🎞️ View video tutorial: Creating prescriptions

🎓 eLearning course: Creating prescriptions and managing medications

You typically start a prescription from an encounter or from the Prescriptions area of a patient's chart. If you're in the process of reviewing a patient's medications and you want to create a prescription, you can create a prescription from the Medications area as well.

You can search for a medication or treatment to prescribe from the CHR's built-in medication list, or quickly prescribe a medication from a list of frequently-used medications or from a list of the patient's current medications.

When you finish a prescription, you can save it as a draft, or sign and print, fax, or download the prescription. See Signing prescriptions.

Steps

1. Open the patient's chart or start an encounter for the patient.

  • If you have an encounter open, in the Prescriptions area of the encounter, click + Add Prescription.

  • If you don't have an encounter open, from the patient's chart, in the Quick Menu or the Start/Open menu, choose Prescriptions. The Prescriptions area opens with a list of the patient's active prescriptions displayed. Click + New Prescription.

2. The Prescription Dialog ("prescription pad") displays.

3. To prescribe a new treatment for the patient, click + Add Medication.

💡 Tip: if the medication you are prescribing is saved in your list of frequently-used medications, click my frequents.

The prescription entry window opens and is split into three areas:

💡 Tip: If grey hover-over text appears beside an allergy or a current medication, this indicates that the allergy or medication is recognized by the Vigilance Santé interaction checker, and is taken into account when searching for possible medication interactions.

4. In the search field at the top of the prescribing area, type part or all of the medication name. As you type, the TELUS CHR displays matching medications in a list. Any of your matching frequent prescriptions display at the top of the list (indicated by a star).

  • Select the medication you want to prescribe. If you selected a medication with a DIN number, it appears above the field on the right.

  • If the treatment you want isn't available in the list - for example, if you're prescribing a non-medication treatment such as crutches or physiotherapy - type the full name in the field. (See Prescribing non-medication treatments for more information).

5. If any interactions or dose issues are identified by the Vigilance Santé interaction checker, they display in the middle of the window, under Alerts. Manage any alerts, as necessary. See Viewing medication interaction alerts for more information.

📌 Note: If you type the treatment name and do not select one from the list, it is not linked to a DIN number, and therefore cannot be included in interaction checking.

6. Complete the remaining fields, as required. The most commonly-used fields are in the General tab.

Field

Description

Dose

Enter the dosage amount. You can enter decimal values and ranges (e.g. 0.5, 1-2).

In the drop-down list, select the dose type (e.g. Tablet(s), mg, etc.)

Frequency

Select a frequency from the list. If none of the options are appropriate, select OTH - Other and then, in the Additional Instructions field, enter the frequency. For example, you can enter "Up to 8x/day".

Duration

Enter the duration in days, weeks, months, or years.

📌 Note: You must type days, weeks, months or years following the number. The CHR remembers values you enter so, in the future, you can quickly choose commonly-used durations from the list.

Duration determines when a short term medication will fall off the active medications list.

PRN

Select this checkbox to indicate that a medication is to be taken on an as needed basis instead of regularly, such as a pain medication or a rash cream.

Add Dose

Use this to enter multiple dosages or consecutive dosage prescriptions.

By default, then appears between the dosage lines. This is for consecutive dose prescriptions. If you are creating a multiple dose (concurrent) prescription, click then and select and from the list.

See Creating variable dose prescriptions for more information.

💡 Tip: to delete a dosage line added in error, click the trash can icon.

Quantity

The Quantity is auto-calculated if you entered a Dose, Frequency, and Duration in the appropriate fields.

If the Quantity did not auto-calculate, type the quantity amount and select the quantity type from the list (e.g. tab, mg etc.)

Route

If you need to enter or change the route in which the medication is to be taken, select a route from the list.

Form

If you want to specify more detail than is selected for the Dose and Quantity type (e.g. chewable tablet when the dose is in tablets) select the form of treatment from the list.

Refill

Enter the number of refills.

💡 Tip: To specify a different Refill Quantity or

Refill Duration, click:

Refill Quantity and Refill Duration are useful for trial medications and to test the success of a medication (such as 1 tablet once a day for 5 days; then 60 tablets once a day for 60 days).

Start At

Defaults to the current date. Update, as necessary, to change the date the patient is to start taking the treatment.

End At

Automatically calculated based on the Duration field, taking into account any Refills.

If not automatically calculated, optionally enter the date the patient is to stop taking the treatment (i.e. when they should run out of medication).

Continuous

Defaults to Not set. The medication will automatically be removed from the Current Medications list after the end date has passed.

Select Yes if the patient will be using the medication for an extended period of time and you do not want the medication to be removed from the Current Medications list after the end date has passed.

Select No to indicate this is a short term prescription. The medication will automatically be removed from the Current Medications list after the end date has passed.

Substitution Not Allowed

Select Yes if the pharmacist should not substitute with a generic version or another brand. Substitution Not Allowed is displayed on the prescription.

Past Medication

Select this checkbox to indicate that this is a past treatment that the patient is no longer taking, but you're recording it for your records.

Save to my frequents

Select this checkbox if this is a prescription you know you will use frequently. The prescription is saved to your frequents (favourites) so that you can prescribe it more quickly in the future.

Additional Instructions

Enter any specific instructions for the patient. For example, “take with food”, or “apply sparingly”. The pharmacy may print these instructions on the label they affix to the medication.

You can also use this area to free-type some or all of your prescription directions instead of using the discrete dosage fields.

7. Optionally, to add more nuanced information to the prescription, click the Extra tab and use as many of the fields as you want to add additional information.

Field

Description

Conditions

Enter the condition(s) the patient has that you are prescribing this medication for. Separate multiple conditions with a comma. e.g. diabetes, hypertension

💡 Tip: When you review a patient's medication and treatments, the condition(s) linked to each treatment displays below the treatment name.

ATC

If you selected a medication with a DIN number, the medication's Anatomical Therapeutic Chemical (ATC) Classification name displays here automatically.

ATC Number

If you selected a medication with a DIN number, the medication's Anatomical Therapeutic Chemical (ATC) number displays here automatically.

Dispense on

If the medication should be dispensed on a specific date, select the dispense date. The Dispense on date appears on the printed prescription.

Original prescriber

If you're recording a treatment that was originally prescribed by another provider, type the provider's name and select them from your list of contacts.

Original prescriber identifier

If you're recording a treatment that was originally prescribed by another provider, type the provider's identifier (for example, the provider's BA number in Alberta or the provider's CPSO number in Ontario).

Medication strength

If you selected a medication with a DIN number, the pill size or dose strength displays here automatically. However, you can modify or add a strength if needed.

Patient compliant

To indicate that the patient is taking the medication as prescribed, select Yes.

To indicate that the patient is not taking the medication as prescribed, select No.

Drug description

To include a visual description of the drug. For example, for Tylenol, a round white tablet.

Diagnosis codes

To link the prescription to the condition(s) it's treating, add the diagnosis code(s):

a) Click + Add Diagnosis.

b) Search for the diagnosis using the code or description.

8. When you are finished, click Save. The prescription displays in the Prescription Dialog with any other medications prescribed at the same time.

9. Optionally record any Notes related to the prescription. These notes are for internal use only and not included on the copy of the prescription for the pharmacy. 💡 Tip: you can add or edit Notes after you have signed a prescription. Select the prescription from the list of the patient's Prescriptions, make your changes in the Notes field, and click the Save icon in the bottom right corner of the Notes field.

10. Now you can save the prescription as draft, or sign it and choose a method of generating a copy of the prescription to be provided to the patient or pharmacy (i.e. printing, faxing, or generating a PDF). See Signing prescriptions for more information.

Updated August 24, 2021

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