Medication Administration Workflow

Overview

The Medication Administration Workflow provides a structured way to document medication-related patient care in the platform. This workflow can be used for three primary purposes:

1. Clinical documentation of medication administration
2. Scheduling and tracking follow-up medication administrations
3. Medical billing, when applicable and appropriately configured

Not every Medication Administration encounter must include billing. The workflow is designed to support documentation-only encounters, self-pay services, and medically billed services, depending on the care provided and organizational setup.

Documenting Patient Care

This workflow allows clinicians and pharmacists to document when a medication is administered or not administered. It captures key clinical details such as:

• The medication given
• How and where it was administered
• Administration timing
• Patient response or side effects
• Prescriber information, when applicable

This ensures the patient record accurately reflects care delivered, even when no billing is submitted.

Scheduling Follow-Up Medication Administrations

Some medications require ongoing or repeat administration. When a follow-up date and frequency are entered:

• A future service is automatically created
• The engagement appears in Upcoming Services
• Reminders are generated in the platform to support timely follow-up

This functionality helps care teams maintain continuity and reduces the risk of missed administrations.

Medical Billing Support Overview

For organizations that choose to use medical billing, this workflow is configured to support billing for commonly medically billable medications and administration services, including medications frequently administered by pharmacists.

Getting Started

Choose a patient

Log into Outcomes, then navigate to the patient profile using one of the following methods:

• Search for an existing patient in the Outcomes global header.

Or

• Find the patient in the Clinical Services Upcoming queue under the Patients on the left hand page navigation if you are documenting a follow up encounter.

Add the patient's medical insurance

• Once you have selected the patient and you wish to submit the encounter as a medical bill, select the 3 dots to the right of patient's name and select Edit Insurance. Or, on the right side of the page, choose the insurance card icon. This will open an insurance drawer where you can select Add Insurance.
• Input the required fields for the patient's medical insurance. Please ensure the patient has medical insurance added to their profile and that the information is entered exactly how it appears on the patient's medical insurance card. Once complete, select Save Changes.
  
  

Document an encounter

• Navigate to the Start a Service section of the patient page using the patient page navigation ribbon on the left side of the patient page.
• On the Start a Service section, select Medication Administration from the list of available clinical protocol templates.

Administration Details

• Indicate whether the medication dose was Administered or Not Administered.

• If Administered, enter the Administration Date and proceed with the rest of the workflow steps.

Medication Details

• Search for the medication administered in the Medication field. 
  • A minimum of 3 characters is required to display search results. 
  • Select the appropriate medication from the list.
• Enter the following details:
  • Drug NDC - enter the full 11-digit NDC number
  • Lot Number
  • Expiration Date
• Select the Primary Route of Administration from Oral, Intramuscular, Subcutaneous
• Select the Secondary Route (Injection Site). This represents the anatomical site of administration and applies to injectable medications only from Deltoid, Gluteal, Abdominal.
  • For Oral medications, select None or leave blank.
• Select the Lateral location from Left or Right or select None or leave blank for oral medications.
  

   

Side Effects or Site Reactions

• Document any side effects or administration site reactions, if applicable. 
• Select Next

Schedule a Follow-Up (Optional)

• If follow-up medication administration is needed:
  • Enter the Next Date
  • Select the Frequency in Weeks or Months

Summary & Billing

• Under Primary Care Provider & Follow-Up, document the patient's primary care provider information as well as any additional notes you wish to include on the Provider Fax Notification.
• Under Encounter Billing, choose the appropriate Place of Service, select whether administration for an injectable medication occurred, appropriate CPT code for the encounter time from the CPT Selection drop down, the Dose Administered (defaults to 1), the primary ICD 10 code from the ICD 10 code drop down, the billing method, and amount collected.
• Select Next.

Visit Summary

• View the summary of all that you have documented for the encounter, review for accuracy, and add any additional encounter notes. 
• Select Submit.

CPT and HCPCS Codes Supported in This Workflow