# Documenting Non-VA Medication Information for Simple Doses

Previously, the designation “Non-VA Meds” caused some confusion as to whether providers were ordering or documenting outside medication. Therefore, throughout CPRS the name has been changed to “Non-VA Medications (Documentation)” or “Non-VA Meds (Documentation)”. When the user selects the Non-VA Medications (Documentation) option, the dialog displays the items that were marked as Non-VA Meds and copied into the CPRS Orderable Items file.

To document Non-VA Medications, use these steps:

1. If you are not already there, go to the Orders tab by either clicking Orders or pressing Ctrl + O .

2. In the Writer Orders list, select Non-VA Medications (Documentation) .

Note: If encounter information has not been entered, the encounter information dialog will appear before the Medication Order dialog. You must complete the encounter information dialog before proceeding.

3. In the Document Herbal/OTC/Non-VA Medications dialog, select the medication or herbal supplement by

a. Typing a few letters of name or its synonym (if your site uses synonyms).

Note: CPRS now only auto-selects (highlights in blue and places that entry in the field) a medication, dosage, route, or schedule if the user types enough characters to uniquely identify an item in the list. If the user does not enter enough characters to uniquely identify an item, CPRS waits until the user manually selects an item using the mouse or the keyboard.

b. Selecting the correct name from the list by double-clicking it or highlighting it and pressing <Enter>. You may need to scroll down to find the name.

Note: If you do not know other information such as dosage, route, or schedule, you may enter only the name of the medication or herbal supplement.

4. Enter a dosage (if known).

The dosage may not begin with a decimal, for example .5; it must begin with a numerical value, 0.5 for example. (The associated cost is displayed to the right of the dosage.)

5. Enter a route (if known).

6. Enter a schedule, including PRN if necessary (if known).

7. (Optional) Enter an Indication. If indications are defined, you can choose one from the drop-down list. If none are defined or the correct indication is not in the list, type in the appropriate indication.

8. Enter any comments.

8. Select one or more Statements/Explanations as to why the patient is taking the medication or supplement.

9. Enter a start date (if known).

10. Review the information entered in the text box at the bottom of the dialog.

11. Place the information into the patient's record by clicking Accept Order or by tabbing to Accept Order and pressing <Enter> .

12. (Conditional) If the medication ordered may be contraindicated because of allergies, drug interactions, or duplicate orders, CPRS will display the Order Check window. Carefully review all order checks and decide if the medication should be ordered. Do one of the following:

o To proceed, select Accept Order.

o To stop the ordering process and return to the dialog, Cancel Order.

13. To enter additional Non-VA Medication Documentation into the patient's record, repeat steps 3-12.

14. When you are through entering Non-VA medications, exit the dialog using the Quit button.

Note: Non-VA Meds do not require an electronic signature, but they will be presented at the end of the current CPRS session on the Sign screen. You can do the normal signing process or if you only have Non-VA meds, you might get OK and Cancel buttons on a dialog instead of the normal Sign screen. You can click on the check box in front of a Non-VA Med to deselect and not approve it.

Related topics

Non-VA Medications (Overview)

Documenting Non-VA Medication Information for Complex Doses