I installed the software and I have been looking around different functions and features. I was wondering what would be the best work flow for a physician to place an order for 10 days IV antibiotic and how to document the treatment / administration from pharmacy inventory.
Thanks for your help
Welcome Nick,
How do you document this now? If you document this on paper, you can document it in the program. You can use the LBF to recreate the paper form that is used to document the treatment.
Here is an in-depth presentation on LBF https://youtu.be/Kkbq4O60dW0?si=Y-SMHU8I-6cd3eSD
If you know how to code, you can do a custom form.
Best!
Hello @Nick -
OpenEMR has multiple methods to document treatment that would be suitable for recording an IV dose. Some of them like the LBFs described, or Nation Notes or CAMOS are v versatile but require considerable setup. You can use Sherwin’s link to the LBFs, (thanks!) or go here to search the wiki for the other features if you wish.
https://www.open-emr.org/wiki/index.php?search=&title=Special%3ASearch&profile=default&fulltext=1
However, in my experience as a former nurse and doing OpenEMR customer support for several years, I’ve seen a lot of customers happy to use the native SOAP note clinical form, or the Patient Message feature. They both are immediately available in a standard OpenEMR install and are really useful.
The SOAP note is found in the menu of clinical forms that can be added to the encounter you’re working in at the moment.
You may add a SOAP note to the encounter to document the medication admin; click the SOAP menu item (rectangle above), fill out the standard SOAP note- or only the sections as you want. Click save at lower left
and it will appear in the encounter summary (round rectangle, 1st pic above)
Another documentation method would be to make a Patient Message in the pt’s record.
In the Dashboard, click on the Messages widget then on the link (round rectangle below)
You can select the type of message this is (the list is customizable so you could add ‘Med Admin’ if you wanted to) and who it’s directed to if anybody.
Enter the note and it will display in the dashboard ‘Messages’ widget panel.
Hope these ideas are useful!
Best- Harley
@Nick
Ok, slowing down and reading your original post more carefully, I see you also wanted to document the order for a med.
You can still use either method, since a SOAP note can be reopened until it’s signed and closed by the originator. So your med nurse could reopen the SOAP note and add their note Re: the administration of the med.
However, new SOAP notes do not announce themselves to staff who don’t know they have been created. If you use the Patient Message, you could direct the original message with the order in it, to the nurse who would see it in their own Messages display. They would give the med and reply to your message with a note that it had been given. Additionally, both your order and their response would be system time/dated which is handy for a legal clinical note to have.
Here’s a link with more on the Patient Message feature, which a few versions of OpenEMR ago used to be called, the ‘Dated Reminder’. But they removed some features and added others then changed its name, so not all of the documented features apply.
https://www.open-emr.org/wiki/index.php/HOWTO:_Use_OpenEMR’s_Dated_Reminder
Also- try accessing it through the main menu ‘Messages’ item, it’s a little easier to navigate.
Go ahead and play with it and see if it works for you.
And come on back with any questions you may have!
Best- Harley
Thank you both for the reply. We currently record Name of Medication, Quantity dispensed, Strength/Dose, NDC, Lot #, Expiration Date.
I would like to take advantage of the Pharmacy Dispensary Module to record these information and and keep track of the Quantity On Hand. I looked into LBF, I was able to pull the product (medication) from the inventory but not sure how to pull the rest of the information associated with the drug. I tried Data Type Pharmacies but no lock.
It would be nice if we can record each administration separate to keep the record clean and billing purposes. Thanks again for your help and suggestions
