Release 4B 5 Ballot

This page is part of the FHIR Specification (v4.3.0: R4B (v5.0.0-ballot: R5 Ballot - STU see ballot notes ). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

Pharmacy icon Work Group Maturity Level : 2   Trial Use Security Category : Patient Compartments : Device , Encounter , Patient , Practitioner , RelatedPerson

Detailed Descriptions for the elements in the MedicationAdministration resource.

MedicationAdministration
Element Id MedicationAdministration
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.

Short Display Administration of medication to a patient
Cardinality 0..*
Type DomainResource
Summary false
MedicationAdministration.identifier
Element Id MedicationAdministration.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.

Short Display External identifier
Note This is a business identifier, not a resource identifier (see discussion )
Cardinality 0..*
Type Identifier
Summary false
Comments

This is a business identifier, not a resource identifier.

MedicationAdministration.instantiates MedicationAdministration.basedOn
Element Id MedicationAdministration.instantiates MedicationAdministration.basedOn
Definition

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

Short Display Plan this is fulfilled by this administration
Cardinality 0..*
Type uri Reference ( CarePlan )
Summary true false
MedicationAdministration.partOf
Element Id MedicationAdministration.partOf
Definition

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

Short Display Part of referenced event
Cardinality 0..*
Type Reference ( MedicationAdministration | Procedure )
Summary true
MedicationAdministration.status
Element Id MedicationAdministration.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.

Short Display in-progress | not-done | on-hold | completed | entered-in-error | stopped | unknown
Cardinality 1..1
Terminology Binding MedicationAdministration Status Codes ( Required )
Type code
Is Modifier true (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)
Summary true
Comments

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

MedicationAdministration.statusReason
Element Id MedicationAdministration.statusReason
Definition

A code indicating why the administration was not performed.

Short Display Reason administration not performed
Cardinality 0..*
Terminology Binding SNOMED CT Reason Medication Not Given Codes ( Example )
Type CodeableConcept
Summary false
MedicationAdministration.category
Element Id MedicationAdministration.category
Definition

Indicates where the The type of medication is expected to administration (for example, drug classification like ATC, where meds would be consumed or administered. administered, legal category of the medication).

Short Display Type of medication administration
Cardinality 0..1 0..*
Terminology Binding MedicationAdministration Category Location Codes ( Preferred Example )
Type CodeableConcept
Summary false
MedicationAdministration.medication[x] MedicationAdministration.medication
Element Id MedicationAdministration.medication[x] MedicationAdministration.medication
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.

Short Display What was administered
Cardinality 1..1
Terminology Binding SNOMED CT Medication Codes ( Example )
Type CodeableConcept | Reference CodeableReference ( Medication )
[x] Note See Choice of Data Types for further information about how to use [x] Summary true
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 Id MedicationAdministration.subject
Definition

The person or animal or group receiving the medication.

Short Display Who received medication
Cardinality 1..1
Type Reference ( Patient | Group )
Summary true
MedicationAdministration.context MedicationAdministration.encounter
Element Id MedicationAdministration.context MedicationAdministration.encounter
Definition

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

Short Display Encounter administered as part of
Cardinality 0..1
Type Reference ( Encounter | EpisodeOfCare )
Summary false
MedicationAdministration.supportingInformation
Element Id MedicationAdministration.supportingInformation
Definition

Additional information (for example, patient height and weight) that supports the administration of the medication. This attribute can be used to provide documentation of specific characteristics of the patient present at the time of administration. For example, if the dose says "give "x" if the heartrate exceeds "y"", then the heart rate can be included using this attribute.

Short Display Additional information to support administration
Cardinality 0..*
Type Reference ( Any )
Summary false
MedicationAdministration.effective[x] MedicationAdministration.occurence[x]
Element Id MedicationAdministration.effective[x] MedicationAdministration.occurence[x]
Definition

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

Short Display Start and end time of administration
Cardinality 1..1
Type dateTime | Period
[x] Note See Choice of Data Types Datatypes for further information about how to use [x]
Summary true
MedicationAdministration.performer MedicationAdministration.recorded
Element Id MedicationAdministration.performer MedicationAdministration.recorded
Definition

Indicates who or what performed The date the medication administration and how they were involved. occurrence of the MedicationAdministration was first captured in the record - potentially significantly after the occurrence of the event.

Short Display When the MedicationAdministration was first captured in the subject's record
Cardinality 0..* 0..1
Type dateTime
Summary true
MedicationAdministration.performer.function MedicationAdministration.isSubPotent
Element Id MedicationAdministration.performer.function MedicationAdministration.isSubPotent
Definition

Distinguishes the type of involvement of the performer in An indication that the medication administration. full dose was not administered.

Short Display Full dose was not administered
Cardinality 0..1
Type boolean
Summary false
MedicationAdministration.subPotentReason
Element Id MedicationAdministration.subPotentReason
Definition

The reason or reasons why the full dose was not administered.

Short Display Reason full dose was not administered
Cardinality 0..*
Terminology Binding MedicationAdministration Performer Function Codes Subpotent Reason ( Example )
Type CodeableConcept
Summary false
MedicationAdministration.performer.actor MedicationAdministration.performer
Element Id MedicationAdministration.performer.actor MedicationAdministration.performer
Definition

Indicates who or what performed the medication administration and how they were involved. For devices, this is the device that is actually performing the administration of the medication. An IV Pump would be an example of a device that is performing the administration. Both the IV Pump and the practitioner that set the rate or bolus on the pump can be listed as performers.

Cardinality Short Display 1..1 Who or what performed the medication administration and what type of performance they did
Type Cardinality Reference ( Practitioner | PractitionerRole | Patient | RelatedPerson | Device ) 0..*
Summary true
MedicationAdministration.reasonCode MedicationAdministration.performer.function
Element Id MedicationAdministration.reasonCode MedicationAdministration.performer.function
Definition

A code indicating why Distinguishes the type of involvement of the performer in the medication was given. administration.

Short Display Type of performance
Cardinality 0..* 0..1
Terminology Binding Reason Medication Given MedicationAdministration Performer Function Codes ( Example )
Type CodeableConcept
Summary false
MedicationAdministration.reasonReference MedicationAdministration.performer.actor
Element Id MedicationAdministration.reasonReference MedicationAdministration.performer.actor
Definition

Condition Indicates who or observation that supports why what performed the medication was administered. administration.

Short Display Who performed the medication administration
Cardinality 0..* 1..1
Type Reference ( Condition Practitioner | Observation PractitionerRole | DiagnosticReport Patient | RelatedPerson | Device )
Summary false true
MedicationAdministration.reason
Comments Element Id MedicationAdministration.reason
Definition

This is a reference to a condition A code, Condition or observation that is the reason for supports why the medication request. If only a code exists, use reasonCode. was administered.

Short Display Concept, condition or observation that supports why the medication was administered
Cardinality 0..*
Terminology Binding Reason Medication Given Codes ( Example )
Type CodeableReference ( Condition | Observation | DiagnosticReport )
Summary false
MedicationAdministration.request
Element Id MedicationAdministration.request
Definition

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

Short Display Request administration performed against
Cardinality 0..1
Type Reference ( MedicationRequest )
Summary false
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 Id MedicationAdministration.device
Definition

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

Short Display Device used to administer
Cardinality 0..*
Type Reference ( Device )
Summary false
MedicationAdministration.note
Element Id MedicationAdministration.note
Definition

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

Short Display Information about the administration
Cardinality 0..*
Type Annotation
Summary false
MedicationAdministration.dosage
Element Id MedicationAdministration.dosage
Definition

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

Short Display Details of how medication was taken
Cardinality 0..1
Summary false
Invariants
Defined on this element
mad-1 Rule If dosage attribute is present then SHALL have at least one of dosage.text or dosage.dose or dosage.rate[x] dose.exists() (dose.exists() or rate.exists() or text.exists())
MedicationAdministration.dosage.text
Element Id MedicationAdministration.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.

Short Display Free text dosage instructions e.g. SIG
Cardinality 0..1
Type string
Summary false
MedicationAdministration.dosage.site
Element Id MedicationAdministration.dosage.site
Definition

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

Short Display Body site administered to
Cardinality 0..1
Terminology Binding SNOMED CT Anatomical Structure S n o m e d c t anatomical structure for Administration Site Codes administration site codes ( Example )
Type CodeableConcept
Summary false
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 Id MedicationAdministration.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.

Short Display Path of substance into body
Cardinality 0..1
Terminology Binding SNOMED CT Route Codes ( Example )
Type CodeableConcept
Summary false
MedicationAdministration.dosage.method
Element Id MedicationAdministration.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.

Short Display How drug was administered
Cardinality 0..1
Terminology Binding SNOMED CT Administration Method Codes ( Example )
Type CodeableConcept
Summary false
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 Id MedicationAdministration.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.

Short Display Amount of medication per dose
Cardinality 0..1
Type SimpleQuantity
Summary false
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 Id MedicationAdministration.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.

Short Display Dose quantity per unit of time
Cardinality 0..1
Type Ratio | SimpleQuantity
[x] Note See Choice of Data Types Datatypes for further information about how to use [x]
Summary false
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 Id MedicationAdministration.eventHistory
Definition

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

Short Display A list of events of interest in the lifecycle
Cardinality 0..*
Type Reference ( Provenance )
Summary false
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.