Clinical Resources

Medications

Overview

The Medications section captures details of the patient’s current, past, or newly prescribed drugs.

This includes prescribed medications, over-the-counter (OTC) drugs, and supplements as documented in clinical notes or discharge summaries.

Accurate medication data ensures safe prescribing, supports medication reconciliation, and enables clinical decision support.

Clinical Data in Source Documents

Medication details are commonly documented in sections such as:

• Current/Active Medications - Lists ongoing prescriptions and their dosing instructions.
• Meds Prior to Visit / Regular Medications - Includes chronic or long-term therapies.
• Assessment/Plan or Discharge Instructions - Often contains new prescriptions or changes to existing therapy.

Information may include:

• Drug name (generic or brand).
• Dosage details (strength, amount, frequency, and route of administration).
• Prescriber and start date or refill details.
• Status (active, discontinued, or planned).

JSON Output

The platform extracts and organizes each medication into a standardized JSON structure.

Each record typically contains:

• Name: The medication name.
• Medication Class: Optional therapeutic class or category, if specified.
• Dosage: Strength and quantity.
• Frequency: How often the medication is taken.
• Route: Method of administration.
• Prescribed Date: Date of prescription or initiation if available.
• Prescriber: Provider who ordered the medication.
• Status: Indicates if the medication is active, recorded, discontinued or planned.

This structured format ensures clarity for downstream analysis and interoperability.

{
  "medications": [
    {
      "name": "Lisinopril",
      "section_header": "Regular Medications",
      "dosage": "10MG",
      "frequency": "daily",
      "route": "Oral",
      "prescribed_date": "01/01/2020",
      "prescriber": "John L. Smith, MD",
      "status": "Active",
      "page_number": 1
    }
  ]
}

FHIR Output

Extracted medication data is converted to a FHIR MedicationStatement resource to enable seamless EHR integration.

Key mappings include:

• Medication Name → MedicationStatement.medication.concept.text – Captures the exact drug name.
• Status → MedicationStatement.status – Reflects the current state (e.g., active, recorded, completed).
• Dosage Details → MedicationStatement.dosage – Stores frequency, route, and dose quantity.
• Route of Administration → dosage.route – Uses standard HL7 route codes (e.g., PO for oral).
• Prescriber/Information Source → MedicationStatement.informationSource – Identifies the provider who prescribed or reported the medication.
• Patient Reference → MedicationStatement.subject – Links the medication to the specific patient.
• Encounter Reference → MedicationStatement.encounter – Associates the medication with the encounter where it was recorded.
• Contextual Note → MedicationStatement.note – Includes references to the originating section or page of the source document.

{
  "fullUrl": "urn:uuid:6efd8529-d469-41d6-bb10-ee14e8d15d13",
  "resource": {
    "resourceType": "MedicationStatement",
    "status": "recorded",
    "medication": {
      "concept": {
        "text": "Lisinopril"
      }
    },
    "subject": {
      "reference": "Patient/b17aaab1-311c-4d98-9c93-030277d0aeb0"
    },
    "encounter": {
      "reference": "Encounter/d4ebe08e-6db9-429a-958a-ed5a1de4cffa"
    },
    "dateAsserted": "2020-01-01",
    "informationSource": [
      {
        "reference": "Practitioner/9a1de72f-33fd-47d9-a0b9-b34d26985db8"
      },
      {
        "display": "John L. Smith, MD"
      }
    ],
    "dosage": [
      {
        "text": "daily",
        "route": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/v3-RouteOfAdministration",
              "code": "PO"
            }
          ]
        },
        "doseAndRate": [
          {
            "type": {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/dose-rate-type",
                  "code": "ordered",
                  "display": "Ordered"
                }
              ]
            },
            "doseQuantity": {
              "value": 10,
              "unit": "MG"
            }
          }
        ]
      }
    ],
    "effectiveDateTime": "2020-01-01",
    "note": [
      {
        "text": "Active"
      },
      {
        "text": "Section: Regular Medications; Page: 1"
      }
    ],
    "id": "6efd8529-d469-41d6-bb10-ee14e8d15d13"
  }
}