Pharmacy Information System Workflows

This document defines eight core workflows for the Pharmacy Information System (PIS) module. Each workflow includes process steps, decision points, integration hooks, exception handling, and the paperless transformation achieved by the HIS.

Regulatory context (UAE):
- UAE Federal Decree-Law No. 45/2021 on Personal Data Protection (UAE PDPL) — governs patient data processing, consent, and access logging.
- UAE MOH controlled substance regulations (Federal Law No. 14 of 1995 and amendments) — schedule checks, vault management, reporting.
- DOH (Abu Dhabi) ADHICS and DHA security standards — logging, access control, encryption.
- NABIDH (Dubai) and Malaffi (Abu Dhabi) HIE requirements — timely, accurate medication and dispensing data submission.

All workflows must ensure role-based access control, full audit trails, and minimal necessary data exposure in line with UAE PDPL.

WF-PIS-001: Medication Order Verification

Process Flow

Actor: Clinical Pharmacist
Trigger: Medication order received from CPOE (HL7 RDE^O11 or FHIR MedicationRequest)
Pre-conditions:

• Patient exists in patients and active encounter in encounters
• Order received into pharmacy_orders with status = PENDING_VERIFICATION
• Patient allergies and current medications available from patient_allergies and EHR medication list
• Formulary and CDS master data loaded (formulary, formulary_items, drug_interactions, dose rules)

1. System receives medication order from CPOE and inserts into pharmacy_orders with order_status = 'PENDING_VERIFICATION', linking to patients, encounters, and providers.
2. System retrieves patient context (age, weight, height, renal/hepatic labs, allergies, active meds) from EHR and displays in the verification queue (SCR-PIS-001).
3. System runs CDS checks in sequence using drug_interactions and dose rules:
   a. Drug–allergy check (against patient_allergies)
   b. Drug–drug interaction check (against active meds)
   c. Dose range check (age/weight/renal-based)
   d. Duplicate therapy check (same drug/class)
   e. Renal/hepatic adjustment suggestions.
4. System logs each CDS alert (including severity, recommendation, and whether it is hard/soft stop) in a PIS CDS log table (not owned entity but assumed, e.g., pharmacy_cds_alerts).
5. Pharmacist opens the order from the queue and reviews: patient context, CDS alerts, order details (dose, route, frequency, duration, PRN indication, priority).
6. Pharmacist checks formulary status via formulary_items (on-formulary, non-formulary, restricted) and sees suggested therapeutic alternatives if applicable.
7. Pharmacist checks payer coverage (via Billing & Claims integration) and prior-authorization flags; if non-covered, pharmacist may propose an alternative.
8. Decision 1 – Clinical appropriateness:
   - If dose/route/frequency inappropriate or contraindicated → pharmacist initiates intervention (go to step 9).
   - If appropriate → proceed to step 11.
9. Pharmacist creates a record in pharmacy_interventions (type: dose adjustment, therapy change, clarification, etc.), documents recommendation, and contacts prescriber (phone/secure messaging).
10. Decision 2 – Prescriber response:
    • If prescriber accepts recommendation → pharmacist updates pharmacy_orders (e.g., new dose, route) and marks intervention outcome as ACCEPTED.
    • If prescriber rejects → pharmacist documents reason and marks outcome as REJECTED; order may still be verified if safe, or cancelled if unsafe.
11. Decision 3 – Formulary compliance:
    • If non-formulary and no justified exception → pharmacist requests change to formulary alternative; if prescriber agrees, update order; if not, require supervisor approval per policy.
    • If formulary-compliant or approved exception → continue.
12. Pharmacist sets order_status = 'VERIFIED' in pharmacy_orders, records verified_by, verified_datetime, and any override justifications.
13. System releases order to dispensing queue (SCR-PIS-002) and creates corresponding entry in pharmacy_dispensing with status PENDING_PICK (or a separate queue table).
14. System generates medication label data (patient name, MRN, Emirates ID, drug, dose, route, frequency, barcode) and stores label metadata in pharmacy_dispensing.
15. System sends status update back to CPOE/EHR (order verified) and, if applicable, triggers billing pre-charge logic.

Data Modified:

• pharmacy_orders — INSERT (on receipt), UPDATE (status, verified_by, verified_datetime, modified details)
• pharmacy_interventions — INSERT (when intervention created), UPDATE (outcome, prescriber_response)
• pharmacy_dispensing — INSERT (queue entry for dispensing)
• pharmacy_cds_alerts (or equivalent) — INSERT (one per alert fired)
• order_audit_log (shared/audit table) — INSERT (verification and overrides; referenced, not owned)

Mermaid Flowchart

Decision Points

1. Clinical appropriateness
   - If CDS alerts indicate contraindication or unsafe dose → pharmacist must intervene.
   - If only minor alerts or acceptable risk with justification → pharmacist may override with documented reason.

2. Prescriber acceptance of intervention
   - If accepted → order updated and verified.
   - If rejected → pharmacist must decide if order is still safe; unsafe orders are cancelled or escalated.

3. Formulary compliance
   - If non-formulary and no exception → require change to alternative or supervisor approval.
   - If formulary-compliant or exception approved → proceed.

Integration Points

• CPOE (cpoe module)
• Inbound: HL7 RDE^O11 / FHIR MedicationRequest with order details.

• Outbound: Order status updates (verified/cancelled) via HL7 ACK or internal API.

• EHR Patient Management (ehr-patient-mgmt)

• Read: patients, patient_demographics, patient_allergies, active medication list, labs (renal/hepatic).

• Write: Order status and pharmacist notes visible in patient chart.

• Billing & Claims (billing-claims)

• Outbound: Pre-charge data (drug, quantity, RxNorm, cost) for verified orders.

• CDS Engine / Drug Database

• Internal: Use drug_interactions, dose rules, formulary master data.

Exception Handling

• Missing patient data (e.g., weight, creatinine):

• System flags missing data; pharmacist may request updated measurements or use conservative dosing; must document assumption in pharmacy_interventions.

• CDS engine timeout or error:

• System displays banner “CDS unavailable”; pharmacist can proceed with manual checks but must document in intervention log; system logs outage for IT.

• Integration failure with CPOE:

• Order stored locally; status updates queued with retry; if not delivered after threshold, alert pharmacy supervisor and CPOE support.

• PDPL-related access violation:

• If user lacks permission to view certain data (e.g., restricted diagnoses), system masks fields and logs access attempt; pharmacist must proceed with available data or escalate.

Paperless Transformation

Remaining Paper Touchpoints: Optional printed pharmacist notes for external providers if electronic channels are unavailable.

Inputs and Outputs

Inputs:

Outputs:

Post-conditions:

• Medication order verified with pharmacist sign-off and documented clinical review
• All CDS alerts logged with pharmacist response (accepted/overridden with reason)
• Dispensing queue entry created for pharmacy technician pickup
• Label data generated for patient-specific medication labels
• CPOE/EHR updated with verification status
• Any interventions documented with prescriber response and outcome

SLA and Timing

State Transition Diagram

WF-PIS-002: Inpatient Dispensing (Unit-Dose)

Process Flow

Actor: Pharmacy Technician, Clinical Pharmacist
Trigger: Medication order verified and released to dispensing queue
Pre-conditions:

• pharmacy_orders.order_status = 'VERIFIED'
• Corresponding dispensing task exists in pharmacy_dispensing with status PENDING_PICK
• Inventory available in pharmacy_inventory for required drug/location
• For controlled substances, controlled schedule and vault location defined

1. System displays dispensing worklist (SCR-PIS-002) filtered by facility, pharmacy location, and priority (STAT, first-dose, routine).
2. Technician selects a task; system shows patient details, drug, dose, quantity, location, and any special instructions.
3. System checks pharmacy_inventory for stock at the assigned location; if insufficient, suggests alternate locations or triggers replenishment.
4. Technician retrieves medication from shelf or Automated Dispensing Cabinet (ADC) and scans the product barcode.
5. System validates scanned barcode against pharmacy_dispensing and pharmacy_inventory (drug, strength, form, lot, expiry).
6. Decision 1 – Barcode match:
   - If mismatch (wrong drug/strength/lot/expired) → system blocks progress and prompts technician to correct (step 3–5).
   - If match → proceed.
7. Technician repackages into unit-dose if necessary and prints patient-specific label with barcode; system updates pharmacy_dispensing.label_printed = TRUE.
8. For controlled substances, system checks pharmacy_orders.is_controlled = TRUE and routes to controlled workflow (WF-PIS-006) for dual-signature and logging.
9. Pharmacist performs final check (visual or barcode re-scan) and sets pharmacy_dispensing.verified_by and dispensing_status = 'VERIFIED_READY'.
10. System decrements pharmacy_inventory.quantity_on_hand and inserts a record into inventory_transactions (type: DISPENSE_TO_PATIENT or DISPENSE_TO_UNIT).
11. Technician delivers medication to nursing unit (cart, tube, or ADC restock) and records delivery method/time in pharmacy_dispensing.
12. System updates pharmacy_dispensing.dispensing_status = 'DISPENSED' and dispensing_datetime.
13. System sends dispensing event to EHR (for eMAR scheduling), Billing & Claims (charges), and NABIDH/Malaffi if applicable (for Abu Dhabi/Dubai encounters).
14. For failed picks (e.g., stockout), technician marks task as ON_HOLD_STOCKOUT; system alerts inventory manager.

Data Modified:

• pharmacy_dispensing — UPDATE (pick status, label_printed, verified_by, dispensing_status, dispensing_datetime, location)
• pharmacy_inventory — UPDATE (quantity_on_hand, last_count_date)
• inventory_transactions — INSERT (dispensing transaction)
• controlled_substance_log — INSERT/UPDATE (if controlled; see WF-PIS-006)
• integration_message_log (shared) — INSERT (for HIE and billing messages)

Mermaid Flowchart

Decision Points

1. Stock availability
   - If insufficient stock → task put on hold, inventory manager notified; urgent STAT items may trigger emergency procurement or borrowing.

2. Barcode validation
   - If mismatch or expired → system prevents dispensing and logs near-miss; technician must re-pick.

3. Controlled substance flag
   - If controlled → additional steps (dual-signature, controlled log) enforced; if not → standard workflow.

Integration Points

• Scheduling / Patient Location (scheduling)

• Read: encounters, locations to determine delivery location and ward.

• EHR (eMAR) (ehr-patient-mgmt)

• Outbound: Dispensing events to update medication administration schedule.

• Billing & Claims (billing-claims)

• Outbound: HL7 DFT^P03 or internal charge messages with drug, quantity, RxNorm/NDC, cost.

• NABIDH / Malaffi

• Outbound: HL7 v2.5.1 dispensing messages for Dubai/Abu Dhabi encounters (INT-PIS-005/006).

• ADC / Automation Systems (if present)

• Internal/External: Stock levels, pick confirmations, restock tasks.

Exception Handling

• Inventory mismatch (negative stock):

• System prevents dispensing if quantity_on_hand would go negative; flags discrepancy for investigation; inventory manager must adjust via inventory_transactions.

• Label printer failure:

• System allows reprint; logs reprint count; if printer offline, technician may redirect to another printer; no manual labels allowed without supervisor override.

• Integration failure to HIE or Billing:

• Dispensing recorded locally; messages queued with retry; if persistent failure, alert IT and pharmacy supervisor; PDPL-compliant logging of failed transmissions.

Paperless Transformation

Remaining Paper Touchpoints: None — fully digital for standard inpatient dispensing.

Inputs and Outputs

Inputs:

Outputs:

Post-conditions:

• Medication dispensed to patient/ward with barcode-verified pick
• Inventory decremented and transaction logged
• eMAR schedule updated with dispensed dose availability
• Billing charge captured
• HIE notified (for Dubai/Abu Dhabi encounters)
• For controlled substances, additional logging completed per WF-PIS-006

SLA and Timing

State Transition Diagram

WF-PIS-003: Outpatient Dispensing

Process Flow

Actor: Pharmacist, Pharmacy Technician
Trigger: Patient presents with prescription (electronic from CPOE or scanned paper)
Pre-conditions:

• Patient identified and linked to patients (Emirates ID / MRN)
• Prescription captured as pharmacy_orders (for outpatient context) with order_status = 'PENDING_VERIFICATION' or already verified
• Insurance details available via payers and insurance plan tables
• Formulary and pricing data configured

1. Patient arrives at outpatient pharmacy; technician searches or registers patient using Emirates ID (e.g., 784-1990-1234567-1) and MRN.
2. For electronic prescriptions, system retrieves orders from CPOE; for paper prescriptions, technician scans and enters structured data into pharmacy_orders.
3. System checks for duplicate prescriptions and active refills for the same drug; flags potential duplication to pharmacist.
4. System verifies insurance eligibility and coverage (via Billing & Claims integration) and calculates estimated co-pay based on payer and plan.
5. Pharmacist reviews order(s) in outpatient queue (similar to WF-PIS-001) including CDS checks and formulary status; updates pharmacy_orders to VERIFIED when appropriate.
6. Technician picks medication, scans barcode, and verifies against order; system checks pharmacy_inventory for outpatient location.
7. Decision 1 – Stock availability:
   - If out of stock → system offers partial fill or alternative pharmacy; marks order as ON_HOLD_STOCKOUT.
   - If in stock → proceed.
8. Technician counts and packages medication; system prints bilingual (EN/AR) patient label with directions, and updates pharmacy_dispensing (quantity_dispensed, label_printed).
9. Pharmacist performs final check, including label accuracy and counseling needs; sets pharmacy_dispensing.dispensing_status = 'READY_FOR_PICKUP'.
10. Pharmacist counsels patient (indication, dose, side effects, storage, missed dose instructions) and records counseling completion in pharmacy_dispensing or a counseling log.
11. Cashier collects co-payment; Billing & Claims receives charge details (drug, quantity, cost, payer, patient share).
12. At pickup, staff verifies patient identity (Emirates ID) and marks pharmacy_dispensing.dispensing_status = 'DISPENSED' with dispensing_datetime.
13. System updates patient’s active medication list in EHR and exposes data to Patient Portal via FHIR MedicationRequest/MedicationDispense.

Data Modified:

• pharmacy_orders — INSERT (for scanned prescriptions), UPDATE (status, verification)
• pharmacy_dispensing — INSERT (dispensing record), UPDATE (quantity_dispensed, label_printed, status, dispensing_datetime)
• pharmacy_inventory — UPDATE (quantity_on_hand)
• inventory_transactions — INSERT (outpatient dispense)
• Counseling log table (e.g., pharmacy_counseling) — INSERT
• Billing/charge tables — INSERT (via integration)

Mermaid Flowchart

Decision Points

1. Prescription source
   - Electronic vs paper; paper requires manual entry and scanning for legal record.

2. Stock and barcode validation
   - If stock unavailable or barcode mismatch → no dispensing; alternative options discussed.

3. Insurance coverage
   - If not covered or high co-pay → pharmacist may suggest lower-cost alternative; requires prescriber approval.

Integration Points

• CPOE

• Inbound: Outpatient electronic prescriptions.

• EHR Patient Management

• Read: Patient demographics, allergies.

• Write: Outpatient medication list and dispensing events.

• Billing & Claims

• Outbound: Charges and co-pay details; eClaimLink formats for Dubai when applicable.

• Patient Portal

• Outbound: FHIR MedicationRequest and MedicationDispense for active meds and refill status.

Exception Handling

• Unreadable paper prescription:

• System requires pharmacist to contact prescriber; order remains PENDING_CLARIFICATION; no dispensing until resolved.

• Insurance system timeout:

• System allows “cash sale” option with patient consent; marks transaction for later insurance submission if policy allows.

• Patient declines counseling:

• System records “counseling offered, declined” to maintain documentation.

Paperless Transformation

Remaining Paper Touchpoints: Scanned image of original paper prescription retained for legal compliance; optional printed medication information leaflets.

Inputs and Outputs

Inputs

Outputs

Post-conditions

• pharmacy_dispensing record created with status DISPENSED and patient signature captured electronically
• pharmacy_inventory decremented; inventory_transactions logged
• Billing charge generated and sent to Billing & Claims
• Patient counseling documented in pharmacy_dispensing.counseling_notes
• Dispensing event submitted to NABIDH/Malaffi within SLA

SLA and Timing

WF-PIS-004: Medication Administration (eMAR)

Process Flow

Actor: Nurse (eMAR role)
Trigger: Scheduled administration time or PRN medication request
Pre-conditions:

• Verified medication orders exist in pharmacy_orders
• Dispensed doses recorded in pharmacy_dispensing (where applicable)
• Patient wristband with barcode present and linked to patients
• Nurse authenticated and authorised (users, roles)
• eMAR schedule generated in medication_administration (planned rows or on-demand creation)

1. Nurse opens eMAR (SCR-PIS-003) for assigned patients and views scheduled and PRN medications.
2. At administration time, nurse authenticates (badge/username/password) and system logs user context.
3. Nurse scans own ID badge; system verifies role and permissions (e.g., can administer IV meds).
4. Nurse scans patient wristband; system confirms correct patient and loads that patient’s eMAR.
5. Nurse selects the due medication; system prompts to scan medication barcode.
6. Nurse scans medication barcode; system matches to pharmacy_dispensing and pharmacy_orders.
7. System performs “five rights” check (right patient, drug, dose, route, time) plus allergy and duplicate dose checks.
8. Decision 1 – Five rights check:
   - If any mismatch (e.g., wrong patient, wrong drug, early/late beyond allowed window) → system displays hard/soft stop alert and blocks or warns accordingly.
   - If all checks pass → proceed.
9. Nurse administers medication and records actual administration details (time, dose, route, site, comments) in medication_administration.
10. For PRN medications, nurse documents indication and later records patient response (pain score, symptom relief).
11. If dose is held/refused/omitted, nurse selects reason (e.g., patient refused, NPO, clinical decision) and system records status and reason.
12. For high-risk or controlled medications, system may require witness scan; witness user ID stored in medication_administration.witness_id.
13. System updates patient’s medication timeline in EHR and marks dose as completed/held in eMAR.
14. System updates barcode verification flag (barcode_verified = TRUE) for successfully scanned administrations to support KPI tracking.

Data Modified:

• medication_administration — INSERT (each administration event), UPDATE (PRN response, status changes)
• pharmacy_dispensing — UPDATE (optional link to mark dose used)
• order_audit_log — INSERT (administration and exceptions)

Mermaid Flowchart

Decision Points

1. Five rights validation
   - If mismatch → system may enforce hard stop (e.g., wrong patient) or soft stop (slightly early/late within policy).

2. Override capability
   - For certain alerts (e.g., early dose), nurse may override with reason; for critical mismatches, override not allowed.

3. PRN vs scheduled
   - PRN requires indication and response; scheduled does not.

Integration Points

• EHR Patient Chart

• Outbound: Administration records and status updates to patient timeline.

• CPOE

• Read: Order details (dose, route, frequency, special instructions).

• PIS Dispensing

• Read: pharmacy_dispensing to validate that dose was dispensed (for unit-dose workflows).

Exception Handling

• Barcode scanner failure:

• System allows manual entry with mandatory reason; flags administration as barcode_verified = FALSE for audit.

• Patient not found or wristband unreadable:

• System prevents administration until patient identity confirmed; nurse must request new wristband.

• Network outage at bedside:

• Offline mode may allow local caching and later sync; all offline administrations logged for reconciliation.

Paperless Transformation

Remaining Paper Touchpoints: None — fully digital for standard eMAR workflow.

Inputs and Outputs

Inputs

Outputs

Post-conditions

• medication_administration record updated with status = 'GIVEN' (or HELD, REFUSED, OMITTED) and administered_datetime
• Five-rights verification result recorded (barcode match = TRUE/FALSE with override reason if FALSE)
• For high-alert medications, witness user ID captured
• PRN effectiveness assessment scheduled if applicable (prn_assessment_due_datetime)
• EHR medication timeline updated in real time

SLA and Timing

WF-PIS-005: IV Admixture Preparation

Process Flow

Actor: IV Pharmacist, Pharmacy Technician
Trigger: IV medication order requiring compounding appears on IV admixture worklist
Pre-conditions:

• IV order exists in pharmacy_orders with route indicating IV infusion/bolus and flagged as requiring compounding
• Order verified by pharmacist (order_status = 'VERIFIED')
• IV base products and recipes defined in master data (IV Solution Base Products, compounding rules)
• Cleanroom and laminar airflow hood available and within environmental specs

1. System identifies IV orders requiring compounding and lists them in IV Admixture Preparation screen (SCR-PIS-005).
2. IV pharmacist reviews each order: base solution, additives, concentration, total volume, infusion rate, stability, and patient-specific factors (weight, renal function).
3. System generates a compounding worksheet from iv_admixture_orders including ingredient list, quantities, sequence of addition, and safety checks.
4. Technician prepares in the cleanroom; before starting, scans own ID and the order barcode to ensure correct patient and product.
5. Technician scans each ingredient barcode (base solution, vials, ampoules); system validates against worksheet and pharmacy_inventory.
6. Decision 1 – Ingredient validation:
   - If ingredient mismatch or expired lot → system blocks and requires correction.
   - If all ingredients valid → proceed.
7. If gravimetric verification is enabled, technician places bag on scale; system compares expected vs actual weight and prompts for adjustment if out of tolerance.
8. Technician completes compounding following on-screen steps; system records preparation steps and timestamps in iv_admixture_orders.
9. IV pharmacist performs final visual check and, if required, re-scans bag barcode; sets iv_admixture_orders.status = 'PREPARED_VERIFIED'.
10. System calculates beyond-use date/time (BUD) based on product type and stability rules; stores in iv_admixture_orders.beyond_use_datetime.
11. System prints IV label (patient name, MRN, drug, concentration, volume, rate, BUD, barcode) and attaches to bag.
12. System updates pharmacy_inventory (deducts used ingredients) and inserts inventory_transactions for each component.
13. Prepared IV is delivered to nursing unit; delivery details recorded in iv_admixture_orders and linked pharmacy_dispensing record.
14. System updates EHR/eMAR with IV preparation status and BUD to support administration scheduling.

Data Modified:

• iv_admixture_orders — INSERT (order-level record), UPDATE (preparation details, status, BUD, prepared_by, verified_by)
• pharmacy_inventory — UPDATE (quantity_on_hand for each ingredient)
• inventory_transactions — INSERT (component usage)
• pharmacy_dispensing — UPDATE (link to admixture_id, dispensing_status)

Mermaid Flowchart

Decision Points

1. Ingredient validation
   - If wrong or expired ingredient scanned → compounding blocked; prevents contamination or incorrect therapy.

2. Gravimetric verification
   - If enabled and weight out of tolerance → technician must adjust; ensures accurate concentration.

3. Final pharmacist verification
   - If pharmacist identifies issue (e.g., incompatibility) → admixture rejected, new order or preparation required.

Integration Points

• CPOE

• Read: IV order details and special instructions.

• EHR/eMAR

• Outbound: IV preparation status, BUD, and administration instructions.

• Inventory Management

• Internal: pharmacy_inventory and inventory_transactions for component usage.

Exception Handling

• Cleanroom environmental failure (e.g., pressure out of range):

• System may block new compounding tasks and display warning; tasks deferred until environment restored.

• Missing IV recipe:

• If no standard recipe found, pharmacist must manually define compounding parameters; system logs as non-standard preparation.

• Printer failure for IV labels:

• System allows reprint; if persistent, labels may be printed at alternate device; manual labels require supervisor override and documentation.

Paperless Transformation

Remaining Paper Touchpoints: Environmental monitoring logs may remain partially paper-based depending on facility equipment.

Inputs and Outputs

Inputs

Outputs

Post-conditions

• iv_admixture_orders record created with status COMPOUNDED and pharmacist verification
• Each component lot tracked in inventory_transactions for recall traceability
• Beyond-use date (BUD) calculated and printed on label
• Compounding steps timestamped with preparer and verifier user IDs
• Prepared product added to dispensing queue for nursing pickup or pneumatic tube delivery

SLA and Timing

WF-PIS-006: Controlled Substance Management

Process Flow

Actor: Pharmacist, Pharmacy Technician, Nurse
Trigger: Controlled substance ordered, dispensed, administered, or wasted
Pre-conditions:

• Medication flagged as controlled in formulary_items.is_controlled = TRUE with controlled_schedule per UAE MOH schedules
• Prescriber authorised for controlled substances
• Controlled substance vault/ADC configured and mapped to pharmacy_inventory locations
• Dual-signature policy configured for specified schedules

1. During order verification (WF-PIS-001), system checks formulary_items.controlled_schedule and flags order as controlled; pharmacy_orders.is_controlled = TRUE.
2. System verifies prescriber authorisation (e.g., MOH/DOH/DHA license attributes) and logs check in audit trail.
3. For dispensing, system requires pharmacist login and a witness (pharmacist or nurse) for vault access; both users authenticated.
4. Pharmacist selects controlled substance transaction (dispense to patient, return, waste, inventory count) in Controlled Substance Register screen (SCR-PIS-006).
5. Pharmacist scans medication from vault; system validates drug, strength, lot, and quantity against pharmacy_inventory.
6. Decision 1 – Transaction type:
   - Dispense to patient → link to pharmacy_orders and pharmacy_dispensing.
   - Return from ward → increase inventory.
   - Waste → record waste amount and witness.
   - Inventory adjustment → require supervisor approval.
7. For dispense to patient, system records transaction in controlled_substance_log with from_user, to_user, patient_id, quantity, and witness_id; updates pharmacy_inventory and inventory_transactions.
8. Medication is delivered to ward; nurse administers via eMAR (WF-PIS-004), scanning patient and medication; system links administration to controlled_substance_log.
9. For partial doses or unused portions, nurse initiates waste transaction; system requires witness scan and records waste_amount and waste_witnessed_by.
10. System supports daily reconciliation: compares controlled_substance_log balances with pharmacy_inventory for each controlled item and location.
11. Decision 2 – Reconciliation result:
    • If balances match → mark reconciliation_status = BALANCED.
    • If discrepancy → flag discrepancy, create investigation record, and alert supervisor.
12. Monthly, system generates MOH-compliant controlled substance reports (dispensing, returns, wastes, discrepancies) and exports via secure file transfer or portal upload.
13. All controlled substance actions are logged with user IDs, timestamps, and workstation IDs for ADHICS/DHA security compliance.

Data Modified:

• pharmacy_orders — UPDATE (is_controlled, controlled_schedule)
• pharmacy_dispensing — INSERT/UPDATE (controlled-related dispensing)
• pharmacy_inventory — UPDATE (controlled stock levels)
• inventory_transactions — INSERT (controlled movements)
• controlled_substance_log — INSERT (each transaction), UPDATE (balance_after, reconciliation_status)
• controlled_discrepancy_investigations (assumed) — INSERT (for discrepancies)

Mermaid Flowchart

Decision Points

1. Transaction type
   - Different logic for dispense, return, waste, and adjustment; each with specific documentation requirements.

2. Reconciliation outcome
   - Balanced vs discrepancy; discrepancies trigger investigation and potential MOH reporting.

3. Prescriber authorisation
   - If prescriber not authorised → order cannot proceed; pharmacist must contact prescriber or supervisor.

Integration Points

• EHR / CPOE
• Read: Controlled order details and prescriber credentials.

• Write: Notes about controlled substance status and any restrictions.

• UAE MOH Reporting

• Outbound: Monthly controlled substance dispensing and discrepancy reports via secure file transfer or portal (INT-PIS-007).

• Security / IAM

• Internal: Role-based access and dual-authentication for vault access; logging per ADHICS/DHA standards.

Exception Handling

• Witness not available:

• System may allow temporary override only for emergency administration with supervisor approval; all such events flagged for audit.

• Vault inventory mismatch:

• System prevents further dispensing of affected item until discrepancy investigated or temporary override authorised.

• MOH report transmission failure:

• System retries; if still failing, alerts Chief Pharmacist; report can be manually downloaded and uploaded via MOH portal.

Paperless Transformation

Remaining Paper Touchpoints: Printed copies of MOH reports may be kept in physical binders per facility policy.

Inputs and Outputs

Inputs

Outputs

Post-conditions

• Each controlled substance movement is double-documented (system + witness confirmation)
• Vault/ADC counts reconciled at shift change; discrepancies flagged immediately
• MOH monthly report generated with all transactions for the period
• Any discrepancy triggers investigation workflow with resolution documented
• Full chain of custody maintained from receipt to patient administration or waste

SLA and Timing

State Transition Diagram

The following state diagram tracks the controlled substance inventory adjustment lifecycle — from receipt into the facility vault through dispensing, administration, waste, and reconciliation.

WF-PIS-007: Medication Reconciliation

Process Flow

Actor: Pharmacist, Physician, Nurse
Trigger: Patient admission, transfer, or discharge
Pre-conditions:

• Active encounter in encounters
• Access to external medication history sources (NABIDH/Malaffi, community pharmacy records) where available
• Reconciliation task created for the encounter (admission/transfer/discharge)

1. At admission/transition, system creates a medication reconciliation task and displays it in Medication Reconciliation screen (SCR-PIS-009).
2. Pharmacist or nurse collects Best Possible Medication History (BPMH) via patient/caregiver interview, medication bottles, and external sources (NABIDH/Malaffi, community pharmacy).
3. System imports available external medication lists and merges them with patient-reported medications; user confirms and edits entries.
4. Home medications are recorded in medication_reconciliation with type HOME and source (patient, HIE, pharmacy).
5. System displays side-by-side comparison of home medications vs current inpatient orders from pharmacy_orders.
6. User identifies discrepancies (omissions, duplications, dose differences, new meds) and flags each in medication_reconciliation.discrepancy_type.
7. Decision 1 – Discrepancy type:
   - Intentional (e.g., medication appropriately discontinued) → document rationale.
   - Unintentional → requires prescriber review.
8. Pharmacist proposes actions (continue, hold, modify, discontinue, new order) and records action_taken and new_order_id (if order created).
9. Physician reviews reconciliation summary, confirms or adjusts actions, and signs electronically.
10. At discharge, system compares discharge medication list to admission and inpatient meds; user finalises discharge list and prints or sends to Patient Portal.
11. Discharge medications are recorded as reconciliation_type = 'DISCHARGE' in medication_reconciliation and linked to new outpatient pharmacy_orders where applicable.
12. System updates EHR medication list and sends discharge medications to NABIDH/Malaffi if required by local policy.
13. System marks reconciliation task as complete and records reconciled_by, reconciled_datetime.

Data Modified:

• medication_reconciliation — INSERT (home, inpatient, discharge reconciliation entries), UPDATE (actions, discrepancy_type, reconciled_by, reconciled_datetime)
• pharmacy_orders — INSERT (new orders resulting from reconciliation), UPDATE (discontinued/modified orders)
• EHR medication list tables — UPDATE (active meds)

Mermaid Flowchart

Decision Points

1. Discrepancy classification
   - Intentional vs unintentional; unintentional discrepancies must be resolved.

2. Action selection
   - Continue, hold, modify, discontinue, or new order; each has different downstream effects.

3. Discharge list finalisation
   - Physician may choose to stop certain chronic meds or add new ones; system must clearly show changes from admission.

Integration Points

• NABIDH / Malaffi
• Inbound: External medication history where available.

• Outbound: Updated medication lists at discharge.

• EHR Patient Chart

• Read: Current inpatient orders and historical meds.

• Write: Updated active medication list and reconciliation notes.

• CPOE

• Outbound: New or modified orders generated during reconciliation.

Exception Handling

• Patient unable to provide history:

• System records limitation (e.g., unconscious, language barrier) and source of any partial data; prompts for follow-up when caregiver available.

• HIE unavailable:

• System logs failure and prompts user to rely on other sources; can schedule later reconciliation update when HIE access restored.

• Reconciliation not completed within SLA (e.g., 24h):

• System escalates task to pharmacist supervisor and notifies attending physician.

Paperless Transformation

Remaining Paper Touchpoints: Printed discharge medication lists for patients who prefer paper or lack portal access.

Inputs and Outputs

Inputs

Outputs

Post-conditions

• medication_reconciliation record completed with all home medications compared against inpatient orders
• Each discrepancy (omission, addition, dose change, therapeutic substitution) documented with clinical rationale
• Physician has reviewed and signed off on reconciled list
• At discharge: patient receives printed and/or portal-accessible medication list in preferred language
• Reconciliation task marked complete; KPI timer stopped

SLA and Timing

WF-PIS-008: Antimicrobial Stewardship Review

Process Flow

Actor: Antimicrobial Stewardship Pharmacist, Infectious Disease Physician
Trigger: Antimicrobial order placed, culture results available, or therapy exceeds defined duration (e.g., 72 hours)
Pre-conditions:

• Antimicrobial orders recorded in pharmacy_orders with antibiotic RxNorm codes
• Stewardship rules configured (restricted antibiotics, duration thresholds)
• LIS integration available for culture and sensitivity results
• Patient clinical data accessible (diagnosis, vitals, labs)

1. System continuously monitors pharmacy_orders for antimicrobial agents and applies stewardship rules (e.g., restricted drugs, broad-spectrum, prolonged therapy).
2. Orders meeting criteria are added to Antimicrobial Stewardship worklist and antimicrobial_stewardship_reviews entries are created with status PENDING_REVIEW.
3. When LIS finalises culture/sensitivity results, system links results to relevant orders via culture_result_id and updates review records.
4. Stewardship pharmacist opens a case from the worklist and reviews: indication, diagnosis, current antibiotics, culture/sensitivity, renal/hepatic function, and previous antimicrobial history.
5. System suggests potential actions based on rules and antibiogram data (e.g., de-escalate from broad-spectrum to narrow-spectrum, IV-to-oral switch, stop if no infection).
6. Decision 1 – Recommendation type:
   - De-escalation, escalation, IV-to-oral switch, duration adjustment, or discontinuation.
7. Pharmacist documents recommendation and rationale in antimicrobial_stewardship_reviews.recommendation and sets review_type (prospective, retrospective, day-3 review).
8. Pharmacist communicates recommendation to prescriber (secure messaging, phone, or EHR note).
9. Decision 2 – Prescriber acceptance:
   - If accepted → prescriber updates orders in CPOE; system sets accepted = TRUE and records prescriber_response.
   - If rejected → accepted = FALSE with documented reason.
10. System tracks outcome (e.g., therapy changed, dose adjusted) and updates antimicrobial_stewardship_reviews.outcome.
11. Aggregated data (DDD per 1000 patient-days, acceptance rates, use of restricted antibiotics) is available for reporting and quality improvement.
12. Annually, system supports generation of facility antibiogram using LIS data and stewardship review outcomes.

Data Modified:

• antimicrobial_stewardship_reviews — INSERT (new reviews), UPDATE (recommendation, accepted flag, reviewed_by, reviewed_datetime, prescriber_response, outcome)
• pharmacy_orders — UPDATE (if orders changed following recommendation)
• LIS result tables — referenced only

Mermaid Flowchart

Decision Points

1. Review criteria
   - Restricted drug, broad-spectrum use, prolonged duration, or high-risk indication; configurable per facility.

2. Recommendation type
   - De-escalation vs escalation vs IV-to-oral vs stop; depends on culture results and clinical status.

3. Prescriber acceptance
   - Acceptance indicates alignment with stewardship; rejection requires documented rationale and may prompt further discussion.

Integration Points

• LIS (Laboratory Information System)

• Inbound: Culture and sensitivity results for microbiology tests.

• CPOE / EHR

• Read: Orders, diagnoses, vitals, labs.

• Write: Stewardship notes and order changes (via prescriber).

• Analytics / Quality Reporting

• Internal: Use antimicrobial_stewardship_reviews and LIS data to compute utilisation metrics and antibiograms.

Exception Handling

• Missing culture results:

• System may prompt for de-escalation based on clinical improvement even without culture; pharmacist documents uncertainty.

• LIS integration failure:

• System flags cases where culture results are delayed; pharmacist may contact lab directly and manually enter key results.

• High alert resistance patterns:

• If antibiogram shows high resistance to chosen agent, system may escalate alert severity and require ID physician review.

Paperless Transformation

Remaining Paper Touchpoints: None — stewardship workflow is fully digital, though printed summary reports may be produced for committee meetings.

Inputs and Outputs

Inputs

Outputs

Post-conditions

• antimicrobial_stewardship_reviews record completed with recommendation and prescriber response
• If recommendation accepted: medication order updated in pharmacy_orders (de-escalated, switched, or stopped)
• Stewardship KPIs updated (DOT, DDD, de-escalation rate, IV-to-PO conversion rate)
• Facility antibiogram data enriched with new culture/sensitivity results
• 72-hour review compliance documented for accreditation and quality reporting

SLA and Timing