Medications Administered in the Office

Version 20.10
Path: Clinical, Billing, or Practice Management tab > Patient Chart button > Encounters tab > Open Note button > Orders

Overview

This article demonstrates best practice when a medication is administered in the office during a visit. For ease of documentation and coding, it is recommended that templates are used. 

Medication Order Workflow

  1. From Orders, click the drop-down in the All templates field or begin typing the name of the medication template, select the template from the list.
  2. Click OK in the Apply Template Dialog box.
  3. Double-click the medication being administered from the Order Worksheet or the Med tab. The Prescription Writer window opens.  
  4. Select Med - administered in the Purpose drop-down and make changes, if necessary. 
  5. Click Save

  1. Click the Other tab then the Add button and complete the following.
  1. In the Task Name/Description field, type the medication name and dosing. 
  2. Confirm the Task Type selection is Checklist.
  3. Click the drop-down and select the Department that will administer the medication.
  4. Click the Save button.
  5. Repeat the above steps for additional medications.
  1. Click the Create button.
  2. Click Coding in the patient's encounter note to confirm the CPT codes for the medication.

Note: If the administration code and medication code are not populated on the medication template that was layered on to the Encounter, it is ultimately the responsibility of the Provider to ensure proper coding is placed in the Services and Procedures Coding window of Coding.

  1. Click Exit to save the note.
  2. Once the medication has been administered, finalize the visit note.

Complete the Medication Administration and Task

  1. From Patient Tracking, review the task to administer the medication. Once the medication has been administered, complete the below steps.
  1. Navigate to the Patient's chart and click Medications.
  2. Select the medication, click the Edit button and complete the below information.
  • (OptionalSite of administration: The site where the medication is administered is entered on the second line of the SIG.
  • Lot Number: Click into the Lot number field and enter the lot number.
  • Expiration date: Click in to the Expiration date field and enter the expiration date.
  1. Click the Save button.


  1. Return to Patient Tracking window and mark the task as Complete.

Medication Entered by Proxy

  1. Starting in Orders, click the All templates dropdown arrow, or begin typing the name of the medication template, and select the template from the list.
  2. Click OK in the Apply Template Dialog box.
  3. Click the Other tab then the Add button and complete the following.
  1. In the Task Name/Description field, type the medication name and dosing.
  2. Confirm the Task Type selection is Checklist.
  3. Click the drop-down and select the Department that will administer the medication.
  4. Click the Save button.
  5. Repeat the above steps for additional medications.
  1. Click the Create button.
  2. Once the medication has been administered, complete the below steps.
  1. Navigate to the Patient's chart and click Medications.
  2. Click the New button, the Prescription Writer displays
  3. Select Med - administered in the Purpose dropdown.
  4. Select the Prescriber. This is the provider ordering the medication.
  5. Click into the Drug field and enter the name of the medication, or click the ellipses button, and select the medication.
  6. Confirm the medication information and complete the below information.
  • Site of administration: The site where the medication is administered is entered on the second line of the SIG.
  • Lot Number: Click in to the Lot number field and enter the lot number.
  • Expiration date: Click in to the Expiration date field and enter the expiration date.
  1. Click the Save button.
  1. Return to Patient Tracking window and mark the task as Complete.
Version 20.8
Path: Clinical, Billing, or Practice Management tab > Patient Chart button > Encounters tab > Open Note button > Plan/Orders

Overview

This article demonstrates best practice when a medication is administered in the office during a visit. For ease of documentation and coding, it is recommended that templates are used. 

Medication Order Workflow

  1. From Plan/Orders, click the drop-down in the All templates field or begin typing the name of the medication template, select the template from the list.
  2. Click OK in the Apply Template Dialog box.
  3. Double-click the medication being administered from the Order Worksheet or the Med tab. The Prescription Writer window opens.  
  4. Select Med - administered in the Purpose drop-down and make changes, if necessary. 
  5. Click Save


  1. Click the Other tab then the Add button and complete the following.
  1. In the Task Name/Description field, type the medication name and dosing. 
  2. Confirm the Task Type selection is Checklist.
  3. Click the drop-down and select the Department that will administer the medication.
  4. Click the Save button.
  5. Repeat the above steps for additional medications.
  1. Click the Create button.
  2. Click Coding in the patient's encounter note to confirm the CPT codes for the medication.

Note: If the administration code and medication code are not populated on the medication template that was layered on to the Encounter, it is ultimately the responsibility of the Provider to ensure proper coding is placed in the Visit Coding.

  1. Click Exit to save the note.
  2. Once the medication has been administered, finalize the visit note.

Complete the Medication Administration and Task

  1. From Patient Tracking, review the task to administer the medication. Once the medication has been administered, complete the below steps.
  1. Navigate to the Patient's chart and click Medications.
  2. Select the medication, click the Edit button and complete the below information.
  • Site of administration: The site where the medication is administered is entered on the second line of the SIG.
  • Lot Number: Click in to the Lot number field and enter the lot number.
  • Expiration date: Click in to the Expiration date field and enter the expiration date.
  1. Click the Save button.


  1. Return to Patient Tracking window and mark the task as Complete.

Medication Entered by Proxy

  1. Starting in Plan/Orders, click the All templates dropdown arrow, or begin typing the name of the medication template, and select the template from the list.
  2. Click OK in the Apply Template Dialog box.
  3. Click the Other tab then the Add button and complete the following.
  1. In the Task Name/Description field, type the medication name and dosing.
  2. Confirm the Task Type selection is Checklist.
  3. Click the drop-down and select the Department that will administer the medication.
  4. Click the Save button.
  5. Repeat the above steps for additional medications.
  1. Click the Create button.
  2. Once the medication has been administered, complete the below steps.
  1. Navigate to the Patient's chart and click Medications.
  2. Click the New button, the Prescription Writer displays
  3. Select Med - administered in the Purpose dropdown.
  4. Select the Prescriber. This is the provider ordering the medication.
  5. Click into the Drug field and enter the name of the medication, or click the ellipses button, and select the medication.
  6. Confirm the medication information and complete the below information.
  • Site of administration: The site where the medication is administered is entered on the second line of the SIG.
  • Lot Number: Click in to the Lot number field and enter the lot number.
  • Expiration date: Click in to the Expiration date field and enter the expiration date.
  1. Click the Save button.
  1. Return to Patient Tracking window and mark the task as Complete.