Entering Medications:

From The Prescriber Note: Access the medication entry area by clicking on the 'Enter' button from PN part 2

From the Nursing Note: Access the medication entry area by clicking on the 'Enter VO Meds' button.

Both of these notes populate the same window for Medication Entry.

To begin a new Medication:

Select the verb Start.

Select the medication from the Drop Down List. (If the medication you want to use is not listed, information on how to add to use the Edit Drug List can be found further down in this Knowledge Base)

Select the Dose.

Select the Route, qty.

Select the Timing.

For Nursing Staff:

The same workflow is used as above but there are a few additional steps to take.

You must indicate that the order is a Verbal Order and if it was Read Back.

Click in the check box for VO to indicate that this order was a verbal order and enter the ordering providers name by clicking on the 'Verbal Order Given By' field to populate a list of providers.

Click on the name of the provider to populate their name in the Order Given By field. You can limit the list of providers by using the check boxes next to the 'Cancel' Button.

Once the Provider's name is present, click 'Done'.

You will encounter a prompt to indicate if you read the order back to the provider. If you do not click Yes, the RB box will not be checked.

Once you have indicated that this was a Verbal Order and has been Read Back, the boxes will be checked and highlighted.

More information can be added to the prescription by using the additional options:

a If you want to prescribe a medication for a specific number of days, you can enter the number of days using the dropdown menu for this field. 

b. You can add a comment or reason the medication was prescribed.

c. You can record if the patient has given consent for this medication.

d. Start date can be entered for a medication that will be started at a later date (Clicking in this field will cause a calendar to populate to allow you to select the date to start the medication).

e. You can enter a set number of doses to prescribe the medication for by selecting from the dropdown menu for this field . 

If you would like to use the Consent option, click on the checkbox to populate the Consent window.

a. Indicate from the dropdown who is giving consent.

b. Include a comment if you would like.

c. Create/Use a custom Button.

d. Done.

If consent is refused, you will be prompted to include a comment.

Once you have documented the essential information in the first five fields, and have added as much information as you would like. You are able to print from the order entry area using the 'Print' button in the upper right corner. Click Done to return to the note. 

For Prescribers:

Your medication order will appear in the Medication window in PN, Part 2. Be sure to review for accuracy. 

Click the 'Save as a Progress Note' button to save your note.

For Nursing Staff:

The medication will not populate in the body of your note.  Click the 'Compile This Note' button to save your note.

Medications ordered will populate in the Compiled note. If your practice uses MAR, the act of compiling the Note will send the medications to the MAR.

Please Note: Once a note with Medication orders has been compiled, the recommended workflow is to begin a new Prescriber or Nursing Note to make changes.

How to use the 'Edit Drug List' function:

If a medication or dose you want to prescribe is not present on the list, you can add to the list using the 'Edit Drug List' button. Clicking the button will the Mediation Entry window allowing you to add entries.

Click on the 'Add Medication' button to populate the Add Medication window.

Enter the details for the medication you would like to add and click 'Save'.

You will see the newly added medication on the Drug List. Click 'Back' to return to the prescribing area.

Clear Entry:

If you have entered a medication in error, or decide not to prescribe it, you can clear the entry with one selection from the Drop Down menu.

Click in the Medication Direction field and select Clear Out from the dropdown menu.

You will be prompted to make a selection to clear the entire line or just the first Column. Click the 'All' button to clear the whole line.

The entry will be cleared.

Making Modifications To Medications:

How to increase/decrease a Medication dose in a single order:

If you would like to change the dose of an existing medication, you can use the Increase or Decrease verbs. 

Use the dropdown to select the dose you would like to use. In this example, decreasing from 40mg to 20mg.

How to increase/decrease a medication dose over time:

If you would like to begin a new medication and gradually increase to a dose, or decrease a medication gradually to stop, you can do this by making multiple entries in the Medication Entry window.

When starting a new medication, the first entry should include the verb 'Start', along with  the Medicine, Dose, Rout, qty and Timing as usual. The xDays or xDoses column can be used to indicate how long you want to prescribe the medication at the specified dose. You will need to choose which you want to use, as XDays and xDoses cannot be used together.

When decreasing a medication, the first entry should include the verb 'Decrease', as indicated above.

Click into the xDays or xDoses to select the desired option from the dropdown.

The next entry should use the Then verb and follow the same steps as indicated above.

You can add as many increase or decrease actions as you wish to arrive at the desired dose. Once you arrive at the desired dose, the entry does not need to have an xDays or xDoses entry, as it will be continuing until you make a change or stop the medication.

When you compile your note, the medication entries will be listed in the Compiled Note as shown below.

You can also make these entries using Start Date. 

When you compile your note, the medication entries will be listed in the Compiled Note as shown below. 

If you are decreasing doses to stop a medication, Then Stop should be the last verb used and the entry also does not need to have xDays or a Start Date as the medication will be stopped. 

When you compile your note, the medication entries will be listed in the Compiled Note as shown below.  

To Stop a medication:

Select the Stop verb from the dropdown menu.

Your practice can set up medication protocols for medications you use frequently. Please see our guide here.