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Help! Entering Historical Meds

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Last Post by Lee 8 years ago

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jessicaw

(@jessicaw)

Posts: 434

Prominent Member

Topic starter

Help!!! What method do your providers use to enter meds historically? Currently when we add a new med on a patient and select the method "Historical" it adds it to the patient's med list but also lists it in the dictation (and on the chart med list) as though the provider will be refilling it. So when the clinical list changes are signed it appears in the patients med list as a refill would.

My thoughts are that when the method "Historical" is used to add the med the user should also go to the "Medications" button at the top and select the line that appears like a refill and click "Change back" This way it only appears in the note as added to the list.

I tried to review this work flow with our Provider Super User and we are not on the same page. She stated that sometimes Historical meds are refilled that day. Which I understand, but then shouldn't the method be something other than historical.....

We are meeting again Wednesday morning to discuss this further. In the meantime can I get some input on work flows that others are using?

Posted : May 16, 2016 11:02 am

Sibylle Freiwald

(@sibylle-freiwald)

Posts: 67

Trusted Member

We use "historical" when entering medications from the patient's medication list. It does populate the patient's med list and the chart note, but with a prescribing method of historical. I guess it depends on which mediation form you are using within your visit. Our medication form contains meds we are and are not prescribing. The only difference is that meds we prescribe have a quantity, refill amount and a different precribing method.

Posted : May 16, 2016 11:23 am

jessicaw

(@jessicaw)

Posts: 434

Prominent Member

Topic starter

We are just using the "Medication" buttons at the top of the encounter to add meds. And then we use the standard Prescription form for Refills.

Our providers are also entering qty and refills on these meds so that they can save it to their custom list as they are adding it. I should have mentioned that above. When they put those in it shows in the note as though they are refilling it.

Posted : May 16, 2016 11:33 am

Sibylle Freiwald

(@sibylle-freiwald)

Posts: 67

Trusted Member

If they are not prescribing the meds, i wouldn't put a quantity and refill on them. Your providers can save to the custom list prior to adding the quantity.

Posted : May 16, 2016 11:40 am

jessicaw

(@jessicaw)

Posts: 434

Prominent Member

Topic starter

They want the Rx saved on their custom list with the qty and refills......

Posted : May 17, 2016 3:06 am

DVI1501

(@dvi1501)

Posts: 80

Trusted Member

We have the same issue. It looks funny on the note when a med is added as historical during an office visit. We have our MA's open up a document when they room the patient that allows them to correct the med list before opening up an office visit. This ensures that any medication changes listed in text translation are medications the physician addressed during the visit.

Posted : May 19, 2016 6:06 am

Lee

(@lee-cooper)

Posts: 348

Reputable Member

If you include quantity and refills, the system assumes that you are writing a prescription. If the desire is to avoid this native functionality, which is, for all intents and purposes, legally proper, then the desire to change workflow should be a natural transition.

Posted : May 26, 2016 9:44 am

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