Treatment records

A treatment dispensation records medication details under the investigation where it was given. It records the medication name, lot number, quantity, unit and the person who authorized it. The Licensed Clinician can capture the record during care work; the Clinical Reviewer can read it with the investigation notes, observations and specimen state. The lot and unit give the quantity enough context to be useful in a later case review.

The investigation may be one of several for a case. Connecting the dispensation to the actual episode matters when a patient returns or care continues over time. The case identifies the person; the investigation identifies when this treatment record belongs in the clinical sequence.

• Episode link. Choose the investigation that explains the dispensation before entering medication details.
• Product trace. Record the medication and lot number together with quantity and unit.
• Authorization. Name the person who authorized the dispensation so the reviewer can inspect clinical authority.

The Clinical Governance Administrator keeps the related clinician privilege record, including verification evidence and effective dates. A Clinical Reviewer can use that record when examining the named authorizer. The dispensation itself is an attributed record of what was entered for the episode.

Agree how medication names and units are written so similar items can be found together. Decide who records the dispensation and how the authorizing person is selected. The clinician should enter the dispensation before the reviewer examines the investigation, particularly when the episode is near completion. Define a correction procedure for a mistaken lot or quantity that preserves the review history in your operating practice.

If medication stock or pharmacy fulfillment is managed elsewhere, plan that connection separately. The record here captures the episode’s dispensation details. It does not need a second, conflicting stock figure for a reviewer to understand which medication, lot and quantity were documented.

Create an active investigation and add a dispensation with a medication, lot, quantity and unit. Set the authorizing person to a clinician whose privilege record can be found by the governance administrator. Have the Clinical Reviewer open the investigation and compare the dispensation with its note and observation dates. Repeat on a second investigation for the same case to confirm each dispensation stays under the right episode. Include a suspended privilege in the rehearsal so the reviewer knows when to seek clarification.

• Investigation review inbox — Episodes awaiting review with their related treatment and evidence records.
• Investigation status board — The current state of each episode across the team’s workload.

See treatment documentation for the recording handoff and investigation review for the final review.