Medications Administered in the Office

Version 14.19

Overview

This article demonstrates best practice when administering medications at the practice. You will see instruction for three scenarios: 

  • When a Provider is responsible for writing the prescription. 
  • When the Nurse is responsible for completing the detail of prescription that the provider has written. 
  • When a Nurse has Proxy privileges and is responsible for writing and completing the medication.
Click here if you need additional information on how to setup Proxy privileges.

Medication Entered by Provider 

Path: Chart in smart toolbar > Encounter tab > Open Note button > Assess/Plan tab
This workflow is based upon an unfinalized Encounter note, because it takes place during the course of an Encounter (and requires creating orders).
  1. Starting in the Assess/Plan tab, click the dropdown arrow in the All templates field, or begin typing the name of the medication template, and select from the list.

  1. Click OK in the Apply Template Dialog box.
  2. Click the Med tab. 
  • If you applied a template for the administration of the medication, proceed to Step 4.
  • If you did not apply a template, begin typing the name of the medication in the Medication/Prescription field and click the ellipses button . Locate the medication in the list and proceed to Step 5.
  1. Double-click the medication being administered in the office. The Prescription Writer window opens.  
  2. Select Med - administered in the Purpose dropdown and make changes if necessary. 
  3. Click Save. You are returned to note in the the Assess/Plan tab.

  1. Click the Other tab.
  2. Click the Create Task Orders  button located at the bottom of the window (not the green plus located in the middle of the window).
  3. Create a task for the Nurse department to administer the medication.
Note: When creating the task for the medication, include the exact medication dosing in the Task Name/Description field.
  1. Click the Coding tab in the patient's chart to confirm the CPT codes for the medication.
  2. Click Exit to save the note.
  3. From the Tracking window, the nurse will see the task to administer the medication.
  4. The nurse will:
  1. Navigate to the Patient's chart.
  2. Click the Medications tab.
  3. Edit the medication entry to include the following:
  • Site of administration, entered on the second line of the SIG
  • Lot Number
  • Expiration date

  1. The Nurse will mark the task as Complete.
Example: In office administration of Ceftriaxone: 
  1. Provider layers in the Ceftriaxone template from the Assessment/Plan tab. 
  2. Provider creates a prescription for the appropriate dosage of Ceftriaxone to be administered and sets the Purpose to "Med-Administered".
  3. Provider sends a task to the Nursing Department, from the Other tab, to administer Ceftriaxone to the patient. The task should include exact dosing of the medication.
  4. Provider codes the visit from the Coding tab.  Coding should include the Ceftriaxone, with the appropriate number of units, the administration code, and the appropriate E&M code.  As a general rule, the Ceftriaxone and Administration Code would be built into the Ceftriaxone template that was layered in at the Assessment and Plan tab, and the charges would already appear on the Coding tab.
  5. Nurse sees an outstanding task on the Tracking Screen and clicks on the task to review information.
  6. Nurse navigates to the Patient Chart > Medication tab, and edits the Ceftriaxone prescription.  While in edit mode, the Nurse populates the site of administration, entered on the second line of the SIG, Lot Number, and Expiration Date of Ceftriaxone vial used.  Nurse saves the medication entry.
  7. Nurse marks the task as Complete from the Tracking window.

Medication Entered by Proxy

Path: Chart in smart toolbar > Encounter tab > Open Note button > Assess/Plan tab
Because this workflow takes place during the course of an Encounter and requires creating orders, it is based upon an unfinalized Encounter note.
  1. Starting in the Assess/Plan tab, click the All templates dropdown arrow, or begin typing the name of the medication template, and select the template from the list.

  1. Click the Other tab.
  2. Click the Create Task Orders  button located at the bottom of the window (not the green plus located in the middle of the window). 
  3. Create a task to the Nurse department to administer the medication.
Note: When creating the task for the medication, include the exact dosing of the medication in the Task Name/Description field.
  1. Click the Coding tab to confirm the CPT codes for the medication.
  2. Click Exit to save the note.
  3. The nurse will see the task to administer the medication on the Tracking window.
  4. The nurse will:
  1. Navigate to the Patient's chart.
  2. Click the Medications tab.
  3. Click the Add a New Prescriptionbutton to add a new prescription. The Prescription Writer window will appear.
  4. Select Med - administered in the Purpose dropdown.
  5. Select the Prescriber. This is the provider ordering the medication.
  6. Click into the Drug field and enter the name of the medication.
      or
      Click the ellipses button and search.
  7. Complete the Prescription Writer window including the below information and save.
  • Site of administration, entered on the second line of the SIG
  • Lot Number
  • Expiration date

  1. From the Tracking window, the Nurse will mark the task as Complete.
Example: In office administration of Ceftriaxone:
  1. Provider layers in the Ceftriaxone template from the Assessment/Plan tab.
  2. Provider sends a task to the Nursing Department, from the Other tab, to administer Ceftriaxone to the patient. The task should include exact dosing of the medication.
  3. Provider codes the visit from the Coding tab.  Coding should include the Ceftriaxone, with the appropriate number of units, the administration code, and the appropriate E&M code.  As a general rule, the Ceftriaxone and Administration Code would be built into the Ceftriaxone template that was layered in at the Assessment and Plan tab, and the charges would already appear on the Coding tab.
  4. Nurse sees an outstanding task on the Tracking Screen and clicks on the task to review information.
  5. Nurse navigates to the Patient Chart > Medication tab, and creates a prescription for Ceftriaxone with the Purpose set to Med-Administered.  While in edit mode, Nurse populates site of administration, entered on the second line of the SIG, Lot Number, and Expiration Date of Ceftriaxone vial used.  Nurse saves the medication entry.
  6. Nurse marks the task Complete from the Tracking window.


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 on the Coding Tab.
Version 14.10

Overview

This article demonstrates best practice when administering medications at the practice. You will see instruction for three scenarios: 

  • When a Provider is responsible for writing the prescription. 
  • When the Nurse is responsible for completing the detail of prescription that the provider has written. 
  • When a Nurse has Proxy privileges and is responsible for writing and completing the medication.
Click here if you need additional information on how to setup Proxy privileges.

Medication Entered by Provider 

Path: Chart in smart toolbar > Encounter tab > Open Note button > Assess/Plan tab
This workflow is based upon an unfinalized Encounter note, because it takes place during the course of an Encounter (and requires creating orders).
  1. Starting in the Assess/Plan tab, click the dropdown arrow in the All templates field, or begin typing the name of the medication template, and select from the list.

  1. Click OK in the Apply Template Dialog box.
  2. Click the Med tab. 
  • If you applied a template for the administration of the medication, proceed to Step 4.
  • If you did not apply a template, begin typing the name of the medication in the Medication/Prescription field and click the ellipses button . Locate the medication in the list and proceed to Step 5.
  1. Double-click the medication being administered in the office. The Prescription Writer window opens.  
  2. Select Med - administered in the Purpose dropdown and make changes if necessary. 
  3. Click Save. You are returned to note in the the Assess/Plan tab.

  1. Click the Other tab.
  2. Click the Create Task Orders  button located at the bottom of the window (not the green plus located in the middle of the window).
  3. Create a task for the Nurse department to administer the medication.
Note: When creating the task for the medication, include the exact medication dosing in the Task Name/Description field.
  1. Click the Coding tab in the patient's chart to confirm the CPT codes for the medication.
  2. Click Exit to save the note.
  3. From the Tracking window, the nurse will see the task to administer the medication.
  4. The nurse will:
  1. Navigate to the Patient's chart.
  2. Click the Medications tab.
  3. Edit the medication entry to include the following:
  • Site of administration, entered on the second line of the SIG
  • Lot Number
  • Expiration date

  1. The Nurse will mark the task as Complete.
Example: In office administration of Ceftriaxone: 
  1. Provider layers in the Ceftriaxone template from the Assessment/Plan tab. 
  2. Provider creates a prescription for the appropriate dosage of Ceftriaxone to be administered and sets the Purpose to "Med-Administered".
  3. Provider sends a task to the Nursing Department, from the Other tab, to administer Ceftriaxone to the patient. The task should include exact dosing of the medication.
  4. Provider codes the visit from the Coding tab.  Coding should include the Ceftriaxone, with the appropriate number of units, the administration code, and the appropriate E&M code.  As a general rule, the Ceftriaxone and Administration Code would be built into the Ceftriaxone template that was layered in at the Assessment and Plan tab, and the charges would already appear on the Coding tab.
  5. Nurse sees an outstanding task on the Tracking Screen and clicks on the task to review information.
  6. Nurse navigates to the Patient Chart > Medication tab, and edits the Ceftriaxone prescription.  While in edit mode, the Nurse populates the site of administration, entered on the second line of the SIG, Lot Number, and Expiration Date of Ceftriaxone vial used.  Nurse saves the medication entry.
  7. Nurse marks the task as Complete from the Tracking window.

Medication Entered by Proxy

Path: Chart in smart toolbar > Encounter tab > Open Note button > Assess/Plan tab
Because this workflow takes place during the course of an Encounter and requires creating orders, it is based upon an unfinalized Encounter note.
  1. Starting in the Assess/Plan tab, click the All templates dropdown arrow, or begin typing the name of the medication template, and select the template from the list.

  1. Click the Other tab.
  2. Click the Create Task Orders  button located at the bottom of the window (not the green plus located in the middle of the window). 
  3. Create a task to the Nurse department to administer the medication.
Note: When creating the task for the medication, include the exact dosing of the medication in the Task Name/Description field.
  1. Click the Coding tab to confirm the CPT codes for the medication.
  2. Click Exit to save the note.
  3. The nurse will see the task to administer the medication on the Tracking window.
  4. The nurse will:
  1. Navigate to the Patient's chart.
  2. Click the Medications tab.
  3. Click the Add a New Prescriptionbutton to add a new prescription. The Prescription Writer window will appear.
  4. Select Med - administered in the Purpose dropdown.
  5. Select the Prescriber. This is the provider ordering the medication.
  6. Click into the Drug field and enter the name of the medication.
      or
      Click the ellipses button and search.
  7. Complete the Prescription Writer window including the below information and save.
  • Site of administration, entered on the second line of the SIG
  • Lot Number
  • Expiration date

  1. From the Tracking window, the Nurse will mark the task as Complete.
Example: In office administration of Ceftriaxone:
  1. Provider layers in the Ceftriaxone template from the Assessment/Plan tab.
  2. Provider sends a task to the Nursing Department, from the Other tab, to administer Ceftriaxone to the patient. The task should include exact dosing of the medication.
  3. Provider codes the visit from the Coding tab.  Coding should include the Ceftriaxone, with the appropriate number of units, the administration code, and the appropriate E&M code.  As a general rule, the Ceftriaxone and Administration Code would be built into the Ceftriaxone template that was layered in at the Assessment and Plan tab, and the charges would already appear on the Coding tab.
  4. Nurse sees an outstanding task on the Tracking Screen and clicks on the task to review information.
  5. Nurse navigates to the Patient Chart > Medication tab, and creates a prescription for Ceftriaxone with the Purpose set to Med-Administered.  While in edit mode, Nurse populates site of administration, entered on the second line of the SIG, Lot Number, and Expiration Date of Ceftriaxone vial used.  Nurse saves the medication entry.
  6. Nurse marks the task Complete from the Tracking window.


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 on the Coding Tab.