Medications

The Medications page of a patient's chart (under Clinical) holds the medications the patient takes, as reported by the patient, a family member or their records. NeatPractice records what you are told; it does not prescribe, check interactions or send anything to a pharmacy.

Add a medication#

1. Click Add Medication.
2. Start typing the Medication name and pick it from your clinic's list. Picking one with a default route fills in Route. If the name is not listed, choose Add "..." to keep it as you were given it, brand or generic; it joins the medication library when you save.
3. Enter the Dose, Route and Frequency if known. Frequency suggests your clinic's list, such as twice daily (BID) or as needed (PRN); a frequency you type that is not listed is added when you save (see Term lists).
4. Choose who it was Reported by. For a minor this starts as Parent or guardian.
5. Add the Started date if known. To record the prescriber or a note, turn on Add the prescriber or a note.
6. Click Add Medication.

The chart keeps the name as saved, so later changes to the library, such as a rename or a merge, never change it.

When a medication changes or stops#

Click Edit on the row and change what is different. When the patient stops taking it, set the Status to Discontinued and enter the Stopped date. Discontinued medications stay on the page as history.

Medications are never deleted. If a row was recorded by mistake, click Mark Entered in Error. The row stays on the page, crossed out, and can no longer be changed. Add it again if part of it was right.

Every change keeps who made it and when, and earlier values stay in the clinic's audit trail.

Review the list with the family#

A list on file is only as good as the last time someone checked it. When you go over the medications with the patient, a family member or the records:

1. Update any rows that changed.
2. Click Record Review.
3. Enter the date, whom you Reviewed with and the Result:
   • List reviewed: the list on the page matches what you were told.
   • No medications reported: the patient takes no medications. You cannot choose this while an active medication is on file.
   • Could not be obtained: nobody could tell you today.
4. Click Record Review.

Reviews are never changed. They are listed under Review history, newest first, with who recorded each one.

The list status#

The badge beside the page title tells you where the list stands:

Rows added or changed after the latest review show Changed since review, and the page counts them, so you know what to go over at the next visit.

Medications in notes#

A note template can include a Medications section (see Templates). While the note is a draft, the section shows the chart's active medications and the last review. When the note is signed, it keeps the list as it was at that moment, and the signed copy prints it. See Clinical documents.

Who can change medications#

Anyone who can edit the chart can add and change medications and record reviews. Anyone who can read the chart can see them.