How to Document Medication Administration/Observation in ZenCharts
Note: You have the ability to use the e-mor or e-mar (depending on your role) within ZenCharts if orders for medications are being entered in ZenCharts. Orders entered in the client's chart is what powers the generation of the e-mar. If orders are not being entered in ZenCharts for the client, the e-mar/e-mor section will be blank.
If you are a non-licensed staff member and are observing medications, you should be accessing an e-mor which will allow you to "Observe" and then have the client sign for their medications. If you are a licensed staff member, you should be accessing an e-mar which will allow you to "administer" medications and does not require the client to sign afterwards.
You have the option to go into each client's chart and work in the individual e-mar, or you can access the e-mar dashboard which displays all clients and all of the clients scheduled medications/action type orders
Accessing and using an Individual Client's E-Mar/E-Mor
1. Login to ZenCharts, and click into the desired client's chart
2. Go to the main menu navigation and click into the medical section, then from the medical sub-menu location, click on the eMAR menu option
3. The e-mar or e-mor will automatically default open into the closest medication pass time tab, you have the ability to change which time tab you view by clicking on the respective time tab.
4. Click the side arrow on the top right of the screen to display a side info section of the client's demographics to complete your checks/verification of the client
5. Under the present days date, you will see all the scheduled medications/orders due for the time tab you are in. To select an option of whether the medication was given, held, refused, etc, click on the select drop down and select the applicable option (if any medications require you to take vitals first, click on the green click vitals button, input vitals and then select which action was taken from the drop down), if any additional notes relevant to that medication needs to be entered, enter it in the notes field (to the left of the medication name, dose, route, alerts)
6. Follow step 4 for all the scheduled orders for that time, once that is done, click Administer (or click observe if you are in an e-mor, then in the pop up modal, allow the client to sign for their medications in the e-mor) and that's it, you've signed off your scheduled medications (once a medication is signed off, it cannot be undone, if anything was signed off in error, a note for that medication can be added stating that it was charted in error)
Tip: By clicking on the name of the medication in the emar or orders page, you can view a threaded history of medication compliance (if the client has been taking refusing or missing the medication)
How To Access and Sign off PRN's
(PRN's can only be signed off from within the client's chart at this time and not the e-mar dashboard (which only displays the client's scheduled medications)
1. Navigate to the Client's chart > Medical > eMAR
2. Click on the PRN collapsible bar to display all PRN's
3. On the left hand side of all the PRN orders are check-boxes, select which items need to be signed off by selecting the appropriate check boxes
4. Click Administer or Observe (if this is an observation record, then you will be prompted for the client's signature), and that's it! You've just signed off multiple PRN's at once.
How to Document Medication Effectiveness in the E-Mar/E-Mor
1. Navigate to the Client's chart > Medical > eMAR
2. Next to medications that have already been signed off you will see a button to "Add Note/Medication Effectiveness", click on this button for a modal to open to document effectiveness and any other notes
3. After entering notes, click on "Add Notes/Medication Effectiveness" to save documentation
You also have the ability to see all Effectiveness notes added for a client's e-mar by clicking on the Medication Effectiveness tab in the e-mar view
How To Access the E-Mar/E-Mor Dashboard
1. Login to ZenCharts
2. From the main navigation, select Medical, then select E-Mar Dashboard
3. This E-mar dashboard will automatically default to the hour tab of the time it is closest to, click into the med-pass hour you want to be in
4. Hover the mouse over each client's name to display their picture, name, DOB, etc.
5. Selecting appropriate action from the select drop down next to each medication
6. Click Administer or Observe to sign off on that client's medications
7. Scroll down to your next client on the list to continue
Tip: To access the client's PRN's hover your mouse over the client's name, and right click on the "View Patient" button and open the client's chart in a separate tab, navigate to client's specific emar, sign off their PRN's. close out that tab, and continue working in the E-Mar Dashboard tab
