6. Log Medications Brought Into the Facility and Active Orders

Logging and verifying medications brought into the facility by patients is a critical process to ensure accurate medication management and compliance with regulatory requirements. This high-level guide outlines the steps to log medications in the Doctor’s Orders tab of the patient chart, verify them, and collect necessary signatures.

By following these procedures, healthcare facilities can maintain accurate records, ensure patient safety, and streamline their workflow for medication management.

Note: This process only describes the admissions process for clients not using a CRM or integrated RCM platform. 

Best Practice Workflow Video

Logging Medications and Active Orders

Let’s review the best practice steps for logging medications and active orders brought into the facility by patients.

1. Navigate to the Doctor’s Orders tab in the patient’s chart and select Meds Brought In.
   
2. Click Add New.
   
3. In the pop-up window, add the medication details:
• Medication, Route, Dosage Form: Use the medication information displayed in the drop-down when possible. This medication is from the database, using database medications ensures that Orders link appropriately in future workflows (like inventory, allergies, and eRx). 
• Expiration Date: Use the current date if no expiration date is provided. Expiration dates in the past will prevent the medication from populating onto the Med Log following state and/or accreditation requirements, which forbid facilities from holding medications without an expiration date. This medication should not be continued upon admission.
• Amount Brought Into Facility: Enter accurate amounts of the medication brought into the facility to simplify inventory management including refill alerts and med counts.
• Justification: Add if available at the time of entry. This will appear on the Med Log for any medications continued upon admission.
4. Click Submit.
5. You can use the Add New button to add as many medications as needed.
• Alternatively, you can click the Add Medication button in the Medications Brought In window.
6. You can modify the entries as needed until the medication is verified by the nurse/physician or signed by the patient.

Documenting No Medications Brought In 

If the patient did not bring in any medications, it is recommended to use the No Medication Brought In button to document and collect signatures. 

Medication Verification Process

Once the medication or medications have been logged, you must decide which action to take for each medication. 

1. Use the Action Taken drop-down to select actions for each medication.
   

• Continue on Admission: Creates a Doctor's Order entry for the medication and adds the medication to the patient's inventory if enabled. 
  • ePrescribe: If your facility uses eRx through Rcopia, you will only need to check the eRx box for this order if you need to refill the medication for the patient. 
• Managed by Patient: Indicates that the patient is responsible for storing and taking the medication as intended. Medications marked as managed by the patient are not included in the patient inventory or on the Med Log but will appear in the Orders section of the Doctor's Orders tab. 
  • This option is often used in Outpatient facilities, where patients often need their current medications listed in their active Doctor's Orders list, but the facility is not responsible for managing the inventory. 
• Store: Store the medication for the patient; will appear in patient inventory as inactive if enabled.
• Destroy: Dispose of the medication. Requires a witness signature and creates a disposed transaction in inventory if enabled.
• Discontinue On Admission: The patient will no longer take the medication after being admitted.
2. Verify Medications from the Meds Brought In section of Doctor's Orders:
   
   • Add a witness for any medications marked as Destroy.
   • Click Verify.
     
3. Create Orders: If Managed by Patient or Continue on Admission are selected, create an order in the subsequent window.
   • Modify order details in the verification window if needed. 
   • If you chose Continue on Admission and entered a dispense amount different from the amount brought in, the order will show the dispense amount.
   • These medications appear in the Order section of the Doctor's Orders tab. Medications managed by the patient are indicated with the Managed By Patient tag.

Collecting Signatures

Three signatures can be applied to the Meds Brought In section: patient, witness, and verification.

1. Patient Signature can be collected at any time by clicking the Patient Signature button, having the patient sign, and clicking Submit. A patient signature is not required to close the chart.
   • Note: Most facilities will have a user complete this process while a patient is resting. In this scenario, the dashboard will show when patient signatures must be collected for Meds Brought In. This step will not restrict the user from continuing.  

2. Witness Signature: Any EMR user can be a witness; Witness signatures are only required for destroyed meds but can be added to all meds brought in as needed. To collect the witness signature, have them open the Medications Brought in by Patient section, click Witness Signature, sign, and submit.

• The signature timestamp replaces the Pending Signature indicator.
  

3. Verification Signature: Can be collected at any time by clicking the Verification Signature button, signing, and submitting. A verification signature is not required to close the chart.

Marking Records as Complete 

• Chart Auditors can mark records as complete even if signatures are missing.
• From the Medications Brought In page, use the checkmark to mark meds as complete.
• Once complete, the Unsigned Medications Brought in by Patient row is removed from the dashboard.