How to Add Medications into an e-Chart
Adding Medications to the eChart
If you chose to not integrate with a pharmacy, you are just getting started or if you have an urgent situation and you need to enter an order quickly this guide will help you through this process. We will first begin with entering a routine order.
To begin you start at the dashboard and then click the individual icon or module to enter the e-Chart.
Once you are in the correct e-Chart you click/touch the medication module.
Your next step is to touch/click the Add Medication tab in green.
When the fields open it is very important to use the pharmacy label and physician order to make sure all information is entered correctly. You must enter the medication name, dosage (strength), start date, RX number, purpose for taking medication and the directions for taking the medication. In this section I also selected that the medication is a routine prescription as well as a PRN. If it were only routine no other box would need to be checked.
The next most important step for entering any medication is setting the schedule. The schedule is when the CMT/DSP will give the ordered medication. This will show on the e-MAR for the time frame you set in the next steps.
As you can see you have the option to add daily, select your days of the week, you can change the frequency (every other day), choose a day of the month (every month on the 4 th) or a day of the year.
Once you have the day selected you choose your time making sure to pay close attention to AM and PM. Once you have your selection you touch/click Add Schedule. You then repeat the process for the next timed dose and Add Schedule until you have all information entered. Select the start time and then click/touch Save.
A screen will pop up to give you a preview of what you have entered. At this time if you need to adjust or make changes you can use the edit feature.
Please note the section at the bottom left. It will tell you who created the order (staff or pharmacy) and who last updated the order. This can be useful information when there is a discrepancy. This order is now complete and will populate on the e-MAR and PMOF.
The next order you will see is an order for narcotic medication. Narcotics are special in that they are counted for reconciliation and security purposes. You should always follow your facility practices regarding the handling of narcotic medications. From the resident medication module the next order can be added.
For narcotic/controlled medications you need to check the box above. Once you have checked it is a control you must enter the quantity that was received. The number entered begins the count process.
Again the purpose and directions are entered according to the order. You can then add any special instruction for staff and because we want to make sure to rotate the patch placement we selected Site Specification. When the patch is placed it will ask where it was put. This can also be useful if a rash should develop or some other type of reaction and a nurse wants to know where the previous patch was placed.
In the direction for this medication a new patch is to be placed every 3 days. To set this schedule you would Select Frequency.
Once you have the frequency set you select the time of day and hit Add Schedule. This is a good time to make sure the schedule is correct. If something is not right you can remove that schedule and fix it. When the order is ready click/touch Save.
Again you will see the order and how it will appear on the e-MAR and PMOF.
There are several important features on this page for Managers and Nurses. You will note under the orange count box the Verify Count and Adjust Count tabs.
The person entering this order should click the verify button before placing the medication into the locked cart. Should there ever be a discrepancy in the count or if a medication is being sent out of the facility the count number can be changed in the Adjust Count tab. It is recommended to put a detailed explanation in when the count is changed.
When a narcotic order appears on the e-MAR it will be orange in color so that it stands out from all other orders. The schedule is set for every third day so you will see at 8 AM a message that it cannot be given. This is an added safety feature.
Adding PRN medications is easier because you do not need to set a schedule but there are some interesting features you can add. You need to make sure to add a dosage. If you cannot find this information on packaging or the pharmacy is unable to provide you can enter a dash symbol (-). Be sure to select that this is PRN medication. You would also select this if you were entering a STAT order.
When entering a PRN you are able to add a type of schedule. If the order clearly states every 6 hours or every 8 hours you are able to add this in the schedule section above. If the order says 3 times daily it is up to the delegating nurse to decide if that is every 8 hours or 3 times during waking hours. You can then set the effectiveness alert and if this is only for a short period of time-10 days, one month you can set a stop date.
When a medication needs to be discontinued this is accessed from the medication module.
Once you touch/click DC the next screen will show up for you to populate. Be sure to add an explanation in the comments section and hit save.
It is up to the facility to set their policy on who can enter medications into the system. Several people should be trained how to do this and all should follow the same protocol for entering. This document can be generated and printed out and a nice uniform look is recommended.
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