When using our EMR you must select ALL medications that a patient is using from those available on the medication list (you must select and click on the medication to add it to the patient's record).
ALL allergies, including allergies to medications, must also be selected from the allergy list (you must select and click on the allergy to add it to the patient's record). There is never a situation in which it is OK to free type (to type the name of) a medication or an allergy.
If a staff member types in a medication or an allergy instead of selecting one from the list, the system does not allow us to use E-Prescribe, nor does it allow a Clinical Care Summary to be printed or emailed (and thus it impacts our ability to successfully meet meaningful use requirements).
Following the above protocol without exception is mandatory for all staff.
If you have any questions or require any further training on utilizing these lists, please speak directly with IT.
It is your responsibility to follow these instructions in all cases in which you are making any entries into a patient's record, including backfilling.