feature: Medication Tracking & Vital Sign Correlation

2026-06-19 10:47:55 +08:00
parent e2d40331b7
commit 5c7e37471b
29 changed files with 2512 additions and 4 deletions
@@ -11,6 +11,7 @@ public static class DbResetHelper
            try
            {
                await db.Database.ExecuteSqlRawAsync(@"
+                    DELETE FROM medication_administrations;
                    DELETE FROM sepsis_bundle_elements;
                    DELETE FROM sepsis_bundles;
                    DELETE FROM reconciliation_alerts;
@@ -0,0 +1,195 @@
+using FluentAssertions;
+using Microsoft.EntityFrameworkCore;
+using Microsoft.Extensions.DependencyInjection;
+using StackExchange.Redis;
+
+[Collection("Integration")]
+public class MedicationCorrelationTests : IAsyncLifetime
+{
+    private readonly ApiFixture _fixture;
+    private Guid _patientId;
+    private Guid _encounterId;
+
+    public MedicationCorrelationTests(ApiFixture fixture) => _fixture = fixture;
+
+    public async Task InitializeAsync() => await ResetAndSeedAsync();
+
+    public Task DisposeAsync() => Task.CompletedTask;
+
+    private async Task ResetAndSeedAsync()
+    {
+        using var scope = _fixture.Services.CreateScope();
+        var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();
+        await DbResetHelper.ResetAsync(db);
+
+        var patient = new Patient
+        {
+            Id = Guid.NewGuid(), Mrn = "MRN-CORR-001", FirstName = "Correlation", LastName = "Test",
+            DateOfBirth = new DateOnly(1970, 6, 10), Gender = "M", CreatedAt = DateTimeOffset.UtcNow
+        };
+        var encounter = new Encounter
+        {
+            Id = Guid.NewGuid(), PatientId = patient.Id, EncounterType = EncounterType.Inpatient,
+            Status = EncounterStatus.Active, Department = Department.Icu,
+            AttendingPhysician = "Dr. Correlation", AdmittedAt = DateTimeOffset.UtcNow,
+            CreatedAt = DateTimeOffset.UtcNow
+        };
+        db.Patients.Add(patient);
+        db.Encounters.Add(encounter);
+
+        db.AlertThresholds.Add(new AlertThreshold
+        {
+            Id = Guid.NewGuid(), ObservationCode = "SYSTOLIC_BP",
+            DisplayName = "Systolic BP", Unit = "mmHg",
+            CriticalLow = 70, WarningLow = 90, WarningHigh = 180, CriticalHigh = 220,
+            CreatedAt = DateTimeOffset.UtcNow
+        });
+        db.AlertThresholds.Add(new AlertThreshold
+        {
+            Id = Guid.NewGuid(), ObservationCode = "RESP_RATE",
+            DisplayName = "Respiratory Rate", Unit = "breaths/min",
+            CriticalLow = 5, WarningLow = 8, WarningHigh = 25, CriticalHigh = 35,
+            CreatedAt = DateTimeOffset.UtcNow
+        });
+        await db.SaveChangesAsync();
+
+        var redis = scope.ServiceProvider.GetRequiredService<IConnectionMultiplexer>();
+        var cache = redis.GetDatabase(1);
+        await cache.StringSetAsync("threshold:SYSTOLIC_BP",
+            """{"ObservationCode":"SYSTOLIC_BP","CriticalLow":70,"WarningLow":90,"WarningHigh":180,"CriticalHigh":220}""");
+        await cache.StringSetAsync("threshold:RESP_RATE",
+            """{"ObservationCode":"RESP_RATE","CriticalLow":5,"WarningLow":8,"WarningHigh":25,"CriticalHigh":35}""");
+
+        _patientId = patient.Id;
+        _encounterId = encounter.Id;
+    }
+
+    [Fact]
+    public async Task MetoprololThenLowBp_AnnotatedDetails()
+    {
+        await ResetAndSeedAsync();
+
+        using var scope = _fixture.Services.CreateScope();
+        var medService = scope.ServiceProvider.GetRequiredService<IMedicationService>();
+        await medService.CreateAsync(_encounterId,
+            new CreateMedicationAdministrationRequest(
+                "metoprolol", 25m, "mg", "PO",
+                DateTimeOffset.UtcNow.AddMinutes(-45), "nurse-1"));
+
+        var evaluator = scope.ServiceProvider.GetRequiredService<WarningEvaluator>();
+        var created = await evaluator.EvaluateAsync(
+            Guid.NewGuid(), _encounterId, _patientId, "SYSTOLIC_BP", 85m);
+
+        created.Should().BeTrue();
+
+        var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();
+        var alert = await db.ClinicalAlerts
+            .SingleAsync(a => a.AlertType == AlertType.WarningSystolicBp);
+        alert.Details.Should().Contain("metoprolol");
+        alert.Details.Should().Contain("min ago");
+        alert.Details.Should().Contain("note:");
+    }
+
+    [Fact]
+    public async Task LowBpWithoutMedication_Unannotated()
+    {
+        await ResetAndSeedAsync();
+
+        using var scope = _fixture.Services.CreateScope();
+        var evaluator = scope.ServiceProvider.GetRequiredService<WarningEvaluator>();
+        var created = await evaluator.EvaluateAsync(
+            Guid.NewGuid(), _encounterId, _patientId, "SYSTOLIC_BP", 85m);
+
+        created.Should().BeTrue();
+
+        var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();
+        var alert = await db.ClinicalAlerts
+            .SingleAsync(a => a.AlertType == AlertType.WarningSystolicBp);
+        alert.Details.Should().NotContain("note:");
+    }
+
+    [Fact]
+    public async Task UnrelatedDrug_NoAnnotation()
+    {
+        await ResetAndSeedAsync();
+
+        using var scope = _fixture.Services.CreateScope();
+        var medService = scope.ServiceProvider.GetRequiredService<IMedicationService>();
+        // Insulin maps to GLUCOSE_MG_DL, not SYSTOLIC_BP
+        await medService.CreateAsync(_encounterId,
+            new CreateMedicationAdministrationRequest(
+                "insulin", 10m, "units", "SubQ",
+                DateTimeOffset.UtcNow.AddMinutes(-30), "nurse-1"));
+
+        var evaluator = scope.ServiceProvider.GetRequiredService<WarningEvaluator>();
+        var created = await evaluator.EvaluateAsync(
+            Guid.NewGuid(), _encounterId, _patientId, "SYSTOLIC_BP", 85m);
+
+        created.Should().BeTrue();
+
+        var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();
+        var alert = await db.ClinicalAlerts
+            .SingleAsync(a => a.AlertType == AlertType.WarningSystolicBp);
+        alert.Details.Should().NotContain("note:");
+        alert.Details.Should().NotContain("insulin");
+    }
+
+    [Fact]
+    public async Task MedicationOutsideWindow_NoAnnotation()
+    {
+        await ResetAndSeedAsync();
+
+        using var scope = _fixture.Services.CreateScope();
+        var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();
+        // Metoprolol administered 2 hours ago — outside 90-min window
+        db.MedicationAdministrations.Add(new MedicationAdministration
+        {
+            Id = Guid.NewGuid(),
+            EncounterId = _encounterId,
+            DrugName = "metoprolol",
+            Dose = 25m,
+            DoseUnit = "mg",
+            Route = "PO",
+            AdministeredAt = DateTimeOffset.UtcNow.AddMinutes(-120),
+            AdministeredBy = "nurse-1"
+        });
+        await db.SaveChangesAsync();
+
+        var evaluator = scope.ServiceProvider.GetRequiredService<WarningEvaluator>();
+        var created = await evaluator.EvaluateAsync(
+            Guid.NewGuid(), _encounterId, _patientId, "SYSTOLIC_BP", 85m);
+
+        created.Should().BeTrue();
+
+        var alert = await db.ClinicalAlerts
+            .SingleAsync(a => a.AlertType == AlertType.WarningSystolicBp);
+        alert.Details.Should().NotContain("note:");
+        alert.Details.Should().NotContain("metoprolol");
+    }
+
+    [Fact]
+    public async Task MorphineThenLowRespRate_Annotated()
+    {
+        await ResetAndSeedAsync();
+
+        using var scope = _fixture.Services.CreateScope();
+        var medService = scope.ServiceProvider.GetRequiredService<IMedicationService>();
+        await medService.CreateAsync(_encounterId,
+            new CreateMedicationAdministrationRequest(
+                "morphine", 4m, "mg", "IV",
+                DateTimeOffset.UtcNow.AddMinutes(-20), "nurse-1"));
+
+        var evaluator = scope.ServiceProvider.GetRequiredService<WarningEvaluator>();
+        var created = await evaluator.EvaluateAsync(
+            Guid.NewGuid(), _encounterId, _patientId, "RESP_RATE", 7m);
+
+        created.Should().BeTrue();
+
+        var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();
+        var alert = await db.ClinicalAlerts
+            .SingleAsync(a => a.AlertType == AlertType.WarningRespRate);
+        alert.Details.Should().Contain("morphine");
+        alert.Details.Should().Contain("min ago");
+        alert.Details.Should().Contain("note:");
+    }
+}
@@ -0,0 +1,154 @@
+using FluentAssertions;
+using Microsoft.EntityFrameworkCore;
+using Microsoft.Extensions.DependencyInjection;
+
+[Collection("Integration")]
+public class MedicationServiceTests : IAsyncLifetime
+{
+    private readonly ApiFixture _fixture;
+    private Guid _patientId;
+    private Guid _activeEncounterId;
+    private Guid _dischargedEncounterId;
+
+    public MedicationServiceTests(ApiFixture fixture) => _fixture = fixture;
+
+    public async Task InitializeAsync() => await ResetAndSeedAsync();
+
+    public Task DisposeAsync() => Task.CompletedTask;
+
+    private async Task ResetAndSeedAsync()
+    {
+        using var scope = _fixture.Services.CreateScope();
+        var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();
+        await DbResetHelper.ResetAsync(db);
+
+        var patient = new Patient
+        {
+            Id = Guid.NewGuid(), Mrn = "MRN-MED-001", FirstName = "Med", LastName = "Test",
+            DateOfBirth = new DateOnly(1980, 3, 15), Gender = "F", CreatedAt = DateTimeOffset.UtcNow
+        };
+        var activeEncounter = new Encounter
+        {
+            Id = Guid.NewGuid(), PatientId = patient.Id, EncounterType = EncounterType.Inpatient,
+            Status = EncounterStatus.Active, Department = Department.Icu,
+            AttendingPhysician = "Dr. Medication", AdmittedAt = DateTimeOffset.UtcNow,
+            CreatedAt = DateTimeOffset.UtcNow
+        };
+        var dischargedEncounter = new Encounter
+        {
+            Id = Guid.NewGuid(), PatientId = patient.Id, EncounterType = EncounterType.Inpatient,
+            Status = EncounterStatus.Discharged, Department = Department.Icu,
+            AttendingPhysician = "Dr. Medication", AdmittedAt = DateTimeOffset.UtcNow.AddDays(-3),
+            DischargedAt = DateTimeOffset.UtcNow.AddHours(-1),
+            CreatedAt = DateTimeOffset.UtcNow
+        };
+        db.Patients.Add(patient);
+        db.Encounters.Add(activeEncounter);
+        db.Encounters.Add(dischargedEncounter);
+        await db.SaveChangesAsync();
+
+        _patientId = patient.Id;
+        _activeEncounterId = activeEncounter.Id;
+        _dischargedEncounterId = dischargedEncounter.Id;
+    }
+
+    [Fact]
+    public async Task Create_OnActiveEncounter_Succeeds()
+    {
+        await ResetAndSeedAsync();
+
+        using var scope = _fixture.Services.CreateScope();
+        var service = scope.ServiceProvider.GetRequiredService<IMedicationService>();
+
+        var med = await service.CreateAsync(_activeEncounterId,
+            new CreateMedicationAdministrationRequest(
+                "metoprolol", 25m, "mg", "PO", null, "nurse-1"));
+
+        med.Should().NotBeNull();
+        med.DrugName.Should().Be("metoprolol");
+        med.Dose.Should().Be(25m);
+        med.DoseUnit.Should().Be("mg");
+        med.Route.Should().Be("PO");
+        med.EncounterId.Should().Be(_activeEncounterId);
+
+        var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();
+        var persisted = await db.MedicationAdministrations.FindAsync(med.Id);
+        persisted.Should().NotBeNull();
+    }
+
+    [Fact]
+    public async Task Create_OnDischargedEncounter_ThrowsConflict()
+    {
+        await ResetAndSeedAsync();
+
+        using var scope = _fixture.Services.CreateScope();
+        var service = scope.ServiceProvider.GetRequiredService<IMedicationService>();
+
+        var act = () => service.CreateAsync(_dischargedEncounterId,
+            new CreateMedicationAdministrationRequest(
+                "metoprolol", 25m, "mg", "PO", null, "nurse-1"));
+
+        await act.Should().ThrowAsync<ConflictException>();
+    }
+
+    [Fact]
+    public async Task ListByEncounter_ReturnsPaginated()
+    {
+        await ResetAndSeedAsync();
+
+        using var scope = _fixture.Services.CreateScope();
+        var service = scope.ServiceProvider.GetRequiredService<IMedicationService>();
+
+        await service.CreateAsync(_activeEncounterId,
+            new CreateMedicationAdministrationRequest(
+                "metoprolol", 25m, "mg", "PO", null, "nurse-1"));
+        await service.CreateAsync(_activeEncounterId,
+            new CreateMedicationAdministrationRequest(
+                "morphine", 4m, "mg", "IV", null, "nurse-2"));
+        await service.CreateAsync(_activeEncounterId,
+            new CreateMedicationAdministrationRequest(
+                "insulin", 10m, "units", "SubQ", null, "nurse-1"));
+
+        var result = await service.ListByEncounterAsync(_activeEncounterId, null, 1, 2);
+
+        result.TotalCount.Should().Be(3);
+        result.Items.Should().HaveCount(2);
+        result.TotalPages.Should().Be(2);
+    }
+
+    [Fact]
+    public async Task GetRecentForEncounter_FiltersByWindow()
+    {
+        await ResetAndSeedAsync();
+
+        using var scope = _fixture.Services.CreateScope();
+        var service = scope.ServiceProvider.GetRequiredService<IMedicationService>();
+        var db = scope.ServiceProvider.GetRequiredService<AppDbContext>();
+
+        // Recent metoprolol — within 90-min window
+        await service.CreateAsync(_activeEncounterId,
+            new CreateMedicationAdministrationRequest(
+                "metoprolol", 25m, "mg", "PO",
+                DateTimeOffset.UtcNow.AddMinutes(-30), "nurse-1"));
+
+        // Old metoprolol — outside 90-min window
+        db.MedicationAdministrations.Add(new MedicationAdministration
+        {
+            Id = Guid.NewGuid(),
+            EncounterId = _activeEncounterId,
+            DrugName = "metoprolol",
+            Dose = 50m,
+            DoseUnit = "mg",
+            Route = "PO",
+            AdministeredAt = DateTimeOffset.UtcNow.AddMinutes(-120),
+            AdministeredBy = "nurse-2"
+        });
+        await db.SaveChangesAsync();
+
+        var recent = await service.GetRecentForEncounterAsync(
+            _activeEncounterId, "SYSTOLIC_BP", 90);
+
+        recent.Should().HaveCount(1);
+        recent[0].Dose.Should().Be(25m);
+    }
+}
@@ -0,0 +1,43 @@
+using System.Net;
+using System.Net.Http.Json;
+using FluentAssertions;
+
+[Collection("Integration")]
+public class MedicationValidationTests
+{
+    private readonly HttpClient _client;
+
+    public MedicationValidationTests(ApiFixture fixture) => _client = fixture.CreateClient();
+
+    [Fact]
+    public async Task EmptyDrugName_Returns400()
+    {
+        var resp = await _client.PostAsJsonAsync(
+            $"/api/v1/encounters/{Guid.NewGuid()}/medications",
+            new { drugName = "", dose = 25, doseUnit = "mg", route = "PO", administeredBy = "nurse-1" });
+
+        resp.StatusCode.Should().Be(HttpStatusCode.BadRequest);
+    }
+
+    [Fact]
+    public async Task ZeroDose_Returns400()
+    {
+        var resp = await _client.PostAsJsonAsync(
+            $"/api/v1/encounters/{Guid.NewGuid()}/medications",
+            new { drugName = "metoprolol", dose = 0, doseUnit = "mg", route = "PO", administeredBy = "nurse-1" });
+
+        resp.StatusCode.Should().Be(HttpStatusCode.BadRequest);
+    }
+
+    [Fact]
+    public async Task FutureAdministeredAt_Returns400()
+    {
+        var futureTime = DateTimeOffset.UtcNow.AddHours(1);
+        var resp = await _client.PostAsJsonAsync(
+            $"/api/v1/encounters/{Guid.NewGuid()}/medications",
+            new { drugName = "metoprolol", dose = 25, doseUnit = "mg", route = "PO",
+                  administeredBy = "nurse-1", administeredAt = futureTime });
+
+        resp.StatusCode.Should().Be(HttpStatusCode.BadRequest);
+    }
+}
@@ -0,0 +1,83 @@
+public class MedicationCorrelationOptions
+{
+    public const string SectionName = "MedicationCorrelation";
+
+    /// <summary>Lookback window for medication-vital correlation (minutes).</summary>
+    public int CorrelationWindowMinutes { get; set; } = 90;
+
+    /// <summary>
+    /// Drug name (lowercase) → observation codes that may be affected.
+    /// Keys are normalized to lowercase for case-insensitive lookup.
+    /// </summary>
+    public Dictionary<string, string[]> DrugVitalMappings { get; set; } = new()
+    {
+        // Beta-blockers
+        ["metoprolol"]      = new[] { "SYSTOLIC_BP", "HEART_RATE", "DIASTOLIC_BP" },
+        ["labetalol"]       = new[] { "SYSTOLIC_BP", "HEART_RATE", "DIASTOLIC_BP" },
+        ["atenolol"]        = new[] { "SYSTOLIC_BP", "HEART_RATE", "DIASTOLIC_BP" },
+        ["propranolol"]     = new[] { "SYSTOLIC_BP", "HEART_RATE", "DIASTOLIC_BP" },
+        ["esmolol"]         = new[] { "SYSTOLIC_BP", "HEART_RATE", "DIASTOLIC_BP" },
+        ["carvedilol"]      = new[] { "SYSTOLIC_BP", "HEART_RATE", "DIASTOLIC_BP" },
+
+        // Vasopressors / inotropes
+        ["norepinephrine"]  = new[] { "SYSTOLIC_BP", "DIASTOLIC_BP", "HEART_RATE" },
+        ["epinephrine"]     = new[] { "SYSTOLIC_BP", "DIASTOLIC_BP", "HEART_RATE", "GLUCOSE_MG_DL" },
+        ["vasopressin"]     = new[] { "SYSTOLIC_BP", "DIASTOLIC_BP" },
+        ["dopamine"]        = new[] { "SYSTOLIC_BP", "DIASTOLIC_BP", "HEART_RATE" },
+        ["dobutamine"]      = new[] { "SYSTOLIC_BP", "HEART_RATE" },
+        ["phenylephrine"]   = new[] { "SYSTOLIC_BP", "DIASTOLIC_BP", "HEART_RATE" },
+
+        // Calcium channel blockers
+        ["diltiazem"]       = new[] { "HEART_RATE", "SYSTOLIC_BP", "DIASTOLIC_BP" },
+        ["verapamil"]       = new[] { "HEART_RATE", "SYSTOLIC_BP", "DIASTOLIC_BP" },
+        ["amlodipine"]      = new[] { "SYSTOLIC_BP", "DIASTOLIC_BP" },
+        ["nicardipine"]     = new[] { "SYSTOLIC_BP", "DIASTOLIC_BP", "HEART_RATE" },
+
+        // Antihypertensives
+        ["nitroglycerin"]   = new[] { "SYSTOLIC_BP", "DIASTOLIC_BP", "HEART_RATE" },
+        ["nitroprusside"]   = new[] { "SYSTOLIC_BP", "DIASTOLIC_BP", "HEART_RATE" },
+        ["hydralazine"]     = new[] { "SYSTOLIC_BP", "DIASTOLIC_BP", "HEART_RATE" },
+
+        // Opioids
+        ["morphine"]        = new[] { "RESP_RATE", "SPO2", "SYSTOLIC_BP", "HEART_RATE" },
+        ["fentanyl"]        = new[] { "RESP_RATE", "SPO2", "HEART_RATE" },
+        ["hydromorphone"]   = new[] { "RESP_RATE", "SPO2", "SYSTOLIC_BP" },
+        ["remifentanil"]    = new[] { "RESP_RATE", "SPO2", "HEART_RATE" },
+
+        // Sedatives / anaesthetics
+        ["propofol"]        = new[] { "RESP_RATE", "SPO2", "SYSTOLIC_BP", "HEART_RATE" },
+        ["midazolam"]       = new[] { "RESP_RATE", "SPO2" },
+        ["lorazepam"]       = new[] { "RESP_RATE", "SPO2" },
+        ["ketamine"]        = new[] { "HEART_RATE", "SYSTOLIC_BP", "RESP_RATE" },
+
+        // Antiarrhythmics
+        ["amiodarone"]      = new[] { "HEART_RATE", "SYSTOLIC_BP" },
+        ["adenosine"]       = new[] { "HEART_RATE" },
+        ["digoxin"]         = new[] { "HEART_RATE" },
+        ["atropine"]        = new[] { "HEART_RATE" },
+
+        // Anticoagulants
+        ["heparin"]         = new[] { "HEART_RATE" },
+
+        // Antipyretics
+        ["acetaminophen"]   = new[] { "TEMP_C" },
+        ["ibuprofen"]       = new[] { "TEMP_C" },
+
+        // Glucose management
+        ["insulin"]         = new[] { "GLUCOSE_MG_DL" },
+        ["dextrose"]        = new[] { "GLUCOSE_MG_DL" },
+        ["glucagon"]        = new[] { "GLUCOSE_MG_DL" },
+
+        // Corticosteroids
+        ["dexamethasone"]       = new[] { "GLUCOSE_MG_DL", "TEMP_C" },
+        ["methylprednisolone"]  = new[] { "GLUCOSE_MG_DL", "TEMP_C" },
+        ["hydrocortisone"]      = new[] { "GLUCOSE_MG_DL", "TEMP_C" },
+        ["prednisone"]          = new[] { "GLUCOSE_MG_DL", "TEMP_C" },
+
+        // Diuretics
+        ["furosemide"]      = new[] { "SYSTOLIC_BP", "DIASTOLIC_BP" },
+
+        // Bronchodilators
+        ["albuterol"]       = new[] { "HEART_RATE", "SPO2" }
+    };
+}
@@ -0,0 +1,71 @@
+using Microsoft.AspNetCore.Mvc;
+
+
+/// <summary>
+/// Medication administration recording and lookup.
+/// </summary>
+[ApiController]
+[Produces("application/json")]
+public class MedicationsController : ControllerBase
+{
+    private readonly IMedicationService _medications;
+
+    public MedicationsController(IMedicationService medications) => _medications = medications;
+
+    /// <summary>
+    /// Records a medication administration for an encounter.
+    /// </summary>
+    /// <param name="encounterId">Encounter id.</param>
+    /// <param name="req">Medication administration details.</param>
+    /// <returns>The created medication administration record.</returns>
+    [HttpPost("api/v1/encounters/{encounterId:guid}/medications")]
+    [ProducesResponseType(typeof(ApiResponse<MedicationAdministration>), StatusCodes.Status201Created)]
+    [ProducesResponseType(typeof(ApiResponse<object>), StatusCodes.Status404NotFound)]
+    [ProducesResponseType(typeof(ApiResponse<object>), StatusCodes.Status409Conflict)]
+    public async Task<IActionResult> Create(Guid encounterId, [FromBody] CreateMedicationAdministrationRequest req)
+    {
+        var med = await _medications.CreateAsync(encounterId, req);
+        return StatusCode(201, ApiResponse<MedicationAdministration>.Created(med));
+    }
+
+    /// <summary>
+    /// Lists medication administrations for an encounter with optional time filter.
+    /// </summary>
+    /// <param name="encounterId">Encounter id.</param>
+    /// <param name="since">Optional ISO 8601 cutoff — only returns administrations at or after this time.</param>
+    /// <param name="page">Page number (1-based).</param>
+    /// <param name="pageSize">Results per page.</param>
+    /// <returns>A paginated list of medication administrations.</returns>
+    [HttpGet("api/v1/encounters/{encounterId:guid}/medications")]
+    [ProducesResponseType(typeof(ApiResponse<object>), StatusCodes.Status200OK)]
+    public async Task<IActionResult> ListByEncounter(
+        Guid encounterId,
+        [FromQuery] DateTimeOffset? since,
+        [FromQuery] int page = 1,
+        [FromQuery] int pageSize = 20)
+    {
+        var result = await _medications.ListByEncounterAsync(encounterId, since, page, pageSize);
+        return Ok(ApiResponse<object>.Ok(new
+        {
+            items = result.Items,
+            page = result.Page,
+            pageSize = result.PageSize,
+            totalCount = result.TotalCount,
+            totalPages = result.TotalPages
+        }));
+    }
+
+    /// <summary>
+    /// Gets a single medication administration by id.
+    /// </summary>
+    /// <param name="id">Medication administration id.</param>
+    /// <returns>The medication administration record.</returns>
+    [HttpGet("api/v1/medications/{id:guid}")]
+    [ProducesResponseType(typeof(ApiResponse<MedicationAdministration>), StatusCodes.Status200OK)]
+    [ProducesResponseType(typeof(ApiResponse<object>), StatusCodes.Status404NotFound)]
+    public async Task<IActionResult> Get(Guid id)
+    {
+        var med = await _medications.GetByIdAsync(id);
+        return Ok(ApiResponse<MedicationAdministration>.Ok(med));
+    }
+}
@@ -15,6 +15,7 @@ public class AppDbContext : DbContext
    public DbSet<News2Score> News2Scores => Set<News2Score>();
    public DbSet<SepsisBundle> SepsisBundles => Set<SepsisBundle>();
    public DbSet<SepsisBundleElement> SepsisBundleElements => Set<SepsisBundleElement>();
+    public DbSet<MedicationAdministration> MedicationAdministrations => Set<MedicationAdministration>();

    protected override void OnModelCreating(ModelBuilder modelBuilder)
    {
@@ -0,0 +1,27 @@
+using Microsoft.EntityFrameworkCore;
+using Microsoft.EntityFrameworkCore.Metadata.Builders;
+
+public class MedicationAdministrationConfiguration : IEntityTypeConfiguration<MedicationAdministration>
+{
+    public void Configure(EntityTypeBuilder<MedicationAdministration> builder)
+    {
+        builder.ToTable("medication_administrations");
+        builder.HasKey(m => m.Id);
+        builder.Property(m => m.Id).HasColumnName("id").HasDefaultValueSql("gen_random_uuid()");
+        builder.Property(m => m.EncounterId).HasColumnName("encounter_id").IsRequired();
+        builder.Property(m => m.DrugName).HasColumnName("drug_name").HasMaxLength(200).IsRequired();
+        builder.Property(m => m.Dose).HasColumnName("dose").HasPrecision(10, 4).IsRequired();
+        builder.Property(m => m.DoseUnit).HasColumnName("dose_unit").HasMaxLength(20).IsRequired();
+        builder.Property(m => m.Route).HasColumnName("route").HasMaxLength(50).IsRequired();
+        builder.Property(m => m.AdministeredAt).HasColumnName("administered_at").IsRequired();
+        builder.Property(m => m.AdministeredBy).HasColumnName("administered_by").HasMaxLength(100).IsRequired();
+
+        builder.HasOne(m => m.Encounter)
+            .WithMany()
+            .HasForeignKey(m => m.EncounterId)
+            .OnDelete(DeleteBehavior.Restrict);
+
+        builder.HasIndex(m => new { m.EncounterId, m.AdministeredAt });
+        builder.HasIndex(m => new { m.EncounterId, m.DrugName });
+    }
+}
@@ -0,0 +1,13 @@
+public class MedicationAdministration
+{
+    public Guid Id { get; set; }
+    public Guid EncounterId { get; set; }
+    public string DrugName { get; set; } = null!;
+    public decimal Dose { get; set; }
+    public string DoseUnit { get; set; } = null!;
+    public string Route { get; set; } = null!;
+    public DateTimeOffset AdministeredAt { get; set; }
+    public string AdministeredBy { get; set; } = null!;
+
+    public Encounter Encounter { get; set; } = null!;
+}
@@ -0,0 +1,39 @@
+using Microsoft.Extensions.Options;
+
+public class MedicationCorrelationHelper
+{
+    private readonly IMedicationService _medicationService;
+    private readonly MedicationCorrelationOptions _options;
+
+    public MedicationCorrelationHelper(
+        IMedicationService medicationService,
+        IOptions<MedicationCorrelationOptions> options)
+    {
+        _medicationService = medicationService;
+        _options = options.Value;
+    }
+
+    /// <summary>
+    /// Appends medication context to alert details if a correlated administration
+    /// exists within the lookback window. Returns the original details if none found.
+    /// </summary>
+    public async Task<string> TryAnnotateDetailsAsync(
+        Guid encounterId,
+        string observationCode,
+        string details,
+        CancellationToken ct = default)
+    {
+        var recent = await _medicationService.GetRecentForEncounterAsync(
+            encounterId, observationCode, _options.CorrelationWindowMinutes);
+
+        if (recent.Count == 0)
+            return details;
+
+        // Use the most recent correlated administration
+        var med = recent[0];
+        var minutesAgo = (int)(DateTimeOffset.UtcNow - med.AdministeredAt).TotalMinutes;
+
+        return $"{details} — note: {med.DrugName} {med.Dose}{med.DoseUnit} " +
+               $"({med.Route}) administered {minutesAgo} min ago";
+    }
+}
@@ -0,0 +1,932 @@
+// <auto-generated />
+using System;
+using Microsoft.EntityFrameworkCore;
+using Microsoft.EntityFrameworkCore.Infrastructure;
+using Microsoft.EntityFrameworkCore.Migrations;
+using Microsoft.EntityFrameworkCore.Storage.ValueConversion;
+using Npgsql.EntityFrameworkCore.PostgreSQL.Metadata;
+
+#nullable disable
+
+namespace VigilCareClinicalAPI.Migrations
+{
+    [DbContext(typeof(AppDbContext))]
+    [Migration("20260619021003_AddMedicationAdministrationsTable")]
+    partial class AddMedicationAdministrationsTable
+    {
+        /// <inheritdoc />
+        protected override void BuildTargetModel(ModelBuilder modelBuilder)
+        {
+#pragma warning disable 612, 618
+            modelBuilder
+                .HasAnnotation("ProductVersion", "8.0.4")
+                .HasAnnotation("Relational:MaxIdentifierLength", 63);
+
+            NpgsqlModelBuilderExtensions.UseIdentityByDefaultColumns(modelBuilder);
+
+            modelBuilder.Entity("AlertThreshold", b =>
+                {
+                    b.Property<Guid>("Id")
+                        .ValueGeneratedOnAdd()
+                        .HasColumnType("uuid")
+                        .HasColumnName("id")
+                        .HasDefaultValueSql("gen_random_uuid()");
+
+                    b.Property<DateTimeOffset>("CreatedAt")
+                        .ValueGeneratedOnAdd()
+                        .HasColumnType("timestamp with time zone")
+                        .HasColumnName("created_at")
+                        .HasDefaultValueSql("NOW()");
+
+                    b.Property<decimal?>("CriticalHigh")
+                        .HasColumnType("decimal(10,3)")
+                        .HasColumnName("critical_high");
+
+                    b.Property<decimal?>("CriticalLow")
+                        .HasColumnType("decimal(10,3)")
+                        .HasColumnName("critical_low");
+
+                    b.Property<string>("DisplayName")
+                        .IsRequired()
+                        .HasMaxLength(200)
+                        .HasColumnType("character varying(200)")
+                        .HasColumnName("display_name");
+
+                    b.Property<string>("ObservationCode")
+                        .IsRequired()
+                        .HasMaxLength(50)
+                        .HasColumnType("character varying(50)")
+                        .HasColumnName("observation_code");
+
+                    b.Property<int?>("SuppressionWindowMinutes")
+                        .HasColumnType("integer")
+                        .HasColumnName("suppression_window_minutes");
+
+                    b.Property<string>("Unit")
+                        .IsRequired()
+                        .HasMaxLength(20)
+                        .HasColumnType("character varying(20)")
+                        .HasColumnName("unit");
+
+                    b.Property<decimal?>("WarningHigh")
+                        .HasColumnType("decimal(10,3)")
+                        .HasColumnName("warning_high");
+
+                    b.Property<decimal?>("WarningLow")
+                        .HasColumnType("decimal(10,3)")
+                        .HasColumnName("warning_low");
+
+                    b.HasKey("Id");
+
+                    b.HasIndex("ObservationCode")
+                        .IsUnique();
+
+                    b.ToTable("alert_thresholds", (string)null);
+                });
+
+            modelBuilder.Entity("ClinicalAlert", b =>
+                {
+                    b.Property<Guid>("Id")
+                        .ValueGeneratedOnAdd()
+                        .HasColumnType("uuid")
+                        .HasColumnName("id")
+                        .HasDefaultValueSql("gen_random_uuid()");
+
+                    b.Property<DateTimeOffset?>("AcknowledgedAt")
+                        .HasColumnType("timestamp with time zone")
+                        .HasColumnName("acknowledged_at");
+
+                    b.Property<string>("AcknowledgedBy")
+                        .HasMaxLength(200)
+                        .HasColumnType("character varying(200)")
+                        .HasColumnName("acknowledged_by");
+
+                    b.Property<string>("AlertType")
+                        .IsRequired()
+                        .HasMaxLength(50)
+                        .HasColumnType("character varying(50)")
+                        .HasColumnName("alert_type");
+
+                    b.Property<string>("Details")
+                        .IsRequired()
+                        .HasColumnType("text")
+                        .HasColumnName("details");
+
+                    b.Property<Guid>("EncounterId")
+                        .HasColumnType("uuid")
+                        .HasColumnName("encounter_id");
+
+                    b.Property<Guid?>("ObservationId")
+                        .HasColumnType("uuid")
+                        .HasColumnName("observation_id");
+
+                    b.Property<Guid>("PatientId")
+                        .HasColumnType("uuid")
+                        .HasColumnName("patient_id");
+
+                    b.Property<DateTimeOffset?>("ResolvedAt")
+                        .HasColumnType("timestamp with time zone")
+                        .HasColumnName("resolved_at");
+
+                    b.Property<string>("Severity")
+                        .IsRequired()
+                        .HasMaxLength(20)
+                        .HasColumnType("character varying(20)")
+                        .HasColumnName("severity");
+
+                    b.Property<string>("Status")
+                        .IsRequired()
+                        .ValueGeneratedOnAdd()
+                        .HasMaxLength(20)
+                        .HasColumnType("character varying(20)")
+                        .HasColumnName("status")
+                        .HasDefaultValueSql("'OPEN'");
+
+                    b.Property<DateTimeOffset>("TriggeredAt")
+                        .ValueGeneratedOnAdd()
+                        .HasColumnType("timestamp with time zone")
+                        .HasColumnName("triggered_at")
+                        .HasDefaultValueSql("NOW()");
+
+                    b.HasKey("Id");
+
+                    b.HasIndex("EncounterId", "TriggeredAt");
+
+                    b.HasIndex("PatientId", "TriggeredAt");
+
+                    b.HasIndex("Severity", "TriggeredAt")
+                        .HasFilter("status = 'OPEN'");
+
+                    b.ToTable("clinical_alerts", null, t =>
+                        {
+                            t.HasCheckConstraint("chk_clinical_alerts_alert_type", "alert_type IN ('SEPSIS_WARNING', 'CRITICAL_HEART_RATE', 'CRITICAL_TEMP_C', 'CRITICAL_POTASSIUM_MEQ_L', 'CRITICAL_SPO2', 'CRITICAL_RESP_RATE', 'CRITICAL_WBC_K_UL')");
+
+                            t.HasCheckConstraint("chk_clinical_alerts_severity", "severity IN ('WARNING', 'CRITICAL')");
+
+                            t.HasCheckConstraint("chk_clinical_alerts_status", "status IN ('OPEN', 'ACKNOWLEDGED', 'RESOLVED', 'ESCALATED')");
+                        });
+                });
+
+            modelBuilder.Entity("Encounter", b =>
+                {
+                    b.Property<Guid>("Id")
+                        .ValueGeneratedOnAdd()
+                        .HasColumnType("uuid")
+                        .HasColumnName("id")
+                        .HasDefaultValueSql("gen_random_uuid()");
+
+                    b.Property<string>("AdmissionReason")
+                        .HasMaxLength(500)
+                        .HasColumnType("character varying(500)")
+                        .HasColumnName("admission_reason");
+
+                    b.Property<DateTimeOffset>("AdmittedAt")
+                        .ValueGeneratedOnAdd()
+                        .HasColumnType("timestamp with time zone")
+                        .HasColumnName("admitted_at")
+                        .HasDefaultValueSql("NOW()");
+
+                    b.Property<string>("AttendingPhysician")
+                        .IsRequired()
+                        .HasMaxLength(200)
+                        .HasColumnType("character varying(200)")
+                        .HasColumnName("attending_physician");
+
+                    b.Property<DateTimeOffset>("CreatedAt")
+                        .ValueGeneratedOnAdd()
+                        .HasColumnType("timestamp with time zone")
+                        .HasColumnName("created_at")
+                        .HasDefaultValueSql("NOW()");
+
+                    b.Property<string>("Department")
+                        .IsRequired()
+                        .HasMaxLength(100)
+                        .HasColumnType("character varying(100)")
+                        .HasColumnName("department");
+
+                    b.Property<string>("DischargeDiagnosis")
+                        .HasMaxLength(500)
+                        .HasColumnType("character varying(500)")
+                        .HasColumnName("discharge_diagnosis");
+
+                    b.Property<DateTimeOffset?>("DischargedAt")
+                        .HasColumnType("timestamp with time zone")
+                        .HasColumnName("discharged_at");
+
+                    b.Property<string>("EncounterType")
+                        .IsRequired()
+                        .HasMaxLength(20)
+                        .HasColumnType("character varying(20)")
+                        .HasColumnName("encounter_type");
+
+                    b.Property<Guid>("PatientId")
+                        .HasColumnType("uuid")
+                        .HasColumnName("patient_id");
+
+                    b.Property<string>("RoomBed")
+                        .HasMaxLength(20)
+                        .HasColumnType("character varying(20)")
+                        .HasColumnName("room_bed");
+
+                    b.Property<string>("Status")
+                        .IsRequired()
+                        .ValueGeneratedOnAdd()
+                        .HasMaxLength(20)
+                        .HasColumnType("character varying(20)")
+                        .HasColumnName("status")
+                        .HasDefaultValueSql("'SCHEDULED'");
+
+                    b.HasKey("Id");
+
+                    b.HasIndex("PatientId", "AdmittedAt");
+
+                    b.HasIndex("Status", "AdmittedAt")
+                        .HasFilter("status = 'ACTIVE'");
+
+                    b.ToTable("encounters", null, t =>
+                        {
+                            t.HasCheckConstraint("chk_encounters_department", "department IN ('ICU', 'GENERAL_MEDICINE', 'EMERGENCY', 'CARDIOLOGY', 'SURGERY', 'PEDIATRICS')");
+
+                            t.HasCheckConstraint("chk_encounters_encounter_type", "encounter_type IN ('INPATIENT', 'OUTPATIENT', 'EMERGENCY')");
+
+                            t.HasCheckConstraint("chk_encounters_status", "status IN ('SCHEDULED', 'ACTIVE', 'DISCHARGED', 'CANCELLED')");
+                        });
+                });
+
+            modelBuilder.Entity("MedicationAdministration", b =>
+                {
+                    b.Property<Guid>("Id")
+                        .ValueGeneratedOnAdd()
+                        .HasColumnType("uuid")
+                        .HasColumnName("id")
+                        .HasDefaultValueSql("gen_random_uuid()");
+
+                    b.Property<DateTimeOffset>("AdministeredAt")
+                        .HasColumnType("timestamp with time zone")
+                        .HasColumnName("administered_at");
+
+                    b.Property<string>("AdministeredBy")
+                        .IsRequired()
+                        .HasMaxLength(100)
+                        .HasColumnType("character varying(100)")
+                        .HasColumnName("administered_by");
+
+                    b.Property<decimal>("Dose")
+                        .HasPrecision(10, 4)
+                        .HasColumnType("numeric(10,4)")
+                        .HasColumnName("dose");
+
+                    b.Property<string>("DoseUnit")
+                        .IsRequired()
+                        .HasMaxLength(20)
+                        .HasColumnType("character varying(20)")
+                        .HasColumnName("dose_unit");
+
+                    b.Property<string>("DrugName")
+                        .IsRequired()
+                        .HasMaxLength(200)
+                        .HasColumnType("character varying(200)")
+                        .HasColumnName("drug_name");
+
+                    b.Property<Guid>("EncounterId")
+                        .HasColumnType("uuid")
+                        .HasColumnName("encounter_id");
+
+                    b.Property<string>("Route")
+                        .IsRequired()
+                        .HasMaxLength(50)
+                        .HasColumnType("character varying(50)")
+                        .HasColumnName("route");
+
+                    b.HasKey("Id");
+
+                    b.HasIndex("EncounterId", "AdministeredAt");
+
+                    b.HasIndex("EncounterId", "DrugName");
+
+                    b.ToTable("medication_administrations", (string)null);
+                });
+
+            modelBuilder.Entity("News2Score", b =>
+                {
+                    b.Property<Guid>("Id")
+                        .ValueGeneratedOnAdd()
+                        .HasColumnType("uuid")
+                        .HasColumnName("id")
+                        .HasDefaultValueSql("gen_random_uuid()");
+
+                    b.Property<DateTimeOffset>("CalculatedAt")
+                        .HasColumnType("timestamp with time zone")
+                        .HasColumnName("calculated_at");
+
+                    b.Property<int>("ConsciousnessScore")
+                        .HasColumnType("integer")
+                        .HasColumnName("consciousness_score");
+
+                    b.Property<Guid>("EncounterId")
+                        .HasColumnType("uuid")
+                        .HasColumnName("encounter_id");
+
+                    b.Property<bool>("HasSingleParamThree")
+                        .HasColumnType("boolean")
+                        .HasColumnName("has_single_param_three");
+
+                    b.Property<int>("HeartRateScore")
+                        .HasColumnType("integer")
+                        .HasColumnName("heart_rate_score");
+
+                    b.Property<Guid>("PatientId")
+                        .HasColumnType("uuid")
+                        .HasColumnName("patient_id");
+
+                    b.Property<int>("RespRateScore")
+                        .HasColumnType("integer")
+                        .HasColumnName("resp_rate_score");
+
+                    b.Property<string>("RiskLevel")
+                        .IsRequired()
+                        .HasMaxLength(20)
+                        .HasColumnType("character varying(20)")
+                        .HasColumnName("risk_level");
+
+                    b.Property<int>("Spo2Score")
+                        .HasColumnType("integer")
+                        .HasColumnName("spo2_score");
+
+                    b.Property<int>("SupplementalO2Score")
+                        .HasColumnType("integer")
+                        .HasColumnName("supplemental_o2_score");
+
+                    b.Property<int>("SystolicBpScore")
+                        .HasColumnType("integer")
+                        .HasColumnName("systolic_bp_score");
+
+                    b.Property<int>("TemperatureScore")
+                        .HasColumnType("integer")
+                        .HasColumnName("temperature_score");
+
+                    b.Property<int>("TotalScore")
+                        .HasColumnType("integer")
+                        .HasColumnName("total_score");
+
+                    b.HasKey("Id");
+
+                    b.HasIndex("EncounterId", "CalculatedAt");
+
+                    b.HasIndex("PatientId", "CalculatedAt");
+
+                    b.ToTable("news2_scores", null, t =>
+                        {
+                            t.HasCheckConstraint("chk_news2_scores_risk_level", "risk_level IN ('LOW', 'LOW_MEDIUM', 'MEDIUM', 'HIGH')");
+                        });
+                });
+
+            modelBuilder.Entity("Observation", b =>
+                {
+                    b.Property<Guid>("Id")
+                        .ValueGeneratedOnAdd()
+                        .HasColumnType("uuid")
+                        .HasColumnName("id")
+                        .HasDefaultValueSql("gen_random_uuid()");
+
+                    b.Property<DateTimeOffset>("CreatedAt")
+                        .ValueGeneratedOnAdd()
+                        .HasColumnType("timestamp with time zone")
+                        .HasColumnName("created_at")
+                        .HasDefaultValueSql("NOW()");
+
+                    b.Property<Guid>("EncounterId")
+                        .HasColumnType("uuid")
+                        .HasColumnName("encounter_id");
+
+                    b.Property<string>("IdempotencyKey")
+                        .HasMaxLength(100)
+                        .HasColumnType("character varying(100)")
+                        .HasColumnName("idempotency_key");
+
+                    b.Property<string>("ObservationCode")
+                        .IsRequired()
+                        .HasMaxLength(50)
+                        .HasColumnType("character varying(50)")
+                        .HasColumnName("observation_code");
+
+                    b.Property<DateTimeOffset>("RecordedAt")
+                        .HasColumnType("timestamp with time zone")
+                        .HasColumnName("recorded_at");
+
+                    b.Property<string>("Source")
+                        .IsRequired()
+                        .ValueGeneratedOnAdd()
+                        .HasMaxLength(20)
+                        .HasColumnType("character varying(20)")
+                        .HasColumnName("source")
+                        .HasDefaultValueSql("'MANUAL'");
+
+                    b.Property<string>("Unit")
+                        .IsRequired()
+                        .HasMaxLength(20)
+                        .HasColumnType("character varying(20)")
+                        .HasColumnName("unit");
+
+                    b.Property<decimal>("Value")
+                        .HasColumnType("decimal(10,3)")
+                        .HasColumnName("value");
+
+                    b.HasKey("Id");
+
+                    b.HasIndex("IdempotencyKey")
+                        .IsUnique()
+                        .HasFilter("idempotency_key IS NOT NULL");
+
+                    b.HasIndex("EncounterId", "ObservationCode", "RecordedAt");
+
+                    b.ToTable("observations", null, t =>
+                        {
+                            t.HasCheckConstraint("chk_observations_source", "source IN ('MANUAL', 'DEVICE', 'LAB')");
+                        });
+                });
+
+            modelBuilder.Entity("Order", b =>
+                {
+                    b.Property<Guid>("Id")
+                        .ValueGeneratedOnAdd()
+                        .HasColumnType("uuid")
+                        .HasColumnName("id")
+                        .HasDefaultValueSql("gen_random_uuid()");
+
+                    b.Property<string>("Description")
+                        .IsRequired()
+                        .HasColumnType("text")
+                        .HasColumnName("description");
+
+                    b.Property<Guid>("EncounterId")
+                        .HasColumnType("uuid")
+                        .HasColumnName("encounter_id");
+
+                    b.Property<string>("OrderType")
+                        .IsRequired()
+                        .HasMaxLength(20)
+                        .HasColumnType("character varying(20)")
+                        .HasColumnName("order_type");
+
+                    b.Property<DateTimeOffset>("OrderedAt")
+                        .ValueGeneratedOnAdd()
+                        .HasColumnType("timestamp with time zone")
+                        .HasColumnName("ordered_at")
+                        .HasDefaultValueSql("NOW()");
+
+                    b.Property<string>("OrderedBy")
+                        .IsRequired()
+                        .HasMaxLength(200)
+                        .HasColumnType("character varying(200)")
+                        .HasColumnName("ordered_by");
+
+                    b.Property<string>("ResultSummary")
+                        .HasColumnType("text")
+                        .HasColumnName("result_summary");
+
+                    b.Property<DateTimeOffset?>("ResultedAt")
+                        .HasColumnType("timestamp with time zone")
+                        .HasColumnName("resulted_at");
+
+                    b.Property<string>("Status")
+                        .IsRequired()
+                        .ValueGeneratedOnAdd()
+                        .HasMaxLength(20)
+                        .HasColumnType("character varying(20)")
+                        .HasColumnName("status")
+                        .HasDefaultValueSql("'PENDING'");
+
+                    b.HasKey("Id");
+
+                    b.HasIndex("EncounterId", "OrderedAt");
+
+                    b.HasIndex("Status", "OrderedAt")
+                        .HasFilter("status IN ('PENDING', 'IN_PROGRESS')");
+
+                    b.ToTable("orders", null, t =>
+                        {
+                            t.HasCheckConstraint("chk_orders_order_type", "order_type IN ('LAB', 'IMAGING', 'MEDICATION', 'PROCEDURE')");
+
+                            t.HasCheckConstraint("chk_orders_status", "status IN ('PENDING', 'IN_PROGRESS', 'RESULTED', 'CANCELLED')");
+                        });
+                });
+
+            modelBuilder.Entity("OutboxEvent", b =>
+                {
+                    b.Property<Guid>("Id")
+                        .ValueGeneratedOnAdd()
+                        .HasColumnType("uuid")
+                        .HasColumnName("id")
+                        .HasDefaultValueSql("gen_random_uuid()");
+
+                    b.Property<DateTimeOffset>("CreatedAt")
+                        .ValueGeneratedOnAdd()
+                        .HasColumnType("timestamp with time zone")
+                        .HasColumnName("created_at")
+                        .HasDefaultValueSql("NOW()");
+
+                    b.Property<string>("PartitionKey")
+                        .HasMaxLength(36)
+                        .HasColumnType("character varying(36)")
+                        .HasColumnName("partition_key");
+
+                    b.Property<string>("Payload")
+                        .IsRequired()
+                        .HasColumnType("jsonb")
+                        .HasColumnName("payload");
+
+                    b.Property<DateTimeOffset?>("ProcessedAt")
+                        .HasColumnType("timestamp with time zone")
+                        .HasColumnName("processed_at");
+
+                    b.Property<string>("Topic")
+                        .IsRequired()
+                        .HasMaxLength(200)
+                        .HasColumnType("character varying(200)")
+                        .HasColumnName("topic");
+
+                    b.HasKey("Id");
+
+                    b.HasIndex("CreatedAt")
+                        .HasFilter("processed_at IS NULL");
+
+                    b.ToTable("outbox_events", (string)null);
+                });
+
+            modelBuilder.Entity("Patient", b =>
+                {
+                    b.Property<Guid>("Id")
+                        .ValueGeneratedOnAdd()
+                        .HasColumnType("uuid")
+                        .HasColumnName("id")
+                        .HasDefaultValueSql("gen_random_uuid()");
+
+                    b.Property<string>("Allergies")
+                        .HasColumnType("text")
+                        .HasColumnName("allergies");
+
+                    b.Property<string>("BloodType")
+                        .HasMaxLength(5)
+                        .HasColumnType("character varying(5)")
+                        .HasColumnName("blood_type");
+
+                    b.Property<DateTimeOffset>("CreatedAt")
+                        .ValueGeneratedOnAdd()
+                        .HasColumnType("timestamp with time zone")
+                        .HasColumnName("created_at")
+                        .HasDefaultValueSql("NOW()");
+
+                    b.Property<DateOnly>("DateOfBirth")
+                        .HasColumnType("date")
+                        .HasColumnName("date_of_birth");
+
+                    b.Property<string>("EmergencyContactName")
+                        .HasMaxLength(200)
+                        .HasColumnType("character varying(200)")
+                        .HasColumnName("emergency_contact_name");
+
+                    b.Property<string>("EmergencyContactPhone")
+                        .HasMaxLength(20)
+                        .HasColumnType("character varying(20)")
+                        .HasColumnName("emergency_contact_phone");
+
+                    b.Property<string>("FirstName")
+                        .IsRequired()
+                        .HasMaxLength(100)
+                        .HasColumnType("character varying(100)")
+                        .HasColumnName("first_name");
+
+                    b.Property<string>("Gender")
+                        .IsRequired()
+                        .HasMaxLength(10)
+                        .HasColumnType("character varying(10)")
+                        .HasColumnName("gender");
+
+                    b.Property<string>("LastName")
+                        .IsRequired()
+                        .HasMaxLength(100)
+                        .HasColumnType("character varying(100)")
+                        .HasColumnName("last_name");
+
+                    b.Property<string>("Mrn")
+                        .IsRequired()
+                        .HasMaxLength(20)
+                        .HasColumnType("character varying(20)")
+                        .HasColumnName("mrn");
+
+                    b.Property<string>("Status")
+                        .IsRequired()
+                        .ValueGeneratedOnAdd()
+                        .HasMaxLength(20)
+                        .HasColumnType("character varying(20)")
+                        .HasDefaultValue("active")
+                        .HasColumnName("status");
+
+                    b.HasKey("Id");
+
+                    b.HasIndex("Mrn")
+                        .IsUnique();
+
+                    b.ToTable("patients", (string)null);
+                });
+
+            modelBuilder.Entity("ReconciliationAlert", b =>
+                {
+                    b.Property<Guid>("Id")
+                        .ValueGeneratedOnAdd()
+                        .HasColumnType("uuid")
+                        .HasColumnName("id")
+                        .HasDefaultValueSql("gen_random_uuid()");
+
+                    b.Property<string>("CheckType")
+                        .IsRequired()
+                        .HasMaxLength(50)
+                        .HasColumnType("character varying(50)")
+                        .HasColumnName("check_type");
+
+                    b.Property<DateTimeOffset>("CreatedAt")
+                        .ValueGeneratedOnAdd()
+                        .HasColumnType("timestamp with time zone")
+                        .HasColumnName("created_at")
+                        .HasDefaultValueSql("NOW()");
+
+                    b.Property<string>("Details")
+                        .IsRequired()
+                        .HasColumnType("text")
+                        .HasColumnName("details");
+
+                    b.Property<Guid?>("EncounterId")
+                        .HasColumnType("uuid")
+                        .HasColumnName("encounter_id");
+
+                    b.Property<Guid?>("PatientId")
+                        .HasColumnType("uuid")
+                        .HasColumnName("patient_id");
+
+                    b.Property<DateTimeOffset?>("ResolvedAt")
+                        .HasColumnType("timestamp with time zone")
+                        .HasColumnName("resolved_at");
+
+                    b.HasKey("Id");
+
+                    b.HasIndex("EncounterId");
+
+                    b.HasIndex("PatientId");
+
+                    b.HasIndex("CheckType", "EncounterId")
+                        .HasFilter("resolved_at IS NULL");
+
+                    b.ToTable("reconciliation_alerts", null, t =>
+                        {
+                            t.HasCheckConstraint("chk_reconciliation_alerts_check_type", "check_type IN ('UNACKNOWLEDGED_CRITICAL_ALERT', 'PENDING_ORDER_NO_RESULT', 'ACTIVE_INPATIENT_NO_OBSERVATION')");
+                        });
+                });
+
+            modelBuilder.Entity("SepsisBundle", b =>
+                {
+                    b.Property<Guid>("Id")
+                        .ValueGeneratedOnAdd()
+                        .HasColumnType("uuid")
+                        .HasColumnName("id")
+                        .HasDefaultValueSql("gen_random_uuid()");
+
+                    b.Property<DateTimeOffset?>("CompletedAt")
+                        .HasColumnType("timestamp with time zone")
+                        .HasColumnName("completed_at");
+
+                    b.Property<string>("ComplianceStatus")
+                        .IsRequired()
+                        .ValueGeneratedOnAdd()
+                        .HasMaxLength(20)
+                        .HasColumnType("character varying(20)")
+                        .HasColumnName("compliance_status")
+                        .HasDefaultValueSql("'IN_PROGRESS'");
+
+                    b.Property<DateTimeOffset>("DeadlineAt")
+                        .HasColumnType("timestamp with time zone")
+                        .HasColumnName("deadline_at");
+
+                    b.Property<Guid>("EncounterId")
+                        .HasColumnType("uuid")
+                        .HasColumnName("encounter_id");
+
+                    b.Property<DateTimeOffset>("RecognizedAt")
+                        .HasColumnType("timestamp with time zone")
+                        .HasColumnName("recognized_at");
+
+                    b.Property<Guid>("TriggeringAlertId")
+                        .HasColumnType("uuid")
+                        .HasColumnName("triggering_alert_id");
+
+                    b.Property<string>("TriggeringAlertType")
+                        .IsRequired()
+                        .HasMaxLength(50)
+                        .HasColumnType("character varying(50)")
+                        .HasColumnName("triggering_alert_type");
+
+                    b.HasKey("Id");
+
+                    b.HasIndex("ComplianceStatus");
+
+                    b.HasIndex("TriggeringAlertId");
+
+                    b.HasIndex("EncounterId", "RecognizedAt");
+
+                    b.ToTable("sepsis_bundles", null, t =>
+                        {
+                            t.HasCheckConstraint("chk_sepsis_bundles_compliance_status", "compliance_status IN ('IN_PROGRESS', 'COMPLIANT', 'NON_COMPLIANT')");
+                        });
+                });
+
+            modelBuilder.Entity("SepsisBundleElement", b =>
+                {
+                    b.Property<Guid>("Id")
+                        .ValueGeneratedOnAdd()
+                        .HasColumnType("uuid")
+                        .HasColumnName("id")
+                        .HasDefaultValueSql("gen_random_uuid()");
+
+                    b.Property<Guid>("BundleId")
+                        .HasColumnType("uuid")
+                        .HasColumnName("bundle_id");
+
+                    b.Property<DateTimeOffset?>("CompletedAt")
+                        .HasColumnType("timestamp with time zone")
+                        .HasColumnName("completed_at");
+
+                    b.Property<string>("ElementType")
+                        .IsRequired()
+                        .HasMaxLength(40)
+                        .HasColumnType("character varying(40)")
+                        .HasColumnName("element_type");
+
+                    b.Property<Guid?>("OrderId")
+                        .HasColumnType("uuid")
+                        .HasColumnName("order_id");
+
+                    b.Property<string>("Status")
+                        .IsRequired()
+                        .ValueGeneratedOnAdd()
+                        .HasMaxLength(20)
+                        .HasColumnType("character varying(20)")
+                        .HasColumnName("status")
+                        .HasDefaultValueSql("'PENDING'");
+
+                    b.HasKey("Id");
+
+                    b.HasIndex("OrderId");
+
+                    b.HasIndex("BundleId", "ElementType")
+                        .IsUnique();
+
+                    b.ToTable("sepsis_bundle_elements", null, t =>
+                        {
+                            t.HasCheckConstraint("chk_sepsis_bundle_elements_element_type", "element_type IN ('BLOOD_CULTURES', 'SERUM_LACTATE', 'BROAD_SPECTRUM_ANTIBIOTICS', 'IV_FLUID_RESUSCITATION')");
+
+                            t.HasCheckConstraint("chk_sepsis_bundle_elements_status", "status IN ('PENDING', 'COMPLETED')");
+                        });
+                });
+
+            modelBuilder.Entity("ClinicalAlert", b =>
+                {
+                    b.HasOne("Encounter", "Encounter")
+                        .WithMany("Alerts")
+                        .HasForeignKey("EncounterId")
+                        .OnDelete(DeleteBehavior.Restrict)
+                        .IsRequired();
+
+                    b.Navigation("Encounter");
+                });
+
+            modelBuilder.Entity("Encounter", b =>
+                {
+                    b.HasOne("Patient", "Patient")
+                        .WithMany("Encounters")
+                        .HasForeignKey("PatientId")
+                        .OnDelete(DeleteBehavior.Restrict)
+                        .IsRequired();
+
+                    b.Navigation("Patient");
+                });
+
+            modelBuilder.Entity("MedicationAdministration", b =>
+                {
+                    b.HasOne("Encounter", "Encounter")
+                        .WithMany()
+                        .HasForeignKey("EncounterId")
+                        .OnDelete(DeleteBehavior.Restrict)
+                        .IsRequired();
+
+                    b.Navigation("Encounter");
+                });
+
+            modelBuilder.Entity("News2Score", b =>
+                {
+                    b.HasOne("Encounter", "Encounter")
+                        .WithMany()
+                        .HasForeignKey("EncounterId")
+                        .OnDelete(DeleteBehavior.Restrict)
+                        .IsRequired();
+
+                    b.Navigation("Encounter");
+                });
+
+            modelBuilder.Entity("Observation", b =>
+                {
+                    b.HasOne("Encounter", "Encounter")
+                        .WithMany("Observations")
+                        .HasForeignKey("EncounterId")
+                        .OnDelete(DeleteBehavior.Restrict)
+                        .IsRequired();
+
+                    b.Navigation("Encounter");
+                });
+
+            modelBuilder.Entity("Order", b =>
+                {
+                    b.HasOne("Encounter", "Encounter")
+                        .WithMany("Orders")
+                        .HasForeignKey("EncounterId")
+                        .OnDelete(DeleteBehavior.Restrict)
+                        .IsRequired();
+
+                    b.Navigation("Encounter");
+                });
+
+            modelBuilder.Entity("ReconciliationAlert", b =>
+                {
+                    b.HasOne("Encounter", "Encounter")
+                        .WithMany()
+                        .HasForeignKey("EncounterId")
+                        .OnDelete(DeleteBehavior.SetNull);
+
+                    b.HasOne("Patient", "Patient")
+                        .WithMany()
+                        .HasForeignKey("PatientId")
+                        .OnDelete(DeleteBehavior.SetNull);
+
+                    b.Navigation("Encounter");
+
+                    b.Navigation("Patient");
+                });
+
+            modelBuilder.Entity("SepsisBundle", b =>
+                {
+                    b.HasOne("Encounter", "Encounter")
+                        .WithMany()
+                        .HasForeignKey("EncounterId")
+                        .OnDelete(DeleteBehavior.Restrict)
+                        .IsRequired();
+
+                    b.HasOne("ClinicalAlert", "TriggeringAlert")
+                        .WithMany()
+                        .HasForeignKey("TriggeringAlertId")
+                        .OnDelete(DeleteBehavior.Restrict)
+                        .IsRequired();
+
+                    b.Navigation("Encounter");
+
+                    b.Navigation("TriggeringAlert");
+                });
+
+            modelBuilder.Entity("SepsisBundleElement", b =>
+                {
+                    b.HasOne("SepsisBundle", "Bundle")
+                        .WithMany("Elements")
+                        .HasForeignKey("BundleId")
+                        .OnDelete(DeleteBehavior.Cascade)
+                        .IsRequired();
+
+                    b.HasOne("Order", "Order")
+                        .WithMany()
+                        .HasForeignKey("OrderId")
+                        .OnDelete(DeleteBehavior.SetNull);
+
+                    b.Navigation("Bundle");
+
+                    b.Navigation("Order");
+                });
+
+            modelBuilder.Entity("Encounter", b =>
+                {
+                    b.Navigation("Alerts");
+
+                    b.Navigation("Observations");
+
+                    b.Navigation("Orders");
+                });
+
+            modelBuilder.Entity("Patient", b =>
+                {
+                    b.Navigation("Encounters");
+                });
+
+            modelBuilder.Entity("SepsisBundle", b =>
+                {
+                    b.Navigation("Elements");
+                });
+#pragma warning restore 612, 618
+        }
+    }
+}
@@ -0,0 +1,56 @@
+using System;
+using Microsoft.EntityFrameworkCore.Migrations;
+
+#nullable disable
+
+namespace VigilCareClinicalAPI.Migrations
+{
+    /// <inheritdoc />
+    public partial class AddMedicationAdministrationsTable : Migration
+    {
+        /// <inheritdoc />
+        protected override void Up(MigrationBuilder migrationBuilder)
+        {
+            migrationBuilder.CreateTable(
+                name: "medication_administrations",
+                columns: table => new
+                {
+                    id = table.Column<Guid>(type: "uuid", nullable: false, defaultValueSql: "gen_random_uuid()"),
+                    encounter_id = table.Column<Guid>(type: "uuid", nullable: false),
+                    drug_name = table.Column<string>(type: "character varying(200)", maxLength: 200, nullable: false),
+                    dose = table.Column<decimal>(type: "numeric(10,4)", precision: 10, scale: 4, nullable: false),
+                    dose_unit = table.Column<string>(type: "character varying(20)", maxLength: 20, nullable: false),
+                    route = table.Column<string>(type: "character varying(50)", maxLength: 50, nullable: false),
+                    administered_at = table.Column<DateTimeOffset>(type: "timestamp with time zone", nullable: false),
+                    administered_by = table.Column<string>(type: "character varying(100)", maxLength: 100, nullable: false)
+                },
+                constraints: table =>
+                {
+                    table.PrimaryKey("PK_medication_administrations", x => x.id);
+                    table.ForeignKey(
+                        name: "FK_medication_administrations_encounters_encounter_id",
+                        column: x => x.encounter_id,
+                        principalTable: "encounters",
+                        principalColumn: "id",
+                        onDelete: ReferentialAction.Restrict);
+                });
+
+            migrationBuilder.CreateIndex(
+                name: "IX_medication_administrations_encounter_id_administered_at",
+                table: "medication_administrations",
+                columns: new[] { "encounter_id", "administered_at" });
+
+            migrationBuilder.CreateIndex(
+                name: "IX_medication_administrations_encounter_id_drug_name",
+                table: "medication_administrations",
+                columns: new[] { "encounter_id", "drug_name" });
+        }
+
+        /// <inheritdoc />
+        protected override void Down(MigrationBuilder migrationBuilder)
+        {
+            migrationBuilder.DropTable(
+                name: "medication_administrations");
+        }
+    }
+}
@@ -250,6 +250,60 @@ namespace VigilCareClinicalAPI.Migrations
                        });
                });

+            modelBuilder.Entity("MedicationAdministration", b =>
+                {
+                    b.Property<Guid>("Id")
+                        .ValueGeneratedOnAdd()
+                        .HasColumnType("uuid")
+                        .HasColumnName("id")
+                        .HasDefaultValueSql("gen_random_uuid()");
+
+                    b.Property<DateTimeOffset>("AdministeredAt")
+                        .HasColumnType("timestamp with time zone")
+                        .HasColumnName("administered_at");
+
+                    b.Property<string>("AdministeredBy")
+                        .IsRequired()
+                        .HasMaxLength(100)
+                        .HasColumnType("character varying(100)")
+                        .HasColumnName("administered_by");
+
+                    b.Property<decimal>("Dose")
+                        .HasPrecision(10, 4)
+                        .HasColumnType("numeric(10,4)")
+                        .HasColumnName("dose");
+
+                    b.Property<string>("DoseUnit")
+                        .IsRequired()
+                        .HasMaxLength(20)
+                        .HasColumnType("character varying(20)")
+                        .HasColumnName("dose_unit");
+
+                    b.Property<string>("DrugName")
+                        .IsRequired()
+                        .HasMaxLength(200)
+                        .HasColumnType("character varying(200)")
+                        .HasColumnName("drug_name");
+
+                    b.Property<Guid>("EncounterId")
+                        .HasColumnType("uuid")
+                        .HasColumnName("encounter_id");
+
+                    b.Property<string>("Route")
+                        .IsRequired()
+                        .HasMaxLength(50)
+                        .HasColumnType("character varying(50)")
+                        .HasColumnName("route");
+
+                    b.HasKey("Id");
+
+                    b.HasIndex("EncounterId", "AdministeredAt");
+
+                    b.HasIndex("EncounterId", "DrugName");
+
+                    b.ToTable("medication_administrations", (string)null);
+                });
+
            modelBuilder.Entity("News2Score", b =>
                {
                    b.Property<Guid>("Id")
@@ -753,6 +807,17 @@ namespace VigilCareClinicalAPI.Migrations
                    b.Navigation("Patient");
                });

+            modelBuilder.Entity("MedicationAdministration", b =>
+                {
+                    b.HasOne("Encounter", "Encounter")
+                        .WithMany()
+                        .HasForeignKey("EncounterId")
+                        .OnDelete(DeleteBehavior.Restrict)
+                        .IsRequired();
+
+                    b.Navigation("Encounter");
+                });
+
            modelBuilder.Entity("News2Score", b =>
                {
                    b.HasOne("Encounter", "Encounter")
@@ -0,0 +1,7 @@
+public record CreateMedicationAdministrationRequest(
+    string DrugName,
+    decimal Dose,
+    string DoseUnit,
+    string Route,
+    DateTimeOffset? AdministeredAt,  // null = now
+    string AdministeredBy);
@@ -172,6 +172,18 @@ public class News2Detector
        var triggeredAt = DateTimeOffset.UtcNow;
        var details = BuildDetails(totalScore, riskLevel, paramScores);

+        var correlation = scope.ServiceProvider.GetRequiredService<MedicationCorrelationHelper>();
+        var annotatedParts = new List<string>();
+        foreach (var code in News2Calculator.ParameterCodes)
+        {
+            var part = await correlation.TryAnnotateDetailsAsync(
+                encounterId, code, "", ct);
+            if (part.StartsWith(" — note:"))
+                annotatedParts.Add(part.TrimStart(' ', '—').Trim());
+        }
+        if (annotatedParts.Count > 0)
+            details += " — " + string.Join("; ", annotatedParts.Distinct());
+
        var affected = await db.Database.ExecuteSqlInterpolatedAsync($"""
            INSERT INTO clinical_alerts
                (id, encounter_id, patient_id, alert_type, severity, details, status, triggered_at)
@@ -71,6 +71,9 @@ try
    builder.Services.Configure<SuppressionOptions>(
    builder.Configuration.GetSection(SuppressionOptions.SectionName));

+    builder.Services.Configure<MedicationCorrelationOptions>(
+    builder.Configuration.GetSection(MedicationCorrelationOptions.SectionName));
+
    builder.Services.AddScoped<IPatientService, PatientService>();
    builder.Services.AddScoped<IEncounterService, EncounterService>();
    builder.Services.AddScoped<IAlertThresholdService, AlertThresholdService>();
@@ -92,7 +95,9 @@ try
    builder.Services.AddScoped<News2Detector>();
    builder.Services.AddScoped<TrendDetector>();
    builder.Services.AddSingleton<IAlertSuppressionService, AlertSuppressionService>();
-
+    builder.Services.AddScoped<IMedicationService, MedicationService>();
+    builder.Services.AddScoped<MedicationCorrelationHelper>();
+    
    builder.Services.AddHostedService<ThresholdCacheLoader>();
    builder.Services.AddHostedService<KafkaTopicProvisioner>();
    builder.Services.AddHostedService<OutboxRelayService>();
@@ -0,0 +1,10 @@
+public interface IMedicationService
+{
+    Task<MedicationAdministration> CreateAsync(
+        Guid encounterId, CreateMedicationAdministrationRequest req);
+    Task<PagedResult<MedicationAdministration>> ListByEncounterAsync(
+        Guid encounterId, DateTimeOffset? since, int page, int pageSize);
+    Task<MedicationAdministration> GetByIdAsync(Guid id);
+    Task<IReadOnlyList<MedicationAdministration>> GetRecentForEncounterAsync(
+        Guid encounterId, string observationCode, int windowMinutes);
+}
@@ -0,0 +1,102 @@
+using Microsoft.EntityFrameworkCore;
+using Microsoft.Extensions.Options;
+
+public class MedicationService : IMedicationService
+{
+    private readonly AppDbContext _db;
+    private readonly MedicationCorrelationOptions _correlationOptions;
+
+    public MedicationService(
+        AppDbContext db,
+        IOptions<MedicationCorrelationOptions> correlationOptions)
+    {
+        _db = db;
+        _correlationOptions = correlationOptions.Value;
+    }
+
+    public async Task<MedicationAdministration> CreateAsync(
+        Guid encounterId, CreateMedicationAdministrationRequest req)
+    {
+        var encounter = await _db.Encounters.FindAsync(encounterId);
+        if (encounter is null)
+            throw new NotFoundException("Encounter not found.", "ENCOUNTER_NOT_FOUND");
+
+        if (encounter.Status != EncounterStatus.Active)
+            throw new ConflictException(
+                "Cannot record medications for a non-active encounter.",
+                "ENCOUNTER_NOT_ACTIVE");
+
+        var med = new MedicationAdministration
+        {
+            Id = Guid.NewGuid(),
+            EncounterId = encounterId,
+            DrugName = req.DrugName.Trim(),
+            Dose = req.Dose,
+            DoseUnit = req.DoseUnit.Trim(),
+            Route = req.Route.Trim(),
+            AdministeredAt = req.AdministeredAt ?? DateTimeOffset.UtcNow,
+            AdministeredBy = req.AdministeredBy.Trim()
+        };
+
+        _db.MedicationAdministrations.Add(med);
+        await _db.SaveChangesAsync();
+        return med;
+    }
+
+    public async Task<MedicationAdministration> GetByIdAsync(Guid id)
+    {
+        var med = await _db.MedicationAdministrations
+            .AsNoTracking()
+            .Include(m => m.Encounter)
+            .FirstOrDefaultAsync(m => m.Id == id);
+
+        if (med is null)
+            throw new NotFoundException("Medication administration not found.", "MEDICATION_NOT_FOUND");
+
+        return med;
+    }
+
+    public async Task<IReadOnlyList<MedicationAdministration>> GetRecentForEncounterAsync(
+        Guid encounterId, string observationCode, int windowMinutes)
+    {
+        var cutoff = DateTimeOffset.UtcNow.AddMinutes(-windowMinutes);
+        var mappings = _correlationOptions.DrugVitalMappings;
+
+        // Find drugs that affect this observation code
+        var relevantDrugs = mappings
+            .Where(kv => kv.Value.Contains(observationCode, StringComparer.OrdinalIgnoreCase))
+            .Select(kv => kv.Key)
+            .ToHashSet(StringComparer.OrdinalIgnoreCase);
+
+        if (relevantDrugs.Count == 0)
+            return Array.Empty<MedicationAdministration>();
+
+        return await _db.MedicationAdministrations
+            .AsNoTracking()
+            .Where(m => m.EncounterId == encounterId
+                     && m.AdministeredAt >= cutoff
+                     && relevantDrugs.Contains(m.DrugName.ToLower()))
+            .OrderByDescending(m => m.AdministeredAt)
+            .ToListAsync();
+    }
+
+    public async Task<PagedResult<MedicationAdministration>> ListByEncounterAsync(
+        Guid encounterId, DateTimeOffset? since, int page, int pageSize)
+    {
+        var query = _db.MedicationAdministrations
+            .AsNoTracking()
+            .Where(m => m.EncounterId == encounterId);
+
+        if (since.HasValue)
+            query = query.Where(m => m.AdministeredAt >= since.Value);
+
+        var total = await query.CountAsync();
+        var items = await query
+            .OrderByDescending(m => m.AdministeredAt)
+            .Skip((page - 1) * pageSize)
+            .Take(pageSize)
+            .ToListAsync();
+
+        return new PagedResult<MedicationAdministration>(items, page, pageSize, total);
+    }
+}
@@ -6,12 +6,12 @@ public static class PlausibilityValidator
    private static readonly Dictionary<string, (decimal Min, decimal Max)> _ranges = new()
    {
        ["HEART_RATE"]       = (1,    300),
-        ["TEMP_C"]           = (20,   50),
-        ["POTASSIUM_MEQ_L"]  = (0.1m, 15),
+        ["TEMP_C"]           = (15,   50),
+        ["POTASSIUM_MEQ_L"]  = (0.1m, 12),
        ["SPO2"]             = (50,   100),
        ["RESP_RATE"]        = (1,    80),
        ["WBC_K_UL"]         = (0.1m, 500),
-        ["GLUCOSE_MG_DL"]    = (10,   1500),
+        ["GLUCOSE_MG_DL"]    = (10,   1000),
        ["SYSTOLIC_BP"]     = (40,    300),
        ["DIASTOLIC_BP"]    = (20,    200),
        ["LACTATE_MMOL_L"]  = (0.1m,  30),
@@ -90,6 +90,10 @@ public class WarningEvaluator
        var triggeredAt = DateTimeOffset.UtcNow;
        var details = BuildWarningDetails(observationCode, value, threshold);

+        var correlation = scope.ServiceProvider.GetRequiredService<MedicationCorrelationHelper>();
+        details = await correlation.TryAnnotateDetailsAsync(
+            encounterId, observationCode, details, ct);
+
        var affected = await db.Database.ExecuteSqlInterpolatedAsync($"""
            INSERT INTO clinical_alerts
                (id, encounter_id, patient_id, observation_id, alert_type, severity, details, status, triggered_at)
@@ -0,0 +1,18 @@
+using FluentValidation;
+
+public class CreateMedicationAdministrationRequestValidator
+    : AbstractValidator<CreateMedicationAdministrationRequest>
+{
+    public CreateMedicationAdministrationRequestValidator()
+    {
+        RuleFor(x => x.DrugName).NotEmpty().MaximumLength(200);
+        RuleFor(x => x.Dose).GreaterThan(0);
+        RuleFor(x => x.DoseUnit).NotEmpty().MaximumLength(20);
+        RuleFor(x => x.Route).NotEmpty().MaximumLength(50);
+        RuleFor(x => x.AdministeredBy).NotEmpty().MaximumLength(100);
+        RuleFor(x => x.AdministeredAt)
+            .LessThanOrEqualTo(DateTimeOffset.UtcNow.AddMinutes(5))
+            .When(x => x.AdministeredAt.HasValue)
+            .WithMessage("AdministeredAt cannot be in the future.");
+    }
+}
@@ -93,5 +93,65 @@
  },
  "AlertSuppression": {
    "DefaultWindowMinutes": 30
+  },
+  "MedicationCorrelation": {
+    "CorrelationWindowMinutes": 90,
+    "DrugVitalMappings": {
+      "metoprolol": ["SYSTOLIC_BP", "HEART_RATE", "DIASTOLIC_BP"],
+      "labetalol": ["SYSTOLIC_BP", "HEART_RATE", "DIASTOLIC_BP"],
+      "atenolol": ["SYSTOLIC_BP", "HEART_RATE", "DIASTOLIC_BP"],
+      "propranolol": ["SYSTOLIC_BP", "HEART_RATE", "DIASTOLIC_BP"],
+      "esmolol": ["SYSTOLIC_BP", "HEART_RATE", "DIASTOLIC_BP"],
+      "carvedilol": ["SYSTOLIC_BP", "HEART_RATE", "DIASTOLIC_BP"],
+
+      "norepinephrine": ["SYSTOLIC_BP", "DIASTOLIC_BP", "HEART_RATE"],
+      "epinephrine": ["SYSTOLIC_BP", "DIASTOLIC_BP", "HEART_RATE", "GLUCOSE_MG_DL"],
+      "vasopressin": ["SYSTOLIC_BP", "DIASTOLIC_BP"],
+      "dopamine": ["SYSTOLIC_BP", "DIASTOLIC_BP", "HEART_RATE"],
+      "dobutamine": ["SYSTOLIC_BP", "HEART_RATE"],
+      "phenylephrine": ["SYSTOLIC_BP", "DIASTOLIC_BP", "HEART_RATE"],
+
+      "diltiazem": ["HEART_RATE", "SYSTOLIC_BP", "DIASTOLIC_BP"],
+      "verapamil": ["HEART_RATE", "SYSTOLIC_BP", "DIASTOLIC_BP"],
+      "amlodipine": ["SYSTOLIC_BP", "DIASTOLIC_BP"],
+      "nicardipine": ["SYSTOLIC_BP", "DIASTOLIC_BP", "HEART_RATE"],
+
+      "nitroglycerin": ["SYSTOLIC_BP", "DIASTOLIC_BP", "HEART_RATE"],
+      "nitroprusside": ["SYSTOLIC_BP", "DIASTOLIC_BP", "HEART_RATE"],
+      "hydralazine": ["SYSTOLIC_BP", "DIASTOLIC_BP", "HEART_RATE"],
+
+      "morphine": ["RESP_RATE", "SPO2", "SYSTOLIC_BP", "HEART_RATE"],
+      "fentanyl": ["RESP_RATE", "SPO2", "HEART_RATE"],
+      "hydromorphone": ["RESP_RATE", "SPO2", "SYSTOLIC_BP"],
+      "remifentanil": ["RESP_RATE", "SPO2", "HEART_RATE"],
+
+      "propofol": ["RESP_RATE", "SPO2", "SYSTOLIC_BP", "HEART_RATE"],
+      "midazolam": ["RESP_RATE", "SPO2"],
+      "lorazepam": ["RESP_RATE", "SPO2"],
+      "ketamine": ["HEART_RATE", "SYSTOLIC_BP", "RESP_RATE"],
+
+      "amiodarone": ["HEART_RATE", "SYSTOLIC_BP"],
+      "adenosine": ["HEART_RATE"],
+      "digoxin": ["HEART_RATE"],
+      "atropine": ["HEART_RATE"],
+
+      "heparin": ["HEART_RATE"],
+
+      "acetaminophen": ["TEMP_C"],
+      "ibuprofen": ["TEMP_C"],
+
+      "insulin": ["GLUCOSE_MG_DL"],
+      "dextrose": ["GLUCOSE_MG_DL"],
+      "glucagon": ["GLUCOSE_MG_DL"],
+
+      "dexamethasone": ["GLUCOSE_MG_DL", "TEMP_C"],
+      "methylprednisolone": ["GLUCOSE_MG_DL", "TEMP_C"],
+      "hydrocortisone": ["GLUCOSE_MG_DL", "TEMP_C"],
+      "prednisone": ["GLUCOSE_MG_DL", "TEMP_C"],
+
+      "furosemide": ["SYSTOLIC_BP", "DIASTOLIC_BP"],
+
+      "albuterol": ["HEART_RATE", "SPO2"]
+    }
  }
 }
@@ -0,0 +1,88 @@
+{
+  "scenario": {
+    "id": "cardiac-ward-01",
+    "name": "Cardiac Ward — Atrial Fibrillation with Rapid Ventricular Response",
+    "description": "78-year-old woman on cardiac ward with known AF. Rate-controlled on admission but develops rapid ventricular response over 3 hours. Heart rate climbs while other vitals remain relatively stable — tests whether the system correctly alerts on isolated tachycardia escalation.",
+    "durationMinutes": 180,
+    "tags": ["cardiac", "afib", "tachycardia", "single-parameter"]
+  },
+  "patient": {
+    "firstName": "Margaret",
+    "lastName": "Tsai",
+    "dateOfBirth": "1948-01-28",
+    "gender": "Female",
+    "mrn": "SIM-005"
+  },
+  "encounter": {
+    "department": "Cardiac",
+    "room": "CARD-2A",
+    "bed": "1",
+    "encounterType": "Inpatient",
+    "chiefComplaint": "Atrial fibrillation — rate control monitoring"
+  },
+  "events": [
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "HEART_RATE", "value": 82, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "RESP_RATE", "value": 16, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 138, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 84, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "TEMP_C", "value": 36.6, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "SPO2", "value": 96, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 30, "type": "observation", "data": { "code": "HEART_RATE", "value": 88, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 30, "type": "observation", "data": { "code": "RESP_RATE", "value": 16, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 30, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 134, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 30, "type": "observation", "data": { "code": "TEMP_C", "value": 36.7, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 30, "type": "observation", "data": { "code": "SPO2", "value": 96, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 30, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "HEART_RATE", "value": 98, "unit": "bpm", "source": "monitor" }, "note": "HR climbing — AF losing rate control" },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "RESP_RATE", "value": 17, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 130, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 82, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "TEMP_C", "value": 36.7, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "SPO2", "value": 96, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "HEART_RATE", "value": 112, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "RESP_RATE", "value": 18, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 126, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 80, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "TEMP_C", "value": 36.8, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "SPO2", "value": 95, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "HEART_RATE", "value": 128, "unit": "bpm", "source": "monitor" }, "note": "Rapid ventricular response" },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "RESP_RATE", "value": 20, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 118, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 76, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "TEMP_C", "value": 36.8, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "SPO2", "value": 94, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 130, "type": "medication", "data": { "drugName": "metoprolol", "dose": 5, "doseUnit": "mg", "route": "IV", "administeredBy": "nurse-rn-3" }, "note": "IV metoprolol for rate control" },
+
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "HEART_RATE", "value": 136, "unit": "bpm", "source": "monitor" }, "note": "Not yet responding to IV metoprolol" },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "RESP_RATE", "value": 22, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 112, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 72, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "TEMP_C", "value": 36.9, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "SPO2", "value": 93, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "HEART_RATE", "value": 108, "unit": "bpm", "source": "monitor" }, "note": "Rate starting to respond" },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "RESP_RATE", "value": 19, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 120, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 76, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "TEMP_C", "value": 36.8, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "SPO2", "value": 95, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } }
+  ],
+  "expectedOutcomes": [
+    { "afterOffsetMinutes": 60, "type": "alert", "alertType": "WARNING_HEART_RATE", "description": "HR 98 enters warning range" },
+    { "afterOffsetMinutes": 90, "type": "alert", "alertType": "RAPID_DETERIORATION", "description": "HR climbed 82→112 in 90 minutes" },
+    { "afterOffsetMinutes": 120, "type": "score", "scoreType": "NEWS2", "expectedMinimum": 5, "description": "NEWS2 medium risk from HR + SpO2 contributions" },
+    { "afterOffsetMinutes": 120, "type": "alert", "alertType": "NEWS2_WARNING", "description": "NEWS2 5-6" },
+    { "afterOffsetMinutes": 150, "type": "alert", "alertType": "NEWS2_EMERGENCY", "description": "NEWS2 ≥7 — HR scores 3 (≥131), SpO2 falling" }
+  ]
+}
@@ -0,0 +1,84 @@
+{
+  "scenario": {
+    "id": "hypothermia-elderly-01",
+    "name": "Elderly Hypothermia — Subtle Deterioration",
+    "description": "85-year-old woman brought from nursing home with low-grade hypothermia and confusion. Vitals look deceptively near-normal except low temperature and altered mentation. Tests whether the system catches the NEWS2 escalation from temperature and AVPU contributions that are easy to miss clinically.",
+    "durationMinutes": 180,
+    "tags": ["elderly", "hypothermia", "subtle", "avpu", "nursing-home"]
+  },
+  "patient": {
+    "firstName": "Mei-Ling",
+    "lastName": "Wu",
+    "dateOfBirth": "1941-04-12",
+    "gender": "Female",
+    "mrn": "SIM-006"
+  },
+  "encounter": {
+    "department": "Emergency",
+    "room": "ED-5",
+    "bed": "B",
+    "encounterType": "Emergency",
+    "chiefComplaint": "Found confused and cold at nursing home, not eating for 2 days"
+  },
+  "events": [
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "HEART_RATE", "value": 68, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "RESP_RATE", "value": 14, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 118, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 72, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "TEMP_C", "value": 35.8, "unit": "°C", "source": "manual" }, "note": "Low-normal temperature" },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "SPO2", "value": 96, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "AVPU", "value": 1, "unit": "score", "source": "manual" }, "note": "Responds to voice — confused" },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "GLUCOSE_MG_DL", "value": 62, "unit": "mg/dL", "source": "lab" }, "note": "Borderline hypoglycemia" },
+
+    { "offsetMinutes": 45, "type": "observation", "data": { "code": "HEART_RATE", "value": 64, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 45, "type": "observation", "data": { "code": "RESP_RATE", "value": 13, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 45, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 114, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 45, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 70, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 45, "type": "observation", "data": { "code": "TEMP_C", "value": 35.4, "unit": "°C", "source": "manual" }, "note": "Temperature dropping further" },
+    { "offsetMinutes": 45, "type": "observation", "data": { "code": "SPO2", "value": 96, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 45, "type": "observation", "data": { "code": "AVPU", "value": 1, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "HEART_RATE", "value": 58, "unit": "bpm", "source": "monitor" }, "note": "Bradycardic — hypothermia effect" },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "RESP_RATE", "value": 11, "unit": "/min", "source": "manual" }, "note": "RR dropping — warning range" },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 108, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 66, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "TEMP_C", "value": 35.0, "unit": "°C", "source": "manual" }, "note": "Hypothermic — critical range" },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "SPO2", "value": 95, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "AVPU", "value": 2, "unit": "score", "source": "manual" }, "note": "Now responds to pain only" },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "GLUCOSE_MG_DL", "value": 54, "unit": "mg/dL", "source": "lab" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "WBC_K_UL", "value": 3.8, "unit": "×10³/µL", "source": "lab" }, "note": "Low WBC — possible immunosuppression" },
+
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "HEART_RATE", "value": 54, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "RESP_RATE", "value": 10, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 104, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 62, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "TEMP_C", "value": 34.8, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "SPO2", "value": 94, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "AVPU", "value": 2, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "HEART_RATE", "value": 50, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "RESP_RATE", "value": 9, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 100, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 58, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "TEMP_C", "value": 34.5, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "SPO2", "value": 93, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "AVPU", "value": 2, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "HEART_RATE", "value": 46, "unit": "bpm", "source": "monitor" }, "note": "HR in critical range" },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "RESP_RATE", "value": 8, "unit": "/min", "source": "manual" }, "note": "RR critical" },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 96, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 54, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "TEMP_C", "value": 34.2, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "SPO2", "value": 91, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "AVPU", "value": 3, "unit": "score", "source": "manual" }, "note": "Unresponsive — ICU transfer" }
+  ],
+  "expectedOutcomes": [
+    { "afterOffsetMinutes": 45, "type": "alert", "alertType": "WARNING_TEMP_C", "description": "Temp 35.4 enters warning range" },
+    { "afterOffsetMinutes": 90, "type": "alert", "alertType": "WARNING_RESP_RATE", "description": "RR 11 enters warning range" },
+    { "afterOffsetMinutes": 90, "type": "score", "scoreType": "NEWS2", "expectedMinimum": 7, "description": "NEWS2 HIGH — temp 3pts + AVPU 3pts + RR + low WBC" },
+    { "afterOffsetMinutes": 90, "type": "alert", "alertType": "NEWS2_EMERGENCY", "description": "NEWS2 ≥7 with AVPU score 3" },
+    { "afterOffsetMinutes": 90, "type": "alert", "alertType": "QSOFA_WARNING", "description": "qSOFA ≥2: AVPU 2 + RR borderline — depends on exact threshold" },
+    { "afterOffsetMinutes": 90, "type": "alert", "alertType": "SEPSIS_WARNING", "description": "SIRS: temp <36, WBC <4 — possible sepsis in elderly" },
+    { "afterOffsetMinutes": 180, "type": "alert", "alertType": "RAPID_DETERIORATION", "description": "Multi-parameter decline: HR, RR, temp, SpO2 all trending down" }
+  ]
+}
@@ -0,0 +1,79 @@
+{
+  "scenario": {
+    "id": "medication-false-alarm-01",
+    "name": "Post-Metoprolol BP Drop — Expected Pharmacology",
+    "description": "68-year-old man admitted for hypertension management. Receives metoprolol for high BP. BP and HR drop into warning range afterward — this is the expected drug effect, not deterioration. Tests whether clinicians rate the post-medication alerts as false positives.",
+    "durationMinutes": 180,
+    "tags": ["medication", "false-positive", "hypertension", "expected-response"]
+  },
+  "patient": {
+    "firstName": "David",
+    "lastName": "Huang",
+    "dateOfBirth": "1958-11-03",
+    "gender": "Male",
+    "mrn": "SIM-004"
+  },
+  "encounter": {
+    "department": "Medical",
+    "room": "MED-7A",
+    "bed": "2",
+    "encounterType": "Inpatient",
+    "chiefComplaint": "Uncontrolled hypertension, headache"
+  },
+  "events": [
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "HEART_RATE", "value": 92, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "RESP_RATE", "value": 16, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 168, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 98, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "TEMP_C", "value": 36.9, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "SPO2", "value": 97, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 30, "type": "medication", "data": { "drugName": "metoprolol", "dose": 50, "doseUnit": "mg", "route": "PO", "administeredBy": "nurse-rn-2" }, "note": "Metoprolol administered for BP control" },
+
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "HEART_RATE", "value": 78, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "RESP_RATE", "value": 15, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 142, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 88, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "TEMP_C", "value": 36.8, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "SPO2", "value": 97, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "HEART_RATE", "value": 64, "unit": "bpm", "source": "monitor" }, "note": "HR dropping — expected metoprolol effect" },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "RESP_RATE", "value": 14, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 118, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 76, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "TEMP_C", "value": 36.8, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "SPO2", "value": 98, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "HEART_RATE", "value": 56, "unit": "bpm", "source": "monitor" }, "note": "HR in low range — metoprolol peak effect" },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "RESP_RATE", "value": 14, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 106, "unit": "mmHg", "source": "manual" }, "note": "SBP approaching warning range" },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 68, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "TEMP_C", "value": 36.7, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "SPO2", "value": 97, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "HEART_RATE", "value": 52, "unit": "bpm", "source": "monitor" }, "note": "HR 52 — warning range but expected" },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "RESP_RATE", "value": 13, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 102, "unit": "mmHg", "source": "manual" }, "note": "SBP 102 — warning range but expected" },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 64, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "TEMP_C", "value": 36.7, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "SPO2", "value": 98, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "HEART_RATE", "value": 58, "unit": "bpm", "source": "monitor" }, "note": "Stabilizing — effect wearing off slightly" },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "RESP_RATE", "value": 14, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 110, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 70, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "TEMP_C", "value": 36.8, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "SPO2", "value": 97, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } }
+  ],
+  "expectedOutcomes": [
+    { "afterOffsetMinutes": 120, "type": "alert", "alertType": "WARNING_SYSTOLIC_BP", "description": "SBP 106 enters warning range — should be annotated with metoprolol context if Phase 15 active" },
+    { "afterOffsetMinutes": 150, "type": "alert", "alertType": "WARNING_HEART_RATE", "description": "HR 52 enters low warning range — expected metoprolol effect" },
+    { "afterOffsetMinutes": 150, "type": "alert", "alertType": "RAPID_DETERIORATION", "description": "HR dropped 92→52 and SBP dropped 168→102 — trajectory alert, but pharmacologically expected" }
+  ]
+}
@@ -0,0 +1,87 @@
+{
+  "scenario": {
+    "id": "post-op-pain-01",
+    "name": "Post-Operative Pain Crisis — Opioid Effect on Respiratory Rate",
+    "description": "45-year-old woman post-abdominal surgery with escalating pain. Morphine administered at 30 minutes. Respiratory rate drops to warning range afterward — expected opioid effect. Heart rate rises from pain before medication, then normalizes. Tests whether clinicians distinguish pain-related tachycardia from pathological tachycardia, and opioid-related respiratory depression from deterioration.",
+    "durationMinutes": 180,
+    "tags": ["post-op", "pain", "opioid", "respiratory-depression", "medication-effect"]
+  },
+  "patient": {
+    "firstName": "Sarah",
+    "lastName": "Lin",
+    "dateOfBirth": "1981-09-17",
+    "gender": "Female",
+    "mrn": "SIM-007"
+  },
+  "encounter": {
+    "department": "Surgical",
+    "room": "SURG-6C",
+    "bed": "1",
+    "encounterType": "Inpatient",
+    "chiefComplaint": "Post-op day 0 — open appendectomy (complicated appendicitis)"
+  },
+  "events": [
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "HEART_RATE", "value": 86, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "RESP_RATE", "value": 16, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 134, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 82, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "TEMP_C", "value": 37.4, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "SPO2", "value": 97, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 20, "type": "observation", "data": { "code": "HEART_RATE", "value": 104, "unit": "bpm", "source": "monitor" }, "note": "Tachycardia from pain" },
+    { "offsetMinutes": 20, "type": "observation", "data": { "code": "RESP_RATE", "value": 20, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 20, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 146, "unit": "mmHg", "source": "manual" }, "note": "Hypertensive from pain" },
+    { "offsetMinutes": 20, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 92, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 20, "type": "observation", "data": { "code": "TEMP_C", "value": 37.5, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 20, "type": "observation", "data": { "code": "SPO2", "value": 97, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 20, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 30, "type": "medication", "data": { "drugName": "morphine", "dose": 4, "doseUnit": "mg", "route": "IV", "administeredBy": "nurse-rn-4" }, "note": "Morphine for post-op pain" },
+
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "HEART_RATE", "value": 82, "unit": "bpm", "source": "monitor" }, "note": "HR normalizing with pain relief" },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "RESP_RATE", "value": 14, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 126, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 78, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "TEMP_C", "value": 37.4, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "SPO2", "value": 96, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "HEART_RATE", "value": 76, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "RESP_RATE", "value": 10, "unit": "/min", "source": "manual" }, "note": "RR dropping — morphine respiratory depression" },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 118, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 72, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "TEMP_C", "value": 37.3, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "SPO2", "value": 95, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "HEART_RATE", "value": 74, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "RESP_RATE", "value": 9, "unit": "/min", "source": "manual" }, "note": "RR 9 — warning range" },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 116, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 70, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "TEMP_C", "value": 37.2, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "SPO2", "value": 94, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "HEART_RATE", "value": 76, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "RESP_RATE", "value": 11, "unit": "/min", "source": "manual" }, "note": "RR recovering slowly" },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 120, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 74, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "TEMP_C", "value": 37.3, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "SPO2", "value": 95, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "HEART_RATE", "value": 78, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "RESP_RATE", "value": 13, "unit": "/min", "source": "manual" }, "note": "RR normalizing" },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 122, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 76, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "TEMP_C", "value": 37.4, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "SPO2", "value": 96, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } }
+  ],
+  "expectedOutcomes": [
+    { "afterOffsetMinutes": 20, "type": "alert", "alertType": "WARNING_HEART_RATE", "description": "HR 104 — pain-related tachycardia, not pathological" },
+    { "afterOffsetMinutes": 90, "type": "alert", "alertType": "WARNING_RESP_RATE", "description": "RR 10 enters warning range — morphine respiratory depression" },
+    { "afterOffsetMinutes": 120, "type": "alert", "alertType": "RAPID_DETERIORATION", "description": "RR dropped 20→9 — trajectory alert but pharmacologically expected" }
+  ]
+}
@@ -0,0 +1,96 @@
+{
+  "scenario": {
+    "id": "respiratory-failure-01",
+    "name": "Post-Surgical Respiratory Deterioration",
+    "description": "55-year-old man on surgical ward after abdominal surgery. Stable for 2 hours, then gradual respiratory deterioration: falling SpO2, rising RR, supplemental oxygen started. NEWS2 reaches HIGH risk by hour 3.",
+    "durationMinutes": 240,
+    "tags": ["respiratory", "surgical", "deterioration", "supplemental-o2"]
+  },
+  "patient": {
+    "firstName": "Robert",
+    "lastName": "Wang",
+    "dateOfBirth": "1971-08-22",
+    "gender": "Male",
+    "mrn": "SIM-002"
+  },
+  "encounter": {
+    "department": "Surgical",
+    "room": "SURG-4B",
+    "bed": "1",
+    "encounterType": "Inpatient",
+    "chiefComplaint": "Post-op day 1 — laparoscopic cholecystectomy"
+  },
+  "events": [
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "HEART_RATE", "value": 76, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "RESP_RATE", "value": 14, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 132, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 82, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "TEMP_C", "value": 37.0, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "SPO2", "value": 98, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "HEART_RATE", "value": 78, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "RESP_RATE", "value": 15, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 130, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 80, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "TEMP_C", "value": 37.1, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "SPO2", "value": 97, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "HEART_RATE", "value": 82, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "RESP_RATE", "value": 18, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 126, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 78, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "TEMP_C", "value": 37.3, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "SPO2", "value": 95, "unit": "%", "source": "monitor" }, "note": "SpO2 starting to drift down" },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 140, "type": "observation", "data": { "code": "HEART_RATE", "value": 88, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 140, "type": "observation", "data": { "code": "RESP_RATE", "value": 21, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 140, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 124, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 140, "type": "observation", "data": { "code": "TEMP_C", "value": 37.4, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 140, "type": "observation", "data": { "code": "SPO2", "value": 93, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 140, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "SUPPLEMENTAL_O2", "value": 1, "unit": "flag", "source": "manual" }, "note": "Nurse starts 2L nasal cannula" },
+
+    { "offsetMinutes": 160, "type": "observation", "data": { "code": "HEART_RATE", "value": 94, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 160, "type": "observation", "data": { "code": "RESP_RATE", "value": 24, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 160, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 120, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 160, "type": "observation", "data": { "code": "TEMP_C", "value": 37.5, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 160, "type": "observation", "data": { "code": "SPO2", "value": 92, "unit": "%", "source": "monitor" }, "note": "SpO2 92 despite supplemental O2" },
+    { "offsetMinutes": 160, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "HEART_RATE", "value": 102, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "RESP_RATE", "value": 26, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 118, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "TEMP_C", "value": 37.6, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "SPO2", "value": 90, "unit": "%", "source": "monitor" }, "note": "SpO2 dropping further" },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "SUPPLEMENTAL_O2", "value": 1, "unit": "flag", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 210, "type": "observation", "data": { "code": "HEART_RATE", "value": 108, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 210, "type": "observation", "data": { "code": "RESP_RATE", "value": 28, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 210, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 116, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 210, "type": "observation", "data": { "code": "TEMP_C", "value": 37.7, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 210, "type": "observation", "data": { "code": "SPO2", "value": 88, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 210, "type": "observation", "data": { "code": "SUPPLEMENTAL_O2", "value": 1, "unit": "flag", "source": "manual" } },
+    { "offsetMinutes": 210, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 240, "type": "observation", "data": { "code": "HEART_RATE", "value": 112, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 240, "type": "observation", "data": { "code": "RESP_RATE", "value": 30, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 240, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 114, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 240, "type": "observation", "data": { "code": "TEMP_C", "value": 37.8, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 240, "type": "observation", "data": { "code": "SPO2", "value": 86, "unit": "%", "source": "monitor" }, "note": "Critical desaturation — ICU consult called" },
+    { "offsetMinutes": 240, "type": "observation", "data": { "code": "SUPPLEMENTAL_O2", "value": 1, "unit": "flag", "source": "manual" } },
+    { "offsetMinutes": 240, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } }
+  ],
+  "expectedOutcomes": [
+    { "afterOffsetMinutes": 140, "type": "alert", "alertType": "WARNING_RESP_RATE", "description": "RR 21 enters warning range" },
+    { "afterOffsetMinutes": 140, "type": "score", "scoreType": "NEWS2", "expectedMinimum": 4, "description": "NEWS2 rising from SpO2 and RR contributions" },
+    { "afterOffsetMinutes": 160, "type": "alert", "alertType": "NEWS2_WARNING", "description": "NEWS2 5-6 with supplemental O2 + low SpO2 + high RR" },
+    { "afterOffsetMinutes": 160, "type": "alert", "alertType": "RAPID_DETERIORATION", "description": "SpO2 dropping 98→92 over short window" },
+    { "afterOffsetMinutes": 180, "type": "alert", "alertType": "NEWS2_EMERGENCY", "description": "NEWS2 ≥7 with critical SpO2 on supplemental O2" },
+    { "afterOffsetMinutes": 210, "type": "alert", "alertType": "WARNING_HEART_RATE", "description": "HR 108 enters warning range" }
+  ]
+}
@@ -0,0 +1,111 @@
+{
+  "scenario": {
+    "id": "sepsis-ed-01",
+    "name": "ED Sepsis Deterioration — UTI Source",
+    "description": "72-year-old woman presents to ED with UTI symptoms. Over 4 hours she develops sepsis: rising temperature, tachycardia, hypotension. Antibiotics started at 1 hour. Sepsis bundle completed by hour 2.",
+    "durationMinutes": 240,
+    "tags": ["sepsis", "ed", "deterioration", "bundle-completion"]
+  },
+  "patient": {
+    "firstName": "Eleanor",
+    "lastName": "Chen",
+    "dateOfBirth": "1954-03-15",
+    "gender": "Female",
+    "mrn": "SIM-001"
+  },
+  "encounter": {
+    "department": "Emergency",
+    "room": "ED-12",
+    "bed": "A",
+    "encounterType": "Emergency",
+    "chiefComplaint": "Fever, confusion, dysuria for 2 days"
+  },
+  "events": [
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "HEART_RATE", "value": 88, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "RESP_RATE", "value": 18, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 128, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 78, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "TEMP_C", "value": 38.2, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "SPO2", "value": 97, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 30, "type": "observation", "data": { "code": "HEART_RATE", "value": 94, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 30, "type": "observation", "data": { "code": "RESP_RATE", "value": 20, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 30, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 122, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 30, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 74, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 30, "type": "observation", "data": { "code": "TEMP_C", "value": 38.6, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 30, "type": "observation", "data": { "code": "SPO2", "value": 96, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 30, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+    { "offsetMinutes": 30, "type": "observation", "data": { "code": "WBC_K_UL", "value": 14.2, "unit": "×10³/µL", "source": "lab" }, "note": "Initial labs — elevated WBC" },
+
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "HEART_RATE", "value": 105, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "RESP_RATE", "value": 22, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 112, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 68, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "TEMP_C", "value": 39.1, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "SPO2", "value": 95, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 65, "type": "medication", "data": { "drugName": "ceftriaxone", "dose": 2, "doseUnit": "g", "route": "IV", "administeredBy": "nurse-rn-1" }, "note": "Broad-spectrum antibiotics started" },
+
+    { "offsetMinutes": 75, "type": "order_result", "data": { "orderDescription": "SEP-1: Blood cultures", "resultValue": "2 sets drawn — pending", "resultedBy": "nurse-rn-1" } },
+    { "offsetMinutes": 80, "type": "order_result", "data": { "orderDescription": "SEP-1: Serum lactate", "resultValue": "2.8 mmol/L", "resultedBy": "lab-tech-1" } },
+
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "HEART_RATE", "value": 112, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "RESP_RATE", "value": 24, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 102, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 62, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "TEMP_C", "value": 39.3, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "SPO2", "value": 94, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "AVPU", "value": 1, "unit": "score", "source": "manual" }, "note": "Patient confused — responds to voice" },
+    { "offsetMinutes": 90, "type": "observation", "data": { "code": "LACTATE_MMOL_L", "value": 2.8, "unit": "mmol/L", "source": "lab" } },
+
+    { "offsetMinutes": 100, "type": "order_result", "data": { "orderDescription": "SEP-1: Broad-spectrum antibiotics", "resultValue": "Ceftriaxone 2g IV administered", "resultedBy": "nurse-rn-1" } },
+    { "offsetMinutes": 105, "type": "order_result", "data": { "orderDescription": "SEP-1: IV fluid bolus", "resultValue": "1L NS bolus started", "resultedBy": "nurse-rn-1" } },
+
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "HEART_RATE", "value": 118, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "RESP_RATE", "value": 26, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 96, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 58, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "TEMP_C", "value": 39.4, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "SPO2", "value": 93, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "AVPU", "value": 1, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "HEART_RATE", "value": 115, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "RESP_RATE", "value": 24, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 100, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 60, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "TEMP_C", "value": 39.0, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "SPO2", "value": 94, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "AVPU", "value": 1, "unit": "score", "source": "manual" } },
+    { "offsetMinutes": 150, "type": "observation", "data": { "code": "LACTATE_MMOL_L", "value": 3.4, "unit": "mmol/L", "source": "lab" }, "note": "Repeat lactate — rising" },
+
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "HEART_RATE", "value": 108, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "RESP_RATE", "value": 22, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 105, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 64, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "TEMP_C", "value": 38.7, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "SPO2", "value": 95, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" }, "note": "Mentation improving — alert again" },
+
+    { "offsetMinutes": 240, "type": "observation", "data": { "code": "HEART_RATE", "value": 98, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 240, "type": "observation", "data": { "code": "RESP_RATE", "value": 20, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 240, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 112, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 240, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 68, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 240, "type": "observation", "data": { "code": "TEMP_C", "value": 38.3, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 240, "type": "observation", "data": { "code": "SPO2", "value": 96, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 240, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+    { "offsetMinutes": 240, "type": "observation", "data": { "code": "LACTATE_MMOL_L", "value": 2.1, "unit": "mmol/L", "source": "lab" }, "note": "Lactate improving after fluids" }
+  ],
+  "expectedOutcomes": [
+    { "afterOffsetMinutes": 30, "type": "alert", "alertType": "WARNING_TEMP_C", "description": "Temperature 38.6 enters warning range" },
+    { "afterOffsetMinutes": 60, "type": "alert", "alertType": "WARNING_HEART_RATE", "description": "HR 105 enters warning range" },
+    { "afterOffsetMinutes": 60, "type": "alert", "alertType": "SEPSIS_WARNING", "description": "SIRS criteria met: temp >38.3, HR >90, RR >20, WBC >12" },
+    { "afterOffsetMinutes": 90, "type": "alert", "alertType": "QSOFA_WARNING", "description": "qSOFA ≥2: RR 24, SBP 102, AVPU 1" },
+    { "afterOffsetMinutes": 90, "type": "bundle", "description": "Sepsis bundle auto-created with 4 orders" },
+    { "afterOffsetMinutes": 105, "type": "bundle", "description": "All 4 bundle elements completed — COMPLIANT" },
+    { "afterOffsetMinutes": 120, "type": "score", "scoreType": "NEWS2", "expectedMinimum": 7, "description": "NEWS2 reaches HIGH risk" },
+    { "afterOffsetMinutes": 120, "type": "alert", "alertType": "NEWS2_EMERGENCY", "description": "NEWS2 ≥7 or single parameter 3" },
+    { "afterOffsetMinutes": 120, "type": "alert", "alertType": "RAPID_DETERIORATION", "description": "HR climbed 88→118 and SBP dropped 128→96 rapidly" }
+  ]
+}
@@ -0,0 +1,65 @@
+{
+  "scenario": {
+    "id": "stable-baseline-01",
+    "name": "Stable Observation Patient — Control",
+    "description": "40-year-old healthy male admitted for 4-hour observation after minor outpatient procedure. Vitals remain normal throughout with natural physiological noise. No alerts should fire. This is a control scenario to test for false positives.",
+    "durationMinutes": 240,
+    "tags": ["stable", "control", "observation", "no-alerts"]
+  },
+  "patient": {
+    "firstName": "James",
+    "lastName": "Liu",
+    "dateOfBirth": "1986-05-10",
+    "gender": "Male",
+    "mrn": "SIM-003"
+  },
+  "encounter": {
+    "department": "Day Surgery",
+    "room": "DS-3",
+    "bed": "A",
+    "encounterType": "Observation",
+    "chiefComplaint": "Post-procedure observation — arthroscopic knee surgery"
+  },
+  "events": [
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "HEART_RATE", "value": 72, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "RESP_RATE", "value": 14, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 124, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 76, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "TEMP_C", "value": 36.8, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "SPO2", "value": 99, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 0, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "HEART_RATE", "value": 75, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "RESP_RATE", "value": 13, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 120, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 74, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "TEMP_C", "value": 36.7, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "SPO2", "value": 98, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 60, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "HEART_RATE", "value": 70, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "RESP_RATE", "value": 15, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 126, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 78, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "TEMP_C", "value": 36.9, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "SPO2", "value": 99, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 120, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "HEART_RATE", "value": 73, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "RESP_RATE", "value": 14, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 122, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 76, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "TEMP_C", "value": 36.8, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "SPO2", "value": 98, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 180, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } },
+
+    { "offsetMinutes": 240, "type": "observation", "data": { "code": "HEART_RATE", "value": 74, "unit": "bpm", "source": "monitor" } },
+    { "offsetMinutes": 240, "type": "observation", "data": { "code": "RESP_RATE", "value": 14, "unit": "/min", "source": "manual" } },
+    { "offsetMinutes": 240, "type": "observation", "data": { "code": "SYSTOLIC_BP", "value": 124, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 240, "type": "observation", "data": { "code": "DIASTOLIC_BP", "value": 76, "unit": "mmHg", "source": "manual" } },
+    { "offsetMinutes": 240, "type": "observation", "data": { "code": "TEMP_C", "value": 36.7, "unit": "°C", "source": "manual" } },
+    { "offsetMinutes": 240, "type": "observation", "data": { "code": "SPO2", "value": 99, "unit": "%", "source": "monitor" } },
+    { "offsetMinutes": 240, "type": "observation", "data": { "code": "AVPU", "value": 0, "unit": "score", "source": "manual" } }
+  ],
+  "expectedOutcomes": []
+}