Medical Cybernetics, Inc.
Medication Order Entry
The MC/PLUS-Rx Order Entry process encompasses the following functions:
- Additions of medications to the patient profile
- Listing of the patient medication profile
- Modification of the existing medication orders
- Selection of common medication order sets for addition to a patient's profile
- Verification of medication orders which were entered by technicians
Order entry begins with patient identification, which is accomplished through the Patient Access application. This application allows patient selection through a scrolling or search operation performed on the patient name, identification number, or room and bed number.
After the patient is identified, MC/PLUS will display the patient's information in the Order Entry application panel. Upon review of this information, any of the order entry functions listed above can be accessed by tool bar or function key selections.
Drug additions are selected by entering the drug code or performing a search or scroll. As specified in the parameters, drugs can be sorted by code, label name, or generic name. This facilitates selection of the proper drug mnemonic. Once a drug has been selected, the following administration information can be optionally entered.
- Dosage modification
- Route of administration
- Frequency of administration, including PRN and irregular hours
- Free text for reference
- Starting date and time
- Total number of doses or total number of hours of therapy
- Stop date and time
- Administration schedule for specific days of the week or month
Completion of order entry can be accomplished rapidly, and experienced users can use abbreviated steps to expedite the entry. Upon completion, the system will automatically calculate the number of doses needed until the next cart fill.
Verification - The Order Entry application allows technicians to enter orders; however, those orders are held by the system until verified and released by a pharmacist. During the drug verification process, pharmacists have an opportunity to review the order and any associated clinical screening information. They can edit the order without having to re-enter the complete information. Once verified and released, an order remains on the patient's profile for the duration of the patient's hospital stay. However, parameters can be set by the pharmacists which allow discontinued orders to become invisible except on demand.
Modification of an existing order can be accomplished without the need for total order re-entry. Audit trails for these orders are created by the system through a cancel-creation process. The original is canceled, a new one is created, and both orders appear on the patient's profile.
Medication Profile - All orders are maintained on a patient profile and are readily available for on-line review at each workstation for a user-specified time. (They can be maintained within the archives for up to five years.) The orders on the profile are listed chronologically, and a status is assigned to each one, i.e., active, discontinued, suspended, canceled, or review. Embedded within the Order entry application are comprehensive order management functions that provide control of the profile. A hard copy of the profile can be generated.
Patient allergies are displayed on the profile and are utilized by the system during order entry to screen for potential drug allergies. (See Clinical Screening)
Stop order notices are generated in conjunction with the MAR for those drugs which will expire automatically within 24 hours. The “hours to automatic discontinuance” is a parameter that is user assigned within the Formulary Database.
Free-form text is allowed during order entry. This information appears on the printed medication labels and the MAR for reference by nursing personnel.
The Order Suspension/Reinstatement application allows orders to be placed on hold indefinitely or for a specific period of time. It also permits reorder without re-entry of information.
Bar Code Support - The Order Entry application assigns each order a unique number for identification. This permits bar code entry and is particularly useful when charging, crediting, and refilling medications, and during inventory.
Drug Interactions - The system automatically screens for drug-drug interactions, drug-food interactions, patient allergies, duplicate orders, dose ranges, and therapeutic duplications at the time of order entry. When an interaction occurs, a warning message is displayed at the workstation. A hard copy of this notice can be generated.
Inpatient Dispensing/Medication Label Printing - Labels for dispensing and the Medication Administration Record (MAR) are generated as a result of order entry. User-defined parameters, which are built into the system, allow the desired number of ADT, dispensing, and MAR labels to be printed automatically for each patient at the time of admission or transfer. Discharged labels can also be produced by the system. In addition, unique label formats for specific medications can be defined based on the medication's route of administration or IV type.
A Dispensing Note is provided on the medication label and the medication pick list. It furnishes the user with free text capabilities.
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