Medication By History Documenting medication by history is used to enter medication orders that the parent or guardian has administered to the patient at home or for meds that were not completed in PowerChart (prescribed by a different provider). The ability to Document Medication by History is dependent on your role and login. Attendings, Residents and Nursing can Document Medications by History.

Medication By History (continued) To document medication by history, complete the following steps: Click Document Medication by HX from the ‘Orders’ or the ‘Medication List’ chart tab. The Document Medication by Hx window will open.

Medication By History (continued) 3. Click Add and the add order window will open. 4. Enter the first few letters of the name of the medication in the Find field. Note: The type should be set at ‘Medication by History’

Medication By History (continued) The Order Sentences will appear, if applicable. Select the appropriate sentence, or click None. Click OK. Continue looking up and adding additional medications, as necessary.

Medication By History (continued) 8. Make modifications to the details window, as necessary. 9. When finished (and after you have reviewed the order), click Document History.

Medication By History (continued) 10. The Medication that you entered will appear in the Medication List (the tab beside the orders tab) with a status of Documented.

Medication By History Tip When complete information about the drug(s) the patient is taking (Example: dose, frequency, etc.) is not available, select the generic drug name and only enter the information known about the drug. The drug name will display (without details) in the Medication History.

This concludes the Documenting Medication by History Lesson You are now ready to proceed to the Next Lesson