How do I create a draft Medication order?

Depending on your role and your permissions, you may be asked to create a draft medication order

Overview of the Medication page

After searching for and selecting your resident, your default view is the Medications tab.

The Personal Information is visible on the left and under the resident image click on the ADR button to show the resident’s Adverse Drug Reactions.

Also note that the Special Considerations appear under this view.

The prescriber will be responsible for the Chart Reviews and the Last and Next Chart Review dates will appear here after medications have been ordered, and the initial Chart Review has been completed.

Creating a Draft Medication Order

To begin this process, click Create New Chart
1. Chart Types include Regular Medicine Orders, Insulin Orders, PRN Medicine, Short Term Medicine, Once Only Meds (Stat), Intermittent Medicine, Non Prescription Meds or Nutritional Supplement
Use the dropdown arrow to select the Chart Type
Select Regular Medicine Order
1. Note that Generics is the default type. This may be changed by clicking on All, Brands or Custom buttons
Click into the Search Medications field and begin typing the name of the medication
Select the correct medication
The Date Created will auto populate
In the Dose Unit field, click on the dropdown arrow to select
In the Route field, click on the dropdown arrow to select
Move to the Prescription Quantity field
Enter the Quantity of tablets in the box or bottle
Enter the Quantity of tablets to be administered to the resident
Then use the dropdown arrow to display the Frequency options
The Periodicity field will default
If you need to update the Daily Time & Dose Quantity field, simply click into the field and adjust the time
The Select Treatment Use dropdown arrow will display options, such as for Dental Treatment only. You may not need to use this field unless relevant
In the Notes/Directions field you may add any additional notes below the line
Then scroll down the page
Enter any Prescription or Administration options if known
If the Prescription Type is Private, click the Private button
If the Prescription Type is PBS/RPBS click the PBS/RPBS button
You may be taken to the Indications and Streamline Codes page where options will display. Click the clinical criteria to review, then select the radio button next to the Correct Approval Code as required
Then click Confirm
Then click the Save Draft button
As the prescription draft and chart have been successfully created, click Close
Scroll up the page
Return to the Resident’s Profile
Your Regular Medication order has been saved as a Draft
You may review the order by clicking on the arrow next to the Order
The Prescriber will then convert the order from a draft to a regular prescription order by clicking on the Save & Approve Chart button
The prescriber will then click Complete. The Prescriber has converted the draft order, as evidenced by the Status recorded as Signed