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Table of Contents

Allergies p. 2

Admission Medication Reconciliation – Resuming after Interruption p. 2

Admission Medication Reconciliation - Entering Meds from Transferring Facility p. 3

Admission Medication Reconciliation Form p. 3

Date Shortcut: Entering Today's Date p. 4

Discharge Medication Reconciliation-Canceling Home Meds p. 4

Favorites - Usage of p. 5

Favorites - Organizing p. 5

Frequently Used Medications p. 6

Medication List - Compliance: Last Dose and Time p. 6

Medication List – Resizing to View Details p. 7

Medication List - Searching for Medications p. 7

Medication Request p. 8

Patient Search (Enhanced View) p. 8

Refresh of PowerChart Data (Enhanced View) p. 9

Reports - Printing of p. 9

SnoMed Abbreviations – Definition p. 10

Allergies

To use the provided list of common drug allergies:

1. When adding or modifying allergies, click Catalog tab

2. Expand the “Common Drugs Allergies” folder

3. Select the appropriate medication

To reactivate an inactive allergy:

1. Within the Allergies window Right click on the substance or “No Known Allergies”

2. Select “Modify”

3. Under Allergy details, use dropdown menu to change status to “Active”

Always compare newly added allergies to active medication orders:

1. After entering allergies, click “Reverse Allergy Check”

2. If a red dot appears in the Interaction column, double-click it for more information.

Notify team members about interactions immediately.

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Entering Medications from a Transferring Hospital’s MAR

To document medications administered at a transferring hospital:

1. From within Medication List, Document Medication by Hx, click “Order Comments” tab

2. Type an Order Comment of *MAR

This Order Comment flags the medication as a transfer facility MAR and prevents it from appearing as a home med on the Transfer and Discharge Medication Reconciliation and the Discharge Home Medications Instructions list given to the patient

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Resuming Admission Medication Reconciliation

To continue documenting when interrupted before finishing:

1. In the left-hand menu, click “Form Browser”

2. Locate the PowerForm in the current, active encounter

3. Right click the form name and select “Modify”

4. You can now finish entering the patient information

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Admission Medication Reconciliation Form

To open a section for the first time:

In center of the window, click the “Open” radio button next to the section you want to open (e.g. Allergy Profile)

To re-open a section:

On the left side of the window, use the menu to select the section you want to re-open. Sections you have already opened are green.

Note: If you use the radio buttons in the center of the window to re-open a section, you will be asked whether you want to UNCHART. This will delete all previously entered information from that section.

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Today’s Date

[pic]

Entering the letter T will make today’s date appear in any date field.

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Canceling Home Meds from Discharge Medications Instructions

There are two Discontinue Reasons that may be used to prevent a home medication from appearing on the Discharge Home Medications Instructions report. This is important to use if a medication has been accidentally entered for the wrong patient.

Entered in Error

Wrong Encounter

To use Discontinue Reasons:

1. In Medication List, right click the medication you want to discontinue.

2. Select “Cancel/DC”

3. Press E or W button, as applicable

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Using Favorites

For quick access, you can save commonly used allergies, medications and reactions/symptoms as Favorites.

To save an allergy or reaction/symptom as a Favorite:

1. Search for the allergy or reaction/symptom

2. Right click on the name

3. Click “Add to Favorites”

To save a medication as a Favorite:

1. Performed steps 1-3 above

2. Choose which folder you want to save the medication in

3. Click OK

To access your Favorites, click the [pic] button in the toolbar.

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Organizing Favorites

1. In the toolbar, click the small arrow button

2. Click “Organize Favorites”

3. A pop-up window showing all your Favorites will open

▪ To reorder your list, select the item to move and then use the arrow buttons on the right to move it up or down in the list

▪ To create new folders, click “Create Folder” on the left

▪ To move items into a folder, select the item to move and click “Move to Folder” on the left

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Frequently Used Medications

To use the provided list of commonly used medications:

1. Click the [pic] button on the toolbar to open the Medications folder

2. Chose from the alphabetized list of medications

If a medication cannot be found or the actual name is unknown (e.g. “little blue pill”):

1. Within the Medications folder, select “Other Frequently Used Meds”

2. Select “Template Non-Formulary”

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Adding Last Dose Date and Time

When adding or modifying an existing med, remember to document the date and time the last dose was taken.

1. In the Details frame, click the Compliance tab

2. Enter the date and time (Press T for today’s date)

This information will display on the printed Admission Medication Reconciliation report.

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Resizing Order Details Screen

If you open the Medication List but cannot see the details:

1. Click the line between the Medications list and the Details tab (below the scroll bar)

2. Drag the line up to reveal more of the Details tab

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Searching Home Medications

You can search for a medication using its first few letters or a partial name.

1. Enter the letters you want to search with

2. Use the dropdown menu next to the Search button to select either “Contains” or “Starts with”

3. Press “Search”

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Entering Medication Requests

From PowerOrders or Medication List:

1. Right-click the inpatient medication

2. Select Medication Request

3. A Medication Request window will open – select the correct reason

4. Enter a comment in the white box (if needed)

5. Click Ok

6. Pharmacy will receive order and send dose with appropriate labels

Return to

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Patient Search

The Patient Search box is located in the toolbar on the top right of the screen.

To search:

1. Type a name in the search field or simply click the binoculars to open the Patient Search page.

2. To search by FIN, enter the number in the FIN NBR field on the left side of Patient Search.

3. Be certain to open the active encounter from the list of encounters presented.

Searching by FIN is preferred. It ensures you will open the correct encounter record.

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Refresh PowerChart

Refresh the information in PowerChart by clicking

Remember to refresh every time you complete a PowerForm or modify home medications.

The length of time since the information was refreshed is displayed next to the refresh button.

[pic]

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Printing Reports

1. In the Task menu at the top left side of the window, select Reports

2. Use the check boxes to select the report(s) you want to print

Note: Disregard the date and time fields at the bottom of the screen – all reports run for a set timeframe that cannot be modified.

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Common SnoMed Abbreviations

You might see the following abbreviations when searching for allergy Substances or Reactions:

Remember: To speed up allergy entry, you can add Substances and Reactions to your Favorites by right clicking on them and selecting “Add to Favorites.”

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