O-12-701 Documenting Medication Changes on ROC/FU

🎯 Purpose

Describes how to document medication changes on a Resumption of Care (ROC) or Follow-Up (FU) document in PointCare by creating a separate Physician Order specific to the medication changes.

Rationale:

• Barrier(s):

  • Due to the format of Resumption of Care (ROC) and Follow-Up (FU) documents in PointCare, the clinician must build the pathways prior to accessing the physician order to review and make appropriate edits to the medications.

    

  • After the physician order has been created, any edits to the pathway order(s) will result in the previous being deleted and the clinician needing to start over.

    

• Solution(s):
  • A separate physician order outside of the ROC/FU visit, is recommended to address medication changes being sent to the provider
  • The order for medication changes, that is completed outside the active visit document, is done AFTER the medication reconciliation is performed.
  • By doing this, the physician order generated within the ROC/FU visit will only include pathway and calendar changes.
  • This prevents pathway edits impacting the medication entries, as they will be in separate orders.

🔄 Process

Review Medication Profile:

1. Within the ROC/FU visit, review the existing medication profile in the medical record:

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

      

   4. 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 ROC/FU visit:

   1. Select appropriate visit (look for paused icon)

      

   2. Select Resume:

      

Add New Order in ROC/FU Document:

1. Select New Order:

   

2. Add appropriate information including provider name, date of order, etc. Order type will default based on document type (**Resumption of Care** or Follow Up):

   

3. Select View Instructions:

   

4. Update order text for all problem statements:

5. Once all pathways have been edited/updated, select Save to return to visit:

   

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 ROC 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: 4/24/2025  |  🔍 Reviewed: —  |  🛠️ Revised: 10/8/2025  |  ✅ Approved by: JS