Modifying a patient’s INR test and anticoagulation medication instructions
View video tutorial: INR management: Adjusting anti-coagulant dosage
You can document and track a patient’s INR test and anticoagulation medication instructions using the Anticoagulation Summary Sheet. Here, you can record:
Anticoagulation medication adjustments
How long before the patient is to return for an INR follow-up visit
Other patient instructions related to INR results
Important: Dosage adjustments made on the Anticoagulation Summary sheet are not reflected in the active medication and inactive medication lists; they do not invoke a prescription change. To see the most recent dosage adjustment, in the medical summary, double-click the last INR review to view any adjustments or double-click on the encounter message (if available). The actual dosage adjustment is found in the Anticoagulation Summary Sheet.
Steps
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3.
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At the top of the window, in the Diagnosis drop-down list, select the patient’s associated diagnosis (if not already selected). |
Note: You can select only diagnoses that were previously added to the patient’s problem list. To add a new diagnosis on the fly, in the Diagnosis drop-down list, select <<Add New Problem>> and then, in the Problem List window, enter a diagnosis. See Recording patient medical problems.
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In the top row of the INR table, in the Follow Up drop-down list, select when the patient is to come in for their next follow up visit. |
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If there are no adjustments to the medication dose, in the INR Result and Adjustment column, in the drop-down list, select No Adjustment. The EMR populates the text “Continue with Current Dose” in the Patient Instructions and Callback Log column. |
Note: If this is the first time a patient’s dose instructions are being adjusted on the Anticoagulation Summary Sheet, you must choose Adjust Anticoagulant,and then enter the current instructions.
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If there are adjustments to the medication dose: |
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a)
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In the INR Result and Adjustment column, in the drop-down list, select Adjust Anticoagulant. The Enter new Anticoagulant dosage window opens. |
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b)
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In the New Dosage field, type2mg the anticoagulation medication dosage directions. |
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c)
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Click . The EMR displays the text “MEDICATION ADJUSTMENT: <medication name and dosage instructions>” in the Patient Instructions and Callback Log column. |
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To record additional instructions for the patient, in the Patient Instructions and Callback Log column, enter the instructions (for example, “INR in 2 weeks”). |
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To indicate that the patient is to stop taking their anticoagulation medication indefinitely, in the Termination field at the top of the Anticoagulation Summary Sheet window, enter a termination date. |
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To view all the changes made to the patient’s Anticoagulation Summary Sheet, click View Change log in the upper right corner. |
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10.
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To close the Anticoagulation Summary Sheet, click Save & Close . |
. The EMR displays the text “MEDICATION ADJUSTMENT: <medication name and dosage instructions>” in the Patient Instructions and Callback Log column.