# Mapping of Konsulta Prescription Slip Form to FHIR - NHDR Implementation Guide Release 1.0 v0.1.0

* [**Table of Contents**](toc.md)
* [**Konsulta Prescription Slip Form**](K4.md)
* **Mapping of Konsulta Prescription Slip Form to FHIR**

## Mapping of Konsulta Prescription Slip Form to FHIR

**View
Form**

<iframe src="K4.pdf" width="700" height="900"></iframe>

### Mapped Fields

| | | | | |
| :--- | :--- | :--- | :--- | :--- |
| **To be filled-out by the facility** |   |   |   |   |
| HCI Name | MedicationRequest.requester | Reference([PH_Organization](StructureDefinition-PH-Organization.md)) | 0..1 |   |
| ► | Organization.name | string | 0..1 |   |
| Case Number | MedicationRequest.encounter | Reference([PH_Encounter](StructureDefinition-PH_Encounter.md)) | 0..1 |   |
| ► | Encounter.identifier | Identifier | 0..* |   |
| HCI Accreditation Number | MedicationRequest.requester | Reference([PH_Organization](StructureDefinition-PH-Organization.md)) | 0..1 |   |
| ► | Organization.identifier | Identifier | 0..* |   |
| Transaction Number | MedicationRequest.identifier | Identifier | 0..* |   |
| PhilHealth Identification Number (PIN) | MedicationRequest.subject | Reference([PH_Patient](StructureDefinition-PH_Patient.md)) | 1..1 |   |
| ► | Patient.identifier | Identifier | 0..* |   |
| Membership Category | MedicationRequest.subject | Reference([PH_Patient](StructureDefinition-PH_Patient.md)) | 1..1 |   |
| ► | Patient.memberType | Codeableconcept |   | ValueSet:[MemberType](ValueSet-MemberTypeVS.md) |
| Membership Type | MedicationRequest.subject | Reference([PH_Patient](StructureDefinition-PH_Patient.md)) | 1..1 |   |
| ► | Patient.type | Codeableconcept |   | ValueSet:[PatientType](ValueSet-PatientTypeVS.md) |
| Patient Name (Last Name) | MedicationRequest.subject | Reference([PH_Patient](StructureDefinition-PH_Patient.md)) | 1..1 |   |
| ► | Patient.name.family | string | 0..1 |   |
| Patient Name (First Name) | MedicationRequest.subject | Reference([PH_Patient](StructureDefinition-PH_Patient.md)) | 1..1 |   |
| ► | Patient.name.given | string | 0..* |   |
| Patient Name (Name extension) | MedicationRequest.subject | Reference([PH_Patient](StructureDefinition-PH_Patient.md)) | 1..1 |   |
| ► | Patient.name.suffix | string | 0..* |   |
| Patient Name (Middle Name) | MedicationRequest.subject | Reference([PH_Patient](StructureDefinition-PH_Patient.md)) | 1..1 |   |
| ► | Patient.name.given | string | 0..* |   |
| Age | MedicationRequest.encounter | Reference([PH_Encounter](StructureDefinition-PH_Encounter.md)) | 0..1 |   |
| ► | Encounter.ageYears | integer |   |   |
| Contact Number | MedicationRequest.subject | Reference([PH_Patient](StructureDefinition-PH_Patient.md)) | 1..1 |   |
| ► | Patient.telecom.value | string |   |   |
| Active Ingredient/Medicine (Generic Name) | MedicationRequest.medication[x] | CodeableConcept | 1..1 | ValueSet:[DrugCodes](ValueSet-DrugCodesVS.md) |
| Quantity | MedicationRequest.dispenseRequest.quantity | SimpleQuantity | 0..1 |   |
| Dosage form (e.g. capsule, tablet) | MedicationRequest.medication[x] | Reference([PH_Medication](StructureDefinition-PH_Medication.md)) | 1..1 |   |
| ► | Medication.form | Codeableconcept | 0..1 | ValueSet:[OrderDrugForm](ValueSet-OrderableDrugForm.md) |
| Strength (mg,ml) | MedicationRequest.medication[x] | Reference([PH_Medication](StructureDefinition-PH_Medication.md)) | 1..1 |   |
| ► | Medication.ingredient.strength | Ratio | 0..1 |   |
| Frequency | MedicationRequest.dosageInstruction.timing | Timing | 0..1 |   |
| Next Dispensing Date | MedicationRequest.supportingInformation | Reference(Any) | 0..* |   |
| ► | MedicationDispense.note.text | Ratio | 0..* |   |
| Physician (Name) | MedicationRequest.requester | Reference([PH_Practitioner](StructureDefinition-PH_Practitioner.md)) | 0..1 |   |
| ► | Practitioner.name | HumanName | 0..* |   |
| Physician (Signature) | Provenance.signature.who | Reference([PH_Practitioner](StructureDefinition-PH_Practitioner.md)) | 1..1 |   |
| ► | Practitioner.name | HumanName | 0..* |   |
| PRC License Number | MedicationRequest.requester | Reference([PH_Practitioner](StructureDefinition-PH_Practitioner.md)) | 0..1 |   |
| ► | Practitioner.identifier | Identifier | 0..* |   |
| PTR Number | MedicationRequest.requester | Reference([PH_Practitioner](StructureDefinition-PH_Practitioner.md)) | 0..1 |   |
| ► | Practitioner.identifier | Identifier | 0..* |   |
| S2 Number | MedicationRequest.requester | Reference([PH_Practitioner](StructureDefinition-PH_Practitioner.md)) | 0..1 |   |
| ► | Practitioner.identifier | Identifier | 0..* |   |
| **To be filled out by the Patient** |   |   |   |   |
| Have you received the above-mentioned medicines? [Y,N] | Questionnaire.item.text | string | 0..* |   |
| How satisfied are you with the medicines you received? | Questionnaire.item.text | string | 0..* |   |
| For your comment, suggestion or complaint | Questionnaire.item.text | string | 0..* |   |
| PhilHealth Identification Number of Patient | MedicationRequest.subject | Reference([PH_Patient](StructureDefinition-PH_Patient.md)) | 1..1 |   |
| ► | Practitioner.identifier | Identifier | 0..* |   |
| Patient**Signature**Over Printed Name | Provenance.signature.data | base64Binary | 0..1 |   |
| Patient Signature Over**Printed Name** | Provenance.signature.who | Reference([PH_Patient](StructureDefinition-PH_Patient.md)) | 1..1 |   |
| ► | Patient.name | HumanName | 0..* |   |
| Patient (thumbprint) | Provenance.signature.data | base64Binary | 0..1 |   |

### Mandatory Elements Not in the Form

| | | |
| :--- | :--- | :--- |
| Provenance.Signature.type | Coding |   |
| Provenance.Signature.when | instant |   |
| Provenance.target | Reference([PH_MedicationRequest](StructureDefinition-PH_MedicationRequest.md)) |   |
| Provenance.agent.who | Reference(Practitioner, PractitionerRole, RelatedPerson, Patient, Device, Organization) |   |
| Provenance.entity.role | code |   |
| Provenance.entity.what | Reference(Any) |   |
| Provenance.recorded | instant |   |
| MedicationRequest.status | code |   |
| MedicationRequest.intent | code |   |
| MedicationRequest.substitution.allowed[x] | boolean,CodeableConcept |   |
| Questionnaire.status | code |   |
| Questionnaire.item.type | code |   |
| Questionnaire.item.linkId | string |   |
| Medication.ingredient.item[x] | CodeableConcept, Reference(Substance, Medication) |   |
| MedicationDispene.status | code |   |
| MedicationDispene.medication[x] | CodeableConcept, Reference(Medication) |   |
| Encounter.status | code |   |
| Encounter.class | coding |   |

