (2x 500 mg tabletten ipv. 1x 1000 mg tabletten) en de patiënt nog voldoende voorraad heeft voor twee weken obv. de eerste toedieningsafspraak:
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – T Toedieningsafspraak

=====Nieuwe medicatieafspraak=====
Als je in deze situatie een nieuwe medicatieafspraak maakt, maak je ook altijd een (technische) stop-medicatieafspraak. Deze stop-medicatieafspraak kent twee verschijningsvormen: 
1) met verwijzing naar een specifieke medicatieafspraak die je stopt 
2) zonder verwijzing, en daarmee stop je de hele medicamenteuze behandeling

Ad 1) Stop-medicatieafspraak voor één actuele medicatieafspraak. Met deze stop-medicatieafspraak stop je één specifieke medicatieafspraak. Je maakt voor die medicatieafspraak ook weer een nieuwe.
Stel dat je alleen de huidige medicatieafspraak wilt wijzigen, dan geeft dit toegepast op de voorbeelden hierboven, op volgorde van afspraakdatum:
* ''Medicatieafspraak'' – T Medicatieafspraak - stop-Medicatieafspraak – Medicatieafspraak 
* ''Medicatieafspraak – Toedieningsafspraak'' – T Medicatieafspraak – T Toedieningsafspraak - stop-Medicatieafspraak – Medicatieafspraak
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik'' – T Medicatieafspraak – T Toedieningsafspraak – T Medicatiegebruik - stop-Medicatieafspraak – Medicatieafspraak

Stel dat je alleen de toekomstige medicatieafspraak wilt wijzigen, dan geeft dit toegepast op de voorbeelden hierboven, op volgorde van afspraakdatum:
* Medicatieafspraak – ''T Medicatieafspraak'' - stop- T Medicatieafspraak – T Medicatieafspraak
* Medicatieafspraak – Toedieningsafspraak – ''T Medicatieafspraak – T Toedieningsafspraak'' - stop- T Medicatieafspraak – T Medicatieafspraak
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – ''T Medicatieafspraak – T Toedieningsafspraak – T Medicatiegebruik'' - stop- T Medicatieafspraak – T Medicatieafspraak 

 Ad 2) Stop-medicatieafspraak voor de hele medicamenteuze behandeling.
Met deze stop-medicatieafspraak stop je alle bestaande (huidige en toekomstige) medicatieafspraken in de medicamenteuze behandeling. Als je nu – naast een huidige - ook weer een medicatieafspraak voor de toekomst wilt maken, moet je ook deze dus opnieuw maken. Hieronder uitgewerkt voor dezelfde drie voorbeelden als bovenstaand, op volgorde van afspraakdatum.
* ''Medicatieafspraak – T-Medicatieafspraak'' – stop-Medicatieafspraak (zonder referentie) - Medicatieafspraak 
* ''Medicatieafspraak – Toedieningsafspraak – T-Medicatieafspraak – T-Toedieningsafspraak'' - stop-Medicatieafspraak (zonder referentie) – Medicatieafspraak – T Medicatieafspraak
* ''Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – T-Medicatieafspraak – T-Toedieningsafspraak – T Medicatiegebruik'' - stop-Medicatieafspraak (zonder referentie) – stop-Toedieningsafspraak -Medicatieafspraak – stop- T Toedieningsafspraak - T Medicatieafspraak 

=====Nieuwe toedieningsafspraak=====
 Je kunt echter ook een nieuwe toedieningsafspraak maken voor alleen de huidige medicatieafspraak. Deze nieuwe toedieningsafspraak moet dan een verwijzing naar die huidige medicatieafspraak hebben. Hieronder uitgewerkt voor drie voorbeelden, op volgorde van afspraakdatum.
* Medicatieafspraak – T Medicatieafspraak – Toedieningsafspraak
* Medicatieafspraak – ''Toedieningsafspraak''– T-Medicatieafspraak – T Toedieningsafspraak - stop-Toedieningsafspraak – Toedieningsafspraak
* Medicatieafspraak – ''Toedieningsafspraak – Medicatiegebruik'' – T Medicatieafspraak – T-Toedieningsafspraak – T Medicatiegebruik – - stop-Toedieningsafspraak – Toedieningsafspraak

Een nieuwe toedieningsafspraak met een verwijzing naar de toekomstige medicatieafspraak ziet er als volgt uit.
* Medicatieafspraak – T Medicatieafspraak – Toedieningsafspraak – T-Toedieningsafspraak
* Medicatieafspraak –Toedieningsafspraak – T-Medicatieafspraak – ''T Toedieningsafspraak'' – stop-T Toedieningsafspraak - T Toedieningsafspraak
* Medicatieafspraak –Toedieningsafspraak – Medicatiegebruik – T Medicatieafspraak – ''T Toedieningsafspraak – T Medicatiegebruik'' - stop- T Toedieningsafspraak – T-Toedieningsafspraak

====Regels van het overrulen opgesomd====
Op basis van bovenstaande beschrijving/voorbeelden zijn de volgende algemene regels voor het overrulen af te leiden. Het gaat hier om de regels om te bepalen of een bouwsteen relevant is voor oplevering in het medicatieoverzicht.
Binnen een medicamenteuze behandeling:
* Een nieuwe medicatieafspraak overrulet alle oudere bouwstenen (medicatieafspraak, toedieningsafspraak, medicatiegebruik) behorende bij de medicatieafspraak/-afspraken die deze medicatieafspraak gestopt heeft.
* Een nieuwe toedieningsafspraak overrulet alle oudere bouwstenen van type toedieningsafspraak of medicatiegebruik die horen bij dezelfde medicatieafspraak als de nieuwe toedieningsafspraak.
* Een nieuwe vastlegging van medicatiegebruik overrulet in principe (zie uitzondering hieronder) oudere vastleggingen van medicatiegebruik die horen bij dezelfde medicatieafspraak als het nieuwe medicatiegebruik.
** Uitzondering op deze regel: medicatiegebruik met als auteur patiënt overrulet NIET een oudere vastlegging van medicatiegebruik met als auteur zorgverlener en vice versa. Beide zijn dan dus relevant voor het medicatieoverzicht.

Deze laatste uitzondering toegepast op een aantal situaties:
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik-ZVL – Medicatiegebruik-PAT
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik-PAT – Medicatiegebruik-ZVL
* Medicatieafspraak – Toedieningsafspraak – ''Medicatiegebruik-PAT'' – Medicatiegebruik-PAT
* Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik-ZVL – ''Medicatiegebruik-PAT'' – Medicatiegebruik-PAT
* Medicatieafspraak – Toedieningsafspraak – ''Medicatiegebruik-ZVL – Medicatiegebruik-PAT'' – Medicatiegebruik PAT – Medicatiegebruik-ZVL

==Verificatie per medicamenteuze behandeling==
Een zorgverlener legt verificatie per medicamenteuze behandeling vast met de bouwsteen medicatiegebruik:
* Auteur = Zorgverlener
* Eventuele informant: de patiënt, een zorgverlener of een andere persoon
* Eventueel kenmerk ‘volgens afspraak’: is het medicatiegebruik volgens de auteur conform medicatieafspraak of toedieningsafspraak?
* Eventuele link naar medicatieafspraak óf toedieningsafspraak:
** Medicatie- of toedieningsafspraak die de referentie is geweest voor het opgeven van dit gebruik.
** Wanneer er wordt aangegeven ‘volgens afspraak’ dan staat hier de medicatie- of toedieningsafspraak conform welke de patiënt gebruikt.
Een dergelijke vastlegging van medicatiegebruik betekent: “Volgens mij gebruikt de patiënt dit medicament als volgt:…..”. 
Bekend: het is nu niet voorzien in de informatiestandaard om aan te geven dat een medicatieafspraak of toedieningsafspraak klopt, los van of de patiënt het ook zo gebruikt.

==Proces van het medicatieoverzicht uitwisselen==
Naast de inhoud en de verificatie is ook het proces rondom het medicatieoverzicht van belang.

===Wie, wanneer, met welke informatie===
De betrouwbaarheid en de compleetheid van een medicatieoverzicht hangt af van:
* wie het heeft samengesteld,
* op welk moment en
* met welke basisinformatie.

Daarover kunnen we afspraken maken, bijvoorbeeld:
* een medicatieoverzicht pas uitwisselen/beschikbaar stellen zodra deze enige vorm van betrouwbaarheid heeft
** na een expliciete actie van een zorgverlener of
** automatisch als aan bepaalde voorwaarden is voldaan.
* medicatieoverzicht volledig automatisch uitwisselen/beschikbaar stellen zonder voorwaarden
* medicatieoverzicht volledig automatisch beschikbaar maken zonder dat een nieuwe gegevenssoort nodig is (dus bij aanmelding van één van de andere medicatie gegevenssoorten ben je automatisch ook bron voor een medicatieoverzicht).

====Besluit====
Bovenstaande vragen zijn nog niet beantwoord. Besloten is dat tijdens de Proof-Of-Concept alle partijen die een medicatieoverzicht kunnen opleveren dit ook doen.

===Verantwoordelijkheden opvrager en bron===
De opvrager krijgt medicatieoverzichten uit meerdere bronnen. Het verwerken hiervan is de verantwoordelijkheid van de ontvanger. De actualiteit van een medicatieoverzicht is hierbij van belang. 
'''Actie:''' de transactie medicatieoverzicht moet de meest recente datum bevatten van de verzameling van beschikbare afspraakdatums/registratiedatums van de opgeleverde instantiaties van bouwstenen. De samensteller (bron) van het medicatieoverzicht moet deze datum dus opleveren. Dit helpt de ontvanger om de actualiteit van het medicatieoverzicht beter in te schatten.

===Afspraken vervolg===
Met de uitkomsten van de Proof-Of-Concept vervolgen we de analyse om te komen tot een goed proces voor het medicatieoverzicht.

==Afleidingsregels==
Het is van belang dat iedere partij de arts, apotheker, verpleging en ook de patiënt uit de medicatiebouwstenen kan opmaken wat de bedoeling is (c.q. wat de actuele afspraken zijn). Die bedoeling mag niet per informatiesysteem verschillen. Daarom moeten informatiesystemen volgens dezelfde afleidingsregels de actuele situatie kunnen berekenen.

De actuele therapeutische situatie wordt berekend aan de hand van zowel medicatie- als toedieningsafspraken. Toedieningsafspraken hebben een relatie met de medicatieafspraak die zij concreet invullen. Toedieningsafspraken zijn daardoor te koppelen aan de medicatieafspraak die zij invullen. 
Het medicatiegebruik is uiteraard ook zinvol om te weten. Het geeft echter niet weer wat de bedoeling van de zorgverlener is, maar wat de patiënt heeft gebruikt. Onderstaande regels nemen daarom niet het ‘gebruik’ mee. Het gebruik is wel onderdeel van een medicatieprofiel maar wordt apart getoond onder de betreffende medicamenteuze behandeling.

===Effectieve periode===
De effectieve periode bestaat uit een ''effectieve ingangsdatum'' en een ''effectieve stopdatum.''
:''De effectieve periode beschrijft de periode waarin een medicatie- of toedieningsafspraak (uiteindelijk) geldt /van toepassing is.''
De effectieve periode is afhankelijk van aanpassingen (wijzigen / staken / onderbreken / hervatten) van medicatie en door de ‘concrete invulling’ van een medicatieafspraak door een toedieningsafspraak. De effectieve periode is niet beschreven in de dataset, omdat het een afgeleid gegeven is dat alleen wordt gebruikt om de actuele situatie te bepalen. De ''effectieve ingangsdatum'', ''effectieve stopdatum'' en ''effectieve periode'' zijn geen gegevens om aan de eindgebruiker te tonen. 
Medicatie voor onbepaalde duur heeft een ''effectieve stopdatum'' die in de toekomst ligt, maar op een (nog) niet af te leiden moment. Het is alleen bekend dat hij 'ergens' in de toekomst ligt.

===Actuele en huidige medicatie===
*''Actuele (medicatie– en toedienings)afspraken:'' de afspraken waarvan de effectieve stopdatum in de toekomst ligt.
*''Huidige (medicatie– en toedienings)afspraken:'' de afspraken waarvan het heden tussen de effectieve ingangsdatum en de effectieve stopdatum ligt.
*''Actuele medicatie:'' de verzameling van actuele (huidige en toekomstige) medicatie- en toedieningsafspraken en het actuele gebruik. Voorbehoud hierbij is dat nooit met zekerheid te zeggen is in hoeverre de patiënt zich aan de afspraken houdt en het daadwerkelijk gebruik meldt.

===Uitwerking===
'''Aanpak''' 
Aan de hand van een aantal situaties worden de afleidingsregels beschreven om te komen tot de effectieve therapeutische periode in een medicatieprofiel: 
:1) Medicatie starten
:2) Maken toedieningsafspraak
:3) Medicatie wijzigen
:4) Medicatie definitief stoppen
:5) Medicatie tijdelijk onderbreken en hervatten

Hieronder worden de afleidingsregels beschreven. Het nummer bij iedere afleidingsregel staat voor de volgorde waarin de regels moeten worden uitgevoerd.

'''1) Medicatie starten''' 
Medicatie wordt gestart door het maken van een nieuwe medicatieafspraak. De medicatieafspraak kent een:
*Afspraakdatum - de datum waarop de afspraak is gemaakt met de patiënt.
*Gebruiksperiode - de periode bestaat uit:
**ingangsdatum - de ingangsdatum van de medicatieafspraak kan in de toekomst liggen;
**gebruiksduur;
**stopdatum - tot wanneer geldt de medicatieafspraak.

1a: De effectieve periode van een ''nieuwe'' medicatieafspraak is gelijk aan diens gebruiksperiode

'''2) Maken toedieningsafspraak''' 
Een toedieningsafspraak vult een medicatieafspraak concreet in. In zekere zin, door de ogen van de patiënt gezien, zou je kunnen zeggen dat een toedieningsafspraak een medicatieafspraak vervangt. Dat is immers dichter bij wat hij zou moeten gebruiken.

Afleidingsregel 1 wordt uitgebreid:

1b: De effectieve periode van een nieuwe toedieningsafspraak is gelijk aan diens gebruiksperiode

Afleidingsregel 2 is van toepassing als een medicatieafspraak onderliggende toedieningsafspraken kent (zie afleidingsregel 2b voor nadere toelichting):

2a: De effectieve periode van een medicatieafspraak is gelijk aan de effectieve periode van de onderliggende toedieningsafspraak.

'''3) Medicatie wijzigen'''
:'''a) Door een medicatieafspraak'''
De voorschrijver wijzigt medicatie (c.q. de medicamenteuze behandeling) door het maken van een nieuwe medicatieafspraak (en het beëindigen van de bestaande) binnen een bestaande medicamenteuze behandeling. 
Doordat de ingangsdatum van een medicatieafspraak in de toekomst kan liggen kunnen er meerdere medicatieafspraken tegelijk actueel zijn. Bijvoorbeeld wanneer een medicatieafspraak geldt ‘voor onbepaalde duur’ (MA1) en er wordt afgesproken over twee weken de dosering te wijzigen (MA2) blijft de eerste medicatieafspraak (MA1) nog twee weken geldig, daarna gaat de tweede medicatieafspraak (MA2) in.
De voorgaande afleidingsregels veranderen hierdoor niet.

:'''b) Door een toedieningsafspraak'''
Een medicatieafspraak wordt concreet ingevuld door een toedieningsafspraak. Op deze toedieningsafspraak kan een wijziging plaatsvinden. Bijvoorbeeld wanneer deeltijden veranderen (wanneer GDS wordt geïnitieerd), of wanneer er van handelsproduct wordt gewijzigd (door bijvoorbeeld een preferentiebeleid). Er kunnen dus meerdere achtereenvolgende toedieningsafspraken onder één medicatieafspraak worden gemaakt. Daarom wordt regel 2 uitgebreid zodat effectieve periode van de medicatieafspraak wordt bepaald door de gehele reeks onderliggende toedieningsafspraken.

2b: Wanneer er meerdere toedieningsafspraken onder een medicatieafspraak gemaakt worden dan is de effectieve ingangsdatum van de medicatieafspraak gelijk aan de meest vroege ingangsdatum van de onderliggende toedieningsafspraken en de stopdatum van de laatste toedieningsafspraak.

Er kunnen parallelle toedieningsafspraken onder één medicatieafspraak zijn waarvan de afspraakdatum en ingangsdatum gelijk zijn. Beide zijn dan tegelijk geldig en daarmee wijzigt regel 2b niet.

In onderstaande figuur is een zeer eenvoudig voorbeeld opgenomen van een actueel profiel samengesteld uit de verschillende bouwstenen. De patiënt-, verificatie-, CiO- en labgegevens zijn in dit overzicht geheel buiten beschouwing gelaten. Er is verder een zeer beperkt aantal gegevens opgenomen om vooral de werking van de effectieve periode te tonen. Regels met een ‘-‘ zijn detailregels en kunnen desgewenst ‘ingeklapt’ worden in het medicatieprofiel. In de eerste regel is de effectieve periode getoond voor de onderliggende MA en TA's. Daaronder is ook gebruik zichtbaar, deze heeft geen invloed op de berekening van de effectieve therapeutische periode in de eerste regel.

{{anchor|figuur 9}}
[[Bestand:Voorbeeldeffectieveperioden.png|Figuur 9 Voorbeeld effectieve periode]]

'''4) Medicatie definitief stoppen''' 
Het stoppen van medicatie (c.q. medicamenteuze behandeling) gebeurt door het maken van een medicatieafspraak, waarin stoptype 'definitief' is aangegeven. De ingangsdatum van deze medicatieafspraak is de datum waarop de originele medicatieafspraak inging. De stopdatum is de datum waarop de medicatie gestopt wordt. De effectieve periode van de originele medicatieafspraak is daarmee vervangen door de effectieve periode van deze nieuwe stop-MA.

1c: Wanneer een medicatieafspraak gestopt wordt dan is de effectieve periode van de medicatieafspraak de effectieve periode van de stop-MA.

Een stop-toedieningsafspraak kan een stop-medicatieafspraak concreet invullen. Zo kan bijvoorbeeld worden uitgedrukt dat het stoppen ingaat met de volgende GDS uitgifte.

'''5) Medicatie tijdelijk onderbreken en hervatten''' 
Het onderbreken van medicatie gebeurt op dezelfde wijze als medicatie stoppen. Er wordt een stop-MA gemaakt (stoptype 'tijdelijk') met dezelfde ingangsdatum als de originele medicatieafspraak. De stopdatum van de stop-MA is het moment van tijdelijk onderbreken, het stoptype is 'tijdelijk'. Hervatten gebeurt door een medicatieafspraak te maken met de oude (of aangepaste) dosering waarbij de ingangsdatum de hervattingsdatum is. Een aansprekende reden (bijvoorbeeld: hervat eerder gemaakt beleid) kan e.e.a. verduidelijken. Als niet hervat wordt kan 'medicatie stoppen (stoptype 'definitief')' worden uitgevoerd om de medicamenteuze behandeling definitief te beëindigen waarmee het niet meer actuele medicatie is. Medicatie die onderbroken wordt blijft actueel zodat deze op het medicatieprofiel zichtbaar blijft.

1d: Wanneer medicatie tijdelijk wordt onderbroken wordt de effectieve periode daardoor niet beïnvloed. De effectieve periode wordt bepaald door de effectieve periode van de originele medicatieafspraak.

Deze afleidingsregels vormen de basis voor het bepalen van de actuele afspraken. Er zijn uitzonderingssituaties denkbaar die gerelateerd zijn aan het slechts deels beschikbaar hebben van medicatiegegevens. Deze zijn niet uitgewerkt.
In de open-source beschikbare medicatie-viewer zijn alle afleidingsregels opgenomen en geïmplementeerd.

==Gegevens die niet getoond hoeven te worden==
Diverse gegevens zijn belangrijk voor het correct kunnen verwerken van informatie, maar zijn voor de eindgebruiker niet relevant:
*Een applicatie hoeft niet de (technische) identificatie van een MBH te tonen (noch die van de bouwstenen zelf), maar wel de uitwerking daarvan: namelijk in samenhang getoonde bouwsteen instantiaties.
*De kopie-indicator bij de MA, TA en MGB bij het raadplegen van medicatieoverzicht. Of een bouwsteen een kopie betreft, is voor een gebruiker niet zo belangrijk en kan afgeleid worden door andere gegevens uit die bouwsteen (zoals auteur van de bouwsteen). Het is dus niet zo belangrijk dat een gebruiker kan zien dat dit 'als kopie' is opgeleverd en vermoedelijk alleen maar verwarrend. Voor leveranciers is dit gegeven echter wél belangrijk, bijvoorbeeld omdat zij soms met de gegevens willen rekenen en het dan veiliger is om het gegeven bij de échte bron op te halen. Het ligt daarom voor de hand om in je informatiesysteem wél bij te houden of je het gegeven van de échte bron hebt ontvangen.
*Een applicatie hoeft niet het stoptype (tijdelijk/definitief) van een stop-afspraak te tonen, maar wel de uitwerking daarvan: namelijk het verwerken van de betekenis, waardoor een gehele MBH als gestopte medicatie getoond wordt of als onderbroken medicatie (blijft inzichtelijk onder huidige medicatie) of als een wijziging in geval van een 'technische stop-afspraak'.

=Toedienlijst en afleidingsregels=

Dit hoofdstuk toont een mogelijke weergave van een toedienlijst en specificeert daarnaast afleidingsregels voor alle relevante bouwstenen en verificatie per medicamenteuze behandeling voor het opstellen van een toedienlijst.

==Inleiding ==

Deze paragraaf bevat een voorbeeld van een toedienlijst. De toedienlijst toont op elk moment van de dag de meeste recente medicatiegegevens zodat de medicatietoediening adequaat kan verlopen. Om te zorgen voor een veilige situatie waarbij een (professionele) toediener de juiste en actuele medicatiegegevens heeft om goed en veilig te kunnen toedienen, dient de toedieningssoftware in staat te zijn om de medicatiebouwstenen te kunnen verwerken en samenhang hierin te brengen met behulp van de spelregels die binnen deze informatiestandaard MP9 zijn bepaald.

Onder de term ‘toedienlijst’ wordt verstaan een digitale lijst van alle geneesmiddelen die zijn voorgeschreven door een voorschrijver en die aan een patiënt/cliënt toegediend moeten worden. Deze lijst wordt opgesteld op basis van de volgende medicatiebouwstenen: medicatieafspraak, wisselenddoseerschema, toedieningsafspraak, medicatieverstrekking en medicatietoediening.

Het (actief) beschikbaar stellen van medicatiegegevens aan (professionele) toedieners zorgt voor een totaal overzicht over alle toe te dienen medicatie. Dit betekent dat zowel het stoppen als het wijzigen van medicatie met of zonder medicatieverstrekking op elk moment beschikbaar is. Wijzigingen in medicatie en wisselende doseerschema’s, zoals van de trombosedienst, zijn direct beschikbaar voor toedieners.

In figuur 1 zijn de medicatiegegevens weergegeven die getoond kunnen worden op een toedienlijst. In tabel 1 wordt door middel van nummers aangegeven welke gegevens daarbij normatief zijn, deze medicatiegegevens zijn verplicht om te tonen. De andere gegevens in de figuur zijn optioneel en worden mogelijk in de toekomst als normatief toegevoegd. De lay-out van de toedienlijst in een informatiesysteem kan verschillen per doelgroep en per device, dit is afhankelijk van de gebruikerseisen.

De toedienlijst in dit voorbeeld is generiek beschreven. De algemene eisen van de eindgebruikers voor het opstellen van de toedienlijst zijn in dit hoofdstuk opgenomen en er worden geen uitspraken gedaan over de technische realisatie of implementatie.

De Veilige principes in de medicatieketen (2016) gaan over wat ‘in principe’ veilig is in de medicatieketen in de sector verpleging, verzorging en thuiszorg. De specificaties, die in de Veilige principes in de medicatieketen (2016), Richtlijn overdracht van medicatiegegevens in de keten herziening 2018/2019 en de nieuwe inzichten uit het programma Medicatieoverdracht zijn opgenomen, zijn in dit hoofdstuk verwerkt.

Uitgangspunten voor de toedienlijst zijn:
*Medicatiebouwstenen
**Medicatieafspraak (MA)
**Toedieningsafspraak (TA)
**Wisselenddoseerschema (WDS)
**Medicatietoediening (MTD)
**Medicatieverstrekking (MVE)
*Alle huidige medicatie, dat wil zeggen alle MA’s, TA’s en WDS’s die beschikbaar zijn en van toepassing zijn op het moment dat medicatie wordt toegediend, worden bepaald op basis van de Gebruiksperiode.
*De PrikPlakLocatie in de bouwsteen MTD wordt geraadpleegd op basis de toedieningsperiode (ToedieningsDatumTijd).
*(Professionele) toedieners kunnen op een toedienlijst een onderscheid maken tussen de verschillende medicatie die een patiënt toegediend krijgt, dit gebeurt op basis van het data-element “Distributievorm” in de bouwsteen TA en het data-element “zo nodig criterium” in de dosering (MA, TA of WDS). Het onderscheid kan er als volgt uit zien:
**GDS-medicatie;
**Niet GDS-medicatie;
**Niet GDS-medicatie zo nodig.
*De resterende bouwstenen (verstrekkingsverzoek, medicatiegebruik en medicatieverbruik) zijn niet relevant voor het opstellen van de toedienlijst.
 

{{anchor|figuur 1}}
[[Bestand:Toedienlijst_figuur_1a.PNG|Figuur 1: Voorbeeldweergave toedienlijst]]
[[Bestand:Toedienlijst_figuur_1b.PNG|Figuur 1: Voorbeeldweergave toedienlijst]]
[[Bestand:Toedienlijst_figuur_1c.PNG|Figuur 1: Voorbeeldweergave toedienlijst]]
 
''Figuur 1: Voorbeeldweergave toedienlijst''
 
 
{| class="wikitable"
|-
! Nr
! style="text-align:left;"|Kop
! style="text-align:left;" colspan="3"|Dataset
|-
| 1 || Type || Medicatieafspraak || Toedieningsafspraak || Wisselenddoseerschema
|-
| 2 || Geneesmiddel || Afgesproken geneesmiddel || Geneesmiddel bij toedieningsafspraak ||
|-
| 3 || Voorschrijver
|style="text-align:left;" colspan="3"|Medicatieafspraak – Voorschrijver – Zorgverlener
|-
| 4 || Verstrekker
|style="text-align:left;" colspan="3"|Toedieningsafspraak – Verstrekker – Zorgaanbieder
|-
| || Auteur
|style="text-align:left;" colspan="3"|Wisselenddoseerschema – Auteur – Zorgverlener (conditioneel)
|-
| 5 || Ingangsdatum || Medicatieafspraak - Gebruiksperiode || Toedieningsafspraak - Gebruiksperiode || Wisselenddoseerschema - Gebruiksperiode
|-
| 6 || Einddatum/duur || Medicatieafspraak - Gebruiksperiode || Toedieningsafspraak – Gebruiksperiode || Wisselenddoseerschema - Gebruiksperiode
|-
| 7 || Omschrijving
|style="text-align:left;" colspan="3"|Gebruiksinstructie – Omschrijving
|-
| || Toedieningsweg
|style="text-align:left;" colspan="3"|Gebruiksinstructie – Toedieningsweg

|-
| || Aanvullende instructie
|style="text-align:left;" colspan="3"|Gebruiksinstructie – Aanvullende instructie
|-
| || Keerdosis
|style="text-align:left;" colspan="3"|Gebruiksinstructie – Doseerinstructie – Dosering – Keerdosis
|-
| || Toedientijd
|style="text-align:left;" colspan="3"|Gebruiksinstructie – Doseerinstructie – Dosering – Toedieningsschema – Toedientijd
|-
| || Toedieningssnelheid
|style="text-align:left;" colspan="3"|Gebruiksinstructie – Doseerinstructie – Dosering – Toedieningssnelheid
|-
| || Toedieningsduur
|style="text-align:left;" colspan="3"|Gebruiksinstructie – Doseerinstructie – Dosering – Toedieningsduur
|-
| 8 || PrikPlakLocatie
|style="text-align:left;" colspan="3"|Medicatietoediening – PrikPlakLocatie
|-
| 9 || Toelichting
|style="text-align:left;" colspan="3"|Toelichting & Aanvullende Informatie
|}
''Tabel 1: Normatieve medicatiegegevens voor de toedienlijst''


==Functionele specificatie==

In de figuren hieronder zijn de onderdelen opgenomen met normatieve gegevens. De andere onderdelen zijn (nog) niet normatief. De in de tabel genummerde elementen zijn normatief, overige elementen zijn vooralsnog optioneel.

[[Bestand:Toedienlijst_Functionele_specificatie.png]]

===Kop en algemeen===

[[Bestand:Toedienlijst_Kop en algemeen.png]]

===Opmerkingen ===

In de opmerkingen kunnen bijvoorbeeld relevante (beperkte) gezondheidsvaardigheden (competenties: geletterdheid, reken- en digitale vaardigheden) vastgelegd worden die impact kunnen hebben op medicatietoediening. Dit onderdeel is bedoeld voor intern gebruik en wordt (nog) niet uitgewisseld.

'''NB.''' Dit onderdeel is nog niet normatief. Deze gegevens komen uit het interne informatiesysteem van de organisatie.

[[Bestand:Toedienlijst_Opmerkingen.png]]

===GDS-medicatie===

Geautomatiseerd geneesmiddeldistributiesysteem (GDS) wordt gedefinieerd als een verpakking waarin geneesmiddelen zijn verdeeld in eenheden per toedieningstijdstip en op naam van een individuele cliënt zijn gesteld ([https://www.knmp.nl/praktijkvoering/richtlijnen/knmp-richtlijnen-praktijkvoering/knmp-richtlijn-voor-geautomatiseerd-geneesmiddeldistributiesysteem-gds-september-2011| KNMP 2011]). Een GDS biedt een patiënt de mogelijkheid om zijn eigen medicatie langer zelf te beheren. Of medicatie in GDS wordt geplaatst wordt door een apotheker bepaald. In het data-element “Distributievorm” in de bijbehorende MVE en TA wordt aangegeven of er sprake is van GDS-medicatie.

Vanuit het zorgveld is de wens uitgesproken dat bij gewijzigde of gestopte medicatie een waarschuwingssignaal getoond wordt met de opmerking dat het geneesmiddel zich mogelijk in de GDS-verpakking bevindt en hier mogelijk een handeling op verricht moet worden. Nadere uitwerking van deze situatie is nodig.

===Niet GDS-medicatie ===

[[Bestand:Toedienlijst_Niet-GDS-medicatie.png]]

Niet GDS-medicatie zijn losse medicatie die om verschillende redenen niet in een geautomatiseerd geneesmiddeldistributiesysteem kunnen worden opgenomen. In het data-element “Distributievorm” in de bijbehorende TA wordt aangegeven of er geen sprake is van GDS-medicatie. Daarnaast is het criterium “ZoNodig” leeggelaten.

===Niet GDS-medicatie zo nodig ===

[[Bestand:Toedienlijst_Niet-GDS-medicatie_zo_nodig.png]]

Niet GDS-medicatie zo nodig zijn losse medicatie die in bijzondere gevallen toegediend mogen worden. De voorwaarde voor het toedienen van een zo nodig medicament kan zijn:

*een fysiologische meetwaarde (plasma glucose concentratie, lichaamstemperatuur, bloeddruk);
*een symptoom of andere omstandigheid (bij hoofdpijn, bij jeuk).

In het data-element “Distributievorm” in de bijbehorende TA wordt aangegeven of er geen sprake is van GDS-medicatie. Daarnaast is het criterium “ZoNodig” ingevuld.

==Bouwsteen instanties ==

Deze paragraaf beschrijft welke instanties van de bouwstenen horen bij de toedienlijst. Dit gaat alleen om ‘eigen’ bouwstenen ([[#Bouwsteen instantiaties|hoofdstuk 5.3.1]]) en dan alleen de laatste, relevante instanties hiervan ([[#Laatste relevante|paragraaf 6.3.2]]).

===Therapie en logistieke bouwstenen ===

De medicatiebouwstenen voor het samenstellen van een toedienlijst zijn zowel therapeutisch als logistiek van aard. Bouwstenen kunnen op basis van afleidingregels overruled worden. Hierbij zijn de afleidregels die eerder in [[#Medicatieoverzicht_en_afleidingsregels|hoofdstuk 5]] benoemd zijn van toepassing (zie [[#Medicatieoverzicht en afleidingsregels|hoofdstuk 5]]). Alleen voor WDS als nieuwe bouwsteen zijn de regels nog niet opgesteld. Deze afleidingsregels zullen in deze paragraaf opgenomen worden. Voor MTD zijn de afleidingsregels niet van toepassing, dit gaat namelijk over een feitelijke gebeurtenis op een bepaald moment en niet over een periode waarbij een bepaalde afspraak actueel is zoals bij de MA, TA en MGB.

Bij het opstellen van een toedienlijst moet er ook rekening gehouden worden met de logistieke bouwsteen MVE om de distributievorm te kunnen bepalen.

====Toedienlijst en afleidingsregels ====

Een toedienlijst kan o.a. in het informatiesysteem van de toediener, door middel van losse medicatiebouwstenen worden samengesteld. De medicatiebouwstenen kunnen worden verkregen uit het eigen informatiesysteem en uit andere bronnen. Voor het raadplegen en beschikbaarstellen van losse bouwstenen wordt de transactie Medicatiegegevens (raadplegen/ beschikbaarstellen) gebruikt.

Met de transactiegroep Medicatiegegevens (sturen/ ontvangen) kunnen losse bouwstenen direct aan een andere zorgverlener of de patiënt worden verstuurd (dus zonder eerst te raadplegen). Dit gebeurt bijvoorbeeld bij ontslag of op verzoek van een medebehandelaar (bijv. een patiënt verschijnt bij een huisarts of apotheker buiten de regio waarbij deze huisarts of apotheker bij de eigen huisarts van de patiënt de gegevens telefonisch opvraagt en digitaal ontvangt).

Bij zowel Medicatiegegevens sturen/ ontvangen als raadplegen/ beschikbaarstellen mogen gegevens die uit andere bron zijn verkregen niet worden opgeleverd.

===Laatste relevante ===

Alleen de laatste relevante bouwstenen (per medicamenteuze behandeling) zijn onderdeel van de toedienlijst. Deze paragraaf beschrijft wat precies die laatst relevante bouwstenen zijn voor een toedienlijst van medicatie op voorschrift. De hierop volgende paragraaf 6.3.2.1 gaat in op de bijzondere situatie waarbij een WDS van toepassing is. Een WDS kan wat betreft afleidingsregels op dezelfde manier behandeld worden als de MA. Bij het opstellen van toedienlijst is bij aanwezigheid van een WDS, dit WDS leidend voor de gebruiksinstructie. Alle andere situaties zonder WDS, die in [[#Laatste relevante|paragraaf 5.3.2]] beschreven worden, zijn ook van toepassing.

Query om te komen tot de juiste, relevante en toekomstige bouwstenen:

{| class="wikitable"
|-
! Nr
! style="text-align:left;"|Bouwsteen
! style="text-align:left;"|Query
! style="text-align:left;"|Wat is de specifieke invulling?
|-
| 1 || MA, TA, WDS || Gebruiksperiode || Alles wat vandaag toegediend moet worden en daarmee van toepassing is: Dag = T, BeginDatum = T: 00:00:00 uur, EindDatum = T: 23:59:59 uur
|-
| 2 || MTD || Toedieningsperiode || Afhankelijk hoe ver in het verleden de prik- en plaklocaties medisch of voor het toedienen noodzakelijk zijn. Bijvoorbeeld als een week voldoende is (er kan ook gekozen worden voor een andere periode): Dag = T, BeginDatum = T-7 dag
|-
| 3 || MVE || Verstrekkingsperiode || Ruim opvragen (+/- één maand)
|}

Als alle bouwstenen verzameld zijn, kunnen de volgende medicatiegegevens afhankelijk van de situatie uit de volgende bouwstenen gebruikt worden:

{| class="wikitable"
|-
! style="text-align:left;"|Bouwsteen
! style="text-align:left;"|Situatie: alleen MA*
! style="text-align:left;"|Situatie: MA + TA
! style="text-align:left;"|Situatie: MA + TA + WDS
|-
| MA || Leidend** voor het opstellen van de toedienlijst (nummer: 2, 5, 6, 7, 9, 10) || Gegevens van de voorschrijver || Gegevens van de voorschrijver
|-
| TA || - || Leidend** voor het opstellen van de toedienlijst (nummer 2, 5, 6, 7, 9, 10) || Gegevens van de verstrekker en geneesmiddel
|-
| WDS || - || - || Leidend** voor het opstellen van de toedienlijst (nummer 5, 6, 7, 10)
|}

* Situatie waarbij een apotheker de MA nog niet verwerkt heeft.
** Met leidend worden de data-elementen die in de functionele eisen zijn opgenomen. De nummers van deze elementen zijn toegevoegd.

====Medicatie op voorschrift met een wisselend doseerschema ====

======Meest eenvoudige ‘happy flow’======

In een medicamenteuze behandeling ontstaat er in de meest eenvoudige ‘happy flow’ een opeenvolging van:

*Medicatieafspraak – Wisselenddoseerschema – Toedieningsafspraak

Normaal gesproken begint een medicamenteuze behandeling met een medicatieafspraak. Een toedieningsafspraak vult de medicatieafspraak concreet in. Daarnaast wordt er met een WDS vastgesteld of er sprake is van een wisselenddoseerschema. In zowel de MA als in de TA wordt “Gebruik volgens schema trombosedienst” bij de dosering vastgelegd. In het WDS wordt invulling gegeven aan de dosering; doseerschema wordt vastgelegd. De drie bouwstenen zijn relevant en horen bij het samenstellen van een toedienlijst, zoals aangegeven in groen hieronder. 

*Medicatieafspraak – Wisselenddoseerschema – Toedieningsafspraak 

Een toedieningsafspraak verwijst in principe naar de medicatieafspraak die hij invult. Ook een wisselend doseerschema verwijst naar de medicatieafspraak die het invult. Een WDS is altijd gerelateerd aan een medicatieafspraak.

======Nieuwe Wisselenddoseerschema ======


*Medicatieafspraak – Wisselenddoseerschema – Toedieningsafspraak – Wisselenddoseerschema

De gebruiksperiode van wisselenddoseerschema is afgelopen en er wordt een nieuw doseerschema aangemaakt. Voor een wisselenddoseerschema waarin al direct een stopdatum is afgesproken, is geen aanvullende stop-WDS nodig.

======Wijziging Wisselenddoseerschema ======


*Medicatieafspraak – Wisselenddoseerschema – Toedieningsafspraak – stop-Wisselenddoseerschema – Wisselenddoseerschema

Het wisselenddoseerschema is gewijzigd.

======Stoppen van medicatie ======

*Medicatieafspraak – Wisselenddoseerschema – Toedieningsafspraak – stop-Medicatieafspraak

Het stoppen van medicatie met een wisselenddoseerschema wordt met behulp van de MA gestopt.

======Wijzigen van handelsproduct ======


*Medicatieafspraak – Wisselenddoseerschema – Toedieningsafspraak – stop-Toedieningsafspraak – Toedieningsafspraak

Het handelsproduct wordt gewijzigd, dit heeft geen invloed op het wisselenddoseerschema.

======Regels van het overrulen opgesomd ======

Op basis van bovenstaande beschrijvingen/voorbeelden zijn de volgende algemene regels voor het overrulen af te leiden. Het gaat hier om de regels om te bepalen of een bouwsteen relevant is voor oplevering in de toedienlijst. Binnen een medicamenteuze behandeling: 
*Een nieuwe medicatieafspraak overrulet alle oudere therapie bouwstenen (medicatieafspraak, toedieningsafspraak, wisselenddoseerschema) behorende bij de medicatieafspraak/-afspraken die deze medicatieafspraak gestopt heeft.
*Een nieuwe toedieningsafspraak overrulet de oudere toedieningsafspraak die hoort bij dezelfde medicatieafspraak als de nieuwe toedieningsafspraak.
*Een nieuw wisselenddoseerschema overrulet alle oudere wisselenddoseerschema’s die horen bij dezelfde medicatieafspraak.


=Systemen en transacties=
Dit hoofdstuk bevat een opsomming van alle systeemrollen en transacties. In de verschillende proceshoofdstukken wordt hiernaar verwezen.

Onderstaande figuur ([[#figuur 10|Figuur 10]]) bevat een overzicht van alle informatiesystemen met hun bijbehorende systeemrollen. De systeemrollen zijn beschreven in de daaronder opgenomen [[#tabel 3|Tabel 3]]. De systeemrollen die betrekking hebben op raadplegen/beschikbaarstellen van medicatiegegevens en medicatieoverzicht zijn voor alle informatiesystemen van belang al naar gelang het proces waarin zij gebruikt worden. Het elektronisch voorschrijfsysteem (EVS) heeft daarnaast de systeemrollen voor het ontvangen van een voorstel verstrekkingsverzoek, het versturen van een antwoord voorstel verstrekkingsverzoek en het ontvangen van een voorstel medicatieafspraak en in de ambulante situatie voor het versturen van een voorschrift en het ontvangen van een vervulling van het voorschrift. Een XIS en PGO hebben naast de generieke systeemrollen ook de systeemrollen voor het versturen van een voorstel medicatieafspraak en voorstel verstrekkingsverzoek en het sturen van gebruik en ontvangen antwoord voorstel verstrekkingsverzoek. Een apotheekinformatiesysteem heeft naast de basis systeemrollen ook de rollen voor sturen van voorstel medicatieafspraak, voorstel verstrekkingsverzoek en afhandeling voorschrift en het ontvangen van een voorschrift en antwoord voorstel verstrekkingsverzoek. In [[#Medicatieproces|hoofdstuk 2]] zijn de belangrijkste systeemrollen per proces benoemd.

{{anchor|figuur 10}}
[[Bestand:Systemen.png|Figuur 10 Overzicht systemen en systeemrollen]]

{{anchor|tabel 3}}
{| class="wikitable" "cellpadding="10"
!style="text-align:left;"|Naam systeemrol
!style="text-align:left;"|Afk.
!style="text-align:left;"|Omschrijving
|-
| style="background-color: white;"| MedicatieGegevensBeschikbaarstellend
| style="background-color: white;"| MP-MGB
| style="background-color: white;"| Beschikbaarstellen medicatiegegevens aan medebehandelaars/patiënt
|-
| style="background-color: white;"| MedicatieGegevensRaadplegend
| style="background-color: white;"| MP-MGR
| style="background-color: white;"| Raadplegen medicatiegegevens bij medebehandelaars/patiënt
|-
| style="background-color: white;"| MedicatieGegevensSturend
| style="background-color: white;"| MP-MGS
| style="background-color: white;"| Sturen medicatiegegevens aan medebehandelaar/patiënt
|-
| style="background-color: white;"| MedicatieGegevensOntvangend
| style="background-color: white;"| MP-MGO
| style="background-color: white;"| Ontvangen medicatiegegevens van medebehandelaar/patiënt
|-
| style="background-color: white;"| MedicatieOverzichtBeschikbaarstellend
| style="background-color: white;"| MP-MOB
| style="background-color: white;"| Beschikbaarstellen medicatieoverzicht aan medebehandelaars/patiënt
|-
| style="background-color: white;"| MedicatieOverzichtRaadplegend
| style="background-color: white;"| MP-MOR
| style="background-color: white;"| Raadplegen medicatieoverzicht bij medebehandelaars/patiënt
|-
| style="background-color: white;"| MedicatieOverzichtSturend
| style="background-color: white;"| MP-MOS
| style="background-color: white;"| Sturen medicatieoverzicht aan medebehandelaar/patiënt
|-
| style="background-color: white;"| MedicatieOverzichtOntvangend
| style="background-color: white;"| MP-MOO
| style="background-color: white;"| Ontvangen medicatieoverzicht van medebehandelaar/patiënt
|-
| style="background-color: white;"| VoorschriftSturend
| style="background-color: white;"| MP-VOS
| style="background-color: white;"| Sturen verzoek tot medicatieverstrekking van medicatie of verwerking van wijziging in medicatieafspraak
|-
| style="background-color: white;"| VoorschriftOntvangend
| style="background-color: white;"| MP-VOO
| style="background-color: white;"| Ontvangen verzoek tot medicatieverstrekking van medicatie of verwerking wijziging in medicatieafspraak
|-
| style="background-color: white;"| VoorschriftAfhandelingSturend
| style="background-color: white;"| MP-VAS
| style="background-color: white;"| Sturen afhandeling van de medicatieafspraak en evt. verstrekkingverzoek in toedieningsafspraak en/of medicatieverstrekking
|-
| style="background-color: white;"| VoorschriftAfhandelingOntvangend
| style="background-color: white;"| MP-VAO
| style="background-color: white;"| Ontvangen afhandeling van de medicatieafspraak en evt. verstrekkingverzoek in toedieningsafspraak en/of medicatieverstrekking
|-
| style="background-color: white;"| VoorstelVerstrekkingsverzoekSturend
| style="background-color: white;"| MP-VVS
| style="background-color: white;"| Informeren voorschrijver over voorstel tot nieuw verstrekkingsverzoek, ontvangen antwoord op voorstel verstrekkingsverzoek
|-
| style="background-color: white;"| VoorstelVerstrekkingsverzoekOntvangend
| style="background-color: white;"| MP-VVO
| style="background-color: white;"| Ontvangen voorstel tot nieuw verstrekkingsverzoek, sturen antwoord op voorstel verstrekkingsverzoek
|-
| style="background-color: white;"| VoorstelMedicatieafspraakSturend
| style="background-color: white;"| MP-VMS
| style="background-color: white;"| Informeren voorschrijver over voorstel tot nieuwe of gewijzigde medicatieafspraak, ontvangen antwoord op voorstel medicatieafspraak
|-
| style="background-color: white;"| VoorstelMedicatieafspraakOntvangend
| style="background-color: white;"| MP-VMO
| style="background-color: white;"| Ontvangen voorstel tot nieuwe of gewijzigde medicatieafspraak, sturen antwoord op voorstel medicatieafspraak
|}Tabel 3 Overzicht systeemrollen
In Tabel 4 is een overzicht opgenomen van alle transactiegroepen, transacties, bijbehorende systeemrollen en de bouwstenen die met deze transactiegroep worden uitgewisseld. De namen van de transactiegroepen en transacties linken naar de Art-decor publicatie waarin per scenario is uitgewerkt welke gegevenselementen daarin voorkomen.

{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| '''Transactiegroep'''
! style="text-align:left;"| '''Transactie'''
! style="text-align:left;"| '''Systeemrol'''
! style="text-align:left;"| '''Bouwstenen'''
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.131-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.299_20220207000000 Medicatiegegevens (Raadplegen/Beschikbaarstellen)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.301-2022-02-07T000000.html Beschikbaarstellen medicatiegegevens]
|style="background-color: white;vertical-align:top;"|MP-MGB
|style="background-color: white;vertical-align:top;" rowspan="2"|Eén of meer: MA, VV, TA, MVE, MTD, MGB, WDS
|-
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.300-2022-02-07T000000.html Raadplegen medicatiegegevens]
|style="background-color: white;vertical-align:top;"|MP-MGR
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.131-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.302_20220207000000 Medicatiegegevens (Sturen/Ontvangen)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.303-2022-02-07T000000.html Sturen medicatiegegevens]
|style="background-color: white;vertical-align:top;"|MP-MGS
|style="background-color: white;vertical-align:top;" rowspan="2"|Eén of meer: MA, VV, TA, MVE, MTD, MGB, WDS
|-
|style="background-color: white;vertical-align:top;"|Ontvangen medicatiegegevens
|style="background-color: white;vertical-align:top;"|MP-MGO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.132-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.315_20220207000000 Medicatieoverzicht (Raadplegen/Beschikbaarstellen)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.317-2022-02-07T000000.html Beschikbaarstellen medicatieoverzicht]
|style="background-color: white;vertical-align:top;"|MP-MOB
|style="background-color: white;vertical-align:top;" rowspan="4"|MA, TA, MGB
|-
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.316-2022-02-07T000000.html Raadplegen medicatieoverzicht]
|style="background-color: white;vertical-align:top;"|MP-MOR
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.132-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.318_20220207000000 Medicatieoverzicht (Sturen/Ontvangen)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.319-2022-02-07T000000.html Sturen medicatieoverzicht]
|style="background-color: white;vertical-align:top;"|MP-MOS
|-
|style="background-color: white;vertical-align:top;"|Ontvangen medicatieoverzicht
|style="background-color: white;vertical-align:top;"|MP-MOO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.133-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.321_20220207000000 MedicatieVoorschrift (Sturen/Ontvangen)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.322-2022-02-07T000000.html Sturen medicatievoorschrift]
|style="background-color: white;vertical-align:top;"|MP-VOS
|style="background-color: white;vertical-align:top;" rowspan="2"|MA met of zonder VV, lengte, gewicht, nierfunctiewaarde
|-
|style="background-color: white;vertical-align:top;"|Ontvangen medicatievoorschrift
|style="background-color: white;vertical-align:top;"|MP-VOO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.135-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.333_20220207000000 MedicatieVoorschrift Afhandeling (Sturen/Ontvangen)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.334-2022-02-07T000000.html Sturen afhandeling medicatievoorschrift]
|style="background-color: white;vertical-align:top;"|MP-VAS
|style="background-color: white;vertical-align:top;" rowspan="2"|TA met of zonder MVE
|-
|style="background-color: white;vertical-align:top;"|Ontvangen afhandeling medicatievoorschrift
|style="background-color: white;vertical-align:top;"|MP-VAO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.134-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.327_20220207000000 Voorstel verstrekkingsverzoek (Sturen/Ontvangen)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.328-2022-02-07T000000.html Sturen voorstel verstrekkingsverzoek]
|style="background-color: white;vertical-align:top;"|MP-VVS
|style="background-color: white;vertical-align:top;" rowspan="2"|VVV
|-
|style="background-color: white;vertical-align:top;"|Ontvangen voorstel verstrekkingsverzoek
|style="background-color: white;vertical-align:top;"|MP-VVO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.134-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.330_20220207000000 Antwoord voorstel verstrekkingsverzoek (Ontvangen/Sturen)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.331-2022-02-07T000000.html Sturen antwoord voorstel verstrekkingsverzoek]
|style="background-color: white;vertical-align:top;"|MP-VVO
|style="background-color: white;vertical-align:top;" rowspan="2"|AVVV
|-
|style="background-color: white;vertical-align:top;"|Ontvangen antwoord voorstel
|style="background-color: white;vertical-align:top;"|MP-VVS
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.134-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.324_20220207000000 Voorstel medicatieafspraak (Sturen/Ontvangen)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.325-2022-02-07T000000.html Sturen voorstel medicatieafspraak]
|style="background-color: white;vertical-align:top;"|MP-VMS
|style="background-color: white;vertical-align:top;" rowspan="2"|VMA met of zonder lengte, gewicht
|-
|style="background-color: white;vertical-align:top;"|Ontvangen voorstel medicatieafspraak
|style="background-color: white;vertical-align:top;"|MP-VMO
|-
|style="background-color: white;vertical-align:top;" rowspan="2"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/sc-2.16.840.1.113883.2.4.3.11.60.20.77.3.134-2022-02-07T000000.html#_2.16.840.1.113883.2.4.3.11.60.20.77.4.372_20220302000000 Antwoord voorstel medicatieafspraak (Ontvangen/Sturen)]
|style="background-color: white;vertical-align:top;"|[http://decor.nictiz.nl/medicatieproces/mp-html-20220402T205710/tr-2.16.840.1.113883.2.4.3.11.60.20.77.4.373-2022-03-02T000000.html Sturen antwoord voorstel medicatieafspraak]
|style="background-color: white;vertical-align:top;"|MP-VMO
|style="background-color: white;vertical-align:top;" rowspan="2"|AVMA
|-
|style="background-color: white;vertical-align:top;"|Ontvangen antwoord voorstel medicatieafspraak
|style="background-color: white;vertical-align:top;"|MP-VMS
|}Tabel 4 Overzicht transactiegroepen

In [[#Medicatieproces|hoofdstuk 2]] zijn per proces alleen de relevante transacties per processtap aangegeven. Daarin zijn de transactiegroepen niet opgenomen. Bovenstaande tabel bevat alle transactiegroepen en transacties.

=Functionaliteit=
Dit hoofdstuk beschrijft aanwijzingen voor de functionaliteit van een informatiesysteem.

==Filteren van medicatie uit 2e/3e lijn (alle informatiesystemen)==
Een instelling stelt alle eigen medicatiegegevens (alle bouwstenen) beschikbaar. Deze gegevens zijn voor de ontvangende zorgverleners mogelijk niet allemaal relevant. De ontvangende informatiesystemen kunnen een filter opnemen afhankelijk van de behoefte van de betreffende zorgverlener/patiënt. Onderstaande lijst (Tabel 5) bevat typen medicatie waarvan benoemd is dat medicatietoediening tijdens de opname relevant is voor zorgverleners buiten de instelling.

{{anchor|tabel 5}}
{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| ATC-groepscode
! style="text-align:left;"| Naam
|-
| style="background-color: white;vertical-align:top;"|L01
| style="background-color: white;vertical-align:top;"|Cytostatica
|-
| style="background-color: white;vertical-align:top;"| L03AX03
| style="background-color: white;vertical-align:top;"|BCG-vaccin urologie
|-
| style="background-color: white;vertical-align:top;"|L04AA23; L04AA25; L04AA26; L04AA33; L04AA34; L04AB; L04AC
| style="background-color: white;vertical-align:top;"|Immunosuppresiva
|-
| style="background-color: white;vertical-align:top;"|B03AC; B03XA; B06AC
| style="background-color: white;vertical-align:top;"| IJzer, epo, middelen tegen angioedeem
|-
| style="background-color: white;vertical-align:top;"|G03GA; G03GB02
| style="background-color: white;vertical-align:top;"|Gonadotropines (HCG etc), clomifeen
|-
| style="background-color: white;vertical-align:top;"|H01CA; H01CC; L02AE04
| style="background-color: white;vertical-align:top;"|Gonadoreline, hypothalamus hormonen, triptoreline
|-
| style="background-color: white;vertical-align:top;"|J06; J07
| style="background-color: white;vertical-align:top;"|Immunoglobulines, vaccins
|-
| style="background-color: white;vertical-align:top;"|M03AX01
| style="background-color: white;vertical-align:top;"|Botox
|-
| style="background-color: white;vertical-align:top;"|R03DX05
| style="background-color: white;vertical-align:top;"|Omalizumab
|-
| style="background-color: white;vertical-align:top;"|S01LA04; S01LA05; S01LA
| style="background-color: white;vertical-align:top;"|Oogheelkundige anti neovasculaire stoffen
|}Tabel 5 Typen klinische medicatie relevant voor extramurale zorgverleners

==Beschikbaarstellen medicatiegegevens (alle informatiesystemen)==
Alle eigen medicatiegegevens mogen beschikbaargesteld worden wanneer de patiënt daarvoor toestemming heeft gegeven (conform vigerende wet- en regelgeving). Gegevens ontvangen van anderen (zorgverleners/patiënt) die men in het eigen informatiesysteem heeft overgenomen en aangemerkt als kopie worden niet beschikbaargesteld. De enige uitzondering is de transactie Medicatieoverzicht PUSH en PULL, daar worden bouwstenen van anderen beschikbaar gesteld mits zij voorzien zijn van de originele identificatie (zie ook [[#paragraaf5.1|paragraaf 5.1]]).

==Aanschrijfdatum of verstrekkingsdatum (apotheekinformatiesysteem)==
In de medicatieverstrekking kan zowel de aanschrijfdatum als de daadwerkelijke datum van uitgifte worden vastgelegd. Wanneer een verstrekkingsverzoek direct verwerkt wordt en de patiënt komt het nog dezelfde dag ophalen zijn beide datums gelijk. Wanneer de patiënt de medicatie één of meerdere dagen later komt ophalen dan moeten deze datums verschillend worden ingevuld. De verstrekkingsdatum is de datum dat de daadwerkelijke medicatie-uitgifte heeft plaats gevonden. De aanschrijfdatum is het tijdstip waarop een apotheker een voorgenomen uitgifte vastlegt. Wanneer er meerdere verstrekkingen worden gedaan onder hetzelfde verstrekkingsverzoek (bijv. bij knippen recept) dan heeft elke verstrekking een eigen aanschrijfdatum.
Wanneer er gewerkt wordt met een uitgifte-automaat is de verstrekkingsdatum het tijdstip waarop de patient de medicatie uit de automaat haalt. Wanneer dit tijdstip niet beschikbaar is in het AIS mag tot die tijd ook het tijdstip worden gebruikt waarop de medicatie in de uitgifte-automaat wordt gelegd. Zie ook [[#Aanschrijven, verstrekken en niet afhalen| paragraaf 4.2.5 Aanschrijven, verstrekken en niet afhalen]].

==Bijwerken na systeemstoring==
Na systeemuitval moet het informatiesysteem van de voorschrijver controleren of er wijzigingen zijn doorgevoerd in medicatieafspraken. Zie voor use cases en onderbouwing [[#Staken van medicatie door derden|paragraaf 4.1.26]] en [[#Twee PRK's onder één medicamenteuze behandeling|paragraaf 4.1.27]].

==Constructie voor interval eenmaal per 36 uur==
Wanneer de doseerinstructie luidt 1 tablet per 36uur kan dit normaliter in één medicatieafspraak worden weergegeven (keerdosis: 1 tablet, interval: 36uur). Maar wanneer een informatiesysteem niet verder gaat dan een interval van bijvoorbeeld 24 uur dan is er een andere oplossing nodig. 

''Variant 1:''
Gebruik maken van een Zo nodig instructie waarbij het criterium is: ‘er is 36 uur verstreken sinds de laatste medicatietoediening’. Maar dit levert een bepaalde mate van vrijblijvendheid die mogelijk niet gewenst is.

''Variant 2:''
Er kan ook een repeterend schema worden gemaakt waarbij gewisseld wordt tussen ochtend en avond en een dag niet:
Herhaalperiode: 3 dagen
Doseerinstructie
Volgnummer: 1
Doseerduur: 1 dag
Dosering
Keerdosis: 1 stuks
Toedientijd: 9uur (bijvoorbeeld, kan ook een dagdeel zijn)
Volgnummer: 2
Doseerduur: 1 dag
Dosering
Keerdosis: 1 stuks
Toedientijd: 21uur (bijvoorbeeld, kan ook een dagdeel zijn)

Wanneer het in het informatiesysteem niet mogelijk is om een interval van 36uur te kiezen wordt variant 2 toegepast.

==EVS/HIS verwerken Afhandeling voorschrift==
Het voorschrijvende informatiesysteem wordt door de apotheker geïnformeerd over alle verstrekkingen en wijzigingen in toedieningsafspraken middels de transactie Afhandeling voorschrift. Deze afhandeling moet automatisch verwerkt worden in het voorschrijvende informatiesysteem. De voorschrijver beoordeelt alleen de toedieningsafspraken en hoeft niet alle verstrekkingen te beoordelen.

==Voorbeelden doseringen==
Zie [[mp:V9.2.0.0 Voorbeelden doseringen|Voorbeelden doseringen 9.2.0 (zowel functioneel als technische uitwerking in HL7v3 CDA én in FHIR)]]

==Medicatiegebruik: gebruikindicator, volgens afspraak indicator, stoptype, gebruiksperiode en doseerinstructie==
{| class="wikitable"
|-
|style="text-align:center;" |Situatie || 1. Medicatie is/wordt in gebruiksperiode gebruikt volgens afspraak|| 2. Medicatie is/wordt in gebruiksperiode gebruikt maar niet volgens afspraak || 3. In tegenstelling tot de afspraak is/wordt in gebruiksperiode de medicatie niet gebruikt || 4. Medicatie is/wordt in de gebruiksperiode niet gebruikt en dat is ook volgens afspraak || 5. Medicatie is/wordt in de gebruiksperiode gebruikt maar onbekend of dit volgens afspraak is of er is geen afspraak (zelfzorgmedicatie)
|-
! Gebruikindicator ''(wordt dit product gebruikt)'' !! Ja !! Ja !! Nee !! Nee !! Ja
|-
! Volgens afspraak indicator!! Ja !! Nee !! Nee !! Ja !! -
|-
! Stoptype!! Nvt !! Nvt!! Definitief of Tijdelijk !! Definitief of Tijdelijk !! Nvt
|-
| || || || Stoptype afhankelijk of er gestaakt of onderbroken wordt || Stoptype conform de stop-afspraak ||
|-
! Gebruiksperiode!! Conform MA of TA !! Max. 2 van de 3 !! Max. 2 van de 3 !! Max. 2 van de 3 !! Max. 2 van de 3
|-
|style="text-align:right;" | ingangsdatum || Het tijdstip waarop het gebruik is gestart. || Het tijdstip waarop het afwijkende gebruik is/wordt gestart. || Het tijdstip vanaf wanneer gestaakt of onderbroken wordt.|| Het tijdstip vanaf wanneer gestaakt of onderbroken wordt. || Het tijdstip waarop het gebruik is gestart.
|-
|style="text-align:right;" | gebruiksduur || De beoogde gebruiksduur. || De beoogde duur van het afwijkende gebruik. || De (beoogde) duur van het onderbreken. (nvt. voor staken)|| De (beoogde) duur van het onderbreken. (nvt. voor staken)|| De beoogde gebruiksduur.
|-
|style="text-align:right;" | stopdatum || Het tijdstip waarop de gebruiksperiode eindigt (of geëindigd is of zal eindigen). || Het tijdstip waarop het afwijkende gebruik eindigt (of geëindigd is of zal eindigen). || Het tijdstip waarop het onderbreken eindigt en gebruik is/wordt herstart (of beoogd wordt te herstarten). (nvt. voor staken)|| Het tijdstip waarop het onderbreken eindigt en gebruik is/wordt herstart (of beoogd wordt te herstarten). (nvt. voor staken) || Het tijdstip waarop de gebruiksperiode eindigt (of geëindigd is of zal eindigen).
|-
! Doseerinstructie!! Conform MA of TA !! Verplicht!! Nvt !! Nvt !! Verplicht
|-
| || Medicatie is/wordt in gebruiksperiode gebruikt volgens afspraak || Medicatie is/wordt in gebruiksperiode niet gebruikt volgens afspraak, daadwerkelijk gebruikte dosering moet doorgegeven worden. || De medicatie is/wordt niet gebruikt, er is geen dosering. || De medicatie is/wordt niet gebruikt, er is geen dosering.|| Dosering die patiënt met zichzelf heeft afgesproken.
|}
'''VOORBEELDEN:''' 
'''Situatie 1: Medicatie is/wordt in gebruiksperiode gebruikt volgens afspraak''' 
Patiënt heeft Ferrofumaraat voorgeschreven gekregen tegen bloedarmoede. Dosering is 3x daags 1 tablet een half uur voor het eten innemen, met als startdatum 4 juni 2018 en zonder stopdatum. 
Op 10 juni registreert de patiënt het medicatiegebruik over de afgelopen periode (van 4 t/m 10 juni). 
{| class="wikitable"
|-
! Situatie 1 !!
|-
| Geneesmiddel || FERROFUMARAAT 100 MG TABLET
|-
| Gebruiksindicator || Ja
|-
| Volgens afspraak indicator || Ja
|-
| Stoptype || nvt
|-
| Ingangsdatum || 4 juni 2018
|-
| Stopdatum || 10 juni 2018
|-
| Doseerinstructie || ''Overeenkomstig de afspraak''
|}

'''Situatie 1: Medicatie is/wordt in gebruiksperiode gebruikt volgens afspraak''' 
Patiënt heeft Ferrofumaraat voorgeschreven gekregen tegen bloedarmoede. Dosering is 3x daags 1 tablet een half uur voor het eten innemen, met als startdatum 4 juni 2018 en zonder stopdatum. 
Op 10 juni registreert de patiënt het medicatiegebruik en het voornemen om deze medicatie te blijven gebruiken volgens de afspraak. 
{| class="wikitable"
|-
! Situatie 1 !!
|-
| Geneesmiddel || FERROFUMARAAT 100 MG TABLET
|-
| Gebruiksindicator || Ja
|-
| Volgens afspraak indicator || Ja
|-
| Stoptype || nvt
|-
| Ingangsdatum || 4 juni 2018
|-
| Stopdatum || -
|-
| Doseerinstructie || ''Overeenkomstig de afspraak''
|}

'''Situatie 2: Medicatie is/wordt in gebruiksperiode gebruikt maar niet volgens afspraak''' 
Patiënt heeft Ferrofumaraat voorgeschreven gekregen tegen bloedarmoede. Dosering is 3x daags 1 tablet een half uur voor het eten innemen, met als startdatum 4 juni 2018 en zonder stopdatum. 
De patiënt is overdag veel op pad en vergeet een werkweek lang om telkens de medicijnen voor de lunch in te nemen. Wel worden de tabletten 's ochtends en 's avonds voor het eten ingenomen 
{| class="wikitable"
|-
! Situatie 2 !!
|-
| Geneesmiddel || FERROFUMARAAT 100 MG TABLET
|-
| Gebruiksindicator || Ja
|-
| Volgens afspraak indicator || Nee
|-
| Stoptype || nvt
|-
| Ingangsdatum || 11 juni
|-
| Stopdatum || 15 juni
|-
| Doseerinstructie || 2x daags 1 tablet
|}
'''Situatie 3: In tegenstelling tot de afspraak is/wordt in gebruiksperiode de medicatie niet gebruikt''' 
Patiënt heeft Ferrofumaraat voorgeschreven gekregen tegen bloedarmoede. Dosering is 3x daags 1 tablet een half uur voor het eten innemen, met als startdatum 4 juni 2018 en zonder stopdatum. 
De patiënt gaat een lang weekend op vakantie en komt er te laat achter dat de medicatie niet ingepakt is. De komende paar dagen zal de patiënt de tabletten niet nemen en ze wil dit registreren. 
{| class="wikitable"
|-
! Situatie 3 !!
|-
| Geneesmiddel || FERROFUMARAAT 100 MG TABLET
|-
| Gebruiksindicator || Nee
|-
| Volgens afspraak indicator || Nee
|-
| Stoptype || Tijdelijk
|-
| Ingangsdatum || 20 juli
|-
| Stopdatum || 23 juli
|-
| Doseerinstructie || nvt
|}
'''Situatie 4: Medicatie is/wordt in de gebruiksperiode niet gebruikt en dat is ook volgens afspraak''' 
Patiënt heeft Ferrofumaraat voorgeschreven gekregen tegen bloedarmoede. Dosering is 3x daags 1 tablet een half uur voor het eten innemen, met als startdatum 4 juni 2018. 
Op 12 augustus blijkt na controle dat er geen sprake meer is van bloedarmoede en de arts stopt de medicatie. De patiënt wil registreren dat ze gestopt is met de medicatie en registreert dit zelf op 15 augustus. 
{| class="wikitable"
|-
! Situatie 4 !!
|-
| Geneesmiddel || FERROFUMARAAT 100 MG TABLET
|-
| Gebruiksindicator || Nee
|-
| Volgens afspraak indicator || Ja
|-
| Stoptype || Definitief
|-
| Ingangsdatum || 12 augustus 2018
|-
| Stopdatum || -
|-
| Doseerinstructie || nvt
|}
'''Situatie 5: Medicatie is/wordt in de gebruiksperiode gebruikt maar onbekend of dit volgens afspraak is of er is geen afspraak (zelfzorgmedicatie)''' 
Patiënt heeft de griep en hij neemt tegen de koorts en pijn paracetamol 500 mg van de plaatselijke drogist. Hij neemt inmiddels al vier dagen 4 tot 6 tabletten per dag en denkt dit nog drie dagen te zullen doen. Hij registreert dit op 12 augustus als medicatiegebruik. 
{| class="wikitable"
|-
! Situatie 5 !!
|-
| Geneesmiddel || Paracetamol 500 mg
|-
| Gebruiksindicator || Ja
|-
| Volgens afspraak indicator || -
|-
| Stoptype || nvt
|-
| Ingangsdatum || 9 augustus 2018
|-
| Duur || 7 dagen
|-
| Doseerinstructie || 4 tot 6 tabletten per dag
|}

==Implementatie geneesmiddel distributiesysteem (GDS)-velden==

===Achtergrond===
Steeds meer patiënten ontvangen hun medicatie via een geneesmiddel distributiesysteem (GDS), waarbij de apotheker overzicht en ordening voor de patiënt aanbrengt in diens geneesmiddelen door deze gereed te maken in afzonderlijke compartimenteenheden. Deze aflevervorm heeft met name een vlucht genomen toen de Geneesmiddelenwet in 2007 bepaalde dat in zorginstellingen zonder apotheek de medicatie voor de patiënten op naam gesteld dient te zijn.

Voor zorgverleners is het van belang om te weten of een patiënt een gebruikmaakt van GDS. In 2018 is geanalyseerd (onder regie van Z-Index, met zorgverleners) wat de knelpunten en wensen zijn rondom het vastleggen dat een patiënt gebruikmaakt van GDS. Daaruit is globaal naar voren gekomen dat het wenselijk is om zowel op medicatieniveau als op patiëntniveau te kunnen zien of een patiënt gebruik maakt van GDS. Voor de details zie volgende paragraaf.

Onderstaande aanwijzingen geven een handreiking hoe het Medicatieproces deze wensen kan ondersteunen.

===Wensen zorgverleners===
In 2018 is met de gebruikersraden van Z-Index geïnventariseerd wat de wensen rondom het vastleggen en uitwisselen van GDS is. Hieronder het overzicht van deze wensen. 

'''Wie'''
*Alle zorgpartijen (van voorschrijver t/m toediener)
'''Wat'''
*Vastleggen/uitwisselen dat iemand gebruik maakt van GDS
*Vastleggen waaróm iemand GDS patiënt is
*Vastleggen/uitwisselen bij medicatie dat dit in de GDS moet
*Vastleggen/uitwisselen wat de duur van een rol is
*Uitwisselen of wijziging per direct is of bij volgende rolwissel
'''Waarom'''
*Bepaalt welke apotheek aflevert
*Apotheek moet weten of wijziging voor lopende rol geldt of niet
*Van belang voor stoppen van eerdere medicatie bij starten van GDS
*Evaluatie van GDS-patiënten voor zorgverzekeraar
*Overige logistieke processen richting thuiszorg/mantelzorg
'''Wanneer'''
*Bij starten van medicatie, in apotheek al voor aanschrijven recept
*Bij overdracht 1e/2e lijn
*Bij wijzigen (incl. stoppen) van medicatie
*Bij wijzigen CiO-gegevens
'''Waar'''
*Bij het werken in het dossier van de patiënt dient inzichtelijk te zijn dat dit kenmerk bij betreffende patiënt van toepassing is. Per soort zorgverlener kan dit een verschillende plaats zijn (patiëntendossier, medicatiedossier). De wens van openbaar apothekers is dat ze dit kenmerk altijd bij de patiënt inzichtelijk hebben.
*Op medicatieoverzicht

===Data-elementen Medicatieproces===
De bouwstenen voor het Medicatieproces kennen de volgende velden die een rol spelen bij het vastleggen van GDS. 

{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| '''Bouwsteen'''
! style="text-align:left;"| '''Data-element nr'''
! style="text-align:left;"| '''Omschrijving'''
! style="text-align:left;"| '''Soort inhoud'''
|-
|style="background-color: white;vertical-align:top;"| Medicatieafspraak
|style="background-color: white;vertical-align:top;"|23283
|style="background-color: white;vertical-align:top;"|Aanvullende informatie
|style="background-color: white;vertical-align:top;"|Aanvullende informatie bevat een lijst van bijzonderheden over de gemaakte afspraak die van belang zijn voor de medicatiebewaking en invulling door de apotheker.
Bijvoorbeeld: ‘wijziging in GDS per direct’.
|-
|style="background-color: white;vertical-align:top;"| Verstrekkingsverzoek
|style="background-color: white;vertical-align:top;"|22759
|style="background-color: white;vertical-align:top;"|Aanvullende wensen
|style="background-color: white;vertical-align:top;"|Logistieke aanwijzingen van belang voor de invulling van het verstrekkingsverzoek door de apotheker. Bijvoorbeeld: ‘niet opnemen in GDS’
|-
|style="background-color: white;vertical-align:top;" rowspan="4"| Verstrekking
|style="background-color: white;vertical-align:top;"|20927
|style="background-color: white;vertical-align:top;"|Distributievorm
|style="background-color: white;vertical-align:top;"|Distributievorm.
Bijvoorbeeld: GDS
|-
|style="background-color: white;vertical-align:top;"|20924
|style="background-color: white;vertical-align:top;"|Verbruiksduur
|style="background-color: white;vertical-align:top;"|Voorraad voor deze duur
|-
|style="background-color: white;vertical-align:top;"|22500
|style="background-color: white;vertical-align:top;"|Aanschrijfdatum
|style="background-color: white;vertical-align:top;"|De aanschrijfdatum is het tijdstip waarop een apotheker een voorgenomen uitgifte vastlegt
|-
|style="background-color: white;vertical-align:top;"|20272
|style="background-color: white;vertical-align:top;"|Datum
|style="background-color: white;vertical-align:top;"|Het tijdstip van uitgifte. De datumtijd waarop het geneesmiddel ter hand gesteld wordt
|}

===Toepassing data-elementen ter ondersteuning gewenste functionaliteit voor GDS-patiënten===
====Vastleggen dát iemand gebruik maakt van GDS====
Bij het werken in het dossier van de patiënt is het van belang om te zien dat iemand gebruik maakt van GDS. Dat geldt zowel voor de apotheek die de GDS levert, als andere zorgverleners van de patiënt. Daarom is het van belang dat dit gegeven kan worden gecommuniceerd naar en getoond aan andere zorgverleners. 
Zolang er nog geen patiëntkenmerk is waarmee GDS vastgelegd kan worden, kan ervoor gekozen worden dit gegeven af te leiden uit de GDS-gegevens die bij de medicatie zijn vastgelegd.
Een mogelijk handvat hiervoor is het feit dat medicatie in de distributiemodule is opgenomen tezamen met het veld Distributievorm in de verstrekking.
*Stap 1: indien medicatie in de distributiemodule is opgenomen: vul het veld Distributievorm in de verstrekking met ‘GDS’.
*Stap 2: op basis van het veld Distributievorm afleiden dat een patiënt gebruikmaakt van GDS. Het feit dat een patiënt enige verstrekking heeft waarbij het veld Distributievorm met ‘GDS’ is gevuld, geeft aan dat de patiënt gebruik maakt van GDS. Deze verstrekking kan een eigen verstrekking zijn, of een verstrekking ontvangen van een andere apotheek (voor zover deze gegevens worden binnengehaald en zodanig worden vastgelegd dat de inhoud van het veld Distributievorm herbruikbaar is). Het gegeven dat een patiënt gebruikmaakt van GDS, kan vervolgens getoond worden bij het werken in het medicatiedossier c.q. het patiëntendossier. In overleg met eindgebruikers dient nader bepaald te worden waar en hoe dit getoond wordt.

====Vastleggen waaróm iemand gebruik maakt van GDS====
Gebruikers hebben aangegeven dat het wenselijk is om te kunnen vastleggen waarom iemand gebruik maakt van GDS. Op dit moment zijn hier geen structurele velden voor beschikbaar.

====Bij medicatie vastleggen dat dit in de GDS moet====
Voorschrijvers willen kunnen aangeven of een middel al dan niet via GDS verstrekt dient te worden. Dit kan als volgt:
*Verstrekkingsverzoek, veld Aanvullende wensen. De codelijst voor dit veld bevat het item ‘niet in GDS’. Deze codelijst is thesaurus 2051 van bestand 902 in de G-Standaard.

====Vastleggen/uitwisselen wat de duur van een medicatierol is====
De duur van de medicatierol kan worden bepaald op basis van de ‘verbruiksduur’ van de verstrekking: de ‘verbruiksduur’ geeft aan wat de loopduur van een medicatierol is.

====Vastleggen/uitwisselen of een wijziging in de medicatie per direct moet of niet====
Het is wenselijk dat een voorschrijver kan aangeven of wijzigingen in de medicatie per direct doorgevoerd moeten worden of dat deze kunnen wachten tot de volgende rolwissel. De handvatten hiervoor zijn als volgt:
*Medicatieafspraak, veld Aanvullende informatie. De codelijst voor dit veld bevat twee items die betrekking hebben op wijzigingen in de GDS, namelijk ‘Wijziging in GDS per direct’ en ‘Wijziging in GDS per rolwissel’. Deze codelijst is thesaurus 2050 van bestand 902 in de G-Standaard.
*Daarbij is het van belang dat de voorschrijver inzicht heeft in de duur van de rol en hoe lang het nog duurt voordat de huidige medicatierol op is. Dit is te herleiden uit:
**De verstrekking, veld Verbruiksduur, zie hierboven. Hiervoor dient het voorschrijfsysteem wel de beschikking te hebben over de verstrekkingsgegevens van eerdere verstrekkingen.
**Verstrekking, veld Aanschrijfdatum of Datum (of als niet dit veld gevuld is maar het veld Aanschrijfdatum, dan het veld Aanschrijfdatum; als beide zijn gevuld heeft Datum de voorkeur). Op basis van deze datum en de verbruiksduur, kan berekend worden per welke datum de huidige medicatierol is verbruikt.

=Beschouwingen=
==Ongeadresseerd voorschrijven (ambulant)==
In deze paragraaf wordt de term “prescriptie” gebruikt om het bericht waarmee een patiënt een geneesmiddel bij een verstrekker mag afhalen aan te duiden. Een prescriptie bevat een medicatieafspraak en een verstrekkingsverzoek.

In Nederland is het tot op heden gebruikelijk om prescripties digitaal te versturen naar een ontvangende apotheek in plaats van het ophalen van prescripties. Daarvoor is nodig, dat de apotheek al van te voren bekend is. 

Deze paragraaf is een beschouwing of er meer flexibiliteit in de logistieke afhandeling van prescripties te bereiken is, zonder de huidige voordelen teniet te doen. Deze paragraaf kan beschouwd worden als een lange termijn visie waar wij naar toe willen werken.

===Uitgangspunten===
In de afweging hoe wij flexibiliteit in de afhandeling kunnen bewerkstelligen zijn uitgangspunten geformuleerd. Deze zijn:
*De patiënt heeft de keuzevrijheid van afhandeling.
*De huidige verwerking van verzenden van prescripties blijft mogelijk.
*Het informatiesysteem moet zoveel mogelijk dezelfde functionaliteit hergebruiken.
*Een prescriptie mag maar éénmaal verstrekt worden.

Omdat de hieronder beschreven methodiek gebruik maakt van de bestaande methode van verzenden van prescripties, gelden dezelfde juridische regels over de geldigheid van de prescripties. Alle discussies over elektronische handtekeningen gelden evenzeer voor de huidige methode van communicatie van prescripties.

===Uitwerking===
Een patiënt kan kiezen uit 3 keuzemogelijkheden:
#Een prescriptie wordt altijd naar een vaste apotheker verzonden.
#De patiënt geeft per keer op waar de prescriptie naar toe verzonden wordt.
#De patiënt geeft niets op en komt bij een apotheek die een prescriptie opvraagt en afhandelt.

Voor opties 1 en 2 is een patiënt portaal nodig, waarin de patiënt zijn voorkeur aangeeft. Bij optie 2 mag een patiënt een voorkeurapotheek definiëren, die boven aan in het selectiescherm zal staan als de patiënt gevraagd wordt, waarheen de prescriptie gestuurd moet worden. Als een patiënt niets opgeeft kan optie 3 de enige werkwijze zijn.

De methodiek maakt deels gebruik van een concept dat “publish en subscribe” heet.

Het is van belang, dat de apotheker aan zijn vaste klanten uitlegt hoe het principe werkt.

===Werkproces===
Een arts besluit een prescriptie te doen aan een patiënt. Dit kan bij een consult of zelfs bij aanvraag van herhaalreceptuur zijn. De arts registreert de prescriptie in zijn voorschrijfsysteem ( EVS). De arts hoeft zich niet te bekommeren om de apotheek, dat doet de patiënt immers via het portaal.

Na akkoord van de prescriptie wordt een centrale prescriptie-index bijgewerkt. Dit gebeurt automatisch door het EVS, die een aanmelding stuurt naar deze prescriptie register. In deze beschouwing wordt de prescriptie-index als een apart register beschouwd met de gegevenssoort “voorschriften”. Later kan altijd nog geëvalueerd worden of dit niet samengevoegd kan worden. In eerste instantie wordt ook gedacht aan een atomaire registratie in het register. Later kan overwogen worden of een categorale registratie niet toereikend is.

Het is belangrijk om te begrijpen, dat er op dit moment alleen nog maar gemeld wordt, dat een prescriptie klaar staat. De prescriptie is immers nog altijd bij het EVS in een database vorm met status “staat klaar”. Er is dus nog geen prescriptie bericht.

Het registersysteem weet uit de voorkeurinstelling van de patiënt wat er met de aanmelding moet gebeuren:
#Bij de keuze vaste apotheker van de patient wordt een signaal naar de ingevulde abonneehouder van de patiënt gestuurd met de melding, dat een prescriptie opgehaald kan worden.
#Bij deze keuze stuurt het registersysteem een signaal (bijv. SMS) naar de patiënt. Vervolgens wacht het registersysteem totdat de patiënt via een app op de smartphone of via het patiëntportaal ingeeft naar welke apotheek het signaal verzonden moet worden.
#Bij deze optie doet het registersysteem niets. De patiënt heeft geen vaste abonneehouder.

===Verwerking in de apotheek===
Een ontvangende apotheek herkent aan het doorgestuurde signaal (gegevenssoort), dat dit om een openstaande prescriptie gaat. In het signaal is ook bekend wie de patiënt is en wie de bron is van de prescriptie.

Bij een patiënt die voor optie 3 gekozen heeft, begint het proces pas hierna. De patiënt identificeert zich en meldt aan de apotheker, dat een prescriptie bij een bepaalde instelling klaar staat. De apotheker zoekt eventueel in het prescriptieregister om welk EVS het gaat.

Het apotheek informatiesysteem vraagt dan aan het EVS bronsysteem om de verzending van de prescriptie van de betreffende patiënt. Aangezien dit ook een verzoek is zonder medische inhoud, zou dit zelfs met een laag vertrouwensniveau verzocht kunnen worden.

===Verzending door het EVS===
Als een EVS een verzoek ontvangt voor “verzending van openstaande prescriptie” dan controleert het EVS of de prescriptie inderdaad nog open staat. Hiermee wordt voorkomen, dat een prescriptie meerdere keren wordt opgevraagd. Het adres van de apotheek wordt ingevuld en het voorbereide prescriptie bericht wordt dan eindelijk aangemaakt. Het prescriptie bericht wordt verzonden naar de betreffende apotheek.

Als de prescriptie al eerder opgevraagd is geweest, dan wordt een foutmelding naar de opvragende apotheek verzonden met de mededeling dat de prescriptie niet meer opvraagbaar is.

'''Het verzenden van een prescriptie is feitelijk het standaard proces, dat nu al gebruikelijk is bij het pushen van prescripties.''' Dit heeft het voordeel dat de ontvangende apotheek alleen één manier hoeft te onderhouden voor het verwerken van ontvangende prescripties. Hier wordt nogmaals opgemerkt, dat dezelfde juridische regels van toepassing blijven.

Na de verzending wordt door het EVS tevens een bericht naar het prescriptie register verzonden om de registratie van de openstaande prescriptie te verwijderen. Hiermee wordt dan duidelijk gemaakt, dat de betreffende prescriptie niet meer op te vragen is.

{{anchor|figuur 11}}
[[Bestand:Interactiediagramvoorschrijven.png|Figuur 11 Interactiediagram Ongeadresseerd voorschrijven]]

=Bijlage referenties=

==Algemene referenties==
{| class="wikitable" "cellpadding="10"
! style="text-align:left;"| Auteur(s)
! style="text-align:left;"| Titel
! style="text-align:left;"| Versie
! style="text-align:left;"| Datum (raadplegen)
! style="text-align:left;"| Bron
! style="text-align:left;"| Organisatie
|-
| style="background-color: white;vertical-align:top;"| NHG, KNMP, Z-index
| style="background-color: white;vertical-align:top;"| Bouwstenen van het medicatieproces
| style="background-color: white;vertical-align:top;"| 2014
| style="background-color: white;vertical-align:top;"| Augustus 2015
| style="background-color: white;vertical-align:top;"| https://www.nhg.org/bouwstenen
| style="background-color: white;vertical-align:top;"| NHG, KNMP, Z-index
|-
| style="background-color: white;vertical-align:top;"| ActiZ, KNMP, NVZA e.a.
| style="background-color: white;vertical-align:top;"| Veilige principes in de medicatieketen
| style="background-color: white;vertical-align:top;"| 2014
| style="background-color: white;vertical-align:top;"| Augustus 2015
| style="background-color: white;vertical-align:top;"| http://www.knmp.nl/patiëntenzorg/samenwerking/brochure-veilige-principes-in-de-medicatieketen
| style="background-color: white;vertical-align:top;"| ActiZ, KNMP, NVZA e.a.
|-
| style="background-color: white;vertical-align:top;"| Diversen
| style="background-color: white;vertical-align:top;"| Richtlijn Overdracht van medicatiegegevens in de keten
| style="background-color: white;vertical-align:top;"| 25-4-2008
| style="background-color: white;vertical-align:top;"| Augustus 2015
| style="background-color: white;vertical-align:top;"| Website KNMP
| style="background-color: white;vertical-align:top;"| Diversen
|-
| style="background-color: white;vertical-align:top;"| Paul Geels
| style="background-color: white;vertical-align:top;"| Beoordeling Eigen beheer van Medicatie (BEM) in verzorgingshuizen, Instituut voor Verantwoord Medicijngebruik
| style="background-color: white;vertical-align:top;"| Februari 2009
| style="background-color: white;vertical-align:top;"|
| style="background-color: white;vertical-align:top;"| http://www.instellingsapotheek.nl/downloads/rapporten/beoordeling_eigen_beheer_van_medicatie_in_verzorgingshuizen.pdf
| style="background-color: white;vertical-align:top;"| Instituut voor Verantwoord Medicijngebruik
|-
| style="background-color: white;vertical-align:top;"| ActiZ
| style="background-color: white;vertical-align:top;"| Veiligheid in de medicatieketen
| style="background-color: white;vertical-align:top;"| Maart 2012
| style="background-color: white;vertical-align:top;"|
| style="background-color: white;vertical-align:top;"| https://www.knmp.nl/downloads/brochure-veiligheid-in-de-medicatieketen.pdf
| style="background-color: white;vertical-align:top;"| ActiZ, Diversen
|-
| style="background-color: white;vertical-align:top;"| KNMG
| style="background-color: white;vertical-align:top;"| Richtlijn electronisch voorschrijven
| style="background-color: white;vertical-align:top;"| September 2013
| style="background-color: white;vertical-align:top;"|
| style="background-color: white;vertical-align:top;"| Website KNMG
| style="background-color: white;vertical-align:top;"| KNMG
|}

==Kwalificatiescripts==
Kwalificatiescripts zijn gepubliceerd op [[mp:Vcurrent Kwalificatie|de wiki pagina "Kwalificatie".]]

=Bijlage: Documenthistorie=

{{anchor|tabel 6}}
{| class="wikitable" "cellpadding="10"
!style="text-align:left;"|Versie
!style="text-align:left;"|Datum
!style="text-align:left;"|Omschrijving
|-
| style="background-color: white;"| 0.95
| style="background-color: white;"| 15 juli 2016
| style="background-color: white;"| Versie t.b.v. pilot
|-
| style="background-color: white;"| 0.96
| style="background-color: white;"| 1 december 2016
| style="background-color: white;"| Paragraaf 2.4 Proces: toedienen aangepast en als gevolg daarvan ook H6: toegevoegd Sturen/ontvangen toediengegevens.
|-
| style="background-color: white;vertical-align:top;"| 0.97
| style="background-color: white;vertical-align:top;"| 22 december 2016
| style="background-color: white;"| Paragraaf 2.4, 4.3.1 opmerkingen review verwerkt. Paragraaf 4.2.11 aanscherping in tekst.
|-
| style="background-color: white;vertical-align:top;"| 9.0.2
| style="background-color: white;vertical-align:top;"| 18 juni 2017
| style="background-color: white;"| Omzetting document naar wiki.
|-
| style="background-color: white;vertical-align:top;"| 9.0.4
| style="background-color: white;vertical-align:top;"| september 2017
| style="background-color: white;vertical-align:top;"|
*Verwerkt [[mp:V9.0_Ontwerpbeslissingen|Ontwerpbeslissingen]] in functioneel ontwerp. Daarmee zijn de ontwerpbeslissingen vervallen. Het huidige FO is vanaf nu leidend. 
*Par. 1.3.1. Definities bouwstenen aangepast en afkorting voor medicatieverstrekking gewijzigd van VS naar MVE. 
*Par. 1.3.3. Medicamenteuze behandeling nu op basis van PRK, stuk herschreven en ontstaan mbh en omgang met parallelle MA toegevoegd. 
*Par. 1.3.4. Nieuw datamodelplaaje, diverse relatie toegevoegd en aangepast op basis van ontwerpbeslissingen. 
*Par. 1.5 Begrippenlijst verwijderd. 
*H.2 Plaatje medicatieproces aangepast: mo toegevoegd bij actief beschikbaarstellen door gebruiker; lijnen in swimlane van toediener/gebruiker aangepast. 
*H4.1 Nieuwe use cases toegevoegd: Niet verstrekken voor, Verschillende PRKs onder dezelfde medicamenteuze behandeling, Staken van medicatie door derden, Achteraf vastleggen medicatieafspraak, Parallelle medicatieafspraken. 
*H4.2 Nieuwe use case: Stop-toedieningsafspraak; gewijzigde use case: Aanschrijfdatum, verstrekken en niet afhalen. 
*H5: Onderscheiden van medicatieprofiel en medicatieoverzicht beschreven; afleidingsregels aangepast op basis van de nieuwe ontwerpbeslissingen. 
*Waar logisch verwijzingen vanuit Art-decor naar FO H7 aangebracht. 
*Diverse grammaticale en kleine tekstuele wijzigingen. 
|-
| style="background-color: white;vertical-align:top;"| 9.0.5
| style="background-color: white;vertical-align:top;"| januari 2018
| style="background-color: white;vertical-align:top;"|
*Terminologie: Stop-MA gewijzigd naar staken-MA conform eerdere projectafspraken. 
*Par. 1.3.4 Aanvulling dat MA ook mag verwijzen naar bouwsteen onder andere medicamenteuze behandeling. 
*Par. 4.1.22 Ontslag aangepast omdat bij ontslag eerder gestaakte ambulante medicatie opnieuw gestart kan worden. 
*Par. 4.1.26 Staken van medicatie door derden aangepast. 
*Par. 4.1.27 Twee PRK's onder één medicamenteuze behandeling. 
*Par. 2.2.5.3 Staken medicatieafspraak aangepast ter verduidelijking van impact op reeds ingevoerde toekomstige medicatieafspraken. 
*Voetnoot 3 Voorlopige en definitieve medicatieopdracht verduidelijkt en use case medicatieopdracht (par. 4.1.31) toegevoegd. 
*Par. 4.1.30 Use case Eenmalig gebruik toegevoegd. 
*Paragraaf 2.2.4, 2.2.5.2, 2.2.5.4, 4.1.16, 4.1.22 aangepast voor substitutie. Bij substitutie wordt een medicamenteuze behandeling niet tijdelijk onderbroken maar daadwerkelijk gestaakt. Het substituut wordt onder een nieuwe medicamenteuze behandeling gestart. 
*Paragraaf 4.1.33 Ontbreken digitale medicatieafspraak bij opname toegevoegd. 
*H5 Medicatieoverzicht aangepast met verwijzing naar nieuwe inhoudelijke pagina met functionele uitwerking. 
*Paragraaf 7.10 Medicatiegebruik: gebruikindicator, volgens afspraak indicator en stoptype toegevoegd. 
*H6 Bouwstenen van medicatieoverzicht gewijzigd naar MA, TA en MGB. 
*Figuur 2 Kleuren in datamodel conform figuur 1. 
*Diverse afkortingen verklaard. 
|-
| style="background-color: white;vertical-align:top;"| 9.0.6
| style="background-color: white;vertical-align:top;"| mei 2018
| style="background-color: white;vertical-align:top;"|
*Aanvulling op voorstel verstrekkingsverzoek en toevoeging van antwoord-voorstel verstrekkingsverzoek 
*Hoofdstuk 6 tabel 4 toevoeging van linkjes naar ART-DECOR transacties 
*Verwijderd: hoofdstuk over LSP 
*Par. 7.10 tabel uitgebreid met gebruiksperiode en doseerinstructie 
*Aanscherpingen in diverse teksten 
*Toevoeging van kenmerk 'bouwsteen van iemand anders' voor MA, TA, MGB in medicatieoverzicht 
|-
| style="background-color: white;vertical-align:top;"| 9.0.7
| style="background-color: white;vertical-align:top;"| december 2018
| style="background-color: white;vertical-align:top;"|
*Par 1.3.3. MBH op HPK niveau in geval van 'niet geneesmiddelen' zonder een PRK niveau 
*Par 1.3.3. MBH voor geneesmiddelen zonder PRK (magistralen, infusen etc) 
*Par 2.2.5.5. Wijzigen medicatie: Technisch stop-MA: afspraak datum voor stop-MA en nieuwe MA moeten hetzelfde zijn. Wijziging op MA die reeds gestopt is toegelicht (geen extra staken-MA nodig) 
*Par 2.2.6. Toegevoegd: VV onder MA van iemand anders 
*Par 4.2.15. Uitleg GDS leverancier levert ander HPK 
*Par 7.10: Medicatiegebruik gebruikindicator, volgens afspraak indicator, stoptype, gebruiksperiode en doseerinstructie: tabel aangepast en voorbeelden toegevoegd 
*Par 4.1.34: Eigen artikelen uitleg toegevoegd 
*Hoofdstuk 5: voorbeeld medicatieoverzicht ingevoegd in deze wiki pagina ipv een losse wiki pagina (om zoeken binnen het FO te vereenvoudigen).
*Diverse tekstuele aanscherpingen/verbeteringen
|-
| style="background-color: white;vertical-align:top;"| 9.0.7
| style="background-color: white;vertical-align:top;"| juli 2019
| style="background-color: white;vertical-align:top;"|
Voorbeelden voor specifieke infrastructuren verwijderd.
|-
| style="background-color: white;vertical-align:top;"| 9.1.0
| style="background-color: white;vertical-align:top;"| 29 januari 2020
| style="background-color: white;vertical-align:top;"|
*Tekstuele aanpassingen staken/stoppen 
*Par 7.11 toegevoegd: Implementatie geneesmiddel distributiesysteem (GDS)-velden
*[https://bits.nictiz.nl/browse/MP-85 BITS MP-85], [https://bits.nictiz.nl/browse/MP-93 BITS MP-93], [https://bits.nictiz.nl/browse/MP-122 BITS MP-122] Use cases toegevoegd (Gebruik registreren op basis van verstrekking, Verstrekkingsverzoek met aantal herhalingen, Voorschrijven van niet geneesmiddelen)
*Hoofdstuk 4: plaatjes bij use cases toegevoegd
*Nierfunctiewaarde in het voorschrift
*[https://bits.nictiz.nl/browse/MP-48 BITS MP-48] Medicatieoverzicht: Par 5.7 toegevoegd 'Velden die niet getoond hoeven te worden'
*Diverse tekstuele aanscherpingen/verbeteringen [https://bits.nictiz.nl/browse/MP-131 o.a. BITS MP-131]
*Paragraaf 'Ongeadresseerd voorschrijven' verplaatst naar hoofdstuk 'Beschouwingen'
*[https://bits.nictiz.nl/browse/MP-151 BITS MP-151] Proces van aanmaken concept-TA verwijderd
*[https://bits.nictiz.nl/browse/MP-128 BITS MP-128] Par 4.1.8: Toelichting 'Medische noodzaak'
*[https://bits.nictiz.nl/browse/MP-129 BITS MP-129] Par 4.1.35: Use case toegevoegd
|-
| style="background-color: white;vertical-align:top;"| 9 2.0.0 bèta
| style="background-color: white;vertical-align:top;"| 01 oktober 2021
| style="background-color: white;vertical-align:top;"| voor alle wijzigingen zie: *[https://informatiestandaarden.nictiz.nl/wiki/mp:V9_2.0.beta_releasenotes Releasenotes]
|}

=Bijlage: Figuren en tabellen=
[[#figuur 1|Figuur 1 Bouwstenen - overzicht]] 
[[#figuur 2|Figuur 2 Bouwstenen - samenhang]] 
[[#figuur 3|Figuur 3 Activiteitendiagram - Medicatieproces algemeen]] 
[[#figuur 4|Figuur 4 Processtappen en transacties - medicatieverificatie]] 
[[#figuur 5|Figuur 5 Processtappen en transacties - voorschrijven]] 
[[#figuur 6|Figuur 6 Processtappen en transacties - ter hand stellen]] 
[[#figuur 7|Figuur 7 Processtappen en transacties - toedienen]] 
[[#figuur 8|Figuur 8 Processtappen en transacties - gebruiken]] 
[[#figuur 9|Figuur 9 Voorbeeld effectieve periode]] 
[[#figuur 10|Figuur 10 Overzicht systemen en systeemrollen]] 
[[#figuur 11|Figuur 11 Interactiediagram Ongeadresseerd voorschrijven]] 

[[#tabel 1|Tabel 1 Bouwstenen – beschrijving]] 
[[#tabel 2|Tabel 2 Informeren versus (Actief) beschikbaarstellen]] 
[[#tabel 3|Tabel 3 Overzicht systeemrollen]] 
[[#tabel 4|Tabel 4 Overzicht transactiegroepen]] 
[[#tabel 5|Tabel 5 Typen klinische medicatie relevant voor extramurale zorgverleners]]