Recording medication administration

Create an administration entry each time you administer medication directly to a patient. You can record multiple administration entries during an extended service.

To record the administration of a medication:
  1. In the Clinical Record, select Medication iconMedication > Admin supplyAdminister & Supply. The Administer and Supply Medication window lists all active medications associated with the current patient, with the medication administered most recently listed first.
    If you are using Communicare V21.1 and later and the CDS service is not available, a warning is displayed at the top of the window. The warning is one of:
    • Condition interaction support not available - if the patient has a recorded condition
    • Pregnancy interaction support not available - if the patient is pregnant and has no other recorded conditions
    • Pregnancy and Condition interaction support not available - if the patient is both pregnant and has a recorded condition
    For example:
    Example CDS service unavailable warning
  2. In either the Regular Medications or Once off/Short Course medications pane, click > to expand the required medication.
    Details of the medication including formulation, dosage instructions and order instructions are displayed. If the medication has been administered in the current encounter or the last 24 hours, administration details are listed.
    Tip: To display the history for medication administered to the patient more than 24 hours ago, click Medication Overview.
  3. If there is an allergy, drug interaction or warning associated with this medication, Medication Interaction is displayed. Click Medication Interaction to display the medication warnings.
  4. From the Brand Name list, select the medication available in Imprest at your organisation, either a brand name or any generic of the same formulation. If the medication brand isn't available in Imprest for your encounter place and a generic alternative is in stock, it is displayed. If neither a brand nor generic are available in Imprest, the Imprest Level displays Stock level not found in imprest.
    Tip: If you select an alternative brand or generic medication in Imprest, that medication is updated for all administer and supply records for the service.
  5. Record the stock details of the medication to update your Imprest system:
    • If the administration uses a whole bottle or pack of medication, for the Whole Stock Used field, click Increment iconIncrement to add the amount of stock used.
    • If the administration completes a bottle or pack of medication, for the Open Stock Finished field, click Increment iconIncrement to add the amount of stock completed.
    • If the administration is from a new bottle or pack of medication, for the New Open Stock field, click Increment iconIncrement to add the amount of stock opened.
  6. Click Add administration.
  7. In the Administration Details fields, record each administration attempt:
    • In the Quantity field, use the arrows to select the amount of medication administered, or enter a fractional amount.
    • From the Unit list, select the measure used for the medication.
    • From the Route list, select the manner in which the medication was administered.
    • From the Site list, select where the medication was administered.
    • From the Status list:
      • If you successfully administered the medication, select Success.
      • If you failed to administer the medication, select Failure.
      • If the status changes in the 24 hours after administration, change the status. For example from Success to Failure.
    • If you failed to administer the medication, from the Failure Reason list, select why the administration failed. For example, Vomited.
    • If required, in the Comments field, add any pertinent information about the event.
  8. Click Save.
An administer record is added to the Progress Notes. The record shows the Administer Medication iconAdminister Medication icon, the date, and is prefixed with the word <Administer>. For example:
Example administer progress note

An entry is also added to the Detail tab, the Rx - Supply class tab and the Medication topic tab.