Write a prescription

Add medicines to the SOAP note with strength, frequency and duration, then sign them so that they print on the prescription.

You prescribe medicines in the Medications section of the SOAP note. Each medicine is one line with its form, strength, frequency and duration. Signing the lines sends them to the prescription.

note

Who can do this: doctors

Where: Doctor Work Bench › Doctor Dashboard › row menu › Start Consultation › Medications

Before you start

• Open the patient's SOAP note. See Start a consultation from the Doctor Dashboard.
• The medicine must be in the hospital's item list. See Set up Item.
• The frequencies you use must exist. See Set up Frequency.

Add a medicine

1. Click the Medications card. The MEDICATION section opens on the New Order tab.

2. Type the first letters of the medicine in the Search box and pick it from the list. The list shows the stock as Qty. Medicines you have prescribed before are highlighted.

3. Fill in the details on the right.

   Field	What to enter	Required
   Drug Form	Tablet, syrup and so on. It fills in from the medicine.	Yes
   Strength	The strength, for example 650 mg.	Yes
   Route of Administration	How the medicine is taken, for example Oral.	No
   Intake Unit (in numbers)	How many units the patient takes each time.	Yes
   Frequency	The dose pattern, for example 1-0-1.	Yes
   Direction	When to take it, if your hospital uses directions.	No
   Duration	The length of the course, for example 3 Days. It fills Duration (in days).	No
   Duration (in days)	The number of days.	Yes
   Start Date & Time	The first day of the course. It starts as today.	Yes
   Total Quantity	Worked out from the frequency and the days for tablets and capsules.	Yes
   PRIORITY	Stat / Emergency, Routine or As Needed.	No
   Special Instructions	A note for the patient, for example After food.	No

4. Read Free Text SIG. It shows the line as the patient will read it, for example 1 Tablet Oral 1-0-1 for 3 Days.

5. Click Add. The medicine moves to the list on the left with the status Pending.

6. Repeat for each medicine.

7. Click Save & Sign at the bottom of the section. The Medications card now shows each medicine as Signed.

tip

For a medicine that is not in the list, tick Free Text and type the name yourself.

Change or remove a medicine

1. Click the three dots at the end of the line.
2. Choose Edit to open the line again, change it and click Add. Choose Remove to delete it.

Reuse earlier medicines

• Quick Orders: your saved medicine sets, under Medication and Templates.
• History: the medicines of the Current Visit, All Visits or the Active ones.
• Save As Template: keeps the medicines in the list as a set you can use again.

Troubleshooting

What you see	What it means	What to do
please select Order Item first	A required field is empty. Most often it is Strength or Frequency.	Fill every field marked with a star, and Strength, then click Add.
You have already added this item	The medicine is already in the list.	Edit the existing line instead.
The medicine is not in the search list	It is not in the hospital's item list.	Tick Free Text, or ask the pharmacy to add it. See Set up Item.
The frequency you want is not in the list	It has not been created.	See Set up Frequency.
The line reads 1-0-1 for with nothing after it	Duration is empty.	Edit the line and choose a Duration, for example 3 Days.

Related

• Save, sign and print a SOAP note: print the prescription for the patient.
• Order lab tests, radiology and services: order investigations from the same note.
• Use a template in a SOAP note: fill a note from a saved template.
• Doctor Work Bench (EMR) FAQs: common questions about orders.