Ordering Inpatient Medications (Simple Dose)

Ordering medications now uses two dialogs in the ordering process and eliminates the dispense drug prompt. Inpatient medication orders now require a valid schedule. 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 item 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 provider 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.

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

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Select Orders tab and bring up the Inpatient dialog by selecting 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". 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 inpatient medication selection dialog.

4. In the Dosage field, select or type 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 Dosage field. Also, the associated cost of the drug is displayed to the right of the dosage.

5. In the Route field, enter the appropriate route (a default route may have been set up) by either selecting one from the list or typing in a valid route.

6. Select a schedule or if the schedule you want to use is not in the list, locate the Other (you can also click the Non-Standard? link and then click OK on the dialog that displays) entry and select it. If you selected Other, use these instructions to create a customized schedule.

Note: See the second inpatient Medication Order dialog for a simple dose.

When the user selects a schedule, the administration times may display under the "Give additional dose now" text. The administration times will display if they have been defined for the ward or if there is a default as long as the order is not a PRN order.

7. Select PRN if desired.

8. Add comments (optional).

9. CPRS displays when the first dose of the medication is expected to be given. (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.) If you want to give an additional dose now, select 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.

10. Check the warning message to ensure that the orders you created are what you expected. If the orders are acceptable, click OK. If not, click Cancel to clear the Give additional dose now check box.

11. Select the drop-down arrow and select a Priority.

12. 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.

13. (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.

14. 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.