Discharge Medications Section¶

OID: 2.16.840.1.113883.10.20.22.2.11.1 Version: 2015-08-01 Badge: Specialized Section

Overview¶

The Discharge Medications Section contains the medications the patient is intended to take (or stop taking) after hospital discharge. This is a critical safety component of the discharge process, as medication discrepancies are a common cause of adverse events post-discharge.

Current, active medications must be listed. The section may also include the patient's prescription history and indicate the source of the medication list. This is an entries-required section, meaning at least one medication entry must be present unless nullFlavor is used.

Template Details¶

Template ID: 2.16.840.1.113883.10.20.22.2.11.1
Extension: 2015-08-01
Conformance: SHALL
Cardinality: 0..1 (Optional in documents)
LOINC Code: 10183-2 "Hospital Discharge Medications"
Translation Code: 75311-1 "Discharge Medications"

Protocol Requirements¶

MedicationProtocol¶

from typing import Protocol, Optional
from datetime import date

class MedicationProtocol(Protocol):
    name: str                      # Medication name
    code: str                      # RxNorm code
    dosage: str                    # Dosage amount (e.g., "10 mg")
    route: str                     # Route of administration (e.g., "oral")
    frequency: str                 # Frequency (e.g., "twice daily")
    start_date: date              # Start date
    end_date: Optional[date]      # End date (None if ongoing)
    status: str                   # Status: "active", "completed", "discontinued"
    instructions: Optional[str]   # Additional instructions

Code Example¶

from ccdakit import DischargeMedicationsSection, CDAVersion
from datetime import date

# Define discharge medications
discharge_medications = [
    {
        "name": "Lisinopril 10 MG Oral Tablet",
        "code": "314076",
        "dosage": "10 mg",
        "route": "oral",
        "frequency": "once daily",
        "start_date": date(2025, 1, 20),
        "end_date": None,
        "status": "active",
        "instructions": "Take in the morning with water"
    },
    {
        "name": "Aspirin 81 MG Oral Tablet",
        "code": "243670",
        "dosage": "81 mg",
        "route": "oral",
        "frequency": "once daily",
        "start_date": date(2025, 1, 20),
        "end_date": None,
        "status": "active",
        "instructions": "Take with food"
    },
    {
        "name": "Metformin 500 MG Oral Tablet",
        "code": "860975",
        "dosage": "500 mg",
        "route": "oral",
        "frequency": "twice daily",
        "start_date": date(2025, 1, 20),
        "end_date": None,
        "status": "active",
        "instructions": "Take with meals"
    },
    {
        "name": "Amoxicillin 500 MG Oral Capsule",
        "code": "308182",
        "dosage": "500 mg",
        "route": "oral",
        "frequency": "three times daily",
        "start_date": date(2025, 1, 20),
        "end_date": date(2025, 1, 30),
        "status": "active",
        "instructions": "Complete full course of antibiotics"
    }
]

# Create section
section = DischargeMedicationsSection(
    medications=discharge_medications,
    version=CDAVersion.R2_1
)

# Generate XML
xml_element = section.build()

Using Null Flavor (No Information Available)¶

from ccdakit import DischargeMedicationsSection, CDAVersion

# When no medication information is available
section = DischargeMedicationsSection(
    medications=[],
    null_flavor="NI",  # No Information
    version=CDAVersion.R2_1
)

xml_element = section.build()

Official Reference¶

HL7 C-CDA Discharge Medications Section Specification

Best Practices¶

Reconcile Medications: Ensure discharge medications are reconciled with pre-admission medications and accurately reflect what the patient should take at home.
Use RxNorm Codes: Always use RxNorm codes for medications to ensure accurate electronic exchange and e-prescribing.
Include Complete Instructions: Provide clear, patient-friendly instructions for each medication including timing, food interactions, and special precautions.
Document Changes: Clearly indicate new medications, discontinued medications, and dose changes from pre-admission medications.
Specify End Dates: For short-term medications (antibiotics, pain medications), always include the end date.
Status Accuracy: Use "active" for ongoing medications, "discontinued" for stopped medications, and "completed" for finished courses.
Coordinate with Discharge Instructions: Ensure discharge medications align with the Hospital Discharge Instructions section.
Address Compliance: Include information about why medications are prescribed to improve patient understanding and compliance.
Include All Medications: Document all discharge medications including over-the-counter, herbal supplements, and "as needed" medications.
Verify with Patient: Confirm the discharge medication list with the patient before discharge to ensure understanding and identify potential barriers.
Follow-up Planning: Note which medications require monitoring or follow-up lab work in the instructions.
Pharmacy Integration: Coordinate with pharmacy to ensure prescriptions are ready and affordable for the patient.