2nd DSTU Draft For Comment

This page is part of the FHIR Specification (v0.4.0: DSTU 2 Draft). 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

4.15.6 Resource MedicationAdministration - Detailed Descriptions

Detailed Descriptions for the elements in the MedicationAdministration resource.

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.

Control1..1
MedicationAdministration.identifier
Definition

External identifier - FHIR will generate its own internal IDs (probably URLs) which do not need to be explicitly managed by the resource. The identifier here is one that would be used by another non-FHIR system - for example an automated medication pump would provide a record each time it operated; an administration while the patient was off the ward might be made with a different system and entered after the event. Particularly important if these records have to be updated.

Control0..*
TypeIdentifier
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.

Control1..1
BindingMedicationAdministrationStatus: Required: http://hl7.org/fhir/medication-admin-status (A set of codes indicating the current status of a MedicationAdministration)
Typecode
MedicationAdministration.patient
Definition

The person or animal to whom the medication was given.

Control1..1
TypeReference(Patient)
MedicationAdministration.practitioner
Definition

The individual who was responsible for giving the medication to the patient.

Control0..1
TypeReference(Practitioner)
MedicationAdministration.encounter
Definition

The visit or admission the or other contact between patient and health care provider the medication administration was performed as part of.

Control0..1
TypeReference(Encounter)
MedicationAdministration.prescription
Definition

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

Control0..1
TypeReference(MedicationPrescription)
MedicationAdministration.wasNotGiven
Definition

Set this to true if the record is saying that the medication was NOT administered.

Control0..1
Typeboolean
Is Modifiertrue
Meaning if MissingIf this is missing, then the medication was administered
MedicationAdministration.reasonNotGiven
Definition

A code indicating why the administration was not performed.

Control0..*
BindingMedicationAdministrationNegationReason: Example: See http://hl7.org/fhir/vs/reason-medication-not-given-codes (A set of codes indicating the reason why the MedicationAdministration is negated.)
TypeCodeableConcept
InvariantsDefined on this element
mad-2: Reason not given is only permitted if wasNotGiven is true (xpath: not(exists(f:reasonNotGiven) and f:wasNotGiven/@value='false'))
Affect this element
mad-2: Reason not given is only permitted if wasNotGiven is true (xpath: not(exists(f:reasonNotGiven) and f:wasNotGiven/@value='false'))
MedicationAdministration.reasonGiven
Definition

A code indicating why the medication was given.

Control0..*
BindingMedicationAdministrationReason: Example: See http://hl7.org/fhir/vs/reason-medication-given-codes (A set of codes indicating the reason why the MedicationAdministration was made.)
TypeCodeableConcept
InvariantsDefined on this element
mad-3: Reason given is only permitted if wasNotGiven is false (xpath: not(exists(f:reasonGiven) and f:wasNotGiven/@value='true'))
Affect this element
mad-3: Reason given is only permitted if wasNotGiven is false (xpath: not(exists(f:reasonGiven) and f:wasNotGiven/@value='true'))
MedicationAdministration.effectiveTime[x]
Definition

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

Control1..1
TypedateTime|Period
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.

Control0..1
TypeReference(Medication)
Comments

Note: do not use Medication.name to describe the administered medication. When the only available information is a text description of the medication, Medication.code.text should be used.

MedicationAdministration.device
Definition

The device used in administering the medication to the patient. E.g. a particular infusion pump.

Control0..*
TypeReference(Device)
MedicationAdministration.note
Definition

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

Control0..1
Typestring
MedicationAdministration.dosage
Definition

Indicates how the medication is/was used by the patient.

Control0..1
InvariantsDefined on this element
mad-1: SHALL have at least one of dosage.quantity and dosage.rate (xpath: exists(f:quantity) or exists(f:rate))
To DoThe RMIM has priority code on the act relationship. How do we handle this?.
MedicationAdministration.dosage.text
Definition

Free text dosage instructions can be used for cases where the instructions are too complex to code. When coded instructions are present, the free text instructions may still be present for display to humans taking or administering the medication.

Control0..1
Typestring
MedicationAdministration.dosage.site
Definition

A coded specification of the anatomic site where the medication first entered the body. E.g. "left arm".

Control0..1
BindingMedicationAdministrationSite: Example: See http://hl7.org/fhir/vs/approach-site-codes (A coded concept describing the site location the medicine enters into or onto the body)
TypeCodeableConcept
MedicationAdministration.dosage.route
Definition

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

Control0..1
BindingRouteOfAdministration: Example: See http://hl7.org/fhir/vs/route-codes (A coded concept describing the route or physiological path of administration of a therapeutic agent into or onto the body of a subject.)
TypeCodeableConcept
MedicationAdministration.dosage.method
Definition

A coded value indicating the method by which the medication was introduced into or onto the body. Most commonly used for injections. Examples: Slow Push; Deep IV.

Terminologies used often pre-coordinate this term with the route and or form of administration.

Control0..1
BindingMedicationAdministrationMethod: Example: See http://hl7.org/fhir/vs/administration-method-codes (A coded concept describing the technique by which the medicine is administered)
TypeCodeableConcept
MedicationAdministration.dosage.quantity
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.

Control0..1
TypeQuantity
Comments

If the administration is not instantaneous (rate is present or timing has a duration), this can be specified to convey the total amount administered over period of time of a single administration (as indicated by schedule).

MedicationAdministration.dosage.rate
Definition

Identifies the speed with which the medication was introduced into the patient. Typically the rate for an infusion e.g. 200ml in 2 hours. May also expressed as a rate per unit of time such as 100ml per hour - the duration is then not specified, or is specified in the quantity.

Control0..1
TypeRatio
Comments

If the rate changes over time, each change should be captured as a distinct "dosage" repetition. This element should not be used to convey an average rate.