How do you order and document medications given in the office?

A typical medication template can do 3 things (in addition to including text in any section of the note).

  • Include the med favorites you would like to select (the actual prescription still has to be created, but saves the step of searching).
  • Create a task for the nurse to administer the medication with the exact dosing.
  • Automatically add CPT codes when the template is applied.

Here is an example: You can create a template that includes the following (using ceftriaxone as an example).

Orders/Workflow Tab:

  • Med Tab: Select med favorite Ceftriaxone 500mg (create entry in medications chart).
  • Other Tab: Ceftriaxone 500mg assigned to Nurse and Usage is standing.

Procedure Tab:

  • J0696 Ceftriaxone 2 units
  • 96732 Injection code 1 unit


  1. This template can be applied to the note from the Assess/Plan tab (as well as CC and Exam tabs).
  2. Select medication on Meds tab and create prescription in chart (this does not create a task for the nurse).
  3. The nurse will get the task to administer the medication.
  4. Go into the medication entry in the patient's chart and enter:
  • information about site of admin if injection
  • lot and expiration date
  1. The nurse will mark the task as complete.
  2. Charges will automatically be sent to the superbill.

Another option is to give your nurses proxy privileges for in-house medications. You would still utilize the same template, but instead of the provider creating the medication the nurse would do so, as the med favorite would be marked as able to be written by proxy. This saves the step of the provider creating the prescription in the medication chart.