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Medications Administered in the Office

Version 20.7
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.
Version 20.6

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.

Note: Click here if you need additional information on how to setup Proxy privileges.

Medication Entered by Provider 

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

Note: 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 Plan/Orders, 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

  1. Click the Other tab.
  2. Click the Add button  located at the bottom 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.

When creating the task for the medication, include the exact medication dosing in the Task Name/Description field.

  1. Click Coding in the patient's encounter note to confirm the CPT codes for the medication.
  2. Click Exit to save the note.
  3. From Patient Tracking, the nurse will see the task to administer the medication.
  4. The nurse will:
  1. Navigate to the Patient's chart.
  2. Click Medications.
  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 Plan/Orders
  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 Coding in the encounter. 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 Plan/Orders 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 > Medications, 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: Clinical, Billing, or Practice Management tab > Patient Chart button > Encounters tab > Open Note button > Plan/Orders

Note: 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 Plan/Orders, 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 Add button located at the bottom 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 Coding 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 Medications .
  3. Click the New button 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 Plan/Orders.
  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 Coding. 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 Plan/Orders, 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 in the Visit Coding.