Premedication

Premedication is a crucial step before surgery where the patient is prepared and informed about the planned procedure. This page shows how various premedication information is structured in FHIR.

Overview

During premedication, the following information is typically captured:

• Planned procedures and associated departments
• Patient information and insurance status
• Scheduling and preparation status
• Clinical assessments and risk factors

Planned Procedures

Information about the planned surgical procedure, executing department, and scheduling.

Procedure Planning

💡Context

This documents the details of the planned procedure. The ServiceRequest forms the basis for the entire surgical planning and is validated and supplemented during premedication.

📋FHIR Resource

ServiceRequest: A record of a request for service such as diagnostic investigations, treatments, or operations to be performed.

UI Field	FHIR Path	Description	Data Type	Required	Example
Planned Procedure	ServiceRequest.code	What is being requested/ordered	CodeableConcept	Yes	{ "text": "Appendectomy", "coding": [ { "system": "http://snomed.info/sct", "code": "80146002", "display": "Appendectomy" } ] }
Department	ServiceRequest.performer	Requested performer	Reference(Practitioner|PractitionerRole|Organization|CareTeam|HealthcareService|Patient|Device|RelatedPerson)	No	{ "reference": "Organization/surgery-department", "display": "Surgery Department" }
Surgery Date	ServiceRequest.occurrenceDateTime	When service should occur	dateTime	No	2024-03-15T09:00:00Z
Status	ServiceRequest.status	Current state of the service request	code	Yes	active
Request Type	ServiceRequest.intent	Whether the request is a proposal, plan, directive or order	code	Yes	order

Common Usage: surgery planning, procedure documentation, premedication, department assignment, surgery scheduling, premedication timing, workflow management, status tracking, workflow classification, authorization levels

Patient Information

Basic demographic and administrative patient data for premedication.

Patient Master Data

💡Context

This patient information is needed during premedication for identification and medical history taking.

📋FHIR Resource

Patient: Demographics and other administrative information about an individual or animal receiving care or other health-related services.

UI Field	FHIR Path	Description	Data Type	Required	Example
Patient ID	Patient.identifier	An identifier for this patient	Identifier[]	No	[ { "use": "usual", "system": "http://hospital.example.org/patients", "value": "123456789" } ]
Patient Name	Patient.name	A name associated with the patient	HumanName[]	No	[ { "use": "official", "family": "Doe", "given": [ "John", "Robert" ] } ]
Gender	Patient.gender	Administrative gender	code	No	male
Date of Birth	Patient.birthDate	The date of birth for the individual	date	No	1980-05-15
Record Status	Patient.active	Whether this patient record is in active use	boolean	No	—

Common Usage: patient identification, medical record number, display names, demographic data, clinical considerations, age calculation, record status, patient management

Insurance Status

Information about the patient's health insurance, relevant for billing and authorization procedures.

Insurance Information

💡Context

The insurance status is important for cost coverage and must be verified before the procedure.

📋FHIR Resource

Coverage: Financial instrument which may be used to reimburse or pay for health care products and services.

UI Field	FHIR Path	Description	Data Type	Required	Example
Coverage Status	Coverage.status	The status of the resource instance	code	Yes	active
Insurance Type	Coverage.type	Coverage category such as medical or accident	CodeableConcept	No	{ "text": "Gesetzliche Krankenversicherung", "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code": "EHCPOL", "display": "Extended Healthcare Policy" } ] }
Insured Person	Coverage.beneficiary	Plan beneficiary	Reference(Patient)	Yes	{ "reference": "Patient/123456", "display": "John Doe" }
Insurance Company	Coverage.payor	Issuer of the policy	Reference(Organization|Patient|RelatedPerson)[]	Yes	[ { "reference": "Organization/insurance-company-123", "display": "AOK Bayern" } ]

Common Usage: insurance verification, coverage validation, insurance classification, billing categories, patient linking, insurance company identification, billing

Workflow Status

During premedication, patients go through different phases:

Phase	ServiceRequest.status	Description
Planned	draft or active	Patient is scheduled for premedication
In Progress	active	Premedication is currently ongoing
Completed	completed	Premedication successfully performed
Postponed	on-hold	Premedication has been postponed