Medication list basics
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Medication List Basics. Adding a Medication by history (HX), documenting compliance and printing the Medication reconciliation admission form. Webinar:3. Standard Action Buttons. Video Buttons. Rewind. Pause. Back. Play. Forward. Pause. Stop. Volume. View the CBL Take the quiz.

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Medication list basics

Medication List Basics

Adding a Medication by history (HX), documenting compliance and printing the Medication reconciliation admission form

Webinar:3


Standard action buttons

Standard Action Buttons

Video Buttons

Rewind

Pause

Back

Play

Forward

Pause

Stop

Volume


Instructions

View the CBL

Take the quiz

Instructions


Objectives

Objectives

  • Upon completion of this CBL the learner will have a basic understanding of how to:

    • Add medications by history(HX)

    • Document compliance on a Med recorded as HX

    • Print the appropriate reconciliation form

  • NOTE:

  • Please remember this module demonstrates Cerner Medication List functionality only.

  • Consult you Clinical management team with any questions you may have about clinical workflow.


Medication list basics

  • Open the patient record...

  • Open the Menu...

  • Open the Medication List band...


Medication list basics

  • Please remember to “capture” the Patient Preferred Pharmacy information.

  • Refer to Webinar 1 for more information on this process.


Medication list basics

  • To add a new medication by history, click the +Add button...


Medication list basics

  • Then change “Type” to Document Medication by Hx by clicking the down arrow...


Medication list basics

  • If the patient is not taking any Home Medications, click the No Known Home Medicationsbox and you are done. 

  • If the patient or Family is unable to provide the information, click the Unable to Obtain Information box and enter the appropriate reason.


Medication list basics

  • Now let’s “search” for the medication...

  • First type the medication name in the Findbox...

  • Click on the Medication Name with no information after it... (I have used Lasix for this example)

  • When finished, click the “Done” button in lower right corner to close the Add Order window.


Medication list basics

  • Now Enter the appropriate Details:

    • Dose, Route of Administration and Frequency...

  • Then scroll down and document the “Type of Therapy”:

    • Acute (short term) or Maintenance (long term)


Medication list basics

  • After completing the “Type of Therapy” click the Compliance tab to add compliance information...

  • Select appropriate Status and Information Source from the drop down menus and then enter Last dose date/time.


Medication list basics

  • You may also add compliance comments if needed.

  • When you have finished click the “Sign” button in lower right corner to complete the process.

Comments may be added in this section


Medication list basics

  • For medications such as Nicoderm, that may be taken as over the counter or by prescription:

    • Continue to document the appropriate Dose, Route of Administration, Frequency and Type of Therapy...

  • You should now have added a medication by hx showing medication name, details and compliance data


Medication list basics

  • Then document compliance:

    • Status, Information Source and Last dose date/time...

    • When finished click the “Sign” button.


Medication list basics

  • For herbal (ST Johns Wort), selecting an appropriate dose may not be possible:

    • Cerner functionality allows you to add instructions in the Dose box. For this example we will type “Per instructions on the label”

  • When the Alert screen opens, click “Yes” to place the free text value in the dose box

REMEMBER:

If you have any questions about this process, please contact your Clinical Leadership Team.


Medication list basics

  • Now that all the medications by HX have been added, the medication reconciliation report must be printed.


Medication list basics

  • To print the medication reconciliation report:

    • Click on Taskmenu...

    • Then click Reports


Medication list basics

  • Now find the appropriate Medication Reconciliation report:

    • Inpatient will print Medication Reconciliation on Admission B

    • OSS or Outpatient, will print the Outpatient Medication Reconciliation.

  • Then select the appropriate printer

REMEMBER: If you are not sure which report to print, contact your Clinical Leadership Team.


Medication list basics

  • Process for documenting the “mystery” pill (the little green one for my liver).

    • Open the Add Order window and type the word “Misc” in Find box:

      • Now select Misc Prescription from list

      • Then Complete the Compliance; status could be Investigating or Unable to obtain

      • Add comments as appropriate.

Follow clinical workflow process and add comment

  • When finished click the “Sign” button


Medication list basics

  • Process for documenting a medication by HX through-out the hospital stay:

    • Capture medication information

    • Call the provider and relay information

    • Record Medication By HX information in Medication List section

      • Document phone call to Provider and orders given in the comment section ( order med, do not order med), see example below

Dr. Test notified, TORB completed, medication order written and sent to Pharmacy

  • REMEMBER:

  • If you have any questions on what you are to do, contact your Clinical Leadership Team.


Conclusion

We hope this Computer Based Learning Module has been both informative and helpful.

Feel free to review the CBL until you are confident about your knowledge of the material presented.

Click the blue button to Take Quiz and complete the requirements for this course.

Conclusion

Click

For further information about this module please contact Clinical Leadership Team


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