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Version: 3.1

Medication Request

Definition​

A medication request in Care is an order or prescription for a specific medicine for a patient. You create a medication request during an encounter. Care groups one or more medication requests together under a named prescription. A medication request records what you order, not what the patient receives.

Care keeps the medication request separate from three related records. Medicine Administration records a dose that staff give to the patient. Dispense History records the pharmacy dispense. Medication Statements record the medicines that the patient reports or took in the past. Care shows each of these records in its own sub-tab of the Medicines tab.

Key Attributes​

ComponentsWhat it captures
MedicineThe drug that you prescribe. You select it from a clinical drug list or from the facility's inventory.
DosageThe amount of the medicine that the patient takes. This field is mandatory.
FrequencyHow often the patient takes the medicine. This field is mandatory.
DurationHow long the patient takes the medicine. This field is optional.
InstructionsMore instructions for the patient. This includes the reason to take the medicine when needed. This field is optional.
RouteHow the patient receives the medicine, for example by mouth or by injection. This field is optional.
SiteThe body site that the medicine applies to. This field is optional.
MethodThe method of administration. This field is optional.
Authored OnThe date that you write the request. Care sets the current date and time by default. You cannot enter a future date.
RequesterThe user that Care records as the person who requests the medicine. This field is optional.
NoteFree text notes about the medicine. This field is optional.
StatusThe current state of the request.
CategoryThe care setting that the request applies to.
PriorityThe urgency of the request.
Dispense StatusHow much of the request the pharmacy dispensed. The separate dispense process updates this field.

Prescription​

A prescription is a named batch that groups one or more medication requests for the same encounter. When you prescribe a medicine, you add it to a new prescription or to an existing one. A new prescription needs a name. You can also add an optional note to it. An encounter can have more than one prescription. Care lets you switch between the prescriptions of an encounter.

Changes after you save​

After you save a medicine on a prescription, you cannot change its dosage, frequency, route, or other clinical details. You can edit its note. You can add new medicines to the same prescription. You can also remove the medicine. When you remove a medicine, Care marks it as Entered in Error and keeps the record.

Category​

CategoryDescription
InpatientThe request applies to a patient who stays in the facility.
OutpatientThe request applies to a patient who visits the facility.
CommunityThe request applies to care in the community.
DischargeThe request applies to the medicines that the patient takes after discharge.

Priority​

PriorityDescription
RoutineThe patient takes the medicine in the normal order of work.
UrgentStaff act on the request before routine requests.
ASAPStaff act on the request as soon as possible.
StatStaff act on the request immediately.

Dispense Status​

Dispense StatusDescription
CompleteThe pharmacy dispensed the full amount of the request.
PartialThe pharmacy dispensed part of the request.
IncompleteThe pharmacy did not finish the dispense of the request.
DeclinedThe pharmacy declined to dispense the request.

Status​

StatusDescription
ActiveThe patient takes the medicine now.
On HoldThe patient stops the medicine for a limited time.
EndedThe request reached its end.
StoppedStaff stopped the medicine before its planned end.
CompletedThe patient took the full course of the medicine.
CancelledStaff cancelled the request before the patient took the medicine.
Entered in ErrorStaff created the request by mistake.
DraftThe request is not complete and staff did not issue it.
UnknownThe state of the request is not known.

Permissions​

PermissionWhat it allows
Update Encounter related clinical dataPrescribe a medication, add medicines to an existing prescription, edit a note, and remove a medicine.
Can view clinical data about patientsView the medication requests and the prescriptions of a patient.
Can Read encounter related clinical dataView the medication requests and the prescriptions of an encounter.

To change medicines, you also need an open encounter. Care blocks changes when the encounter status is Completed, Cancelled, Discontinued, or Entered in Error.

Care has a separate Pharmacist role. This role has its own permissions for pharmacy work on dispense records and prescription status.

Configuration​

No deployment configuration changes which fields are mandatory. One configuration option sets the default tab of the medicine picker. This option selects either the clinical drug list or the facility's inventory.