Recording and Managing Prescriptions

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

Before you start

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

Electronic prescribing, or eRx, requires an integration with Ensora.

Manual prescription entry

If your organization does not want to use an integrated eRx vendor, you can still manually document prescriptions in the system.

If your system is configured for ePrescribing, you will not be able to do manual prescription entry via the UI.

1. Open the patient’s chart and go to the Prescriptions table.
2. Click on Add Prescription. This opens the Prescription modal.
3. Enter in the prescription information including medication name, dosage instructions, and dispsense request.
4. Select Save.

How to search and filter the Prescription list

• Search by name: Use the search box to find an presciption by medication name.
• Filter by prescriber: Narrow the list to a specific provider.
• Filter by prescription date: Narrow the list by prescription date.
• Filter by status: Narrow the based on prescription status, e.g. active, on hold, unknown, and completed.
• Sort: Select a column header to sort by Medication name, Prescriber, eRx date, and Status.

Understanding what you’re looking at

Prescription fields

Field	What it means
Allergen	The substance the patient is allergic to. Prefered vocabulary is SNOMED. Required field
Status	Whether the allergy is currently Active, Inactive, or Resolved. Defaults to Active for new allergies
Criticality	How severe the potential risk is: High, Low, or Unable to Assess
Reaction	The reaction(s) the patient has had
Last occurence	Last known occurence of a reaction
Severity	How severe the reaction was: Mild, Moderate, Severe
Onset	When the allergy or intolerance was identified
Description	Free text description of reaction event as a whole
Note	Free text field to document any information related to the allergen not captured in other fields
Verification status	Assertion about the certainty associated with the propensity of a reaction to the identified substance. Defaults to Confirmed
Type	Underlying physiological mechanism for the reaction. Options are Allergy (default) or Intolerance
Category	Category of the identified substance, e.g. Food, Medication, Environment, or Biologic
Date recorded	Date the allergen was recorded. Defaults to current day for new allergies
Asserter	Source of the information about the allergy, e.g. the patient
Linked encounter	Links to encounter notes where allergy was documented via macro

How allergies are sorted

By default, the table sorts allergies by Criticality first (High, then Low, then Unable to Assess, then unspecified), and within the same criticality level, alphabetically by allergen name.

What the empty states mean

The table can show two different messages when there’s nothing to display — it’s important to know which one you’re looking at:

• “No allergies recorded” — Nothing has been documented for this patient at all. No one has confirmed whether the patient has allergies or not.
• “No Active Allergies Recorded” — The patient does have allergy information on file, but nothing matches the table’s default view (active, unconfirmed or confirmed allergies). This can happen if all recorded allergies are inactive or resolved.

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.

Troubleshooting

I can’t find an allergy I know was documented. Check your active filters (Criticality, Status, Severity, and any search text). A filter may be hiding it. Clear all filters and search again.

I tried to document NKA but got a warning. This means the patient already has allergies recorded. Confirm with the patient before proceeding — saving NKA will mark those existing allergies as refuted.

I tried to add an allergy but got a warning about NKA. The patient previously had “No Known Allergies” documented. Saving your new allergy will update that NKA record to refuted, since it’s no longer accurate.