Medication Administration

A medication administration is the record that a dose was actually given to a patient — or that giving it was attempted and did not happen. It is the moment an order becomes a real event at the bedside, closing the loop on what a clinician prescribed.

What it represents

In Care's FHIR-aligned model, this maps to the MedicationAdministration resource. A single record answers four questions about one dose: what was given, how and when it was given, who gave it, and — if it was not given — why.

The distinction that matters most is between the administration and the order behind it. The order (Medication Request) is the plan: what should be given. The administration is the event: was this dose actually given? One order produces many administrations over time, one for each scheduled dose, so the two together tell you whether the plan was followed.

This is also why recording a "not given" event matters as much as recording a completed one. It makes a gap in the patient's medication history explicit and auditable, rather than leaving it silent.

Lifecycle

The status field tracks what happened to a single dose. A normal administration moves through the active path:

in_progress → completed
            → on_hold → in_progress
            → stopped
            → not_done

• in_progress — the dose has started but is not finished (typical for an infusion still running)
• on_hold — administration was paused and may resume
• completed — the dose was fully given
• stopped — administration was halted before completion
• not_done — the dose was deliberately not given, recorded with a reason

Three further statuses are administrative rather than clinical: cancelled (the planned dose was called off), entered_in_error (the record was a mistake and should be disregarded), and unknown (the outcome cannot be determined).

Classification

The category marks the setting in which the dose was given, which drives reporting and reconciliation:

• inpatient — given to an admitted patient on a ward
• outpatient — given during a clinic or day visit
• community — given outside the facility, such as a home or field setting
• discharge — supplied or given as the patient leaves

How it connects

A medication administration sits at the centre of the medication workflow and ties together several other records:

• Patient — every administration belongs to a patient. The patient is derived automatically from the encounter, never entered directly, so the record can never drift from the visit it happened in.
• Encounter — the encounter during which the dose was given anchors it in time and place.
• Medication Request — the order this administration fulfils, which is what turns a list of given doses back into "did we follow the plan?".
• Product — when a specific catalogued item was used, the administration points to that product knowledge entry so the dose can be reconciled against supply.

A record names either a coded medication or a specific product, never both. The coded form describes the substance; the product form ties the dose to a real item that left your stores.

Permissions

Access to recording and viewing administrations is governed by facility-scoped permissions.

Permission	Description	System Roles
can_write_encounter_clinical_data	Create, update, and delete a medication administration on the encounter (write encounter clinical data). Blocked once the encounter is closed	Admin, Doctor, Nurse, Facility Admin
can_view_clinical_data	View a patient's clinical data, including listing and retrieving their medication administrations	Staff, Doctor, Nurse, Admin, Facility Admin
can_read_encounter_clinical_data	Read an encounter's clinical data; used as the fallback read check when a specific encounter is supplied	Admin, Doctor, Nurse, Facility Admin

Roles are granted through a user's facility and organization memberships, and permissions cascade down the organization tree — a role held high in the hierarchy carries to the facilities beneath it.

Related

• Reference: Medication Administration (technical)
• Concept: Medication Request
• Concept: Medication Dispense
• Concept: Medication Statement
• Concept: Encounter
• Concept: Product Knowledge

FHIR reference

This concept aligns with the FHIR MedicationAdministration resource, which records the consumption or administration of a medication to a patient.