Page # MED058

Medication Log

DESCRIPTION

The Medication Log screen MED 062 allows you to document medication events, such as a medication administration or a medication dispensing for an existing medication order, including the ability to also document missed, refused or late doses, or to document that a client did not show for a medication appointment.

Before You Start

The user must have Read/Write access to the Medication Log Screen The following roles will have access to this:

Security Administrator and Medication Specialist Licensed.

General Business Rules

• Client medication events will not appear on this list unless the client has:

• A Client Profile record
• An open Admission record
• A Begin Service record for at least one service type
• At least one active Medication Order with a Provision Type of either Administered or Dispensed that is not currently On Hold.

• The Medication Log list will automatically default to display medication events for the current date. You can expand this period by entering a date range in the From Date and To Date fields and CLICKING Search.
• To return to the view for just the current date,CLICK the As of Today button.
• The Medication Log list will include an entry for every medication event for the specified period.
• A medication event is an instance at which a medication is due to be administered or dispensed.

The Medication Log List can be sorted in ascending order according to any of the column headings listed:

• Date
• Medications
• Dosage
• Route
• Frequency
• Last Action
• Comments, Billable
• Funding Source

To sort by a particular column, just click the name of the column heading.

Using the Medication Log Screen

To navigate to the Medication Log screen, follow the instructions listed below:

 

From the Medication List:

1. Select a Client using the Find/Add Client function
2. Locate the Service Documentation Link on the left menu.
3. Hover over the link with your cursor to open the sub-menu.
4. Locate Medication in the Service Documentation sub-menu.
5. Hover over the Medication link to open its sub-menu.
6. CLICK ON Medication List.The Medication List window opens.
7. Next, highlight one of the client’s active medication orders
8. CLICK ON the Medication Log button.

 

From the Medication Provision List:

1. CLICK ON the Provider Tools menu on the top toolbar to open the sub-menu.
2. CLICK ON the Medication in the sub-menu.
3. Click on the Medication Provision List link within this sub-menu.
4. Locate an active order for the client you wish to document and highlight it.
5. Next, click the Medication Log button.

Locate the Medication event you wish to log within the list displayed.If the event you wish to log is not displayed, it may be for a different date. If so, search for that date using the From Date and To Date function.

To expand or collapse any of the section headings,

1. CLICK ON the plus/minus button next to the text of the section, or CLICK ON the blue text of the heading itself. Highlight the event you will be logging.
2. The screen refreshes showing different options depending on whether the event is a Medication Administration or a Medication Dispensing event.

To select a Medication Administration Event:

1. First, select whether the medication administration is a billable or non-billable service and select a funding source from the list.
2. Next, SELECT an action from the list displayed.Choices include:
   • Administered
   • Client Refused
   • Administered Early
   • Administered Late
   • Not Administered
   • Wrong Dose Administered
   • No Show or Other.
3. Next, ENTER a date and time that the administration event occurred. You can also enter any comments you may have in the comments section.
4. CLICK Submit.

To select a Medication Dispensed Event:

1. First, select whether the medication dispensing is a billable or non-billable service and select a funding source from the list.
2. Next, SELECT an action from the list displayed. Choices include:
   • Dispensed
   • No Show
   • Other
   • Not Dispensed
   • Client Refused
3. Enter a dispensed quantity.
4. Next, ENTER a date and time that the dispensing event occurred.You can also enter any comments you may have in the comments section.
5. CLICK Submit.
6. After entering all medication events for this client, CLICK Save to permanently document your medication event logs.

 

• You can proceed to repeat this process and log another medication event for the same client in the same manner.
• You can also re-select any event you already entered and edit the information in that log.

NOTES:

If you navigate away from this screen without saving, your work will be lost.

It is critical to client safety that a licensed professional verify the accuracy and safety of all medication orders, checking for drug allergies, interactions, therapeutic duplications, and appropriate dosing.

The CMBHS system is not designed to substitute for the clinical judgment of a licensed professional.

 Next

Medication Order