Medications Administered Section

Template ID: 2.16.840.1.113883.10.20.22.2.38 Version: V2 (2014-06-09) Badge: Procedural Section

Overview

The Medications Administered Section documents medications and fluids administered to a patient during a procedure, encounter, or other clinical activity. This section captures the actual administration events with specific timing, dose, route, and other administration details, excluding anesthetic medications (which should be documented in the Anesthesia Section).

Clinical Purpose and Context

The Medications Administered Section documents: - Medications given during procedures or encounters - IV fluids administered during treatment - Contrast agents used during imaging - Medications administered during emergency department visits - Intraoperative medications (non-anesthetic) - Procedural medications and sedation

This section provides a record of what medications were actually given to the patient, which is essential for continuity of care, medication reconciliation, and clinical decision-making.

When to Include

The Medications Administered Section is typically included in: - Procedure Notes (medications during procedures) - Operative Notes (non-anesthetic medications) - Emergency Department Notes (medications given in ED) - Visit Summaries (medications administered during visit) - Observation Notes (medications during observation)

Note: This section differs from the Medications Section, which documents ongoing medication regimens and prescriptions.

Template Details

Official OID

• Root: 2.16.840.1.113883.10.20.22.2.38
• Extension: 2014-06-09 (V2)

Conformance Level

• Conformance: MAY (Optional)
• Section Code: 29549-3 (LOINC - "Medications Administered")

Cardinality

• Section: 0..1 (Optional)
• Entries: 1..* (SHALL contain at least one entry if not nullFlavored)

Related Templates

• Medication Activity (V2): 2.16.840.1.113883.10.20.22.4.16:2014-06-09

Protocol Requirements

The MedicationAdministeredProtocol defines the data contract for medication administration entries. Each administered medication must provide:

Required Properties

Property	Type	Description
name	str	Human-readable medication name
code	str	RxNorm code for the medication
administration_time	datetime	When medication was administered
dose	str	Dosage amount with units
route	str	Route of administration
status	str	Administration status

Optional Properties

Property	Type	Description
administration_end_time	Optional[datetime]	When administration ended (for infusions)
rate	Optional[str]	Rate of administration (e.g., "100 mL/hr")
site	Optional[str]	Anatomical site of administration
performer	Optional[str]	Person who administered medication
indication	Optional[str]	Reason for administration
instructions	Optional[str]	Administration instructions/notes

Data Types and Constraints

• name: Medication name with strength and form
• code: RxNorm code (preferred) or SNOMED CT
• administration_time: Datetime object for precise timing
• dose: Amount with units (e.g., "500 mg", "100 mL")
• route: From FDA Route of Administration value set
• status: Typically 'completed' for administered medications

Code Example

Here's a complete working example using ccdakit to create a Medications Administered Section:

from datetime import datetime
from ccdakit.builders.sections.medications_administered import MedicationsAdministeredSection
from ccdakit.core.base import CDAVersion

# Define administered medications using a class that implements MedicationAdministeredProtocol
class AdministeredMedication:
    def __init__(self, name, code, admin_time, dose, route, status="completed",
                 end_time=None, rate=None, site=None, performer=None,
                 indication=None, instructions=None):
        self._name = name
        self._code = code
        self._administration_time = admin_time
        self._administration_end_time = end_time
        self._dose = dose
        self._route = route
        self._rate = rate
        self._site = site
        self._status = status
        self._performer = performer
        self._indication = indication
        self._instructions = instructions

    @property
    def name(self):
        return self._name

    @property
    def code(self):
        return self._code

    @property
    def administration_time(self):
        return self._administration_time

    @property
    def administration_end_time(self):
        return self._administration_end_time

    @property
    def dose(self):
        return self._dose

    @property
    def route(self):
        return self._route

    @property
    def rate(self):
        return self._rate

    @property
    def site(self):
        return self._site

    @property
    def status(self):
        return self._status

    @property
    def performer(self):
        return self._performer

    @property
    def indication(self):
        return self._indication

    @property
    def instructions(self):
        return self._instructions

# Example 1: Medications administered during a procedure
medications = [
    AdministeredMedication(
        name="Ondansetron 4mg/2mL injection",
        code="312086",  # RxNorm
        admin_time=datetime(2024, 10, 15, 9, 30),
        dose="4 mg",
        route="IV",
        site="left arm",
        performer="Jane Smith, RN",
        indication="Nausea prophylaxis"
    ),
    AdministeredMedication(
        name="Cefazolin 1g injection",
        code="1659149",  # RxNorm
        admin_time=datetime(2024, 10, 15, 9, 15),
        dose="1 g",
        route="IV",
        site="left arm",
        performer="Jane Smith, RN",
        indication="Surgical prophylaxis",
        instructions="Given 30 minutes prior to incision"
    ),
    AdministeredMedication(
        name="Normal Saline 0.9% 1000mL",
        code="313002",  # RxNorm
        admin_time=datetime(2024, 10, 15, 9, 0),
        end_time=datetime(2024, 10, 15, 13, 0),
        dose="1000 mL",
        route="IV",
        rate="125 mL/hr",
        site="left arm",
        performer="Jane Smith, RN",
        indication="Fluid maintenance"
    )
]

section_builder = MedicationsAdministeredSection(
    medications=medications,
    title="Medications Administered",
    version=CDAVersion.R2_1
)

# Example 2: Emergency department medications
ed_medications = [
    AdministeredMedication(
        name="Nitroglycerin 0.4mg sublingual tablet",
        code="564666",  # RxNorm
        admin_time=datetime(2024, 10, 15, 14, 22),
        dose="0.4 mg",
        route="Sublingual",
        performer="Dr. Johnson",
        indication="Chest pain"
    ),
    AdministeredMedication(
        name="Aspirin 325mg oral tablet",
        code="243670",  # RxNorm
        admin_time=datetime(2024, 10, 15, 14, 25),
        dose="325 mg",
        route="Oral",
        performer="Dr. Johnson",
        indication="Suspected acute coronary syndrome",
        instructions="Chewed and swallowed"
    )
]

# Example 3: No medications administered (using null flavor)
section_no_meds = MedicationsAdministeredSection(
    medications=[],
    null_flavor="NI",  # No Information
    version=CDAVersion.R2_1
)

# Generate XML element
section_element = section_builder.build()

# Convert to XML string (for demonstration)
from lxml import etree
xml_string = etree.tostring(section_element, pretty_print=True, encoding='unicode')
print(xml_string)

Official Reference

For complete specification details, refer to the official HL7 C-CDA R2.1 documentation: - HL7 C-CDA R2.1 Implementation Guide - Section: Medications Administered Section (V2) - Entry: Medication Activity (V2) - Conformance IDs: CONF:1098-8152 through CONF:1098-15499

Best Practices

Common Patterns

1. Document Complete Administration Details
2. Include precise administration times
3. Record exact doses and units
4. Specify route and site when relevant

5. Note who administered the medication

6. Distinguish from Anesthesia

7. Use Anesthesia Section for anesthetic agents
8. Use this section for other medications during procedures

9. Don't duplicate anesthetic medications

10. Handle IV Infusions

11. Use administration_end_time for infusions
12. Include rate for continuous infusions

13. Document total volume administered

14. Track Emergency Medications

15. Precise timing is critical in emergencies
16. Include indication for emergency meds
17. Document response to medication when relevant

Validation Tips

1. Section Code Validation
2. Ensure section code is 29549-3 (LOINC "Medications Administered")

3. This is automatically set by the builder

4. Template ID Validation

5. Verify template ID includes extension="2014-06-09"

6. V2 is the current version

7. Entry Requirements

8. SHALL contain at least one entry if nullFlavor not present
9. Each entry is a Medication Activity (V2)

10. Entry typeCode should be "DRIV"

11. Timing Validation

12. Use datetime objects for administration_time
13. End time must be after start time for infusions
14. Precise timestamps are important

Common Pitfalls

1. Confusing with Medications Section
2. Medications Section: Ongoing prescriptions and regimens
3. Medications Administered: Actual administration events

4. Different clinical contexts and purposes

5. Missing Administration Time

6. Administration time is required
7. Must be datetime, not just date

8. Precision is important for medication reconciliation

9. Incomplete Dose Information

10. Always include units with dose
11. Specify exact amount administered

12. For infusions, include total volume and rate

13. Not Documenting IV Fluids

14. IV fluids are medications
15. Include maintenance fluids

16. Document boluses and continuous infusions

17. Missing Route Information

18. Route is required
19. Use standard route codes

20. Be specific (e.g., "IV" not "parenteral")

21. Anesthesia Medication Confusion

22. Don't include anesthetic agents here
23. Use Anesthesia Section for anesthesia drugs
24. This section is for other procedural medications

Related Sections

• Anesthesia Section: Anesthetic medications during procedures
• Medications Section: Ongoing medication regimens
• Procedures Section: The procedure requiring medication administration
• Allergies Section: Medication allergies to check before administration

Code Systems and Terminologies

Medication Codes

• RxNorm (Preferred): Standard for medication names
• OID: 2.16.840.1.113883.6.88
• Use RxNorm Clinical Drug or Branded Drug codes
• Examples: "312086" (Ondansetron 4mg injection)

Route Codes

• FDA Route of Administration: Value set 2.16.840.1.113883.3.88.12.3221.8.7
• Common routes:
• C38276 - Intravenous (IV)
• C38288 - Oral
• C38276 - Intramuscular (IM)
• C38279 - Subcutaneous
• C38284 - Topical
• C38300 - Sublingual

Status Codes

• completed - Medication was administered (most common)
• active - Administration in progress (for infusions)
• aborted - Administration was stopped
• held - Planned but not given

Section Codes

• Primary: 29549-3 - "Medications Administered" (LOINC)

Implementation Notes

Narrative Table Generation

The builder creates a comprehensive table with columns: - Medication name - Dose - Route - Administration Time (or time range for infusions) - Site - Rate (if applicable) - Performer - Status

Time Range Display

For medications with end times (infusions): - Displays as: "2024-10-15 09:00 - 2024-10-15 13:00" - Single-dose medications show only administration time

Null Flavor Support

The section supports null flavor:

section = MedicationsAdministeredSection(
    medications=[],
    null_flavor="NI",  # No Information
    version=CDAVersion.R2_1
)

Valid null flavors: - NI - No Information - NA - Not Applicable

Medication Activity Entries

Each medication becomes: - A Medication Activity (V2) entry - Entry typeCode="DRIV" - Contains consumable, dose, route, timing

Integration with Procedure Notes

Commonly used in procedure notes: 1. Preoperative Diagnosis: Why procedure needed 2. Anesthesia: Anesthetic agents 3. Medications Administered: Other medications (this section) 4. Procedure Description: What was done 5. Postoperative Diagnosis: Findings

Medication Reconciliation

Administered medications inform: - Post-procedure medication orders - Discharge medication reconciliation - Allergy checking and documentation - Drug-drug interaction screening

Emergency Medicine Use

Critical in emergency documentation: - Time-sensitive medication administration - Code blue medications - Rapid sequence intubation drugs - Emergency cardiac medications

IV Fluid Documentation

For IV fluids: - Document type (crystalloid, colloid) - Total volume administered - Rate of administration - Indication (maintenance, resuscitation, etc.)

Example:

AdministeredMedication(
    name="Lactated Ringer's 1000mL",
    code="313422",  # RxNorm
    admin_time=datetime(2024, 10, 15, 8, 0),
    end_time=datetime(2024, 10, 15, 16, 0),
    dose="1000 mL",
    route="IV",
    rate="125 mL/hr",
    indication="Maintenance fluid"
)

Contrast Agents

Document contrast for imaging:

AdministeredMedication(
    name="Iohexol 300mg/mL injection",
    code="242970",  # RxNorm
    admin_time=datetime(2024, 10, 15, 10, 15),
    dose="100 mL",
    route="IV",
    indication="CT scan contrast enhancement",
    performer="Radiology Tech"
)

Medication Reconciliation Context

This section helps with: - Pre-procedure medication review - Intraoperative medication tracking - Post-procedure orders - Discharge medication reconciliation - Continuity of care documentation

Performer Documentation

The performer field should include: - Name of person who administered - Credentials (RN, MD, PharmD, etc.) - Role if relevant (e.g., "ED Nurse", "OR Nurse")

Site Specificity

For injections and IV medications: - Specify anatomical location - Use standard anatomical terms - Important for site rotation tracking - Relevant for adverse event documentation

Rate Documentation

For continuous infusions: - Specify infusion rate with units - Use standard units (mL/hr, mg/min, etc.) - Important for dosing calculations - Critical for vasoactive medications

Clinical Decision Support

Administered medications data supports: - Medication allergy alerts - Drug-drug interaction checking - Dose range verification - Route appropriateness validation - Cumulative dose tracking - Medication use evaluation