Add a Medication Not Ordered

The Add Medication Not Ordered option allows you to properly document specific medications that are not being ordered for a patient along with the reasons and applicable SNOMED codes. Use the following steps to add a medication not ordered for a patient in a chart note.

 

 

  1. Open an existing or new Chart Note for the patient.
     

  2. Click the Medication button, and then select Add Medication Not Ordered.



     

  3. A Search For Medication Not Ordered dialog will appear allowing you to search for the specific medication that is not being ordered. Type in the first few letters of the medication, and then click the Search button. The system will then display the results of your search. Once the medication has been located, highlight the applicable Medication.
     

  4. In the Reason section, you can select Medical, Patient, or System, and then further define the reason in the SNOMED Selection section with the specific reason along with the applicable SNOMED code.



     

  5. In the SNOMED Selection section, click the Search button to locate specific reasons and the corresponding SNOMED codes for not ordering the selected medication.

     

  6. In the Search List dialog, you can select a particular Category, as well as enter the first few letters of the SNOMED in the description field. Once the applicable reason has been located, highlight that reason, and then click the OK button.



     

  7. You can repeat step 6 to add multiple codes, if needed. You also have the ability to remove any selected codes by highlighting the specific reason, and then clicking the Delete button.
     

  8. Once the applicable SNOMED codes have been selected, be sure the Apply column is checked for all codes you want to apply for this medication, and then click the OK button.



     

  9. The medication not ordered will then appear in the Medications Not Ordered: section next to the Medication button. Likewise, this information will be tracked in the History tab and will be used for any applicable Meaningful Use Quality Measures.