eMM - Documenting Medication History

A patient’s medication history is documented electronically. It includes home medications and discharge prescriptions.

Viewing Home Medications

1. To enter medication history click on Orders page from the Menu
   
   
    

2. Then select Document Medication by Hx
   
   

The Document Medication by Hx window appears, showing the patient’s home medications and discharge prescriptions

 
 

• The Pill and Bottle icon indicates previous prescriptions

• The Scroll icon indicates home medications

Documenting Medication History

• Tick No Known Home Medications, if there are no home medications.

• Tick Unable To Obtain Information if you can’t obtain information.  

• Tick Use Last Compliance if nothing has changed from previously entered medications. Use this option if the patient has recently been discharged from hospital and is known to be fully compliant with the medication regimen.

Adding Home Medications

1. Click Add to document new home medication

2. The Add Order screen opens. Type the medication into the search field and hit the Enter key. Pressing enter displays all options.

3. Select the order sentence closest to the patient’s medication prescription. Then click Done
   
   
    

4. Change or give as much additional information as possible in the Details tab and Compliance tab.
   Adding as much information as possible helps to convert it into an inpatient order on admission.
   
   
   
   
    

5. Repeat step 4 for each home medication

6. To sign home medications, click Document History and enter your password.
   
   Keep the tick for Med History Incomplete - Finish Later, if a pharmacist should review the patient’s home medication. This notifies the Pharmacist to check medication history as well and modify if necessary
   
   
    

Update Existing Medication History

1. Right click on the home medication
   
   
    
2. Select the appropriate option to update the home medications.
    

   Modify without Resending	Used for scripts only to change minor details
   Suspend	Suspend a medication
   Complete	Use if the medication course has finished prior to presenting to hospital
   Cancel/DC	Cancel a medication that should no longer be taken
   Void	Unchart a medication, documented in error
   Add/Modify Compliance	Change compliance details

   
    
3. Tick Document History when finished.