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Flows/Administer a dose

From OHC Network Wiki
flowmedicationsCARE 3.0+

Overview

This flow describes how to record a dose of a prescribed medicine that staff gave to a patient during an encounter in Care.

Pre-requisites

  • The patient is registered in Care, and you record the dose for that patient.
  • The medicine is prescribed on the encounter. See Prescribe a medication.
  • The medicine is active. Care does not let you administer a discontinued medicine.
  • The encounter is open. You cannot record a dose when the encounter status is Completed, Cancelled, Discontinued, or Entered in Error.
  • You have the permission listed below.

Permissions

Permission Access
Update Encounter related clinical data Lets you record a medicine administration on the encounter.

Steps

1. Open the Medicine Administration sub-tab

  1. Open the encounter.
  2. Select the Medicines tab.
  3. Select the Medicine Administration sub-tab.
馃摑 Note
Press g then m to go to the Medicines tab.

Care shows a grid. The Medicine column lists the prescribed medicines. Four columns to the right show six-hour time slots.

2. Find the medicine

Care opens the grid on the Medications tab. Select the Nutrition tab for nutritional products. To narrow the list, enter the name in the Search Medication box.

3. Open the administration form

In the current time slot column, select Administer for the medicine. Care opens the Administer Medicine dialog.

馃摑 Note
Care shows Administer only in the current time slot. Care also hides it when the medicine is discontinued, or when the time slot falls outside the prescribed schedule.
馃摑 Note
To record doses for more than one medicine at a time, select Administer Medicine at the top of the sub-tab. Select each medicine that you gave, then submit the panel.

4. Check the dosage

Care fills the dose, the route, the site, and the method from the prescription. If the prescription has more than one dosage instruction, select the instruction that you gave under Select Dosage Instruction.

5. Set the status

Care sets Status to Completed. Change the status if staff did not complete the dose.

6. Record the time

Care sets Start Time and End Time to the current date and time.

To record a dose from an earlier time, select Yes for Is this administration for a past time. Care then lets you set Start Time and End Time.

馃摑 Note
Care warns you when the time falls outside the prescribed schedule. Care still saves the record.

7. Add a note

Enter free text in Administration Notes to record more detail. This field is optional.

8. Save the administration

Select Administer Medicine to save the record.

Expected Outcome

  • Care shows the message "Medicine Administration saved".
  • Care adds the dose to the time slot as a coloured chip with the time of the dose.
  • Care shows the last administered time on the medicine row.