You can add and edit medications from two sections of the patient's chart.
- Within the patient's Summary
- Within an encounter
Add, edit, and delete medications from the Summary
1. Scroll down to Medications or use the "Go to" feature to jump to Medications.
2. Add a medication by clicking the + symbol to the right of the Medications section. To edit/delete an existing medication or create a new prescription, select the medication from the list.
Note: You may see a Therapeutic duplications warning below the Medications section if the same exact medication (name, dose, route, and form) has been added multiple times. For more information about duplicate medications, please click here.
3. A pane will open to the right where you can search for and select a medication. Type the first few letters of the medication name to search. The most common route, strength, and form will appear at the top of the list. The search results will display both generic and brand choices, based on the active ingredient of the drug you searched for.
Note: If you repeatedly prescribe a specific drug, the medication will be added to your frequent medication list, which you can review on the left.
4. Enter the SIG and start date, and associate a diagnosis from the patient’s chart, if desired. Interaction alerts will display to notify you of potential therapeutic duplications (based on class and ingredients), drug interactions, and drug allergies.
5. Click Order to create a new prescription or Save to simply record the medication.
Add, edit, and delete medications from an encounter
You can add a medication in two sections of an encounter:
- Within the Medication table.
- Within the Plan section of a SOAP note encounter.
When adding or editing a medication in a patient’s encounter, you may see also see a Therapeutic duplications warning, indicating that the medication already exists in the patient’s chart. For more information about duplicate medications, please click here.
Adding medications to the Medication table
1. Scroll to the Medication section. To view the previous prescriptions associated with a particular medication, click the Show drop-down menu and check the Prescriptions box.
2. To record a new medication, select the Record button and a pane will open to the right. To edit or delete an existing medication, click the blue highlighted text in the medication list.
3. A pane will open to the right where you can search for and select a medication. Use your Frequent list to quickly select from your most frequently used medications.
4. After selecting the medication, enter the SIG, associate a diagnosis from the patient’s chart, and enter the start date. Interaction alerts may display to notify you of potential therapeutic duplications (based on class and ingredients), drug interactions, and drug allergies.
To discontinue the medication at a later date, you may also enter a future stop date. For additional information about discontinuing medications, click here.
5. If applicable, check the box to Attach the medication to this encounter. You may also click the Patient education materials link to print educational resources pertaining to the medication.
6. Click Order to create a new prescription or Save to simply record the medication.
Adding a medication through the Plan section
Within the Plan section, expand the fly-out pane and select the Medications tab. Record a new medication or attach an existing medication to the encounter from the patient’s Rx list or your Frequent list.
For additional information, please see: