How to add a Medication

To create a new medication in the client’s Medication profile, you will need to complete an Add medication form. To learn how to do this for multiple medications, refer to the steps below and the section called Adding multiple medications to the medication profile.

Navigate to Care Delivery> Medication under the client profile, then click on the "Add" button. Four categories are available under the Add Medication form: Medication and dosage, Timing, Orders, and Discrepancy and reconciliation.

Let's take a look at what each section and subsequent field does:

• Medication and dosage
  • Library medication
  • Custom Medication
  • Ingredient strength 
  • Dosage Form
  • Medication frequency
• Timing
• Orders
• Discrepancy and reconciliation

Medication and dosage

This section contains information that defines the medication, which are a medication's Medication status, Generic/chemical name, Brand name, Drug number, Ingredient strength, Dosage form, Dosage/quantity, Route, Administration site details, Frequency, Medication types, Drug family, Purpose, Administration type, High alert/Narcotic flags, and Website.

As fields in this section are filled, The medication’s concatenated name will as the header on the page when you fill in fields under this section. Once submitted, the same name will appear throughout the rest of the medication module once submitted.

This section may be supported by a template called Library medication, or created as a Custom medication.

Library medication

This is a template containing read-only and editable fields. When using a Library medication, the user may modify everything except the Generic/chemical name, Brand name, Drug number, High alert/Narcotic flags, and the Website. Other fields such as Medication types and Administration instructions are populated from the library, but users can modify the value with these fields.

Custom Medication

This is a completely blank form where all fields are editable, as shown below.

Ingredient strength 

The Ingredient strength of a medication refers to the amount of active ingredient contained in the medication (e.g. 40mg, 100g, etc).

Dosage Form

The Dosage form refers to the form which the medication is made available, such as gel pills, tablets, etc. The Dosage/quantity refers to the amount of medication the client will take, or have administered (e.g. 2 tablets, or 80mg daily). All unit options can be configured and controlled by navigating to Medication System Settings>Units.

Medication frequency

Medications are administered based on their Medication frequency. The Frequency field under the Medication and dosage captures these rules and is required. Medication frequency labels can be configured and controlled by navigating to Medication System Settings.

A Frequency is comprised of a Frequency, PRN/as needed flag, and a PRN reason, if applicable. The PRN reason field is enabled when the "PRN/as needed" box is checked.

Timing

This section is disabled by default, unless the user selects a Medication frequency under the Medication and dosage section. The Timing section will then be enabled and populated with that frequency-specific information and fields. The required fields are Start date/time, Ends on, and Administration times. While the Start date may be marked as unknown, Ends on may be defined by a specific Date/time, which may also be marked as unknown or upon a specific Count. A Count is a finite number of administration instances off of the Start date/time.

Administration times are populated based on the configured settings the medication's particular frequency and may be modified. If certain individual frequencies have specific input, you must define two unique Administration times.

Orders

This section contains an optional field called Ordering physician.

Discrepancy and reconciliation

Contained within this section are several optional fields called Information source, Discrepancy type, Discrepancy status, Discrepancy note, Healthcare professional notified, and Needs education. These are the only editable fields once a medication is added to a client's profile.

Adding multiple medications to the medication profile

To add multiple medications to the client's medication profile, click on the “Save and add another” button. Each medication is then submitted to the medication profile. This means that when the client's client’s medication profile is fully submitted, it will contain all of these medications. A summary of all these recently added medications will be available, and each medication will have a hyperlink, leading to a page containing more details about the medication.