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Entering Instructions for Medications

How to update the Instructions in the Medication List and Medication Reconciliation Task

Aubree Dorr avatar
Written by Aubree Dorr
Updated over 4 years ago

Capturing the dosing instructions for medications is quite flexible, ranging from ultra-simple (one tablet orally daily) to highly complex (0.5ml intramuscularly every Monday, Wednesday and Saturday as needed with food). You get the idea. ;)

Utilize the Structured framework for instructions that are simple, and utilize the Free Text instructions, which provides a free text box, for instructions that don't fit well into the Structured framework.

There are also separate options to capture similar instructions depending on the level of detail you'd like to include. For example, "Take one tablet orally twice daily" can be captured as: 

  1. Quantity=1, Route=orally, Quantity=2 time every, Unit of time=day; OR 

  2. Quantity=1, Route=orally, _ time every Quantity=12, Unity of time=hours (Take one tablet orally every 12 hours); OR 

  3. Select the "Additional Instruction" button, and in the top section enter Quantity=1, Route=orally, Unity of time=day, Special instructions=in the morning, and in the bottom section enter Quantity=1, Route=orally, Unit of time=day, Special instructions=in the evening (Take one tablet orally every day in the morning and one tablet orally every day in the evening).

The "Additional Instruction" option is handy for any time the instructions have multiple daily doses specified for a time of day or with a specific meal, and you can check the As Needed box to indicate as such.

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