Medication List Basics

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Medication List Basics
Webinar3

• Adding a Medication by history (HX), documenting
  compliance and printing the Medication
  reconciliation admission form

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Instructions

• View the CBL
• Take the quiz

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Objectives

• Upon completion of this CBL the learner will have
  a basic understanding of how to
• Add medications by history(HX)
• Document compliance on a Med recorded as HX
• Print the appropriate reconciliation form

• NOTE
• Please remember this module demonstrates Cerner
  Medication List functionality only.
• Consult you Clinical management team with any
  questions you may have about clinical workflow.

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• Open the patient record...
• Open the Menu...
• Open the Medication List band...

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• Please remember to capture the Patient
  Preferred Pharmacy information.
• Refer to Webinar 1 for more information on this
  process.

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• To add a new medication by history, click the
  Add button...

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• Then change Type to Document Medication by Hx
  by clicking the down arrow...

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• If the patient is not taking any Home
  Medications, click the No Known Home Medications
  box and you are done. ?
• If the patient or Family is unable to provide the
  information, click the Unable to Obtain
  Information box and enter the appropriate reason.

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• Now lets search for the medication...
• First type the medication name in the Find box...
  
• Click on the Medication Name with no information
  after it... (I have used Lasix for this example)
• When finished, click the Done button in lower
  right corner to close the Add Order window.

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• Now Enter the appropriate Details
• Dose, Route of Administration and Frequency...
• Then scroll down and document the Type of
  Therapy
• Acute (short term) or Maintenance (long term)

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• After completing the Type of Therapy click the
  Compliance tab to add compliance information...
• Select appropriate Status and Information Source
  from the drop down menus and then enter Last dose
  date/time.

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• You may also add compliance comments if needed.
• When you have finished click the Sign button in
  lower right corner to complete the process.

Comments may be added in this section
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• For medications such as Nicoderm, that may be
  taken as over the counter or by prescription
• Continue to document the appropriate Dose, Route
  of Administration, Frequency and Type of
  Therapy...

• You should now have added a medication by hx
  showing medication name, details and compliance
  data

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• Then document compliance
• Status, Information Source and Last dose
  date/time...
• When finished click the Sign button.

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• For herbal (ST Johns Wort), selecting an
  appropriate dose may not be possible
• Cerner functionality allows you to add
  instructions in the Dose box. For this example we
  will type Per instructions on the label
• When the Alert screen opens, click Yes to place
  the free text value in the dose box

REMEMBER If you have any questions about this
process, please contact your Clinical Leadership
Team.
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• Now that all the medications by HX have been
  added, the medication reconciliation report must
  be printed.

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• To print the medication reconciliation report
• Click on Task menu...
• Then click Reports

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• Now find the appropriate Medication
  Reconciliation report
• Inpatient will print Medication Reconciliation on
  Admission B
• OSS or Outpatient, will print the Outpatient
  Medication Reconciliation.
• Then select the appropriate printer

REMEMBER If you are not sure which report to
print, contact your Clinical Leadership Team.
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• Process for documenting the mystery pill (the
  little green one for my liver).
• Open the Add Order window and type the word
  Misc in Find box
• Now select Misc Prescription from list
• Then Complete the Compliance status could be
  Investigating or Unable to obtain
• Add comments as appropriate.

Follow clinical workflow process and add comment

• When finished click the Sign button

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• Process for documenting a medication by HX
  through-out the hospital stay
• Capture medication information
• Call the provider and relay information
• Record Medication By HX information in Medication
  List section
• Document phone call to Provider and orders given
  in the comment section ( order med, do not order
  med), see example below

Dr. Test notified, TORB completed, medication
order written and sent to Pharmacy

• REMEMBER
• If you have any questions on what you are to do,
  contact your Clinical Leadership Team.

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Conclusion

• We hope this Computer Based Learning Module has
  been both informative and helpful.
• Feel free to review the CBL until you are
  confident about your knowledge of the material
  presented.
• Click the blue button to Take Quiz and complete
  the requirements for this course.

Click
For further information about this module please
contact Clinical Leadership Team