This article explains how to add a client's medication to their record, as well as extra information about their health conditions.
The Health tab allows you to review a client's medical details and keep track of their medication and health conditions. Under the tab, you can add information about a client's:
This information can be added to intake or client contact records. To add health information:
- Navigate to the relevant intake or client contact record.
Intake records can be found by clicking on a client's name on their enquiry record. Client contact records can be found by clicking on the Contacts tab.
- Click on the Health tab.
To add a medication:
- Scroll down to the Medications section and click on the New button.
- This will open the New Medication form. Different record types can be used depending on the frequency of the medication. Regular is for medication that's used regularly or on an ongoing basis. Short Term is for medication that will be used for a limited amount of time. Select a record type and then click on the Next button.
- The client's name will be auto-filled. Click in the Medication Name field and start typing the generic name of the medication. If it's already on the system, it will appear below the search field. If not, select + New Reference Data.
Depending on your organisation's approach, medications will usually be listed under their generic name, not their brand name. Make sure you search for the generic name before adding a new medication.
- The fields on the new medication form are the same for both regular and short term medications. Fields on the left column of the form capture information about when the medication was prescribed, how it is to be administered and, if known, when it should be stopped. This includes text entry fields for the dose, route and frequency.
- The right column of the form uses checkboxes to capture other information about the scheduling of the medication, including whether administration should be started immediately and whether it is administered 'as needed' (PRN).
- Once you've added all of the information about a medication, click on the Save button. If you have several medications to add, you can click on Save & New to automatically open a new record.
- The medication will now be listed in the medication section of the client's record. To edit the entry, click on the drop-down arrow at the end of the row and select Edit.
Information about health conditions can be tracked and displayed as an alert in the Health Conditions section. To add information about a health condition:
- Scroll down to the Health Conditions section and click on the New button.
- Select a record type from the list and click on the Next button.
- The information section of the form is similar for most conditions. The Client, Status and Date fields are filled in automatically. You should add yourself or whoever completed the record to the Completed by field. There's a separate field for the Medical Officer Name, which should be the person who provided advice about the condition.
- The fields in the Details section will depend on the condition. You can use these fields to add more information about the condition and whether a plan is required. You can also put a tick in the Display as Alert checkbox and add information to the Alert Summary if elements of the condition present a risk. Alerts are displayed at the top of the record for quick reference by other workers.
- The condition will now be listed in the Health Conditions section of the client's record. To edit the entry, click on the drop-down arrow at the end of the row and select Edit.
- If you put a tick in the Display as Alert checkbox, an alert summary about the condition will be listed at the top of the record.