Recording Administered Medications in EHR 24/7

If you need to document medications that were administered during a patient visit in Office Ally’s EHR 24/7, follow the steps below. This process is different from recording immunizations or prescribing medications, allowing you to log medications administered to a patient while being seen.

Before We Begin

Before recording administered medications, ensure that your User Medication List is set up under the Manage Office tab. This allows you to quickly select commonly used medications without having to search through the full system list each time.

Steps to Record Administered Medications

Administered medications can be added to a patient chart in two different ways – either while completing patient documentation in a Progress Note, or by manually adding to the patient’s Administered Medications list on their chart:

1. Record Administered Medications from a Progress Note

• Open or edit a Progress Note that uses a SOAP Layout with the Administered Medication section enabled.

• Scroll to the Administered Medication section.

• Click Administered Medication Search/Select.

• The same pop-up used in the patient chart view will appear.

• Follow the same process to select and document the medication.

• Once saved, the administered medication will appear in the current Progress Note, in the main Medication List, and in the Administered Meds List.

2. Record Administered Medications from the Patient Chart

• Navigate to the patient’s chart.

• Hover your mouse over the Medication section in the top menu.

• From the drop-down options, click Administered Meds.

• On the next page, review any previously recorded administered medications.

• Click Add Administered Med.

• In the pop-up window select the Provider who saw the patient from the drop-down list.

• To choose a medication:

• Click the first ellipsis (…) button to open your User Medication List (configured under Manage Office), or

• Click the second ellipsis (…) button to search the Office Ally System Medication List (a comprehensive list curated by Office Ally).

• Click Select next to the appropriate medication.

• Complete the required fields:

• Date Given

• Administered Amount

• Office

• (Optional) Enter additional details such as Medication Manufacturer, Administered Units, or Drug Administrator.

• Click Update to save the medication record to the patient’s list.

Important Notes

• Medications recorded using the Administered Medication tool will not be included in the e-Prescribing drug interaction checking.  

• Be sure to review all entries for accuracy before saving to ensure complete patient documentation.

‍