MedicationAdministration

Records the actual administration of a medication to a patient, capturing when, how, and by whom a medication dose was given or refused. Documents both successful administrations and non-administrations with documented reasons for safety tracking and compliance.

Overview

MedicationAdministration documents the point of care when medication is actually given to a patient. It tracks the medication, dose, route, site, rate (for infusions), timing, and performer. Critically, it also records when medication was NOT given (refusals, holds, errors) with explanatory reasons. This entity supports medication safety, nursing documentation, billing, and closed-loop medication verification.

Key Concepts

Administration Status

The status field tracks the event lifecycle:

Status	Description	Common Scenario
`in-progress`	Currently being given	IV infusion running
`completed`	Successfully administered	Oral dose taken
`not-done`	Not administered	Patient refusal
`on-hold`	Temporarily paused	Awaiting lab results
`stopped`	Discontinued early	Adverse reaction
`entered-in-error`	Record invalid	Documentation error

Status Reason

The statusReason field explains non-administration:

Patient refusal
NPO status
Clinical contraindication
Medication unavailable
Adverse reaction concern
Order discontinued

Dose Documentation

Dose fields capture what was actually given:

doseQuantity - Numeric amount
doseUnit - Unit of measure (mg, ml, tablet)
May differ from ordered dose
Supports dose verification

Route of Administration

The route field documents how medication entered the body:

Route	Description	Documentation Focus
`oral`	By mouth	Swallowing difficulty
`intravenous`	Into vein	Site, rate, patency
`intramuscular`	Into muscle	Site rotation
`subcutaneous`	Under skin	Site rotation
`inhalation`	Breathed in	Technique
`sublingual`	Under tongue	Absorption complete

Administration Site

The site field links to HealthReferenceBodySite:

Injection sites (deltoid, vastus lateralis)
IV access locations
Topical application areas
Supports site rotation tracking

Infusion Rate

For IV medications:

rateQuantity - Speed of administration
rateUnit - Usually ml/hr
Critical for medication safety
Titration documentation

Timing

The effectiveDateTime captures:

Exact time of administration
When dose was refused
Supports medication timing analysis
MAR (Medication Administration Record) documentation

Use Cases

Scheduled Medication

For routine administration:

Verify patient identity
Scan medication barcode
Confirm dose and route
Document administration time
Set status: "completed"
Record performer

IV Infusion

For continuous infusions:

Document initial rate
Set status: "in-progress"
Record infusion site
Update rate changes
Document completion or stop

Patient Refusal

When patient declines:

Set status: "not-done"
Document statusReason
Record discussion with patient
Notify provider if needed
Add clinical notes

PRN Administration

For as-needed medications:

Assess indication for PRN
Document trigger (pain score)
Record administration
Note expected response time
Document follow-up assessment

Medication Error

When error discovered:

If not yet given, mark entered-in-error
If given, document event
Notify provider immediately
Complete incident report
Monitor patient

Related Entities

Entity	Relationship	Description
Patient	References	Recipient of medication
Encounter	References	Visit context
PrescriptionLine	References	Order being fulfilled
Medication	References	Drug administered
Practitioner	References	Who administered
HealthReferenceBodySite	References	Administration site

Calculated Fields

Field	Type	Description
`wasGiven`	boolean	True when status is completed
`wasRefused`	boolean	True when status is not-done

Enums

status

Value	Description
`in-progress`	Medication administration is currently underway
`not-done`	Medication was not administered (refused, held, contraindicated)
`on-hold`	Administration temporarily paused
`completed`	Medication was successfully administered
`entered-in-error`	Record was created in error and should be disregarded
`stopped`	Administration was discontinued before completion
`unknown`	Administration status cannot be determined

route

Value	Description
`oral`	Administered by mouth and swallowed
`intravenous`	Administered directly into a vein
`intramuscular`	Injected into muscle tissue
`subcutaneous`	Injected under the skin
`topical`	Applied to external body surface
`inhalation`	Breathed into the lungs
`rectal`	Administered into the rectum
`sublingual`	Placed under the tongue for absorption

17 properties

Schema

Properties

Property	Type	Mode	Description	Required
patient	Patient	stored	The individual who received or was intended to receive the medication, serving as the primary subject of this administration record across any healthcare context Example: `"Patient/12345"`	Required
encounter	Encounter	stored	The specific healthcare interaction during which the medication was administered, linking this administration event to a broader episode of care such as an inpatient stay, outpatient visit, or emergency department encounter Example: `"Encounter/67890"`	Optional
prescriptionLine	PrescriptionLine	stored	The specific prescription order line item being fulfilled by this administration, establishing the connection between what was ordered and what was actually given to verify compliance with prescriber intent Example: `"PrescriptionLine/11223"`	Optional
status	string	stored	The current state of this administration event, indicating whether the medication was successfully given, is in process of being administered, was refused or withheld, or contains erroneous data that should be disregarded Values: `in-progress, not-done, on-hold, completed, entered-in-error, stopped, unknown` Example: `"completed"`	Required
statusReason	string	stored	The clinical, operational, or patient-centered rationale explaining why the medication was not administered as ordered, particularly important when status indicates non-administration such as patient refusal, clinical contraindication, medication unavailability, or adverse reaction concerns Example: `"Patient reported nausea and declined oral medication"`	Optional
medication	Medication	stored	The specific pharmaceutical product that was administered, providing standardized identification of the drug substance, strength, and formulation to ensure accurate clinical documentation and decision support Example: `{"reference":"Medication/98765","display":"Acetaminophen 500mg Tablet"}`	Required
effectiveDateTime	DateTime	stored	The precise date and time when the medication was administered to the patient or when administration was attempted, serving as the definitive timestamp for medication timing verification, pharmacokinetic calculations, and adverse event correlation Example: `"2024-03-15T14:30:00Z"`	Required
performer	Practitioner	stored	The healthcare professional who physically administered the medication to the patient, establishing accountability and enabling contact for clarification or follow-up questions about the administration technique, patient response, or documentation details Example: `"Practitioner/44556"`	Optional
doseQuantity	number	stored	The numerical amount of medication actually given to the patient in this administration event, which may differ from the ordered dose due to patient factors, available formulations, or clinical judgment at the time of administration Example: `500`	Optional
doseUnit	string	stored	The unit of measurement for the dose quantity, specifying whether the amount is measured in milligrams, milliliters, tablets, puffs, or other standard pharmaceutical units to ensure unambiguous dose documentation Example: `"mg"`	Optional
route	string	stored	The anatomical path or method by which the medication entered the patient's body, determining absorption characteristics, onset time, and clinical effects of the administered drug Values: `oral, intravenous, intramuscular, subcutaneous, topical, inhalation, rectal, sublingual` Example: `"intravenous"`	Optional
site	HealthReferenceBodySite	stored	The specific anatomical location on the patient's body where the medication was administered, particularly relevant for injections, topical applications, and site rotation tracking to prevent tissue damage or ensure optimal absorption Example: `{"reference":"BodySite/right-deltoid","display":"Right deltoid muscle"}`	Optional
rateQuantity	number	stored	The speed at which the medication was infused or administered over time, primarily used for intravenous medications where controlling the administration rate is critical for safety and therapeutic effect Example: `100`	Optional
rateUnit	string	stored	The unit of measurement for the administration rate, typically expressing volume per time such as milliliters per hour for IV infusions, ensuring precise communication of how quickly the medication was delivered Example: `"ml/hr"`	Optional
note	string	stored	Free-text clinical observations, patient reactions, administration challenges, or other contextual information recorded by the administering clinician that may be relevant for future medication decisions, adverse event investigation, or quality improvement Example: `"Patient tolerated IV infusion well, no adverse reactions observed during 30-minute administration period"`	Optional
wasGiven	boolean	calculated	Indicates whether the medication was successfully administered to the patient, computed as true when status equals completed, providing a simple boolean flag for queries and reports focused on actual medication delivery	Optional
wasRefused	boolean	calculated	Indicates whether the medication was not administered due to patient refusal or other reasons, computed as true when status equals not-done, enabling tracking of non-administration events for clinical review and patient adherence monitoring	Optional

Examples

Example 1

{
  "@type": "MedicationAdministration",
  "patient": "Patient/12345",
  "encounter": "Encounter/67890",
  "prescriptionLine": "PrescriptionLine/11223",
  "status": "completed",
  "medication": {
    "reference": "Medication/98765",
    "display": "Vancomycin 1000mg in 250ml Normal Saline"
  },
  "effectiveDateTime": "2024-03-15T14:30:00Z",
  "performer": "Practitioner/44556",
  "doseQuantity": 1000,
  "doseUnit": "mg",
  "route": "intravenous",
  "site": {
    "reference": "BodySite/left-antecubital",
    "display": "Left antecubital fossa"
  },
  "rateQuantity": 100,
  "rateUnit": "ml/hr",
  "note": "Patient tolerated IV infusion well, no adverse reactions observed during 2.5-hour administration period. Vital signs stable throughout.",
  "_comment": "wasGiven: true, wasRefused: false"
}

Example 2

{
  "@type": "MedicationAdministration",
  "patient": "Patient/23456",
  "encounter": "Encounter/78901",
  "prescriptionLine": "PrescriptionLine/22334",
  "status": "completed",
  "medication": {
    "reference": "Medication/87654",
    "display": "Acetaminophen 500mg Tablet"
  },
  "effectiveDateTime": "2024-03-15T08:00:00Z",
  "performer": "Practitioner/55667",
  "doseQuantity": 1000,
  "doseUnit": "mg",
  "route": "oral",
  "note": "Patient took medication with breakfast and water. No difficulty swallowing observed.",
  "_comment": "wasGiven: true, wasRefused: false"
}

Example 3

{
  "@type": "MedicationAdministration",
  "patient": "Patient/34567",
  "encounter": "Encounter/89012",
  "prescriptionLine": "PrescriptionLine/33445",
  "status": "not-done",
  "statusReason": "Patient reported severe nausea and declined all oral medications this morning. Will attempt administration after anti-emetic takes effect.",
  "medication": {
    "reference": "Medication/76543",
    "display": "Metformin 500mg Tablet"
  },
  "effectiveDateTime": "2024-03-15T09:00:00Z",
  "performer": "Practitioner/66778",
  "route": "oral",
  "note": "Patient experiencing post-operative nausea. Physician notified. Plan to retry after ondansetron administration.",
  "_comment": "wasGiven: false, wasRefused: true"
}