Home Forums Discussions Feedback and Recommendations Best way to document patient call and new Rx?

Hi All,

I'm wondering how to best handle this message sitution:

A patient calls the office, I take the call and I speak with her. She is having anxiety and would do well with the little lorazapam.

I want to document the conversation and also document a new script which will become part of her medication history.

How are people most successfully doing this? (this exchange did *not* take place via a message transmitted to me through AC message center, so I can not simply reply back to a message).

Currently I see one of a few possibilities -- none perfect:

1. Enter a brand-new note in most recent encounters

2. Try using the "addendum" function (though it does not appear to have an Rx writer)

3. Somehow make myself a message in the message center which I can then save and use the "refill" function to generate a prescription.

Thoughts? Suggestons? ideas? (perhaps we'll take a "poll"?) - (a tribute to Bert )

Bruce Morgenstern, MD (Neurology)
Denver CO

start a message with name attached, type whatever info you want in the note, press scrip button and write/send the scrips and then hit save note instead of send......works great.

Steven - PERFECT!!!

- didn't see that one (about starting a new message) Thank you!!

two questions along that line -

1. What does "Attach" do? (as opposed to "Save to Chart"?

2. Have you (or anybody) noticed that using that "Refill" button on messages (far right screen) , while adding the Rx to "Current Meds" list in Most Recent Encounters, fails to add the new medication to the list of prescribed meds in "Medicatons Only" button (in Past Encounters)?

Bruce

Regarding "ATTACH": Select/highlight a patient's name on the patient list. When you hit "ATTACH", it attaches to the selected patient's chart.

To clarify: It attaches the new message to the selected patient's chart.

Got it!! Thank you!!

What about using "Refill" button in messages - anyone notice that it seems to not add the Rx to the medication history generated by "Medicatons Only" button in Past Encounters page (though it Does add it to "Current Medications" field)

Trying to figure out if this is a bug or not.

Bruce

I believe pastmmeds is to imply with last office visit. Same with letter writer as it has a button which brings up medication list from last visit and an updated med list which brings up all current medications in patient list reflecting any changes made in interim. I think we can all argue utility but I think it is by design.

I think you are right; , Although newly prescribed meds are shown under "plan" when selecting "Assessment and Plan" button" (on the Past Encounters Page), it appears that the "Medicaton Only" button shows only the lists of "Current Medications" as they appear in Most Recent Encounter page, and does not provide an actual historical list of the medications we have actually prescribed.

How then, in AC, does one best answer the question, "Well, how many percocet DID I actually prescribe this patient in the past year!!??"

This seems like a potential oversight of the program it it can't easily answer that question . Is there a way to pull up an isolated medication history showing a list of all medication prescriptions written by the provider?

Bruce

Bruce,

Just in case you weren't aware, in order to use Attach, you have to highlight the patient in the patient list. In order to highlight the patient in the patient list, you have to left click on the name. So if you have to put the mouse pointer on the name, you may as well just hold it down and drag and drop the patient onto the note.

Just another way of doing it.

You may look at one med by bringing up the scrip writer highlighting the appropriate scrip and choosing history - one drawback is that you cannot print it

What about this scenario: I receive a message from the front desk saying B.O. needs a Viagra refill. I right-click on the message open "Medications and ePrescribing, refill the Viagra. Now I can click "Save to Chart" and the message and documented refill is saved to the chart. But, if I want to first send that info to my nurse to notify the patient the refill is done, when I hit "Send Message", it deletes the part documenting the refill and only sends the original "B.O. needs a refill" message. Anybody figured out a way to get the whole message, refill documentation sent to the nurse who could then notify the patient the refill has been done and save that documentation to the chart?

Dave

Dave, while I'm still waiting for credentials to be approved so I can ePrescribe, would a solution to your scenario be to hit "reply" before you enter the prescription. That way it gets included as a reply, which is sent when you hit send.

Hitting "Reply" after entering the prescription wipes out the prescription documentation in the message window and returns you back to the original refill message only. This is still a work in progress. There must be a way. Right now, the workaround is Prescribe, Save to Chart. Then open a New Message telling the front desk they can tell the patient the refill was done. If I was more sophisticated, I suppose I could email the patient that info, but we're not there yet and many of our patients will never be.

Dave

Dave, my suggestion was to hit reply BEFORE adding the prescription information. My testing has allowed me, on a sample patient, to do this and send a message to another user by typing a note either above or below the "PRESCRIBE..." line in the reply text.

Definitely hit "Reply" before doing anything else. Then the refill shows up in the body of your replied message. If you escribe it will also say it was transmitted to the pharmacy

That works for me. Thanks NeuroDawg and Leslie.

Dave