Plain text Part of the drug administration record. Medicine Record of administration to the patient, administered including self-administration. Date administered and by whom. Reason why drug not administered (e.g. Part of the drug administration record. Reason for patient refused, patient unavailable, Plain text drug not available). Use NHS Dictionary of Medicines and Devices (DM+D), where possible, but may be plain text, e.g. where patient is providing the information. Relevant Previous Record of relevant previous medications Medications Relevant previous medications to be communicated between healthcare settings in addition to current medications Suggestions about duration and or Plain text Medication review, ongoing monitoring Medication recommendations to be communicated between Recommendations requirements, advice on starting, healthcare settings where relevant. discontinuing or changing medication. The record of dietary supplements, dressings and equipment that the patient The data items are attributes of medical device record. is currently taking or using. Also record start and stop dates, where relevant. Data items: Use NHS Dictionary of Medicines and Devices (DM+D) only for Medical devices *Device name prescribable devices. Increasing numbers of medical devices contain active pharmacological * Device Identifier ingredients. Medical devices should not therefore be separated from *Batch number medicines in the viewable record. *Serial number
Plain text Medicine administered Record of administration to the patient, including self-administration. Part of the drug administration record. Date administered and by whom. Reason for Reason why drug not administered (e.g. patient refused, patient unavailable, drug not available). Part of the drug administration record. Plain text Relevant Previous Medications Record of relevant previous medications Use NHS Dictionary of Medicines and Devices (DM+D), where possible, but may be plain text, e.g. where patient is providing the information. Relevant previous medications to be communicated between healthcare settings in addition to current medications Medication Recommendations Suggestions about duration and or review, ongoing monitoring requirements, advice on starting, discontinuing or changing medication. Plain text Medication recommendations to be communicated between healthcare settings where relevant. Medical devices The record of dietary supplements, dressings and equipment that the patient is currently taking or using. Data items: *Device name * Device Identifier *Batch number *Serial number The data items are attributes of medical device record. Also record start and stop dates, where relevant. Use NHS Dictionary of Medicines and Devices (DM+D) only for prescribable devices. Increasing numbers of medical devices contain active pharmacological ingredients. Medical devices should not therefore be separated from medicines in the viewable record.