Create Medication Orders

If you are a doctor, create a Medication Order for medication to be administered or supplied at your health service. If you are a nurse or health worker, create a medication order for the associated verbal or written order from an authorised provider.

If Medication > Add Medication is not available, ask your Communicare Administrator to enable Prescribing - Full or Prescribing - Once Off/Short Course for your user group.

If there are no details in the Drug Browser, ask your Communicare Administrator to arrange the import of MIMS Pharmaceutical Database.

You cannot record a medication with a date after a patient's date of death.

When you add a medication order, it always defaults to the date of the service; you cannot change the date of an individual medication.

To add a medication order for a patient:
  1. In a patient's Clinical Record, click Medication > Add Medication or press F9.
    • If a warning is displayed that there is no adverse reaction information recorded, click Yes and review with the patient.
    • To record any problems, on the Main Summary, click New Adverse Reaction. See Adverse Reaction Maintenance for more information.
  2. From the Drug Browser, select the medication you want to order. If your user group has a restricted formulary, only medications included in that formulary are displayed.
    Tip: When using generic prescribing, formulation and pack are displayed in a single field. If you are searching for a specific formulation and pack for a specific brand, to display all options for equivalent active ingredient medications that have slightly different packaging or formulation, deselect Show generics not brands.
  3. If there are any drug interactions or warnings, they are listed in the Medications Warnings window. In the Medications Warnings window:
    • If the patient is pregnant, the gestation is displayed.
    • If the patient is pregnant or possibly pregnant and there is a pregnancy interaction with the selected drug, ADEC Pregnancy Category warnings are displayed.
    • If you want to proceed, click Noted, otherwise click Cancel and repeat steps 1-2.
  4. Details from MIMS for the selected medication are added to the Add Medication window, including:
    • Interactions and warnings - for example, if the patient is pregnant or possibly pregnant, ADEC Pregnancy Category warnings
    • PBS information - Strength, Pack Size
    • LEMI and LMBC information
  5. In the Add Medication window, go to the Create a Medication Order tab.
    • To add adverse reactions, click Add allergies & adverse reactionsAdd. See Adverse Reaction Maintenance for more information.
    • To check any existing medications, click Medication Overview iconMedication Overview
    • If the medication is outside your scope of practice, the following message is displayed:
      Example verbal order required banner
  6. For Medication Type, select either Once Off / Short Course or Regular Medication depending on whether this medication is to treat an acute or chronic condition.
  7. Where available, for Order Using, select either Generic name or Brand name.
    • For brand name medications, the formulation, strength, pack size and number of packs are displayed, except for items on the LEMI, which display only the brand name.
    • These details are not displayed for generic drugs, except:
      • If there are multiple items in the pack, full details are included
      • If the words modified or release appear in the formulation, the generic formulation is shown. For example, Metformin hydrochloride modified release tablet, 500 mg.
    Tip: Ensure you read any information banners relating to brand prescribing.
  8. If you want to change medication, in the Medication field, click Choose. To add this medication to your list of preferred medications and list it automatically every time you enter the drug browser, click Favourite iconFavourite.
  9. If the selected medication falls outside your Scope of Practice, enter details of the verbal or written order from an authorised provider. You cannot select yourself as the authorising clinician.
    1. From the Authorising Clinician > Doctor Review list, select the provider who provided the verbal or written order. The list includes providers who:
      • Have a prescriber number
      • Have a username associated with their provider name
      • Have a Communicare log in name and whose access has not been disabled
      • Have Clinical Records and Medication View system rights for their user group
    2. If required by your health service, from the Authorising Clinician > Staff Member list, select a second provider who verified the verbal or written order. The list includes all providers whose access has not been disabled.
  10. If you want to edit the pack size, in the Pack Size field, enter the required value.
  11. In the No. of Packs field, enter the number of packs included in the Medication Order.
  12. The default value in the Duration field is the total number of packs together with repeats, assuming that each pack lasts 1 month, and determines how long the prescription is listed on the Medication Summary. The dosage that you specify does not affect the default calculation. The date in the Until field is calculated from the duration. The duration is used by the drug interactions function to determine if a warning should be displayed. Adjust either the duration or date until if required.
  13. In the Order Instructions field, enter administer or supply instructions for the medication using short codes or full text. For example, enter BD for twice a day, or CF for with food.
    • To see a list of short codes available for your health organisation, click Add short code iconAdd shortcode or press F2.
    • If the medication is for supply and you want to copy the order instructions to the Label Instructions field, click Copy iconCopy to Label Instructions.
  14. If the medication is for supply, in the Label Instructions field, edit the instructions copied from the order instructions or enter dosage instructions to be printed to a label using short codes or full text.
  15. In the Comments field, enter any additional information to include in the order.
  16. From the Reason list, select from the existing clinical items attached to the patient. If you haven't yet added a clinical item for the condition that the medication treats, click Add Reason and select a new clinical item.
  17. If your health service supplies medication from the medication order and you want to print a label to adhere to the medication, set Print medication label.
    Tip: If your health service uses this approach for supplying medications, the Medications Management module is not enabled in File > System Parameters > System tab and Enable label printing is set in File > System Parameters > Clinical tab.
  18. If required, click Ellipsis iconEllipsis and set one or both of the following options:
    • Save medication as favourite - add the medication to your list of favourites displayed when you first open the Drug Browser.
    • Save medication as default - to save the quantity, repeats, dosage instructions and duration for this medication. This information is automatically included whenever you prescribe this medication for any patient. Set this option for medications that typically require the same dosage instructions for any patient, for example, Yasmin.
      Note: If you have Generic Prescribing set in System Parameters and you save a medication that you have prescribed by brand as default, the medication is still prescribed by generic when you next prescribe it.
  19. If you want to add another medication for the patient, click Add another itemAdd another item to save the first medication and clear all fields. Repeat steps 2-16 to add another medication.
  20. If your user group has the the appropriate system rights and you want to now administer or supply the medication, click Save & Supply.
  21. Click Save.

If you clicked Save & Supply, the Adminster and Supply Medication window is displayed. Enter administer or supply information about the medication. For more information, see Administer and Supply Medication.

If you set Print medication label, medication labels are printed.

If the medication order was raised from a verbal order, the authorising Doctor is notified of the verbal order awaiting approval.

The medication and associated condition are recorded in the patient's clinical record. Medications are listed on the Summary > Medication Summary, the Progress Notes tab, and the Detail > Rx - Prescription tabs.

On the Medication Summary:
  • Medication is visible and current on the Current/Regular Medication window on the Summary page of the clinical record until the duration elapses.
  • Regular medications are listed on the Medication Summary until they are removed. If the duration has elapsed, regular medication shows a red until date.
  • Once-off or Short Course medications are listed on the Medication Summary only until the specified duration expires.
  • The Unreviewed verbal orderUnreviewed Verbal Order icon is displayed for medication orders raised through a verbal order that are not yet reviewed

The medication can now be administered or supplied to the patient, either by you or a health worker.