Medication Administration

Definition

A medicine administration in Care records a dose of medicine that staff gave to a patient. It is separate from the medication request, which is the order. You record an administration against a medicine that is already prescribed on the encounter.

Care shows the administrations of an encounter in the Medicine Administration sub-tab of the Medicines tab. The sub-tab shows a grid of medicines against six-hour time slots.

Key Attributes

Components	What it captures
Medicine	The prescribed medicine that this dose belongs to. This field is mandatory.
Status	The state of the dose. See Status below. This field is mandatory.
Start Time	When the dose started. This field is mandatory. Care sets the current date and time by default.
End Time	When the dose ended. This field is optional.
Dosage	The dose, the route, the site, and the method. Care copies these from the prescription.
Administration Notes	Free text about the dose. This field is optional.
Performer	The staff member who gave the dose, and their role in giving it. The administration form does not collect this field. Care records the user who saves the record.

Changes after you save

After you save an administration, the form lets you change only the Status and the Administration Notes. You cannot change the medicine, the dosage, the start time, or the end time. Care keeps the record when you mark it as Entered in Error.

Status

Status	Description
In Progress	Staff are giving the dose now.
Completed	Staff gave the dose.
Not Done	Staff did not give the dose.
On Hold	Staff paused the dose.
Stopped	Staff stopped the dose before it finished.
Cancelled	Staff cancelled the dose before they gave it.
Entered in Error	Staff created the record by mistake.
Unknown	The state of the dose is not known.

Note: The administration form offers all of these states except Unknown.

Permissions

Permission	What it allows
Update Encounter related clinical data	Record or update a medicine administration. Held by Doctor, Nurse, Admin, and Facility Admin.
Can view clinical data about patients	View the medicine administrations of a patient. Held by Staff, Doctor, Nurse, Admin, and Facility Admin.
Can Read encounter related clinical data	View the medicine administrations of one encounter. Held by Doctor, Nurse, Admin, and Facility Admin.

To record or change an administration, you also need an open encounter. Care blocks changes when the encounter status is Completed, Cancelled, Discontinued, or Entered in Error.

Related

• Flow: Administer a dose
• Flow: View the medicine administration record
• Flow: Update an administration record
• Concept: Medication Request