# Ordering Inpatient Medications (Complex Dose)

Ordering medications now uses two dialogs in the ordering process and eliminates the dispense drug prompt. Inpatient medication orders now require a valid sc hedule. If users do not find the appropriate schedule in the list, they can choose to create a day-of-week/administration time schedule using the new Schedule builder. This feature also works for renewing, copying, and changing inpatient medication orders. The procedure for ordering medications is described below.

Note: Because a valid schedule is required, if you attempt to modify an existing medication order that does not have a valid schedule, you will receive a message box stating that and will have to enter a valid schedule.

Note: Your site's IRM staff may have specified rules governing the status of inpatient medication orders when patients are transferred from one ward or service to another. It may have also specified the number of days an inpatient medication order remains active. Please check with your site's IRM staff for information about these rules.

CPRS now requires a unique match in the Medication, Dosage, Route, and Schedule fields for inpatient medications before CPRS will auto-select an it em from the list. For inpatient medications, the Medication and Schedule fields must be an item from the list, but the Dosage and Route can be a free-text entry (the route must be in the MEDICATION ROUTES file #51.2). If the desired schedule is not on the list, the user can build a day-of-week/administration time schedule using the Schedule Builder.

CPRS displays unit dose routes based on the following rules:

1. If a default medication route is defined in the orderable item file, CPRS displays only the default medication route for the Unit Dose orderable item in the medication route selection list.

2. If there is no default medication route defined for the orderable item, CPRS displays all possible medication routes for the dosage form to the provider for selection.

3. If there is only one possible medication route, it will be used as the default.

4. If a medication route name or its abbreviation is not included in the selection list, a user may type it in.

Also, medications that are not in the formulary display in the list with the letters "NF" after the name or synonym, which is also displayed. CPRS checks for non-formulary dosages (e.g., the VA formulary may not have a 2.5 MG pill, but it may have a 5.0 MG pill) and for non-formulary orderable items (e.g., the VA may not carry a specific kind of allergy medication).

New Clozapine Requirements

With the Food and Drug Administration required changes for administering Clozapine, the following criteria must be met for a provider to order Clozapine:

· The patient is part of the treatment program.

· The patient has proper WBC (White Blood Count) and ANC (Absolute Neutrophil Count) lab tests within the past 7 days.

· The ordering provider has the YSCL AUTHORIZED key.

· The ordering provider has a valid Drug Enforcement Agency number or Veterans Administration number (DEA/VA#).

CPRS checks these criteria by calling an API provided by the Mental Health package that determines whether the patient should be permitted to receive the new prescription. CPRS gives order checks if the patient's lab test values are in the mid or low range as shown below:

Lab Test Ranges

| Low Range | Mid Range | High Range
WBC | < 3 | between 3 and 3.5 | >3.5
ANC | <1.5 | between 1.5 and 2 | >2

The labs test results determine what level of override is needed for the patient to receive Clozapine:

· High Range No override needed.

· Mid Range Local override. This is like a normal medication order check and can be overridden at the local level.

· Low Range National Clozapine Coordinating Center (NCCC) override required. If the patient's lab values are in the low range, the provider must contact the NCCC to receive an override that is valid for a single Clozapine order.

The other order checks related to Clozapine will continue to work as they have prior to these changes.

Additionally, the values of the Days Supply, Quantity, and Refills fields are restricted based on the type of patient that Mental Health designates in their files when the pr ovider is ordering Clozapine. This can be a 7, 14, or 28-day recipient of the Clozapine drug. For refills, the following rules apply:

· Patients on a 7-day monitoring frequency have no refills available.

· Patients on a 14-day monitoring frequency can receive a full 14-day supply or a 7-day supply and ONE refill.

· Patients on a 28-day monitoring frequency can receive EITHER a full 28-day supply, or a 14-day supply and ONE refill, or a 7-day supply and THREE refills.

CPRS now prevents the user from renewing outpatient and inpatient Clozapine orders.

To write a new Inpatient Medications order, follow these steps:

Note: If the user attempts to order inpatient medications for an inpatient from an outpatient location, CPRS discontinues the order process and returns the user to original Orders or Meds tab display.

In a complex dose order, the user must define specific characteristics for the order. Because the dose can affect the quantity, for example, changing certain fiel ds may cause the quantity field to either recalculate or reset to zero to force the user to enter the quantity.

1. Select the Meds tab and select Action | New Medication.

-or-

Select the Orders tab and bring up the Inpatient dialog by cl icking the appropriate item under the Write Orders box.

2. Locate the desired medication or medication quick order.

Note: CPRS now only auto-selects (highlights in blue and places that entry in the field) a medication, dosage, route, or schedule if the user types enough characters to uniquely identify an item in the list. If the user does not enter enough characters to uniquely identify an item, CPRS waits until the user manually selects an item using the mouse or the keyboard.

3. Select the quick order or medication name.

Once the name is selected, CPRS displays a second dialog to select the items for the rest of the order. In the top field of the second dialog, the generic medication name and the synonym (usually a brand name) are displayed.

Note: CPRS now uses a look up from Pharmacy to check if the selected medication is a controlled substance that will require the signature of a provider with a DEA or VA number. A message will appear to the provider "Provider must have DEA# or VA# to order this medication" as shown in the graphic below. Before an order for a controlled substance can be entered, the provider selected for the encounter must be able to sign the order. You may need to exit the dialog, change the provider, and then reenter the dialog.

Click here to see the new medication selection dialog.

4. Select the Complex Dose tab.

Note: Once you begin a complex order, you must remain on the Complex tab until you finish that order. Do not attempt to start from or switch back to the Dosage tab. If you do, all complex dosages will be erased and you will be forced to start again.

a.) Select the appropriate dosage.

The dosage may not begin with a decimal, for example .5; it must begin with a numerical value, 0.5 for example. Also, the character "^" may not be entered in the Dosage field. (The associated cost is displayed to the right of the dosage.)

b.) Enter the route.

c.) Select the Schedule cell and enter how often the medication should be taken (click PRN if desired). To create a customized schedule, select Other and use these instructions.

When the user selects a regular schedule that does not have PRN, the administration times may display in the Schedule column. The administration times will display if they have been defined for the ward or if there is a default.

d.) Select the Duration cell and enter a number and select units ("days" is the default) a patient should use the specified dose.

e.) Add the appropriate conjunction: And, Then, Except (Except is only for Outpatient Meds) or no conjunction for the final line.

Note: The conjunction "Then" requires a duration to be added.

f.) Select the Dosage field in the next row and select a dosage.

The dosage may not begin with a decimal, for example .5; it must begin with a numerical value, 0.5 for example. Also, the character ^ may not be entered in the Dosa ge field. (The associated cost is displayed to the right of the dosage.)

g.) CPRS will fill in the Route and Schedule fields. If necessary, select and change the Route and Schedule cells.

h.) Select and enter a duration and a conjunction.

Note: Your site's IRM staff may have specified rules governing the status of inpatient medication orders when patients are transferred from one ward or service to another. It may have also specified the number of days an inpatient medication order remains active. Please check with your site's IRM staff for information about these rules.

i.) Repeat steps f-h until you have completed the complex dose.

Note: You can also add or remove a row in the complex dosage. If you add a row, the new row will be placed above the selected row. To add a row, click the gray area in front of the row and click Add Row. To delete a row, click the gray area in front of the row to be deleted and click Delete Row.

5. Add comments, as needed.

The date and time that the patient is scheduled to receive the first dose of the medication appears under the Comments field. (For example, CPRS cannot show an expected first dose for "on call" or schedules with PRN. On the complex tab, it will not try to determine an expected first dose after a THEN because the first item must be completed.)

6. CPRS displays when the first dose of the medication is expected to be given. If you want to give an additional dose now, click to place a check in the "Give additional dose now" check box.

Note: Make sure that you are careful about using give-additional-dose-now functionality. When you click the check box, CPRS creates two new orders and sends it to Inpatient Medications. Make sure the "Give additional dose now" and the regular order with the original schedule you entered do not overmedicate the patient. "Give additional dose now" is not available for ONCE, ONE-TIME, or NOW orders. It is also not available for delayed orders.

7. Check to ensure that the dosage is okay and then select OK to close the dialog.

8. Select a Priority from the drop-down list.

9. Select Accept Order.

Note: If you do not complete the mandatory items or if the information is incorrect, CPRS sends a message that tells you that the information is incorrect and shows you the correct type of response.

10. (Conditional) If the medication ordered may be contraindicated because of allergies, drug interactions, or duplicate orders, CPRS will display the Order Check window. Carefully review all order checks and decide if the medication should be ordered. Do one of the following:

o To proceed, select Accept Order.

o To stop the ordering process and return to the dialog, Cancel Order.

11. Enter another medication order

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select Quit.

Note: The order must be signed before it is sent to pharmacy. You can either sign the order now or wait until later.

Related Topics

Viewing Medications

Sorting the Medications View

Ordering Inpatient Medications (Simple Dose)

Ordering Outpatient Medications (Simple Dose)

Ordering Outpatient Medications (Complex Dose)

Change Medication Order

Discontinue Medication Order

Hold Medication Order

Renew Medication Order

Other Medication Actions (popup menu)