Medication Fields / Options







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Medication data entry takes place in the following sections:

Administration Records / MAR - A subsection of medication records.  Used to record medication administration information.

Medication Information - The primary component of medication records.  Used to record medication details, including prescribing info and schedule (if applicable).

Pharmacy Orders - A subsection of medication records.  Used to record pharmacy-related information for medications.

Below is an alphabetical list of the fields and options located in each of these sections.  To jump directly to the information for a specific field or option, press <Ctrl+F> to access your browser's search field and enter the name of the field/option in question.

  NOTE: A gear icon  next to a field or option in this list indicates that it is either optional (and therefore not automatically in all AWARDS databases), or that some aspect of it (for example drop-down selections or its status as required/not required) is configurable.  For information on the ways in which these data entry pages can be configured, see the Medical Module - Implementation Requests Form (Medication Options and Medication Search sections) and/or the MAR - Implementation Requests FormTo request some or all of the configuration options detailed there, complete the relevant form(s) and submit to [email protected].

Administration Records / MAR

  TIP: Please keep in mind that the "Administration" label is configurable; as a result, this portion of medication records may look different in your AWARDS database.  Regardless of the label, the functionality works as described here.

After a medication record is saved for the first time, administration records can be entered for it.  Administration records can be entered from the MAR feature located on the Medication index (used to administer one or more medications at once), or directly from the Administration Records sub-index accessed via the medications data entry page (used for single medication administration), shown below.

  NOTE: The fields and options available for MAR data entry are the same regardless of the access point.  

When Administration Records is clicked, the corresponding sub-index is displayed.

Any previously recorded administration information is displayed in this table, as is the option to add a new record. 

WARNING! Saving an administration record requires an electronic signature from the user completing the data entry process.  As a result, care should be used during the data entry process as saved medication administration records cannot be edited or deleted after signing. A single exception is made in those instances in which the MAR has been set to collect Outcome information.  Only MARs configured in that way will have the edit icon available to them on the index above, and only the Outcome information is editable in those cases.

Below is an alphabetical list of the fields and options located on data entry page when adding a new administration record (with the Add New icon from the index above, OR when using the MAR feature directly). 

  NOTE: The fields and options available for MAR data entry are the same regardless of the access point.  

To jump directly to the information for a specific field or option, press <Ctrl+F> to access your browser's search field and enter the name of the field/option in question.

Administration Date (Administration From/To)

In this field, type or make changes to the date on which the medication is being administered (using mm/dd/yyyy format), or select the date using the date picker arrows. The default date is today's date.

For programs set to record a batch of administration records over a date range, Administration From and Administration To date fields are displayed, instead of a single field. The default value in each field is today's date.

Administration Done By

This drop-down list is shown if the program's type has been configured to use the third party data entry option, which enables users other than the medication administrators to enter administration records into AWARDS.  When shown, click the drop-down arrow and select the individual who completed the administration.  The list contains the names of staff members who have chart access to the program, and have at least one of the following permissions assigned under Permissions Maintenance:  "List as Clinician," "List as Nurse,"  "Prescribing/Diagnosing Physician," or "Include in Direct Care Staff List."

Administration Dosage

In this field, type or make changes to the dosage being administered, and then select the measurement of that dosage from the corresponding drop-down list.  If this information is recorded in the medication record or in previous administration records for this medication, it is automatically dropped in here.

  TIP: This field accepts decimal values.

Administration Recorded By

This read-only value displays the name of the user entering the administration record.

Administration Time

In this field, type or make changes the time at which the medication is being administered (using HH:MM AM/PM format).  The default value is the current time.

Comments

In this text box, enter any comments regarding the medication administration being recorded, if applicable.

E-Signing Options

Upon clicking Save on an administration record, the Electronic Signatures Signing by PIN dialog box is displayed. Configure the options in the dialog box as follows, and then click SIGN NOW to complete the saving process.

  NOTE: If, during the process of setting up your electronic signature, you specified default signature settings, those settings are reflected in this dialog box.  As a result, you may not need to configure some of the options below unless it is necessary to adjust the defaults.

  Sign With - Click the radio button next to the type of image with which you want to sign this record - "No Image," "Initials Image," or "Full Name Image."

  NOTE: Sign with options are only available for the images you uploaded during the process of setting up your electronic signature.  So, for example, if you only uploaded a full name image, the "Initials Image" option is not available here.

  Authority Level - Click the radio button next to the appropriate authority level for this record, indicating whether you have completed or recorded the medication delivery.  

  NOTE: The "recorded" option is only available if the third party data entry option has been set for your agency as detailed in the MAR - Implementation Requests Form.  

 Credentials - Click the checkbox next to each credential to be included with your signature.

  NOTE: This portion of the signing dialog box is only available when credentials have been specified for you in the Human Resources module's Staff Information feature.

  PIN - In this field, type your five-digit PIN to confirm your identity.

Key Code

Click this drop-down arrow and select the key code for the medication administration being recorded.  List selections, along with a default value, are configurable and will vary by agency.

Medication

Displays the name of the medication as a read-only value.

On Time

  NOTE: This option is only available when scheduled time information is being collected.

Click this drop-down arrow and select "Yes," "No," or "N/A" to indicate whether the administration is on time.

Outcome

  NOTE: This option is only available after an administration record is saved, and then accessed again in data entry mode.

In this field, enter the outcome that occurred from the medication being administered.

Scheduled Time

  NOTE: This option is only available when scheduled time information is saved on the corresponding medication record.

Click this drop-down arrow and select the scheduled time of the administration.  Available selections are those recorded for this medication in the Medications feature.

  TIP: When using the MAR, each scheduled time for each medication appears in its own row on the Medication table. The default view is "Scheduled" medications. If necessary, use the Filter by drop-down located above the table and select "All" or "Unscheduled" to update the list of medications displayed.

SIG 

Displays the SIG entered on the medication as a read-only value. When using the MAR, the SIG is displayed in the info mouse-over next to the medication name.

Strength

Displays the strength of the medication as a read-only value.

Unscheduled 

  NOTE: This option is only available when scheduled time information is being collected.

If applicable, click this toggle to indicate that the medication is being administered off-schedule.  When this option is set, Scheduled Time and On Time selections are not required.

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Medication Information

# Refills

In this field, type or make changes to the number of refills prescribed for the medication.

  NOTE: This information is not editable for medications that have been e-prescribed or that have administration records entered for them.

Consent

Click this toggle to indicate that the client or his/her surrogate has given informed consent for the medication.  When this option is selected, Consent End Date and Consent Start Date can also be recorded.

Consent End Date

  NOTE: This field is only available if the Consent toggle is set to "Yes."

In this field, type or make changes to the date on which consent expires (using mm/dd/yyyy format), or select the date using the date picker drop-down arrow.

Consent Start Date

  NOTE: This field is only available if the Consent toggle is set to "Yes."

In this field, type or make changes to the date on which consent was given (using mm/dd/yyyy format), or select the date using the date picker drop-down arrow.

Dosage

In this field/option combination, record or make changes to the medication dosage.  In the first field type the dosage number, and then choose the measurement/form from the corresponding drop-down list; for example, 1 teaspoon.

  NOTE: Agencies using AWARDS E-Prescribing are required to use a default selection list, and cannot configure the options on this drop-down.

  NOTE: Dosage information is not editable for medications that have been e-prescribed or that have administration records entered for them.

Drug Type

Click this drop-down arrow and select "Branded" or "Generic" to indicate the medication type.

  NOTE: This information is not editable for medications that have been e-prescribed or that have administration records entered for them.

End Date

In this field, type or make changes to the date on which the client stopped, or will stop, taking the medication (using mm/dd/yyyy format), or select the date using the date picker drop-down arrow.

IMPORTANT! If administration records have been entered for this medication the medication end date must be after the last recorded administration date.

  NOTE:  This information is not editable for medications that have been e-prescribed

End Time

In this field, type or make changes to the time at which the client stopped, or will stop, taking the medication (using HH:MM AM/PM format).

  TIP: An End Date must be specified before the End Time can be entered.

Estimated End Date

  NOTE: This option is only available if an End Date has been entered.

Check this option if the End Date is an estimated date and not confirmed.

Frequency

Click these drop-down arrows to record or make changes to the medication frequency. Specifically, from the first drop-down selection list choose the number of times a day the client is to take the medication, and then from the second list choose how often; for example, 1 x per day.  Keep in mind that if "As Needed" is selected in the second drop-down, the number of times becomes irrelevant and the first drop-down is hidden, along with the "x per" notation.

  NOTE: Agencies using AWARDS E-Prescribing are required to use a single default selection list, and cannot configure the options on this drop-down.

  NOTE:  Frequency information is not editable for medications that have been e-prescribed or that have administration records entered for them.

Instructions

In this text box, type or make changes to instructions for the medication, if any.

Medication Details

This is a multi-select option.  Click all values that apply as details for this medication.  To de-select a value, click the x for the item to be removed.

  NOTE:  This selection list is configurable.  If "Controlled Substance" is present, it auto-populates for e-prescribed medications, and is also selectable for other medications.

Medication Expiration Date

In this field, type or make changes to the expiration date of the client's medication (using mm/dd/yyyy format), or select the date using the date picker drop-down arrow. 

Medication Flag

If manually entering a medication, click all values that apply for it using this multi-select option.  Available selections are "Controlled Substance" and "PRN."  To de-select a value, click the x for the item to be removed.

For electronically prescribed medications, this option displays a read-only value of "E-Prescribed."  If the electronically prescribed medication is also a controlled substance, "Controlled Substance" is also displayed.

For medications originating from the client's C-CDA, this option displays a read-only value of "Incorporated Health Record."

Name

In this field, type or make changes to the name of the medication.  Keep in mind that this will be the medication's main identifier on the client's medications index.

As the medication name is typed, a search feature automatically suggests medication matches after five characters have been entered.  The search results contain the name (both branded and generic) and the strength/unit information.  Once a match is selected from the list, the medication is displayed in the Name field, and the associated Strength/Unit and Rx Norm information is automatically populated and cannot be edited.

  TIP: If the medication being entered is not listed in the search results, free text can be entered in the Name field without a selection from the searchable library, instead saving what was manually entered.

  NOTE:  In some databases this field may instead be shown as a drop-down list of medications for which the content has been provided by the agency.  If this enhancement is turned on, an "Other" option is included in the drop-down.  When selected, a corresponding text field will be available for the purposes of typing in the medication's name.  Medications added using this "Other" selection are NOT added to the main medications list for the agency and are only recorded in this specific medication record.

  NOTE: This information is not editable for medications that have been e-prescribed or that have administration records entered for them.

Next Meds Review Appt Date

In this field, type or make changes to the next review date for this medication if applicable (using mm/dd/yyyy format), or select the date using the date picker drop-down arrow.

No Known Medications

If a client's medication index contains no records and Add New is clicked, the data entry form includes a No Known Medications checkbox at the top of the page.  If this option is checked off and the page is saved, a "No Known" record is then displayed in the medications index for the client.  This can be used to help more easily distinguish which clients are not taking medications as opposed to those for whom no medications data entry has been done.  If a medication record is later entered for the client, the "No Known" record is automatically removed and this checkbox is no longer available on new medication records for him/her, even if that medication later has an end date recorded for it.

Phone

In this field, type or make changes to the prescribing physician's phone number (using (xxx) xxx-xxxx format).

Prescribing Physician

Specify the name of the physician who prescribed the medication.  Depending on how the medications data entry page has been configured, you will either type the name into a text field, or click the available drop-down arrow to select the person who prescribed the medication. 

  NOTE:  For agencies using the Providers feature, Prescribing Physician displays as a drop-down of the selected client's current providers.  An "Add New" option is also available for users to add a new provider to the client's record without leaving the medication data entry page.

For agencies NOT using the Providers feature, this option displays as a drop-down of users who have both of the following permissions assigned to them under Permissions Maintenance:

  Have the "List as Prescribing/Diagnosing Physician" permission, assigned on the individual permissions layer

  Have chart access permission to the program in which medications data entry is being done, assigned on the individual permissions layer

  NOTE: This information is not editable for medications that have been e-prescribed or that have administration records entered for them.

Purpose

In this field, type or make changes to the purpose for which the medication is being taken.

Quantity

In this field, type or make changes to the number of medication items (pills, swabs, patches, inhalers, etc.) prescribed.

  NOTE: This information is not editable for medications that have been e-prescribed or that have administration records entered for them.

Rationale for Change

In this field, type or make changes to the rationale for changing or discontinuing the medication, if applicable.

Reactions

In this text box, type or make changes to a list of the reactions the client has to the medication, if any.

Renewal Date

In this field, type or make changes to the renewal date for this medication if applicable (using mm/dd/yyyy format), or select the date using the date picker drop-down arrow.

Route

Click this drop-down arrow and select the medication administration route.

  NOTE: Agencies using AWARDS E-Prescribing are required to use a set selection list, and cannot configure the options on this drop-down.

  NOTE: Route information is not editable for medications that have been e-prescribed or that have administration records entered for them.

RX / OTC

Click this drop-down arrow and select "Rx" or "OTC" to indicate whether the medication is prescription-grade or an over-the-counter medication, respectively.

  NOTE:  information is not editable for medications that have been e-prescribed or that have administration records entered for them.

RX #

In this field, type or make changes to the medication's prescription number.

RxNorm

RxNorm is a unique identifier for medication name, strength, and unit used for AWARDS Certified Edition use cases such as Interoperability and quality measures.  It auto-populates with the RxNorm code for the medication and strength combination entered on the page. 

A link to the RxNav medication search tool is available next to the field name, which opens the national RxNav database to allow you to search for a more specific RxNorm code if desired, or if no match was found by the system.

  NOTE: This information is not editable for medications that have been e-prescribed, where the medication name was selected from the searchable library, or for medications that have administration records entered for them.  For all other records, while the code pre-populates it remains in data entry mode for editing if it is necessary to make any changes.

Scheduled Times

In this field, type the specific times at which the client is to take the medication (using HH:MM AM/PM format).  Press <Tab> to enter additional times.  To remove a time, click the x next to the time to be removed.

Self Administering

If the medication can be self-administered by the client, click this toggle to set it to "Yes."

  TIP: Medication records marked as self-administering can have future administration records saved for them.

SIG

In this field, type or make changes to the SIG text, which typically appears as an instruction on a prescribed medication's label.  This open text field can be used to record dosage and frequency information if the selections available for those options do not fit the necessary instructions.

  NOTE: This information is not editable for medications that have been e-prescribed or for those that have administration records entered for them.

Source of Knowledge

In this field, type or make changes to the source of knowledge regarding the medication's purpose and use, if applicable.

Start Date

In this field, type or make changes to the date on which the client began, or will begin, taking the medication (using mm/dd/yyyy format), or select the date using the date picker drop-down arrow.

  NOTE: This information is not editable for medications that have been e-prescribed or that have administration records entered for them.

Start Time

In this field, type or make changes to the time at which the client began, or is to begin, taking the medication (using HH:MM AM/PM format).

Strength

In these fields type or make changes to the strength of the medication and/or the unit of measurement.  Keep in mind that the strength field only allows numeric values and the unit allows for the entry of non-numeric text.

  NOTE: This information is not editable for medications that have been e-prescribed, those for which the medication name was selected from the searchable library, or for those that have administration records entered for them.

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Pharmacy Orders

After a medication record is saved for the first time, pharmacy information can be entered for it.  Pharmacy orders can be entered from the Pharmacy Orders sub-index accessed via the medications data entry page, shown below.

When Pharmacy Orders is clicked, the corresponding sub-index is displayed.

Any previously recorded pharmacy orders are displayed in this table, as is the option to add a new record, or to edit or delete existing orders. 

Below is an alphabetical list of the fields and options located on data entry page when adding or editing a pharmacy order.  To jump directly to the information for a specific field or option, press <Ctrl+F> to access your browser's search field and enter the name of the field/option in question.

Comments

In this text box type or make changes to any notes for the pharmacy order.

Date Filled

In this field, type or make changes to the date on which the prescription for the medication was filed (using mm/dd/yyyy format), or select the date using the date picker drop-down arrow.  This will be the record's main identifier on the pharmacy orders index.

Pharmacy Address, Address 2, City, State, Zip

In these fields type or make changes to the pharmacy's address.  After one pharmacy order has been entered, the pharmacy address for a new record defaults to that specified in the previous record.

Pharmacy Name

In this field, type or make changes to the name of the pharmacy that filled the prescription.  After one pharmacy order has been entered, the pharmacy name for a new record defaults to that specified in the previous record.

Pharmacy Phone

In this field, type or make changes to the pharmacy's phone number (using (xxx) xxx-xxxx format).  After one pharmacy order has been entered, the pharmacy phone number for a new record defaults to that specified in the previous record.

Projected Out of Stock Date

In this field, type or make changes to the date on which the medication will be out of stock (using mm/dd/yyyy format), or select the date using the date picker drop-down arrow.

Qualifier

Click this drop-down arrow and select the form in which the medication was provided by the pharmacy; for example, tablet, kit, or inhaler.

Total Quantity

In this field, type or make changes to the total quantity of the "qualifier" provided by the pharmacy; for example, 30 tablets, 1 kit, or 2 inhalers.

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