Medication List Management Guide- Documenting, discontinuing or merging medications

The patient's medication history is an essential part of their clinical care. This article will provide you with information on how to view the patient's medication history and how to maintain the medication list.

 

Contents

• How do I view a patient's medication history?
  • Viewing the Medication History from the Clinical Profile
  • Viewing the full Medication History from the Medication History window
• How do I document a medication?
  • Medications patient is actively taking
  • Discontinuing Medications
    • Medications patient previously took but discontinued (not previously documented in Elation)
    • Medications that need to be discontinued (previously documented in Elation)
  • Medications that need to be designated as “temporary” from the Medication List
• How do I merge and un-merge medications?
  • Merging Medications
  • Unmerging Medications
• How do I delete a medication?

 

How do I view a patient's medication history?

• In the Notes field you can note any additional details about this medication as needed.
• Click the “more…” button at the bottom of the box to log the quantity of the medication, units and refills.
  • User Tip: Entering this information when you document new medications for patients is useful to make medication refills easy.
• Click "Save & Add Another" to continue documenting additional medications, or "Save & Close" when you are finished. 

 

Discontinuing Medications

Medications patient previously took but discontinued (not previously documented in Elation)

New patients joining your practice may have previously been taking certain medications, but have now discontinued taking them. To document a medication that a patient previously took, but discontinued, please follow the steps listed below: 

1. Click the "Rx" button at the top of the patient's chart and select "Document Discontinued Med"
2. In the D/C/Date: field, document the date the medication was discontinued
   • User Tip: If the patient does not remember the exact month and date the medication was discontinued, type in the year and then press the "Tab" key on your keyboard. Elation will automatically set the date as January 1st of that year. 
3. In the Started: field, document the date the medication was started
   • User Tip: If the patient does not remember the exact month and date the medication was started, type in the year and then press the "Tab" key on your keyboard. Elation will automatically set the date as January 1st of that year. 
4. Click on the "Rx" button at the top of the patient's chart
5. Click "Document Discontinued Med"
6. Enter the medication name in the Med: field by typing in the drug name and selecting it from the medication database
7. Fill in the Sig: field to note directions for use of the medication as needed
8. In the D/C By: field, note the name of the provider that discontinued the medication for the patient
9. In the Reason field, note the reason the medication was discontinued
10. In the Rx'd By: field, note the name of the provider that prescribed the medication for the patient
11. In the Notes field you can note any additional details about this medication as needed.
12. Click "Save & Add Another" to continue documenting the discontinuation of additional medications, or "Save & Close" when you are finished. 

 

Medications that need to be discontinued (previously documented in Elation)

You can document that a medication is no longer used by the patient after receiving the patient’s confirmation by clicking “Actions” next to the medication in either of the Permanent Meds lists and selecting “Document Discontinue” from the dropdown. This will remove the medication from the Permanent Meds list and the medication will be documented as discontinued in the Chronological Record and in the Medication History window.

• User Tip: You can access the full medication history by clicking “Meds Hx” from the grey navigation bar in the patient chart and selecting “Medication History” from the dropdown. 

 

Medications that need to be designated as “temporary” from the Medication List 

There are two options for managing temporary medications, such as antibiotics or other short term prescriptions, in a patient’s chart. If a medication is not designated as a “temporary” medication when it is ePrescribed in Elation, the medication will be displayed in the Permanent Medication lists in the Clinical Profile (left hand column of the chart) when prescribed/documented, and will be sorted into the “Permanent Rx Meds” list or the “Permanent OTC Meds” list. You can designate the medication as “temporary” immediately after it has been prescribed/documented in the chart, or discontinue the medication after you receive confirmation from the patient that they have stopped taking the medication.

You can designate the medication as temporary by clicking “Actions” next to the medication in the Permanent Medication list and selecting “Set as Temporary Med” from the dropdown. This will remove the medication from the Permanent Medication list, but the record of the medication will still remain in the Chronological Record and in the Temporary Medications section of the Medication History window. 

• User Tip: You can view the temporary medications in the full medication history by clicking “Meds Hx” from the grey navigation bar in the patient chart and selecting “Medication History” from the dropdown.

 

How do I merge and un-merge medications?

Merging Medications

The merge medications feature can come in handy when you have multiple records of the same medication in the patient's medication history and you want to consolidate them to keep a cleaner list.

 

Medications can be merged with other medications in the patient's list by completing the following steps.

1. From within the Clinical Profile or Medication History, click on the “Actions” button to the right of the medication you wish to merge.
   • User Tip: Do not click the "Actions" button next to a specific Script because you can only merge medications from the start of the entire medication record
2. Scroll down the list of Actions and click “Merge with other Med”
3. A box will appear for you to “Choose Med(s) to Merge with”. Simply select the appropriate med(s) and click “Merge with Selected Med(s)”

3. In the "Choose Med to Move to" box that appears you can select to set the medication as its own medication entry again or merge it with a different medication.

4. Click “Move order into Selected Med” to complete the action

 

 

Discontinuing a medication

To discontinue a medication complete the following actions:

1. Click "Actions" on the right-hand side of the medication you wish to discontinue
2. Scroll down the menu and select “Rx: Discontinue” or "Document Discontinue"
   1. "Rx: Discontinue" is for a provider in the practice to order a medication to be discontinued
   2. "Document Discontinue" is for the practice to document that a medication was discontinued by someone else
3. Enter a reason for discontinuing the medication and then save.

Discontinued medications will appear in the Discontinued section of the Medication History

 

Deleting a medication?

Medication history is very important for proper clinical care. Best practice is to only delete medications if they were inaccurately documented. Please use one of the discontinue options if the medication should remain in the patient's historical records as a previously active medication.

1. Click "Actions" on the right-hand side of the medication you wish to discontinue
2. Scroll down the menu and select "Remove Medication"
3. Click “Yes, Delete” to complete the action

 

Related Articles

• Introduction to Elation's Medication History Download feature
• How to manage downloaded medication history