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Flows/Record a medication statement

From OHC Network Wiki
flowmedicationsCARE 3.0+

Overview

This flow describes how to record a medication statement for a patient in Care.

Pre-requisites

  • The patient is registered in Care, and you record the statement for that patient.
  • The patient has an encounter at your facility. Care records every medication statement against an encounter.
  • The encounter is open. Care blocks the record when the encounter status is Completed, Cancelled, Discontinued, or Entered in Error.
  • You have the permissions listed below.

Permissions

Permission Access
Can view questionnaire responses on patient Lets you open the Updates tab of the patient.
Can submit questionnaire about patients Lets you open a form for the patient and submit it.
Update Encounter related clinical data Lets you record a medication statement against the encounter.

Steps

1. Open the Updates tab

Open the patient.

Select the Updates tab.

2. Start a new form

Select Add Patient Updates. Care opens the form page for the patient.

3. Select the Medication Statement form

Enter Medication Statement in the Search Forms box.

Select Medication Statement in the results.

馃摑 Note
Medication Statement is a patient form. It is not in the Forms list of the encounter.

4. Select the medicine

Select Add Medication.

Search the clinical drug list for the medicine that the patient reports taking.

Select the medicine in the results. Care adds an entry for it.

5. Complete the entry

Complete the fields of the entry.

Components What it captures
Source Who reported the medicine: the Patient, a Practitioner, or a Related Person. Care selects Patient by default.
Status The state of the medication statement. Care selects Active by default.
Dosage Instructions How the patient takes the medicine. This field is mandatory.
Medication Taken Between The start date and the end date of the period. The start date is mandatory. Leave the end date empty when the patient still takes the medicine.
Reason Why the patient takes the medicine. You can enter up to 100 characters.
Note More information about the medicine.

To record another medicine, repeat step 4 and step 5.

6. Submit the form

Select Submit.

馃摑 Note
To finish the form later, select Save as Draft.

Expected Outcome

  • Care shows the message "Questionnaire submitted successfully".
  • Care opens the Updates tab of the patient.
  • Care shows the medication statement in the Medication Statements sub-tab of the Medicines tab of the encounter.