🎞️ 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.
📌 Note: The Prescriptions area is different from the Medications area of the chart. The Prescriptions area displays only prescriptions for the patient that were created from your TELUS CHR (i.e. you or someone in your clinic wrote a prescription to provide to the patient or pharmacy). You cannot record externally-prescribed medications from the Prescriptions area. The Medications area is a list of all a patient's current and past medications, whether they were prescribed by someone in your clinic or prescribed elsewhere. You can create a prescription from the Medications area as well as record externally-prescribed medications, and over-the-counter medications.
You can search for a medication or treatment to prescribe from the TELUS Collaborative Health Record (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.
⚠️ Important: If you modify any part of the medication name in the medication search field, any prescription details that you had entered (such as dose, frequency, or additional information) are cleared.
When you finish a prescription, you can save it as a draft, or sign and print, fax, or download the prescription. See Signing prescriptions.
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.
Alternatively, if you don't have an encounter open you can start the prescription from the Medications area of the chart. In the Quick Menu or the Start/Open menu, choose Medications and then click +New Medication.
2. The Prescription Dialog ("prescription pad") displays. To prescribe a new treatment for the patient, click + Add Medication.
📌 Note: if you started the prescription from the Medications area of the chart, this window does not appear.
💡 Tip: If the medication you are prescribing is saved in your list of frequently-used medications, click my frequents.
3. The prescription entry window opens and is split into three areas:
A prescribing area (left)
A drug interaction area (middle) (see Overview of the drug interaction checker)
A summary of the patient's allergies and current medications (right)
💡 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 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. For more information, see Viewing medication interaction alerts.
📌 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.
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.)
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".
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.
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.
💡 Tip: if you do not enter both a duration (numeric) as well as a unit (days, weeks etc.), or if the duration is not a whole number, the field will turn red when you tab past it. You must fix the error before saving the prescription.
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.
For more information, see Creating variable dose prescriptions.
💡 Tip: To delete a dosage line added in error, click the trash can icon.
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.)
If you need to enter or change the route in which the medication is to be taken, select a route from the list.
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.
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).
Defaults to the current date. Update, as necessary, to change the date the patient is to start taking the treatment.
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).
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.
Do Not Autofill
Select this checkbox if you do not want the pharmacy to fill the medication order unless requested by the patient. For example, the patient has gone for a regular checkup but already has a supply of the medication on hand, or an antibiotic where the patient has been told not to start taking it until the doctor has received the lab results confirming the need for the antibiotic.
Select this checkbox if you do not want renewal requests for this medication. You can leave a comment in Additional Instructions explaining the reason. For example, the patient must have a visit with the provider, or there is a charge for a renewal, or the specialist wants renewals to come from the family doctor.
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.
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.
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.
If you selected a medication with a DIN number, the medication's Anatomical Therapeutic Chemical (ATC) Classification name displays here automatically.
If you selected a medication with a DIN number, the medication's Anatomical Therapeutic Chemical (ATC) number displays here automatically.
If the medication should be dispensed on a specific date, select the dispense date. The Dispense on date appears on the printed prescription.
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).
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.
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.
To include a visual description of the drug. For example, for Tylenol, a round white tablet.
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.
If you created the prescription from the Prescriptions area, the prescription displays in the Prescription Dialog with any other medications prescribed at the same time.
If you created the prescription from the Medications area, the prescription appears in the Medications list. Click Create Prescription to view the "prescription pad" as above.
9. Optionally record any Notes (Internal Use Only) 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 sign a prescription. Select the prescription from the list of the patient's Prescriptions, make your changes in the Notes (Internal Use Only) field, and click the Save icon in the bottom-right corner of the Notes (Internal Use Only) 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). For more information, see Signing prescriptions.
Updated May 10, 2022