Recording Medication

To record medication, either:

1. From a Current Encounter with an encounter type selected, enter the details of the medication required. A combination of drug name, strength and form can be used to refine your search, for example, ibup 400 tab to find Ibuprofen 400mg tablets:

Or

1. From Current Encounter, select Add Medication and the Prescribe screen displays. Enter the details of the medication required, a combination of drug name, strength and form can be used to refine your search, for example, ibup 400 tab to find Ibuprofen 400mg tablets.

   The following symbols next to the drug indicate:

   • - ACBS item
   • - Black Triangle item
   • - Brand/Generic Branded
   • - Controlled drug
   • - Discontinued drug
   • - Toxicity alert

2. Select the medication required from the list offered and the Prescribe screen displays:

   

3. Complete as required:
   • Drug Class - If required, update the Drug Class. You can search for a drug by class using Drug Dictionary next to the drug name.
   • Dosage and Frequency - The defaults populate from the Gemscript drug dictionary. Practice default dosages are not currently available.
   • Preparation - Completed in conjunction with the selected drug.
   • Quantity - Select from the available quantities or enter directly.
     Note - When adding a prescription for a controlled drug item, a warning displays in orange if you enter more than 30 days supply into Quantity. This utilises the calculated daily dose.
   • Source of Drug - Defaults to In Practice, select from the available list to update if required.
     Note - Print is disabled if the Source of drug is elsewhere.
   • Print - Remove the tick to record a handwritten prescription.
   • Repeat prescription - If you would like the item to be added as a repeat:
     • Sync with existing repeats - Optional, tick to link the medication issue frequency and repeat until date, with the existing schedule, see Synchronising Repeats for details.
     • Number of repeats - Enter the number of repeats required.
     • Repeat Until - Optional, select a date to repeat this medication until.
     • Also create an acute - Optional, tick to create a separate acute prescription for this medication.

   • Advice for the patient - Enter any advice for your patient, this prints on the right hand side of the prescription and is copied to an acute item if created.
   • Notes for the pharmacy / pharmacist - Enter any notes for the pharmacist, this prints on the left hand side of the prescription and is copied to an acute item if created.
   • Authoriser's name - Defaults to:
     • The clinician logged on, or
     • The Usual GP if a non-clinician is logged in, select to update if required.
4. Decision Support and Prescriber Warnings display on the right of the screen and should be checked, select the warning to view the details:
   
   • - Drug Doubling
   • - Severe Drug Interaction
   • - Major Drug Interaction
   • - Minor Drug Interaction
   • - Contraindication - triggered by a patient condition
   • - Precautions - triggered by a patient condition

   Entries with no symbols are generic warnings.

   You must have an internet connection for prescriber warnings to display. If you do not have an internet connection a warning displays "Decision support is not available"

   

   Prescriber warnings depend on your Prescribing Preferences settings, see Prescribing Preferences for details.

   Note - If you are an existing Vision 3 user your prescriber preferences do not automatically import and need to be configured in settings.

5. Select Save to add the item to the patient record.
6. If appropriate the Decision Support Summary screen displays:

   

   Note - There is no time frame for Decision Support, all medical history is included.

7. Enter any comments required in the Reason for overriding these warnings section.

8. Select Prescribe.

The item(s) are now part of your current encounter, select the Current Encounter screen to print.