The Medication screens can be used by any treatment provider, but are primarily used by Opioid Treatment and Detoxification providers to document the provision of medication to clients. The medication screens are Medication Order, Medication List, and Medication Service Note.
The CMBHS Medication Order page allows the user to document information about a client’s medications, whether they are medications that are being prescribed, administered, or dispensed to the client as part of his/her services. The CMBHS Medication Order process also ensures that there is a valid Medication Order for the medication prior to allowing the provider to bill for delivery of the service.
This function is designed to be used by a licensed healthcare professional whose scope of license includes this function. If you are a healthcare professional licensed in Texas, and you have any questions about the credentials required to use this function, contact your Texas professional licensing board. The medication documents can be documented by non-licensed staff on behalf of the licensed staff if necessary.
Because the Medication Order function does not currently contain safeguards such as checking for contraindications from drug allergies, interactions, therapeutic duplications, or overdoses, this CMBHS function is not intended to replace the judgment of a licensed healthcare professional.
You must have Read/Write access to the Medication Order page to document a medication order in a client health record.
Click here for a listing of Page Rights by Role in CMBHS.
To document a medication order in a client’s CMBHS record, a Client Profile, Admission, and a Service Begin for at least one service must already have been documented in CMBHS for the client.
Some fields in the Medication Order page are required, others are optional. Required fields are designated by a red * asterisk. Different types of Medication Orders have different required fields. Be sure that you have completed all of the required fields for the type of order you are entering.
HHSC requires that some service types have an active Medication Order to bill HHSC for a Medication Service. If you have unanswered questions, call the HHSC CMBHS Help Line for more information about Medication Orders and billing for Medication Services in CMBHS.
From the Client Services Toolbar, hover over Service Documentation > Medication, and then click on Medication Order.
The Medication Order/Medication Claim Information screen will be displayed.
The Custom Order Section will display a list of the Medication Custom Orders that have been created for that location. To view the list, click on the + to expand.
The fields are:
If a Medication order is selected from the list and the Select button is clicked, the system will populate the medication in the following Order Information section. The behavior of the Order Information section is the same whether the medication was selected from the Custom Medication Order or entered by typing the name in the Medication field, as described below.
For a list of Page Rights by Role for working with a Medication Custom Order, click here.
In the Medication field, start typing the name or brand name of the medication. The list will populate with matches to the information you type into this field. The more information that is entered, the shorter the list will become.
When the name of the medication is displayed, click on the name and it will populate the field. If the medication is not listed, select the MORE option at the bottom of the list. For a non-listed medication, use the Medication not in List checkbox and the system will display a text box where you can enter the name of the medication.
Over-the-counter medications, vitamins, herbal and nutritional supplements, and some other medications are not listed in the current CMBHS Medication database. If the medication you wish to document is not in the medication list, you can add that medication directly into a client's record.
NOTE: Remember to be specific as to the medication's name, strength, route, and dosage form, since using the Medication not in List function will not offer you any of these selections elsewhere. (Example: Instead of typing "Vitamin B," type in "Vitamin B1 50mg oral tablet.")
Since the medication list is fairly comprehensive, you may need to try several different medication selections in order to find the correct one.
Check these to verify that the medication you have selected is the one that you want. If not, return to the Medication text box and select again.
Once you SELECT a medication, or enter the name if the medication was not found, the screen will refresh with fields to enter dosage, forms, strengths, and administration routes for that medication.
For a medication found in the list, the system will display:
Start Date – Enter the date the medication was first administered, dispensed, or prescribed.
Provision Type – Select the appropriate provision type:
Form – Depends on medication. Select the appropriate form.
Strength – Depends of medication. Select the appropriate strength.
Dosage – Is a text field for entering a numeric amount. Enter the appropriate dosage.
Dosage unit – Depends on the form. Select the appropriate dosage unit.
Route – Depends on the medication. Examples are: oral, subcutaneous, intravenous.
Frequency – How often will the medication be taken. Select the correct answer from the dropdown list.
PRN – Means "when necessary" – Checkbox indicates this medication has special conditions.
Duration – Text field for a numeric amount.
Time Period – Days, Hours, Weeks, Months, Minutes.
Conditions – And, May Adjust, and Then.
When PRN is selected, the PRN Indications section is displayed with a field for explaining the reason for the medication and an optional comment field.
Once the above information is completed, the system will display the Order Narrative, which will be the summary of the medication order.
Prescribing Practitioner – Dropdown list of staff. Select the appropriate name. If the individual's name does not appear in the dropdown list, a user account will need to be created for the person. Contact your local security administrator for assistance.
Service Type – Select the appropriate service type from the dropdown list.
Buttons:
The CMBHS Medication List page allows the user to view, edit, discontinue, or hold medication orders for a specific client. From this page you have access to all of a client’s existing medication orders.
You must be assigned a CMBHS role that gives you Write access to the Medication List Screen.
Click here for a list of Page Rights according to CMBHS Role.
You must have selected a client. The selected client must have a Client Profile record, an open Admission, a Service Begin record for at least one service type, and at least one medication order on file.
A Medication List record is automatically generated for a client whenever there is at least one medication order successfully created for the client in CMBHS. If the client does not have a medication order, the screen will display, but the medication list will show "No records found."
From the Client Workspace, go to the Client Services Toolbar on the left side of your screen. Hover over Service Documentation and then click Medication > Medication List. This opens the Medication List for the selected client.
The Medication List displays all Medication orders for a selected client, regardless of the order’s status, whether active, discontinued, or on hold.
The Orders in the Medication List can be sorted in ascending order according to each of the different column headings by CLICKING on the column heading:
If the medication was not on the list and was added using the "not on list" function, the medication will be listed in the "Other Medication List" section. The columns in this section are:
This page is used by Licensed Medication Specialists to document the provision of medication services. CMBHS will verify the credentials of the user specialist to ensure that they have the proper credentials.
Before You Start
You must be assigned a CMBHS role that gives you Write access to the Medication Service Screen.
Click here for a list of Page Rights according to CMBHS Role.
You must have selected a client. The selected client must have a Client Profile record, an open Admission, a Service Begin record for at least one service type, and at least one medication order on file.
At the Client Services Toolbar on your left, select Service Documentation > Medication > Medication Service. The Medication Service screen will be displayed.
The fields are:
Client – The Client's name will be displayed and will not be editable.
Medication – Dropdown field based on active medication orders.
Funding Source – Dropdown field list of potential funding sources. Choices are: DSHS Program Funding; LBHA Funding; Medicaid – Claim; Medicaid – Documentation; Other; Private Insurance; Self-Pay; TAIP.
Services Provided Between:
Billable – checkbox to indicate this was a billable service.
When finished, click SAVE and the Medication Service Note will generate a pending claim that can be found on the Pending claim screen.
This page is used by Licensed Medication Specialists to document the provision of medication services. CMBHS will verify the credentials of the user specialist to ensure that they have the proper credentials.
Before You Start
You must be assigned a CMBHS role that gives you Write access to the Medication Service Screen.
Click here for a list of Page Rights according to CMBHS Role.
You must have selected a client. The selected client must have a Client Profile record, an open Admission, a Service Begin record for at least one service type, and at least one medication order on file.
How to Document a Multi-Client Medication Order
Hover over Provider Tools on the Administrative Toolbar. Select Medication Service (Multi-Client). The Medication Service screen displays.
The fields are:
Medication – Dropdown field based on active medication orders.
Funding Source – dropdown field list of potential funding sources. Choices are: DSHS Program Funding; LBHA Funding; Medicaid – Claim; Medicaid – Documentation; Other; Private Insurance; Self-Pay; TAIP.
Services Provided Between:
Click Search and the system will search for matching Medication, Funding Source, and Services open between begin and end dates.
A list of clients is displayed.
In the Select Client section, a grid of clients will be displayed. The columns are:
Select – A checkbox for selecting which client will be billed for this time frame, funding source, and medication. The Select All button will select all the clients in the grid and the Unselect All button will deselect all the clients in the grid.
When the correct clients have been selected, click SAVE and the Medication Service Note will generate a pending claim for each client, which can be found on the Pending claim screen.
Medication Screens – Administrative Menu
The Medication screens can be used by any treatment provider but are primarily used by Opioid Treatment and Detoxification providers to document the provision of medication to clients. The medication screens are Medication Order, and Medication Service Note.
The Clinical Management for Behavioral Health Services (CMBHS) application provides the user the ability to document a wide array of medication related services. Your program may administer medications directly to clients, dispense medications, or prescribe medications.
This section of CMBHS Online Help provides instructions on how to create medication custom orders for frequently documented medication orders. Medication custom orders are stored in a list from which the user can select and then enter an order into a client record with just one CLICK.
This function is designed for use only by a person licensed in Texas to perform this task. Click here to view tables of all CMBHS pages and what roles have Read-Only or Read-Write access to each page. A non-licensed staff can enter data on behalf of the licensed staff, if necessary.
Users need to be aware of all applicable laws, rules, and contract provisions related to documentation of client medications. CMBHS cannot ensure that providers know and follow the rules or prevent users from making medication errors. If you are not sure that you know the applicable laws, rules, and contract provisions related to documentation of medications, do not document medications in CMBHS. Contact your supervisor.
The Medication Custom Order function does not currently have safeguards such as checking for contraindications for drug allergies, interactions, therapeutic duplications, or overdoses. This function is not intended to replace the judgment of a licensed professional.
To be documented on this page, the client must have a Client Profile, an Admission, and a Begin Service record for at least one service type in CMBHS.
Fields which are required in the Medication Custom Order screen are marked with a red * asterisk.
The user must have a role that permits Write access to the Custom Order page.
Click here for a listing of Page Rights by Role in CMBHS.
The user must create the custom orders at the CMBHS location where the custom orders will be used.
Since the Custom Medication Orders are created by multiple users within a service location, it is important that users adhere to a naming convention (as determined by your agency) and delete duplicate and outdated custom orders.
From Provider Tools on the Administrative Toolbar at the top of the CMBHS screen, select Medication > Medication Custom Order.
At the top of the Medication Custom Order page you will see the Existing Custom Orders List. To the left of the List is a box with a + or – sign inside. Click in this box to open or close the list. Check this Existing Custom Orders list to see if the order you need to create has already been created.
This will ensure that you are not creating a duplicate custom order. If no duplicate custom order exists, you may create the custom order.
Enter a name for your custom order. You may use any name for your custom order; however, it is recommended that appropriate staff within your organization agree upon a naming convention for custom orders.
Complete all the required data fields with the order information.
Check the order narrative to ensure that it is correct and then CLICK on the Save button.
If there are already existing custom orders for your location, information about the order/s displays on the Existing Custom Orders List.
To use this medication documentation function, start TYPING the first 3 to 5 letters of the name of the medication for which you are searching. Medications beginning with the letters you type will begin to display. The medication you want may display at any time, even after typing only one or two letters.
When you see the medication you want, CLICK on it. The name of the medication will fill in the appropriate data fields.
If you do not see the medication you are looking for, an alternative is to CLICK on the word MORE when you see it. The list will then display all the medications in the list with the medication you have entered as an ingredient.
If the system does not find the medication, No record(s) found will display.
If the medication you are looking for is not in the List, CLICK on the Medication Not on List box and Type the name of the medication directly into the Custom Order.
You can then continue to complete the order data fields.
Provision Type refers to the type of medication service provided to the client.
You may select only one Provision Type.
Provision Type answer choices:
|
Provision Type (Required) |
Custom Medication Order Data Fields |
|
Prescribed |
The client will get a filled prescription for the medication at an outside pharmacy. This may mean that the client leaves with a paper prescription, or that a prescription is transmitted to an outside pharmacy via fax or other electronic means from your facility. |
|
Administered |
The client is given a dose of the medication at your facility to be taken immediately, onsite. |
|
Dispensed |
The client will leave with a supply of the medication provided by your facility. |
|
Other |
Select Other if none of these Provision Types apply. |
Form refers to the shape and structure of the medication. Possible medication Forms are numerous, but the dropdown list will populate only with those appropriate to that medication.
If the appropriate dosage Form is not already displayed, select it from the list.
Select the medication Strength from the dropdown list. Remember, you can specify amounts greater or less than one unit later, in the Dosage Unit section.
Enter a numeric dosage in the Dosage box, indicating the number of units to be given. This is not the same as the dosage strength.
In the Dosage Unit field, TYPE in the unit to be used.
The Unit will vary based on the Forms in which the medication is available.
Document the Route by which the medication will be given. This field will generally populate itself, based on the medication.
Select the Frequency with which the client will take the medication from the dropdown list.
If the order is for a medication to be given PRN, also document the following:
Adjustment Amount
Displays if the "May Adjust" selection is made in the Conditions field. If the Medication Order specifies an amount by which the Dose may be adjusted, document it here as the Adjusted Amount.
Adjustment Amount Unit
Displays if the "May Adjust" selection is made in the Conditions field. If the Medication Order specifies an amount by which the Dose may be adjusted, document the Adjustment Amount Unit here.
Adjustment Frequency
Displays if the "May Adjust" selection is made in the Conditions field. If the Medication Order specifies a Frequency for adjustment, document the Adjustment Frequency here.
Not to Exceed Amount
Displays if the "May Adjust" selection is made in the Conditions field. If the Medication Order specifies a Not to Exceed Amount document the Not to Exceed Amount in this field.
Dosage Unit
Displays if the "May Adjust" selection is made in the Conditions field. Select the dosage unit from the dropdown list.
Not to Exceed Frequency
Displays if the "May Adjust" selection is made in the Conditions field. This is where you can provide a limit on the frequency of the dosage.
Enter the number of units of time the medication should be taken, for example, 30.
Choose the time unit for the Duration minutes — days, hours, weeks, months, or minutes.
Select And, May Adjust, or Then and the word/s chosen will be added to the Order Narrative.
CMBHS translates the data you have entered into a narrative medication order. Review the narrative to ensure that the medication order reads correctly.
If the order does not read correctly, review the information you entered in the data fields that appear to be in error and make a change.
After completing the required data fields, CLICK on the Save or Cancel buttons.
Save will add your new Custom Medication Order to the Custom Order List. The medication will be available to you when documenting medication orders for clients at your location.
If you CLICK on Cancel, the Custom Medication Order will be deleted and cannot be retrieved.