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Medication and Reason for Medication MedicalDirector Train IT Medical


Hi, this video is for users of Medical
Director Clinical software, and will demonstrate how to enter a medication
and reason for medication in a patient record. Ideally a list of patients current medications are displayed on their health summary, the ‘Summary’ page
of Medical Director Clinical. And there are numerous ways to add and access
medication and medication information with a Medical Director Clinical. I will
go to the ‘Current RX’ page and here is a list of the patient’s current
medications. To add a medication I can ‘right click’ and select ‘New item’ another
popular way to add a medication is to ‘click’ on the ‘RX’ icon at the top of the
screen. This also allows the creation of a list of favourites and easy access to
those. So favourites been commonly prescribed medications.
If you just type a few letters of the medication you can then see the coded
list displayed. And it’s very important to choose from a coded list as this
enables cross checking of the database for allergies and contraindications, and
will provide relevant alerts and warnings. Make your selection by ‘double
clicking’, warning will appear if that’s appropriate, for example this
patient has coeliac disease. There is the ‘Product information’ ‘PI’ ‘Monograph’ available make your decision and in this case, add the ‘Dosage’ the ‘Frequency’ and any
‘Instructions’. Noting there are also ‘Other’ instructions and ‘Text’ that can be ‘Saved’
and ‘Inserted’ for more complex instructions. A very important button
here is whether this medication is a ‘Long-term’ or ‘Limited’. So for antibiotic
cover for example, choosing ‘Limited’ means that when that medication
should have elapsed there will be a prompt to mark that medication is
‘Completed’ or re prescribe. If you mark it as ‘Completed’ that medication will
thereafter be available in the ‘Old script’ section. Helping to ensure that this current medication list remains accurate. This information of course being shared on referral letters, on admission letters,
on summaries uploaded to My Health Record and care plans. We can select ‘OK’
in this example and there’s the ‘Add to favourites’ we can see over there. Change
the ‘Quantity’ and ‘Repeats’ as required or ‘tick’ ‘Use defaults’. This
‘Reason for medication’ is extremely helpful, it is also part of the General
Practice Standards to include that. So your patients coded ‘Past history” list
will appear on the right of the screen. If the reason you are prescribing is one
of those conditions simply ‘double click’ to select. If it’s not start typing and
you’ll find the diagnostic list will appear. So for this example I might
choose ‘bacterial URTI’, it is not something significant enough to add to
the coded past history, but it is a ‘Reason for the patient’s contact’ today.
So I can ‘tick’ that ‘Okay’. The medication prescription prompt will appear again in
case I wish to prescribe more than one at this time. I’ll ‘Close’ that, and you’ll
note that the ‘Printer’ icon remains to the left of the medication I prescribed
waiting to see if there will be more than one medication. If not I can go up
to the ‘Printer’ icon at the top of the screen and ‘select’ to print. Correctly
recording medication details and specifying a reason for the medication
in Medical Director Clinical is important for a number of reasons.
Firstly it helps to maintain the integrity of the client’s current
medication list ensuring it is as accurate as possible.
This improves safety when prescribing and ensures warnings about drug
interactions are accurately displayed when adding additional medications.
Secondly it ensures that client’s medication list transferred to external
organisations are accurate. So that includes referrals, care plans,
patient file transfers and uploads to external sources such as My Health
Record. And finally specifying a reason for the medication adds important detail
that benefits internal and external users of prescribing information. The
same medication can be used for different indications. So having each
medication linked to a reason improved safety and assists in understanding
medication usage patterns and management of health issues in our client
population. you

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