CC-UC-00800 - Primary Health Care: Basic Flow - Medication Request

Actors

• Client/client caregiver
• Medical administrator
• Registered nurse (RN)
• Medical doctor (MD)/nurse practitioner (NP)

Pre-conditions

• Client is covered under provincial/territorial health care insurance.
• Client is an existing customer at clinic.
• Client is seeking care for a health concern.
• The intake and registration process has been completed.

Step	Description	Data elements collected	Result
1	RN records client's current medications.	Medication Statement Date and Time Medication Usage Status Medication Usage Status Reason	The medication statement is provided and the details are recorded in the client's medical record.
2	RN records description/symptoms of health concern.	Health Concern(s) Health Concern(s) Health Concern Body Site Health Concern Severity Health Concern Evidence Health Concern Date of Onset Health Concern Date of Resolution Health Concern Date of Diagnosis Health Concern Clinical Status Health Concern Category Health Concern Verification Status Health Concern Reporting Source	Health concern symptoms are recorded in the client's medical record.
3	RN records client's vital signs.	Vital Signs (Adult) Date and Time of Observation Measurement Type Body Weight Body Height Height Percentile Weight Percentile Weight for Length Percentile Body Mass Index (BMI) BMI Percentile Waist Circumference Body Temperature Body Temperature Measurement Method Blood Pressure Blood Pressure Measurement Methods Blood Pressure Body Site Blood Pressure Measurement Body Position Heart Rate Heart Rhythm Respiratory Rate Pulse Oximetry Unit of Measure Vital Signs (Child) Date and Time of Observation Measurement Type Unit of Measure Body Weight Weight Percentile Body Height Height Percentile Body Mass Index (BMI) Body Mass Index (BMI) Percentile Waist Circumference Body Temperature Body Temperature Measurement Method Blood Pressure Blood Pressure Measure Body Site Blood Pressure Measurement Method Blood Pressure Body Site Blood Pressure Measurement Body Position Heart Rate Heart Rhythm Respiratory Rate Pulse Oximetry Weight for Length Percentile Head Circumference Head Circumference Percentile	Client's vital signs are recorded client's medical record.
4	MD/NP addresses health concern and recommends care plan.	Health Concern Date of Diagnosis Health Concern Clinical Status Health Concern Category	Health concern is addressed and a care plan is provided and recorded in the client's medical record
5	MD/NP prescribes new medication.	Medication Medication Route of Administration Medication Request Authored Date Prescribed Medication No Substitution Flag Prescribed Medication No Substitution Reason Medication Usage Start Date and Time Medication End Date and Time Medication Dosage as Needed Flag Medication Dose per Administration Medication Dose Unit of Measure Medication Duration Value Medication Duration Unit of Time Medication Repeats Medication Notes	A new medication request is created and the details are documented in the client's medical record. CC-UC-00801 Renew Medication Request. CC-UC-00802 Update Medication Request. CC-CC-UC-00803 Cancel Medication Request.
6	MD/NP provides information about medication.	Medication Reason Medication Dose Value Medication Dose Unit of measure Medication Timing Medication Usage Information	Client is educated (re-educated) about medication and the details are recorded in the client's medical record.
7	The medical administrator notifies the pharmacy of the new prescription.	Not applicable	The pharmacy is notified of the new medication request, and the details are details are recorded in the client's medical record.
8	Use case ends.	Not applicable	Not applicable

Post-conditions

• Health concern is addressed and a care plan is provided.
• A new medication request is created.
• Information about the medication is provided to the client.
• Pharmacy is notified of the new prescription.
• The client medical record is updated.

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Contact us

If you have questions about this initiative, would like to be added to our stakeholder notification list or would like to participate in our consultations, please email us.

connectedcare@cihi.ca