Home Forums Discussions Feedback and Recommendations E-prescribe in Addendum Field

Wouldn't it be nice if when a patient called in for an Rx renewal, we could open their chart, open an addendum, tap the E-Rx button (that does not presently exist there), write the Rx, have it documented as an addendum and then save it to the chart under the heading of Rx Renewal?

we get the message or fax, my MA forwards it to me, I use the e-Rx and send the message back to the MA who acts on it. (Calls the patient, Pharm etc, or tells the patient we sent an E-Rx.) and then SAVES the message. That is all the documentation I need, as I am compulsive that the Rx History is JUST THE FACTS.
For example, if I enter an Rx to the record from the cardiologist, I leave the # and Refills both blank. That leaves just the sig, and I add, Per Dr. Smith. Later if I give the refills, I enter the amounts, and delete the Per Dr. Smith.
On the one or two occasions when I wrote the Rx, printed the paper and the patient said, "Oh, I didn't need that one". I actually shred the unneeded Rx AND IN THAT DAYS NOTE, I RECORD THE STATEMENT, No Rx was actually issued on this date, it was written in error.

Hi Ed, You must have a good reason for that, but I can't see why that is helpful. Please explain. Thanks.

Bert, How do you document it when a patient calls for an Rx Refill? The way I do it is to open their record and activate the e-prescribe module, write the script and send it. It records that Rx as an additional line of info appended to the note that is open. I cut this and past it as a new addendum, entitled " renewal for such and such medication". If I could just do it as an addendum, then it would be easier to document the Rx. Or perhaps there is a much easier way of documenting it that I am completely unaware of. I need enlightenment... : )

I am probably not the best person to ask as we pretty much allow the history of the medication to document for us. May not be extremely accurate.

I guess as far as our method it depends on what you want to document, how much info you want on the refill, etc.

For instance, if the patient calls for a refill on Pataday. The prescription itself will record the day it will prescribed and who sent it. But, if you wanted to insure you knew it was a refill, you could write that in the comment section, and it will show up in the comment section of the history. You can put as much as you want up to a certain amount of characters, and it will all show up in history. Unfortunately, all of this will be seen by the pharmacist.

I am hoping that in a future release, there will be a comment intended for the pharmacist and a comment section that only we can see. Either or both should show up in the history. HTH. It sounds like your method is a lot of work. I don't think I would use the addendum if I were going to document that way. I would likely use a message and label the subject line as such. This would put it in the visit history as well. As would the addendum.

So you keep track of all the refills within the e-Rx prescribing module itself. I am so used to having things documented in the main body of the EMR record that I did not even think of using that aspect of the record. I will have to look at that more closely and see how I can save myself some time and effort... Thanks!

Anyone have best practice for documentation of scheduled refills that cannot be sent yet electronically? I currently use e rx and in comment line say 'to be called to pharmacy xyz' then my MA adds addendum that it HAD been called. It is neat during unclosed visit; messy between visits.

No problem. I hope it works for you.

@mkweiss Not sure this is what you are looking for, but we always start a message with the paptient's name, then I use the refill/script button and write the script but don't send it. In the comment line, I put Call to such and such. This puts all of the info in the message.

I send to MA. She calls the script in and verifies the time it was sent.

We take the call the nurse puts in the message rx request as if I was going to be sent electronically and where she wants it called I push prescribe and the now it gets forwarded back to nurse to call in.

This way ex note stays clean for next refill.

Does anyone have suggestions for best way to say write for three month adderral. I put new date for refill date. For example refill: 4/11/11.
When I do this it showing up as discontinued.