How to Access the Medication Order Pag
- Select the client that you want to enter a medication order for.
- After you select the client, their name will display at the top of the page, above the Administrative Toolbar.
- Once you open the Medication order screen, the client’s name and date of birth will also appear in the Client Information section of the Medication Order screen.
How to Document Medication Order
- On the Client Services toolbar on the left side of your screen, Hover over the Service Documentation tab with your pointer. When the menu will displays, CLICK on Medication tab
- Then CLICK on Medication Order to open the Medication Order page.
- On the Medication Order page verify that the client has no drug allergy or adverse drug reaction issues by CLICKING on the plus/minus symbol to the left of the page or CLICK on the blue title name to review the client’s Medication, Allergy and Adverse Drug Reaction information. You can expand or collapse the Allergies and Adverse Drug Reactions section either by clicking on the plus/minus to the left of the section title or by clicking on the blue text of the title itself. Now proceed to enter a medication order.
- Enter the order in either in the Order Information section, or in the Custom Order section.
When using the Order Information section:
- CLICK in or TAB to the text box next to Medication.
- Start TYPING the name of the medication you wish to enter, using either trade or generic names of medications. The CMBHS system will search for medications matching your search and display a list of all results in a drop-down menu below the text box.
- SELECT the medication you will be documenting from the list of search results.
- Since the medication list is very comprehensive, including every prescription medication licensed by the FDA, you may need to try several different medication selections in order to find the correct one.
- Once you SELECT a medication, the screen will refresh with the available dosage forms, strengths, and administration routes for that medication.
- 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.
- Occasionally, you may find that the medication you wish to document is not in this list, especially if the medication is not a prescription drug. If this occurs, use the “Medication not in list” function.
Over-the-counter medications, vitamins, and herbal nutritional supplements
Medication Not in List
- Over-the-counter medications, vitamins, herbal and nutritional supplements are not listed in the database. If the medication you wish to document is not in the list, you may input the name of the medication yourself. To do this, CLICK the Medication Not in List check box. The screen will refresh.
- After the refresh, TYPE the name of the medication in the Medication text box.
- Enter the Order’s Start Date, by TYPING in the eight numbers of the date (mmddyyyy). CMBHS will format the date with the slash marks /.
- 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 B 150mg oral tablet.”
- As you go through the process of entering data in the Medication Order page, note that the Order Narrative field begins to display a narrative version of the Medication Order in a large text box below the area where you are entering information. This will be helpful to ensure that the order reads as you intend.
Provision Type (Required)
- Next, select a Provision Type. Provision Type refers to the type of medication service provided to the client.
- Selecting “Administered” or “Dispensed” as a Provision Type will add the medication to the Medication Provision List [link] page.
- You may select only one Provision Type.
- Provision Type answer choices:
Provision Type Provision Type Description 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, on site. 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
- If the appropriate dosage Form is not already displayed, select it from the drop-down list.
Strength
- Select the medication Strength from the list. Remember, you can specify amounts greater or less than one unit later, in the Dosage Unit section.
Dosage
- 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.
- Example 1: An order stating “50mg Promethazine” could be entered as “Promethazine Hcl tablet, 25mg, 2, whole” to equal 50mg.
- Example 2: Similarly, an order for 12.5mg Promethazine could be entered “Promethazine Hcl tablet, 25mg, 1, half” which is equal to the 12.5mg Promethazine ordered.
Dosage Unit
- In the Dosage Unit field, TYPE in the unit to be used. This will vary based on what forms the medication is available in. Tablets and capsules will generally be indicated in whole, half, or another fraction of a unit, while other medications will list units such as weights, volumes or other dosage units.
Unit
- SELECT a Unit that will clearly indicate how the medication will be dispensed.
Route
- Indicate the Route by which the medication will be given. This field will generally populate itself, based on the medication.
Frequency
- SELECT a dosage Frequency from the list, or with your cursor in the section, TYPE in the abbreviation for the frequency you want.
- NOTE: A translation of the abbreviation will appear for your selection in the Order Narrative Section. Make sure that the Frequency you have selected translates into the dosage frequency you want.
If the medication is to be given only as needed, check the PRN box.
- Checking the PRN Box will open another section on the Medication Order page that will allow you to specify PRN Indications to further clarify when the medication should be given.
- In addition to PRN Indications, you will also see a text box in which you can type additional instructions, cautions, or notes, as needed.
- Many of these instructions can also be entered using the May Adjust function (see below)
- If the medication is to be given only for a specified period, you can enter that period in the Duration section by typing a numeric value in the text box below Duration and a unit, such as Day(s), Hour(s), Week(s), Month(s), or Minute(s).
- If the medication order does not have a specified Duration, leave the text box empty and choose None Selected from the dropdown menu.
How to Discontinue an Existing Order
- The Discontinue function allows you to discontinue a medication order.
- Select the line that the order appears on and CLICK on the Discontinue button.
- A window opens displaying the order that you are discontinuing.
- Select a Discontinued Reason from the list and CLICK on OK.
- If the displayed order is not the order you wish to discontinue, CLICK on Cancel.
- NOTE: If the discontinued order had a Provision Type of Dispensed or Administered, it will be removed from the Medication Provision and Medication Log Lists.
Using the Hold/Un-hold Function
- The Hold/Un-hold function allows you to temporarily place a medication order on hold, without permanently discontinuing the order. Later, you can return to this function to take the medication off of hold.
Placing a Medication Order on Hold
- Select the line that the order appears on, and CLICK the Hold/Unhold button.
- A window opens displaying the order that you are putting on hold.
- CLICK OK or, if the displayed order is not the order you wish to place on hold, CLICK Cancel.
- If the order placed on hold had a Provision Type of Dispensed or Administered, it will be removed from the Medication Provision and Medication Log Lists.
Removing the “Hold” on a Medication Order currently on “Hold”
- Select the line that the order appears on, and CLICK the Hold/Unhold button.
- A window opens displaying the order that you are removing from Hold.
- CLICK OK, Or, if the displayed order is not the order you wish to remove from Hold, CLICK Cancel.
- If the Order Placed on Hold had a Provision Type of Dispensed or Administered, it will be replaced in the Medication Provision and Medication Log Lists.
Copying a Medication Order
- This function allows you to copy an existing medication order, thereby creating a new order, which may be modified in order to change a dose, frequency, or directions.
- Select the line that the order appears on, and CLICK the Copy button.
- A Medication Order window opens displaying the copied order.
- In this window, you can make modifications to the order’s details, just as in a new Medication Order.
- When you have modified the order to your satisfaction, verifying that all of the displayed medication details are accurate, CLICK the blue Add link.
- Once you have successfully added the order, it will appear as a line in a table, including links to Delete the order or Edit it.
- You can now proceed to enter another medication order for the same client, or choose one of the Save options at the bottom of the screen. Be sure to save your order before leaving this page.
Editing a Medication Order
- The Edit function allows you to make changes to an existing order. This function should be used when a medication order was not entered correctly. If the order was entered correctly, then changed, discontinue the existing order, and then copy it to reflect the updated changes.
- Select the line that the order appears on, and CLICK the Edit button. A Medication Order window opens displaying the existing details of the order.
- Make whatever modifications are necessary, and CLICK the blue Update link.
- Once you have finished updating the order, be sure save your changes before leaving the page.
Viewing an Order’s History
- This function allows you to see all of the ways that a medication order has been changed, and view any administration or dispensing activities for the order.
- Select the line that the order appears on, and click the History button.
- A Medication History window opens, including any pertinent history information, such as Order Changes, Medication Administration History, Dispensing History, and Status Changes.
- You can expand or collapse any of these sections, either by CLICKING on the plus/minus to the left of the section title or by CLICKING on the blue text of the title itself.
- When you have finished viewing the Order History, CLICK the Cancel button to close the History window.
- You can also navigate directly to the Medication Log page for the selected client by CLICKING the Medication Log button at the bottom of the window.
- Caution: It is critical to client safety that a licensed professional verify the accuracy 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.
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