Apr 9, 2012
Pharmacy Student
What is the best way to go about documenting a note on a rx on intercom plus? Lets say I am unsure about filling a particular medication and I want to talk to the patient first, can I just cap it and then go back and leave a annotation on the image? If I leave an annotation on the image saying that I called to verify some issue with the dr, does the annotation get saved if a problem arises in the future? I just dont know any other way to make sure I am documenting things besides the annotation..
What do you guys do?
Jun 15, 2011
If you need to call the doctor to clarify, use the annotation tool so if there are refills on it, your note can be seen in the future. You can also resize the note on the image to fit essentially whatever you want. If you want to counsel the patient, put a cap on it. When you remove the cap, put a note in there saying what you and the patient discussed. It gets saved in their consultation history which is accessible by going to the main menu on intercom plus and going into CAP. If there is a drug interaction and you aren't able to speak with the prescriber at the time, put a DUR on it so it doesn't get filled and dispensed and potentially cause harm. Some people are different. Some will put a msc on everything. I don't like that because anyone can remove the exception.

Just whatever you do, make sure you leave comments somewhere so someone else can figure out what is going on! Communication is key.