Write your initial note:

  • choose “General exam note – eMEDS”
  • This is the preferred initial note type
  • Title your notes “ED medical”
  • Many fields can auto-populate – see below for medication histories!

Contemporaneous entries are important: “sign and submit” every time

  • You can “correct” your original note if needed

Document the patient’s progress:

  • open a new “Progress  Note” to record:
    • Results checked and documented
    • Response to treatment
    • Discussions with ED senior (include name of senior doctor)
    • Referrals made (including the doctor’s name and the time of referral and outcome of subsequent discussions)
    • Changes to patient status or updates to management plan
  • creating a new note for each change or addition to the plan helps with contemporaneous documentation
  • nursing colleagues will be able to see that a new entry has been made and adapt their plans accordingly

Document the patient’s medications:

Documentation in Home Meds is the standard of care for all patients

  • preferred over writing a free-hand list in the patient’s note
  • it saves time when a patient is admitted: admission reconciliation (prescribing inpatient meds) can be performed “at the click of a button”
  • it improves communication when a patient is discharged: after discharge reconciliation, the discharge letter will automatically list medications that are new or have changed.
  • it keeps the medication list in an easy locatable electronic form for the patient’s next presentation

You can import a patient’s medication history into “General exam adult eMEDS” – so make this your preferred note type

  • when you are ready to document the medication history “save and close” the note
  • Go to “Medication List” in the left menu and select “Document Medication by Hx”

No Known Home Medications can be quickly checked if the patient has none.

Then select “Document History”

And finally, re-open your original note and click “refresh”

You may need to click past this dialog box

And ensure that “Medication History” is checked here:

Please request a pharmacy consult in EMR if you are unable to perform a medication reconciliation to your satisfaction.

Incomplete documentation of medications is a source of avoidable error:

  • Patients don’t receive their regular medications
  • At risk of increased length of stay and potential adverse effects
  • Decreased satisfaction with quality of care received
  • Drug interactions missed
  • Missed warfarin or NOAC doses leading to thromboembolic events
    • or additional anticoagulants inadvertently prescribed, leading to bleeding events
  • Pain not controlled
    • Chronic pain medications not charted
  • Potential for complaints against the hospital or MO