Medications Brought In by Patient Workflow

Medications Brought In is the process to log and verify the medications the patient brought into the facility upon admission in the Doctor's Orders tab of the patient chart. This feature is primarily used for inpatient facilities. 

Log Meds Brought In

Let's review how to log the medications brought in by the patient.

1. From the patient chart, open the Doctor's Orders tab.
1. Note: The name of this tab is customizable and may be called something else in your instance.
2. Click on the Meds Brought In button.
3. Click Add New.
4. In the new pop-up window, add the details of the medication the client brought in.
5. Click Submit. 
6. You can use the Add New button to add as many medications as needed.
1. Alternatively, you can click the Add Medication button in the Medications Brought In window.
7. Before medications are verified or signed by the patient, you can modify entered information by clicking on the edit icon or deleting the medication.
8. After the medication is added, you can click on + and - icons to expand or collapse the medication details, notes, and attachments.

Medication Verification Process

Once the medication(s) that the patient brought into the facility have been logged, decide what should be done with each medication. Choose one of the following options for each med: 

• Continue on Admission: Creates a Doctor's Order for this medication. If patient inventory is enabled, this action adds the medication to the patient's inventory as active. If your facility uses Rcopia/DrFirst, you will only create an order in Rcopia/DrFirst for this medication if you need to procure more for the patient.
• Managed by Patient: This action indicates the patient is responsible for storing the medication and taking it 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.
• Store: Keep the medication in storage for the patient. If the patient inventory feature is in use, the store action keeps medication in the patient's inventory as inactive.
• Destroy: Dispose of the medication. The Destroy action requires a Witness signature. If patient inventory feature is in use, this action would create a Disposed transaction in the patient's inventory.
• Discontinue On Admission: Indicates that, while the patient was taking this medication up until admission, they are no longer taking it.

Select Verification Actions

From the Doctors Orders tab on the patient chart, complete the following steps to verify the medication(s):

1. Click on the Meds Brought In button. The number inside of the brackets indicates the total number of meds logged.
2. From the Action Taken drop-down select an action for each medication you want to verify at this time.
3. Add a Witness if applicable. A witness is required when selecting Destroy.
4. Click Verify.
5. If you have any Managed by Patient or Continue On Admission medications, a window allowing you to create the Order(s) opens.
• If you chose Continue on Admission and entered a dispense amount different from the amount brought in, the order will show the dispense amount.
1. From this window, you can modify the start date and time, justification, warning, notes, remaining duration, frequency time, and refills, and indicate if the medication should be continued upon discharge.
2. If you choose Continue on Admission, you can assign a dispense amount that is different than the amount the patient brought into the facility.
3. If you are not a doctor, select Ordering Physician and Ordered Via.
4. Click Submit.
5. These medications appear in the Order section of the Doctor's Orders tab. Medications managed by the patient are indicated with a Managed By Patient tag.

Collect Signatures

There are three signatures that can be applied to the Meds Brought In section: Patient, Witness, and Verification. Check out the Dashboard section below to learn how to identify charts with pending signatures.

Patient Signature

Patient signatures on the Meds Brought In log can be collected at any time. Click on the Verification Signature button to add the signature, sign, and click on Submit to stamp the signature.

Note: The patient's signature is not required for the chart to be closed.

Witness Signature

Any EMR user with access to the Meds Brought In section can be chosen as a witness for a medication. The EMR requires the Witness's signature for any meds marked as Destroy, but a witness can be set for meds regardless of the chosen action. If a witness is selected for any action type, the signature is required for the patient chart to be closed or a Chart Auditor must mark the medication as complete.

To add the witness signature, the witnessing user to one or multiple medications needs to:

1. Open the Doctor's Orders tab of the patient chart.
2. Click Meds Brought In.
3. Click on Witness Signature.
4. Sign and click Submit.
5. The witness's signature will not be visible in this view, but the Pending Signature indicator in the Witness field is replaced with the timestamp of when the witness signed.
6. The actual witness signature is visible in the transaction's details if you are using the Patient Inventory feature.

Verification Signature

Once medication(s) are verified, you can add a Verification signature to finish the verification process. Click on the Verification Signature button to add the signature, sign, and click on Submit to stamp the signature.

Note: A verification signature is not required for the chart to be closed.

Mark Meds Brought In Records as Complete

Chart Auditors can mark Meds Brought In records as complete, even if they are missing witness, verification, or patient signatures.

From the Medications Brought In page, use the checkmark to mark the med(s) as complete.

Once marked as complete, the Unsigned Medications Brought in by Patient line will be removed from that patient in Dashboard > Current Census and Dashboard > Discharged Patients.

No Medications Brought In

You can also log that the patient didn't bring in any meds. 

1. From the Doctor's Order tab, click on the Meds Brought In button.
2. Select No Medication Brought In.
3. Confirm the action by accepting the pop-up.
   
4. A new transaction will appear with a note No Medication Brought In by Patient.
5. You can designate a witness, and collect a patient, witness, and/or verification signature as required by facility policy. 
6. If the patient remembers they actually do have some medications that need to be documented, the Add New button remains available.

Dashboard

Users can track pending Medication Brought In actions for patients in their care.

The actions are available in Current Census and Discharged Patients tabs:

• Unverified Brought In Medications: Indicates that some of the medications the patient brought in still need to be verified.
• Unsigned Medications Brought in by Patient - Verification: Indicates that some of the verified medications brought in by the patient haven't been signed by the verifier.
• Unsigned Medications Brought in by Patient - Witness: Indicates that some of the medications brought in still require a witness signature.

The My Items tab displays pending items specific to the user if the user is responsible for verifying the medications or adding a witness signature. 

Forms: Medications Brought In

Use the patient.brought_in_medication in Evaluations to display a list of all medications the patient brought in.

When added to the template, the form will show the summary of all medications brought in by the patient with the current status and signatures:

User Permissions

All users with access to the Doctor's Orders tab can view the medications brought in by the patient.

• Log Meds Brought In: Techs, Nurses, Doctors, Records Admins, Super Admins, and users with Log Medication Brought In or Verify Medication Brought In can log the medications brought in by the patient. 
• Verify Meds Brought In: Techs, Nurses, Doctors, Records Admins, Super Admins, and users with Verify Medication Brought In can verify the medications brought in by the patient by marking them as Continue on Admission, Destroy, or Store.

Check the table below to get the full list of permissions related to the Medication Brought In feature: