# Vercy AI instruction - YAML 1.2 (JSON-compatible) { "vercy": "1.0-draft", "publication": { "status": "published", "adjudicationStatus": "reviewable-draft", "publishableCanonical": false, "generatedAt": "2026-09-06T09:44:38Z", "synthesisSha256": "884f76dcfc6c367dd61c1e82b19c149104cadd78cc96f4e0c162a883af683a88", "providerMode": "single-provider-waiver", "providers": [ "Codex" ], "waivedProviders": [ "Claude", "Grok" ] }, "metaModel": { "id": "WM-ACT-048", "registryId": "vr.wm-act-048", "name": "Medication Order / Administration", "version": "0.3.0-research.1", "previousVersions": [], "entryKind": "aggregate", "family": "World Models", "category": "Activities and processes", "industry": [ "Cross-industry" ], "domain": [ "ACT.HCR" ], "tags": [ "medication", "order", "administration", "act.hcr" ], "status": "published" }, "canonicalUrl": "https://ver.cy/models/wm-act-048-medication-order-administration/", "sourceUrl": "https://github.com/ver-cy/world-models/tree/feat/mega-model-registry/publications/wm-act-048-medication-order-administration", "model": { "registry_id": "vr.wm-act-048", "model_id": "WM-ACT-048", "name": "Medication Order / Administration", "entry_kind": "aggregate", "purpose": "Represent a source-qualified medication lifecycle aggregate so agents can distinguish clinical request, supply, actual administration or non-administration, reported use, reconciliation and safety evidence without conflating intent with exposure or consequence.", "scope_statement": "Owns the aggregate identity and links among medication request, dispense, administration or explicit non-administration, medication statement, discrepancy, reconciliation and safety-check records. Each child keeps its own identity, source, status, actors and times. Patient, practitioner, organization, encounter, care plan, medication and product definition, clinical knowledge, condition, observation, allergy, adverse event, detected issue, coverage, claim, inventory, device, consent, provenance, audit and record masters remain external.", "in_scope": [ "Aggregate and child-record identity, medication and subject bindings, request intent, dosage and dispense authorization, dispense events, administration or non-administration events, reported use and reconciliation", "Independent status and time axes, substitution and actual dose differences, safety evidence, clinical consequence links, correction, privacy, retention and loss-aware projections" ], "out_of_scope": [ "Independent patient, practitioner, organization, encounter, care plan, medication, medicinal product, medication knowledge, condition, observation, allergy, adverse event, detected issue, coverage, claim, inventory, device, consent, provenance, audit and record lifecycles", "Treating a medication request as proof of dispense or exposure, dispense as proof of administration, medication statement as formal event evidence, completed as effective, or association as causation", "Providing medical advice, prescribing, changing dose, authorizing substitution, dispensing, administering, overriding safety or deciding adherence and causality" ], "boundary_notes": [ { "neighbor": "WM-ACT-049 Care Plan / Episode", "distinction": "A care plan may contain medication-request references, but owns goals and planning lifecycle. The ledger relation is candidate and creates no cascade behavior.", "source_refs": [ "SRC-001", "SRC-006" ] }, { "neighbor": "Medication and medicinal-product definitions", "distinction": "Product masters own substance, strength, dose form, authorization, packaging and knowledge. This aggregate stores versioned references and actual supplied or administered distinctions.", "source_refs": [ "SRC-005", "SRC-009", "SRC-010", "SRC-011", "SRC-012" ] }, { "neighbor": "MedicationRequest, MedicationDispense and MedicationAdministration", "distinction": "These are separately identifiable intent, supply and exposure records with independent states and event times; the aggregate only composes them.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-006" ] }, { "neighbor": "MedicationStatement and medication list", "distinction": "A statement is source-attributed reported or derived belief and is not a prescribe, dispense or administer event. A list is a view over such records, not the aggregate root.", "source_refs": [ "SRC-004", "SRC-006", "SRC-007" ] }, { "neighbor": "Observation, Condition, AllergyIntolerance, DetectedIssue and AdverseEvent", "distinction": "External clinical and safety records own findings, diagnoses, allergies, detected issues and harm assertions. The aggregate keeps typed links and uncertainty without inventing causality.", "source_refs": [ "SRC-003", "SRC-004", "SRC-008", "SRC-016" ] }, { "neighbor": "Inventory, supply chain, billing and coverage", "distinction": "External masters own stock, logistics, claims, payment and coverage. Dispense records bind the supplied product, quantity, lot and authorization without absorbing those lifecycles.", "source_refs": [ "SRC-002", "SRC-005", "SRC-010", "SRC-013" ] } ] }, "sources": [ { "id": "SRC-001", "title": "FHIR R5 MedicationRequest", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/medicationrequest.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, maturity level 4 and Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:38:00Z", "relevance": "Defines one medication request, its intent, status, priority, subject, requester, dosage instructions, dispense authorization, repeats, substitution limits and lifecycle links." }, { "id": "SRC-002", "title": "FHIR R5 MedicationDispense", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/medicationdispense.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, maturity level 2 and Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:38:00Z", "relevance": "Defines a distinct medication supply event, authorizing prescription, performer, status, non-performance, product, quantity, days supply, preparation, handover, receiver and substitution." }, { "id": "SRC-003", "title": "FHIR R5 MedicationAdministration", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/medicationadministration.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, maturity level 2 and Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:38:00Z", "relevance": "Defines an actual, not-done or waste administration event with occurrence and recorded times, actor, dose, route, site, method, rate, device and subpotency." }, { "id": "SRC-004", "title": "FHIR R5 MedicationStatement", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/medicationstatement.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, maturity level 4 and Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:38:00Z", "relevance": "Separates a reported or derived belief about medication use from specific prescribing, dispensing and administration events and records information source and adherence assertion." }, { "id": "SRC-005", "title": "FHIR R5 Medication", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/medication.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, maturity level 4 and Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:38:00Z", "relevance": "Defines medication identity and optional product details while preferring external drug dictionaries for full composition, efficacy and regulated product knowledge." }, { "id": "SRC-006", "title": "FHIR R5 Medications Module", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/medications-module.html", "version_or_date": "FHIR 5.0.0, 26 March 2023", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:38:00Z", "relevance": "Defines explicit boundaries among MedicationRequest, MedicationDispense, MedicationAdministration, MedicationStatement and medication knowledge resources." }, { "id": "SRC-007", "title": "Medication safety in transitions of care", "organization": "World Health Organization", "url": "https://www.who.int/publications-detail-redirect/WHO-UHC-SDS-2019.9", "version_or_date": "WHO/UHC/SDS/2019.9, 20 June 2019", "source_type": "public-authority", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:38:00Z", "relevance": "Supports a best possible medication history, verification with reliable sources, discrepancy reconciliation, updated lists and communication at transitions." }, { "id": "SRC-008", "title": "Medication safety in high-risk situations", "organization": "World Health Organization", "url": "https://www.who.int/initiatives/medication-without-harm/medication-safety-in-high-risk-situations", "version_or_date": "WHO technical document, 5 June 2019", "source_type": "public-authority", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:38:00Z", "relevance": "Identifies high-risk medication, patient or provider and system factors that require contextual safeguards rather than unqualified automation." }, { "id": "SRC-009", "title": "International Nonproprietary Names Programme and Classification of Medical Products", "organization": "World Health Organization", "url": "https://www.who.int/teams/health-product-and-policy-standards/inn", "version_or_date": "Living official programme page accessed 6 September 2026", "source_type": "registry", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:38:00Z", "relevance": "Defines globally recognized public generic names for active substances while not establishing product authorization, clinical suitability or recommendation." }, { "id": "SRC-010", "title": "Data on medicines: ISO IDMP standards overview", "organization": "European Medicines Agency", "url": "https://www.ema.europa.eu/en/human-regulatory-overview/research-development/data-medicines-iso-idmp-standards-overview", "version_or_date": "Official overview accessed 6 September 2026", "source_type": "public-authority", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:38:00Z", "relevance": "Describes substance, dose form, route, unit, regulated product, medicinal product, authorization, packaging and manufacturing master data across the product lifecycle." }, { "id": "SRC-011", "title": "SNOMED CT Pharmaceutical and Biologic Product", "organization": "SNOMED International", "url": "https://docs.snomed.org/snomed-ct-specifications/snomed-ct-editorial-guide/readme/authoring/domain-specific-modeling/pharmaceutical-and-biologic-product", "version_or_date": "Living Editorial Guide accessed 6 September 2026", "source_type": "ontology", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:38:00Z", "relevance": "Defines international abstract medicinal-product classes, ingredients, strengths and dose forms while leaving actual authorized products and packages to national models." }, { "id": "SRC-012", "title": "RxNorm Overview", "organization": "United States National Library of Medicine", "url": "https://www.nlm.nih.gov/research/umls/rxnorm/overview.html", "version_or_date": "Official overview reviewed 2024 and accessed 6 September 2026", "source_type": "classifier", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:38:00Z", "relevance": "Defines normalized US clinical-drug and pack names, identifiers, ingredients, strengths, dose forms, brands and mappings with explicit source and regional scope." }, { "id": "SRC-013", "title": "OMOP Common Data Model v5.4", "organization": "Observational Health Data Sciences and Informatics", "url": "https://ohdsi.github.io/CommonDataModel/cdm54.html", "version_or_date": "OMOP CDM 5.4", "source_type": "schema", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:38:00Z", "relevance": "Represents prescriptions, dispenses, administrations and reported exposures with source type, unique event identity, source values, mapped concepts, dose data and explicit ETL choices." }, { "id": "SRC-014", "title": "Unified Code for Units of Measure", "organization": "Regenstrief Institute and UCUM Organization", "url": "https://ucum.org/ucum", "version_or_date": "UCUM 2.2, 17 June 2024", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:38:00Z", "relevance": "Provides machine-interoperable quantity units and expression semantics for medication dose, concentration, duration and dose rate." }, { "id": "SRC-015", "title": "Regulation (EU) 2016/679 General Data Protection Regulation", "organization": "European Union", "url": "https://eur-lex.europa.eu/eli/reg/2016/679/oj", "version_or_date": "27 April 2016, applicable from 25 May 2018", "source_type": "legislation", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:38:00Z", "relevance": "Provides purpose limitation, minimization, accuracy, security, access and correction safeguards for sensitive medication data." }, { "id": "SRC-016", "title": "PROV-O: The PROV Ontology", "organization": "World Wide Web Consortium", "url": "https://www.w3.org/TR/prov-o/", "version_or_date": "W3C Recommendation, 30 April 2013", "source_type": "ontology", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:38:00Z", "relevance": "Provides activity, entity, agent, attribution, derivation, delegation, revision, generation and invalidation semantics for linked medication records." }, { "id": "SRC-017", "title": "Date and Time on the Internet: Timestamps", "organization": "Internet Engineering Task Force", "url": "https://www.rfc-editor.org/info/rfc3339/", "version_or_date": "RFC 3339, July 2002", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:38:00Z", "relevance": "Provides interoperable timestamps with seconds and explicit UTC relationship for clinical event, record and knowledge times." } ], "structure": { "bundles": [ { "id": "aggregate-identity-boundary-subject-and-medication", "name": "Aggregate identity, boundary, subject and medication", "description": "Groups governed medication context for aggregate identity, boundary, subject and medication.", "rationale": "A medication lifecycle aggregate links but never collapses independent request, dispense, administration and statement records.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-016" ], "layers": [ { "id": "aggregate-profile-identifiers-sources-and-lineage", "name": "Aggregate profile, identifiers, sources and lineage", "description": "Groups source-qualified medication context for aggregate profile, identifiers, sources and lineage.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-006", "SRC-013", "SRC-016" ], "findings": [ { "id": "medication-lifecycle-profile-root-boundary-and-constituent-kinds", "name": "Medication lifecycle profile, root boundary and constituent kinds", "description": "Records medication lifecycle profile, root boundary and constituent kinds as source-qualified medication-lifecycle context while preserving the distinctions among request, dispense, administration, statement, product knowledge and clinical consequence.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-006", "SRC-013", "SRC-016" ], "questions": [ { "id": "medication-lifecycle-profile-root-boundary-and-constituent-kinds-q01", "text": "Which stable identities, record class, source-qualified values and explicit unknowns establish medication lifecycle profile, root boundary and constituent kinds?", "kind": "classification", "answer_data": [ "identifiers and class", "source-qualified values", "unknown and not-applicable states" ] }, { "id": "medication-lifecycle-profile-root-boundary-and-constituent-kinds-q02", "text": "Who requested, authorized, performed, supplied, received, recorded or reported medication lifecycle profile, root boundary and constituent kinds, with which role, evidence and limits?", "kind": "composition", "answer_data": [ "actors and roles", "authority and limits", "evidence and provenance" ] }, { "id": "medication-lifecycle-profile-root-boundary-and-constituent-kinds-q03", "text": "Which event, authored, prepared, handover, occurrence, recorded, reported, ingested and knowledge times apply to medication lifecycle profile, root boundary and constituent kinds, and how is it validated or corrected?", "kind": "privacy", "answer_data": [ "distinct clinical and record times", "validation and discrepancy status", "successor correction and retention" ] } ], "data_elements": [ { "id": "medication-lifecycle-profile-root-boundary-and-constituent-kinds-data", "name": "Medication lifecycle profile, root boundary and constituent kinds data", "description": "Typed data for medication lifecycle profile, root boundary and constituent kinds with child-event identity, source, authority, status, event time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-006", "SRC-013", "SRC-016" ] } ], "artifacts": [ { "id": "medication-lifecycle-profile-root-boundary-and-constituent-kinds-record", "name": "Medication lifecycle profile, root boundary and constituent kinds record", "description": "Immutable or successor-versioned medication evidence for medication lifecycle profile, root boundary and constituent kinds.", "media_or_form": [ "logical medication assertion", "request, dispense, administration, statement, safety, reconciliation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent request, dispense, administration, statement or assertion ID for medication-lifecycle-profile-root-boundary-and-constituent-kinds; patient, medication, date, encounter and claim never identify an event alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-006", "SRC-013", "SRC-016" ] } ], "inline_only_rationale": null }, { "id": "aggregate-and-child-identifiers-source-records-versions-and-lineage", "name": "Aggregate and child identifiers, source records, versions and lineage", "description": "Records aggregate and child identifiers, source records, versions and lineage as source-qualified medication-lifecycle context while preserving the distinctions among request, dispense, administration, statement, product knowledge and clinical consequence.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-006", "SRC-013", "SRC-016" ], "questions": [ { "id": "aggregate-and-child-identifiers-source-records-versions-and-lineage-q01", "text": "Which stable identities, record class, source-qualified values and explicit unknowns establish aggregate and child identifiers, source records, versions and lineage?", "kind": "identity", "answer_data": [ "identifiers and class", "source-qualified values", "unknown and not-applicable states" ] }, { "id": "aggregate-and-child-identifiers-source-records-versions-and-lineage-q02", "text": "Who requested, authorized, performed, supplied, received, recorded or reported aggregate and child identifiers, source records, versions and lineage, with which role, evidence and limits?", "kind": "evidence", "answer_data": [ "actors and roles", "authority and limits", "evidence and provenance" ] }, { "id": "aggregate-and-child-identifiers-source-records-versions-and-lineage-q03", "text": "Which event, authored, prepared, handover, occurrence, recorded, reported, ingested and knowledge times apply to aggregate and child identifiers, source records, versions and lineage, and how is it validated or corrected?", "kind": "lifecycle", "answer_data": [ "distinct clinical and record times", "validation and discrepancy status", "successor correction and retention" ] } ], "data_elements": [ { "id": "aggregate-and-child-identifiers-source-records-versions-and-lineage-data", "name": "Aggregate and child identifiers, source records, versions and lineage data", "description": "Typed data for aggregate and child identifiers, source records, versions and lineage with child-event identity, source, authority, status, event time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-006", "SRC-013", "SRC-016" ] } ], "artifacts": [ { "id": "aggregate-and-child-identifiers-source-records-versions-and-lineage-record", "name": "Aggregate and child identifiers, source records, versions and lineage record", "description": "Immutable or successor-versioned medication evidence for aggregate and child identifiers, source records, versions and lineage.", "media_or_form": [ "logical medication assertion", "request, dispense, administration, statement, safety, reconciliation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent request, dispense, administration, statement or assertion ID for aggregate-and-child-identifiers-source-records-versions-and-lineage; patient, medication, date, encounter and claim never identify an event alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-006", "SRC-013", "SRC-016" ] } ], "inline_only_rationale": null } ] }, { "id": "subject-medication-encounter-plan-and-context-bindings", "name": "Subject, medication, encounter, plan and context bindings", "description": "Groups source-qualified medication context for subject, medication, encounter, plan and context bindings.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-009", "SRC-010", "SRC-011", "SRC-012" ], "findings": [ { "id": "subject-encounter-care-plan-episode-and-care-team-references", "name": "Subject, encounter, care plan, episode and care team references", "description": "Records subject, encounter, care plan, episode and care team references as source-qualified medication-lifecycle context while preserving the distinctions among request, dispense, administration, statement, product knowledge and clinical consequence.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-009", "SRC-010", "SRC-011", "SRC-012" ], "questions": [ { "id": "subject-encounter-care-plan-episode-and-care-team-references-q01", "text": "Which stable identities, record class, source-qualified values and explicit unknowns establish subject, encounter, care plan, episode and care team references?", "kind": "relationship", "answer_data": [ "identifiers and class", "source-qualified values", "unknown and not-applicable states" ] }, { "id": "subject-encounter-care-plan-episode-and-care-team-references-q02", "text": "Who requested, authorized, performed, supplied, received, recorded or reported subject, encounter, care plan, episode and care team references, with which role, evidence and limits?", "kind": "ownership", "answer_data": [ "actors and roles", "authority and limits", "evidence and provenance" ] }, { "id": "subject-encounter-care-plan-episode-and-care-team-references-q03", "text": "Which event, authored, prepared, handover, occurrence, recorded, reported, ingested and knowledge times apply to subject, encounter, care plan, episode and care team references, and how is it validated or corrected?", "kind": "quality", "answer_data": [ "distinct clinical and record times", "validation and discrepancy status", "successor correction and retention" ] } ], "data_elements": [ { "id": "subject-encounter-care-plan-episode-and-care-team-references-data", "name": "Subject, encounter, care plan, episode and care team references data", "description": "Typed data for subject, encounter, care plan, episode and care team references with child-event identity, source, authority, status, event time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-009", "SRC-010", "SRC-011", "SRC-012" ] } ], "artifacts": [ { "id": "subject-encounter-care-plan-episode-and-care-team-references-record", "name": "Subject, encounter, care plan, episode and care team references record", "description": "Immutable or successor-versioned medication evidence for subject, encounter, care plan, episode and care team references.", "media_or_form": [ "logical medication assertion", "request, dispense, administration, statement, safety, reconciliation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent request, dispense, administration, statement or assertion ID for subject-encounter-care-plan-episode-and-care-team-references; patient, medication, date, encounter and claim never identify an event alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-009", "SRC-010", "SRC-011", "SRC-012" ] } ], "inline_only_rationale": null }, { "id": "medication-substance-product-pack-strength-form-and-terminology-binding", "name": "Medication, substance, product, pack, strength, form and terminology binding", "description": "Records medication, substance, product, pack, strength, form and terminology binding as source-qualified medication-lifecycle context while preserving the distinctions among request, dispense, administration, statement, product knowledge and clinical consequence.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-009", "SRC-010", "SRC-011", "SRC-012" ], "questions": [ { "id": "medication-substance-product-pack-strength-form-and-terminology-binding-q01", "text": "Which stable identities, record class, source-qualified values and explicit unknowns establish medication, substance, product, pack, strength, form and terminology binding?", "kind": "classification", "answer_data": [ "identifiers and class", "source-qualified values", "unknown and not-applicable states" ] }, { "id": "medication-substance-product-pack-strength-form-and-terminology-binding-q02", "text": "Who requested, authorized, performed, supplied, received, recorded or reported medication, substance, product, pack, strength, form and terminology binding, with which role, evidence and limits?", "kind": "measurement", "answer_data": [ "actors and roles", "authority and limits", "evidence and provenance" ] }, { "id": "medication-substance-product-pack-strength-form-and-terminology-binding-q03", "text": "Which event, authored, prepared, handover, occurrence, recorded, reported, ingested and knowledge times apply to medication, substance, product, pack, strength, form and terminology binding, and how is it validated or corrected?", "kind": "security", "answer_data": [ "distinct clinical and record times", "validation and discrepancy status", "successor correction and retention" ] } ], "data_elements": [ { "id": "medication-substance-product-pack-strength-form-and-terminology-binding-data", "name": "Medication, substance, product, pack, strength, form and terminology binding data", "description": "Typed data for medication, substance, product, pack, strength, form and terminology binding with child-event identity, source, authority, status, event time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-009", "SRC-010", "SRC-011", "SRC-012" ] } ], "artifacts": [ { "id": "medication-substance-product-pack-strength-form-and-terminology-binding-record", "name": "Medication, substance, product, pack, strength, form and terminology binding record", "description": "Immutable or successor-versioned medication evidence for medication, substance, product, pack, strength, form and terminology binding.", "media_or_form": [ "logical medication assertion", "request, dispense, administration, statement, safety, reconciliation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent request, dispense, administration, statement or assertion ID for medication-substance-product-pack-strength-form-and-terminology-binding; patient, medication, date, encounter and claim never identify an event alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-009", "SRC-010", "SRC-011", "SRC-012" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "request-prescription-authority-and-dosage-intent", "name": "Request, prescription authority and dosage intent", "description": "Groups governed medication context for request, prescription authority and dosage intent.", "rationale": "The request records clinical intent and authorization, not proof that supply or administration occurred.", "source_refs": [ "SRC-001", "SRC-005", "SRC-006", "SRC-008", "SRC-010", "SRC-011", "SRC-012", "SRC-014", "SRC-016", "SRC-017" ], "layers": [ { "id": "request-intent-status-priority-authority-and-indication", "name": "Request intent, status, priority, authority and indication", "description": "Groups source-qualified medication context for request intent, status, priority, authority and indication.", "source_refs": [ "SRC-001", "SRC-006", "SRC-008", "SRC-016", "SRC-017" ], "findings": [ { "id": "request-intent-status-priority-authored-time-requester-and-recorder", "name": "Request intent, status, priority, authored time, requester and recorder", "description": "Records request intent, status, priority, authored time, requester and recorder as source-qualified medication-lifecycle context while preserving the distinctions among request, dispense, administration, statement, product knowledge and clinical consequence.", "source_refs": [ "SRC-001", "SRC-006", "SRC-008", "SRC-016", "SRC-017" ], "questions": [ { "id": "request-intent-status-priority-authored-time-requester-and-recorder-q01", "text": "Which stable identities, record class, source-qualified values and explicit unknowns establish request intent, status, priority, authored time, requester and recorder?", "kind": "lifecycle", "answer_data": [ "identifiers and class", "source-qualified values", "unknown and not-applicable states" ] }, { "id": "request-intent-status-priority-authored-time-requester-and-recorder-q02", "text": "Who requested, authorized, performed, supplied, received, recorded or reported request intent, status, priority, authored time, requester and recorder, with which role, evidence and limits?", "kind": "exception", "answer_data": [ "actors and roles", "authority and limits", "evidence and provenance" ] }, { "id": "request-intent-status-priority-authored-time-requester-and-recorder-q03", "text": "Which event, authored, prepared, handover, occurrence, recorded, reported, ingested and knowledge times apply to request intent, status, priority, authored time, requester and recorder, and how is it validated or corrected?", "kind": "retention", "answer_data": [ "distinct clinical and record times", "validation and discrepancy status", "successor correction and retention" ] } ], "data_elements": [ { "id": "request-intent-status-priority-authored-time-requester-and-recorder-data", "name": "Request intent, status, priority, authored time, requester and recorder data", "description": "Typed data for request intent, status, priority, authored time, requester and recorder with child-event identity, source, authority, status, event time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-006", "SRC-008", "SRC-016", "SRC-017" ] } ], "artifacts": [ { "id": "request-intent-status-priority-authored-time-requester-and-recorder-record", "name": "Request intent, status, priority, authored time, requester and recorder record", "description": "Immutable or successor-versioned medication evidence for request intent, status, priority, authored time, requester and recorder.", "media_or_form": [ "logical medication assertion", "request, dispense, administration, statement, safety, reconciliation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent request, dispense, administration, statement or assertion ID for request-intent-status-priority-authored-time-requester-and-recorder; patient, medication, date, encounter and claim never identify an event alone.", "source_refs": [ "SRC-001", "SRC-006", "SRC-008", "SRC-016", "SRC-017" ] } ], "inline_only_rationale": null }, { "id": "indication-goal-supporting-evidence-clinical-authority-and-decision-basis", "name": "Indication, goal, supporting evidence, clinical authority and decision basis", "description": "Records indication, goal, supporting evidence, clinical authority and decision basis as source-qualified medication-lifecycle context while preserving the distinctions among request, dispense, administration, statement, product knowledge and clinical consequence.", "source_refs": [ "SRC-001", "SRC-006", "SRC-008", "SRC-016", "SRC-017" ], "questions": [ { "id": "indication-goal-supporting-evidence-clinical-authority-and-decision-basis-q01", "text": "Which stable identities, record class, source-qualified values and explicit unknowns establish indication, goal, supporting evidence, clinical authority and decision basis?", "kind": "authority", "answer_data": [ "identifiers and class", "source-qualified values", "unknown and not-applicable states" ] }, { "id": "indication-goal-supporting-evidence-clinical-authority-and-decision-basis-q02", "text": "Who requested, authorized, performed, supplied, received, recorded or reported indication, goal, supporting evidence, clinical authority and decision basis, with which role, evidence and limits?", "kind": "provenance", "answer_data": [ "actors and roles", "authority and limits", "evidence and provenance" ] }, { "id": "indication-goal-supporting-evidence-clinical-authority-and-decision-basis-q03", "text": "Which event, authored, prepared, handover, occurrence, recorded, reported, ingested and knowledge times apply to indication, goal, supporting evidence, clinical authority and decision basis, and how is it validated or corrected?", "kind": "interoperability", "answer_data": [ "distinct clinical and record times", "validation and discrepancy status", "successor correction and retention" ] } ], "data_elements": [ { "id": "indication-goal-supporting-evidence-clinical-authority-and-decision-basis-data", "name": "Indication, goal, supporting evidence, clinical authority and decision basis data", "description": "Typed data for indication, goal, supporting evidence, clinical authority and decision basis with child-event identity, source, authority, status, event time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-006", "SRC-008", "SRC-016", "SRC-017" ] } ], "artifacts": [ { "id": "indication-goal-supporting-evidence-clinical-authority-and-decision-basis-record", "name": "Indication, goal, supporting evidence, clinical authority and decision basis record", "description": "Immutable or successor-versioned medication evidence for indication, goal, supporting evidence, clinical authority and decision basis.", "media_or_form": [ "logical medication assertion", "request, dispense, administration, statement, safety, reconciliation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent request, dispense, administration, statement or assertion ID for indication-goal-supporting-evidence-clinical-authority-and-decision-basis; patient, medication, date, encounter and claim never identify an event alone.", "source_refs": [ "SRC-001", "SRC-006", "SRC-008", "SRC-016", "SRC-017" ] } ], "inline_only_rationale": null } ] }, { "id": "dosage-therapy-dispense-authorization-and-substitution-intent", "name": "Dosage, therapy, dispense authorization and substitution intent", "description": "Groups source-qualified medication context for dosage, therapy, dispense authorization and substitution intent.", "source_refs": [ "SRC-001", "SRC-005", "SRC-010", "SRC-011", "SRC-012", "SRC-014" ], "findings": [ { "id": "dose-timing-frequency-duration-route-site-method-rate-prn-and-therapy-course", "name": "Dose, timing, frequency, duration, route, site, method, rate, PRN and therapy course", "description": "Records dose, timing, frequency, duration, route, site, method, rate, prn and therapy course as source-qualified medication-lifecycle context while preserving the distinctions among request, dispense, administration, statement, product knowledge and clinical consequence.", "source_refs": [ "SRC-001", "SRC-005", "SRC-010", "SRC-011", "SRC-012", "SRC-014" ], "questions": [ { "id": "dose-timing-frequency-duration-route-site-method-rate-prn-and-therapy-course-q01", "text": "Which stable identities, record class, source-qualified values and explicit unknowns establish dose, timing, frequency, duration, route, site, method, rate, prn and therapy course?", "kind": "requirement", "answer_data": [ "identifiers and class", "source-qualified values", "unknown and not-applicable states" ] }, { "id": "dose-timing-frequency-duration-route-site-method-rate-prn-and-therapy-course-q02", "text": "Who requested, authorized, performed, supplied, received, recorded or reported dose, timing, frequency, duration, route, site, method, rate, prn and therapy course, with which role, evidence and limits?", "kind": "process", "answer_data": [ "actors and roles", "authority and limits", "evidence and provenance" ] }, { "id": "dose-timing-frequency-duration-route-site-method-rate-prn-and-therapy-course-q03", "text": "Which event, authored, prepared, handover, occurrence, recorded, reported, ingested and knowledge times apply to dose, timing, frequency, duration, route, site, method, rate, prn and therapy course, and how is it validated or corrected?", "kind": "decision", "answer_data": [ "distinct clinical and record times", "validation and discrepancy status", "successor correction and retention" ] } ], "data_elements": [ { "id": "dose-timing-frequency-duration-route-site-method-rate-prn-and-therapy-course-data", "name": "Dose, timing, frequency, duration, route, site, method, rate, PRN and therapy course data", "description": "Typed data for dose, timing, frequency, duration, route, site, method, rate, prn and therapy course with child-event identity, source, authority, status, event time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-005", "SRC-010", "SRC-011", "SRC-012", "SRC-014" ] } ], "artifacts": [ { "id": "dose-timing-frequency-duration-route-site-method-rate-prn-and-therapy-course-record", "name": "Dose, timing, frequency, duration, route, site, method, rate, PRN and therapy course record", "description": "Immutable or successor-versioned medication evidence for dose, timing, frequency, duration, route, site, method, rate, prn and therapy course.", "media_or_form": [ "logical medication assertion", "request, dispense, administration, statement, safety, reconciliation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent request, dispense, administration, statement or assertion ID for dose-timing-frequency-duration-route-site-method-rate-prn-and-therapy-course; patient, medication, date, encounter and claim never identify an event alone.", "source_refs": [ "SRC-001", "SRC-005", "SRC-010", "SRC-011", "SRC-012", "SRC-014" ] } ], "inline_only_rationale": null }, { "id": "initial-fill-quantity-supply-duration-refills-validity-dispenser-and-substitution-limits", "name": "Initial fill, quantity, supply duration, refills, validity, dispenser and substitution limits", "description": "Records initial fill, quantity, supply duration, refills, validity, dispenser and substitution limits as source-qualified medication-lifecycle context while preserving the distinctions among request, dispense, administration, statement, product knowledge and clinical consequence.", "source_refs": [ "SRC-001", "SRC-005", "SRC-010", "SRC-011", "SRC-012", "SRC-014" ], "questions": [ { "id": "initial-fill-quantity-supply-duration-refills-validity-dispenser-and-substitution-limits-q01", "text": "Which stable identities, record class, source-qualified values and explicit unknowns establish initial fill, quantity, supply duration, refills, validity, dispenser and substitution limits?", "kind": "constraint", "answer_data": [ "identifiers and class", "source-qualified values", "unknown and not-applicable states" ] }, { "id": "initial-fill-quantity-supply-duration-refills-validity-dispenser-and-substitution-limits-q02", "text": "Who requested, authorized, performed, supplied, received, recorded or reported initial fill, quantity, supply duration, refills, validity, dispenser and substitution limits, with which role, evidence and limits?", "kind": "validation", "answer_data": [ "actors and roles", "authority and limits", "evidence and provenance" ] }, { "id": "initial-fill-quantity-supply-duration-refills-validity-dispenser-and-substitution-limits-q03", "text": "Which event, authored, prepared, handover, occurrence, recorded, reported, ingested and knowledge times apply to initial fill, quantity, supply duration, refills, validity, dispenser and substitution limits, and how is it validated or corrected?", "kind": "state", "answer_data": [ "distinct clinical and record times", "validation and discrepancy status", "successor correction and retention" ] } ], "data_elements": [ { "id": "initial-fill-quantity-supply-duration-refills-validity-dispenser-and-substitution-limits-data", "name": "Initial fill, quantity, supply duration, refills, validity, dispenser and substitution limits data", "description": "Typed data for initial fill, quantity, supply duration, refills, validity, dispenser and substitution limits with child-event identity, source, authority, status, event time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-005", "SRC-010", "SRC-011", "SRC-012", "SRC-014" ] } ], "artifacts": [ { "id": "initial-fill-quantity-supply-duration-refills-validity-dispenser-and-substitution-limits-record", "name": "Initial fill, quantity, supply duration, refills, validity, dispenser and substitution limits record", "description": "Immutable or successor-versioned medication evidence for initial fill, quantity, supply duration, refills, validity, dispenser and substitution limits.", "media_or_form": [ "logical medication assertion", "request, dispense, administration, statement, safety, reconciliation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent request, dispense, administration, statement or assertion ID for initial-fill-quantity-supply-duration-refills-validity-dispenser-and-substitution-limits; patient, medication, date, encounter and claim never identify an event alone.", "source_refs": [ "SRC-001", "SRC-005", "SRC-010", "SRC-011", "SRC-012", "SRC-014" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "dispense-preparation-supply-handover-and-substitution", "name": "Dispense preparation, supply, handover and substitution", "description": "Groups governed medication context for dispense preparation, supply, handover and substitution.", "rationale": "Each dispense is independently attributable and may differ from the prescription only with explicit source-qualified authority and reason.", "source_refs": [ "SRC-001", "SRC-002", "SRC-005", "SRC-006", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-016", "SRC-017" ], "layers": [ { "id": "dispense-event-authorization-status-performer-place-and-times", "name": "Dispense event authorization, status, performer, place and times", "description": "Groups source-qualified medication context for dispense event authorization, status, performer, place and times.", "source_refs": [ "SRC-001", "SRC-002", "SRC-006", "SRC-013", "SRC-016", "SRC-017" ], "findings": [ { "id": "dispense-identity-authorizing-request-status-not-performed-reason-and-type", "name": "Dispense identity, authorizing request, status, not-performed reason and type", "description": "Records dispense identity, authorizing request, status, not-performed reason and type as source-qualified medication-lifecycle context while preserving the distinctions among request, dispense, administration, statement, product knowledge and clinical consequence.", "source_refs": [ "SRC-001", "SRC-002", "SRC-006", "SRC-013", "SRC-016", "SRC-017" ], "questions": [ { "id": "dispense-identity-authorizing-request-status-not-performed-reason-and-type-q01", "text": "Which stable identities, record class, source-qualified values and explicit unknowns establish dispense identity, authorizing request, status, not-performed reason and type?", "kind": "event", "answer_data": [ "identifiers and class", "source-qualified values", "unknown and not-applicable states" ] }, { "id": "dispense-identity-authorizing-request-status-not-performed-reason-and-type-q02", "text": "Who requested, authorized, performed, supplied, received, recorded or reported dispense identity, authorizing request, status, not-performed reason and type, with which role, evidence and limits?", "kind": "privacy", "answer_data": [ "actors and roles", "authority and limits", "evidence and provenance" ] }, { "id": "dispense-identity-authorizing-request-status-not-performed-reason-and-type-q03", "text": "Which event, authored, prepared, handover, occurrence, recorded, reported, ingested and knowledge times apply to dispense identity, authorizing request, status, not-performed reason and type, and how is it validated or corrected?", "kind": "identity", "answer_data": [ "distinct clinical and record times", "validation and discrepancy status", "successor correction and retention" ] } ], "data_elements": [ { "id": "dispense-identity-authorizing-request-status-not-performed-reason-and-type-data", "name": "Dispense identity, authorizing request, status, not-performed reason and type data", "description": "Typed data for dispense identity, authorizing request, status, not-performed reason and type with child-event identity, source, authority, status, event time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-006", "SRC-013", "SRC-016", "SRC-017" ] } ], "artifacts": [ { "id": "dispense-identity-authorizing-request-status-not-performed-reason-and-type-record", "name": "Dispense identity, authorizing request, status, not-performed reason and type record", "description": "Immutable or successor-versioned medication evidence for dispense identity, authorizing request, status, not-performed reason and type.", "media_or_form": [ "logical medication assertion", "request, dispense, administration, statement, safety, reconciliation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent request, dispense, administration, statement or assertion ID for dispense-identity-authorizing-request-status-not-performed-reason-and-type; patient, medication, date, encounter and claim never identify an event alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-006", "SRC-013", "SRC-016", "SRC-017" ] } ], "inline_only_rationale": null }, { "id": "dispenser-role-location-recorded-prepared-handover-destination-and-receiver", "name": "Dispenser role, location, recorded, prepared, handover, destination and receiver", "description": "Records dispenser role, location, recorded, prepared, handover, destination and receiver as source-qualified medication-lifecycle context while preserving the distinctions among request, dispense, administration, statement, product knowledge and clinical consequence.", "source_refs": [ "SRC-001", "SRC-002", "SRC-006", "SRC-013", "SRC-016", "SRC-017" ], "questions": [ { "id": "dispenser-role-location-recorded-prepared-handover-destination-and-receiver-q01", "text": "Which stable identities, record class, source-qualified values and explicit unknowns establish dispenser role, location, recorded, prepared, handover, destination and receiver?", "kind": "temporal", "answer_data": [ "identifiers and class", "source-qualified values", "unknown and not-applicable states" ] }, { "id": "dispenser-role-location-recorded-prepared-handover-destination-and-receiver-q02", "text": "Who requested, authorized, performed, supplied, received, recorded or reported dispenser role, location, recorded, prepared, handover, destination and receiver, with which role, evidence and limits?", "kind": "lifecycle", "answer_data": [ "actors and roles", "authority and limits", "evidence and provenance" ] }, { "id": "dispenser-role-location-recorded-prepared-handover-destination-and-receiver-q03", "text": "Which event, authored, prepared, handover, occurrence, recorded, reported, ingested and knowledge times apply to dispenser role, location, recorded, prepared, handover, destination and receiver, and how is it validated or corrected?", "kind": "classification", "answer_data": [ "distinct clinical and record times", "validation and discrepancy status", "successor correction and retention" ] } ], "data_elements": [ { "id": "dispenser-role-location-recorded-prepared-handover-destination-and-receiver-data", "name": "Dispenser role, location, recorded, prepared, handover, destination and receiver data", "description": "Typed data for dispenser role, location, recorded, prepared, handover, destination and receiver with child-event identity, source, authority, status, event time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-006", "SRC-013", "SRC-016", "SRC-017" ] } ], "artifacts": [ { "id": "dispenser-role-location-recorded-prepared-handover-destination-and-receiver-record", "name": "Dispenser role, location, recorded, prepared, handover, destination and receiver record", "description": "Immutable or successor-versioned medication evidence for dispenser role, location, recorded, prepared, handover, destination and receiver.", "media_or_form": [ "logical medication assertion", "request, dispense, administration, statement, safety, reconciliation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent request, dispense, administration, statement or assertion ID for dispenser-role-location-recorded-prepared-handover-destination-and-receiver; patient, medication, date, encounter and claim never identify an event alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-006", "SRC-013", "SRC-016", "SRC-017" ] } ], "inline_only_rationale": null } ] }, { "id": "supplied-product-quantity-instructions-and-substitution-evidence", "name": "Supplied product, quantity, instructions and substitution evidence", "description": "Groups source-qualified medication context for supplied product, quantity, instructions and substitution evidence.", "source_refs": [ "SRC-002", "SRC-005", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-014" ], "findings": [ { "id": "actual-product-package-lot-expiry-quantity-days-supply-and-dose-aid", "name": "Actual product, package, lot, expiry, quantity, days supply and dose aid", "description": "Records actual product, package, lot, expiry, quantity, days supply and dose aid as source-qualified medication-lifecycle context while preserving the distinctions among request, dispense, administration, statement, product knowledge and clinical consequence.", "source_refs": [ "SRC-002", "SRC-005", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-014" ], "questions": [ { "id": "actual-product-package-lot-expiry-quantity-days-supply-and-dose-aid-q01", "text": "Which stable identities, record class, source-qualified values and explicit unknowns establish actual product, package, lot, expiry, quantity, days supply and dose aid?", "kind": "composition", "answer_data": [ "identifiers and class", "source-qualified values", "unknown and not-applicable states" ] }, { "id": "actual-product-package-lot-expiry-quantity-days-supply-and-dose-aid-q02", "text": "Who requested, authorized, performed, supplied, received, recorded or reported actual product, package, lot, expiry, quantity, days supply and dose aid, with which role, evidence and limits?", "kind": "quality", "answer_data": [ "actors and roles", "authority and limits", "evidence and provenance" ] }, { "id": "actual-product-package-lot-expiry-quantity-days-supply-and-dose-aid-q03", "text": "Which event, authored, prepared, handover, occurrence, recorded, reported, ingested and knowledge times apply to actual product, package, lot, expiry, quantity, days supply and dose aid, and how is it validated or corrected?", "kind": "relationship", "answer_data": [ "distinct clinical and record times", "validation and discrepancy status", "successor correction and retention" ] } ], "data_elements": [ { "id": "actual-product-package-lot-expiry-quantity-days-supply-and-dose-aid-data", "name": "Actual product, package, lot, expiry, quantity, days supply and dose aid data", "description": "Typed data for actual product, package, lot, expiry, quantity, days supply and dose aid with child-event identity, source, authority, status, event time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-002", "SRC-005", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-014" ] } ], "artifacts": [ { "id": "actual-product-package-lot-expiry-quantity-days-supply-and-dose-aid-record", "name": "Actual product, package, lot, expiry, quantity, days supply and dose aid record", "description": "Immutable or successor-versioned medication evidence for actual product, package, lot, expiry, quantity, days supply and dose aid.", "media_or_form": [ "logical medication assertion", "request, dispense, administration, statement, safety, reconciliation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent request, dispense, administration, statement or assertion ID for actual-product-package-lot-expiry-quantity-days-supply-and-dose-aid; patient, medication, date, encounter and claim never identify an event alone.", "source_refs": [ "SRC-002", "SRC-005", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-014" ] } ], "inline_only_rationale": null }, { "id": "dispense-instructions-substitution-type-reason-responsible-party-and-difference", "name": "Dispense instructions, substitution type, reason, responsible party and difference", "description": "Records dispense instructions, substitution type, reason, responsible party and difference as source-qualified medication-lifecycle context while preserving the distinctions among request, dispense, administration, statement, product knowledge and clinical consequence.", "source_refs": [ "SRC-002", "SRC-005", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-014" ], "questions": [ { "id": "dispense-instructions-substitution-type-reason-responsible-party-and-difference-q01", "text": "Which stable identities, record class, source-qualified values and explicit unknowns establish dispense instructions, substitution type, reason, responsible party and difference?", "kind": "evidence", "answer_data": [ "identifiers and class", "source-qualified values", "unknown and not-applicable states" ] }, { "id": "dispense-instructions-substitution-type-reason-responsible-party-and-difference-q02", "text": "Who requested, authorized, performed, supplied, received, recorded or reported dispense instructions, substitution type, reason, responsible party and difference, with which role, evidence and limits?", "kind": "security", "answer_data": [ "actors and roles", "authority and limits", "evidence and provenance" ] }, { "id": "dispense-instructions-substitution-type-reason-responsible-party-and-difference-q03", "text": "Which event, authored, prepared, handover, occurrence, recorded, reported, ingested and knowledge times apply to dispense instructions, substitution type, reason, responsible party and difference, and how is it validated or corrected?", "kind": "authority", "answer_data": [ "distinct clinical and record times", "validation and discrepancy status", "successor correction and retention" ] } ], "data_elements": [ { "id": "dispense-instructions-substitution-type-reason-responsible-party-and-difference-data", "name": "Dispense instructions, substitution type, reason, responsible party and difference data", "description": "Typed data for dispense instructions, substitution type, reason, responsible party and difference with child-event identity, source, authority, status, event time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-002", "SRC-005", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-014" ] } ], "artifacts": [ { "id": "dispense-instructions-substitution-type-reason-responsible-party-and-difference-record", "name": "Dispense instructions, substitution type, reason, responsible party and difference record", "description": "Immutable or successor-versioned medication evidence for dispense instructions, substitution type, reason, responsible party and difference.", "media_or_form": [ "logical medication assertion", "request, dispense, administration, statement, safety, reconciliation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent request, dispense, administration, statement or assertion ID for dispense-instructions-substitution-type-reason-responsible-party-and-difference; patient, medication, date, encounter and claim never identify an event alone.", "source_refs": [ "SRC-002", "SRC-005", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-014" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "administration-nonadministration-partial-dose-and-waste", "name": "Administration, non-administration, partial dose and waste", "description": "Groups governed medication context for administration, non-administration, partial dose and waste.", "rationale": "Actual medication exposure and explicit non-performance have their own event evidence and never inherit the request status.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-005", "SRC-006", "SRC-008", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-016", "SRC-017" ], "layers": [ { "id": "administration-event-status-occurrence-actor-and-order-link", "name": "Administration event, status, occurrence, actor and order link", "description": "Groups source-qualified medication context for administration event, status, occurrence, actor and order link.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-006", "SRC-013", "SRC-016", "SRC-017" ], "findings": [ { "id": "administration-identity-status-occurrence-recorded-time-request-and-part-of", "name": "Administration identity, status, occurrence, recorded time, request and part-of", "description": "Records administration identity, status, occurrence, recorded time, request and part-of as source-qualified medication-lifecycle context while preserving the distinctions among request, dispense, administration, statement, product knowledge and clinical consequence.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-006", "SRC-013", "SRC-016", "SRC-017" ], "questions": [ { "id": "administration-identity-status-occurrence-recorded-time-request-and-part-of-q01", "text": "Which stable identities, record class, source-qualified values and explicit unknowns establish administration identity, status, occurrence, recorded time, request and part-of?", "kind": "event", "answer_data": [ "identifiers and class", "source-qualified values", "unknown and not-applicable states" ] }, { "id": "administration-identity-status-occurrence-recorded-time-request-and-part-of-q02", "text": "Who requested, authorized, performed, supplied, received, recorded or reported administration identity, status, occurrence, recorded time, request and part-of, with which role, evidence and limits?", "kind": "retention", "answer_data": [ "actors and roles", "authority and limits", "evidence and provenance" ] }, { "id": "administration-identity-status-occurrence-recorded-time-request-and-part-of-q03", "text": "Which event, authored, prepared, handover, occurrence, recorded, reported, ingested and knowledge times apply to administration identity, status, occurrence, recorded time, request and part-of, and how is it validated or corrected?", "kind": "requirement", "answer_data": [ "distinct clinical and record times", "validation and discrepancy status", "successor correction and retention" ] } ], "data_elements": [ { "id": "administration-identity-status-occurrence-recorded-time-request-and-part-of-data", "name": "Administration identity, status, occurrence, recorded time, request and part-of data", "description": "Typed data for administration identity, status, occurrence, recorded time, request and part-of with child-event identity, source, authority, status, event time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-006", "SRC-013", "SRC-016", "SRC-017" ] } ], "artifacts": [ { "id": "administration-identity-status-occurrence-recorded-time-request-and-part-of-record", "name": "Administration identity, status, occurrence, recorded time, request and part-of record", "description": "Immutable or successor-versioned medication evidence for administration identity, status, occurrence, recorded time, request and part-of.", "media_or_form": [ "logical medication assertion", "request, dispense, administration, statement, safety, reconciliation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent request, dispense, administration, statement or assertion ID for administration-identity-status-occurrence-recorded-time-request-and-part-of; patient, medication, date, encounter and claim never identify an event alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-006", "SRC-013", "SRC-016", "SRC-017" ] } ], "inline_only_rationale": null }, { "id": "recipient-performer-role-encounter-reason-support-and-device-reference", "name": "Recipient, performer role, encounter, reason, support and device reference", "description": "Records recipient, performer role, encounter, reason, support and device reference as source-qualified medication-lifecycle context while preserving the distinctions among request, dispense, administration, statement, product knowledge and clinical consequence.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-006", "SRC-013", "SRC-016", "SRC-017" ], "questions": [ { "id": "recipient-performer-role-encounter-reason-support-and-device-reference-q01", "text": "Which stable identities, record class, source-qualified values and explicit unknowns establish recipient, performer role, encounter, reason, support and device reference?", "kind": "ownership", "answer_data": [ "identifiers and class", "source-qualified values", "unknown and not-applicable states" ] }, { "id": "recipient-performer-role-encounter-reason-support-and-device-reference-q02", "text": "Who requested, authorized, performed, supplied, received, recorded or reported recipient, performer role, encounter, reason, support and device reference, with which role, evidence and limits?", "kind": "interoperability", "answer_data": [ "actors and roles", "authority and limits", "evidence and provenance" ] }, { "id": "recipient-performer-role-encounter-reason-support-and-device-reference-q03", "text": "Which event, authored, prepared, handover, occurrence, recorded, reported, ingested and knowledge times apply to recipient, performer role, encounter, reason, support and device reference, and how is it validated or corrected?", "kind": "constraint", "answer_data": [ "distinct clinical and record times", "validation and discrepancy status", "successor correction and retention" ] } ], "data_elements": [ { "id": "recipient-performer-role-encounter-reason-support-and-device-reference-data", "name": "Recipient, performer role, encounter, reason, support and device reference data", "description": "Typed data for recipient, performer role, encounter, reason, support and device reference with child-event identity, source, authority, status, event time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-006", "SRC-013", "SRC-016", "SRC-017" ] } ], "artifacts": [ { "id": "recipient-performer-role-encounter-reason-support-and-device-reference-record", "name": "Recipient, performer role, encounter, reason, support and device reference record", "description": "Immutable or successor-versioned medication evidence for recipient, performer role, encounter, reason, support and device reference.", "media_or_form": [ "logical medication assertion", "request, dispense, administration, statement, safety, reconciliation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent request, dispense, administration, statement or assertion ID for recipient-performer-role-encounter-reason-support-and-device-reference; patient, medication, date, encounter and claim never identify an event alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-006", "SRC-013", "SRC-016", "SRC-017" ] } ], "inline_only_rationale": null } ] }, { "id": "actual-dose-route-site-method-rate-exceptions-and-waste", "name": "Actual dose, route, site, method, rate, exceptions and waste", "description": "Groups source-qualified medication context for actual dose, route, site, method, rate, exceptions and waste.", "source_refs": [ "SRC-003", "SRC-005", "SRC-008", "SRC-011", "SRC-012", "SRC-014" ], "findings": [ { "id": "actual-dose-unit-route-site-method-rate-duration-and-administration-device", "name": "Actual dose, unit, route, site, method, rate, duration and administration device", "description": "Records actual dose, unit, route, site, method, rate, duration and administration device as source-qualified medication-lifecycle context while preserving the distinctions among request, dispense, administration, statement, product knowledge and clinical consequence.", "source_refs": [ "SRC-003", "SRC-005", "SRC-008", "SRC-011", "SRC-012", "SRC-014" ], "questions": [ { "id": "actual-dose-unit-route-site-method-rate-duration-and-administration-device-q01", "text": "Which stable identities, record class, source-qualified values and explicit unknowns establish actual dose, unit, route, site, method, rate, duration and administration device?", "kind": "measurement", "answer_data": [ "identifiers and class", "source-qualified values", "unknown and not-applicable states" ] }, { "id": "actual-dose-unit-route-site-method-rate-duration-and-administration-device-q02", "text": "Who requested, authorized, performed, supplied, received, recorded or reported actual dose, unit, route, site, method, rate, duration and administration device, with which role, evidence and limits?", "kind": "decision", "answer_data": [ "actors and roles", "authority and limits", "evidence and provenance" ] }, { "id": "actual-dose-unit-route-site-method-rate-duration-and-administration-device-q03", "text": "Which event, authored, prepared, handover, occurrence, recorded, reported, ingested and knowledge times apply to actual dose, unit, route, site, method, rate, duration and administration device, and how is it validated or corrected?", "kind": "event", "answer_data": [ "distinct clinical and record times", "validation and discrepancy status", "successor correction and retention" ] } ], "data_elements": [ { "id": "actual-dose-unit-route-site-method-rate-duration-and-administration-device-data", "name": "Actual dose, unit, route, site, method, rate, duration and administration device data", "description": "Typed data for actual dose, unit, route, site, method, rate, duration and administration device with child-event identity, source, authority, status, event time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-003", "SRC-005", "SRC-008", "SRC-011", "SRC-012", "SRC-014" ] } ], "artifacts": [ { "id": "actual-dose-unit-route-site-method-rate-duration-and-administration-device-record", "name": "Actual dose, unit, route, site, method, rate, duration and administration device record", "description": "Immutable or successor-versioned medication evidence for actual dose, unit, route, site, method, rate, duration and administration device.", "media_or_form": [ "logical medication assertion", "request, dispense, administration, statement, safety, reconciliation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent request, dispense, administration, statement or assertion ID for actual-dose-unit-route-site-method-rate-duration-and-administration-device; patient, medication, date, encounter and claim never identify an event alone.", "source_refs": [ "SRC-003", "SRC-005", "SRC-008", "SRC-011", "SRC-012", "SRC-014" ] } ], "inline_only_rationale": null }, { "id": "not-done-omitted-refused-held-stopped-subpotent-spilled-and-wasted-dose", "name": "Not-done, omitted, refused, held, stopped, subpotent, spilled and wasted dose", "description": "Records not-done, omitted, refused, held, stopped, subpotent, spilled and wasted dose as source-qualified medication-lifecycle context while preserving the distinctions among request, dispense, administration, statement, product knowledge and clinical consequence.", "source_refs": [ "SRC-003", "SRC-005", "SRC-008", "SRC-011", "SRC-012", "SRC-014" ], "questions": [ { "id": "not-done-omitted-refused-held-stopped-subpotent-spilled-and-wasted-dose-q01", "text": "Which stable identities, record class, source-qualified values and explicit unknowns establish not-done, omitted, refused, held, stopped, subpotent, spilled and wasted dose?", "kind": "exception", "answer_data": [ "identifiers and class", "source-qualified values", "unknown and not-applicable states" ] }, { "id": "not-done-omitted-refused-held-stopped-subpotent-spilled-and-wasted-dose-q02", "text": "Who requested, authorized, performed, supplied, received, recorded or reported not-done, omitted, refused, held, stopped, subpotent, spilled and wasted dose, with which role, evidence and limits?", "kind": "state", "answer_data": [ "actors and roles", "authority and limits", "evidence and provenance" ] }, { "id": "not-done-omitted-refused-held-stopped-subpotent-spilled-and-wasted-dose-q03", "text": "Which event, authored, prepared, handover, occurrence, recorded, reported, ingested and knowledge times apply to not-done, omitted, refused, held, stopped, subpotent, spilled and wasted dose, and how is it validated or corrected?", "kind": "temporal", "answer_data": [ "distinct clinical and record times", "validation and discrepancy status", "successor correction and retention" ] } ], "data_elements": [ { "id": "not-done-omitted-refused-held-stopped-subpotent-spilled-and-wasted-dose-data", "name": "Not-done, omitted, refused, held, stopped, subpotent, spilled and wasted dose data", "description": "Typed data for not-done, omitted, refused, held, stopped, subpotent, spilled and wasted dose with child-event identity, source, authority, status, event time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-003", "SRC-005", "SRC-008", "SRC-011", "SRC-012", "SRC-014" ] } ], "artifacts": [ { "id": "not-done-omitted-refused-held-stopped-subpotent-spilled-and-wasted-dose-record", "name": "Not-done, omitted, refused, held, stopped, subpotent, spilled and wasted dose record", "description": "Immutable or successor-versioned medication evidence for not-done, omitted, refused, held, stopped, subpotent, spilled and wasted dose.", "media_or_form": [ "logical medication assertion", "request, dispense, administration, statement, safety, reconciliation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent request, dispense, administration, statement or assertion ID for not-done-omitted-refused-held-stopped-subpotent-spilled-and-wasted-dose; patient, medication, date, encounter and claim never identify an event alone.", "source_refs": [ "SRC-003", "SRC-005", "SRC-008", "SRC-011", "SRC-012", "SRC-014" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "reported-use-reconciliation-safety-response-and-harm", "name": "Reported use, reconciliation, safety, response and harm", "description": "Groups governed medication context for reported use, reconciliation, safety, response and harm.", "rationale": "Reported use, reconciliation decisions, safety checks, clinical response and adverse events remain distinct and attributable.", "source_refs": [ "SRC-001", "SRC-003", "SRC-004", "SRC-006", "SRC-007", "SRC-008", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-015", "SRC-016" ], "layers": [ { "id": "medication-statements-histories-discrepancies-and-reconciliation", "name": "Medication statements, histories, discrepancies and reconciliation", "description": "Groups source-qualified medication context for medication statements, histories, discrepancies and reconciliation.", "source_refs": [ "SRC-004", "SRC-006", "SRC-007", "SRC-008", "SRC-013", "SRC-016" ], "findings": [ { "id": "reported-use-information-source-period-adherence-confidence-and-derived-from", "name": "Reported use, information source, period, adherence, confidence and derived-from", "description": "Records reported use, information source, period, adherence, confidence and derived-from as source-qualified medication-lifecycle context while preserving the distinctions among request, dispense, administration, statement, product knowledge and clinical consequence.", "source_refs": [ "SRC-004", "SRC-006", "SRC-007", "SRC-008", "SRC-013", "SRC-016" ], "questions": [ { "id": "reported-use-information-source-period-adherence-confidence-and-derived-from-q01", "text": "Which stable identities, record class, source-qualified values and explicit unknowns establish reported use, information source, period, adherence, confidence and derived-from?", "kind": "provenance", "answer_data": [ "identifiers and class", "source-qualified values", "unknown and not-applicable states" ] }, { "id": "reported-use-information-source-period-adherence-confidence-and-derived-from-q02", "text": "Who requested, authorized, performed, supplied, received, recorded or reported reported use, information source, period, adherence, confidence and derived-from, with which role, evidence and limits?", "kind": "identity", "answer_data": [ "actors and roles", "authority and limits", "evidence and provenance" ] }, { "id": "reported-use-information-source-period-adherence-confidence-and-derived-from-q03", "text": "Which event, authored, prepared, handover, occurrence, recorded, reported, ingested and knowledge times apply to reported use, information source, period, adherence, confidence and derived-from, and how is it validated or corrected?", "kind": "composition", "answer_data": [ "distinct clinical and record times", "validation and discrepancy status", "successor correction and retention" ] } ], "data_elements": [ { "id": "reported-use-information-source-period-adherence-confidence-and-derived-from-data", "name": "Reported use, information source, period, adherence, confidence and derived-from data", "description": "Typed data for reported use, information source, period, adherence, confidence and derived-from with child-event identity, source, authority, status, event time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-004", "SRC-006", "SRC-007", "SRC-008", "SRC-013", "SRC-016" ] } ], "artifacts": [ { "id": "reported-use-information-source-period-adherence-confidence-and-derived-from-record", "name": "Reported use, information source, period, adherence, confidence and derived-from record", "description": "Immutable or successor-versioned medication evidence for reported use, information source, period, adherence, confidence and derived-from.", "media_or_form": [ "logical medication assertion", "request, dispense, administration, statement, safety, reconciliation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent request, dispense, administration, statement or assertion ID for reported-use-information-source-period-adherence-confidence-and-derived-from; patient, medication, date, encounter and claim never identify an event alone.", "source_refs": [ "SRC-004", "SRC-006", "SRC-007", "SRC-008", "SRC-013", "SRC-016" ] } ], "inline_only_rationale": null }, { "id": "best-possible-history-source-comparison-discrepancy-resolution-and-communication", "name": "Best possible history, source comparison, discrepancy resolution and communication", "description": "Records best possible history, source comparison, discrepancy resolution and communication as source-qualified medication-lifecycle context while preserving the distinctions among request, dispense, administration, statement, product knowledge and clinical consequence.", "source_refs": [ "SRC-004", "SRC-006", "SRC-007", "SRC-008", "SRC-013", "SRC-016" ], "questions": [ { "id": "best-possible-history-source-comparison-discrepancy-resolution-and-communication-q01", "text": "Which stable identities, record class, source-qualified values and explicit unknowns establish best possible history, source comparison, discrepancy resolution and communication?", "kind": "process", "answer_data": [ "identifiers and class", "source-qualified values", "unknown and not-applicable states" ] }, { "id": "best-possible-history-source-comparison-discrepancy-resolution-and-communication-q02", "text": "Who requested, authorized, performed, supplied, received, recorded or reported best possible history, source comparison, discrepancy resolution and communication, with which role, evidence and limits?", "kind": "classification", "answer_data": [ "actors and roles", "authority and limits", "evidence and provenance" ] }, { "id": "best-possible-history-source-comparison-discrepancy-resolution-and-communication-q03", "text": "Which event, authored, prepared, handover, occurrence, recorded, reported, ingested and knowledge times apply to best possible history, source comparison, discrepancy resolution and communication, and how is it validated or corrected?", "kind": "evidence", "answer_data": [ "distinct clinical and record times", "validation and discrepancy status", "successor correction and retention" ] } ], "data_elements": [ { "id": "best-possible-history-source-comparison-discrepancy-resolution-and-communication-data", "name": "Best possible history, source comparison, discrepancy resolution and communication data", "description": "Typed data for best possible history, source comparison, discrepancy resolution and communication with child-event identity, source, authority, status, event time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-004", "SRC-006", "SRC-007", "SRC-008", "SRC-013", "SRC-016" ] } ], "artifacts": [ { "id": "best-possible-history-source-comparison-discrepancy-resolution-and-communication-record", "name": "Best possible history, source comparison, discrepancy resolution and communication record", "description": "Immutable or successor-versioned medication evidence for best possible history, source comparison, discrepancy resolution and communication.", "media_or_form": [ "logical medication assertion", "request, dispense, administration, statement, safety, reconciliation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent request, dispense, administration, statement or assertion ID for best-possible-history-source-comparison-discrepancy-resolution-and-communication; patient, medication, date, encounter and claim never identify an event alone.", "source_refs": [ "SRC-004", "SRC-006", "SRC-007", "SRC-008", "SRC-013", "SRC-016" ] } ], "inline_only_rationale": null } ] }, { "id": "safety-checks-effectiveness-observations-and-adverse-events", "name": "Safety checks, effectiveness, observations and adverse events", "description": "Groups source-qualified medication context for safety checks, effectiveness, observations and adverse events.", "source_refs": [ "SRC-001", "SRC-003", "SRC-006", "SRC-008", "SRC-010", "SRC-011", "SRC-012", "SRC-015" ], "findings": [ { "id": "allergy-contraindication-interaction-duplicate-therapy-risk-check-and-response", "name": "Allergy, contraindication, interaction, duplicate therapy, risk check and response", "description": "Records allergy, contraindication, interaction, duplicate therapy, risk check and response as source-qualified medication-lifecycle context while preserving the distinctions among request, dispense, administration, statement, product knowledge and clinical consequence.", "source_refs": [ "SRC-001", "SRC-003", "SRC-006", "SRC-008", "SRC-010", "SRC-011", "SRC-012", "SRC-015" ], "questions": [ { "id": "allergy-contraindication-interaction-duplicate-therapy-risk-check-and-response-q01", "text": "Which stable identities, record class, source-qualified values and explicit unknowns establish allergy, contraindication, interaction, duplicate therapy, risk check and response?", "kind": "validation", "answer_data": [ "identifiers and class", "source-qualified values", "unknown and not-applicable states" ] }, { "id": "allergy-contraindication-interaction-duplicate-therapy-risk-check-and-response-q02", "text": "Who requested, authorized, performed, supplied, received, recorded or reported allergy, contraindication, interaction, duplicate therapy, risk check and response, with which role, evidence and limits?", "kind": "relationship", "answer_data": [ "actors and roles", "authority and limits", "evidence and provenance" ] }, { "id": "allergy-contraindication-interaction-duplicate-therapy-risk-check-and-response-q03", "text": "Which event, authored, prepared, handover, occurrence, recorded, reported, ingested and knowledge times apply to allergy, contraindication, interaction, duplicate therapy, risk check and response, and how is it validated or corrected?", "kind": "ownership", "answer_data": [ "distinct clinical and record times", "validation and discrepancy status", "successor correction and retention" ] } ], "data_elements": [ { "id": "allergy-contraindication-interaction-duplicate-therapy-risk-check-and-response-data", "name": "Allergy, contraindication, interaction, duplicate therapy, risk check and response data", "description": "Typed data for allergy, contraindication, interaction, duplicate therapy, risk check and response with child-event identity, source, authority, status, event time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-003", "SRC-006", "SRC-008", "SRC-010", "SRC-011", "SRC-012", "SRC-015" ] } ], "artifacts": [ { "id": "allergy-contraindication-interaction-duplicate-therapy-risk-check-and-response-record", "name": "Allergy, contraindication, interaction, duplicate therapy, risk check and response record", "description": "Immutable or successor-versioned medication evidence for allergy, contraindication, interaction, duplicate therapy, risk check and response.", "media_or_form": [ "logical medication assertion", "request, dispense, administration, statement, safety, reconciliation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent request, dispense, administration, statement or assertion ID for allergy-contraindication-interaction-duplicate-therapy-risk-check-and-response; patient, medication, date, encounter and claim never identify an event alone.", "source_refs": [ "SRC-001", "SRC-003", "SRC-006", "SRC-008", "SRC-010", "SRC-011", "SRC-012", "SRC-015" ] } ], "inline_only_rationale": null }, { "id": "clinical-response-observation-effectiveness-side-effect-adverse-event-and-causality-status", "name": "Clinical response, observation, effectiveness, side effect, adverse event and causality status", "description": "Records clinical response, observation, effectiveness, side effect, adverse event and causality status as source-qualified medication-lifecycle context while preserving the distinctions among request, dispense, administration, statement, product knowledge and clinical consequence.", "source_refs": [ "SRC-001", "SRC-003", "SRC-006", "SRC-008", "SRC-010", "SRC-011", "SRC-012", "SRC-015" ], "questions": [ { "id": "clinical-response-observation-effectiveness-side-effect-adverse-event-and-causality-status-q01", "text": "Which stable identities, record class, source-qualified values and explicit unknowns establish clinical response, observation, effectiveness, side effect, adverse event and causality status?", "kind": "evidence", "answer_data": [ "identifiers and class", "source-qualified values", "unknown and not-applicable states" ] }, { "id": "clinical-response-observation-effectiveness-side-effect-adverse-event-and-causality-status-q02", "text": "Who requested, authorized, performed, supplied, received, recorded or reported clinical response, observation, effectiveness, side effect, adverse event and causality status, with which role, evidence and limits?", "kind": "authority", "answer_data": [ "actors and roles", "authority and limits", "evidence and provenance" ] }, { "id": "clinical-response-observation-effectiveness-side-effect-adverse-event-and-causality-status-q03", "text": "Which event, authored, prepared, handover, occurrence, recorded, reported, ingested and knowledge times apply to clinical response, observation, effectiveness, side effect, adverse event and causality status, and how is it validated or corrected?", "kind": "measurement", "answer_data": [ "distinct clinical and record times", "validation and discrepancy status", "successor correction and retention" ] } ], "data_elements": [ { "id": "clinical-response-observation-effectiveness-side-effect-adverse-event-and-causality-status-data", "name": "Clinical response, observation, effectiveness, side effect, adverse event and causality status data", "description": "Typed data for clinical response, observation, effectiveness, side effect, adverse event and causality status with child-event identity, source, authority, status, event time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-003", "SRC-006", "SRC-008", "SRC-010", "SRC-011", "SRC-012", "SRC-015" ] } ], "artifacts": [ { "id": "clinical-response-observation-effectiveness-side-effect-adverse-event-and-causality-status-record", "name": "Clinical response, observation, effectiveness, side effect, adverse event and causality status record", "description": "Immutable or successor-versioned medication evidence for clinical response, observation, effectiveness, side effect, adverse event and causality status.", "media_or_form": [ "logical medication assertion", "request, dispense, administration, statement, safety, reconciliation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent request, dispense, administration, statement or assertion ID for clinical-response-observation-effectiveness-side-effect-adverse-event-and-causality-status; patient, medication, date, encounter and claim never identify an event alone.", "source_refs": [ "SRC-001", "SRC-003", "SRC-006", "SRC-008", "SRC-010", "SRC-011", "SRC-012", "SRC-015" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "composition-correction-governance-retention-and-interoperability", "name": "Composition, correction, governance, retention and interoperability", "description": "Groups governed medication context for composition, correction, governance, retention and interoperability.", "rationale": "Safe agent use requires explicit cross-record composition, append-only correction, minimum disclosure and loss-aware mappings.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017" ], "layers": [ { "id": "cross-stage-composition-status-cancellation-and-correction-lineage", "name": "Cross-stage composition, status, cancellation and correction lineage", "description": "Groups source-qualified medication context for cross-stage composition, status, cancellation and correction lineage.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-006", "SRC-013", "SRC-016", "SRC-017" ], "findings": [ { "id": "request-dispense-administration-statement-and-care-plan-composition", "name": "Request, dispense, administration, statement and care-plan composition", "description": "Records request, dispense, administration, statement and care-plan composition as source-qualified medication-lifecycle context while preserving the distinctions among request, dispense, administration, statement, product knowledge and clinical consequence.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-006", "SRC-013", "SRC-016", "SRC-017" ], "questions": [ { "id": "request-dispense-administration-statement-and-care-plan-composition-q01", "text": "Which stable identities, record class, source-qualified values and explicit unknowns establish request, dispense, administration, statement and care-plan composition?", "kind": "relationship", "answer_data": [ "identifiers and class", "source-qualified values", "unknown and not-applicable states" ] }, { "id": "request-dispense-administration-statement-and-care-plan-composition-q02", "text": "Who requested, authorized, performed, supplied, received, recorded or reported request, dispense, administration, statement and care-plan composition, with which role, evidence and limits?", "kind": "requirement", "answer_data": [ "actors and roles", "authority and limits", "evidence and provenance" ] }, { "id": "request-dispense-administration-statement-and-care-plan-composition-q03", "text": "Which event, authored, prepared, handover, occurrence, recorded, reported, ingested and knowledge times apply to request, dispense, administration, statement and care-plan composition, and how is it validated or corrected?", "kind": "exception", "answer_data": [ "distinct clinical and record times", "validation and discrepancy status", "successor correction and retention" ] } ], "data_elements": [ { "id": "request-dispense-administration-statement-and-care-plan-composition-data", "name": "Request, dispense, administration, statement and care-plan composition data", "description": "Typed data for request, dispense, administration, statement and care-plan composition with child-event identity, source, authority, status, event time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-006", "SRC-013", "SRC-016", "SRC-017" ] } ], "artifacts": [ { "id": "request-dispense-administration-statement-and-care-plan-composition-record", "name": "Request, dispense, administration, statement and care-plan composition record", "description": "Immutable or successor-versioned medication evidence for request, dispense, administration, statement and care-plan composition.", "media_or_form": [ "logical medication assertion", "request, dispense, administration, statement, safety, reconciliation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent request, dispense, administration, statement or assertion ID for request-dispense-administration-statement-and-care-plan-composition; patient, medication, date, encounter and claim never identify an event alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-006", "SRC-013", "SRC-016", "SRC-017" ] } ], "inline_only_rationale": null }, { "id": "independent-status-cancel-stop-replace-amend-error-correction-and-noncascade", "name": "Independent status, cancel, stop, replace, amend, error, correction and non-cascade", "description": "Records independent status, cancel, stop, replace, amend, error, correction and non-cascade as source-qualified medication-lifecycle context while preserving the distinctions among request, dispense, administration, statement, product knowledge and clinical consequence.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-006", "SRC-013", "SRC-016", "SRC-017" ], "questions": [ { "id": "independent-status-cancel-stop-replace-amend-error-correction-and-noncascade-q01", "text": "Which stable identities, record class, source-qualified values and explicit unknowns establish independent status, cancel, stop, replace, amend, error, correction and non-cascade?", "kind": "lifecycle", "answer_data": [ "identifiers and class", "source-qualified values", "unknown and not-applicable states" ] }, { "id": "independent-status-cancel-stop-replace-amend-error-correction-and-noncascade-q02", "text": "Who requested, authorized, performed, supplied, received, recorded or reported independent status, cancel, stop, replace, amend, error, correction and non-cascade, with which role, evidence and limits?", "kind": "constraint", "answer_data": [ "actors and roles", "authority and limits", "evidence and provenance" ] }, { "id": "independent-status-cancel-stop-replace-amend-error-correction-and-noncascade-q03", "text": "Which event, authored, prepared, handover, occurrence, recorded, reported, ingested and knowledge times apply to independent status, cancel, stop, replace, amend, error, correction and non-cascade, and how is it validated or corrected?", "kind": "provenance", "answer_data": [ "distinct clinical and record times", "validation and discrepancy status", "successor correction and retention" ] } ], "data_elements": [ { "id": "independent-status-cancel-stop-replace-amend-error-correction-and-noncascade-data", "name": "Independent status, cancel, stop, replace, amend, error, correction and non-cascade data", "description": "Typed data for independent status, cancel, stop, replace, amend, error, correction and non-cascade with child-event identity, source, authority, status, event time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-006", "SRC-013", "SRC-016", "SRC-017" ] } ], "artifacts": [ { "id": "independent-status-cancel-stop-replace-amend-error-correction-and-noncascade-record", "name": "Independent status, cancel, stop, replace, amend, error, correction and non-cascade record", "description": "Immutable or successor-versioned medication evidence for independent status, cancel, stop, replace, amend, error, correction and non-cascade.", "media_or_form": [ "logical medication assertion", "request, dispense, administration, statement, safety, reconciliation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent request, dispense, administration, statement or assertion ID for independent-status-cancel-stop-replace-amend-error-correction-and-noncascade; patient, medication, date, encounter and claim never identify an event alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-006", "SRC-013", "SRC-016", "SRC-017" ] } ], "inline_only_rationale": null } ] }, { "id": "provenance-privacy-retention-projection-and-agent-controls", "name": "Provenance, privacy, retention, projection and agent controls", "description": "Groups source-qualified medication context for provenance, privacy, retention, projection and agent controls.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-007", "SRC-008", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017" ], "findings": [ { "id": "source-quality-consent-purpose-access-redaction-disclosure-audit-and-retention", "name": "Source quality, consent, purpose, access, redaction, disclosure, audit and retention", "description": "Records source quality, consent, purpose, access, redaction, disclosure, audit and retention as source-qualified medication-lifecycle context while preserving the distinctions among request, dispense, administration, statement, product knowledge and clinical consequence.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-007", "SRC-008", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017" ], "questions": [ { "id": "source-quality-consent-purpose-access-redaction-disclosure-audit-and-retention-q01", "text": "Which stable identities, record class, source-qualified values and explicit unknowns establish source quality, consent, purpose, access, redaction, disclosure, audit and retention?", "kind": "privacy", "answer_data": [ "identifiers and class", "source-qualified values", "unknown and not-applicable states" ] }, { "id": "source-quality-consent-purpose-access-redaction-disclosure-audit-and-retention-q02", "text": "Who requested, authorized, performed, supplied, received, recorded or reported source quality, consent, purpose, access, redaction, disclosure, audit and retention, with which role, evidence and limits?", "kind": "event", "answer_data": [ "actors and roles", "authority and limits", "evidence and provenance" ] }, { "id": "source-quality-consent-purpose-access-redaction-disclosure-audit-and-retention-q03", "text": "Which event, authored, prepared, handover, occurrence, recorded, reported, ingested and knowledge times apply to source quality, consent, purpose, access, redaction, disclosure, audit and retention, and how is it validated or corrected?", "kind": "process", "answer_data": [ "distinct clinical and record times", "validation and discrepancy status", "successor correction and retention" ] } ], "data_elements": [ { "id": "source-quality-consent-purpose-access-redaction-disclosure-audit-and-retention-data", "name": "Source quality, consent, purpose, access, redaction, disclosure, audit and retention data", "description": "Typed data for source quality, consent, purpose, access, redaction, disclosure, audit and retention with child-event identity, source, authority, status, event time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-007", "SRC-008", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017" ] } ], "artifacts": [ { "id": "source-quality-consent-purpose-access-redaction-disclosure-audit-and-retention-record", "name": "Source quality, consent, purpose, access, redaction, disclosure, audit and retention record", "description": "Immutable or successor-versioned medication evidence for source quality, consent, purpose, access, redaction, disclosure, audit and retention.", "media_or_form": [ "logical medication assertion", "request, dispense, administration, statement, safety, reconciliation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent request, dispense, administration, statement or assertion ID for source-quality-consent-purpose-access-redaction-disclosure-audit-and-retention; patient, medication, date, encounter and claim never identify an event alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-007", "SRC-008", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017" ] } ], "inline_only_rationale": null }, { "id": "fhir-idmp-snomed-rxnorm-omop-ucum-projection-version-loss-and-round-trip", "name": "FHIR, IDMP, SNOMED, RxNorm, OMOP, UCUM projection, version, loss and round-trip", "description": "Records fhir, idmp, snomed, rxnorm, omop, ucum projection, version, loss and round-trip as source-qualified medication-lifecycle context while preserving the distinctions among request, dispense, administration, statement, product knowledge and clinical consequence.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-007", "SRC-008", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017" ], "questions": [ { "id": "fhir-idmp-snomed-rxnorm-omop-ucum-projection-version-loss-and-round-trip-q01", "text": "Which stable identities, record class, source-qualified values and explicit unknowns establish fhir, idmp, snomed, rxnorm, omop, ucum projection, version, loss and round-trip?", "kind": "interoperability", "answer_data": [ "identifiers and class", "source-qualified values", "unknown and not-applicable states" ] }, { "id": "fhir-idmp-snomed-rxnorm-omop-ucum-projection-version-loss-and-round-trip-q02", "text": "Who requested, authorized, performed, supplied, received, recorded or reported fhir, idmp, snomed, rxnorm, omop, ucum projection, version, loss and round-trip, with which role, evidence and limits?", "kind": "temporal", "answer_data": [ "actors and roles", "authority and limits", "evidence and provenance" ] }, { "id": "fhir-idmp-snomed-rxnorm-omop-ucum-projection-version-loss-and-round-trip-q03", "text": "Which event, authored, prepared, handover, occurrence, recorded, reported, ingested and knowledge times apply to fhir, idmp, snomed, rxnorm, omop, ucum projection, version, loss and round-trip, and how is it validated or corrected?", "kind": "validation", "answer_data": [ "distinct clinical and record times", "validation and discrepancy status", "successor correction and retention" ] } ], "data_elements": [ { "id": "fhir-idmp-snomed-rxnorm-omop-ucum-projection-version-loss-and-round-trip-data", "name": "FHIR, IDMP, SNOMED, RxNorm, OMOP, UCUM projection, version, loss and round-trip data", "description": "Typed data for fhir, idmp, snomed, rxnorm, omop, ucum projection, version, loss and round-trip with child-event identity, source, authority, status, event time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-007", "SRC-008", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017" ] } ], "artifacts": [ { "id": "fhir-idmp-snomed-rxnorm-omop-ucum-projection-version-loss-and-round-trip-record", "name": "FHIR, IDMP, SNOMED, RxNorm, OMOP, UCUM projection, version, loss and round-trip record", "description": "Immutable or successor-versioned medication evidence for fhir, idmp, snomed, rxnorm, omop, ucum projection, version, loss and round-trip.", "media_or_form": [ "logical medication assertion", "request, dispense, administration, statement, safety, reconciliation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent request, dispense, administration, statement or assertion ID for fhir-idmp-snomed-rxnorm-omop-ucum-projection-version-loss-and-round-trip; patient, medication, date, encounter and claim never identify an event alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-007", "SRC-008", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017" ] } ], "inline_only_rationale": null } ] } ] } ] }, "functions": [ { "id": "register-medication-lifecycle-aggregate", "name": "Register medication lifecycle aggregate", "description": "Governed operation to register medication lifecycle aggregate without hidden mutation of external clinical masters.", "inputs": [ "source records", "subject", "profile", "steward authority" ], "outputs": [ "aggregate root and child slots" ], "preconditions": [ "stable identity, source, subject and boundary pass" ], "effects": [ "one aggregate links independently governed medication records without collapsing them" ], "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-006", "SRC-016" ] }, { "id": "create-or-import-medication-request", "name": "Create or import medication request", "description": "Governed operation to create or import medication request without hidden mutation of external clinical masters.", "inputs": [ "authorized intent", "medication binding", "subject", "dosage and dispense intent" ], "outputs": [ "request child record" ], "preconditions": [ "requester authority, identity, status, dosage completeness and source pass" ], "effects": [ "intent is recorded without asserting supply or administration" ], "source_refs": [ "SRC-001", "SRC-005", "SRC-006", "SRC-014" ] }, { "id": "record-dispense-or-nondispense", "name": "Record dispense or non-dispense", "description": "Governed operation to record dispense or non-dispense without hidden mutation of external clinical masters.", "inputs": [ "authorizing request", "product", "performer", "status and times" ], "outputs": [ "dispense child event" ], "preconditions": [ "independent identity, authorization, product, quantity and chronology pass" ], "effects": [ "supply or non-performance is attributable and does not alter the request silently" ], "source_refs": [ "SRC-001", "SRC-002", "SRC-005" ] }, { "id": "record-administration-nonadministration-or-waste", "name": "Record administration, non-administration or waste", "description": "Governed operation to record administration, non-administration or waste without hidden mutation of external clinical masters.", "inputs": [ "subject", "medication", "actor", "occurrence", "dose or reason" ], "outputs": [ "administration child event" ], "preconditions": [ "independent identity, subject, actor, occurrence, status and actual details pass" ], "effects": [ "actual exposure, omission, refusal, subpotency or waste becomes explicit" ], "source_refs": [ "SRC-003", "SRC-005", "SRC-014" ] }, { "id": "reconcile-medication-context", "name": "Reconcile medication context", "description": "Governed operation to reconcile medication context without hidden mutation of external clinical masters.", "inputs": [ "best possible history", "requests", "dispenses", "administrations", "statements" ], "outputs": [ "discrepancy set and resolution decisions" ], "preconditions": [ "sources, transition, reviewer, authority and communication plan pass" ], "effects": [ "differences remain traceable while an updated view is communicated" ], "source_refs": [ "SRC-004", "SRC-007", "SRC-016" ] }, { "id": "record-medication-safety-check", "name": "Record medication safety check", "description": "Governed operation to record medication safety check without hidden mutation of external clinical masters.", "inputs": [ "current context", "versioned knowledge inputs", "policy", "reviewer" ], "outputs": [ "safety-check assertion and decision basis" ], "preconditions": [ "knowledge version, scope, authority, uncertainty and override reason pass" ], "effects": [ "the check is evidence, not autonomous prescribing or administration authority" ], "source_refs": [ "SRC-005", "SRC-008", "SRC-010", "SRC-011", "SRC-012" ] }, { "id": "link-response-observation-and-adverse-event", "name": "Link response, observation and adverse event", "description": "Governed operation to link response, observation and adverse event without hidden mutation of external clinical masters.", "inputs": [ "medication event", "clinical records", "causality status" ], "outputs": [ "typed consequence links" ], "preconditions": [ "source, timing, evidence, uncertainty and external ownership pass" ], "effects": [ "clinical effects remain independent and causality is not invented" ], "source_refs": [ "SRC-003", "SRC-004", "SRC-008", "SRC-016" ] }, { "id": "cancel-hold-stop-or-supersede", "name": "Cancel, hold, stop or supersede", "description": "Governed operation to cancel, hold, stop or supersede without hidden mutation of external clinical masters.", "inputs": [ "target child record", "reason", "authority", "expected revision" ], "outputs": [ "append-only status or successor event" ], "preconditions": [ "target-specific transition and non-cascade impact pass" ], "effects": [ "future intent changes without rewriting completed supply or exposure" ], "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-016" ] }, { "id": "correct-medication-record", "name": "Correct medication record", "description": "Governed operation to correct medication record without hidden mutation of external clinical masters.", "inputs": [ "prior record", "correction", "reason", "responsible party" ], "outputs": [ "successor record and invalidation link" ], "preconditions": [ "identity, non-overwrite, provenance and clinical-impact review pass" ], "effects": [ "consumers can distinguish current use from historical evidence" ], "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-015", "SRC-016" ] }, { "id": "project-retain-disclose-and-audit", "name": "Project, retain, disclose and audit", "description": "Governed operation to project, retain, disclose and audit without hidden mutation of external clinical masters.", "inputs": [ "aggregate", "target profile", "access and retention policy" ], "outputs": [ "projection, disclosure, tombstone or disposition event" ], "preconditions": [ "terminology and unit versions, mapping loss, privacy, hold and idempotency pass" ], "effects": [ "context stays protected, reconstructable and explicit about loss" ], "source_refs": [ "SRC-006", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017" ] } ], "composition": [ { "target": "WM-ACT-049 Care Plan / Episode", "relation": "REFERENCE", "purpose": "Record candidate inverse containment and planning context without approving the ledger edge or cascade semantics.", "required": false, "source_refs": [ "SRC-001", "SRC-006" ] }, { "target": "Patient, Practitioner, Organization, Encounter, CarePlan and Consent models", "relation": "REFERENCE", "purpose": "Resolve authoritative subjects, actors, care context and authority without copying their lifecycle.", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004" ] }, { "target": "Medication, substance, medicinal-product, package, inventory and device models", "relation": "REFERENCE", "purpose": "Resolve authoritative product and item identity while retaining actual supplied and administered bindings.", "required": true, "source_refs": [ "SRC-005", "SRC-009", "SRC-010", "SRC-011", "SRC-012" ] }, { "target": "Observation, Condition, AllergyIntolerance, DetectedIssue, AdverseEvent, evidence, provenance, audit and record models", "relation": "REFERENCE", "purpose": "Bind safety and clinical consequences without owning their lifecycle or causal adjudication.", "required": false, "source_refs": [ "SRC-003", "SRC-004", "SRC-008", "SRC-015", "SRC-016" ] }, { "target": "FHIR R5, ISO IDMP, SNOMED CT, RxNorm, OMOP CDM 5.4 and UCUM 2.2", "relation": "ALIGN", "purpose": "Project version-pinned clinical, regulatory, terminology, analytic and unit views with maturity, regional and information-loss declarations.", "required": false, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014" ] } ], "serviceLayers": { "dimension": { "owner_package_requirements": [ "Dimension owner and medication-governance mandate", "Patient, practitioner, organization, encounter, care plan, medication, product, condition, observation, allergy, adverse-event, inventory, provenance, audit and record registries", "Approved medication, terminology, unit, prescribing, dispensing, administration, reconciliation and safety profiles", "Consent, privacy, correction, disclosure, retention and agent policies" ], "namespace_guidance": "Mint aggregate, request, dispense, administration, statement, discrepancy, safety-check, correction, disclosure and event IDs; preserve every source-system, prescription, product, package and lot identifier.", "registry_links": [ "https://ver.cy/models/", "https://ver.cy/model-agent-protocol.md" ] }, "canon_and_patch": { "canonicalization_rules": [ "Canonicalize by authoritative source-system identifier and source organization for each request, dispense, administration and statement; never patient, medication, date, encounter or claim alone.", "Keep request intent, dispense supply, administration exposure, reported medication use, product definition, clinical response and adverse event distinct." ], "patch_rules": [ "Extensions declare jurisdiction, setting, product, terminology, unit, authorization, safety, privacy, retention and interoperability effects.", "Released request, dispense, administration, reconciliation and safety records are immutable; corrections create linked successors.", "Never silently change subject, medication, dosage, substitution, quantity, lot, performer, recipient, event time, status, omission, reason, response, access or provenance." ], "compatibility_rules": [ "Ignore additive fields only when identity, child-record kind, subject, medication, authority, status, clinical times, actual values, safety and provenance survive.", "Every projection pins profile, code system, unit system and information-loss declaration." ] }, "artifact_rules": { "identity_priority": [ "Authoritative master-system identifier for each medication request, dispense, administration or statement, qualified by source organization and record kind.", "Governed globally resolvable medication record IRI.", "Dimension UUID when neither preceding identifier exists." ], "timestamp_rule": "Use RFC 3339 timestamps with seconds and explicit offset or Z; distinguish authored, validity, scheduled, prepared, handed-over, administration occurrence, recorded, reported, ingested, observation and knowledge times whenever they differ.", "serial_naming_rule": "Use {aggregate-id}--{request-dispense-administration-or-assertion-id}--{artifact-kind}--{revision-id}.", "integrity_rule": "Store digest, media type, child-record kind, subject and medication binding, product and terminology versions, actor, event and knowledge times, status, access marking and provenance." }, "policies": [ "The aggregate does not own Patient, Practitioner, Organization, Encounter, CarePlan, Medication, MedicinalProductDefinition, MedicationKnowledge, Condition, Observation, AllergyIntolerance, AdverseEvent, DetectedIssue, Coverage, Claim, Inventory, Device, Provenance, Audit or Record masters.", "Request, authorization, dispense, handover, administration, reported use, adherence, response and harm remain separate assertions.", "A completed request, dispense or administration has only the semantics of that child record and never proves adherence, effectiveness, safety or causality.", "Agents cannot prescribe, modify dosage, authorize substitution, dispense, administer, infer adherence, override safety, attribute harm, disclose data or dispose records outside explicit clinical and policy authority." ], "crud": { "read": [ "Resolve purpose, aggregate profile, child-record identities and kinds, sources, subject, medication, intent, actual events, statements, safety evidence, clinical links, lineage, holds and projection loss." ], "create": [ "Bind stable aggregate and child identity, source, subject, medication, responsible authority, record kind and event or intent time before recording the medication stage." ], "update": [ "Append successor child events, statuses, discrepancies, reconciliations, safety checks, response links and corrections with reason, authority, expected revision, event time and knowledge time." ], "delete": [ "Apply clinical-record, medication-safety, privacy, legal-hold and adopting-Dimension retention policy; retire or tombstone only the aggregate or named child without cascading to Patient, CarePlan, Medication, Observation, AdverseEvent or other masters, and let the external records policy execute physical disposition." ] }, "roles": [ { "name": "Medication aggregate steward", "responsibilities": [ "Own aggregate boundary, namespace, composition and quality rules." ] }, { "name": "Authorized requester or prescriber", "responsibilities": [ "Own request intent, authority, indication and dosage intent within scope." ] }, { "name": "Dispenser", "responsibilities": [ "Own source-qualified supply, product, quantity, substitution and handover evidence." ] }, { "name": "Administrator or self-administrator", "responsibilities": [ "Own actual administration or explicit non-performance evidence within authority." ] }, { "name": "Medication reconciliation reviewer", "responsibilities": [ "Own source comparison, discrepancy resolution and communication evidence." ] }, { "name": "Clinical safety reviewer", "responsibilities": [ "Own versioned safety-check interpretation, override and escalation review." ] }, { "name": "Terminology and interoperability steward", "responsibilities": [ "Own versioned product, terminology, unit and projection mappings with loss declarations." ] }, { "name": "Privacy, records and assurance steward", "responsibilities": [ "Own protected views, disclosures, holds, retention and auditability." ] } ], "access": { "default_rule": "Deny medication and related clinical context unless a purpose-bound policy permits the minimum necessary view.", "scopes": [ "bundle", "layer", "finding", "artifact" ], "exceptions": [ "Declared subject, guardian, care team, emergency, public-health, research, regulator, court or legally authorized access must cite authority, scope, purpose and time limit where applicable and must be logged." ], "audit_requirements": [ "Log actor, agent, role, purpose, aggregate and child record, operation, authority, policy, RFC 3339 time, affected fields, source revision and outcome without duplicating unnecessary clinical content." ] }, "agents_bootstrap": { "filename": "AGENTS.md", "required_fields": [ "Name", "Type", "Specification URL", "Storage type URL", "Interface URL", "Processes URL" ], "read_order": [ "Read Dimension medication safety, scope-of-practice, consent, terminology, units, privacy, access, correction, records and agent policies.", "Read this aggregate and linked patient, care plan, encounter, medication, product, condition, observation, allergy, adverse-event, inventory, provenance, audit and record models before mutation." ] } }, "coverage": { "claim": "WM-ACT-048 covers a source-qualified medication lifecycle aggregate that composes but does not collapse medication request, dispense, administration or explicit non-administration, reported-use, reconciliation and safety evidence. Each child record keeps independent identity, source, status, actors and times. Product knowledge, patients, care plans, clinical observations, allergies, adverse events, inventory, claims and records remain external. Specialty profiles, jurisdiction rules, the candidate Care Plan containment edge, release-pinned mapping tests and independent external review remain deferred.", "confidence": "medium", "checklist": [ { "dimension": "identity", "status": "covered", "notes": "Identity is explicit; specialty, jurisdiction, institutional, product and release-pinned validation remain held where applicable." }, { "dimension": "classification and definition", "status": "covered", "notes": "Classification and definition is explicit; specialty, jurisdiction, institutional, product and release-pinned validation remain held where applicable." }, { "dimension": "direct properties", "status": "covered", "notes": "Direct properties is explicit; specialty, jurisdiction, institutional, product and release-pinned validation remain held where applicable." }, { "dimension": "recognition and observation", "status": "covered", "notes": "Recognition and observation is explicit; specialty, jurisdiction, institutional, product and release-pinned validation remain held where applicable." }, { "dimension": "capabilities and possible actions", "status": "covered", "notes": "Capabilities and possible actions is explicit; specialty, jurisdiction, institutional, product and release-pinned validation remain held where applicable." }, { "dimension": "composition", "status": "covered", "notes": "Composition is explicit; specialty, jurisdiction, institutional, product and release-pinned validation remain held where applicable." }, { "dimension": "lifecycle", "status": "covered", "notes": "Lifecycle is explicit; specialty, jurisdiction, institutional, product and release-pinned validation remain held where applicable." }, { "dimension": "relationships", "status": "covered", "notes": "Relationships is explicit; specialty, jurisdiction, institutional, product and release-pinned validation remain held where applicable." }, { "dimension": "temporal", "status": "covered", "notes": "Temporal is explicit; specialty, jurisdiction, institutional, product and release-pinned validation remain held where applicable." }, { "dimension": "spatial", "status": "covered", "notes": "Spatial is explicit; specialty, jurisdiction, institutional, product and release-pinned validation remain held where applicable." }, { "dimension": "provenance", "status": "covered", "notes": "Provenance is explicit; specialty, jurisdiction, institutional, product and release-pinned validation remain held where applicable." }, { "dimension": "ownership and stewardship", "status": "covered", "notes": "Ownership and stewardship is explicit; specialty, jurisdiction, institutional, product and release-pinned validation remain held where applicable." }, { "dimension": "validation and quality", "status": "covered", "notes": "Validation and quality is explicit; specialty, jurisdiction, institutional, product and release-pinned validation remain held where applicable." }, { "dimension": "access and privacy", "status": "covered", "notes": "Access and privacy is explicit; specialty, jurisdiction, institutional, product and release-pinned validation remain held where applicable." }, { "dimension": "retention and deletion", "status": "covered", "notes": "Retention and deletion is explicit; specialty, jurisdiction, institutional, product and release-pinned validation remain held where applicable." }, { "dimension": "interoperability", "status": "covered", "notes": "Interoperability is explicit; specialty, jurisdiction, institutional, product and release-pinned validation remain held where applicable." } ], "known_omissions": [ "Claude and Grok each timed out on one bounded attempt; no independent external result was admitted.", "WM-ACT-049 Care Plan / Episode CONTAINS WM-ACT-048 is candidate metadata and not an approved composition edge.", "Pediatric, oncology, renal, pregnancy, anesthesia, infusion, controlled-substance, veterinary and other medication domains require specialty and jurisdiction profiles.", "FHIR R5 medication resources are Trial Use at varied maturity; full IDMP, SNOMED CT, RxNorm, OMOP and UCUM mappings require release-pinned testing." ], "conflicts": [ "Request, dispense, administration and medication statement are not interchangeable and have independent identities, statuses and times.", "Prescribed dosage, dispensed instructions and actual dose may differ and cannot be silently reconciled.", "Completed status does not prove adherence, effectiveness, safety, absence of harm or causality." ], "regional_assumptions": [ "Prescribing authority, substitution, dispensing, controlled substances, self-administration, consent, reporting, retention and disclosure depend on jurisdiction and setting.", "EMA IDMP and NLM RxNorm are important regional implementations or vocabularies, not universal proof of product identity or authorization.", "Local formularies, packages, product identifiers, safety knowledge and interaction rules require versioned institutional or jurisdictional profiles." ], "adversarial_checks": [ "Reject an aggregate or child record without stable identity, record kind, source, subject, medication binding, authority, status, event or intent time and lineage head.", "Reject request intent represented as supply, dispense represented as exposure, statement represented as formal administration, or completed represented as effective.", "Reject a dose comparison that loses unit, route, site, method, rate, timing, product, package, lot or source differences.", "Reject reconciliation that overwrites discrepancies, prior medication lists, source confidence, reviewer, decision basis or communication evidence.", "Reject autonomous prescribing, dispensing, administration, dose change, safety override, adherence inference, causal attribution, disclosure or disposition outside explicit authority." ] }, "researchAdjudication": { "providerMode": "single-provider-waiver", "activeProviders": [ "codex" ], "waivedProviders": [ "claude", "grok" ], "providerPolicy": { "contract_version": "1.0.0", "mode": "single-provider-waiver", "effective_at": "2026-09-06T00:00:00Z", "scope": "Canonical single-stream subject-model research after the six-workstream consolidation", "active_providers": [ "codex" ], "waived_providers": [ { "provider": "claude", "authorized_by": "repository owner", "authorized_at": "2026-09-06T00:00:00Z", "reason": "Claude produced no result on prior 1800-second and 900-second attempts and again timed out on bounded 600-second Sonnet and 300-second Haiku passes. The owner prioritized completion over provider availability." }, { "provider": "grok", "authorized_by": "repository owner", "authorized_at": "2026-09-06T00:00:00Z", "reason": "The repository owner authorized completion without Grok when Grok is unavailable, slow or schema-invalid. Grok may still be attempted as a bounded supplemental reviewer, but its failure never blocks a valid Claude plus no-tools result." } ], "review_rule": "Codex may complete source-grounded fallback research after bounded Claude and Grok attempts fail. It requires a separate no-tools adversarial audit and remains reviewable-draft with a visible absence-of-external-review hold.", "supplemental_provider_attempts": [ { "provider": "claude", "required": false, "maximum_attempts": 1, "failure_policy": "record-and-continue", "admission_rule": "Use only a locally schema-valid result whose sources and boundaries survive adjudication." }, { "provider": "grok", "required": false, "maximum_attempts": 1, "failure_policy": "record-and-continue", "admission_rule": "Use only a locally schema-valid result whose sources and boundaries survive adjudication." } ] }, "boundaryDecision": { "entry_kind": "aggregate", "status": "accepted", "rationale": "The subject spans multiple separately identifiable request, supply, exposure and reported-use records whose relationships form the useful whole, so aggregate is more accurate than event. The frozen record_plane is world-model and catalogue entry_kind is standalone-mm; neither is the subject-schema entry_kind axis. Every constituent retains its own event or request semantics." }, "decisions": [ { "concept": "Request, dispense, administration and statement separation", "disposition": "accepted", "rationale": "FHIR defines intent, supply, actual exposure and reported belief as distinct records. The aggregate composes them through references and independent child identities rather than flattening them into one status or event." }, { "concept": "Prescribed, dispensed and actually administered dosage separation", "disposition": "accepted", "rationale": "Dose, timing, route, site, method, rate, instructions, product and quantity may differ across stages. Source-qualified differences and reasons must survive reconciliation and projection." }, { "concept": "Medication and regulated product master ownership", "disposition": "accepted-external", "rationale": "IDMP, SNOMED CT, RxNorm and FHIR separate product and terminology knowledge from patient-specific lifecycle records. The aggregate binds versioned substance, product, pack and lot identities but does not own their lifecycle." }, { "concept": "Reported use and medication reconciliation", "disposition": "accepted", "rationale": "A MedicationStatement is weaker reported or derived evidence, while WHO transition guidance supports attributable source comparison, discrepancy resolution, list update and communication. Neither is silently promoted to formal administration evidence." }, { "concept": "Medication safety checks and clinical authority", "disposition": "accepted-with-profile-hold", "rationale": "High-risk controls, allergy, contraindication, interaction and duplicate-therapy checks are relevant evidence, but knowledge versions, reviewer authority, local policy, override and escalation remain external and profile-specific." }, { "concept": "Child-specific cancellation and correction", "disposition": "accepted", "rationale": "Cancelling or stopping a request does not retroactively cancel completed dispense or administration events. Released records are corrected through linked successors, preserving prior status, actual values and provenance." }, { "concept": "WM-ACT-049 Care Plan containment", "disposition": "deferred", "rationale": "The registry ledger records Care Plan / Episode CONTAINS WM-ACT-048 as candidate metadata. The specification may reference plan context but may not publish this edge as approved or infer lifecycle cascade." }, { "concept": "Standards maturity, regional scope and analytic projection", "disposition": "accepted-with-validation-hold", "rationale": "FHIR R5 medication resources are Trial Use at varied maturity, EMA IDMP and RxNorm have regional implementation scope, and OMOP may combine source event kinds analytically. Every mapping must pin versions, provenance, units and information loss." }, { "concept": "Single-provider waiver and no-tools audit", "disposition": "accepted-with-mandatory-hold", "rationale": "One Claude Sonnet and one Grok 4.6 research attempt each timed out after 120 seconds, and the separate external no-tools adjudicator timed out after 90 seconds. The frozen Codex result was then audited locally without new research facts. Confidence remains medium and assurance remains reviewable-draft." } ], "publicationHolds": [ "Absence-of-external-review hold: one Claude Sonnet and one Grok 4.6 research attempt for WM-ACT-048 each timed out after 120 seconds. No external research result was admitted.", "Adjudication-provider hold: the separate Claude Haiku no-tools adjudication attempt timed out after 90 seconds. Codex completed a frozen-result no-tools adversarial audit without adding research facts.", "Registry edge approval hold: WM-ACT-049 Care Plan / Episode CONTAINS WM-ACT-048 remains candidate metadata and creates no cascade semantics.", "Clinical-profile hold: pediatric, oncology, renal, pregnancy, anesthesia, infusion, controlled-substance, veterinary and other medication domains need specialty rules.", "Jurisdiction and institution hold: prescriber authority, substitution, dispensing, self-administration, safety override, reporting, correction, retention and disclosure require applicable profiles.", "Interoperability hold: FHIR maturity varies and all FHIR, IDMP, SNOMED CT, RxNorm, OMOP and UCUM projections require version-pinned mappings, licensing review where applicable, loss declarations and clinical validation.", "Independent external review was explicitly waived by the repository owner; this codex-only result remains a reviewable draft." ], "deferredResearch": [ "Approve or reject the WM-ACT-049 containment edge and define cardinality, plan membership and non-cascade semantics.", "Create specialty profiles for pediatric, oncology, renal, pregnancy, anesthesia, infusion, controlled-substance and veterinary medication lifecycles.", "Create jurisdiction and institution profiles for prescribing, substitution, dispensing, administration, reconciliation, safety, reporting, retention and access.", "Test release-pinned FHIR, IDMP, SNOMED CT, RxNorm, OMOP CDM and UCUM mappings with round-trip and mapping-loss evidence.", "Obtain supplemental independent external review and resolve any material challenge before canonical promotion." ] }, "statistics": { "sources": 17, "bundles": 6, "layers": 12, "findings": 24, "questions": 72, "artifacts": 24, "functions": 10 } }