Medications

This lesson will demonstrate how to document the patients active medications in the Summary Medications field.

Summary Medications Field

The Medications field in the Summary is used to record an active medication list for the patient.

Placing of the Insertion Point

Placing of the Insertion Point

With a patient chart open and the Summary chart section visible:

  1. Place the insertion point to the right of the field header.
  2. Left-click the mouse to insert the cursor.

If the bold green brackets appear (as shown above), then the field is active and ok to begin entering data.

Entering a Medication Using Shortcut Codes

Entering a Medication Using Shortcut Codes

To enter data into the Medications field, click next to or just below the Medications field header in the Summary.

To enter a medication using a SMARText Shortcut Code, type the medication shortcut code and then press the space bar. *Note: SOAPware default medications do not contain preassigned shortcut codes.  However, the user can edit a default medication and add a custom shortcut code that can be used to enter the medication.

Recording "Current Meds: None"

Recording "Current Meds: None"

When a patient has no current medications, documentation must be entered as structured data by using the SMARText Item for "Current Meds: None".

Type "NoMeds" into the Summary Medications field and Press the space bar. This will expand into the structured data required for this field.

*Note: Users will need to re-download the "NoMeds" SMARText Item for use within SOAPware.  For instructions on re-downloading this item, please see: Using No Known SMARText Item Types in the Summary.

Entering a Medication Using Keywords

Entering a Medication Using Keywords

To enter a medication into the Summary Medications field, type the name of the medication into the field, leaving the cursor at the end of word (as shown above).

Conducting a Shift + F11 Search to Enter a Medication

Conducting a Shift + F11 Search to Enter a Medication

With the cursor at the end of the medication name, insert the medication using a Shift F11 search:

  1. Press the Shift + F11 key on the keyboard to conduct the search.
  2. A search results dialog box will be displayed (as shown above).

Inserting the Medication

Inserting the Medication

To insert the desired medication, simply double-click on the desired medication.

Using other Methods to insert SMARText Medications

The above instructions demonstrated the Shift F11 search method that can be used to enter SMARText Medication.  In addition to using Shift F11, the following SMARText entry methods could also be used:

  1. F11 search
  2. Custom Pick List
  3. Quick Access Pick List
  4. SMARText Items Manager
  5. Shortcut Codes

For more information on the above entry methods, please see: SMARText Data Entry Methods.

Medication Sub-Items

Medication Sub-Items

All SMARText Items, including Medication SMARText Items, have sub-items that can be changed.

The above medication Lexapro has three sub-items that are currently displayed in the Summary Medications field.  It includes the Strength (20 mg tablet), the Dose (1 tab), and the Frequency (once a day).  

Changing Medication Sub-Items

To change or edit a sub-item of a medication:

  1. Click on top of the sub-item (ie: 20mg tablet OR 1 tabs OR once a day)
  2. Select the desired option from the SMARText Quick Access window

Sending a Summary Medication to the Rx Manager History

Sending a Summary Medication to the Rx Manager History

Medications that are added to the active Summary Medications list can be stored in the Medication History within Rx Manager if desired.  To do this:

  1. Right Click on the medication name
  2. Choose Send to History
Rx Manager History

Send to History Date & Notes window:

  1. Today's date will be defaulted for "Stored On"
  2. Type "Active" in the notes area
  3. Click Store

Viewing the Medication History

Press F8 on the keyboard to open the Rx Manager.  Within the Rx Manager, on the History tab, the stored medications will be displayed with the date stored.  

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