Release 5 Ballot

This page is part of the FHIR Specification (v5.0.0-ballot: FHIR R5 Ballot Preview). 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 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.

Short DisplayAdministration of medication to a patient
Cardinality0..*
TypeDomainResource
Summaryfalse
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.

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

This is a business identifier, not a resource identifier.

MedicationAdministration.basedOn
Element IdMedicationAdministration.basedOn
Definition

A plan that is fulfilled in whole or in part by this MedicationAdministration.

Short DisplayPlan this is fulfilled by this administration
Cardinality0..*
TypeReference(CarePlan)
Summaryfalse
MedicationAdministration.partOf
Element IdMedicationAdministration.partOf
Definition

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

Short DisplayPart of referenced event
Cardinality0..*
TypeReference(MedicationAdministration | Procedure)
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.

Short Displayin-progress | not-done | on-hold | completed | entered-in-error | stopped | unknown
Cardinality1..1
Terminology BindingMedicationAdministration 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.

Short DisplayReason administration not performed
Cardinality0..*
Terminology BindingSNOMED CT Reason Medication Not Given Codes (Example)
TypeCodeableConcept
Summaryfalse
MedicationAdministration.category
Element IdMedicationAdministration.category
Definition

The type of medication administration (for example, drug classification like ATC, where meds would be administered, legal category of the medication).

Short DisplayType of medication administration
Cardinality0..*
Terminology BindingMedicationAdministration Location Codes (Example)
TypeCodeableConcept
Summaryfalse
MedicationAdministration.medication
Element IdMedicationAdministration.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 DisplayWhat was administered
Cardinality1..1
Terminology BindingSNOMED CT Medication Codes (Example)
TypeCodeableReference(Medication)
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.

Short DisplayWho received medication
Cardinality1..1
TypeReference(Patient | Group)
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.

Short DisplayEncounter administered as part of
Cardinality0..1
TypeReference(Encounter)
Summaryfalse
MedicationAdministration.supportingInformation
Element IdMedicationAdministration.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 DisplayAdditional information to support administration
Cardinality0..*
TypeReference(Any)
Summaryfalse
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.

Short DisplayStart and end time of administration
Cardinality1..1
TypedateTime|Period
[x] NoteSee Choice of Datatypes 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.

Short DisplayWhen the MedicationAdministration was first captured in the subject's record
Cardinality0..1
TypedateTime
Summarytrue
MedicationAdministration.isSubPotent
Element IdMedicationAdministration.isSubPotent
Definition

An indication that the full dose was not administered.

Short DisplayFull dose was not administered
Cardinality0..1
Typeboolean
Summaryfalse
MedicationAdministration.subPotentReason
Element IdMedicationAdministration.subPotentReason
Definition

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

Short DisplayReason full dose was not administered
Cardinality0..*
Terminology BindingMedicationAdministration Subpotent Reason (Example)
TypeCodeableConcept
Summaryfalse
MedicationAdministration.performer
Element IdMedicationAdministration.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.

Short DisplayWho or what performed the medication administration and what type of performance they did
Cardinality0..*
Summarytrue
MedicationAdministration.performer.function
Element IdMedicationAdministration.performer.function
Definition

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

Short DisplayType of performance
Cardinality0..1
Terminology BindingMedicationAdministration Performer Function Codes (Example)
TypeCodeableConcept
Summaryfalse
MedicationAdministration.performer.actor
Element IdMedicationAdministration.performer.actor
Definition

Indicates who or what performed the medication administration.

Short DisplayWho performed the medication administration
Cardinality1..1
TypeReference(Practitioner | PractitionerRole | Patient | RelatedPerson | Device)
Summarytrue
MedicationAdministration.reason
Element IdMedicationAdministration.reason
Definition

A code, Condition or observation that supports why the medication was administered.

Short DisplayConcept, condition or observation that supports why the medication was administered
Cardinality0..*
Terminology BindingReason Medication Given Codes (Example)
TypeCodeableReference(Condition | Observation | DiagnosticReport)
Summaryfalse
MedicationAdministration.request
Element IdMedicationAdministration.request
Definition

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

Short DisplayRequest administration performed against
Cardinality0..1
TypeReference(MedicationRequest)
Summaryfalse
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.

Short DisplayDevice used to administer
Cardinality0..*
TypeReference(Device)
Summaryfalse
MedicationAdministration.note
Element IdMedicationAdministration.note
Definition

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

Short DisplayInformation about the administration
Cardinality0..*
TypeAnnotation
Summaryfalse
MedicationAdministration.dosage
Element IdMedicationAdministration.dosage
Definition

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

Short DisplayDetails of how medication was taken
Cardinality0..1
Summaryfalse
Invariants
Defined on this element
mad-1Rule If dosage attribute is present then SHALL have at least one of dosage.text or dosage.dose or dosage.rate[x](dose.exists() or rate.exists() or text.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.

Short DisplayFree text dosage instructions e.g. SIG
Cardinality0..1
Typestring
Summaryfalse
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".

Short DisplayBody site administered to
Cardinality0..1
Terminology BindingS n o m e d c t anatomical structure for administration site codes (Example)
TypeCodeableConcept
Summaryfalse
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.

Short DisplayPath of substance into body
Cardinality0..1
Terminology BindingSNOMED CT Route Codes (Example)
TypeCodeableConcept
Summaryfalse
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.

Short DisplayHow drug was administered
Cardinality0..1
Terminology BindingSNOMED CT Administration Method Codes (Example)
TypeCodeableConcept
Summaryfalse
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.

Short DisplayAmount of medication per dose
Cardinality0..1
TypeSimpleQuantity
Summaryfalse
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.

Short DisplayDose quantity per unit of time
Cardinality0..1
TypeRatio|SimpleQuantity
[x] NoteSee Choice of Datatypes for further information about how to use [x]
Summaryfalse
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.

Short DisplayA list of events of interest in the lifecycle
Cardinality0..*
TypeReference(Provenance)
Summaryfalse
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.