Concepts/Medication Request

conceptmedicationsCARE 3.0+

A medication request in Care is an order or prescription for a specific medicine for a patient. You create a medication request during an encounter. Care groups one or more medication requests together under a named prescription. A medication request records what you order, not what the patient receives.

Care keeps the medication request separate from three related records. Medicine Administration records a dose that staff give to the patient. Dispense History records the pharmacy dispense. Medication Statements record the medicines that the patient reports or took in the past. Care shows each of these records in its own sub-tab of the Medicines tab.

Key Attributes

Components	What it captures
Medicine	The drug that you prescribe. You select it from a clinical drug list or from the facility's inventory.
Dosage	The amount of the medicine that the patient takes. This field is mandatory.
Frequency	How often the patient takes the medicine. This field is mandatory.
Duration	How long the patient takes the medicine. This field is optional.
Instructions	More instructions for the patient. This includes the reason to take the medicine when needed. This field is optional.
Route	How the patient receives the medicine, for example by mouth or by injection. This field is optional.
Site	The body site that the medicine applies to. This field is optional.
Method	The method of administration. This field is optional.
Authored On	The date that you write the request. Care sets the current date and time by default. You cannot enter a future date.
Requester	The user that Care records as the person who requests the medicine. This field is optional.
Note	Free text notes about the medicine. This field is optional.
Status	The current state of the request.
Category	The care setting that the request applies to.
Priority	The urgency of the request.
Dispense Status	How much of the request the pharmacy dispensed. The separate dispense process updates this field.

Prescription

A prescription is a named batch that groups one or more medication requests for the same encounter. When you prescribe a medicine, you add it to a new prescription or to an existing one. A new prescription needs a name. You can also add an optional note to it. An encounter can have more than one prescription. Care lets you switch between the prescriptions of an encounter.

Changes after you save

After you save a medicine on a prescription, you cannot change its dosage, frequency, route, or other clinical details. You can edit its note. You can add new medicines to the same prescription. You can also remove the medicine. When you remove a medicine, Care marks it as Entered in Error and keeps the record.

Priority

Priority	Description
Routine	The patient takes the medicine in the normal order of work.
Urgent	Staff act on the request before routine requests.
ASAP	Staff act on the request as soon as possible.
Stat	Staff act on the request immediately.

Dispense Status

Dispense Status	Description
Complete	The pharmacy dispensed the full amount of the request.
Partial	The pharmacy dispensed part of the request.
Incomplete	The pharmacy did not finish the dispense of the request.
Declined	The pharmacy declined to dispense the request.

Status

Status	Description
Active	The patient takes the medicine now.
On Hold	The patient stops the medicine for a limited time.
Ended	The request reached its end.
Stopped	Staff stopped the medicine before its planned end.
Completed	The patient took the full course of the medicine.
Cancelled	Staff cancelled the request before the patient took the medicine.
Entered in Error	Staff created the request by mistake.
Draft	The request is not complete and staff did not issue it.
Unknown	The state of the request is not known.

Permissions

Permission	What it allows
Update Encounter related clinical data	Prescribe a medication, add medicines to an existing prescription, edit a note, and remove a medicine.
Can view clinical data about patients	View the medication requests and the prescriptions of a patient.
Can Read encounter related clinical data	View the medication requests and the prescriptions of an encounter.

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

Care has a separate Pharmacist role. This role has its own permissions for pharmacy work on dispense records and prescription status.

Configuration

No deployment configuration changes which fields are mandatory. One configuration option sets the default tab of the medicine picker. This option selects either the clinical drug list or the facility's inventory.

Pages that link here:

Concept: Concepts/Patient
Reference: References/Medication Request

Category	Description
Inpatient	The request applies to a patient who stays in the facility.
Outpatient	The request applies to a patient who visits the facility.
Community	The request applies to care in the community.
Discharge	The request applies to the medicines that the patient takes after discharge.