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Concepts/Medication Statement

From OHC Network Wiki
conceptmedicationsCARE 3.0+

Definition

A medication statement in Care records a medicine that a patient reports taking, or has taken on an ongoing basis. Unlike a medication request, a medication statement is not an order. It records what the patient says they take, not what staff prescribe. Care records every medication statement against an encounter of the patient.

Key Attributes

Components What it captures
Medication The medicine that the patient takes. This field is mandatory. You cannot change it after you save the entry.
Source Who reported the medicine: the Patient, a Practitioner, or a Related Person. Care selects Patient by default. You cannot change it after you save the entry.
Status The current state of the statement. See Status below. This field is mandatory. You can change it after you save the entry.
Dosage Instructions Free text that describes how the patient takes the medicine. This field is mandatory. You cannot change it after you save the entry.
Medication Taken Between The start date and the end date of the period in which the patient takes the medicine. The start date is mandatory. The end date is optional. Care shows Ongoing when there is no end date. You cannot change these dates after you save the entry.
Reason Why the patient takes the medicine, as free text of up to 100 characters. This field is optional. You cannot change it after you save the entry.
Note Free text about the medicine. This field is optional. You can change it after you save the entry.

Where Care shows medication statements

Care shows the medication statements of a patient in two places. The Medication Statements sub-tab of the Medicines tab shows them during an encounter. The Past Medications section of the patient's Clinical History tab shows them by date.

Both places list every medication statement of the patient. They do not list only the statements of one encounter.

Status

Status Description
Active The patient currently takes the medicine.
On Hold The patient has paused the medicine.
Completed The patient finished the course.
Stopped The patient stopped the medicine before finishing.
Intended The patient plans to take the medicine.
Not Taken The patient did not take the medicine.
Unknown The state is not known.
Entered in Error Staff recorded the statement by mistake.

Care offers the Entered in Error status only for a statement that you saved. Care keeps a statement with this status, but hides it from the Medication Statements sub-tab and from Past Medications.

Permissions

Permission What it allows
Update Encounter related clinical data Record, update, or retract a medication statement.
Can submit questionnaire about patients Open the form that records a medication statement.
Can view questionnaire responses on patient Open the Updates tab of the patient.
Can view clinical data about patients View the medication statements of a patient.
Can Read encounter related clinical data Read the clinical records of the encounter.

To record, change, or retract a medication statement, you also need an open encounter. Care blocks these actions when the encounter status is Completed, Cancelled, Discontinued, or Entered in Error.

馃摑 Note
After you save a medication statement, you can only change its Status and its Note. The medicine, the source, the dosage instructions, the period, and the reason stay fixed.

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