O-12-702 Documenting Medication Changes on Recert

🎯 Purpose

Describes how to document medication changes during a Recertification (RCT) encounter in PointCare.

Rationale:

• Barrier(s):

  • When a RCT visit is performed, the clinician generates the 485/POC for the next certification period.

  • The clinician cannot select a medication “start” date that comes before the new 485/POC certification dates.

    Solution(s):

  • Clinician must PAUSE their RCT visit to create a separate physician order outside of the RCT document to address medication changes effective at the time of the RCT visit.
  • This order MUST be synced immediately so it can be approved prior to the approval of the new 485.

🔄 Process

Review Medication Profile:

1. With the RCT visit, review the existing medication profile:

   1. Select Menu (3 dots in upper right corner)

      

   2. Select Medical Records

      

   3. Select Medications

      

   4. Review Medication Profile

      

      
      

Create Order to Update Medication Profile:

1. If edits or additions are needed, PAUSE the visit:

   1. Go to the Visit Command Center

      

   2. Select Sign Out

      

   3. Select Pause from dropdown

      

      then Pause

      

2. Find the client’s Medical Record:

   1. Select Menu

      

   2. Select Medical Records

      

   3. Select appropriate client/episode

      

      

   4. Scroll down to select Features (at the bottom of the list)

      

   5. Select New Orders

      

3. Create the Physician Order for Medication Changes Only:
   1. Refer to O-12-100 Physician Order Content for additional details regarding content

   2. Select “Add” to create the new order

      

   3. Select Order Type – Physician Order

      

   4. Add Instructions

      

   5. Select Add/Edit Medications

      

4. Make appropriate edits to Medications:
   1. Discontinue any changed or discontinued medications FIRST (including dose changes):

   1. Select and hold on the medication name

      

   2. Select Discontinue

      

   3. Enter Discontinued Date

      

   2. Select “Add” to add any new or changed medications

      

   3. Search and add new medications as directed (ensure start date is accurate)

      

   4. When all appropriate medication changes have been made, select Menu

      

   5. Select Save

      

5. Address any medication interactions as appropriate. Refer to O-12-703 Address Medication Interactions Warnings for detailed steps

6. Select Save to close the Physician Order

   

   

7. Select back icon x2 to return to Rolling Calendar

   

8. Sync Device to send Physician Order to Back Office

   

9. When back in Rolling Calendar, resume paused RCT visit:

   1. Select appropriate visit (look for paused icon)

      

   2. Select Resume

      

Special Instructions for Medication Setup Clients:

• Clinicians are unable to utilize the Medication Setup Visit Action to document newly added medications during the visit when the order is added outside of the visit.
• If a clinician is performing a medication setup on a RCT AND there are new or changed medications, clinician must document the medication setup details of the new or changed medications in the Skilled Procedures section of the Physical Assessment:

1. Go to Skilled Procedures section of Physical Assessment

   

2. Answer “Yes” to the following question: “Were new or changed medications added on this visit?”

   

3. Document the setup details of the new or changed medications that were added in the order outside of the visit:

   1. Each medication must include the medication name, dose, route, time and dates each medication was set up

      

4. Finish documentation for the rest of the visit

📅 Effective: 6/12/2025  |  🔍 Reviewed: —  |  🛠️ Revised: 8/21/2025  |  ✅ Approved by: JS