# Ordering Inpatient Medications (Complex Dose)

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 fields may cause the quantity field to either recalculate or reset to zero to force the user to enter the quantity.

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

Select the link above to view the new requirements. 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 fields 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 .

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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.

The lab results for the most recent lab test associated with the selected medication are displayed in the Information field, if an associated lab test was performed within the last 365 days.

Note: A CAC or ADPAC will need to set the OR CPRS LAB DISPLAY ENABLED parameter to ON to activate the lab results display at a site.

To view associated lab results for Quick Orders, a TIU OBJECT must be inserted into the Quick Order. For more information, refer to the Text Integration Utility (TIU) Clinical Coordinator & User Manual.This functionality will work for generalized Quick Orders only (orders assigned to Order Menus). It is not currently implemented for personal Quick Orders.

The lab results functionality will not work properly for multi-divisional facilities or any sites that use different lab test names at different sites, as only one lab test name can be associated with each drug. To successfully implement this functionality, all facilities/divisions that share a VistA system must use the same name for each monitored lab test.

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.

You must have a DEA# to order certain medications

Note: CPRS requires a patient have a valid address if the selected outpatient medication is a controlled substance that requires the signature of a provider with a DEA number. For outpatient controlled substances, CPRS displays a message – “Controlled substance prescriptions require a patient address. Please contact administrative support to update patient address information.” if the patient does not have a valid address. The contact information in the display may be customized using the Enter/Edit Missing ZIP Code Message option in the GUI Parameters menu.

Controlled substance prescriptions require a patient address

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.

5. In the Dosage field, select or type 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.)

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.

Once a dosage is selected, any lab test results displayed in the Information field are replaced by the National Standard Orderable Item information.

6. In the Route field, enter the appropriate delivery route for the medication (a default route could have been set up) by either selecting one from the list or by typing a valid route.

7. In the Schedule field, select an existing schedule from the list or, to use a day-of week/administration time schedule not on the list, select OTHER.

8. If you entered an existing schedule, skip to step 9. If you selected OTHER, CPRS displays the Order with Schedule ‘OTHER’ dialog. Take the following steps:

a) Select one or more checkboxes by the appropriate days of the week.

b) If the schedule requires specific administration times skip to steps c and d. To select a schedule from the list, highlight the schedule and select Add.

Note: Users can assign either a schedule from the list or specific administration times, but not both. Also, because the user is specifying days of the week and a schedule, the list will contain only schedules less than 24 hours (for example, Q36H will not be in the list).

c) To use a specific administration time, select the hour and minutes (if the user only selects the hour, the minutes will default to zero) and select Add.

d) Repeat step c until you have entered all required administration times.

Warning: The administration times in the Schedule field apply to each day of the week that is listed, such as TU-TH-SA@08002000, for example. To create a schedule such as TU@0800 TH@2000, users would have to enter two separate orders using the complex medication order dialog. Also, users may not enter a schedule that only has administration times and PRN but no days.

e) If you make a mistake while selecting an administration time or schedule, do one of the following to remove it:

f) Review the Schedule field.

g) When you have the correct schedule, select OK.

- For a single administration time, highlight the hour and minutes in the Set Administration Time fields and select Remove (so to remove 08:00, you would have to select that time in the Set Administration Time fields not in the Schedule text box.)
- To remove the schedule, highlight the schedule and select Remove.
- To remove the entire schedule and begin again with step a, select Reset.
- The Order with Schedule ‘OTHER’ dialog allows you to enter a customized day-of-week and/or administration-time schedule. The user can enter specific administration times or select a schedule from the available list

9. Select PRN, if necessary.

Note: When selecting the PRN checkbox, the quantity and say supply are zeroed out and will need to be adjusted manually. If the checkbox was accidentally selected, de-selecting it corrects the quantity and day supply.

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

11. Add the appropriate conjunction: And, Then, or no conjunction for the final line.

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

12. 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 Dosage field. (The associated cost is displayed to the right of the dosage.)

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

14. Select and enter a duration and a conjunction.

Note: Your site 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 staff for information about these rules.

15. Repeat steps 12-14 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.

16. Enter an Indication. If indications are defined, you can choose one from the drop-down list. If none are defined or the correct indication is not in the list, type in the appropriate indication.

17. Add comments (optional).

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). If you want the patient to receive an additional dose now, select the Give additional dose now check box.

If you select the check box, the Give Additional Dose Now for Complex Order warning dialog box appears, as shown below.

CPRS displays a warning to providers who select “Give additional dose now” when placing a complex order

When you select the Give additional dose now check box, CPRS creates two new orders. Depending on your version of CPRS, the order priority and dosing schedule may be set automatically or may require manual adjustments. The pop-up messages displayed will also vary.

The dosing schedule and priority are set automatically for each order. The first order is scheduled for immediate administration (NOW) and is assigned a priority of ASAP (or a site-specific alternative). The second order is given the priority ROUTINE and follows the regular dosing schedule that you defined when placing the order.

If you select a value for the Priority field before you select the Give additional dose now checkbox, a message notifies you that the selected priority will be changed to the “Give additional dose now” priority settings.

Note: If your site does not use the priority ASAP, then an alternative priority (for example, STAT) will display in place of ASAP.

Warning displayed when “Give additional dose now” is selected

18. Check the orders and then select OK to close the warning dialog,

19. Choose a primary from the Priority drop-down list.

When Give additional dose now is selected, the Priority field is automatically set to ASAP (or a site-specific alternative). If you select a value for the Priority field before you select the Give additional dose now checkbox, a message notifies you that the selected priority will be changed to the “Give additional dose now” priority settings.

CPRS displays a notification that “Give additional dose now” overrides any previously selected priority

20. 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.

21. (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.

22. 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 Medications Overview

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)