CERNER POWERCHART ENTERING MEDICATION HISTORY (EZ SCRIPT)

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1 CERNER POWERCHART ENTERING MEDICATION HISTORY (EZ SCRIPT) Scenario: The Medication Profile is the first step in the Medication Reconciliation process. This screen will replace the current medication history grid in the Patient Profiles. It can be accessed from the Med Profile tab in the patient s chart or in the Medication History section of the Profile. It is a much more interactive tool, and will allow clinicians to readily see the patient s home and inpatient medications in one place. This simulation will show you how to enter a patient s medication history. To begin, right-click on the gray Sig bar in the center of the screen.

2 Click Add Medication by Hx... This screen is similar to the Allergy entry screen. You will search for medications on the left side of the screen and enter the details on the yellow script pad on the right side. The first medication your patient takes is coumadin. Type coumadin in the Search field. Press Enter.

3 The window on the upper left will show the name of the medication you searched for. The lower window will display common doses and frequencies. Your patient takes 2.5 mg, PO, daily. Double click on this in the lower window. The details about the medication copy over to the yellow script pad. Part of a complete medication history includes when the patient last took their medications. To enter this information, click on the Order Details button near the bottom right of the yellow portion of the script pad.

4 Click on the <> after Hx Last Dose Dt Tm <>. You will need to enter both a date and a time. The cursor is already in the first field, which is for the date; the second is for the time. In this example, type 11/28/05 in the Date field. Type 0800 in the Time field. Press Enter.

5 This is all you need to enter about this medication. To search for another medication, double- click on coumadin in the search field in the upper left window, type lasix and press Enter. Your patient takes 30 mg of lasix daily. This is not one of the standard doses listed in the lower window, so you will choose 20 mg and change it on the script pad. Double-click on 20 mg, PO, daily from the lower window on the left.

6 To change the dose, click on the 20 mg just under Lasix on the script pad. The drop-down list of common doses will appear. You can just ignore this and type 30 mg, and press Enter. This is the only field in which you can free-text like this.

7 Enter the date and time the patient last took this medication just as you did with the coumadin. Click on the <> after the Hx Last Dose Dt Tm <>. Type 11/28/05 in the Date field, press Tab and type 0800 in the Time field.

8 Your patient also takes Tenormin. You don't have to type the complete name of the medication in the search field. You can just enter the first few letters of a medication and search for it. Double-click in the search field on the left where it says lasix. Type tenor and press Enter. It's important to enter all the detail about your patient's medications, but at least enter the name of the medication if that is all the information you have. Your patient is not sure of the dose he takes, so just double-click on Tenormin in the upper window. This will at least record that this is a medication he takes.

9 This finishes this patient's medication history. Click the Sign Orders button in the lower right corner to enter these into the patient's chart. The information will display in the Current folder under the Prescription(s)/Home Medication(s) section. Later, Mr. Martin's significant other arrives with information about the Tenormin he takes. You will add this information to the Med Profile by modifying what was previously entered. To do this right click on atenolol (Tenormin) on the Med Profile.

10 Click Modify. When modifying, you do not have the typical orders in the lower window on the left to choose from, so you will select the details of the medication on the script pad separately. On the script pad, under Tenormin, click <Dose>

11 This is a list of common dosages for Tenormin. Click 25 mg. Click <Route>

12 Click PO. Click <Freq>

13 Click daily. You've also learned that Mr. Martin was taking amoxicillin prior to admission. You can search for and enter that now as well. Type amoxic in the Search field. Press Enter.

14 He was taking 500 mg PO TID. Double-click on this in the lower window. The same interaction checking that happens with medications and allergies also happens when entering a medication history here. You may see the allergy/duplicate therapy window pop up. This window appeared now because Mr. Martin has a documented amoxicillin allergy. You can ignore this alert in this case because you are simply entering a medication history; you are not actually ordering medications. Click OK in the lower right to close this window.

15 Click Sign Orders to enter these changes into the Medication History. The data you have just entered will be printed out and used by the physician to reconcile the patient's medication history when writing orders. The report needs to be printed whenever you complete a medication history or make any modifications to it, when your patient goes to surgery, transfers to a different level of care, or is discharged. Printing the report is the same process as printing the Allergy report. Click Task from the menu bar at the top left of the screen.

16 Click Reports... Click the Meds Reconciliation Report.

17 You may need to choose a printer from the Printer destination drop-down list if one does not default in. After choosing the printer, click Save as Default and click Print to run the report. Place the report in the Physician Orders section of the chart.

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