Overview
Use this workflow to document medications in the EMR (ECW) when:- Medication is prescribed by an outside provider
- Patient brings medication from home
- Medication is dispensed by a non-AllCare pharmacy
- Facility administers medication not yet in EMR
- Medication reconciliation identifies missing medications
Quick Reference
SLA: Add within 24 hours of identificationSystems: ECW, AllCare.ai, Freshdesk
Step-by-Step Procedure
1. Gather Medication Information
Required Details:- Medication name (generic and brand if applicable)
- Strength and dosage form (e.g., 10mg tablet, 50mg capsule)
- Dose and frequency (e.g., “Take 1 tablet by mouth daily”)
- Route of administration (oral, topical, injection, etc.)
- Start date (when patient began taking)
- Stop date (if known or if short-term medication)
- Prescribing provider name
- Clinical indication/reason for medication
- Facility MAR (medication administration record)
- Hospital discharge summary
- Outside prescription bottles/labels
- Patient or family report
- Other pharmacy records
2. Verify Medication Details
Before adding to EMR: Check for Duplicates:- Search ECW medication list for same or similar medications
- Look for both generic and brand names
- Verify not already documented under different name
- Confirm medication name spelling
- Verify strength matches source document
- Ensure dosing instructions are clear and complete
- Check route is appropriate for dosage form
- Check for potential drug interactions with current medications
- Verify no documented allergies to this medication
- Confirm indication is appropriate for patient’s conditions
3. Add Medication in ECW
In ECW: Step 1: Open Patient Chart- Navigate to patient chart
- Click Medications tab
- Click Add Medication button
- Search for medication by name (generic preferred)
- Select correct medication from dropdown
- Medication name: [Select from ECW drug database]
- Strength: [e.g., 10mg]
- Dosage form: [tablet, capsule, liquid, etc.]
- Dose: [e.g., 1 tablet]
- Route: [by mouth, topical, injection, etc.]
- Frequency: [daily, twice daily, as needed, etc.]
- Start date: [Date patient began medication]
- Stop date: [If known or if short-term medication]
- Indication: [Reason for medication, e.g., “Hypertension”]
- Prescribing provider: [Name of provider who prescribed]
- Pharmacy: [If known and not AllCare]
- Notes: [Any special instructions or context]
- Mark as Active if patient is currently taking
- Mark as Inactive if discontinued (with stop date)
- In Notes or Comments field, document:
- “Added per [facility MAR / discharge summary / patient report]”
- Date information was obtained
- Any verification performed
4. Review and Verify
Before Saving: Double-Check:- ✓ Medication name is correct
- ✓ Strength and dose are accurate
- ✓ Frequency matches source document
- ✓ Route is appropriate
- ✓ Start date is documented
- ✓ Source of information is noted
- Review for drug interactions (ECW may auto-alert)
- Verify no allergy conflicts
- Confirm appropriate for patient’s age and conditions
5. Save and Sign
Save Entry:- Click Save to add medication to patient’s active list
- Verify medication appears in the medication list
- Ensure entry is properly signed in ECW
- Some entries may require provider co-signature
- If medication requires provider review or approval:
- Create brief secure message or tele-encounter
- Note: “Medication added to EMR per [source], please review”
- Assign to treating provider
6. Update Related Systems
In AllCare.ai:- Navigate to patient profile → Medications
- Verify medication appears (if systems are synced)
- If not synced, manually add note:
- “Medication added to ECW: [medication name, strength, frequency]”
- “Source: [facility MAR / discharge summary / etc.]”
- “Date added: [date]”
- If this was part of a ticket (e.g., medication reconciliation, discharge follow-up):
- Log action: “Medication added to EMR: [medication details]”
- Update ticket status as appropriate
7. Notify Facility (if needed)
When to Notify:- If medication was missing from EMR and facility requested update
- If discrepancy was identified during reconciliation
- If medication list was requested by facility
- Email or call facility contact
- Provide updated medication list if requested
- Confirm facility MAR matches EMR
Common Scenarios
Scenario 1: Hospital Discharge Medication
Situation: Patient discharged from hospital with new medications not prescribed by AllCare provider Actions:- Obtain discharge summary with medication list
- Add each new medication to ECW with:
- Source: “Per hospital discharge summary [date]”
- Prescriber: Hospital provider name (if available)
- Create tele-encounter for AllCare provider to review and decide:
- Continue hospital medications
- Modify or discontinue
- Assume prescribing responsibility
Scenario 2: Patient Brings Medication from Home
Situation: Patient transferred to facility with medications from home pharmacy Actions:- Request list of medications from facility or family
- Verify details from prescription bottles if available
- Add to ECW with:
- Source: “Patient’s home medications per [facility/family]”
- Note outside pharmacy name if known
- Notify provider for review and decision on continuing
Scenario 3: Specialist Prescribed Medication
Situation: Patient saw outside specialist who prescribed new medication Actions:- Obtain copy of specialist’s prescription or visit summary
- Add to ECW with:
- Prescriber: Specialist name and specialty
- Indication: Specialist’s diagnosis/reason
- Source: “Per [specialist name] [date]”
- Notify AllCare provider for awareness and coordination
Scenario 4: Over-the-Counter (OTC) Medication
Situation: Facility administering OTC medication (e.g., Tylenol, vitamins) not in EMR Actions:- Confirm medication name, strength, and frequency from facility MAR
- Add to ECW as OTC medication
- Mark prescriber as “Patient” or “Facility” (per ECW options)
- Document: “OTC medication per facility MAR”
Best Practices
Documentation Standards
Always Include:- Complete medication name (generic preferred)
- Exact strength and dosage form
- Clear dosing instructions
- Source of information
- Date added to EMR
- Vague descriptions (“blood pressure pill”)
- Incomplete dosing (“take as directed” without specifics)
- Missing start dates
- Undocumented sources
Provider Communication
Notify Provider When:- New medication from outside source
- Medication requires clinical review
- Potential interaction or safety concern
- Medication affects treatment plan
- Routine OTC medications (unless policy requires)
- Medications already discussed with provider
- Medications being discontinued
Quality Checks
Periodic Review:- Verify EMR medication list matches facility MAR
- Confirm active medications are still being administered
- Update discontinued medications promptly
- Remove duplicates or errors
Troubleshooting
Issue: Medication not found in ECW drug database
Solution:- Try alternate spellings or brand/generic names
- Search by therapeutic class
- If still not found, contact ECW support or use “free text” option if available
- Document exact medication name and source in notes
Issue: Unclear dosing instructions from source document
Solution:- Contact facility to clarify current administration
- Review prescription bottle if available
- Check standard dosing references (e.g., UpToDate, Lexicomp)
- If still unclear, escalate to provider for clarification
Issue: Conflicting information from multiple sources
Solution:- Verify with facility what is currently being administered
- Check most recent source (e.g., latest discharge summary)
- Document discrepancy in notes
- Escalate to provider for clinical decision
Issue: Medication requires provider signature but provider unavailable
Solution:- Save medication as draft or pending if ECW allows
- Create secure message or tele-encounter for provider review
- Document in Freshdesk as pending provider approval
- Follow up when provider available