Dispense & Administer Medications – Profile EMR User Help

Background
Definitions and Overview
Confirm an Order is Active via Prior Scripts List
Review a Medication Dispensing and/or Administration Record (MADR) History
Dispense and/or Administer from an Active Medication Order
Information Resources

Background

In order to dispense or administer medications, there has to be an active medication order or prescription. In Profile EMR, this record sits in the Prior Scripts tab.

The Usual Scripts tab is just a medication list. This list can contain medications which are over the counter or prescribed medications – this list can be likened to a Best Possible Medication History.

Definitions and Overview

Usual Scripts List (Rx): represents the regular, on-going medications clients are receiving. It is the primary list used for medication reconciliation purposes and must be kept up to date. Interim or short term medications should not be included on this list.

Current Orders List: generates a prescription to hand to the client or fax to pharmacy or to record that this client has taken this medication.

Prior Scripts List: represents the chronological history of all past prescriptions entered in the EMR through the Usual Scripts or Current Order (excluding Controlled Prescription Form (Duplicate Rx)).

Discontinued Medications List: medications for a client that a Profile EMR prescriber has discontinued from the Usual Scripts list.

Scripts overview.jpg

Confirm an Order is Active via Prior Scripts List

Clinician's should only enter a dispensing or administration record against active orders
To determine an order is active, navigate to Prior Scripts to review:

1. Finished Flag Column:

The "Finished Flag" icon automatically populates or is manually set in the finished flag column when an order is no longer active (prescription is expired or medication has been discontinued or changed from the client's usual scripts and the provider has "end-dated" the previous prescription. MADR finished flag.jpg

2. Order 'Details':

The order 'Details' confirm the following information:

Medication name
Medication dose
Date medication ordered
Quantity = how long order is valid for should reflect a time freq. e.g. 2 weeks, 1 month, etc.)
Author = Clinician who prescribed the medication
**Note: An order is only valid if entered by an authorized prescriber
**Note: Orders entered by unauthorized prescribers should be end-dated; and any medication dispensing or administration entries recorded against same should be noted as Entered in Error and recorded against an active order

To view the order Details, 1) right click on the order in the Prior Scripts list, 2) select details; the Details window will open

**Note: In the event a client has multiple active orders for the same or similar/like medications an authorized prescriber should review and end-date those which are conflicting or have been discontinued - see 'End Date a Medication in the Prior Scripts List'

Review Medication Dispensing and/or Administration (MADR) History

Medication dispensing/administration records are located in the client medical record in the Prior Scripts list and are listed under the medication order they were recorded against.
The Prior Scripts list can be viewed from 1) the Prescriptions tab or 2) from the Actions Panel in a New Encounter

Review MADR from Prior Scripts list via Prescriptions tab

From the client's Medical Record: 1) navigate the the Prescriptions tab, 2) Click on Prior Scripts, 3) Click on the medication order you wish to view the dispensing/administration history for

Prescriptions tab MAR.jpg

Review MADR from Prior Scripts list via New Encounter Actions Panel

In a New Encounter, 1) Click on the Scripts tab in the Actions Panel, 2) Click on the Prior Scripts tab, 3) Click on the medication order you wish to view the dispensing/administration history for

New Encounter MAR.jpg

Medication Administration Record (MAR) Stored Query

This report provides a list of the last two years of medication administrations that have been entered using the Medication Administration icon via the Prior Scripts list in the New Encounter Actions Panel
This list populates all medication administration entries including those with a status of 'Cancelled', which reflects an entry that was entered in error.
The report is printable when needed to support continuity of care for client's

Dispense and/or Administer from an Active Medication Order

Key Points when entering a medication dispense or administer record:

Medication Dispense and/or administration records are entered in a New Encounter via the Scripts tab
Only dispense or administer against active orders
If an active order does not exist:
- An authorized prescriber should enter an new order
- When indicated and supported by your practice guidelines and program, a medication administration record may be recorded against a verbal order - see 'Record and Sign off a Verbal and Telephone Order'

Document Medication Dispense

1. From a New Encounter navigate to the Prior Scripts List and select the active order which you have dispensed the medication from

2. Select the Dispense icon

dispense icon.jpg

3. Review and updated the fields in the Dispense To window as below:

dispense details.jpg

4. Click OK to save your details and close the administration window

**Note: Your Dispense record should be visible in the 1. Dispense/Administer field as well as in the encounter actions column

Document Medication Administration

1. From a New Encounter navigate to the Prior Scripts List and select the active order which you have administered the medication from

2. Select the Administer icon

administer icon.jpg

3. Review and updated the fields in the Administer to window as below:

administer details.jpg

4. Click OK to save your details and close the administration window

**Note: Your Administer record should be visible in the Dispense/Administer field as well as in the encounter actions column

Document that a Dispense or Administer record was "Entered in Error"

Key Points:

Medication dispensing and administration records which have been "Entered in Error" should not be deleted from the client record.
The following 4 steps should be carried out by the clinician who recorded the error:

1) Change the Encounter Contact Description to "Entered in Error"

2) Cancel the dispense or administer action

3) Document the nature of the error in the encounter body

4) Create a new encounter to document the correct medication dispense and/or administer record

Change the Encounter Contact Description to "Entered in Error"'

1. Click on the Contact heading for the encounter the dispense or administer record has been documented into. 2) In the contact properties window type "Entered in Error" into the contact description field. 3) Click Ok to save this change

enterred in error contact.jpg

Cancel the Dispense or Administer action

1) Right click on the dispense or administer action in the encounter action column. 2) Select "Cancel Action".

**Note: After cancelling the entry the 1) status icon of the dispense/administer record will change from a Green checkmark to Red 'x'. 2) The record will no longer be present in the med dispense/administer window in the Prior scripts list and 3) the cancelled entry will be crossed out once the Entered in Error encounter is saved

Document the Nature of the Error in the Encounter Body

Free text details outlining the nature of the documentation error into the body of the encounter note as per your program/roles documentation guidelines (E.g. Incorrect medication dose documented, entry documented in incorrect client record)

**After completing the above steps (1-3), the encounter window should look as below:

cancelled complete.jpg

**When viewed from the client's Encounters tab the record should look as below:

review encounter view.jpg

Information Resources

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