Medication History

Use Medication History to record current medications for a patient of your health service that your patient is taking but which may have been prescribed in hospital or at another service.

Tip: If your health service would prefer to use another term for Medication History, contact Communicare Support. The term you select will be used throughout the clinical record.

Any user who belongs to a user group with Medication History system rights can add a medication to a patient's Medication History, regardless of formulary or prescribing rights. If Medication History is not enabled for your group, ask your administrator to it. For more information, see User Groups.

If there are no details in the Drug Browser, ask your administrator to arrange the import of MIMS Pharmaceutical Database.

The medication history of a patient is not shared with My Health Record or MeHR.

Note: You cannot prescribe, print or issue repeats for medications recorded in the Medication History window.

You cannot record a medication with a date before a patient's birth or after a patient's date of death.

Complete as much information in the record as possible.

To add medication history for a patient:
  1. In a patient's Clinical Record, select Medication > Medication History iconAdd Medication History or press Shift+F9.
  2. In the Drug Browser window, select the appropriate medication and read and acknowledge any interactions or other prescriptions.
  3. In the Add Medication History window, check that the patient's biographics, your provider details and the service details displayed in the banner are all correct.
  4. In the Medication frequency field, select either Once Off/Short Course or Regular Medication.
  5. From the Start Date calendar, select when the medication was first administered or type the date in the format dd/mm/yyyy.
  6. From the End Date calendar, select when the medication was last administered if applicable.
  7. In the Dosage Instructions field, enter dosage information using short codes or full text.
  8. From the Source list, select where information about the medication came from: Advised by Patient, Advised by Care Giver, Discharge Summary or Other.
  9. In the Additional Comments field, add any further relevant information.
  10. If you want to add another medication for the patient, click Add another itemAdd another item to save the first medication and clear all fields. Repeat steps 2-9 to add another medication.
  11. Click Save.
An entry is added to the patient's historical clinical record. The entry is dated with the start date selected in the record and added to the medication window, including:
  • Detail > Rx - Prescription tab, prefixed with<History>
  • Medication Summary, prefixed with <History> and with a script number of History. For example:

  • Progress Notes, prefixed with <Medication History>

In the Medication Summary or Medication Detail window, you can edit, stop and delete any medication added to a patient's record in the Add Medication History window. However, you can't prescribe, complete verbal orders, issue a repeat, print a prescription or supply and administer medication for any medication added to a patient's record in the Add Medication History window.

If you add medications to a letter using Clinical Record > Current/Regular Medication, medication history items are also included if they are still current. For these items, a prefix of Source: source selected in step8; is added to any comments that may have been included when the medication was added to the patient's record. For example, Source: Advised by Patient; tonsillitis.