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Pharmacy Work GroupMaturity Level: 2 Trial UseSecurity Category: Patient Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson

Detailed Descriptions for the elements in the MedicationAdministration resource.

MedicationAdministration
Element IdMedicationAdministration
Definition

Describes the event of a patient consuming or otherwise being administered a medication. This may be as simple as swallowing a tablet or it may be a long running infusion. Related resources tie this event to the authorizing prescription, and the specific encounter between patient and health care practitioner.

Cardinality0..*
TypeDomainResource
MedicationAdministration.identifier
Element IdMedicationAdministration.identifier
Definition

Identifiers associated with this Medication Administration that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate. They are business identifiers assigned to this resource by the performer or other systems and remain constant as the resource is updated and propagates from server to server.

NoteThis is a business identifier, not a resource identifier (see discussion)
Cardinality0..*
TypeIdentifier
Comments

This is a business identifier, not a resource identifier.

MedicationAdministration.instantiatesCanonical
Element IdMedicationAdministration.instantiatesCanonical
Definition

A protocol, guideline, orderset, or other definition that was adhered to in whole or in part by this event.

Cardinality0..*
Typecanonical(PlanDefinition | ActivityDefinition)
Summarytrue
MedicationAdministration.instantiatesUri
Element IdMedicationAdministration.instantiatesUri
Definition

The URL pointing to an externally maintained protocol, guideline, orderset or other definition that is adhered to in whole or in part by this MedicationAdministration.

Cardinality0..*
Typeuri
Summarytrue
MedicationAdministration.partOf
Element IdMedicationAdministration.partOf
Definition

A larger event of which this particular event is a component or step.

Cardinality0..*
TypeReference(MedicationAdministration | Procedure)
PatternsReference(MedicationAdministration,Procedure): Common patterns = Event
Summarytrue
MedicationAdministration.status
Element IdMedicationAdministration.status
Definition

Will generally be set to show that the administration has been completed. For some long running administrations such as infusions, it is possible for an administration to be started but not completed or it may be paused while some other process is under way.

Cardinality1..1
Terminology BindingMedication administration status codes (Required)
Typecode
Is Modifiertrue (Reason: This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
Summarytrue
Comments

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

MedicationAdministration.statusReason
Element IdMedicationAdministration.statusReason
Definition

A code indicating why the administration was not performed.

Cardinality0..*
Terminology BindingSNOMED CT Reason Medication Not Given Codes (Example)
TypeCodeableConcept
MedicationAdministration.category
Element IdMedicationAdministration.category
Definition

Indicates where the medication is expected to be consumed or administered.

Cardinality0..*
Terminology BindingMedication administration category codes (Preferred)
TypeCodeableConcept
MedicationAdministration.medication[x]
Element IdMedicationAdministration.medication[x]
Definition

Identifies the medication that was administered. This is either a link to a resource representing the details of the medication or a simple attribute carrying a code that identifies the medication from a known list of medications.

Cardinality1..1
Terminology BindingSNOMED CT Medication Codes (Example)
TypeCodeableConcept|Reference(Medication)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Comments

If only a code is specified, then it needs to be a code for a specific product. If more information is required, then the use of the medication resource is recommended. For example, if you require form or lot number, then you must reference the Medication resource.

MedicationAdministration.subject
Element IdMedicationAdministration.subject
Definition

The person or animal or group receiving the medication.

Cardinality1..1
TypeReference(Patient | Group)
PatternsReference(Patient,Group): Common patterns = Participant
Summarytrue
MedicationAdministration.encounter
Element IdMedicationAdministration.encounter
Definition

The visit, admission, or other contact between patient and health care provider during which the medication administration was performed.

Cardinality0..1
TypeReference(Encounter)
MedicationAdministration.supportingInformation
Element IdMedicationAdministration.supportingInformation
Definition

Additional information (for example, patient height and weight) that supports the administration of the medication.

Cardinality0..*
TypeReference(Any)
MedicationAdministration.occurence[x]
Element IdMedicationAdministration.occurence[x]
Definition

A specific date/time or interval of time during which the administration took place (or did not take place). For many administrations, such as swallowing a tablet the use of dateTime is more appropriate.

Cardinality1..1
TypedateTime|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
MedicationAdministration.recorded
Element IdMedicationAdministration.recorded
Definition

The date the occurrence of the MedicationAdministration was first captured in the record - potentially significantly after the occurrence of the event.

Cardinality0..1
TypedateTime
Summarytrue
MedicationAdministration.performer
Element IdMedicationAdministration.performer
Definition

Indicates who or what performed the medication administration and how they were involved.

Cardinality0..*
Summarytrue
MedicationAdministration.performer.function
Element IdMedicationAdministration.performer.function
Definition

Distinguishes the type of involvement of the performer in the medication administration.

Cardinality0..1
Terminology BindingMedication administration performer function codes (Example)
TypeCodeableConcept
MedicationAdministration.performer.actor
Element IdMedicationAdministration.performer.actor
Definition

Indicates who or what performed the medication administration.

Cardinality1..1
TypeReference(Practitioner | PractitionerRole | Patient | RelatedPerson | Device)
PatternsReference(Practitioner,PractitionerRole,Patient,RelatedPerson,Device): Common patterns = Participant
Summarytrue
MedicationAdministration.reasonCode
Element IdMedicationAdministration.reasonCode
Definition

A code indicating why the medication was given.

Cardinality0..*
Terminology BindingReason Medication Given Codes (Example)
TypeCodeableConcept
MedicationAdministration.reasonReference
Element IdMedicationAdministration.reasonReference
Definition

Condition or observation that supports why the medication was administered.

Cardinality0..*
TypeReference(Condition | Observation | DiagnosticReport)
PatternsReference(Condition,Observation,DiagnosticReport): Common patterns = Event
Comments

This is a reference to a condition that is the reason for the medication request. If only a code exists, use reasonCode.

MedicationAdministration.request
Element IdMedicationAdministration.request
Definition

The original request, instruction or authority to perform the administration.

Cardinality0..1
TypeReference(MedicationRequest)
Comments

This is a reference to the MedicationRequest where the intent is either order or instance-order. It should not reference MedicationRequests where the intent is any other value.

MedicationAdministration.device
Element IdMedicationAdministration.device
Definition

The device used in administering the medication to the patient. For example, a particular infusion pump.

Cardinality0..*
TypeReference(Device)
MedicationAdministration.note
Element IdMedicationAdministration.note
Definition

Extra information about the medication administration that is not conveyed by the other attributes.

Cardinality0..*
TypeAnnotation
MedicationAdministration.dosage
Element IdMedicationAdministration.dosage
Definition

Describes the medication dosage information details e.g. dose, rate, site, route, etc.

Cardinality0..1
Invariants
Defined on this element
mad-1Rule SHALL have at least one of dosage.dose or dosage.rate[x]dose.exists() or rate.exists()
MedicationAdministration.dosage.text
Element IdMedicationAdministration.dosage.text
Definition

Free text dosage can be used for cases where the dosage administered is too complex to code. When coded dosage is present, the free text dosage may still be present for display to humans.

The dosage instructions should reflect the dosage of the medication that was administered.

Cardinality0..1
Typestring
MedicationAdministration.dosage.site
Element IdMedicationAdministration.dosage.site
Definition

A coded specification of the anatomic site where the medication first entered the body. For example, "left arm".

Cardinality0..1
Terminology BindingSNOMED CT Anatomical Structure for Administration Site Codes (Example)
TypeCodeableConcept
Comments

If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension bodySite. May be a summary code, or a reference to a very precise definition of the location, or both.

MedicationAdministration.dosage.route
Element IdMedicationAdministration.dosage.route
Definition

A code specifying the route or physiological path of administration of a therapeutic agent into or onto the patient. For example, topical, intravenous, etc.

Cardinality0..1
Terminology BindingSNOMED CT Route Codes (Example)
TypeCodeableConcept
MedicationAdministration.dosage.method
Element IdMedicationAdministration.dosage.method
Definition

A coded value indicating the method by which the medication is intended to be or was introduced into or on the body. This attribute will most often NOT be populated. It is most commonly used for injections. For example, Slow Push, Deep IV.

Cardinality0..1
Terminology BindingSNOMED CT Administration Method Codes (Example)
TypeCodeableConcept
Comments

One of the reasons this attribute is not used often, is that the method is often pre-coordinated with the route and/or form of administration. This means the codes used in route or form may pre-coordinate the method in the route code or the form code. The implementation decision about what coding system to use for route or form code will determine how frequently the method code will be populated e.g. if route or form code pre-coordinate method code, then this attribute will not be populated often; if there is no pre-coordination then method code may be used frequently.

MedicationAdministration.dosage.dose
Element IdMedicationAdministration.dosage.dose
Definition

The amount of the medication given at one administration event. Use this value when the administration is essentially an instantaneous event such as a swallowing a tablet or giving an injection.

Cardinality0..1
TypeSimpleQuantity
Comments

If the administration is not instantaneous (rate is present), this can be specified to convey the total amount administered over period of time of a single administration.

MedicationAdministration.dosage.rate[x]
Element IdMedicationAdministration.dosage.rate[x]
Definition

Identifies the speed with which the medication was or will be introduced into the patient. Typically, the rate for an infusion e.g. 100 ml per 1 hour or 100 ml/hr. May also be expressed as a rate per unit of time, e.g. 500 ml per 2 hours. Other examples: 200 mcg/min or 200 mcg/1 minute; 1 liter/8 hours.

Cardinality0..1
TypeRatio|SimpleQuantity
[x] NoteSee Choice of Data Types for further information about how to use [x]
Comments

If the rate changes over time, and you want to capture this in MedicationAdministration, then each change should be captured as a distinct MedicationAdministration, with a specific MedicationAdministration.dosage.rate, and the date time when the rate change occurred. Typically, the MedicationAdministration.dosage.rate element is not used to convey an average rate.

MedicationAdministration.eventHistory
Element IdMedicationAdministration.eventHistory
Definition

A summary of the events of interest that have occurred, such as when the administration was verified.

Cardinality0..*
TypeReference(Provenance)
Comments

This might not include provenances for all versions of the request – only those deemed “relevant” or important. This SHALL NOT include the Provenance associated with this current version of the resource. (If that provenance is deemed to be a “relevant” change, it will need to be added as part of a later update. Until then, it can be queried directly as the Provenance that points to this version using _revinclude All Provenances should have some historical version of this Request as their subject.