Use these instructions when administering orders from
the Scheduled and PRN tabs. These tabs are used to administer Non-Continuous
IV and Non-IV medication orders. For additional information on using the
BCMA (bar coded medication administration)functionality (BCMA
button), see the BCMA:
Bar-coded Medication Administration topic.
To administer Non-Continuous IV orders
To document medication as Not Given
All conflicts must be viewed prior to administration.
Click the red exclamation button to the right of the medication to
display any Allergy/Reaction (PAR), Dose Conflict, Duplicate Therapy
(DT), Drug Interaction and/or Food/Alcohol (DFA) interactions for
this medication. Click Close
to close the Conflict window when you are finished with your review.
Check the boxes of the desired medications, and click
Administer Selected to display
the Administration window. The Administration window has multiple
tabs based on the type of medication selected: Administration,
Immunization (for Immunizations),
Add Charges, Additives
(for IV orders), and Order Detail.
Administration Tab:
On the Administration tab in the Order Details section, the Physician,
Default Dosage, Ordered Dosage, Frequency, Dose Schedule, Quantity,
Ordered Rate Range, and Route are displayed. Modify the Admin
Quantity, Route,
and Site fields as necessary
to document the appropriate administration information.
Need to document a waste? You may enter waste information by clicking
the Waste Log button (located
next to the Ordered Dosage field) to display the Medication Waste
Log box:
In the Waste Amount field, enter the amount of the medication that was wasted.
In the Reason field, select the reason for the waste.
In the Disposal Method field, select the method used to dispose of the medication.
In the Witness section, have the witness enter their username and password in the Witness Username and Witness Password fields.
Then, click Save
to return to the Administration Details box.
If applicable, click the Site
drop-down list and select the site where the medication was administered
on the body.
In the Administration Details section, the Administered
By field displays the current user ID, the Administered
date and time fields display the current date and time. Edit these
fields as necessary to document the appropriate administration information.
If a witness is required, the Witness Username and Witness Password
fields are displayed. Have the witness enter their username and password,
and click Authenticate (or
Verify) to verify the information.
If the witness is unavailable, click the Bypass
button. This displays the medication with an
hourglass icon indicating the signature is pending. Once the
witness is available, go to the Administration Details to enter the
appropriate credentials from the eMAR.
If not administered at this time, check the Not Administered box. Note: If a
medication is documented as Not Administered, to remove (or edit)
the administration, go to the eMAR
> All tab and select the Edit option to remove the Not Administered
check mark.
If applicable, enter notes in the Comment
field.
In the Drug Details
section, enter details in the Manufacturer,
Lot No, and Expiration
Date fields. The Manufacturer
field uses a progressive search. Begin typing the first few letters
to display a list of matches. Then, click the desired item to select
it.
Sliding Scale Tab: Select the Sliding Scale tab if you are administering a sliding scale medication so you can determine the quantity to administer.
In the Value field, enter the patient's current value (i.e. blood sugar, PTT, etc.). The dose is calculated and displayed.
In the Action field, use the drop-down list to select the action to take.
Enter any comments in the Comment
field.
Select the Instructions
tab to view special instructions or comments from Order Entry, or
schedule-specific comments associated with the order. These are comments
that apply to this dose and/or dose time only, e.g. "Draw labs
30 minutes after this dose." This tab displays only if instructions
or comments have been entered.
Immunization Tab: Select the Immunization tab if you are administering an immunization to view and enter vaccine details.
In the Immunization Details section, select the Immunization, Manufacturer, Lot Number, and Expiration Date in the appropriate fields.
In the VIS Presented Date field (Vaccine Information Sheet), the date on which the patient or family member was provided information/material regarding the immunization.
(Optional) In the VIS Publication Date field (Vaccine Information Sheet), the date (or published date) on the material that was given to the patient. You can set the default for the VIS Published Date in the Immunization master file in the Healthcare Maintenance Items master files in Clinical Documentation.
In the Funding Program Eligibility field, use the drop-down list to select if the patient is eligible for the Vaccines for Children (VFC) program. (Note: This field is also available in Patient Registration > Edit MPI > Medical Summary > Vaccines for Children field. If completed in Patient Registration, this field here is populated with that information.
In the Immunization Funding Source field, use the drop-down list to select the appropriate funding source.
In the Immunization Registry Status field, enter the status of the Immunization Registry. This field is used to enter the status of the patient as it relates to the Immunization Registry. If the patient leaves the area, you can remove them from the transmission file to the registry by selecting an inactive status. This means they wouldn't be included in any further transmissions to the registry.
In the Immunization Registry Status Effective Date field, enter the date that the status identified in the previous step became effective.
In the Send Reminder field, select the appropriate type of reminders to generate for this immunization item, if desired.
In the Reminder Effective Date field, enter the date that the reminder identified in the previous step became effective.
The Consent to Share Immunization Information check box is used to grant permission to submit this immunization data to the registry.
In the Consent Information section, enter the consent date, the decision (Consent, Defer, or Refuse), name of who made the decision and their relationship to the patient, and any additional comments.
Add Charges Tab: Select the Add Charges tab to add, view, or edit additional charges. To add a charge, click the Add button to display the Add Additional Charges window. Enter the charge, quantity, and up to 2 modifiers in the appropriate fields. Then, click Save and the added charge is displayed. Located to the right of each additional charge are function buttons that allow you to edit or remove the charge. Click the Edit button to edit, or click the Remove button to remove it.
Additives Tab (if applicable): Select the Additives tab to view a list of additives to be given to the patient along with the main order. The additive name, strength, dose, volume, and quantity are displayed. This tab is displayed only if there are additives associated with the main order and is view-only. Use the Additives tab to ensure the additives are not missed and are charged.
Order Detail Tab: This tab displays existing order details regarding this order.
To mark a medication as a home medication, scroll down to the Home Medication check box and check it.
To view historical details regarding the order, click the View History Log button.
Click Administer, or if administering multiple orders, click Administer and Next to display the next order. Based on the circumstances of the administration, one or more of the following may appear:
If you administered the
medication outside of the "acceptable" timeframe, the
Reason box is displayed. Select the appropriate reason for giving
the medication early or late and click Save.
For PRN orders, if the stop date of the order has passed the current date and time, the message, The stop date has passed. Would you like to discontinue this order? is displayed. Click Yes if you want discontinue the order, or click No to continue with this order.
When administering Non-Continuous IV or Non-IV orders, once order details are saved, the order is dropped from the Scheduled orders tab; however orders on the PRN tab remain on the list until they are discontinued from Orders Tracking.
All conflicts must be viewed prior to administration. Click the red exclamation button to the right of the medication to display any Allergy/Reaction (PAR), Dose Conflict, Duplicate Therapy (DT), Drug Interaction and/or Food/Alcohol (DFA) interactions for this medication. Click Close to close the Conflict window when you are finished with your review.
Check the boxes of the desired medications, and click Administer Selected to display the Administration window.
On the Administration tab in the Order Details section, the Physician, Dosage, Volume, Rate, Frequency, Route, IV Method, and IV Type are displayed.
Confirm and, if necessary, modify the Rate Administered field.
In the IV Site field, use the drop-down list to select the appropriate IV site used.
In the Administration Details section, the New Bag Hung check box identifies a new IV bag and applies a charge to the account. This box is automatically checked for the first administration of the medication. For subsequent administrations, this box is unchecked until the full volume has been administered (i.e. Remaining Volume = 0). If you check this box during a subsequent administration, the message, Do you want to discontinue the current bag and start a new bag, is displayed. Click Yes if you are starting a new bag, or click No if you are administering the current bag.
Enter the time the bag was started in the Bag Start Date/Time fields.
Enter the time the bag was stopped in the Bag Stop Date/Time fields. Based on the start and stop times, the total run time is automatically calculated and displayed in the Bag Total Run Time field.
If a witness is required, the Witness Username and Witness Password fields are displayed. Enter the witness username and password, and click Authenticate to verify the information.
Enter any notes in the Comment field.
(Optional) Select the Instructions tab to view special instructions or comments associated with the order. These are comments that apply to this dose and/or dose time only, e.g. "Draw labs 30 minutes after this dose." This tab displays only if instructions or comments have been entered.
(Optional) Select the Add Charges tab to add, view, or edit additional charges. To add a charge, click the Add button to display the Add Additional Charges window. Enter the charge, quantity, and up to 2 modifiers in the appropriate fields. Then, click Save and the added charge is displayed. Located to the right of each additional charge are function buttons that allow you to edit or remove the charge. Click the Edit button to edit, or click the Remove button to remove it.
(Optional) Select the Additives tab to view a list of additives to be given to the patient along with the main order. The additive name, strength, dose, volume, and quantity are displayed. This tab is displayed only if there are additives associated with the main order and is view-only. Use the Additives tab to ensure the additives are not missed and are charged.
(Optional) Select the Order Detail tab to view the current details of the order, including related diagnosis, history, and the ability to mark this as a home medication. (To indicate this, check the Home Medication box.)
Click Administer, or if administering multiple orders, click Administer and Next to display the next order.
If you administered less than the whole dose, the
Waste Log window is displayed to document the waste of a medication.
The medication name, administration time, and administered amount are displayed. In the Waste Amount field, enter the amount of medication that was wasted according using the appropriate unit of measure.
In the Reason field, use the drop-down to select the reason for the wasted medication.
In the Disposal Method field, use the drop-down to select the method used to dispose of the wasted medication.
If the medication is a controlled substance, the Witness section is displayed and requires a second signature. Enter the witness' login and password in the appropriate fields. The login must be different than the user currently logged in.
Click Save.
For PRN orders, if the stop date of the order has passed the current date and time, the message, The stop date has passed. Would you like to discontinue this order? is displayed. Click Yes if you want discontinue the order, or click No to continue with this order.
When administering Non-Continuous IV or Non-IV orders, once order details are saved, the order is dropped from the Scheduled orders tab; however orders on the PRN tab remain on the list until they are discontinued from Orders Tracking.
Check the boxes of the desired medications, and click Administer Selected to display the Administration window.
On the Administration tab, check the Not Given check box.
In the Reason field, select a reason for not giving the medication.
Enter notes in the Comment field.
Click Administer.
The Waste Log window is displayed to document the waste of a medication (may require a witness signature).
The medication name, administration time, and administered amount are displayed. In the Waste Amount field, enter the amount of medication that was wasted according using the appropriate unit of measure.
In the Reason field, use the drop-down to select the reason for the wasted medication.
In the Disposal Method field, use the drop-down to select the method used to dispose of the wasted medication.
If the medication is a controlled substance, the Witness section is displayed and requires a second signature. Enter the witness' login and password in the appropriate fields. The login must be different than the user currently logged in.
Click Save.