Medication List Basics

Medication List Basics Adding a Medication by history (HX), documenting compliance and printing the Medication reconciliation admission form Webinar:3

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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.

Open the patient record... • Open the Menu... • Open the Medication List band...

Please remember to “capture” the Patient Preferred Pharmacy information. • Refer to Webinar 1 for more information on this process.

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

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

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.

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.

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)

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.

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

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

Then document compliance: • Status, Information Source and Last dose date/time... • When finished click the “Sign” button.

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.

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

To print the medication reconciliation report: • Click on Taskmenu... • Then click Reports

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.

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

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.

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

Medication List Basics