Recording and Managing Medications

This guide walks you through recording, editing, and reviewing a patient’s medications in the Clinical section of the Patient Chart.

The Medication section can be used to capture medications that patient is currently taken, has taken in the past, or will take in the future.

The source of this information may be the patient, significant other (such as a family member or spouse), clinician, among many others. As a result, details such as date/time of medication administration and quantity may be incomplete, missing, or less precise.

Before you start

You’ll need to have a patient chart open. The medications table lives under the Clinical section of the Chart Navigation.

How to record a new allergy

1. Open the patient’s chart and go to the Medications table.
2. Select Add Medication. This opens the Medication modal.
3. Enter the Medication.
4. Add Status about the state of the medication. Typically, this will be Active or Completed.
5. Enter the Start date and End date of the medication, if known.
6. Enter a Reason why the medication is being/was taken, such as an ICD-10 diagnosis code.
7. Add a Note if you want to capture free-text context about the medication statement.
8. Complete the Dosage section if medication information such as SIG, Dose amount, Unit, Route, PRN, Timing/Frequency, and Additional Instruction is known.
9. Review the Additional Information section if you need to set fields such as Date asserted and Information source. Encounters linked to this medication statement may also appear.
10. Select Save.

How to edit an existing allergy

1. In the Medications table, select the row for the medication you want to update.
2. The Medication modal opens, pre-filled with the existing information.
3. Make your changes and select Save.

How to search and filter the medication statement list

• Search by name: Use the search box to find a medication by name.
• Filter start or end date: Use to narrow the time window for medication adminstrations
• Status: User to filter by medication status such as Active or Completed.
• Sort: Select a column header to sort by Medication, Start, End, or Status.

Understanding what you’re looking at

Medication fields

Field	What it means
Medication	What medication was taken. Required
Status	State of the medication statement such as Active or Completed. Defaults to Unknown. Required
Start date	The start date of when the medication is/was/will be taken
End date	The end date of when the medication is/was/will be taken
Reason	The reason or condition, e.g. ICD-10, why the medication is being/was taken
Note	Capture any additioanl free text about the medication statement
SIG	Dosage instructions

How medications are sorted

By default, the table sorts allergies by Status first (active, intended, on hold, completed stopped, unknown, not taken), then by adminstration start date, and finally by medication name.

What the empty states mean

No medications have been recorded or no records match the current filter.

If you’re not sure which state you’re seeing, check whether any filters are applied — clearing filters will show you the full picture of what’s on file for the patient.