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Concepts/Medication Administration

From OHC Network Wiki
conceptmedicationsCARE 3.0+

Definition

A medicine administration in Care records a dose of medicine that staff gave to a patient. It is separate from the medication request, which is the order. You record an administration against a medicine that is already prescribed on the encounter.

Care shows the administrations of an encounter in the Medicine Administration sub-tab of the Medicines tab. The sub-tab shows a grid of medicines against six-hour time slots.

Key Attributes

Components What it captures
Medicine The prescribed medicine that this dose belongs to. This field is mandatory.
Status The state of the dose. See Status below. This field is mandatory.
Start Time When the dose started. This field is mandatory. Care sets the current date and time by default.
End Time When the dose ended. This field is optional.
Dosage The dose, the route, the site, and the method. Care copies these from the prescription.
Administration Notes Free text about the dose. This field is optional.
Performer The staff member who gave the dose, and their role in giving it. The administration form does not collect this field. Care records the user who saves the record.

Changes after you save

After you save an administration, the form lets you change only the Status and the Administration Notes. You cannot change the medicine, the dosage, the start time, or the end time. Care keeps the record when you mark it as Entered in Error.

Status

Status Description
In Progress Staff are giving the dose now.
Completed Staff gave the dose.
Not Done Staff did not give the dose.
On Hold Staff paused the dose.
Stopped Staff stopped the dose before it finished.
Cancelled Staff cancelled the dose before they gave it.
Entered in Error Staff created the record by mistake.
Unknown The state of the dose is not known.
馃摑 Note
The administration form offers all of these states except Unknown.

Permissions

Permission What it allows
Update Encounter related clinical data Record or update a medicine administration. Held by Doctor, Nurse, Admin, and Facility Admin.
Can view clinical data about patients View the medicine administrations of a patient. Held by Staff, Doctor, Nurse, Admin, and Facility Admin.
Can Read encounter related clinical data View the medicine administrations of one encounter. Held by Doctor, Nurse, Admin, and Facility Admin.

To record or change an administration, you also need an open encounter. Care blocks changes when the encounter status is Completed, Cancelled, Discontinued, or Entered in Error.

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