| DESCRIPTION OF ENHANCEMENTS |
This patch PSO*7*313 includes the following enhancements:
The Outpatient Pharmacy application currently allows the entry of a
have the letter 't' postfix to the RX # as seen below (entry #1):
: : :
ISSUE LAST REF DAY
# RX # DRUG QTY ST DATE FILL REM SUP
-------------------------------ACTIVE-------------------------------
1 100005024t AMOXAPINE 50MG TAB 30 S 09-26 09-26 2 30
2 100005022 AMOXICILLIN 250MG CAP 30 A 08-18 08-18 11 30
3 100005035 KALETRA 3 A 09-29 09-29 0 3
: : :
complex order, which contains a "THEN" conjunction. This type of order is
Note: A prescription can be unmarked as Titration/Maintenance by
invoking the same TM action on an already marked prescription.
b. A new hidden action is being introduced in the Patient Prescription
Processing [LM BACKDOOR ORDERS] option called TR (Convert
Titration Rx). This action will populate the new field MAINTENANCE
DOSE RX (#45.2) in the PRESCRIPTION File (#52).
When a titration to maintenance prescription needs to be
allowed to leave the Duration field preceding the "THEN" conjunction
refilled so the patient can continue on the Maintenance Dose
this option will allow the users to create a new prescription with
the maintenance dose only. The process works similar to copying an
existing prescription, however it can only be used on prescriptions
with the following characteristics:
- Rx is a complex order with a THEN conjunction
- Rx was not digitally signed
- Rx is released
- Rx status is ACTIVE
as null. This null duration field is causing issues when the Outpatient
- Rx does not have refills previously ordered
- Rx # Of Refills is greater than 0 (zero)
Before the new Maintenance Rx can be accepted the Pharmacist is
prompted to validate the QTY field for the new Rx, which may or may not
be automatically re-calculated. Only the last dose from the original
prescription is carried over to the new Maintenance Rx and the # of
Refills field is decreased by 1 because the new Maintenance Rx counts
as a fill. The Fill Date for the new Maintenance prescription is
automatically set with the next possible fill date from the existing
Pharmacy order was being transferred to an Inpatient Medication Order(s).
prescription, which can be changed by the pharmacist.
Once the pharmacist verifies the information for the Maintenance Rx is
accurate they can accept the Maintenance Rx. This action will trigger
a Duplicate Drug check against the original complex order, which must
be discontinued before the new Maintenance Rx can be accepted.
After the new Maintenance Rx is accepted it will have the new
indicator 'm' on the right side of the Rx # in the patient's Medication
Profile as seen below (entry #1):
: : :
The default stop dates were for thirty (30) days for the two (2) new
ISSUE LAST REF DAY
# RX # DRUG QTY ST DATE FILL REM SUP
-------------------------------ACTIVE-------------------------------
1 100005436m AMOXAPINE 50MG TAB 30 S 09-26 09-26 1 30
2 100005022 AMOXICILLIN 250MG CAP 30 A 08-18 08-18 11 30
3 100005035 KALETRA 3 A 09-29 09-29 0 3
: : :
c. The new Titration/Maintenance indicator (t/m) will be included in the
following menu options where the prescription number is displayed:
inpatient orders created and the Start/Stop dates in the sequence were
View Prescriptions [PSO VIEW]
Patient Prescription Processing [PSO LM BACKDOOR ORDERS]
Complete Orders from OERR [PSO LMOE FINISH]
ePharmacy Medication Profile (View Only) [PSO PMP]
Medication Profile [PSO P]
d. External refill requests such as from AudioFax and Internet will not
be processed for Titration/Maintenance marked prescriptions.
incorrect. The pharmacist did not notice the incorrect dates and finished
Subj: ALBANY External Application Refills: Not processed List
[#101509] 01/28/09@13:52 11 lines
From: POSTMASTER In 'IN' basket. Page 1
-------------------------------------------------------------------------
Refills Not Processed Report for the ALBANY Division.
The following refill requests were not processed:
Patient: OPPATIENT,TWO (9999)
off the orders. Upon transfer of a complex order from Outpatient Pharmacy
Rx #: 100005122 (REF #1) Qty: 55
Drug: ZINC SULFATE 66MG TAB
Reason: 'Titration/Maintenance Rx' cannot be refilled.
e. CPRS refill requests will not be automatically processed for
Titration/Maintenance marked prescriptions. The refill request will
remain in the patient's Medication Profile as PENDING and the mailman
message above (item d) will also be sent to PSOAUTRF security key
holders.
to Inpatient Medication order(s), the resulting order will start at the
f. The activity logs for both Titration and Maintenance Rx's will record
the corresponding Titration and Maintenance Rx # if they exist as seen
below:
Titration Rx:
------------
# Date Reason Rx Ref Initiator of Activity
======================================================================
1 09/29/08 EDIT ORIGINAL OPUSER,ONE Comments:
1. Complex Orders Duration Field
first step rather than continue at the step the patient was at as an
Maintenance
Dose Rx: 100005130
Maintenance Rx:
--------------
# Date Reason Rx Ref Initiator of Activity
======================================================================
1 09/29/08 EDIT ORIGINAL OPUSER,TWO Comments:
Titration Dose Rx: 100005392
Outpatient. It looks like a new complex order to the finishing pharmacist,
g. The VistA Integration Control Registration (ICR) #2398 provided to
Computerized Patient Record System V. 1.0 (CPRS) was modified to
prevent the renewal of a Titration dose order with the following
message:
"Prescription was marked as Titration to Maintenance Dose by Pharmacy
and cannot be renewed. To repeat the titration, enter a new prescription
or copy the prior titration order. To continue the maintenance dose,
since the Start date is populated with the date of finishing so that the
refill this prescription if refills are available or enter a new
prescription for the maintenance dose."
h. When using the Barcode Batch Prescription Entry option
[PSO BATCH BARCODE], if the prescription has been marked
as a Titration/Maintenance Rx, and the user attempts to
renew or refill the prescription, the following message
will display:
patient would be started on the first step, which may not be correct.
For a renewal:
"Rx# XXXXXX is marked as Titration Rx and cannot be renewed."
For a refill:
"Rx# XXXXXX is marked as Titration Rx and cannot be refilled."
i. The PSO HIDDEN ACTIONS Protocol in the PROTOCOL File (#101)
will be modified to include the two new Hidden Actions
introduced by this enhancement. PSO LM BACKDOOR MARK AS
This would pertain to complex orders that taper or titrate doses up or
TITRATION and PSO LM BACKDOOR TITRATION RX REFILL are both
new protocols added to the PROTOCOL File (#101).
****************************** IMPORTANT ******************************
The enhancements related to Titration/Maintenance dose Rx are made only
for Outpatient Pharmacy package. The corresponding changes to CPRS
package are not included at this time. Therefore, the CPRS Order Copy and
Order Change functionalities will continue to function as is.
down and potentially impacts patients by receiving too much or too little
Furthermore, there will be no indication of a Titration/Maintenance order
in the CPRS application.
*************************************************************************
3. Remedy Ticket #1022059
This patch fixes an issue that could create duplicate prescriptions on
a patient profile. When a complex order is copied and the duration
field is edited, upon accepting the order, the message to discontinue
the original order is not triggered. This causes duplicate
prescriptions to appear on the patient profile. This patch corrects
medication.
this problem by prompting the user to discontinue the original order.
The Outpatient Pharmacy is being modified to require the entry of a
duration for a dose preceding a THEN conjunction if the schedule for such
2. Titration/Maintenance Rx
dose is not a ONE-TIME type schedule. If the dose preceding the THEN
conjunction is a ONE-TIME type schedule the software will continue to
allow the Duration field to be left blank (optional). The corresponding
change to CPRS will be done in a future CPRS patch.
Example of an acceptable SIG ('NOW' is ONE-TIME type schedule):
--------------------------------------------------------------
TAKE ONE TABLET BY MOUTH NOW THEN TAKE TWO TABLETS EVERY 8 HOURS
No longer acceptable SIG ('Q4H' is not ONE-TIME type schedule):
--------------------------------------------------------------
TAKE ONE TABLET BY MOUTH EVERY 4 HOURS THEN TAKE TWO TABLETS EVERY 8
HOURS
Note: The SIG above is not acceptable because it does not have a
Duration for the first dose. In order to be acceptable the
SIG above would have to have a duration like the one below:
TAKE ONE TABLET BY MOUTH EVERY 4 HOURS FOR 3 DAYS THEN TAKE TWO
TABLETS EVERY 8 HOURS
1. Complex Orders Duration Field
The Duration field is not required for the dose following the last "THEN"
conjunction.
Below is an example of a complex order being entered via Patient
Prescription
Processing [PSO LM BACKDOOR ORDERS]
: :
VERB: APPLY
================================
ROUTE: PO// PO ORAL
Schedule: QD (EVERY DAY)
LIMITED DURATION (IN DAYS, HOURS OR MINUTES):
CONJUNCTION: THEN
Duration field required for the dosage entered prior to this THEN
conjunction.
This Enhancement is related to Patient Safety Issue PSI-07-167 and Remedy
LIMITED DURATION (IN DAYS, HOURS OR MINUTES):
: :
2. Titration/Maintenance Rx
===========================
This Enhancement is related to PSI-06-176 and Remedy Ticket #168928.
The Outpatient Pharmacy (OP) application was modified to accommodate
Titration/Maintenance prescription functionality. The existing software
presented patient safety risks when prescriptions dispensed with a
Ticket # 203088.
titrating dose followed by a maintenance dose were being copied, renewed
or refilled. The issue was that refills as well as the new prescriptions
(derived from copy, renewals or edits) automatically carried over the
initial titrating dose into the new fill/prescription, which was not
always the user's intention.
The new functionality provides two steps for processing Titration/
Maintenance prescriptions.
a. First, the user will have the ability to mark prescriptions as
'Titration to Maintenance' when finishing prescriptions from CPRS as
well as via the Patient Prescription Processing [PSO LM BACKDOOR
ORDERS] option by invoking the new hidden action 'TM' - Mark Rx
as Titration. This action will result in preventing the following
actions to be taken on the prescription: Refill, Renewal (including
via CPRS), Copy and editing of any field that requires a new Rx to be
created. This action will also set the new field TITRATION RX FLAG
(#45.3) in the PRESCRIPTION File (#52) as well as the new field
TITRATION DOSE RX (#45.1) in the PRESCRIPTION File (#52).
Prescriptions that are marked as Titration/Maintenance will
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