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Version: 3.1

Medication Statement

Definition​

A medication statement in Care records a medicine that a patient reports taking, or has taken on an ongoing basis. Unlike a medication request, a medication statement is not an order. It records what the patient says they take, not what staff prescribe. Care records every medication statement against an encounter of the patient.

Key Attributes​

ComponentsWhat it captures
MedicationThe medicine that the patient takes. This field is mandatory. You cannot change it after you save the entry.
SourceWho reported the medicine: the Patient, a Practitioner, or a Related Person. Care selects Patient by default. You cannot change it after you save the entry.
StatusThe current state of the statement. See Status below. This field is mandatory. You can change it after you save the entry.
Dosage InstructionsFree text that describes how the patient takes the medicine. This field is mandatory. You cannot change it after you save the entry.
Medication Taken BetweenThe start date and the end date of the period in which the patient takes the medicine. The start date is mandatory. The end date is optional. Care shows Ongoing when there is no end date. You cannot change these dates after you save the entry.
ReasonWhy the patient takes the medicine, as free text of up to 100 characters. This field is optional. You cannot change it after you save the entry.
NoteFree text about the medicine. This field is optional. You can change it after you save the entry.

Where Care shows medication statements​

Care shows the medication statements of a patient in two places. The Medication Statements sub-tab of the Medicines tab shows them during an encounter. The Past Medications section of the patient's Clinical History tab shows them by date.

Both places list every medication statement of the patient. They do not list only the statements of one encounter.

Status​

StatusDescription
ActiveThe patient currently takes the medicine.
On HoldThe patient has paused the medicine.
CompletedThe patient finished the course.
StoppedThe patient stopped the medicine before finishing.
IntendedThe patient plans to take the medicine.
Not TakenThe patient did not take the medicine.
UnknownThe state is not known.
Entered in ErrorStaff recorded the statement by mistake.

Care offers the Entered in Error status only for a statement that you saved. Care keeps a statement with this status, but hides it from the Medication Statements sub-tab and from Past Medications.

Permissions​

PermissionWhat it allows
Update Encounter related clinical dataRecord, update, or retract a medication statement.
Can submit questionnaire about patientsOpen the form that records a medication statement.
Can view questionnaire responses on patientOpen the Updates tab of the patient.
Can view clinical data about patientsView the medication statements of a patient.
Can Read encounter related clinical dataRead the clinical records of the encounter.

To record, change, or retract a medication statement, you also need an open encounter. Care blocks these actions when the encounter status is Completed, Cancelled, Discontinued, or Entered in Error.

Note: After you save a medication statement, you can only change its Status and its Note. The medicine, the source, the dosage instructions, the period, and the reason stay fixed.