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Version: 3.1

Record a medication statement

Overview​

This flow describes how to record a medication statement for a patient in Care.

Pre-requisites​

  • The patient is registered in Care, and you record the statement for that patient.
  • The patient has an encounter at your facility. Care records every medication statement against an encounter.
  • The encounter is open. Care blocks the record when the encounter status is Completed, Cancelled, Discontinued, or Entered in Error.
  • You have the permissions listed below.

Permissions​

PermissionAccess
Can view questionnaire responses on patientLets you open the Updates tab of the patient.
Can submit questionnaire about patientsLets you open a form for the patient and submit it.
Update Encounter related clinical dataLets you record a medication statement against the encounter.

Steps​

1. Open the Updates tab​

Open the patient.

Select the Updates tab.

2. Start a new form​

Select Add Patient Updates. Care opens the form page for the patient.

3. Select the Medication Statement form​

Enter Medication Statement in the Search Forms box.

Select Medication Statement in the results.

Note: Medication Statement is a patient form. It is not in the Forms list of the encounter.

4. Select the medicine​

Select Add Medication.

Search the clinical drug list for the medicine that the patient reports taking.

Select the medicine in the results. Care adds an entry for it.

5. Complete the entry​

Complete the fields of the entry.

ComponentsWhat it captures
SourceWho reported the medicine: the Patient, a Practitioner, or a Related Person. Care selects Patient by default.
StatusThe state of the medication statement. Care selects Active by default.
Dosage InstructionsHow the patient takes the medicine. This field is mandatory.
Medication Taken BetweenThe start date and the end date of the period. The start date is mandatory. Leave the end date empty when the patient still takes the medicine.
ReasonWhy the patient takes the medicine. You can enter up to 100 characters.
NoteMore information about the medicine.

To record another medicine, repeat step 4 and step 5.

6. Submit the form​

Select Submit.

Note: To finish the form later, select Save as Draft.

Expected Outcome​

  • Care shows the message "Questionnaire submitted successfully".
  • Care opens the Updates tab of the patient.
  • Care shows the medication statement in the Medication Statements sub-tab of the Medicines tab of the encounter.

Concepts:

Flows: